Transcripts For CSPAN Q A 20130930

Cardiac surgery is an at lettic event. You have to use your hands, stand there all day long. Athletes were out in time. I see a lot of surgeons come to the end of their careers and not stop when the athletic abilities deteriorated. I wanted to stop before that happened. And so i was trying to i didnt think i was ready to sort of hang up my spikes completely. So i didnt know exactly what i was going to do. So i had looked at some opportunities. I had been in a Venture Capital company for the Cleveland Clinic. I thought maybe id go do that. Then my predecessor, ceo, announced his retirement and they asked me to throw my hat in the ring. And i thought, gees, at least i dont have to move. One thing youve done since 2004 to improve the situation, what would it be . I think the best thing i did was focussed why we have a Health Care Organization with the Cleveland Clinic. My opening speech was i said were going to put patients first. I handed out 45 buttons that said patients first. Thats been the north star. Thats the thing that unites us all, whether youre an educator or a search scientist or a administrator or work in the loading dock, youre all working for the patient. Thats the most important thing that happened. Get back to some of your past. But the Cleveland Clinic has been mentioned many times in the last several months because of the new health bill coming in effect on october 1. I want to show you a little bit of a speech that senator ted cruz of texas made on the floor of the senate when he did his marathon speech. He mentioned you. Lets lets let you break this down. Some members of this body might say, well, these are hard times. Everyone is struggling. So maybe the Cleveland Clinic is just responding to economic challenges. Whos to say what the Cleveland Clinic is doing has anything to do with obama care . Well, madam president , the answer to that is whos to say the Cleveland Clinic is to say . A spokeswoman for the Cleveland Clinic said, quote, to prepare for health care reform, Cleveland Clinic is transforming the way care is delivered to patients. She added that 330 million would be cut from the clinics annual budget. You want to talk about direct job losses from obama care, go to cleveland, ohio. Go to those working at the Cleveland Clinic. Go to those depending on the k4r50e6d clinic for health care. Thats one real manifestation of the train wreck that is obama care. What do you think . I think what we have to understand is whats going on in health care across the country. And we have gotten ourselves in a situation where we knew we had to change health care. Health care has become so expensive in the United States that its now a its consuming 18 of the gdp. Its starting to eat into things like education and other social programs that we want to have and we need to have. And we are more expensive than any other country in the world. And we have to harness that inflation rate. We have to control it and bring the costs down so that we can remain competitive. Now, weve been at this a long time in the beginning to drive this. Thats a process that started several years ago. And how we began to try to make our Health Care Delivery more efficient. We have, for example, we consolidated conservatives in the hospitals. We have closed one hospital it was two miles from 2000 beds and hospitals. Frankly, weve consolidated services. Weve consolidated services for obstetrics, for rehabilitation, for cardiac surgery, for pediatrics, and for trauma. And just, for example, in trauma, when we consolidated the services from five Trauma Centers from cleveland to three, we saw a 21 improvement in mortality rates. So this has been a long process where were trying to reform this. And whats going on right now is that it a lot of the things are coming to a head. That we have concentrated on taking out costs over the last couple of years, for example, things like purchasing. In the last two years, we took out 180 million out of purchasing. So weve been and weve done things like eliminated a redundancy. Weve put blocks in so you cant order redundant lab tests and eliminated 12,000 tests that would have been redundant. Weve been working on it all along. We know there are things that are happen right now that were getting paid less going to be paid less by private and public payers. Insurance companies are paying us less. Medicare is less. Sequestration have an effect on hospitals, the nih funding decreasing has had an effect on our research. And so we had to decrease our costs still further. And all of this goes into trying to change how Health Care Comes together. Not one single thing that did it. Not one single payer that did it. Not a program that did it. Its a whole series of things that we were doing starting back five, six, seven years ago, culminating in when we decided this changes are so significant in terms of when were going get paid that we now have to be even more stringent. And thats what led to offering people early retirement. Did you expect that after you made this announcement that the obama Care Connection was going to be made . Absolutely not. One of my biggest concerns was for the people who worked at the Cleveland Clinic and the Cleveland Clinic. We are concerned about driving great Quality Health care and were looking after our employees. Because our employees, all of us, all of our care givers are what the Cleveland Clinic is. Were not buildings, were people. And so my concern really was about those people. And how we could make that transition, most graceful if we have to do it or reduce its effect. Now, i thought it would have implications for the local community and we reached out in many Different Directions to tell people what we were doing and why it was coming. And i had a ninemonth scheduled meeting that i do every quarter where we televise it to all of the locations. I thought is the time to stand up and explain to the organizations whats going on and what were going to do as a result. And i did that. And i never thought that this was something that was going to become a political football. This was concern about delivering great care and looking at the people who do it. How many employees do you have . 43,000. How many will you reduce it to because of your cutbacks . What weve offered them 3,000 people, we offered early retirement. We expect well get 600 to 800 people to take that. Now, we dont know exactly what the longterm implications are. Will we have to reduce it more, we wont. Well have to wait and see. But were poised if we have to reduce it further to do that in january. How much money do you collect a year and how is it that youre nonprofit . Were a 6. 5 billion organization and we are not Profit Organization like almost every other hospital in the country. All of the there is no stockholders. There is no shareholders. There is no incentives, theres no bonuses. All of the residual goes back to building the organization, doing the research, paying the employees. You specifically pointed out in the past that i read that theres no tenure at the Cleveland Clinic. Explain why you say that. What difference does that make . A really good point. Were all of us are salaried. And we have no financial incentives. So i could look at you and say, you need a heart operation. And thats what im going to suggest to you. Have no effect whatsoever on my back pocket. Its all about whether i think you need it or not. So thats a wonderful feeling to be able to say to a patient, i think you need something and not have them worried that youre doing it for your own financial benefit. So all of us are salaried. And we have annual professional reviews. So each year we sit down with each doctor and we go through what how theyre doing and they tell us what they think they need from the organization. Its a wonderful way to get that feedback. And frankly, its a way almost every business in the country workings. Now, except health care in the most part. Let me add a question however youre not tenured, but the more heart surgery you do, the more you bring to the hospital, the more money that comes in, the better off that everybody can do. Thats correct. But the direct onetoone relationship is not there. For example, if youre a psychiatrist, for example, and we need you to help us with our transplant program, youre not going to bring any money to the Cleveland Clinic, we dont want you thinking about the fact that, you know, youve got to do Something Else rather than what the institution needs. And we all get paid on the basis of our total contribution to the organization. And the contribution might be clinical. It might be research. It might be education. It might be a combination of those. It might be management. It might be business. And all of those things go into how we decided to pay people. Now and the annual professional the fact that we dont have tenure, i think, is a wonderful thing. Tenure, frankly, allows us to say to people, look, you know, youre not fitting into the organization. Youre not contributing to the organization. And thank you very much for your service and time to go. When you think back on your career and the 22,000 operations, if you had to pick one or two that youll always remember, what would you pick . This is a tough thing to say for a surgeon. But surgeons dont remember the successes. They remember the failures. And the fail you always learn more from those failures than you do from your successes. And you play them over and over and over in your mind. Happily cardiac surgery over time became quite safe. But those those failures really stand out in your mind and you replay them and remember them even to this day. Whats a failure . Somebody dying. And how often does that happen to you . It happens less and less. Its interesting cardiac surgery when i started was in its infancy. I remember being a medical student, working on boston Childrens Hospital and in one day we lost five children. Terrible to come back the next day and try to do that do that again. And when i was a resident, you know, mortality rates for cardiac surgery were double digits. So my whole career was trying to get the mortality and the morbidity of cardiac surgery to come down. Now the mortality for cardiac surgery is 1 or less. And its the complications and staying in the operating room and the incisions and the quality of outcome has gotten better and bert all the time. When did you decide to put on the website how many operations were held in the last year and how many people died from them. Its an interesting story. I became about 25 years ago, i became chairman of cardiac surgery. We always worked hand in glove with the cardiologist. Cardiologist would see the patient, make the diagnosis and refer them to cardiac surgery. I thought it was important for the cardiologist to be part of the team and understand what the potential for outcomes from cardiac surgery were. So we had at the end of each year, we had a report where we asked all of the cartologists to come. We stood up and one after the other, reported the results of a bypass or a valve replacement or a microvalve replacement or Something Like that. The cardiologist started to ask for results. We put together a little booklet that had all of the results so they could intelligently tell the patient, look, the risk of what im suggesting is this. Then we said lets distribute it nationally. Because we think that every time you look at those results, you always find something that you can do better. And its a its a regular its a steady improvement, looking at all of those Little Things that are not as good as they should be. So we put it out there. And then when i became co, i said lets do it for everything. Hes do it for cardiac surgery and for dermatology, etc. Now, the issue really was in cardiac surgery is pretty easy to give you the results. You know, people either make it or they dont make it. And so you count up the results pretty easily. Its much harder than a lot of the other specialties, take dermatology, for example. You know, what is quality dermatology . I mean, i said dermatologist you cant just tell me youre a great dermatologist. Show me numbers, give mehmet ricks. So what i asked them to do is set up the metrics for their specialty. So we now have 17 or so books that we publish. Each year they get more sophisticated. And lets talk about the good, the bad, the ugly. But its transparency. And transparency is a wonderful thing. Transparency and quality and really didnt happen at all in medicine up until maybe 15, 20 years ago. Whose decision was to put your 990 tax form on the website . Thats part of our transparency. When did that start . Oh. I cant tell you. I dont remember, actually. I want to tell you some video of a former Vice President talking about cardiology, mr. Chooe cheney. I got a phone call one day before the transplant, from the Cleveland Clinic. They were going to put on a conference of innovation and care of Heart Disease. He said weve got all of the suppliers coming, the makers of the devices and so forth. We have all of the doctors coming. They said we decided we need a patient. And someone said lets get cheney. Hes had everything done to him that you can do to a heart patient. It was true. Its the idea that you can tell the story of a 40year miracle, really, of whats happened in our ability to deal with Heart Disease in this country through my story, my case history. Is there any way that connect what went on in his life and all of the heart all of the operations that he had and the heart attacks to obama care and what will change because of that . I think thats hard. First of all, i was there, i heard him very eloquently describe and very personally describe what had gone on in that point. He had an artificial assist in him. And just to put sort of the things in perspective, we know almost 50 years into the development of an artificial heart and left ventricular assist, he lived on the basis of that research for several couple years waiting for a heart transplant. And you know that is a tremendous amount of investment over time and improvement. I hope well be able to continue to do that sort of Research Going forward. Thats an important aspect for all of us. Whether its heart or cancer or whatever specialty its in, we need to continue to have the sorts of missions. If you look at Academic Medical Centers across the country, they have a tripartide mission as we do. Theyre educating people, theyre researching, theyre taking care of patients. So we need to continue to do that. And we need to see how it all works out over time. How much federal money do we get in a year . We get about 70 million. What for . For research. Of the research money. How have you been how have you been hit in the sequester era . We have been flat over the last several years in the amount of nih money we get for research. And we get other moneys from other locations. You said there are 27,000 pages of regulations that have come out of the obama care bill . Has that ever happened in your life . Well, it hasnt happened in medicine. Its the equivalent of what the irs says. 27 what are they saying . Well, ill be honest with you. Im dyslexic. I havent read them all. They are continuing to outline how were going to set up these types of care Delivery Systems and how were going to get paid, etc. What would you have done if someone had asked you to write this bill . Differently, maybe . I think well, i think one of the things that we understand is we had to have access. And i think the bill has done a great job at providing access. Access to what . Access to Insurance Coverage so that the people dont wind up going to emergency room but get a continuum of care along the way. And thats been a process that ongoing. We know we had to take the costs out. And theres only really two ways you can take costs out of health care. One is you have to make a more efficient delivery system. And i think were on the way to getting a more efficient delivery system. The other one is we have to reduce the burden of disease in the United States. We cant we have to take care of ourselves a little bit. And smoking and obesity and lack of exercise are very big factors right now in driving up the cost of health care. Obesity, for example, now accounts for 10 of the Health Care Costs in the United States. And we are in the midst of a tsunami of obesity across the United States. And that we have to deal with that. That was left pretty much alone in the bill. And i would have liked to have seen more emphasis on trying to help educate people about taking care of themselves and helping all of society from food manufacturers to educators to food providers to understand that we need to understand this epidemic of obesity and begin to make a change. After you analyze those 27,000 pages and you had a board meeting, and you took this to your board, what did you tell them that the impact is going to be on the Cleveland Clinic in the future . What we did is we gradually over time have been each board meeting, weve been bringing the board along so they understand it as we understood it. And then we have told them the that weve gone through the financial projections for the Cleveland Clinic as a result of all of the things that are changing. Not just one thing, but everything thats changing across health care on the financial projections for the future. And we recognize that we had to reduce the expenses substantially going forward. Did anybody get their salaries cut . We have not cut salaries. What we want to do is we want to keep the people who want to stay there and who are good workers and we want to continue to pay them well at a competitive rate. In fact, we pay competitive rates for doctors, for nurses, for everybody that works at the Cleveland Clinic relative to what they do. What would you say to an Insurance Company that you deal with all the time about what they do that you dont like that they do . Well, we talked to Insurance Companies, in fact, i was talking with the co of some of the Insurance Companies last night. He said its important we need to figure out how to Work Together better. We need to take the friction out of the gears of the transaction between the two different organizations and reduce that. For example, if we send in a bill for someone who had a delivery, they have someone who checks it bill out. And then they pay us and we have someone who checks if they paid the right amount. Wouldnt it be nice if we could just say, lets figure out how much it costs, how much youre going to pay us per delivery and what the average delivery costs and thats what when he get paid. And that well take the checkers out at both ends. Thats taking sand out of gears. Television personality that played a role in perhaps you played a role in his life, dr. Oz. A clip from that. Get you to explain it. Toby cosgrove, walked in the door, what are you doing tonight . I dont know, going to go read a book in the library. I got tickets to the indians. Took me to nobody, just a visitor, to an indians game where he gave he some food and he talked about me about life and why i had come to cleveland and what i was going to do at the clinic and what his passion was about medicine. It was many years ago. It taught me about how you treat people. Someone his level, division chief at the time but became head of the whole institution is a towering figure in medicine to take someone young and come out the way he did, thats the role model i wanted to follow and i think ive tried to do that. When did you learn to use that philosophy, treating people . I think probably the first time i came along was the time in vietnam. I ran a casualty station in vietnam where we had where we get, you know, 50 to 100 sick and wounded new troops in every day. My job was to go bed to bed to bed to make sure theyre ready to fly and get on an airplane. I realized at that point just the plain touching of them made a different. I didnt have hours to spend with each one of them. But i would touch them, maybe just shake their hand or touch their toe. And i recognize i made a difference as a personal connection with people. I think you learn these things as you go along. But that was one of the things that i remember viftly. What years were you in vietnam . I went there after the tet offensive in 6869. Whats the impact of your life . The vietnam experience . Well, i learned a lot of things. First, i learned the horrors of war. And theres no such thing as a good war. Where were you . Denang. They were fighting on the perimeter. We watched a fire fight from the hospital. And then i also learned a lot about the world. And people and medicine in the military. They do some terrific things. They have a Transportation System, for example, the helicopter pick you up in the field, move you to a station where they stop the bleeding and splint your wounds, then move you to a back line hospital where you get the most sophisticated care. After they got you patched up, theyd send them to me and we would evacuate them to japan or the philippines or some place. Actually, we took that idea and we did the same thing for our system, we set a Transportation System up. We dont think all hospitals could be all things to all people. We think you move the patient to the right location at the right time for the right care. So we have fixed wings. We have helicopters, ambulances, and we move 20,000 patients a year to the right locations for the right care. That way we can concentrate people with a similar sort of problem in a location and it drives up the quality and it drives up the efficiency. Its called the practice of medicine. The more you practice, the better you get at it. Let people practice. How did you become a doctor in the service . What service was it . Well, i was there was a time of the vietnam war and so we all had to get commissions come out of medical school. So i went after i had a surgical internship and i had a surgical residency. And i went into the air force and straight to de nang. What did you think of the war when you were in the middle of it . You know, its first of all, the war was the human effect of a war really are horrible. I thought that, you know, it was hard to understand it. It was hard to understand the reporting of it. I was there at the same time as david halverstand was. David and i subsequently before he died. He was killed in a car wreck we used to talk about the war quite a lot and the effect on both of us and how we had different perspectives on it. Hi from the medical side, he from reporting it and others from fighting it. It was a it was difficult to understand from any one position in it. Did you change your mind about the war at any time in the last 40 years . I i dont think i did. I nonenthusiastic about the United States getting involved in overseas activities. What about what about what part of that conversation with David Halverstam he was one of the early guests on this program do you remember . And how did you two differ or did you . He was he was much more into the Bigger Picture of it. And was very upset about the u. S. Involvement there. And the people who were there leading and was very vocal about the issue as you may remember. And i was a little more confused and very concerned, not only the patients i was taking care of, but the effect it was having on the vietnamese populace. I ran a clinic for the vietnamese while i was there trying to help them along the way as well. You applied to 13 medical schools, 12 said no. The university of virginia said yes. Thank goodness. You talk often about your being a c student, d student, all that. At 32, you discover youre dyslexic. How do you get to the university of virginia . I dont know why they picked me to be honest with you. Im glad they did. They treated me very well. Gave me a great education. Youve gone on to run the Cleveland Clinic. How many patients a year . Multiple millions. Did plenty of operations as cardiologist. Go back to the education part of this. Why did those 12 turn you down . Frankly, i went to williams college. I heard a story of taking french. I never heard a word of french spoken in my life until i went to college. I thought, well, i better learn how to speak french, the language. So i found out that i couldnt do french at all. I first day walked in and everybody was saying wiwi. And i oui, ui. I looked up for wewe and couldnt find it. I had three d minuses and a d. I was not a great student. I worked very hard. But the amount of reading and languages that i had to do in college were difficult. Not surprised that most medical schools didnt take me. I think the interesting thing is going back and looking at this now understanding that im dyslexic, i realize dyslexia was a gift. I think about things differently. I look at things differently. It taught me persistence. If you look at the writings on dyslexia, a professor at yale is probably the expert on dyslexia. She finds dyslexic people are more creative because they think differently than other people do. Why did it take you until you were 32 years old to find out . I never heard the word before until i was that age. People didnt recognize it as a particular defect or a learning disability at that point. So i just thought i was not very quick. How do you know what is it that you see that we dont see . Well, you know, i cant tell you that. But ive warm wound up developing a bunch of products and a bunch of patents that came out as a result of that. And i gather i must think about things differently than other people do to do that. I have got a daughter whos dyslexic. And she is the same way. Shes become a fashion designer. Following a difficult academic career from age 4 all the way through college. But as you i mean, if youre reading a book versus doing an operation, is there two different experiences . Very painful to read. Very painful. I dont think ive ever read a novel. How do you read reports . How did you . Work at it. Its work. I have go up and settle down and find a quiet place where theres no distraction and concentrate, take notes, write in the margins. Go back and reread it slowly. Its very painful. Going back to education, you know what the system is. You take the s. A. T. Tests . You have to get good grades and all that. Is there something wrong with that . Well, yeah. We really have to think about letting people who have that diagnosis have extra time. Because theyre not dumb. Theyre just slow. And have extra time on tests and a lot of now reading can be changed into tapes. So theres a lot of accommodations that can be made for people who are dyslexic. Frankly involved with chuck schwab who is also dyslexic. He and i talked to a bunch of admissions people in colleges allowing people to have timed tests and bringing early and people who have dyslexia come in and they can be very productive members of society. Going back to the obama care issue. I want to run this in 2009 with people who are now president talking about the whole business. The reason i visited the Cleveland Clinic is because along with the mayo clinic, they have been able to drive down costs more than any other Health Care System out there while maintaining the highest quality. How did you go about doing it . They started this thing when was it started . Cleveland clinic . 1921. And what theyve done is, for example, doctors who are part of the Cleveland Clinic get paid a salary instead of getting paid fee per service. That makes it easier for them to make some of the changes because people dont feel like maybe theyre losing mount of pocket. They know theyre getting a salary. Should everybody else do what youve done . Get rid of the tenure, pay the salary . Not fee for service . I think increasingly were starting to see some of that happen. Its interesting how that is coming about. Were seeing now a consolidation in health care. Were seeing hospitals coming together in systems. Were seeing doctors want to be salaried. 60 of people want to be salaried. They would prefer to be salaried than going out and being selfemployed. A major shift so people are coming closer and closer to our model of care where you work with the hospital or forfor the hospital. Its a we have a slight difference. Were a Group Practice that has facilities. Theyre a and the other is a hospital that employs physicians. A subtle but important difference for us. How many billings do you have on the cleveland campus . Oh, gosh, 160 acres on the main campus and probably 60, 70 buildings. Again, how many doctor s . 3,200 physicians. How do you hire them based on what you just talked about, not getting in 12 medical schools, how do you approach only the harvard doctors getting in . Oh, no. We look for physicians first of all, coming to work in cleveland is a great filter. Because people arent coming to cleveland to go to the beach or go skiing. Theyre coming to cleveland because theyre interested in working there. Thats a great filter. So people are coming there because they want to work. And they want to work in the services that we have. So thats a terrific opportunity for us. And we look for people who are really concentrating and driven and about driving Great Health Care and great quality. Theyre not going to get paid as much as they can make in other places. In fact giving you an example when i started out, i was doing 500 heart operations a year. Two years after that, i was offered a job to go make 1 million. I stayed at the Cleveland Clinic because i liked the environment, the teamwork. How many doctors were there at the Cleveland Clinic when you started . 140 doctors when i came to the Cleveland Clinic. Its grown a little. How many of your patients are from ohio. We draw most of our patients from the six county area around. 80 of the patients come from the sixcounty area around that. The rest are a fivestate area around that. We have people all around the United States. Less than 1 come from overseas. I heard 132 different nations have shipped people to your clinic. How do you deal with that . Who can come . Anybody can come. We look after is the largest number of medicaid patients in ody. Tate of ohio. The lawyers, meanwhile, are getting 1,000 an hour in this town. Their rates go up. Theyre not on salary. You have malpractice. How much of that 6 billion a year goes to malpractice insurance. Our malpractice costs last year were about 50 million. Up, down . Working hard to bring them down. We said, look, when we have a problem, we know weve had a problem with the patient, we go to them and say, you know, we had a problem. Were sorry about what happened. We want to do everything we can to make it right. We want to be straightforward with you. We opened up the medical record for everybody. Five years ago, we said this is not Cleveland Clinics record, this is your record. So you can read it any time you want. And we sign everybody up for their Electronic Medical record when they come for a visit. We want them engaged. If you take away the secrecy of what is going on and you decrease hiding stuff, it reduces the amount of lawsuits you have. How many doctors have you had . I was responsible for hiring the physicians that worked in cardiac surgery when i was running it. Probably over time, i must have hired 30 just on the staff. Then there were all of the residents and fellows who came to work there and those were in the hundreds. We have, for example, about 1800 residents and fellows in training at any one time. So were a large education organization. Whats your own criteria about whether or not you hire somebody . Well, i think you look for a number of things. First of all, you have to find someone who you think has had the training. They have the dedication to what they want to do. And i think interpersonal communication capabilities are a big part of that, emotional intelligence. How often do you look at their grade point snanch. Almost never. Why . Because by the time theyve come to us from being hired theyve gone from college to medical school and now theyre coming into a residency. And so i look theyre the general ones that apply to us, the top portion of their class. I dont really care if theyre number one or number 15 or 20. But we get top applicants. So i dont go to that. Based on what you know now, if youre predicting what the world will look like in medicine in this country in five years based on the new law that comes in on october 1, what would you tell people . I think what were doing. You have to understand this, is not a law. This is about the economics of this country. And, you know, we have a patriotic duty to reduce the costs of health care in the United States. Or at least and also keep the quality first class. So a number of things that are going to change. Which insurance, who youre going get the insurance from is probably going change. Who youre going to the medical community. The care giver is going to change. A lot more people are physicians assistants. Theres a shortage of physicians across the country. Good or bad . Good thing, actually. It allows everybody to practice it at the top of the capabilities. Physicians do physicians work and nurses do nurses work and not have technicians help them. So were going bring a whole new workforce to come in and look after the shortage of doctors and nurses. So the people are going to look at you are going to be different. The diseases theyre treating are different. Chronic diseases are way up. Acute diseases have gone way down. So youre going to see more people treated as outpatients instead of being impatients. And youve seen that happen already with surgery going to outpatients from impatient. Youve also seen that people with chronic disease are going to be treated as an outpatient and at home, so youre going have more outpatient visits and thats been going on now for 15 years and more home care. So where youre going to be treated, whos going to treat you and the sort of diseases youre treated for are all going to change. What percentage of the Cleveland Clinics money comes from medicaid or medicare . Medicare well, if its medicare is about 20 about 30 medicare. Medicaid is about 15 . And then the private payers and the people who dont pay at all. In five years, what would those percentages be . I think people are going to be a bigger percentage probably in ten years, probably 70 will be some sort of government pay, medicare, medicaid, of some sort. Its not just who pays. Its in the country. What will that impact be on you . Well, i think the impact on us is that going to be dependent upon what happens with the payment systems. Right now for example in ohio, theres no medicaid. They happen to have a medicaid expansion. Thats for the state of ohio, thats about a 14 billion nut over a period of time. And that we think that makes sense from both economic standpoint to get that passed and from the humanitarian standpoint to get that bill passed. I hope that happens soon. What about the individuals, though, sitting in this country . A lot of promises in the last five years from politicians. A lot of complaining. People are saying its the worst thing thats happened is going to bring the country down and the other side says its going president oh what says its going to cut your bill by 2500 a year. Where do you come down . We dont know, frankly . No idea. We really dont know. We dont know how this is going to play out over time. I think if you look at the bill in general, we know we had to change. And were in the process of changing. It is not a perfect bill, probably never be a perfect bill. There will be changes that happen in the next five to ten years to that bill to modify it. So i dont think we can tell you at this point what its going to mean. We have so many factors that are going on. Is obesity going to continue . Is the population going to continue to age . Are we going to be able to eliminate diseases like Heart Disease and cancer . Are we going to find new ways of treating people . And so to tell you that i know the answer to this, i dont know the answer to this. I do know that its a major change. I know theres going be adjustments. Theres going be new ways to treat people and care for people. But all the time, i think, the quality is going to go up and health care in the United States ultimately will deliver great care like it does now. Why is the health care in this country so much more expensive than it is overseas. One of the reasons is that we have put our emphasis in the different place in the United States. The emphasis is always been on treating people who are at the end of their lives and very sick, cancer, Heart Disease. In the last 20 years, weve driven down the Heart Disease by 20 in the United States. That made a big difference. So we put our emphasis there on the hightech. A lot of other places put their emphasis and other places, primary care, for example, great example of that is what happened in china right after the second world war. Life expectancy was in the high 20s in the end of the war primarily from Infectious Disease and starvation. And just by Public Health measures, they doubled it. Now on the other hand, if you look at russia, you see Life Expectancy of males going down because of alcoholism and suicide, etc. So theres a lot of difference where people put the emphasis, where they put their money. We have not had a national system. Its been, you know, entrepreneurs, various locations. Every hospital was billed as a standalone. Doctors are independent. There was not a national Health Care System across the country. Much on a different from where i practiced in london, for example. Which country in the world besides the United States and european has the best medical system . Thats a tough one. They all have something to admire. Germany is effective in what theyve done in combining private and government pay. They have done a terrific job in putting emphasis on primary care in england. So, you know, i think youre trying to look at the best you can find in various countries. Why is the Cleveland Clinic building an abu dhabi hospital. Glad you asked. Its an interesting story. And its a story that was sort of goes back to 9 11. In 9 11, we were seeing about 35 patients a month, particularly from the middle east. And for heart surgery, just heart surgery. And they went to five in two weeks. And that started us on the opportunity to be in to looking could we do something to meet these patients all of the places. We operated on the king of saudi arabia on a couple of occasions and a lot of members of the royal families and its been good for the Cleveland Clinic economically. And as we began to look, there were about 60 or 70 countries approached us about coming to do a facility in their country and we said there have to be five criteria. These were basic. One it had to be a stable country. Two, we had to have a stable partner. Three, it was not going to be Cleveland Clinic money invested there, because i wasnt going to invest cleveland money in another country. Thirdly, it had to be financial return to the Cleveland Clinic. And fourth, we had to deliver value and that was going to require a longterm relationship. It was going to require that we were there to transfer our culture to them. Thats what they wanted. And abu dhabi fit all of those criteria. How many beds . Were running at 750bed hospital there. And were building the Cleveland Clinic abu dhabi that will have 500 beds. You mentioned patents. How many have you received over the year s . 30. Give us an example of what some of them are . I developed a ring for repairing microvalves that holds the anulus in place and you do put it in when you do that . What year . Almost 20 years ago. How did you invent that . Well, i knew that there at the time that one of the problems that happens with the microvalve has two little leaflets that come together like this. Which is the mitral valve . In the middle of the heart, on the left side of the heart. The two leaflets come together like this. Theyre held together in a ring. And when some people, the ring die lates and so the leaflets dont bump against each other, they they dont come together and so the blood leaks backwards. So people were using a ring that wtz rigid at that time and i knew that the heart was not a rigid structure, it went like this, it contracted. I thought, gee, what we really want to do is develop a ring that we put in that flexes with the heart that will be more physiologic. And so i tried a number of things. But i put a stitch through the heart and i put it through some flexible piece and i tied it down and depends on if i had a big breakfast in the morning or not how tightly i tied the knot. There was no measured way to reduce the circumference of the the ring that was around the valve. And so i remembered back have you ever seen an embroidery hoop . A hoop that holds a piece of cloth tight. You put the stitches through, pull them tight, you take it off, and theres an embroidered handkerchief, Something Like that . I said thats what were going to do. We made a frame, tied the stitches through, took the frame off, had a flexible piece with a measured reduction. So that was some of the thinking that went into it. Everybody using that now. Probably one of the most use in the world. When you were operating, what was your day like . What time did you start . Operating room started at 8 00. I would get there at 7 00 and i generally get home after 7 00. How many would you do a day . Ive done just as few as two and as many as six or seven. What would you advise patients that are that have a heart problem . What would you say to them to try to put them at ease . And what did they most often worry about . Besides the obvious, death . Everybody worries about that, i think. But the second thing they worry about is strokes. And so we talk very candidly about, you know, we looked at whos at risk of this, at a stroke. Whos at risk of dying. We can tell them. We project what the risks are and we tell them in a very matter of fact way about that. And i think probably the other thing is people dont want to go to war with somebody that they dont know. And i think that you go to they think theyre going to war. So they look at them talk to them straight. And they appreciate that. The other thing is we found we give classes to people who are going to have heart surgery. Because they used to be that everybody used to be terribly anxious. They thought, gee, i was the only one they were going to happen to. Tainnd put them in the class and say, okay, heres whats going to happen to you in the next day. Its like group therapy. Theyre marching through this together. Its a calming effect on people. You were born in 1940 . Yes. Makes you 73 . Yes. How long are you going to do this . Im going to bo there for a couple of more years anyhow, or until such time something happens to me or the board of trustees tells me its time to move on. Or if i get tired of it. You talk about obesity. What do you personally do to stay in shape . I use the elliptical on a regular basis and i watch what i eat. And how have you seen over the years the obesity change . Well, you know, i grew up in a little town of upstate new york. I dont remember anybody weighing 300 pounds. And, you know, you just gradually saw that begin to change and how the American Public looks. Go back and look at the pictures of the depression or guys going off to world war i or coming home from world war ii. They dont look like our population looks now. What caused it. Multiple factorial. I think you have to look at how plentiful food is now. And also how people have begun to look at just look at yue used to drink coke out of a little bottle. Now you get them out of half gallon jugs. Its changed. The food has become cheaper, more plentiful, and people dont walk or exercise as much as they used to. What do you know about the heart after all of these operations other than i know as a doctor, you know a lot about it. What do you know about the heart that you want the public to know . Well, first of all, its an amazing orgap. Its absolutely incredible. And if you take care of yourself and take care of it, dont smoke, exercise, and keep your weight under control, its going serve you for a very long time. And whats happened over the years with heart transplants. Heart transplants have really come very safe. And great longterm results with those. The problem with availability hasnt changed. Theres probably 30,000 people in the country right now who are a year who are eligible for heart transplant and only a fraction of that get them. Is there a time when its a complete artificial heart that someone can live with . Well, i dont know. Its been the holy grail. Weve been searching for that for a long time, for more than 50 years. Were getting closer and closer. I think probably were going have better results and more people with a partial assisting heart than a total artificial heart. Last question how do you walk the line with the politicians, the left and the right . Im not a politician. And, you know, i im not into running into running into the political arenas. What im trying to do is to look after a group of people, the Cleveland Clinics takes care of. Pro provide them great Quality Health care, the best i possibly can. And make the organization fiscally sound so that they can produce those sort of results. Dr. Toby cosgrove, ceo of the Cleveland Clinic, thank you very much. Q a programs are available as cspan podcasts. Coming up next, washington journal. 10 00 eastern, live coverage of the house as members proceed with todays legislative dismiss. Business. Coming up next, your calls and the days latest headlines. Then we will discuss the likelihood a Government Shutdown with the Brookings Institution thomas mann and American Enterprise institutes norman ornstein. Galewitzt, phil talking about Health Insurance exchanges. Then a discussion with peter couric about the debt ceiling limit. He will talk about how the issue has been handled in the past and what the potential consequences might be for not raising the limit. Host good morning. It is monday, september 30 two yet today marks the last day of the federal governments go year. The government does not have a spending plan in place to fund itself tomorrow. If it stays that way the government will undergo its first shutdown in nearly 23 years beginning at midnight. Took placeiations yesterday, plenty of pointer finger and was go finger pointing was going on. Our phone lines are open to