burning fossil fuels traps heat. we know -- they call them greenhouse gases for a reason. they didn't make up the term greenhouse gases because the gases don't act like a greenhouse, they do. and if there were no greenhouse gases in the atmosphere, the planet would be 60 degrees fahrenheit colder, and there would be no civilization as we know it. i'd just like to make a point. i've learned a great deal at this hearing. i'm not an expert on short-term forest management. i'm kind of an expert on the medium and long term. this notion, there's no question that trees compete for water, and there's no question that drought is a big problem for trees, and it also exacerbates the bark beetle problem because trees kill bark beetle by releasing sap. but i've now heard this theory that the solution to the drought problem is that we thin forests so that trees don't compete so much. the problem is, we're on a track

where your districts are going to see levels of soil moisture in the coming decades that are worse than the dust bowl which was a -3 on the severity experts, which means another congressman in your district in 20 years will come and say we've got to thin some more. and 20 years after that we'll thin til there's nothing left. the thinning to deal with drought is not a sustainable solution, it's the end of all trees in all of your districts, and as someone who has skied and lived and hiked in your district, i must say i love your district -- >> mr. rome, i thank you. and in the same way we knew that utility infielders and substitute outfielders who went from 13 home runs to 50 home runs, somehow we knew something must be wrong and the extra weight lifting they were doing wasn't making them mickey mantle and willie mays. i think most people know that there's something wrong and we're contributing to it, and as soon as we admit it, i think --

and i mean the beef industry and every other industry, i think we'll get to the heart of the solutions we have to put in place. thank you, mr. chairman. >> thank you. let me just ask one question, and i hope i think this'll be the end of it. you have planes to catch, we've got -- bobby richardson was probably the best second baseman in the history of the world. i loved him. [laughter] casey tech el once said he doesn't smoke, he doesn't drink, and he still can't hit.250. >> although he was roommates with mickey mantle -- >> it was the perfect -- that was billy martin. no, i'm sorry, that was roger here is. it was the perfect nonshe question to have that not smoking, not carousing can help you live longer, but it doesn't help you hit a curveball. so i appreciate that. unless there are other questions from any members, i want to thank our witnesses for being

here. there may be additional questions from members that will be sent to you. if you do, i would ask you to respond in a very timely manner with that. i thank you. i hope you make your flights. i appreciate your chance to visit with us. i do appreciate all the testimony that was given here today. thank you very much. and this committee will stand adjourned. [inaudible conversations] >> this weekend on booktv from new york city the harlem book fair. live coverage starts today at 12:30 eastern with a panel discussion on the future of african-american publishing. that's followed at 2 with a look at public education. at 3:30, cornel west sits in on a panel examining the next election. and sunday at 2 p.m. eastern the eagle forum collegiate leadership summit with authors. the harlem book fair and the

eagle forum collegians leadership summit this weekend on c-span2. >> cleveland clinic's president and ceo discussed upcoming changes in health care policy at the national press club. he said the health care law makes great strides in providing access but does not do enough to control costs. he also noted that the law does not have enough incentives to encourage people to take care of themselves. from washington, d.c., this is an hour. [applause] >> today's speaker heads up one of america's most respected medical institutions, ohio's cleveland clinic. as ceo, dr. toby cosgrove presides over a $6 billion health care system comprised of the cleveland clinic, eight community hospitals, 18 family and ambulatory surgery centers, a hospital in florida, a center for brain health in nevada, a wellness and executive health

center in toronto and a hospital currently under construction in abu dhabi. his leadership has emphasized patient care and patient experience including the reorganization of clinical service into patient-centered organ and disease-based institutes. he has launched major wellness initiatives for patients, employees and communities. under his leadership, the cleveland clinic has consistently been named among america's 99 most ethical companies. dr. cosgrove is a graduate of the university of virginia school of medicine and completed clinical training at massachusetts general hospital, boston's children's hospital and brook general hospital in london. he was a surgeon in the u.s. air force and served in vietnam as the chief of u.s. air force casualty staging flight. he was awarded the bronze star and the republic of vietnam

commendation medal. he joined the cleveland clinic in 1975 and was named chairman of the department of thoracic and cardiovascular surgery in 1989. under his leadership the clinic's heart program was ranked number one in america by "u.s. news & world report" for ten years in a row. he has performed more than 22,000 operations and earned an international reputation for expertise in all areas of cardiac surgery, especially valve repair. he has 30 patents for developing medical and clinical products used during surgical environments. his visionary thinking, medical and business expertise and dedication have we wered him numerous awards and honors. he is a member of both the cleveland medical hall of him a and the cleveland business hall of fame. he topped inside business power 100 listing for northeast ohio and is highly ranked among modern health care's 100 most powerful physician executives.

among dr. coz bro grove's -- cosgrove's many attributes, he is known for his ability to provide high quality care while holding costs down. health care reform might sty l medical innovation. we look forward to hearing his views on these and other issues reflected in the supreme court's ruling on the affordable health care act. ladies and gentlemen, please, join me in welcoming to the national press club dr. cosgrove. [applause] >> well, thank you very much. that's the nicest introduction i've had today. [laughter] well, i'd like to share with you some of the experience and some of the things that are going on around the cleveland clinic and how it reacts to the affordable care act. first of all, let me tell you a little bit about our organization. we're a very innovative organization. we're 91 years old. we're a not-for-profit.

we have a tripartheid mission of research, education and clinical care. we're physician-led, and all of us are salaried and employed by the institution. there are no financial incentives to do more or to do less which is an important aspect of where we are. we all have one-year contracts, and there's no tenure. and each year we have an annual professional review which is part of maintaining the quality of our organization. now, it's interesting to look at health care and see exactly where we came from and what -- how we are organized. the design that we currently have dates back to 1950, and much of it relates to the hill burton act which encouraged commitments across the united states to develop hospitals and be responsible for the care of that community. since that time, health care has improved, longevity has extended, and with that we've seen diseases change as well as

therapies change. and it's now we're dealing with chronic diseases, six of the seven major causes of death in the united states are chronic diseases. so it's no longer possible to have all the technology in one hospital, and no hospital can be all things to all people. so what is the crisis that we're currently dealing with that we've heard so much about in the united states, and what did the affordable care act and how did it try to address these things? well, there are three main things that we tried to address. the first is access. and you've heard about how the affordable care act put another 32,000 -- 32 million people who currently did not have insurance is currently have insurance, and this is a major step forward. the other problems that were around quality, and quality was variable across the country. and finally, cost, which was escalating. right now with a $16 trillion

obligation that the united states has, 50% of that is related to medicare. and the health care bill will do little to affect that obligation. in fact, we probably will see increasing costs. so how are we as an organization and how is health care as an organization beginning to deal with these issues as we go forward? well, let's take them one at a time, and we'll talk a little bit about how we as an organization begin to deal with these. first of all, access. insurance doesn't necessarily mean that you get to see your physician. one of the individuals in the audience today came to me and said that here in washington it was now difficult to see a physician. and there's a number of steps that you go to to try and get to see a physician. so we have begun to try to address each one of these. the first thing we did was put in place nurse on call. so at 2:00 in the morning when

your child has a temperature of 103, you can get on the telephone and get some good advice from a nurse or get a suggestion about where you might go. laos year we had -- last year we had 20,000 phone calls. this is a free service of the cleveland clinic. the second area we did was frequently when you call up, it's hard to get through on the telephone. so we put together a call center. the call center now has an average of 40 seconds to answer the phone and only a 3% dropped rate on your phone calls. and when you call to make an appointment, each time you're asked would you like to come today. last year we saw one million same-day appointments. the ability to see those appointments we were able to make 95% of those appointments available on a same-day basis. then there's the emergency room.

everybody would complain about the waits there are in the emergency room. we changed our method a year ago on how we see people in the emergency room, and now i the average wait is under 30 minutes from door to seeing a doctor, and all of our emergency rooms across our entire health care system. so we've tried to begin to address, actually, the day-to-day needs of access. the second issue is quality. and i would point out to you that quality is really not one thing, it is three things at health care. first of all, it's a clinical experience, it's a physical experience, and it's an emotional experience. the clinical experience we've begun to address with the electronic medical record. electronic medical record now begins to make your data available to you across the entire organization. you can move from outpatient facility to a community hospital to the main campus with your electronic medical records going with you all the time.

so anytime you see a doctor, that information is available at that point. the other thing we thought was incredibly important is begun to have transparency. and transparency comes in a lot of forms. starting some 30 years ago, we began to look at outcomes and begin to try and understand how you understood what outcomes were. and each time we looked at those, we always found that there was an issue that we could do better in. and so starting eight years ago, we said we'd like each one of our institutes to put together an outcomes book and make it publicly available. these outcomes books are published, and they're available on our web site. and that is part of transparency around our quality and, additionally, we think that the transparency about what's going on in your care should be available to you at any point.

so we open the medical charts, and you can see your chart anytime that you want in the hospital by simply asking for it. so further, you should be able to know about your medical history and your medical record when you're not in the hospital. so we have electronic medical records which can be available to you or the internet, and we had almost 500,000 people who now have access to this. interestingly, we now know that people who use this take better care of themselves. the diabetics know their blood glucose levels, and they take better care. so we encourage people to actively participate in their care along the way. further, we have begun to understand complications within the hospitals. and we've looked specifically and been very transparent not only about the entire organization, but the individual departments and the individual

physicians' outcomes. and we post those publicly for the physicians. now, interestingly, i would tell you there's no more competitive group of people than doctors. and doctors do not like to see themselves on the bottom of a list. and if you want to improve the quality of a physician, all's you have to do is rank them and make it public, and it's amazing how fast things move up. so we've had a lot of good experience that way. the physical part of coming into the hospital is also part of everybody's experience. so we have begun to look at everything as far as the physical experience in the hospital is concerned. from the architecture, from the light coming into the room. we've increased glass across to bring more natural light in. we've begun to bring art into the hospital. the speakers no longer spend all their time paging people, they play in the public spaces classical music as you come in which adds nothing to the cost,

but greatly enhances the atmosphere of the facility. so, and we bring in art therapy, music therapy and even, amazingly, we have dogs walking around our hospital. i laughingly say there's nothing better than a lick from a lab -- [laughter] and the pediatrics, i see that regularly. so we like to have the physical experience be a positive one as well because it helps with healing. the third and perhaps the most important aspect is the emotional aspect of being in the hospital. we're very concerned about this because anybody of the 43,000 people who work for the cleveland clinic can ruin the experience of a patient in the hospital. and i had one of those experiences one time when a relative called me to the room, a relative of my wife's called me to the room and said -- very upset family, and i wanted to know why they were so upset. the heart surgery had gone so

great with. underneath the bed there were dust bunnies. that ruined their entire experience. so we brought all of our 43,000 people together and took them offline for three hours. we sat them around round tables like you have here with doctors, nurses, environmental service people, people that drove buses, people that worked in loading docks, and we talked about the cleveland clinic experience. and that has been a major factor in the changing how these people are engaged. and we no longer address them as staff and doctors. everyone at the cleveland clinic is addressed as a caregiver. and that has changed the atmosphere. and with that we now find ourselves in the top 90th percentile in the country as far as hcap scores and patient satisfaction is concerned, an important factor around people's experience when they go to the hospital.

finally, let me talk about cost. and one of the important things we have to realize about cost is we have perverse incentives. one of the major things about reducing cost is employing physicians. all of the physicians at the cleveland clinic are employed, myself included. and i get a straight salary. so it did not make any difference whether i did three heart operations or four, i got paid exactly the same amount. so there was no incentive to do more. our system really encourages people to do more. essentially, in the trade it's knowing eat what you kill. little strange. [laughter] but nonetheless, the incentives are wrong, and so as we need to begin to move to an incentive that does not incent you to do more, but, in fact, incents you to take care of the patient and

be paid for that. now, the involvement of the doctors, um, has been proven that the salaried doctors, it's been proven that it reduces cost. the dartmouth atlas looked at top organizations around the country, and the two that came out with the lowest medicare costs were mayo clinic and the cleveland clinic, both of which employ physicians. the other thing that physicians do is they bring, employee positions brings them around. we're physician-of led, we involve them in our purchasing decisions and our utilization decisions, all of which helps bring about lower cost. the other aspect of bringing about lower cost is integration of health care systems. we are completely integrated across our organization. and so that has allowed us to do

a couple of of very important things. first of all, we have reduced duplication of services, we have rationalized services, we have rationalized and gone around and consolidated pediatrics, trauma, rehabilitation, heart surgery, obstetrics and gone to places which do a bigger volume. and as a result of doing bigger volumes, they do more. and as a result of that, they get better quality and more efficient. finish and that, certainly, has been proven to be the case in multiple studies across the country. we also recognize now that health care is changing. where it is done is changing. the hospital is becoming less and less the end center of -- the end center of care delivery. care delivery is going from inpatient to outpatient to home care. and we now can see that hip replements and knee replacements are done with

24-hour stays and many people going home the same day as they've had those procedures. it's simply the advance of care, it is also the advance and change in the type of diseases we're dealing with. more chronic diseases, less acute diseases, and the acute diseases and surgical diseases are now more taken careful of as outpatients than inpatients. now, the other perverse incentives is around all of us. there's no incentive for us to take care of ourselves. we smoke, we become obese, we don't exercise, and we go to get health care and expect to get great care. let me just give you a couple of examples. first of all, you have to realize that 40% of the premature deaths in the united states are secondary to three things; smoking, eating and lack of exercise. let's take smoking, for example.

the incidence of smoking in the united states is 20%, and the scary part is it's rising. it is associated with the majority of the cases of cancer in the united states. so we began a very aggressive approach to this. we started out by having no smoking allowed not just in our buildings, but anywhere on our campuses, our parking garages, anywhere property of the cleveland cling. clinic. then we had smoking cessation for all of our employees free. then we decided that we'd make a bold step and stop hiring smokers. we test people -- by the way, it's legal. [laughter] i checked. [laughter] one of the smart things i've done. [laughter] and then we rolled this program out of smoking cessation into the community and helped drive smoking cessation laws in public

places in the state of ohio. in cuyahoga county where we're located, the incidence of smoking has gone from 28% to 15% in five years. so you can make a difference and perhaps we've saved more lives by doing that than one would in a cardiac surgical career. the epidemic of obesity is terrifying. right now one-third of the united states is overweight, one-third so piece. obese. obesity is leading the epidemic of diabetes. right now 10% of the cost of health care in the united states is secondary to obesity, and the projections are in the next ten years that that will go to 20%. so we will not control the cost of health care in the united states unless we control the pandemic of obesity.

so again, we figured that we needed to begin to address this. so we started out with food. we took the trans fats out of all the food we serve in the hospital. we made 40 changes in the cafeteriases of the food that we served. we took the candy bars out of vending machines, the sugar drinks out of the vending machines, and then we turned to exercise. we gave our employees free curves, free weight watchers, free yoga, free access to our gyms, and over the last two years we've lost 330,000 pounds. [laughter] it's a start. [laughter] but, so these, i think, represent an effort that you can also take out into the country, and we need to begin to address these. let me just for a moment tell you a story.

and i think you will understand the reason for this story. two-and-a-half years ago a 25-year-old opera singer was flown into the cleveland clinic in the dead of the night from here as she was end stage lung disease and had she not had a lung transplant, she clearly would have died. she received a lung transplant, double lung transplant, was extremely sick, kept in a medically-induced coma for four weeks, eventually recovered, left the hospital, came back to sing opera three months later for the team that had looked after her. that summer she married the man who had stood by her through this entire event. and then he began to get short

of breath again. she came back to the cleveland clinic after extensive medical therapy and could not be sustained or improved on that therapy. she was placed on an artificial lung for three weeks waiting for a second set of lungs. she received those second set of lungs and is now living in washington and singing opera again. i'd like to have you meet charity tillman dick who's with us today. [applause] charity, i think, is here with her grandmother. her grandmother is tom lantos'

wife. tom was a congressman, and last time she was here he spoke before this group. he was a congressman from california for 27 years. mrs. lantos, would you stand up? [applause] i introduce this to you because i think this is an example of american medicine at its very best. and we need to address the three issues that i talked about; access, quality and cost if we're going to be able to continue to drive this sort of quality medicine in the united states and provide quality care so people like charity can return and sing opera for us and contribute to our society. thank you very much for the privilege of talking to you today and sharing some of our

experiences. [applause] >> thank you. how has the cleveland clinic managed to reduce costs without sacrificing the outstanding care for which the clinic has long been known for? >> yeah. i think one of the main things we've done is we've involved the physicians in our decision making. and the physicians understand about the things that they can do. for example, they came together around pacemakers, hips, knee replacements, purchasing, and we reduced our purchasing by about $125 million in the last two years. >> what can be done about the decreasing number of doctors, and who will take care of our growing population? >> um, the number of doctors, actually, is not decreasing. the problem is that we have never produced enough physicians

in the united states to look after the demands. we've been a net importer of physicians forever. we're going to have a shortage of about 90,000. doctors across the united states, and we're similarly going to have a shortage of nurses bordering on a million nurses. and so we're going to have to find other people to be the caregivers. physicians assistants are becoming increasingly used. that allows everybody to practice at the top of their licensure, and technicians are coming in to replace much of the work that nurses have previously done. no need to have a nursing degree in order to take a blood pressure or record a temperature. >> do pharmaceutical companies reward physicians who prescribe their medicines? if so, how? >> well, i think all of us have seen many stories about pharmaceutical companies and device companies encouraging

physicians to do that. i think that is being less and less a issue in the health care world. there used to be a lot of entertainment that went that way. that is almost completely gone to the best of my knowledge. >> is the cleveland clinic more or less likely to hire employees as a result of the affordable care act? >> whoa. [laughter] i don't think we know yet how the affordable care act is going to effect us. we haven't seen yet the implications in terms of the number of patients that we're going to see or, um, the -- and figure out how we're going to take care of them. clearly, any health care organization the major cost is people. it's about 60% of the cost of running the cleveland clinic right now. and, obviously, we like to do that in the most efficient way that we can, and we'll have to

wait to see what the demands require. >> tens of thousands of patients die each year from infections contracted in hospitals and doctors' offices. how can we reduce that staggering toll? >> yeah, that's a great question, and, you know, that is one of those things that has been brought to the attention. we've seen probably a 50% reduction in the incidence of central lininfections across the country simply by bunding and using standard procedures. and i think that we're increasingly looking at the same thing that pilots look at, checklists. i think it's particularly effective in bringing checklists to medicine. interestingly now, part of the other major issue in cost is end of life, and we think that there is a lot that we can do to both make that a more civil and kind experience and at the same time let people pass in a less costly

way. and so we're looking at a check list and the cleveland clinic are now doing a research project trying to develop those sort of end-of-life checklists that will remind people about where you are in the process, have you talked to the family about it. and i might just say parenthetically here, if you don't mind, i think this is an important topic. and i would encourage you all to think about this yourselves, and i know many of you have had this experience. both physicians and family and patients are stressed at the end of life. the worst thing that can happen is not to have the discussion about the difficulty that this represents for those people. i found in my surgical career that if i would enter into the discussion with a family and say

i will do everything possible to keep your loved one alive if they can, i think they can return to a useful member of society. at the end of that time, if i think that we've come to the point where i don't think that's going to happen, i will come to you, and we will have a discussion about this, and i will not make life go on just endlessly for keeping your loved one alive. i've always been greeted by thank you so much, doctor, i'm really pleased, and i look forward to those discussions, and i'm greatly relieved that you had that discussion with me. it takes -- and if you will enter into those as individuals, laymen, and have that discussion with your physicians, it will be good for the patient, it will be good for you, and it will be good for the doctor. >> are there growing risks from antibiotic-resistant bacteria, and how serious are those risks, and what needs to be done in describing antibiotic development process? >> i'm clearly in over my head

here now. somebody has just cut themselves. clearly, antibiotic therapy is something that increasingly people are concerned about getting resistant strains. we've seen this in tuberculosis and in staph infections that we have selected out by our use of antibiotics. i think it's important that antibiotics be used judiciously and that the pharmaceutical companies be encouraged and supported as they develop increasing antibiotics to take care of those currently-resistant strains. >> how can health insurance companies reduce their costs so that they can devote more of their income to providing needed health services to their clientele? >> i'm going to plead total ignorance on that. i'm not in the insurance business. >> prostate cancer is often in the news these days with differing medical opinions as to watchful waiting versus

immediate treatment, psa testses and surgery. what is your take on this? >> yeah, it's interesting. now we're beginning to understand the differences there are in prostate cancer, and that has been done out of a study that is now almost ten years old done at the cleveland clinic looking at the genetics of the prostate cancer. we realize that some are very aggressive and some are not aggressive at all. and by differentiating between those, we can begin to decide what is the most appropriate type of therapy. >> when omega 3 fatty acids were discovered to include heart and blood vessel ailments, some pharmaceutical companies were concerned this would reduce sales of their drugs. has this happened, and how do these fatty fish acids help improve heart health? >> i'm sure that you're aware that we've seen about a 30% decrease in the incidence of cardiac death in the united states in the last 25 years.

and i think in this has been the result of several things. t not just coronary stents and coronary bipass surgery. it's about the fact that there's better awareness of taking care of yourself, more increasing use of fish oils, etc., and better diet and exercise. and i don't know that any of these drugs have been substantially decreased in their use. >> what do you think of steps such as mayor bloomberg proposed to cap items being sold? [laughter] >> well, first of all, i think you have to salute mayor bloomberg for encouraging wellness across new york city. he was one of the first people to begin to take trans fats out of the food, he raised our awareness on many issues. whether this is the solution to

the obesity problem with the size of your drinks and the size of your cup i -- remains to be seen. i'm not particularly optimistic about it. >> with you said that you no longer hire smokers. do you hire folks at the clinic that are obese? [laughter] >> um, the americans with disability act protects -- [laughter] protects people from discriminating against people who are obese, and under advisement we do not discriminate against people who are obese. [laughter] >> if a patient who received care at the cleveland clinic later sees a doctor who is not affiliate with the the clinic, under your system of record access, will the doctor have access to those records? >> yeah. we like to provide access to the records but without being involved in the electronic medical record, it's not possible to send the electronic medical record. but if we can give their electronic medical record to patient and the patient can take

it to his referring doctor. so if you get treated at the cleveland clinic and you get sick in los angeles, you have access to your records, and you can take it with you. >> how serious an issue is noncompliance by patients, failing to take the full dosage of prescribed medications? >> this is a very big -- noncompliance is a big issue. and we're trying to figure out how we can begin to address this. we realize that just making a phone call and saying did you take your pill today doesn't do it. and we're actively involved right now in an interesting discussion with time warner cable who can bring into people's television sets a way to communicate back and forth between the doctor. so you can actually say to the patient, would you hold up your bottle of pills, and did you take one of those today? and i think that this is the next step beyond the phone call which started out as a routine office visit, then a phone call

reminder and a group of ways to do this in a skype sort of fashion. and i think this is the next step, hopefully, for the future to begin to drive compliance. >> a news report yesterday indicated that there have been 18,000 cases of whooping cough in the u.s. this year, and the original vaccine is not sufficient. what should be done to prevent or reduce further outbreaks? >> you know, i think the concern about whooping cough is a major concern. it's mainly driven by the fact of the scare about autism. and that mothers and fathers are not getting their children immunized because of the fear of autism. i think that has been pretty much disproven. i don't think there's much question about that now. but this whooping cough epidemic would not happen had we had the continuation of the immunization, and i think that's the reason for it. >> copd is the third largest

killer of america, second leading cause of disability in the u.s. what is the importance of research into lung disease, and does the clinic plan to increase such research? >> yeah. i think the -- my father died of copd, and he was a smoker. and i don't think i have ever seen someone with chronic obstructive pulmonary disease who, frankly, was not a smoker. and the biggest thing we can do is begin to drive smoking out of the general public. this is a huge public concern, and we're not going to get that improved until we do, take care of the major cause which is really smoking. >> how can health care institutions better work together to share or codevelop more effective and/or innovate i processes, technologies or clinical capabilities? >> i'm starting to feel like dr. oz here. [laughter]

um, about collaboration. i think -- there's, let me take this to a little higher level, if i could. we're starting to see now a tremendous change in hospitals across the country. the hospitals are coming together in systems, systems are collaborating, we're starting to see systems, talk to systems, and as we begin to head in and just one little fact here, 60% of the hospitals now in the united states are part of the system. and as we have the systems come together, we start to get more standardization of care, more efficiency and more collaboration going on there. >> speaking of dr. oz, being a popular tv figure, what more can the media do to motivate about the public about better health care practices? >> yeah. well, i think there's a tremendous need for medical

education, and in this goes to television, print, everything. and there's going to be a big process of educating people about what the current health care act entails. i think very, very few people recognize exactly what's in that bill and what the implications are both for your personal care and for the health of the nation. so that's going to be a big education process for you all too. but i don't think you can do too much to emphasize the importance of people taking care of themselves in terms of smoking and obesity and stuff. frankly, my major concern is the public generally has not come to grips with the pandemic of obesity. and just to put that in some sort of perspective for you, if you look at the disability, the total disability of employees at the cleveland clinic and you take out people who have cancer, 90% of those on permanent disability are morbidly obese.

that's how big the problem is. >> a number of states have indicated they're unwilling to expand medicaid as part of its affordable health care act. what will this do to the health care systems like the cleveland clinic? >> well, we'll -- if we don't have medicaid patients covered, we're going to have more patients who are not, not paying patients. currently, we're the largest medicaid provider in the state of ohio, and this is going to having just more patients without any reimbursement for us. so, and that will cause the rest of us who buy insurance to have their premiums go up. >> how did your hospital in abu dhabi come about, and are you planning other hospitals in more countries? >> it's an interesting sort of a history. um, 9/11 happened, we were

operating on about 35 patients a month particularly from the middle east. and at that point it went to five in about two weeks. and so my predecessor ceo said why don't we try and meet them halfway, and we'll establish something in london. and we tried to buy a hospital in london, we tried to lease a hospital in london, we looked at greenfields, and in the meantime, people began to realize that perhaps the cleveland clinic was willing to go offshore. we had inquiries of one type or another from 70 countries, and we looked at many of these, and by far the most attractive was abu dhabi. and i think it's important that we point out to you that our arrangement in abu abu dhabi ist such that instead of spending money in northeast ohio we are investing it in abu dhabi. that's not the case.

in abu dhabi they are building the -- the government is building the hospital, they're paying our salaries, and they're paying us a management and consulting fee. now, and so, essentially, we're using our intellectual capital there to drive your petrol dollars back to northeast ohio. [laughter] now, in the bigger scheme of things if you look at what the world wants from the united states right now, they're not particularly interest inside our steel or our refrigerators, in many cases our cars, but they do want our entertainment, our innovation. they do want our graduate education, and they do want our health care. and our facility is the first facility from the united states that's taken the challenge of going entirely overseas and staffing the hospital, bringing the design to the hospital, bringing the protocols to the hospital and taking responsibilities for doing it. and it's a great opportunity to begin to help design a health

care delivery system for a country. >> given the success of the cleveland clinic and it being replicated in other countries, why aren't there more hospitals like yours here in the united states? >> the cleveland clinic was started as a system that was looked at as very innovative and radical at the time that it was founded. with employed physicians. in fact, they were looked at as medical bolsheviks at the time that that was started. [laughter] and then that has not been the tradition. it is very difficult to change from the system that currently exists in most places to what we are, and, um, because most physicians are very entrepreneurial. now, what's happening right now across the united states is changing that enormously. right now 60% of the doctors in the united states are employed, and 75% of the medical graduates now are going to be employed

instead of being self-employed. so you're seeing hospitals come together in the systems, hospitals employing physicians. essentially, that is looking increasingly like the cleveland clinic over a period of time. and i think that you're beginning to see that change happening. it will not happen fast, but it is important, i think, for the long term affordability that it does happen. >> you talked about your staff being on salary. how serious are the other side of concerns that physicians cannot afford to practice or don't find the pay compelling? has that been a problem that you have had in your profession? >> no. i think it's worthwhile talking a little bit about how we pay and how we set salaries. um, we look at what the average salary of academic medical center is across the united states, and we try and play for a department in the average of

the 90th percentile of that. and that means -- and pediatricians don't get paid the same as neurosurgeons do, but we pay according to the specialty, the expertise that the individual has within his specialty and what the national standard for that specialty is. >> to what extent do medical malpractice lawsuits and premiums weigh on places like the cleveland clinic, and is this situation getting better or worse? >> well, tort reform has been something that was clearly not part of the affordable care act, and i think it's important thing that we are going to have to eventually deal with. in this ohio we have had -- in ohio we have had tort reform, and it has decreased our costs of malpractice very significantly. we think that there is estimated that about 4% of the health care

costs in the united states here are attributable to malpractice and people trying to avoid it. >> what are the costs and benefits of medical tourism where americans go to other nations for major procedures that are very costly in the u.s.? >> it's interesting that there's been a great deal made out of people leaving the united states to get care outside of the united states. and the data, essentially, looks at medical tourism principally to places like india and singapore, and they always give the data above the numbers that go there -- about the numbers that go there. now, the vast, vast, vast majority of those are from southeast asia and the middle east and not from the united states. so it is a trickle of people who leave the united states for health care outside. i think it has almost negligible nick influence on health care in the united states.

>> do the people who utilize your 24-hour call service have to have insurance? >> no. [laughter] >> aren't there other factors beyond smoking and obesity that cause ill health like chemicals, air and water quality, and what are you doing about these? [laughter] >> you guys are mean. there's no question that there are multiple other things that affect health care, but those are the, those are the three really big ones. the thing that concerns me, quite frankly, is the epidemic of autism. autism, frankly, was something that was not seen when most of us were kids. and now it's 1 in 88 live births. the implications for that both for society and for the economics are stunning.

at the other end of life, the other thing that concerns us is alzheimer's disease. if you get to be 80 years old, your chances of having alzheimer's is 25%. the economics of that -- and it's now risen into the top, one of the top seven causes of death in the united states -- the implications of those two things at the beginning and the end of life are stunning. and until we begin to identify whether the it's an environmental factor or just other factors and begin to deal with those, it is going to put a huge burden on the cost of health care both in the united states and around the world. >> what recommendations do you have to get schools to change their lunch menus and vending machines away from junk food drinks to healthier offerings? >> yeah. we're very fortunate at the cleveland clinic to have mike rosen as our chief wellness officer, and he has reached out

into the schools of cleveland, and we've begun to actively help them improve the quality of their lunch meals that they serve. and this has been a big effort that's gone on a long time. the other, the corollary of that is the epidemic of childhood obesity which is directly related to school grades. and we have done a great deal of research on that particular topic as well. so the food issue in schools is acute. we're trying to deal with it locally. i think this is going to have to be something that's going to be taken up on a national issue probably right here in washington. there are 30 some agencies, by the way, here in washington that regulate food in one way or another at this point. [laughter] >> how will the affordable care act effect medical innovation? >> i'm a little concerned about the beginning to look at the

efficacy of a drug or a device when it's in practice to decide whether you're going to pay for it or not. let me give you an example. if you develop a heart valve, it takes you about ten years of work with animals and through the regulatory process to get that approved by the fda to be sold. if you're going to tell whether one heart valve is better than another heart valve, it's going to take you another ten years to be able to understand that. i don't think there are very many venture capitalists who are willing to invest in a 20-year project. so i'm concerned, frankly, that beginning to fundt( things on tt basis will begin to drive a lot of the innovation out of health care in the united states. and you have to realize that health care and products that are developed here are sold all over the world and one of the

major exports from the united states whether it be pharmaceuticals or devices or other things used in health care. and that may well slow because right now we know quite clearly that the regulatory process is a lot faster outside the united states than it is inside the united states. and i think we also have to remember sort of on a bigger scale that you can't do anything new without attendant risk. and if a society becomes so risk-averse, we are not going to see innovation that has driven health care to the point which has doubled the life expectancy in the united states in the last 900 years. 100 years. >> republicans in congress have talked about a need to repeal and replace obama's health care law. are there any aspects you would repeal, and what would you replace them with? [laughter] >> let me, let me defer just a little bit on that. [laughter]

i think more importantly we have to say that we're -- the law does a couple things very well and some things that it doesn't do quite so well. first of all, we know that it's not going to control cost, and so we're going to have to do that, and it's probably going to be led bethe private sector. by the private sector. and the second thing -- and one of the things about controlling cost is there's not a lot in this law about providing incentives to take care of yourself. and i would like to see more incentive for people to do that. and interestingly, just recently we helped senator wyden and senator portman introduce a bill in the united states senate that would set up criterion for people under medicare to begin to have financial incentives for meeting various milestones. keeping their weight under control, blood pressure, etc. and we've found that very small

incentives, financial incentives, drive significant behavior. and by that i mean we found, for example, we had 3,000 diabetics at the cleveland clinic. only 15% of those were seeing a doctor regularly. finish and we were shock -- and we were shocked when we found that. so what we did was we put a series of incentives in place. now 50% of people with chronic disease are in chronic disease management with the wellness that i talked to you about before, with those financial incentives we've now seen our cost curve flatten, so we are no longer seeing inflation in our costs of looking after our patients. >> which other health care facilities do you consider to be innovative? have any other clinics had ideas you find impress i have? -- impressive? >> innovation can happen in the i place, and we see it happening across all sorts of places. i don't think that you can look

at health care and expect it to come from one organization. i think there are great things happening on multiple locations. i think the important thing is to go and try and find those and ip corporate them boldly into your organization. a number of years ago i told everyone of the doctor employees of the cleeveland clinic that -- clearland clinic that i would ask them to take one trip a year, i didn't care where in the world they went. so i thought we were turning loose a couple thousand spies to go out and find really good things. so i think there are lots of places, and we have to look for new ideas wherever we can find them. >> with what is the impact of providing more home-based medical care for elders? >> yeah. the thing that is driving home care is the fact that the diseases have changed. people now have chronic diseases that are not going to be looked

after in the hospital. the implications are, first of all, we have to build the system to do that and, secondly, it's going to reduce the cost of looking after patients, and they're going to be better cared for at home. and i don't think anybody would rather be in the hospital than be at home, and that's the direction we're trying to move. >> we're almost out of time, but before asking the last question, we have a couple of housekeeping matters to take care of. first of all, i'd like to remind you of our upcoming speakers. on july 24th, judy woodruff will discuss the complex issues in play in the runup to the november 6th general election. on august 28th, general james amos, commandant of the u.s. marine corps, will discuss the role of marines, and on september 6th kathleen turner, iconic film and can stage turner and chair of planned parenthood's board of advocates will discuss reproductive rights and the state of women eat

health, and on october 2nd, secretary arne duncan will be here. second, i would like to present our guest with the traditional annual press club mug to be used, of course, for low-cal', healthy beverages. [laughter] and the last question. traditionally, hospital food has been regarded as being pretty terrible, bland and uninspired. do you sample a patient's food, and any advice for other hospital systems? [laughter] >> i sampled patient's food every day at lunch. [laughter] and thank you very much for the opportunity to be here. and my mug. [applause] >> thank you for coming today. i'd also like to thank the national press club staff including it journalism institute and broadcast center for organizing today's event. finally, here's a reminder that you can find more information about the national press club on our web site. also, if you'd like to