>> rosemary gibson create some men patient protection affordable care act in the recent passage in fiscal protection providers in the government. this is just over an hour. ..

the time of franklin roosevelt america has tried to have universal health insurance coverage in this country. and for decades people have tried but failed. how did it happen this time? what went on behind the scenes? and the deals that were done for the important players in it? the health-care industry? the drug companies? what went on? what made it happen? what were the special ingredients? did america get a good deal? i we going to see costs controlled and health care? we will talk about that today. will health care be safer? will there be less overtreatment? for you and future physicians there are many residents in this room today. what will health care look like for you as future physicians? really important question. finally did we build in health

care reform a sustainable system? we build a house but will it be one that generations will be able to live in? let's get started. helped -- why health care reform? why is so important. you see it every day. the clinic for the uninsured here and you see patients come in with advance health disease and people with cancer that has spread. because they lacked health insurance because it was too expensive and the enormous suffering takes place because people don't have access to health care. this is a photograph of what happens when volunteer physicians and others come together on a weekend to provide health care for the uninsured. this is america's saved the best. and yet another picture. if you are uninsured and can't afford medical care this is

where people drive hundreds of miles to receive needed care. a pair of eyeglasses and a sore tooth if it needs to be pulled or cancer treatments but can't afford the follow-up care this is where you go. this has been health care for millions of people. the decision about what to do about it, this is a picture from washington d.c.. the white house summit in early 2010. democrats and republicans together debating, quarreling over what it should look like. if it should even happen at all. the battle over health care will continue. today health care reform is the law of the land signed by presidents and passed both houses of congress. and the constitutionality of the individual mandate. the battle will continue.

republicans have vowed to repeal it. they vowed to prevent it being funded. and many substantive issues that remain to be addressed. we still have a shortage of primary-care physicians. primary care and specialty care remains a special challenge. and nurses to take care of the thirty-two million people. who might have health insurance coverage because of health care reform and then we have the elderly population as the boomers turn on thirty million people will be on medicare in the next 20 or 30 years. additional people. to we have enough doctors and nurses to take care of them. this is a lot to be done and the battle will continue. and this is a look at health care reform. we can cover the whole waterfront in an hour.

51 to build a house, this provides a good foundation. will be around or support people did care for generations to the come so presidents who are here 40 years from now, did we do health care reform right? that is the question. there are four parts to this conversation. did health care diagnose the right problems? you know how important getting an accurate diagnosis is? did we do that as a matter of public policy. what will be covered and what will it cost. we will focus on what does health-care reform mean for u.s. future physicians and those of you who are currently practicing? finally where are we headed from an economic point of view and can we financially sustain the systems we are creating and if we can't what can we do about it and what should we start doing now to fix it? did health care reform diagnose

the problems? the reform law diagnoses the problem as lack of health insurance and it is true. up to fifty million people don't have insurance so the solution that has been prescribed, the treatment orders let's have more in insurance and so sixty million people will have access to private health insurance coverage. many with subsidies. we will talk about that in a minute and sixty million people could have medicaid coverage. one of the reasons so many people cannot afford insurance is they can't afford it. it is too expensive because health-care costs are too high. we will drill down on that for the next few minutes. a study published in the archives of internal medicine earlier this year looked at the cost data for uncomplicated

appendicitis in the state of california. researchers have access to data from all hospitals in the state and median cost of a hospital bill to treat uncomplicated appendicitis was $33,611. that amount is 75% of the annual per-capita income in california which was $44,481 in 2011. what is especially interesting is a range of how much the hospital bills were. at local county hospital only $1,500. at other hospitals it went up to $183,000. from the higher cost hospitals according to the study report profit institutions. how do we sustain this? is it sustainable? i am writing a book on medicare and have the pleasure of interviewing a gentleman from rural kentucky who went into the hospital for one night for procedure he wanted to keep private but he needed an

operating room and chances are he might have had a pacemaker or defibrillator implanted. he got a hospital bill for $240,000 for that one night in the hospital. that is what it costs to buy a house in this community. for some of the houses you can buy a house is cheaper than that. keep $18,000. the call hospital, and said what about insurance? he said we will still make you pay it. i recently did a radio interview in washington d.c. and a woman called in and she said her husband had gone in for a treatment for kidney stones. he had two and they each -- the bill was $52,000 for each one. . this is the reality of how much health care is costing and this is why we have health insurance

premiums that keep spiking. in 2011 a drug company gained exclusive rights to produce a shot use for premature births. you used to be able to buy for $10 an injection. when they gained exclusive rights they increase the price to $1,500 an injection. the total cost of $30,000 for pregnancy. is that sustainable? this happens in the united states because there's nothing to stop it. there's nothing to stop the price increases. in this case the american college of gynecology pushed back. station statement that said the u.s. health-care system cannot be expected to absorb the costs at its current prohibitive price without significant negative repercussions. in this case the company backed down. this is the exception rather than the rule and individual patients and have the power to put pressure to reduce their hospital bills.

so we have this problem of uncontrolled prices in american health care at a time when thirty-two million people will be getting coverage. we have an interesting situation with volume. recent study in the archives of internal medicine. survey of primary-care physicians. 42% of them believe there patients receive too much medical care. 25% believe they themselves provide too much medical care. the good news is 75% of those surveyed said they are interested in learning how their practice compares to other doctors's practice to concur unnecessary medical treatment and as young residents you have the opportunity to do that. you will learn how to do that. and you should. you will be aware of the internal medicine foundation choosing wisely campaign to encourage doctors to provide the

care people need. not the care they don't. a shootout five lists coming gawker 27 specialties within medicine of things we can do less of and have good care for patients. here are the top five internal medicines. you know them from previous presentations but i will run through them quickly. imaging low back pain often overused. waiting for the first board six weeks when there are no red flags. and a symptomatic healthy adults. don't do the annual electrocardiograms. and a systematic low risk patient. and don't do the bone screening for osteoporosis for women under 65. the recommendations coming from the evidence of primary-care physicians. we will talk more about this later what we can do to try to curb the inexorable rise in

health-care spending so we can have health care reform that last generations to come. this is a medical index of annual cost for a family of four for medical care. in 2012, $20,728. has been rising $1,000 a year. you can see that. that is where we are in health care today and nothing to stop that trajectory. meanwhile the median family income in the u.s. in 2011 was $50,000. how in a family of four the average annual spending is $20,000. how do you do that? are there enough federal subsidies. when i was writing the battle, an interview on abc nightly

news. these are reported stories about increases in health-insurance. 20% or 40%. i found a question, the answer quite remarkable. question that was asked by the interviewer, what should people do if they get an increase in their insurance premiums at 20% or 30% or 40% and can't afford it. this was after health-care reform. the most remarkable answer which i was not aware of until it was said so starkly her reply was they should contact the governor of their state and state legislature demanding the laws be changed and she is referring to laws pertaining to health insurance rate review. what that told me was there's nothing in the health care reform law to stop the increase and the cost of private health insurance or medicaid.

nothing. so we defined health-care reform as lack of insurance. is that the real problem. is the problem of portability? are subsidies -- also i was writing the battle over health care. remember the oil spill in the gulf of mexico. and there is no way to stop it. day-by-day by day people watched us around the world. finally the engineers were able to cap it. i couldn't help resist making a comparison with health care. it keeps coming and coming and there's nothing to stop it. just a word about medicare. one part of health-care reform that has brakes on it pertains to medicare. there are some other provisions. adding preventive benefits for

annual mammograms without co-payments, closing be done not hole for prescription drugs. all good things and that is just where we are heading in medicare. from the medicare reports on the financial state of medicare it starts in 1967. this is data for how much the average person over 65 and collecting social security. let's take someone who earned $50,000 a year. the average wage over their working life. they retire and when you retire you pay for medicare. it is not free. you pay premiums and co-payments. you pay for part b which is doctors's charges and part b is prescription drugs. in 1967 two years after medicare was started the average person on social security paid 6% of their social security checks just for physicians and

prescription drugs at the time. 6% of social security checks. in 201027%. in 2035 going up to 40%. in 2085 when young people in your 80s will be spending 46% of your social security check just for physician visits and prescription drugs. doesn't include the cost of hospital care. the deductible for the copayment you have to pay. these are projections but this is very sobering. in the health care reform law there is a recognition that medicare, we need to find a way to address the cost trajectory. there's a provision for independent payment advisory board to be set up with 15 members appointed by the president and confirmed by the senate and recommend ways medicare can keep spending in check. there's one thing that believe it or not president obama and

rush limbaugh agree on. they agree that medicare is unsustainable as it is now. they agree on something, it must be true. here's what president obama said. the u.s. government is not going to be able to afford medicare on the current trajectory. the notion that we can keep doing what we're doing that is a cannot true. and rush limbaugh's that i don't like the idea of matting of medicare collapse. and they cannot raise premium. if congress doesn't like recommendations it doesn't have to implement them but congress has to find an equivalent amount of savings and medicare spending. the independent payment to advisory board is targeted for repeal.

by very powerful forces. in part this is a consistent pattern in health care reform and how the deals were done that any curb on revenue, any effort to curb that revenue they want to stop. just as thirty two million people have insurance the health-care industry will take $32 million in customers'. that is what of revenue. they don't want any impediment on getting that revenue. what is interesting is the year the health care reform law was signed, the wall street journal reported annual ceo compensation survey they reported the highest median compensation of any sector in the u.s. economy that year was health-care. was in the banking industry. was in the oil industry. it is healthcare. i am also mindful during the financial crisis charles prince

who was head of citigroup set when the music stopped things will get complicated but as long as the music is playing with the banking. i feel that way about health care. we have the looming trajectories and where are we headed? is health care reform bill to last? what do you think? let's talk about the cost and coverage provisions under health-care reform? who will be covered under the patient protection and affordable care act and what will cost? the good news is sixty million low-income people may be covered under medicaid. maybe because there are a number of state governors not inclined to expand medicaid. i think it is more for political reasons and sirius budget situation is. i suspect there will be a lot of pressure from hospitals and others in this state that will wear down that opposition. it is not clear all sixty million projected people will be on medicaid.

new jersey estimates 400,000 people, some of the people who come to your clinic who are uninsured now will have insurance. that would be a good thing. what is this individual mandate? requires almost everyone under age 65 to have insurance from their employer or medicaid or private insurance. and if they don't have it they will have to buy it and the individual mandate applies to those without employer coverage or medicate and that will affect sixty million people. and they have to start getting insurance at 18 months in january of 2014. what hasn't received a lot of attention is how much will the mandate costs? there's a lot of talk about subsidies but how much will really cost? the kaiser family foundation has a wonderful subsidy calculated that just estimates and projections based on data from the congressional budget office

and they report that a 45-year-old head of household with an income of $46,000 a year will pay $2,600 a year for insurance in 2014 and that is subsidized and in addition they will have maximum out-of-pocket costs of a $4,000. the way the subsidies are structured the benefits are different. 60-year-old person earning $48,000 a year will pay $10,000 for insurance in 2014. out of pocket costs up to $6,000. i was surprised how much that is. that is the enormous. what is an exchange and how will it work? people will get their private insurance on an online exchange and access it by telephone. will provide information to help consumers shop for state approved health-insurance plans

applying for subsidies and tax credits. like a travel web site will all be there. you can select your choices from it. make a lot easier than what it is now. you might have heard about the penalty. do i have to pay a penalty of i don't buy insurance? in 2016 the penalty will be $695 a year or 2.5% of income. whichever is greater. there will be exceptions. you will be exempt if you have financial hardship. for religious reasons and others who won't have to pay the penalty. as health care reform moves from the supreme court to the court of public opinion will people buy insurance? will they be able to afford it even with subsidies? are the penalties strong enough to encourage people to buy insurance? you can imagine people with the serious illness who haven't been able to buy insurance because they have been excluded will be

delighted at the prospects and so relieved they will have insurance and happy to buy it. others may feel differently. if healthy people in relent only sick people enroll what is going to happen to those premiums if you have only sick people? they will go up even higher. there's no enforcement of the penalty and no means on your property or wages. even though we have come this far, there are many unanswered questions and uncertainties. what about employer provided insurance? that will affect most of you in this room who are fortunate to have it? how many of you have insurance? what will employer provided insurance costs? what benefits will it offer? lawyers continue to provide insurance? most employers will provide insurance as they are now but it is changing. i am sure you have seen the changes yourself. you are paying more income for

health insurance. people are getting fewer benefits. deductibles are higher. i collet swiss cheese. health-care insurance has become like swiss cheese. lots of holes. more holes, less cheese. here is data from the kaiser family foundation. on the bottom wine you see the growth in employees' income from 1999 to 2011. people's in congress have been growing over that time by 50%. cumulative increase. but look at the top line. that is how much people are paying for health insurance. the increase in their health insurance out of pocket for employees is 169%. you have a huge gap. what it means is incomes are not rising anywhere near as fast as the cost of health care.

and you see that trajectory going up and up and up. if you look in the top right corner right here, cost of insurance going up but employees are being asked to pay a higher share and that is reflected here in this slide. if you work in a company with 299 workers, that is the top line here, you will see 29% of employees are paying $2,000 deductible. and look at the growth trajectory from 2006 to 6%. and much higher. in 2011. there will be insurance. it will have a lot of holes. there's a penalty for employers if they don't provide insurance depending upon how large the

employers are. 50 employees who have one full-time employee, the insurance exchange will pay a penalty. will be $2,000 for full time employee. the businesses of party calculated it is cheaper to pay the penalty that it is to pay insurance. what is going to happen? this is the trajectory of all firms from 1999 to 2001. the researchers -- and the overall trajectory. is moving downward. i predict that that will continue particularly among small employers. what they may do is just offer like we have done with retiree benefits moved from benefits to defined contribution and a set of money and you get your insurance. i predict that that will happen. what about states and medicaid?

they will pay 100% of the cost of medicaid expansion from 2014 to 2019. and states will pay 10% of the costs. if you have been reading the news, in new york headed by democratic -- medicaid budgets. they're under tremendous pressure. a former state medicaid director, arnold schwarzenegger said this. medicaid provides care that is invaluable but reeling under its own weight. stocks are asked to implement the largest program sins medicare and medicaid began. medicaid is falling apart is states cut benefit and enrollment increases because of the recession. a recent report came out about the state of state finances two weeks ago.

a very challenging environment. health care reform what does it mean for u.s. physicians? what will be different? more of your patients will have health insurance. when we were having dinner last night dr. katary was mentioning when medicare got started basically had to close the clinic because older people no longer needed a free clinic for the uninsured because they had medicare. here there will still be uninsured americans but there will be far fewer. that is a good thing. what about primary-care? access to primary care will be more challenging than ever. the way i talk about it is health care reform is like building a house without a first war. there are some provisions in

health care reform, terms you may have heard called patient centered medicare homes which are wonderful things but not enough primary-care physicians or nurse practitioners to be able to handle the number of people who need care. many hospitals, to get a point where the primary care physician cannot and we will have thirty two million more people on to the system. people on medicare, while we close the doughnut hole for prescription drugs the number of geriatricians is shrinking. who is going to take care of those thirty-five million more people who are going to be on medicare in the coming decades for? who is going to take care of them? who will coordinate their care? as future physicians you will be practicing in a professional team based care.

and expected competency. practice will need high functioning teams and comprise physicians and physician assistants and clinical pharmacists and others that u.s. future physicians will be expected to demonstrate competency in working in a professional team. this will be part of your maintenance of certification assessments. this will be an expected competency because we have to work in teams to manage all the care. the other thing you will be seeing is downward pressure on physician payment. as all those cost pressures keep escalating there is only a few ways to cut that and that is to keep payments low. we are already seeing that and we're seeing as a consequence demand for increased productivity, more patients in a shorter period of time. that is very dissatisfied and to u.s. physicians and very

dissatisfied and to patients. on the flip side what is going to happen is increasing volume. working even faster and faster. the question we have for the day is how do we ensure that health care reform is built to last? how are we going to ensure that the house that is built is going to be around for generations to come? if current trends continued they are really clear that we just can't continue and this would have happened whether or not there was health-care reform. we have more people using care. everyone bears responsibility for it. what happens if we don't act. economics for a few minutes.

you may have heard about the national debt. it is how much the federal government goes the people who have lent money. in 1985 the united states was a net creditor. the u.s. went from that creditor to net debtor. we have to borrow from them to pay the bills so when you see medicare patients and those bills go into medicare the federal government doesn't have enough money to cover all of its bills. to borrow money from countries like china to pay those doctor bills and hospital bills. how much get the as the u.s. have? presently the total debt is $60 trillion. try to get your hands around

$60 trillion. here is what $1 trillion is. if i paid dr. katary $1 million a day since the year 1, since the year jesus christ was born that would not total $1 trillion. and we have 16 of those. that is how much debt the u.s. has. and it won't come up again about raising the debt ceiling. that is what it is all about. are we going to allow the country to borrow more and more and more. a scenario we put in a battle over health care which i hope never happens but if we don't act to do something now, at some point we are looking at the euro zone countries. places like "the battle over healthcare: what obama's reform means for america's future" -- places like greece and spain that cannot pay their debt. they have to ask for bailout money in euro zone countries and

the international monetary fund. heaven forbid the united states ever gets in that position. the international monetary fund is monitoring health care reform because the united states remembered the international monetary fund. that is the debt situation we're looking at. why do we begin to change course? that is where all of you come in especially those of you who are future physicians taking care of patients. what can you do? the institute of medicine estimates that about 30% of all the money spent on health care in the united states is wasted meaning it does not add value to the care of patients. what is included in that? includes overuse and inefficiency and fraud.

we will talk about each of these and $760 trillion and we waste that every single year. if we can take that out of the system we will be -- even a portion of it -- we will be in really good shape and we will build a house with health care reform that will be around for generations to come but it will depend in part on you. not alone. so what is due to reduce overtreatment? the pan and the keystroke that you use to order prescription drugs. very powerful tool that you have in your hand. as mentioned earlier when the choosing wisely campaign there are 27 medical societies developing the top 25 lists for are developing them things that we can do a lot less of. maybe stop doing at all. in addition there are other

procedures and surgery's that have been well-documented in the medical literature as being overuse. heart bypass surgery, angioplasty and antibiotic use. all overuse. in september of this year the joint commission which accredits the nation's hospitals will be hosting its first meeting on overtreatment and they will be looking at a number of these topics and trying to come to consensus on what it can do as an creditor of hospitals. and health care reform -- we have unnecessary procedures. let's stop doing them on people who don't need them and use the talent and skill and resources of people who really do need them. if we can make that switch now, everyone will be kept intact.

board certification, seeking board certification in the future i see you're heads come up. in 2015 appropriate use will be part of maintenance certification. to knowing when it is appropriate to do imaging for low back pain. screening for osteoporosis. when is inappropriate if you do oncology for that third round of chemotherapy and when is there no evidence that will benefit the patient. what is angioplasty opprobrium and not? this is where you have the opportunity required to learn and is a good thing so we can keep the system hole for everybody who needs it. what is overuse? defined as when the potential for harm accedes possible benefit. this is not about rationing. this is not about cost control. this is in fact about good care.

i am happy to say there's more momentum to address this issue of overtreatment. here is what patients are saying about their experience. a colleague i used to work with said the meeting and eat kgb since i was 27, i am 41. i don't know why i have been getting it. i have no heart disease. my husband gets one too. i spoke with this person recently and she said i went and talked to my doctor and i don't get those anymore and the same with my husband because they are not medically necessary. here is another one. i get a chest x-ray every three month. don't have any underlying medical condition.

next time i am going to ask him why. this came from a state legislator. i gave a talk at the council of state governments recently. the east coast regional conference. it was how we really have to address this issue of overuse if we are going to have a sustainable system and a house where everyone can live and he brought this up and he said he is going to go to his doctor and say why am i getting this? who is counting that? do you know how much it is? we are not tracking it and we probably should. here is another one. my knees were hurting and went to a well-known orthopedic surgeon. he said he could do surgery. he didn't talk about me or my situation. i left and found a personal trainer who helped me strength and my muscles. i am much better now. and informed and educated people make good informed decisions about the use of health care.

is not anybody by any stretch but we are beginning to see it and we're seeing good doctors have good conversations with their patients. about the appropriate use of resources. that is what the choosing wisely campaign is about an why i am delighted presidents will be learning choosing wisely as part of your curriculum. finding my 83-year-old mother-in-law having problems with her shoulder she went to a doctor who said he could operate. i went with her to get a second opinion with physical therapy and time for healing. she was fine. better outcomes, better care and it costs money. there are abundant opportunities in our health-care system to do this. how we deal with food. on the one hand we have an obesity epidemic that is off the charts. people eating too much food be gristle the wrong kind of food and pockets of communities where

people are malnourished. we have this extraordinary imbalance. people are getting too much medical care and yet we have people who can't get what they need. if we can reduce the overuse and put to good use people who really need it we will have enough to take care of everyone. we have that opportunity to do it now. we have to get started. we don't have much time or money to waste. now a topic of the book the treatment trap over use. how do we curb it? finally a fact i found so interesting. the fbi has done an estimate how much fraud there is in health-care. i began to look at this and gave a talk at the health care anti-fraud association. turned out 10% of health-care spending the fbi estimates lost

to fraud. the sophistication of its is enormous. if we take a 10% of health-care spending with the $2.6 trillion a year. that is $2.6 million that we spend $4,260,000,000,000 that we spend loss to fraud. that amount of money will cover every single uninsured person in america. just reducing that. the health-care reform law includes provisions. and important steps, far cry to take that out of the system and money for people who needed to come to your clinic who are uninsured. we will be able to get better care. what can you do? we have to preserve and sustain the goodness medicine does and

the only way to do that is take out the things that don't add value and use those resources for the things that do add value to life. what can you do? you as physicians and nurses? you can ask if the test or procedure your contemplating will really do that person any good? will they be better off? what is the evidence objectively? what do your peers say? do they agree? the good news is we are seeing more and more consensus of those there is a lot of different points of view on it. i will leave you with this quote. it is from mohammed hadi. recall the case of the force and weakest man who you may have seen and ask yourself if what you contemplate is going to be of any use to him. will he be better off because of it?

then your doubting yourself will melt away. that is how we can make health care sustainable. it is how we can make cac health care reform live for generations to come to serve everybody so they get the care they need. the care that will sustain them and bring healthier and happier lives. thank you for all you do and happy to have some questions. [applause] >> you will have to go to the microphone so anybody can here because we are on tape. >> good morning. >> nice to hear you again. the starting point might be

collapsing under its own wage. the health-care system might collapse. but on its way to collapsing means there are a lot of things and various other avenues that might materialize in this global leader still open world where even health care might be exported and people might even go seeking health care elsewhere. noaa all-and already we're seeing the globalization of the trade. lots of the industry's going abroad. lot of people are missing out on employment and likewise health-care and it seems -- it is this particular part which is

so troubling, unregulated, unsavory practices might pop up along the way and we have to deal with all those. one other thing that comes to mind is the way we have talked. at mid school we learn indication of this, indication of this operation or that operation or this treatment for that treatment, many times comes to take care of a patient's we tend to think the same way. i have an operation. i am a surgeon. i have an operation to offer you. nothing else must talk about for that patient and the patient's left rightly so. so the mindset has to change.

with a single patient, what is the treatment? along the way, not particularly you offer the most expensive treatment for most rewarding treatment for yourself. i don't think that is taking care of the patient's welfare. i leave you with that. the medical establishment at the med school level, we are teaching you this way and 40 years ago, i thought this notion, indication of this or that and such. >> you mentioned the word disruption. and because of a federal law, federal officials are required to report. at a certain point when the medicare program in a certain

fiscal situation. and the obama administration, and medicare's financial state. a disruptive consequences for society. if we don't fix this long term trajectory. let me say something about globalization. and the british medical journal and health care improvement conference in april on the evidence of overuse translating into improvements. i ask this audience of people from around the world, 70 countries represented. don't know if they were all there that particular session. have you or someone you know ever had medical care you or they thought was unnecessary and all these hands went up and i asked how many of you reside outside the united states and all these hands went up.

i was surprised when people came up afterwards to say from finland, germany, the uk and new zealand. emerging-market in brazil and india evidence of overuse so this is a global phenomenon we will have to tackle. problemss in canada 41% and 42% of the state budget with better health care. if doing that you are not spending money on education or infrastructure or investment in science and technology. and enormous issue globally. 8 you for your questions and your time. >> debbie gold seen. i am a gastroenterologist the spent a lot of time in primary care. i could spend an hour just counterpointing and raising so many issues. it is infinite. i wanted to make a couple of

points. the primary care physician is asked to be the foundation. primary-care physician has the most responsibility of any other physician. they have to know everything. they have to know what the right and left hand is doing. they are responsible for everything they refer people to. they have the least amount of time. they are the ones that have to talk to that patient who went to the orthopedic surgeon and could have been talking about going somewhere else for care. they don't do that because they have to go faster because they have to seek more patients and it is crushing. there is no incentive for people to become primary care physicians. they get the least amount of money and most amount of responsibility and biggest

burden for lawsuits. that brings me to the issue of the fact that there is an imbalance. this imbalance that we have and i really don't know who was behind closed doors when the hole obamacare of fifty billion pages was implemented but i got to believe as a physician out in the trenches here that there weren't enough of us helping to formulate a plan. i feel just from i got, from my soul have to believe because all the people who implemented this plan, all the congressmen happened to be lawyers and because we can't control health care costs, part of the overuse of health care has to do with the fact the we are shaking in our boots about being sued for things we shouldn't have to be sued for because using clinical

judgments and standards of care isn't good enough sometimes because one lawyers are breathing down our throats we still have to worry about the time we have to spend in a court room for a frivolous lawsuits that is going to take us away from our patients and even if we are found to be not guilty we spend time. we are a way. we lose money. our patients suffered and the lawyers are laughing to the bank. the same happens and i will close because i know i am going on like a mad person. the other thing is as wrong as you have political action committees that are powerful and the political action committees of the insurance companies are powerful. everybody has to have health insurance. anyone laughing to the bank. everybody has to have health

insurance and no competition across -- to make a product. is going to provide people with the care that they meet. people having $2,000 of deductibles so they never get health insurance at all land premiums going up and no competition across state wines. if you could go online and pick any health care insurance product in the country may be we would have competition and maybe people would care about providing a good product and there would be good insurance and ceos would take less of a bonus. we are talking fraud on such a huge magnitude that has to be rooted out and we have a lot of work to do and a lot of it has to do with government. >> thank you very much for your

comments. it reflects the views of a lot of physicians. [applause] >> in the end came out and supported the health care reform law despite tremendous opposition so the physician community was divided when it came -- that division continues. i think you make a good point from the patient perspective. did health care reform denied the system that would be good for the patients? in the battle over health care will cut the price bubbles. the toxic assets in health care. drugs go on the market and off because they are found to be harmful. we have a lot of too big to fail. a lot of financial interests at stake that make it difficult to change. that sacred relationship between the patient and physician. not sure health-care reform was built around that. that is not good for doctors or

patients. thank you. >> can you comment and address how the health care reform would address this issue of the dartmouth at this recently published, 50% of health care costs in the last two years of life? and guess which state leads the way in that dartmouth atlas report? new jersey. can you comment on care at the end of life and how the new health care reform will address that? >> as you know there was an attempt to put a provision on the reform law that would allow -- between a doctor and the patient about serious issues that a life limiting illness -- we have this term called death

panels that cropped up and took that provision out. the intention of that provision was to recognize patients who are seriously ill -- seven minutes is not enough time to talk to your physician when you got a bad diagnosis. the intent of that was to create a space of time, what i call the sacred conversation about what people's choices are and what is important to them. we tried it but it was for political reasons i believe taken out. i spent 12 years trying to bring quality of care into the mainstream of the u.s. health-care system. it started when a major study was published showing how poorly we care for people at the end of life. so we've launched a major

initiative and started to help hospitals and physicians and nurses with these programs in their hospital which is a good thing for people to get care that they want. an early form of shared decisionmaking. that has taken off and we have a specialty, the question remains how come end of life care costs go up and up? what will stop it? on the other side of the equations our families who are deeply troubled, many are deeply troubled about what they see their loved ones going through. manifestation we don't know when to stop and don't have a mechanism to stop it. that will rely on physicians, future generations. i would love to hear your thoughts on what we can do to make sure people get the care they need that will actually benefit them. public expectations. that is why we have an overuse

problem. we think there's a cure for everything. turn on those television dramas almost every night, they think we can work miracles. we have fed the public a steady diet that more is better. there's a cure for everything. the television show house. every test known to mankind can be done and should be done. we have created this environment for the public to believe that more is better and how do we begin to reverse that? the choosing wisely campaign attempts to do that. one of the things we stop doing is chemotherapy under certain conditions. when you throw around there is no evidence. why are you doing that? i can't agree with you more. very tough politically to do but first-time i heard patients and families describe what they see their loved ones going through, very terrible terms. almost like post-traumatic stress they experience because

of the intensity and medicine at desire to want to do good but we need the wisdom to know when to stop. consistent with preferences of patients and families. thank you. >> this is probably not an answerable question that is there any reform on the actual cost? it is impossible to get your brain around the cost of medicine because it costs $33,000. what does it cost if a hospital can sustain itself based on what they get then what does it cost? >> it is a great question. i would hope the young physicians in the room and everybody will start asking what does it cost? i had the privilege of knowing a wonderful physician in the midwest who heard a talk in washington not long ago about how physicians are good stewards

of resources. so he went back home to his hospital and ask the financial people to go through the inventory with him in his operating room to find out how much all those things cost. he had no idea. .. >> just by asking a simple question. when you prescribe a drug for your patients, when you do a test, you don't want to be down in the basement of price, but just being aware of how much these things cost. because we've done these things

sort of by default, let's just do it. we all need to be good stewards of resources. so simply asking the question. and can now we're seeing more price transparency begin to come up with the health care bluebook. so patients go in, they have no idea, they think they're going to pay $1500 for a colon os coby, but that's if there's no polyps. but that's no guarantee that we'll see prices come down. but i think just asking the question, simple question, how much does that cost, is a place to start. hi. >> my name is -- [inaudible] i'm a fourth year medical student, and my question has to deal with more about medical and education the cost of it. i go to probably the most expensive medical school in the country, and that kind of goes with what dr. goldstein earlier, like, when we're coming out of medical school with such a high amount of debt, that kind of changes, you know, the opinion

of the students, what field should i go into, how am i going to sustain myself in the future and pay off my debt and have a good living? so what -- and already the way we get our loans, the subsidies, i think they've taken some of it away this year. what is being done about that? and then, also, with 32 million people, i know more and more medical schools are opening up, but how are we able to provide and sustain for the cost of education and producing one physician, um, more and more i feel requires, like, a lot from society, you know? college, medical school and then training. so your thoughts on that. >> well, thank you, as a fourth-year medical student, for asking your question. i think we should ask what does it cost to train and why does it cost that much. on what basis do we decide that it should cost, that it does, in

fact, cost as much? i think what we have with medical education is we have the confluence of education costs going up and health care costs going up. and we have this perfect storm of both health care and education coming together. and you fall right in the middle of that storm, you and other medical students. um, and i don't think that there is any answer for that. health care reform law has some, you know, loan provisions if people want to go into primary care and work in underserved communities, but that's not an answer. and the reality is health care reform did not fix that. thank you. we have one final comment, and i think -- >> yeah. i'm a urologist, and i sympathize with the medical students' plight. the current education system and the debt burden that they have doesn't lend them into primary care at all x. this is what we need. and so the system has to be

steered in such a way. there should be incentive enough or some sort of relief on the cost of education in the system. otherwise we'll wind up importing doctors specifically geared for primary care. i think that's the avenue that the country will have to take. >> i think that's what's happened to geriatrics. it's the lowest paid of all the specialties, i believe, within medicine. and 40% of the fellowships are unfilled, as i understand. so it's symptomatic of that, plus many foreign medical graduates, national medical graduates come in and do those fellowships. they may not have the same desperation that we have in the u.s. so health care reform only fixed part of it, and there are many, many other things that need to be done, and that needs to be put on the agenda. thank you very much for all you do, for the care you provide for your patients. [applause] >> visit booktv.org to watch any of the programs you see here

online. type the author or book title in the search bar on the upper left side of the page and click search. you can also share anything you see on booktv.org easily by clicking share on the upper left side of the page and selecting the format. booktv streams live online for 48 hours every weekend with top nonfiction books and authors. booktv.org. >> the shock value is in the northeast part of afghanistan. it cannot be more remote. it's called where god lost his shoe. i mean, this valley is a cul-de-sac that goes nowhere, and it's, it's up near the himalayas. so getting up there's hard, flying helicopters is hard. the only way in was by foot or helicopter. so trying to get there initially to plan the mission was tough. um, what they were up there to do was go after what they call

an hvp, a high value target, and this guy was a hague commander. the hague are a terrorist group, essentially, that have some association with al-qaeda, have some sort of truce with the taliban. but these guys are, they're nasty characters. they are a lot of foreign fighters from chechnya, guys that aren't really there to fight against -- to fight for afghanistan or fight for their version of afghanistan, these guys are mercenaries. and what the hv, the was doing was recruiting, pressing people the fight for the hague, and he was rumored to have surface-to-air missiles and was stockpiling guns. and he was also credited with a series of ambushes in the koren gal valley that had caught the attention of some of the commanders that were in the east. so they decided they had to go up to the valley to get him and take care of this network because it was becoming, you know, he was able to export a lot of the violence from this safe haven. so the idea was to go get him

and take care of this safe haven. well, what they ran into was not only were they fighting the geography because it was such a hard place to get to, they're also fighting some of the restrictions that are placed on soldiers in afghanistan. i'm sure we've all seen the news. these night raids are highly regulated, who controls the battle space is highly regulated, and it takes a long time to get a mission planned. one of the things they were running into planning this mission was how to get there, what the helicopters could do and what, when and where they'd be allowed to go. and, essentially, what they came back with was the idea that they were going to fly to the valley, land in the valley, unload their soldiers and then fly off. now, the team initially wanted to fly up to the top of the valley, to the top of the village and then fast rope down which is, essentially, they rap el out of the -- rappel out of

the helicopter. they ended up having to settle for this mission which was to land in the valley and unload their troops. which anyone who knows any kind of basic infantry tactics, to fight uphill is never, never a good idea. you never want to do it. that's sort of, you know, infranty 101. if you can take the high ground, you want it. so what the commanders had to pretty much reconcile was, was it riskier to fly the helicopters to the top of the village or put them on the ground and have guys, hopefully, get up the hill before the bad guys found out they were there. that's sort of where the team was left on the morning of the mission, which is where the book starts. they know they have to do this mission, it's spring in the mountains of afghanistan, the weather has already delayed the mission once or twice, and they all have this sinking feeling that i don't know if this is a good idea. and that feeling is one of the things that propelled this book, and it propelled us. because it's very rare that you

get soldiers that have universal bad feelings like that and the candor to stand up and say, hey, not only do we have this bad feeling, but we sort of took it up the chain and said, look, we don't really want to do this mission. and that sort of starts the book, and it also starts them on this path that, ultimately, gets them in an ambush. >> and that's, and that's pretty critical, what kevin just mentioned, in the book. you don't usually get soldiers who speak out about flaws in a plan. and there was a captain, captain kyle walton, who basically knew and -- just like other members in oda33's ranks knew that there were flaws in this plan. you don't fight uphill, you try to have the element of surprise. so tactically, he knew that it was unsound. so he took his concerns to his commanders. and his commanders, it was real important to do this mission because the hv, the, like kevin

said, was a really bad guy. he helped finance his men by this gem-smuggling operation. and, in fact, what they later found out through the fbi and cia was that some of those gems had even showed up in, you know, gem shops in arizona. so he was selling these gems to finance his whole, you know, this whole campaign. and, again, going back to that this is a remote value, members on the team knew tactically that this plan s flawed. but even though they knew that it was flawed, knew that there was incredible danger landing the helicopter at the bottom of the valley and then they would have to climb to the top of the mountain to get to this compound where he knew he was surrounded by some of the, you know, some of the best mercenaries, so to speak, in the world, these really trained mercenaries who had been fighting, you know, the soviets for, you know, for that ten years during the 1980s.

they still went, and they still went to carry out this mission. and i think, kevin, you can describe a little bit about what happened once they land. >> okay. so they take off from a base on the border, jalalabad, and they fly into this valley. and there's some concern at this point, obviously, with the plane. there's also concern about the weather. there's a certain window they could get in and out before the cloud cover came in, so they have to work quickly as well before they get stuck. but if you can imagine land anything a helicopter, and, you know, the plan was to land and the helicopter to get out, but there was so much rubble and ice, and the ground was so uneven, the helicopter, some of them couldn't even land. so there were guys jumping 10 feet out of the back of these chinook helicopters and landing on these rubble fields. and some of them landed in this river that was running right through the middle of their landing zone. so they get past that with no real major injuries with that

alone's a feat. i mean, 10 feet is about the size of a basketball court, so imagine jumping out of that into big gravel, big boulders. and they look up, and this valley is a lot -- the mountains surrounding this valley are a lot higher than they imagined. they were only looking at satellite images. i can only equate to standing, you know, in midtown manhattan and looking up at the buildings and just being surrounded on all sides by just sheer cliffs. and they consolidate their guys, and they start walking towards this village. and when we say village, i'm sure in your heads you think, you know, i don't know what you see in your heads for an afghan village. depending on where you are in the country, sometimes they're discut-colored -- biscuit-colored mud huts, but this was literally cut into the walls almost, and it was stone houses. these were like castles stacked on top of each other that would line all the way up and around them, and they were surrounded almost -- not 360, but almost

360 with these stone houses. and as they're walking up, it takes them a little while to find a path. but they get to the base of the hill, and the path pretty much cuts back and forth in a zigzag up the hill of switchbacks as they head up. so i know a lot of veterans, i've met a few of you, and you're shaking your heads. you know that's bad, number one, because there's only one way up, okay? you know you're in the cul-de-sac of a valley, and they know that you're there because they heard the helicopters. if they hear helicopters in this valley, it's not them. it's not their buddies. it's their bad guys, right? it's really quiet as they're walking up. and all of a sudden they see three guys running on -- luis actually sees three guys running on the top of the valley, and one of 'em's got a gun. >> you can watch this and other programs online at booktv.org.

>> here's a look at some upcoming book fairs and festivals happening around the country. the atlanta journal constitution's decatur book festival will take place august 3 1-september 2nd highlighting a children's area, poetry slams and author panels. then the florida heritage book festival and writers' conference will be in st. augustine, florida, the weekend of september 13th. award-winning author jeff lindsay will be the keynote speaker for the festival. kirkland, washington, will host the northwest book fest. the event will feature dozens of author signings and presentations including appearances from blaine harden and boyd morrison. also the weekend of september 22nd, booktv will be live from the national mall in washington, d.c. for the national book festival. be sure to checkbook tv.org for updated information on live author panels and interviews. please let us know about book