I did 22,000 procedures, mostly cardiac surgery. I started out doing a lot of bypass operations and why did you leave cardiology surgery and go to the administrative side . You have to use your hands and stand there all day long. I have seen a lot of surgeons come to the end of their careers and not stop when their athletic abilities deteriorated. I wanted to stop before that happened. Toid not think i was ready hang it up completely. I did not know exactly what i was going to do. I had looked at some opportunities. I thought maybe i would go to the Cleveland Clinic. , the ceo announced his retirement and asked me to throw my hat into the ring. Thing to could do one improve the situation, what would it be . I think the best thing i did was focus on the Cleveland Clinic. My opening speech, i said were going to put patients first. I handed out buttons that said patients first. That is the thing that really unites us all, whether you are an educator or a Research Scientist or administrator or you work on the loading dock. I think thats probably the most important thing that happens. We will get back to some of your past. The Cleveland Clinic has been mentioned many times over the past several months because of the new health bill that comes in effect on october the first. I want to show you a little bit of the speech that senator ted cruz of texas made when he did his marathon speech. Lets let you break this down. Some members of this body might say well, these are hard times. Struggling. So maybe the Cleveland Clinic is to economicing challenges. Whos to say what the Cleveland Clinic is doing has anything to do with obamacare . Madam president , the answer to that is him whos to say . A spokeswoman for the cleveland prepare for to health care reform, Cleveland Clinic is transforming the way health care is delivered to patients. She added that millions would be cut from the annual budget. You want to talk about direct obamacare, goom to cleveland, ohio. Go to those working at the Cleveland Clinic. Go to those depending on the Cleveland Clinic for health care. That is one very real manifestation of the train wreck that is obama care. What do you think . You have to understand what is going on in health care across the country. We have gotten ourselves in a situation where we knew we have to change health care. Health care is becoming so expensive in the United States. It is starting to eat into things like education and other social programs that we want to have and need to have. Expensive than any other country in the world. To harness that and control it and bring the costs down so that we can remain competitive. We have been at this for a long time. It is a process that started several years ago. And how we begin to make our Health Care Delivery more efficient, for example we have consolidated services in hospitals. We have enclosed one hospital that was two miles from a 2000 bed hospital. Frankly, we consolidated obstetrics, for rehabilitation, for cardiac surgery, for pediatrics. , and for trauma. When we consolidated from five we sawcenters to three, a 20 improvement in mortality rates. So it has been a long process where we are trying to reform this. Whats going on right now is that a lot of the things are coming to a head that we have concentrated on costs in the last couple of years, for example things like purchases. Likeve done things illuminated redundancies. Cannotblocks in so you order redundant labs test and eliminated some 12,000 tests that would be redundant. We have been working on this all along. We know that there are things happening right now that we are going to be paid less by private and public players, Insurance Companies are paying us less, medicare is paying us less. Sequestration had an effect on hospitals, the nih funding decreasing has had an effect on our research, so we had to decrease our costs still further. All of this goes into trying to change how Health Care Comes together. Not one single thing did it we would not one single payer or program, it is a whole series of things we are doing starting back 5, 6, 7 years ago and the changes are so significant in terms of what were going to pay that we have to now be even more stringent. That is what led to people offering people early retirement. Did you expect that after you made this announcement that the obama connection was going to be made which more absolutely not. One of my biggest concerns was for the people that worked at the Cleveland Clinic. We are concerned about driving great Quality Health care and we are looking after our employees, because all of our caregivers are really what the clinic is. We are not buildings, we are people. My concern really was about those people and how we could either make that transition if we had to do it, or to reduce its effect. I thought it would have implications for the local Community Thomas and we reached out in many Different Directions to tell people what we are doing and why it was coming. I had a nine month schedule of meetings that i do every quarter where we televise it to all of our locations. I thought this is the time for me to stand up and explain to the organization whats going on and what were going to do as a result, and i did that. I never thought this was something that was going to become a political football. This was concern about delivering great care and letting those people do it. Will you reduce it to because of cutbacks question mark what we have offered is 3000 people we have offered early retirement. We expect we will get 600800 people to take that. We dont know exactly what the. Ongterm implications are we will have to wait and see. But we are poised if we have to reduce it further to do that in january. How is it that you are not profitable we are a 6. 5 billion organization and we are a Nonprofit Organization like almost every other hospital in the country. Stockholders, no shareholders, no incentives, no bonuses. Backf the residual goes into building the organization and doing the research and paying the employees. I read that there is no tenure at the Cleveland Clinic. What difference does that make is to mark all of us are we have nond financial incentives. I could look at you and say you need a heart operation. It would have no effect whatsoever on my back pocket. Its all about whether i think you need it or not. Tot is a wonderful feeling be able to say to a patient, i think you need something, and not have them worry that you are doing it for your own financial benefit. Salaried, andre we have annual professional reviews. Each year we sit down with each doctor and we go through how usy are doing, and they tell what it can mean for the organization. Its a wonderful way to get that feedback, and its the way almost every business in the country works except health care. , let me add a question however you are 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 everybody can be. X that is correct. The direct onetoone relationship is not there. You are ae, if psychiatrist and we need you to help us with our transplant program, youre not going to bring any money to the Cleveland Clinic, but we dont want you thinking about the fact that you guys are Something Else rather than what the institution needs. We all get paid on the basis of our total contribution to the organization tom 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, mib business. It. Of those things go into dont haveat we tenure i think is a wonderful thing. Tenure frankly allows us to say to people, youre not fitting into the organization. Youre not contributing to the organization and thank you very much for your service and its time to go. When you think back on your career on those 22,000 operations, if you had to pick one or two that youll always remember, what would you pick . You know, this is this is tough thing to say for a surgeon but, the surgeons dont remember the successes. They remember the failures. And youll always learn more from those failures than you did 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. For a d. V. D. Copy of this in one day we lost five children. Terrible to go back the next day and try to do it again. When i was a resident, or talent he rates for accord ex were double digits. Was trying toreer get the mortality and morbidity of cardiac surgery to come down. Now were tally for cardiac surgery is one percent or less. And the complications and the stay in the operating room and the incisions and the quality outcome has gotten better and better over time. When you did you decide to put on your web site how many operations are held in the last year and how many people have died from . Yes, an interesting story because i became about 25 years ago, i became chairman of cardiac surgery. And we always work hand in glove with the cardiologists. Cardiologists see the patient and make the diagnosis and then potentially refer them to cardiac surgery. And i thought it was very important for the cardiologists to be part of the team and understand what the potential for outcomes for from cardiac surgery were. So we had at the end of each year, we had a report where we ask all the cardiologists to come and we all gathered and we stood up and we one after another reported the results of the coronary bypass or aortic valve replacement or mitral valve replacement, Something Like that. Then the cardiologists started to ask us for the results so we put together a little booklet that had all these results and so they could intelligently tell the patient, look, the risk of what im suggesting is this. And then we said, lets distribute it nationally. Because we think that every time you look at those results, youll always find something that you can do better and its a regular, steady improvement looking at all those Little Things that are not as good as they should be. So we put it out there and then when i became ceo, i said, lets do it for everything. Lets do it for cardiac surgery and for dermatology, et cetera now, the issue really was and cardiac surgery is pretty easy to give you the results. You know, people either make it or they not make it. And so you count up the results pretty easily. Its much harder in a lot of the other specialties. Take dermatology, for example, you know, what is quality dermatology . I mean i said to the dermatologist, you cant just tell us youre a great dermatologist. Show me some numbers, give me some metrics. So what i asked them to do is set up the metrics for their specialty. And so we now have 17 or so outcomes books that we publish each year to get more sophisticated and we should talk about the good, the bad and the ugly, but its transparency. 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 it to put your 990 tax form on the web site . Thats part of our transparency. When did that start . I cant tell you. I dont remember actually. I want to show you some video of a former Vice President talking about cardiology, mr. Cheney. I got a phone call one day, and this is just before the transplant, from the Cleveland Clinic. And they were going to put on a conference on innovation and cardiology and care of Heart Disease. And they said, weve got all the suppliers coming, the makers of the devices and so forth. Weve got a lot of the docs coming, but they said, we decided we need a patient. And somebody said, well, lets get cheney. And he said, everything done to him, you can do to a heart patient, which was true. Up to that point, i havent had a transplant yet, but this gave us the idea that you can tell the story of that 40year miracle, really, of what happened with respect to our ability to deal with Heart Disease in this country, through my story, and my case history. Is there any way to connect what went on in his life in all the heart operations he had and heart attacks to obamacare and what will change because of that . I think thats hard i think. Well, first of all, i was there and heard him very eloquently describe and very personally describe what had gone on. At that point, he had a artificial assist in him. And just to put sort of the things in perspective, we know almost 50 years into the development of a artificial heart and left ventricular assist. He lived on the basis of that research for several couple of years waiting for a heart transplant. And, you know, that is the tremendous amount of investment over time and improvement. I hope that were going to be able to continue to do that sort of Research Going forward. Thats an important aspect for all of us. And whether its in heart or whether its in cancer or whatever specialty its in, we need to continue to have those sorts of missions. Now, if you look at Academic Medical Centers across the country, they have a Tripartite Mission as we do. Theyre educating people to they are researching and theyre taking care of patients. So we need to continue to do that and, you know, well have to see how that all works out over time. How much federal money do you get a year . We get about 70 million. What for . For research. Oh, the research money, thats how have you been . Nih money. How have you been hit in this sequester era . We have been flat over the last several years in the amount of nih money that we get for research and we get other moneys from other locations. You said that there are 27,000 pages of regulations that have come out of the obamacare bill . Yes. Has that ever happened in your life . Well, it hasnt happened in medicine. Thats about equivalent to what the irs does. What do they say . 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 System and how are we going to get paid, et cetera. What would you have done if somebody had asked you to write 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 of providing access. Access to what . Access to insurance coverage, so that people, you know, dont wind up just going to emergency room but gets some sort of continuum of care along the way and thats been a process thats ongoing. But we know we had to take the cost out, and theres only really two ways that you can take cost out of healthcare. One is you have to make a more efficient Delivery System and i think were on our 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 that 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 to healthcare. Obesity, for example, now accounts for 10 percent of the healthcare cost in the United States. And we are in the midst of a tsunami of obesity across 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 analyzed those 27,000 pages and you had a Board Meeting and you took this to your board, what did you tell them that the impacts are going to be on the Cleveland Clinic in the future . Well, what we did is we gradually over time have been you know, at each Board Meeting, weve been bringing the board along so they understand it as we understood it. And then we have told them that weve gone through the financial projections for the Cleveland Clinic is a result of all the things that are changing, not just one thing but everything thats changing across healthcare and our financial projections for the future and, you know, we recognize that we had to reduce our expenses substantially going forward. Anybody get their salaries cut . We have not cut salaries and 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. And in fact, we pay competitive rates for doctors, for nurses, for everybody who 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 talk to the Insurance Companies. In fact, i was talking it was the ceo of some of the Insurance Companies last night and i said, you know, its important that we begin to figure out how were going to Work Together better. We have 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 whos had a delivery, they have someone who checks the bill out and then they pay us and we have someone who checks that they paid us the right amount. Wouldnt it be nice if we could just say, lets figure out how much it cost, how much youre going to pay us for a delivery and what the average delivery cost, and, you know, thats what we get paid. And that and well take the checkers out at both ends. Thats taking sand out of the gears. Theres a Television Personality that played a role in or maybe its you played a role in his life, his name is dr. Oz. Here is a clip from that and gets you to explain it. And toby cosgrove, first day, i walked into the door, and said, what are you doing tonight . I said, i dont know, i guess ill go read a book in the library. He said, no, i got tickets to the indians. And he took me, a nobody, just a visitor, to an indians game where he gave me some food and watered me down, but he talked to 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. And, you know, this is many years ago. We have stayed Close Friends since, but it taught me a lot about how you treat people. Someone at his level, because he was a division chief at that time, but ultimately became the head of the whole institution, really is a towering figure in medicine, could take care of someone young and just coming out the way he did, that is a role model that i want to expound and i want to follow and i have done that, i have tried. When did you first learn to use that philosophy of treating people . You know, i think probably the first time i came along with my time in vietnam, i was in i ran a casualty staging flight in vietnam where we had we get, you know, 50 to 100 sick and wounded new troops in everyday. And my job was to go bed to bed to bed to make sure that theyre ready to fly and get on an airplane. And i realized at that point just the plain touching of them made a difference. I didnt have hours to spend with each one of them. But i would touch them, maybe id just shake their hand or touch their toe or 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 those things that i remember vividly. What years were you in vietnam . I went to them right after the tet offensive of 1968, 1969. Whats the impact on your life, vietnam experience . Well, i learned lots of things. First of all, i learned the horrors of war. There is no such thing as a good war. Where were you . I was in da nang. At the time i arrived there, they were fighting on the perimeter and we watched a firefight from the hospital. And then i also learned a lot about the world and people and i learned about medicine in the military. They do some terrific things. They had a Transportation System, for example, that picked helicopter that pick you up in the field, move you to a station where they stop the bleeding and splint your wounds or whatever then move you to a back line hospital where you could get the most sophisticated care, than after they got you patched up, they would send to me and wed 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. So we dont think all hospitals can 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, we have ambulances and we move about 20,000 patients a year to the right location for the right care. And 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 and the more you practice, the better you, and so let people practice. How did you become a doctor in the service and what service was it . Well, i was it was the time of the vietnam war and so we all had to go we all got commissions coming out of medical school and so i went after i had a surgical internship and a surgical residency and i went into the air force and straight to danang. What did you think of the war when youre in the middle of it . You know, its first of all, the war was the human effects of a war are really 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 Halberstam was. Dave and i david and i have subsequently, before he died, he was killed in a car wreck, used to talk about the war quite a lot and its effect on both of us and how we had different perspectives on it, i from the medical side and he from reporting it and others from fighting it. 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 dont think i did. I am not enthusiastic about the United States getting involved in overseas activities. What about the what part of that conversation with David Halberstam he was one of our early guests on this program do you remember and how did you two differ or did you . Well, 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 but very concerned not only about the patients that i was taking care of but the effect it was having on the vietnamese populace. So i ran the clinic for the vietnamese during the time that 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, a d student and all that. Now, at 32, you discovered youre dyslexic. How did you get into the university of virginia . I think that they were very benevolent. I dont know why they took me to be perfectly honest with you but im awfully glad i did and they treated me very well. They gave me great education and i am eternally appreciative. But what does that say though about youve gone on to run the Cleveland Clinic, one of the biggest hospitals in the world . How many patients do you see a year, not you but the clinic . We see multiple millions. And you did 22,000 operations as a cardiologist. Go back to the education part of this, why did those 12 turn you down and well, because i you know, frankly, i went to Williams College and i was not a great student at Williams College. In fact, i frequently tell a story about taking french. I never heard a word of french spoken in my life when i went to college and so i thought, well, i better learn about speak french, the language. Well, i found out that i couldnt do french at all. First day, i walked in and everybody was saying, ouioui and i had to look up and down the page for wewe and i couldnt find it at any place. And it turns out that i had four semesters of remedial french and three dminuses and a d. So i was not a great student. I worked very hard but the amount of reading and languages that i had to do in college really were difficult. So im not surprised that most medical most medical schools didnt take me. Now, i think the interesting thing is going back and looking at this now understanding that i am dyslexic, it i realized that dyslexia was really a gift because i think about things differently. I look at things differently. I and also it taught me tremendous persistence. And if you look at the writings on dyslexia now of a person by the name of Sally Shaywitz at yale, a professor there who is probably the expert on dyslexia, sally would say that she finds that dyslexic people are more creative because they think differently than other people do. Ive seen that thing in myself and in my family. Whats the first thing that tells you, you are a dyslexic and why did it take till youre 32 years old to find out . Well, i never heard the word before until i was that age and people didnt recognize it as a particularly as a defect or learning disability at that point. And 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, you know, i wind up developing a bunch of products and i have a whole bunch of patents that came out of the results of that and i gather that i must think about things differently than other people do and to do that. And, you know, i have got a daughter who is dyslexic and she is the same way. She has now become a Fashion Designer following a difficult academic career from age four all the way through college. But as you i mean if youre reading a book versus doing an operation, is there two different experiences . Oh, yes, painful to read very painful to read. I dont think ive ever read a novel. Its just its how do you read reports . How did you i work at it. Its work. I have to go up and settle down and find a quiet place where theres no distraction and concentrate, take notes write them in the margins, go back and reread it slowly. Its very painful. But getting back to education, you know what the system is. You take the sat test. You have to get good grades and all that. Is there something wrong with that . Well, yes, we you know, we really have to think about living people who have that diagnosis have extra time because theyre not dumb, theyre just slow. And have extra time on timed tests and a lot of reading can be changed into tapes. So theres a lot of a combinations that can be made for people who are dyslexic. And frankly, ive been involved with chuck schwab, for example, who is also dyslexic. He and i have talked to a bunch of the administrator admissions people and colleges about allowing people to have timed tests and letting people who are dyslexic come in because they can be very productive members of society. Go back to the obamacare issue, i want to run this from 2009 with our now president talking about this 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 Healthcare System out there while maintaining some of the highest quality. Now, when i asked, you know, how did you go about doing it . Well, they started this thing when was it started . The Cleveland Clinic . 1921. And they what they have done is, for example, doctors who are part of the Cleveland Clinic, get paid a salary, instead of being paid fee for service. So that makes it easier for them to make some of these changes because people dont feel like maybe they are losing some money out of pocket, they just know that they are getting a salary. Should everybody else do what you have done . Get rid of the tenure, pay the salary not fee for service . Well, i think that, increasingly, were starting to see that happen. Its interesting how this is coming about. Were seeing now a consolidation in healthcare. Were seeing hospitals come together in systems. Were also seeing now doctors want to be salaried. Sixty percent of the doctors in the United States now are salaried. And if you look at the people graduate from the medical school, they would prefer to be salaried rather than going out and being selfemployed. So its a major shift, so people are coming closer and closer to our model of care where you work with the hospital or for the hospital. Thats we have a slight difference. Were a Group Practice that has facilities. There are and the other is a hospital that employs physicians, thats a subtle difference but an important difference for us. How many buildings do you have on the cleveland campus . Oh, gosh. We have 160 acres on the main campus and probably 60, 70 buildings. Again, how many doctors . Three thousand two hundred physicians. And how do you hire them based on what you just talked about not getting in 12 medical schools, how do you approach i mean only the harvard doctors getting in . Oh, no. You know, we look for physicians first of all, let me say that cleveland coming to work in cleveland is a great filter because people arent coming to cleveland or go to the beach or go skiing. Theyre coming to cleveland because theyre interested in working there and thats a great filter. And so people are coming there because they want to work and they want to work in the Service System 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 healthcare and great quality. Theyre probably not going to get paid as much as they can in other places. In fact, you know, just to give you an example of that, when i started out, i was doing about 500 heart operations a year and i was getting paid 50,000 or 60,000. Two years after id been there, i was offered another job to go work and make 1 million. I stayed at the Cleveland Clinic because i would like that environment and the teamwork that went with it. How many doctors were there at the Cleveland Clinic when you started . There are 140 doctors when i came to the Cleveland Clinic. Its grown a little. And what how many of your patients are from ohio . Well, we we draw most of our patients from the sixcounty area around about 80 percent of our patients are coming from the sixcounty area around that and then the rest of them from about a fivestate area around that but then we have people from all over the United States. About less than 1 percent come from overseas. I read that 132 different nations that shipped people to your clinic. How do you deal with that . Who can come . Anybody can come. You know, we look after the largest number of medicaid patients is in the state of ohio, and we take everybody. So the lawyers meanwhile are getting 1,000 an hour in this town. Their rates keep going up. Theyre not on the salary. And you have something called malpractice. How much of that 6 billion a year that you gross goes to malpractice insurance . Our malpractice costs last year were about 50 million. Up . Down . Compared to the past . Actually actually, theyve been coming down and we worked very hard to bringing them down. Weve done several things to bring them down. One of the things we did is we said, look, when weve had a problem and we know weve had a problem with the patient, we go to them and say, you know, we had a problem. And were really sorry about whatever happened but well do everything we can to make it right but we want to be straightforward with you. Second thing we did is we opened up the medical record for everybody. About five years ago, we said, this is not Cleveland Clinics record. This is your record. So you can read it anytime you want. And we sign everybody up for their Electronic Medical record when they come for a visit because we want them engaged. And if you take away the secrecy of whats going on and if you take away the fact that you might be hiding something, it really does begin to decrease the number of lawsuits that you have. Do you have any idea how many doctors youve hired over the years . Me personally . Yes. Gee, i was responsible mostly for hiring the physicians that work in cardiac surgery when i was running it and probably over time i must have hired 30 just on the staff and then they were all the residents and fellows who came to work there and those are in the 100s. We have, for example, about 1,800 residents and fellows in training at any one time. So were a very large education organization. So as a as somebody comes in front of you, what are your whats your own criteria about whether or not you hire somebody . Well, i think you look for a number of things. First of all, i think 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 from emotional intelligence. How often do you look at their grade point average . Almost never. Why . Because by the time they come to us for to be hired, theyve gone from college and medical school and now theyve gone through coming into a residency and i saw so i look there generally the ones that are applying to us are top portion of their class and i dont really care whether 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 this new law that comes in october the 1st, what would you tell people . Well, i have i think that what were doing and this i think you have to understand that this is not all a law. This is about the economics of this country. And, you know, we have a patriotic duty to reduce the cost of healthcare in the United States or at least and also keep the quality first class. So there are going to be a number of things that are going to change. Who whats your insurance, who youre going to get your insurance from, thats going to probably change. Who youre going to see in the medical community, your caregiver is going to change. Youre going to see a lot more people who are physicians assistants because theres a shortage of physicians across the country. Good or bad . I think thats a good thing actually because it allows everybody to practice it at the top of their capabilities. Physicians do physician work and nurses should do nurse work and not have technicians help them. So were going to be a whole new work force that is going to come in to look after the shortage of doctors and nurses. So, the people who are going to look after you are going to be different. The diseases were treating are clearly different. The chronic chronic diseases have gone way up, acute diseases have gone down. So that youre going to see more people treated as outpatients instead of being inpatients. And youve seen that happened already with surgery going to outpatient from inpatient. Youve also seen that people with chronic disease are going to be treated as an outpatient and at home so youre going to have more outpatient visits and thats been going on now for 15 years, and more homecare. As so where are you going to be treated, whos going to treat you in the sort of disease that youre going to be treated for is all going to change. What percentage of the Cleveland Clinics money comes from medicaid or medicare . Well, if you medicare is about 20 about 30 percent of medicare, medicaid is about 15 percent, and then the private payers and then people who dont pay at all. In five years, what will those percentages be . I think people are i think that there is going to be a bigger percentage and probably in 10 years, probably 70 percent will be some sort of government pay, medicare and medicaid of some sort. And thats not just the change in who pays, its also the change in the demographics of the country because more people are going to be in the medicare age group. And what will that impact be on you . Well, i think the impact on us is going to be that its going to depend upon what happens to those payment systems. Right now, for example, in ohio, there is no medicaid. They havent had a medicaid expansion. And thats about for the state of ohio, thats about a 14 billion nut over a period of time. And that we think that that makes sense both from an economic standpoint to get that passed and it also makes sense in terms of a humanitarian standpoint to get that bill passed. I hope that it happens soon. So what about the individual though sitting in this country . If you weve had a lot of promises over the last five years from politicians. A lot of complaining. People are saying its the worst thing thats ever happened is going to bring the country down. And then the other side says, its going to president obama said its going to cut your bill by 2,500 a year. Where do you come down on this . We dont know frankly. No idea. I 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 knew we had to change and were in the process of changing. It is not a perfect bill. Probably never been a perfect bill written. And there are going to be changes that are going to happen over the next five to 10 years to that bill to modify it. And so i dont think we can tell you at this point what its going to mean. Weve got 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 the diseases like Heart Disease and cancer . Are we going to find new ways of treating people that and so to tell you that i know the answer to this, i dont know the answer to this. I do know theres a major change. I know theres going to be adjustments. I know there is going to be new ways that were going to treat people and care for people. But all the time i think the quality is going to go up in healthcare in the United States. Ultimately, well deliver great care like it does now. Why is the healthcare in this country so much more expensive than it is overseas . One of the reasons is that we have put our emphasis in a 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. And we in fact, in the last 20 years, weve driven down the deaths from Heart Disease by 20 percent across the United States. Made a big difference. So we put out emphasis there in the high tech. A lot of other places have put their emphasis in other places, primary care, for example. A great example of that is what happened in china after the second world war. The Life Expectancy was in the high20s at the end of the war primarily from Infectious Disease and starvation. And just by Public Health measures, they doubled it. And now, on the other hand, if you look in russia, you see the Life Expectancy of males going down because of alcoholism and suicides, et cetera. So, you know, its theres a lot of difference in where people put the emphasis and where they put their money. We have not had a national system. Its been, you know, entrepreneurs in various locations, every hospital is built as a standalone. Doctors were independent. There was not a national Healthcare System across the country much different from where i practiced in london, for example. Which country in the world besides the United States in your opinion has the best medical system . Thats a tough one. I think every one of them had something that you admire. Germany has been very effective in some of the things that they have done and combining private and government pay. They have done a terrific job in putting emphasis on primary care in england. So, you know, i think you try to look at the best you can find in various countries. Why is the Cleveland Clinic building an abu dhabi hospital . Im glad you asked. Its an interesting story and its the story that was sort of goes back to 9 11. And in 9 11, we were seeing about 35 patients a month particularly from the middle east, and for heart surgery, just heart surgery, and it went to five in two weeks. And that started us on opportunity to be on the look and could we do something that would meet these patients other places. Wed operated on the king of saudi arabia in a couple occasions and a lot of members of the royal families and it had been good for the Cleveland Clinic economically. And as we began to look, there were about 60 or 70 countries approached us about coming and doing a facility in their country and we said, there have to be five criteria to pick it out. These are sort of really 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 a financial return to the Cleveland Clinic; and fourth, i thought we had to deliver value and that really is going to require a longterm relationship. That was going to require that we were there to transfer our culture to them and thats really what they wanted. And abu dhabi fit all those criteria. How many beds . Were running a 750bed hospital there right now and were building the Cleveland Clinic abu dhabi which ultimately will have 500 beds. Earlier you mentioned patents. How many have you received over the years . Thirty. And give us an example of what some of them are . Well, i developed a ring for repairing mitral valves that holds the annulus in place and you put it in when you do that. What year . It must have been almost 20 years ago. How did you invent that . Well, i knew that at the time, one of the problems that happens with the mitral valve is it got two little leaflets that come together like this and where is the mitral valve . Its in the middle of the heart and the left side of the heart. And these two valve leaflets come together like this and theyre held again in a ring. And with some people, the ring dilates and so the leaflets dont bump against each other. They dont come together and so the blood leaks backwards. So people who were using a ring that was rigid at that time and i knew that the heart was not a rigid structure. It went like this, contracted. And so i thought, gee, you know, what we really want to do is develop a ring that we put in that flexes with the heart which will be more physiologic. And so i tried a number of things but, you know, i put a stitch through the heart and then i put it through some flexible piece and id tie it down and itd depend if i had a big breakfast in the morning or not how tightly i tied the knot. And so i there was no sort of measured way to reduce the circumference of the ring that around the valve. And so i remember back if you ever seen an embroidery hoop, you know, its a hoop that holds a piece of cloth tight and you put the stitches through and you pull them tight then you take it off and youve got an embroidery handkerchief or Something Like that. I said thats what were going to do. So we made a little frame that held the piece of cloth tight and put the stitches through, tied the stitches down and put the frame off and you had a flexible piece with a measured reduction. So that was some of the thinking that went into it. Does everybody use that now . Its probably one of the most used in the world. When you were operating, what was your day like, what time did you start . Well, we went into the operating room start at 8 00 and i would get there at 7 00 and i generally get home after 7 00. How many would you do a day . Ive done as few as two and as many as six or seven. What would you advise patients that are have a heart problem . What do you 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 . Well, everybody worries about that i think but and the second thing they worry about is strokes. And so we talk very candidly about you know, and weve looked at whos at risk to this, of a stroke, whos at risk of dying, we can tell them and project what their risks are and we tell them in a verymatter offact 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 and so you look, 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 it used to be that everybody used to be terribly anxious. They thought, geez, im the only ones that this is going to happen to. And so then youd take 10 or 15 people in and put him in a class and say, ok, here is whats going to happen to you over the next day. So they thought, well, you know, its like group therapy. Theyre all marching through this together and its a very calming effect on people. You were born on 1940. Yes. It makes you about 73. Yes. How long are you going to do this . Well, im going to be there for a couple more years anyhow and or until such time as if something happens to me or the board of trustees says its time for me to move on or if i get tired of it. Youre talking 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 in upstate new york. I dont remember anybody weighing 300 pounds. And you know, and, you know, 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 does now. What caused it . Its multiple factorial. I think you only have to look at the how plentiful food is now and also how people have begun to look at. I mean just look at we used to drink coke out of a bottle, a little bottle, now you get it out of half gallon jugs. Its changed. The food has become cheaper. Its more plentiful and people dont walk or exercise as much as they used to. What do you know about the heart after all these operations other than i mean i know as a doctor you know a lot about it, but what do you know about the heart that you want the public to know . Well, first of all, its an amazing organ. Its absolutely incredible. And if you take care of yourself and take care of it, dont smoke, and exercise and keep your weight under control, its going to serve you for a very long time. And whats happened over the years with heart transplants . Well, heart transplants have really become very safe and great longterm results with those. The problem of availability hasnt changed. There is 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. Will there ever be a time when theres a complete artificial heart that somebody can live with . Well, i dont know. I mean thats been the holy grail. Weve been searching that for that for a long time, more than 50 years. Yet, were getting closer and closer. I think probably were going to have better results and more people with a partial assisting heart then the 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, im not into running in a political arenas. What im trying to do is to look after a group of people the Cleveland Clinics takes care of, provide them great Quality Healthcare, the best there possibly can and make the organization fiscally sound and show that they can produce those sort of results. Dr. Toby cosgrove, ceo of the Cleveland Clinic, thank you very much. Its been my pleasure. For free transcripts or to give us your comments about this program, visit us at q a. Org. Q a programs are also available as cspan podcast. The 60s were different. [laughter] and there were a lot of things , the breakdown and structure in society. I was suddenly out of the seminary and things were falling apart. Structure, its very, very difficult to navigate. I was extremely fortunate to still have had a residual him of the way i was raised, the structure that the nuns had given me, the structure that the seminary had given me. I had already been in predominantly white schools. I was only the black student in my school in savannah. The transition to a school with , academicallys and otherwise, i was ahead of the game. It allowed me to continue to do well. Thanksgiving on cspan, hear from two Supreme Court justices, Clarence Thomas at 9 p. M. , followed by elena kagan. Also this holiday weekend, four ,ays of the tv on cspan2 including Deborah Solomon on the life and art of norman rockwell. The 150th anniversary of the gettysburg address. At thent lincoln spoke dedication of Soldiers National cemetery at gettysburg at 4 p. M. And 10 p. M. Theoming up tonight, november 1963 speech to congress of president johnson after the assassination of president kennedy. Reaches out to others in the community. Five days after the assassination of president kennedy, Lyndon Johnson addressed a joint session of congress. In his 25minute remarks, he talked about carrying out the works and mission of his predecessor. [applause]