the small research departmented at bell labs. they succeeded in deploying a cross country phone link and from them on the research department at bell labs grew as it worked more fundamentally on the singes. >> you can watch this and other programs online at booktv.org. . . >> the topic this morning is health care reform, and as the doctor mentioned, it's based on a book for which i am principal

author called "the battle over health care." a nonpartisan an access of health care -- analysis of health care reform and where we're headed. i approached writing that book with a question, how did it happen? since the time of franklin roosevelt, america has tried to have universal health insurance coverage in this country. and for decades people have tried, but it failed. how did it happen this time? what went on behind the scenes? and the deals that were done, who were the important players in it? the health care industry, the insurance industry, the drug companies. what went on? what made it happen? what were the special ingredients? and did america get a good deal? are finally we going to see costs controlled in health care? we'll talk a lot about that today. will health care be safer? will there be less

overtreatment? for you as future physicians, there are many residents in this room today, what will health care look like for you as future physicians? really an important question. and finally, did we build in health care reform a sustainable system? we built a house, but will it be one that generations will be able to live in? let's get started. why health care reform? just a reminder of why it's so important. you here at st. peter's see it every day. night at dinner we were talking about the clinic for the uninsured here, and you see patients come in with advanced heart disease, unmanaged diabetes, people with cancer that has spread. why? because they've lacked health insurance, because it's too expensive. and they have enormous suffering that takes place because people don't have access to health care. this is a photograph of what

happens when volunteer physicians, nurses and others come together on a weekend to provide health care for the uninsured. this has been america's safety net. and yet another picture. if you're uninsured and can't afford medical care, this is where people drive hundreds of miles to receive needed care. whether it's a pair of eye glasses, a sore tooth that needs to be pulled, or you've gone for cancer treatment, but can't afford the follow-up care. this is where you go. this has been health care in america for millions of people. and so the decisions about what to do about it then went here. this is a picture of blair house in 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. and the battle over health care will continue.

today health care reform is the law of the land, it's been signed by the president, passed both houses of congress. the supreme court affirmed the institutionalty of the individual mandate last month, but still the battle will continue. republicans have vowed to repeal it. if not that, they have vowed to prevent it from being funded. and there are many sub substante issues that remain to be addressed. we still have a shortage of primary care physicians. the imbalance between primary care and specialty care remains a huge challenge. are there enough physicians and nurses to take care of the 32 million people who might have health insurance coverage because of health care reform? and then we have a surge in the elderly population as the boomers turn on medicare. 30 million people over age 65 will be on medicare in the next 25, 30 years, additional people. do we have enough doctors and nurses to take care of them? health care reform couldn't fix everything, but there's still a lot to be done, and the battle

will continue. so this presentation is a nonpartisan look at health care reform. the focus will be on two main areas, coverage and cost. we can't cover the whole water front in just an hour because it's such a huge bill. the bottom line is if you want to build a house, then health care reform will provide a good foundation, and will it support people with good care for generations to come? so the residents who are here now, 40 years from now you look back on it, did we do health care reform right? that's the question. there'll be four parts to this presentation this morning. did health care reform diagnose the right problem? you as physicians know how important getting an accurate diagnosis is. did we do that as a matter of public policy? the second question is, what will be covered, and what will it? third, we'll focus on what does health care reform mean for you as future physicians and for those of you who are currently practicing. and finally, where are we headed from an economic point of view,

and fiscally can we sustain financially the systems that we're creating? and if we can't, what can we do about it, and what should we start doing now to fix it? so part one, did health care reform diagnose the problem correctly? the reform law diagnoses the problem as lack of health insurance, and it's true, there are up to 50 million people estimates suggest people don't have insurance. so the solution that has been prescribed, the treatment order is let's have more insurance. and so now up to 16 million people will have access to private health insurance coverage, many of them with subsidies. we'll talk about that in a minute. and up to 16 million people could have medicaid coverage. one of the reasons that so many people could not, cannot afford to buy -- cannot get insurance is was they can't afford it, because it's too expensive, and that's because health care costs are too high.

we're going to drill down on that for the next few minutes. there's a study published in the archives of internal medicine earlier this year that looked at the cost data for uncomplicated appendicitis in the state of california. the researchers had access to data for all the hospitals in the state, and the yield yang cost of a hospital -- median cost of a hospital bill to treat uncomplicated appendicitis was $33,811. that amount is 75% of the annual per capita income in the state of california which was $44,481 in 2011. what's especially interesting is the range of how much the hospital bills were. at the local county hospital, it was only $1500. at other hospitals it went up theory $18 -- nearly $180,000. how do we sustain this?

is it sustainable? i'm writing a book on medicare presently, and i had the pleasure of interviewing a 65-year-old gentleman from rural kentucky. he went into the hospital for one night for a procedure which he wanted to keep private, but he said he needed an operating room, and chances are he might have had a pacemaker or defibrillator implanted, and he got a hospital bill for $244,000 for that one night in the hospital. and that's about the cost to buy a house in his community. in fact, for some of the -- you can buy houses cheaper than that in his community. he was on medicare, and medicare paid only $18,000. he was so floored by this bill he called the hospital and said what happens if i didn't have insurance? he said, well, we'll still make you pay it. i recently did a radio interview in washington, d.c., and a woman called in, and she said that her husband had gone in for treatment for kidney stones. he had two of them, and they

each cost -- at least the bill they got 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 progesterone shot used to prevent premature births. used to be able to buy it for $10 per injection. when they gained the exclusive right, they increased the cost to $1500. is that sustainable? and 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 obstetrics and gynecology pushed back. they issued a statement that said in part the u.s. health care system simply cannot be expected to absorb the costs

without significant negative repercussions. in this case the company backed down. but this is the exception rather than the rule, and individual patients don't 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 32 million people will be getting coverage. we also have an interesting situation in this country with volume. a recent study in the archives of internal medicine, it was a survey of physicians, primary care physicians, 42% of them believe that their patients receive too much medical care. 25% of them believe that they themselves provide too much medical care. the good news is about 75% of those surveyed said they're interested in learning how their practice compares to how other doctors practice so they can curb unnecessary medical treatment. and as young residents, you have

the opportunity to do that. i'm sure with dr. katari's leadership, you'll learn how to do that, and you should. you'll be aware the american board of internal medicine foundation's choosing wisely campaign to encourage doctors to provide the care people need, not the care they don't. they issued top five lists that are coming out for 27 different specialties within medicine of things that we can do less of and have really good care for patients. here are top five in internal medicine. you might already know them from previous presentations, but i'll run through them very quickly. imaging for low back pain, often overused. let's do watchful waiting for the first 4-6 weeks when there are no red flags. don't do the blood chemistry panels in asymptomatic, healthy adults. don't do the annual electrocardiograms, again, in asymptomatic, low-risk patients x. don't do the bone screening for osteoporosis sis in women

under age 65. these are recommendations coming from the evidence from primary care physicians. we'll talk more ant this later -- about this later, about what we can do to try to curb the inexorable rise in health care spending so we can have health care reform that lasts for generations to come. this is a millman medical index of the annual cost for a family of four for medical care. and note in 2012, 20,728 dollars. it's been rising a thousand dollars a year. you can see that. i don't know if that's showing. that's where we are in health care today, and there's nothing to stop that trajectory. and meanwhile, the median family income in the u.s. in 2011 was $50,000. so how for a family of four the average annual spending is $20,000, how do you do that? and are there even enough

federal subsidies, is there enough money in the federal government to ceeb subsidizing that? -- keep subsidizing that? while i was writing the battle over health care, i listened to an interview on the abc nightly news. the secretary of health and human services, kathleen sebelius, was being interviewed in the context of stories being reported about tremendous increases in health insurance premiums that individuals were having to pay, you know, 20, 30, 40%. and i found the question and the answer really quite remarkable. the question that was asked by the interviewer, what should people do if they get an increase in their insurance premiums of 20, 30 or 40% and they can't afford it? and this was after health care reform. and the most remarkable answer which i, frankly, 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 that laws be changed. and she's referring to laws pertaining to health insurance

rate review. and what that told me was that there is nothing in the health care reform law to stop the increase in the cost of private health insurance or medicaid. there's nothing. so we defined health care reform, the problem, as a lack of insurance. is that the real problem? is the real problem affordability? are the subsidies a band-aid on exploding costs? also while i was writing the battle over health care, you'll remember the oil spill in the gulf of mexico. and these pictures like this were seen around the world of the oil coming out of the earth, and there was no way to stop it. day by day by day people watched this around the world. there was no way to cap it. finally, the engineers were able to cap it, and i couldn't help resist making a comparison with health care. there's nothing to stop it. it keeps coming and coming, and it's nothing to stop it.

and there's nothing to stop it. just a word about medicare. one part of health care reform law that has brakes on it pertains to medicare. there are a number of other provisions adding preventive benefits for annual mammograms and colonoscopy without copayments, closing the dough out hole for prescription drugs, all good things. and that's -- here's where we're headed in medicare. this is a, from the medicare trustees' report that reports on the financial state of medicare. it starts in 1967. this is data for how much the average person who is over 65 and collecting social security, let's take someone who's earned $50,000 a year, the average wage, over the course of their working life. they retire, and when you retire, you have to pay for medicare. it's not free. you have to pay premiums, and you have to pay copayments. you pay it for part b which is doctors' charges and part d is

prescription drugs. in 1967, two years after medicare was started, the average person on social security paid 6% of their social security check just for physician visits. there wasn't part d, the prescription drugs, at the time. so 6% of their social security checks. in 2010 it's 27%. in 2035 it's going up to 40%. 2085 when the young people in this room, when you're in your 80s, you'll be spending 46% of your social security check just for physician visits and prescription drugs. it doesn't include the cost of hospital care, the e -- the deductible, nor the copayments you'll have to pay. again, these are projections, but these are very sobering. so in the health care reform law, there's a recognition that medicare -- we need to find a way to address that cost trajectory. there's a provision for an

independent payment advisory board set up with 15 members appointed by the president and confirmed by the senate, and they would recommend ways that medicare can keep spending in check. now, 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. if 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 its current trajectory. the notion that somehow we can just keep on doing what we're doing and that's okay is just not true. and rush limbaugh said, i don't like the idea of letting medicare collapse. there won't be any medicare if we don't fix it. it's not sustainable. so independent payment advisory board was included in the health care reform legislation. it cannot change eligibility, ration care, raise premiums. if congress doesn't like the recommendations, it doesn't have to implement them.

but congress does have to find an equivalent amount of savings to pare back medicare spending. the independent payment advisory board has been targeted for repeal by very powerful forces. and in part because, and this is a consistent pattern in health care reform and how the deals were done, that any curb on any revenue, any effort to curb that revenue they want to stop. so just as 32 million people have insurance, the health care industry will be getting 32 million new customers. that's lots of revenue, and they don't want any impediment on getting that revenue. what's so interesting, the year that the health care reform law was signed, the "wall street journal" reported its annual ceo compensation survey. they reported that the highest median compensation of any sector in the u.s. economy that year was health care. it wasn't the banking industry, it wasn't the oil industry, it's

health care. i'm also mindful of, um, during the financial crisis charles prince who was head of citigroup who said when the music stops, things will get complicated, but as long as the music is playing, we've got to get up and dance, and we're still dancing. i sometimes feel that about health care. we have these looming trajectories, and where are we headed? so the question remains, is health care reform built 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 it cost? the good news is up to 16 million low income people may be covered under medicaid, the joint federal/state program. i say maybe because there are a number of state governors who are not inclined to expand medicaid. i think it's more for political reasons, but they also have some

very serious budget situations. i suspect there'll be a lot of pressure from hospitals and others in the state that will wear down that, um, opposition. so it's not clear all 16 million projected people will be on medicaid. in new jersey it's estimated that about 450,000 people, some of the people who come to your clinic who are uninsured now, will have insurance. that will be a good thing. so what is this individual mandate? it requires almost everyone under age 65 to have insurance either from their employer or from medicaid. or private insurance. and if they don't have it, they'll have to buy it. and the individual mandate applies to those without employer coverage or medicaid, and that will effect an estimated up to 16 million people. and they have to start getting insurance starting in 18 months, in january 2014. what hasn't received a lot of attention is how much will the

mandate cost. there's been a lot of talk about subsidies, but how much will it really cost? so the kaiser family foundation has a wonderful subsidy calculator where, again, they're 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 about $46,000 a year will pay $2600 a year for insurance in 2014, and that's subsidized. in addition, they'll have maximum out-of-pocket costs of more than $4,000. the way the subsidies are structured, the benefits are different. a 60-year-old person earning $48,000 a year will pay $10,000 for insurance in 201. 2014. and plus out-of-pocket costs of up to $6,000. i was surprised at how much that is. that's enormous. so what is an exchange, and how

will it work? people will be able to get their private insurance on an online exchange. they'll also be able to access it by telephone. it'll provide information to help consumers shop for state-approved health insurance plans and apply for subsidies and tax credits. so like a travel web site, like expedia, it will all be there. you can select your choices from that. make it a lot easier than what it is now. you might have heard about the penalty. gee, do i have to pay a penalty if i don't buy insurance? in 2016 the penalty will be $695 a year or 2.5% of income, whichever is greater, but there will be exemptions. you'll be exempt if you have financial hardship, for religious reasons and others who won't have to pay the penalty. so 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 that people with a serious illness who haven't been able to buy insurance because they've been excluded, they'll be delighted the prospect, so relieved. they'll sleep better at night that they'll be able to have insurance, and they'll be happy to buy it. others may feel differently. and if the healthy people don't enroll and only the sick people enroll, what's going to happen to those premiums? if you have only sick people, they're going to go up even higher. there's no enforcement of the penalty, there's no liens on your property or garnishment of wages. so there's -- even though we've come this far, still many unanswered questions and uncertainties. what about employer-provided insurance? that will probably effect most of you in this room who are fortunate to have it. how many of you have insurance? so what will employer-provided

insurance cost? what benefits will it offer? will employers continue to provide insurance? most employers will probably continue to provide insurance as they are now, but it's changing. i'm sure you've seen the changes yourself. you're paying more of your income for health insurance. people are getting fewer benefits. the deductibles are higher. i call it swiss cheese. health care insurance has become like swiss cheese, has lots of holes, more holes, less cheese. here's data from the kaiser family foundation and hret. on the bottom line, you'll see the growth in employees' income from 1999 to 2011. so people's incomes have been growing over that time period by about 50%. the cumulative increases. but then look at the top line. that's how much people are paying more for health

insurance. the increase in their health insurance out of pocket for employees is 169%. so 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. it's still going up and up and up. and if you look at the top-right corner right here, while the costs for insurance are going up, employees are being asked to pay a higher share of it. and that's reflected here in this slide. if you work in a company with 199 workers, that's the top line here, you'll see that 29% of employees are paying $2,000 deductible before their insurance kicks in, and look at that growth trajectory from 2006 at 6% and much higher in 2011. so we'll have -- there will be

insurance, but it'll have a lot of holes. there's a penalty for employers if they don't provide insurance depending upon how large the employers are. employers with more than 50 employees that don't provide insurance and have at least one full-time employee who receive subsidies from the insurance exchange will pay a penalty. it'll be $2,000 for a full-time employee excluding the first 30 employees. but the businesses have already calculated that it's cheaper for them to pay the penalty than it is to pay insurance. so what's going to happen? this is the trajectory of all firms offering health benefits from 1999 to 2001. the researchers can't -- i'm not sure about what causes that blip that you see here, but you see the overall trajectory. it's moving downward. and i predict that that will continue, particularly amongst small employers. what they may do is just

offer -- just like we've done with retiree benefits -- we've moved from defined benefit to defined contribution. you'll get a set amount of money, and then you can go get your insurance. i predict that that's what will happen. what about states and medicaid? there's a medicaid expansion, and the federal government will pay 100% of the cost from 2014 to 2019, but begin anything 2020 that will change, and states will have to pay 10% of the cost. if you've been reading the news, if you have time, you'll see that california and new york both headed by democratic governors have had to slash medicaid budgets. because overall state budgets are under tremendous pressure. a former state medicaid director in california under governor arnold schwarzenegger said this: medicaid provides care that's invaluable, but it is reeling under it own weight. states are now being asked to implement the largest social

program since medicare and medicaid began. medicaid is falling apart as states cut benefits, as enrollment increases because of the recession, and we're still seeing the after effects of the recession. a recent report came out about the state of state finances two weeks ago, and it's a very challenging environment still. what does health care reform mean for you as physicians? what will be different? what will life be like? the good news is, more of your patients will have health insurance. while we were having dinner last night, dr. katari was mentioning how when he was around in 1965 when medicare got started, basically had to close the clinic because older people no longer needed a free clinic because they had medicare. here there will still be uninsured americans, but there'll be far fewer of them, and that's 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 floor. there are some provisions in the health care reform law, terms you may have heard called patient-centered medical homes which are wonderful things. but there are not enough of them, and there are not enough primary care physicians, nor nurse practitioners to be able to handle the number of people who need care. in fact, in many hospitals around the country today if you call up to get a visit, to get an appointment with a primary care physician, you cannot. and we're going to be having 32 million more people come onto the system. and for people on medicare, while we closed the doughnut hole for prescription drugs, the number of jeer ya traditions is actually shrinking. so who's going to take care of those 35 million more people who will be on medicare in the coming decades as the boomers

retire? who's going to cake care of them? who will coordinate their care? as future physicians, you will be practicing professional, team-based care. that will be an expected competency for you. practices will need high functioning teams, advanced practice nurses, clinical pharmacists and others, and you as future physicians will be expected to demonstrate competency in working on professional teams. this will be part of your maintenance of certification assessment. this will be an expected competency, because we have to work in this teams to manage all the care. the other thing that you'll be seeing is downward pressure on physician payment. as all those cost pressures keep escalating, there's only a few ways to cut that, and that is to keep payments low.

we're already seeing that, and we're seeing as a consequence demand for increased -- we use the term "productivity." see more patients in a shorter period of time. that's very dissatisfying to you as physicians, and it's very dissatisfying to patients. on the flip side what's going to happen is increasing volume. we'll be working even faster and faster. so the question we have for the day is, how do we insure that health care reform is, indeed, built to last? how are we going to insure that the house that we've built is going to be around for generations to come? if current trends continue, the data are really clear that we just can't continue. and this would have happened whether or not there was health care reform. if anything, health care reform may accelerate it because we have more people using more care.

but this was going to happen even without health care reform. and this is not a democrat or republican issue. everyone bears responsibility for it. and so happens if we -- what happens if we don't act? an economic fact for just a few minutes. you may have heard about the national debt. the national debt is how much the federal government owes the people who have lent it money. in 1985 the united states was a net creditor to the world. we used to loan money to countries. and here we are in 2012, the u.s. has gone from net creditor to net debtor. we don't loan people money anymore. 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, so it has to borrow money from countries like china to pay

those doctor bills and hospital bills. how much debt does the u.s. have? presently, the total debt is $16 trillion. it's hard to get your hands around what is $16 trillion. so here's what $1 trillion is. if i pay dr. katari a million dollars a day since the year one, since the year jesus christ was born, that would not total a trillion dollars. ..

bailout money from eurozone countries from the international monetary fund. heaven forbid that the united states ever gets in that position. they are monitoring health care reform because the united states is a member of the international monetary fund. that's the situation we're looking at as a country. so where do we begin to change course? that's where all of you come in. especially those who are future physicians will be 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. it does not improve their health. so what's included in that? includes overuse, includes inefficiency, it includes fraud. we'll talk about each of these. and how much the [inaudible] and we waste that every single year. if we can take that out of the system, we'll be in -- even a portion of it we'll be in really good shape and we will have built 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 to do to reduce overtreatment? you're pen the ski stroke to order tests and prescription drugs. it's a powerful tool you have in your hand. as mentioned earlier with the choosing wisely campaign,

there's 27 million societies that have developed the top five listing or are developing them of things question do a lot less of. or maybe stop doing at all. in addition, there are other procedures and surgeries that have been well documented in the medical literature as being overused. heard bypass surgery, back surgery, antibiotic use. all overused. in september of this year the joint commission which accredits the nation's hospitals or many of them. will be hosting the first meeting on overtreatment and looking at number of topics and trying to comic-con census on what it can do as an i creditor of hospitals to encourage hospitals to reduce unnecessary treatment. i think we have a moment in time now with health care reform that if we have unnecessary procedures, let's stop doing

them on people who don't need them and use the talent and skills and resources on people who need them. if we can make that switch now, everybody will be kept intact. maintenance and board certification if you'll be seeking it in the future, i see your heads come up in 2015 appropriate youth will be part of maintenance of session. knowing when it is appropriate to do imaging for low back pain, for screening or osteopathy, when it appropriate if you do oncologist for that third round of chemotherapy and when is there no evidence it will actually benefit the patient. this is what you have the opportunity will be required to learn and a good thing. so we can keep the system whole for everybody who needs it.

what is overuse? it was defined by the instituted of medicine as a potential for harm exceeds the possible benefit. so this is not about rationing twhb is not about cost control, this is in fact about good care of the patient. i've been continuing to work on overtreatment, i was here two years to talk about the book i wrote called "treatment trap" i'm happy to say now that there's a lot more momentum to address this issue of overtreatment. here's what some patients are saying about their experience. a colleague i used to work with said getting an ekg since i was 27. i'm 41 now. i don't know i've been getting it. i have no heart disease. my husband gets one too. i spoke with a person recently and she said, you know, i went and talked to my doctor and i don't get those anymore.

and the same with my husband they're not medically necessary. here's another one, i get a chest x-ray every three months from my doctor. i don't have any gorped lying medical condition. next time i'm going it ask why. this actually came from a state legislature. i gave a caulk at the counsel of state recently. it was how we really have to address this issue of overuse if we're going have a sustainable system and house where everywhere can line in. he brought this up, and he said he was going go back to the doctor and say why am i getting it? think about the radiation he was exposed to. who is counting that? do you know how much it is? we're not tracking it. and we probably should. here's another one from a patient my knees were hurting and i well to a well known orthopedic surgeon he said he could do surgery.

he didn't talk about me and situation. i left and found a personal trainer who helped me strengthen my muscles. i'm better now. we are see good informed people make good decisions. it's not everybody by every stretch. we're beginning to see it and good doctors have good conversation with their patients about the appropriate use of resources. that is what the choosing wisely is about. i'm happy that you'll be learning choosing wisely as part of the curriculum. and finally, my 83-year-old mother-in-law was having problem with her shoulder. she went to a doctor who said he could operate i wind with with to a second opinion. she was fine after physical therapy. better outcomes better care, and by the way it cost less there are abundant opportunities in the health care system to do this. i think the way i think about

health care is how we deal with food. on the one hand, we have an obese epidemic that is off the charts. people eating too much food, the wrong kind of food. we have pockets of communities where people are malnourished. if we the extraordinary inbans. the same is true in health care. i have people getting too much and people who can't get what they need. if we can reduce the overuse, and naught to a good use for people who need it, we'll have enough to take care of everyone. we had that opportunity to do it now. we have to get started. because we don't have much time or money to waste. that was the topic of the book. how do we curve? and finally here is a factoid i fount interesting, the fbi has done an estimate of how much

fraud there is in health care. i began to look at this and gave a talk at the health care ain't fraud association. turns out about 10% of health care spending is loss to fraud. and the extent of it in the sophistication of it is enormous. if we can take 10% of health care spending we spend 2.6 trillion a year. that's $2.6 billion that we -- $260 million that we spend that's 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 to curb it. there are modest steps. very important steps with the far cry what we could do to take it out of the system and use that money for good care for

people who need it. the people who come to your clinic here at st. peters who are uninsured who get better care. what can you do? we have to preserve and sustain the god that 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 add value to life. what can do you? you as physicians and nurses? you can ask yourself if the test or procedure you're contemplating, will it do them any good? will they be better off? what do your peers say? do they agree? the good news is we're seeing more and more consensus although there is a lot of different points of view on this. but i'll leave you with the quote. it from began i ghandi. he says recall the faith of the

poorest in the weakest man whom you may have seen and ask yourself if the step you contemplate is going to be of any use to him. will he be better off because of? then your doubt and yourself will melt away. that's how we make health care sustainable. h's how we can make health care reform live for generations to come so they get the care they need. the care that will sustain then and bring them healthier happier lives. thank you for all you do. i'd be happy to have your questions. [applause] [inaudible] jowl to go to the microphone so everybody can hear. we're on tape.

>> hello, good morning. >> good morning. >> [inaudible] >> hello. >> might be [inaudible] what i'm seeing is the own rate, the health care system -- [inaudible] as you say on the grid to equality there will be a lot of pain and other avenue that materialize in the open world where even the health care might be exported, and people might even [inaudible] seeking health care elsewhere. knowing all that, and only seeing the globalization of the trade not industry going abroad a lot of people aren't missing

out on employment and like wise health care to the -- [inaudible] and it seems that a lot of pain along the way. it is this particular part which is going to be so troubling unregulated, un[inaudible] practices might prop up along the way and we'll have to dream with all of those. one of the things that comes to mind is the way we have taught at med school we learn indication of this indication of this operation indication of that operation or this treatment or that treatment. then when the time comes to take care of a patient, we tend to think the same way the indicators -- [inaudible] on the operation. by the way, i'm a surgeon. i have an operation to offer

you. nothing else was talked about about for the patient. the patient left. rightly so. so the mind set has to be changed as we [inaudible] with a single patient what is the treatment? along the way not particularly the offer the most excessive treatment or the most rewarding treatment for yourself. but i don't think that's taking care of the patient welfare. i leave you with the thought that the medical establishment has to particularly -- and the med school level. we are teaching you this way. in fact i taught myself 0 years ago. i fought myself indication of this and that and such. thank you. >> you mentioned the word

disruption. because of a federal law, federal officials are required to report at the certain point when the medicare program reaches the certain fiscal situation. i won't go into all the details. but since the administration of george bush and more recently with the obama administration, federal officials have issued funding warnings about medical medicare financial state. they use the term the descriptive consequences to society if we don't fix the long-term trajectory. so you're right about that. let also say something about globalization. i had the privilege of speaking at the british medical journal institute for health care aimprovement conference in april on the evidence of overuse and translating it into improvement. i asked the audience from people around the world. 70 countries represented. a noim the sure if they were all

there. i asked them have you or someone you know have medical care you or they thought was unnecessary. all the hands went up. i ask how many reside outside the united states. all these hands went up. i was surprised to come up after ward from the finland, japan, germany were seeing the emerging markets in brazil and india evidence of overuse. this is a global phenomena that we'll have to tackle. in provinces in canada. 42% of the bucket is spent for health care. if you're doing that you're not spending education on infrastructure, investment science and technology. thank you for your question and comment. hi. >> i'm debby gold seen. i'm the gastroneurologist i

could spent an hour counter pointing and rising there's so many issues that infiment. i want to make a couple of points. that is the first thing is the whole issue of primary care. the primary care physician is being asked to be the foundation. the primary care physician has the most responsibility of any other physician. they have to know everything, they have to know -- they have know what the right and left-hand is doing. they have to coordinate. 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 health care. they can do that. they have to go dpasser they have to see more patients and

it's crushing. it is crushing. and there is no incent iive for people to become primary care physicians. they get the least amount of money, the most responsibility, they have the biggest burden for lawsuits, and that brings me to the whole issue of the fact there is an inbalance. this inbalance that we have and i really don't know who was behind closed doors when the whole obamacare of 50 billion pages was implemented. but i got -- as a physician out in the trenches here there weren't enough of us in there to formulate the plan. and i feel that, you know, just from my gut, from my soul have to believe that because all of the people who implement this plan all of the congressman has been to be lawyers and because of the fact we can't control health care costs, part of the

overuse of health care has to do with the fact that we are shaking in our boots and have -- half the time about being sued for things we shouldn't have to be sued for because using clinical judgment and standards of care just isn't good enough sometimes because when the lawyers are breathing down our throats, we still have to worry about the time that we have to spend in a courtroom for a five louse lawsuit that's going to take us away from the patients and even if we are found to be not guilty we spend time, we're away, we lose money, our patients suffer, and the lawyers are laughing to the bank. the same thing happens with -- and i'll close. i know, i'm going on and on like a mad person. [laughter] >> no. >> but the other thing that is that as soon as you have political action committees that are powerful and the political action committees of the

insurance companies are powerful. so what do we do? we said everything has to have health insurance. okay. so the ceos who are making all the money that you talked about are laughing to the bank because now everybody has to have health insurance, but there's no competition across state lines. we have lost the sense of exe toyings make a product that gives good care that is going to provide people with a care that they need. instead we have, you know, we have people having $2,000 of deductibles. they never get any health care coverage at all. premiums going up. no competition across state lines. if you can go online and pick any health care insurance product in the country. maybe we would have competition and people would care about providing a good product. maybe there would be good insurance and maybe those ceos would have to take less of a bows us in.

we're talking about fraud of such a huge magnitude that has to be routed out. we have a lot of work to do and a lot has to do with government. >>well, you know, thank you very much for your comment. i think it reflects a vows of lot of physicians and doctors. [applause] [inaudible] the ama in the end came out and supported the health care reform law despite many opposition the community was divided when it came to whether or not to support it. the division now continues. i think you make a good point, i would take at from the patient perspective. did health care reform design a system that was going to be good for patients. in "the battle over health care" we take a look at the price bubbles. the toxic assets in health care. drugs that go on the market and go off because they're found to be harmful. we have a lot of too big to

fail. we have a lot, you know, financial interest at stake here that make it difficult to change. i think that relationship between the patient and the physician -- i'm not sure health care reform was built around that. and that's not good for doctors and it's not good for patients. thank you. yes, sir? >> can you comment and also address how the health care reform would address the issue of the dart mouth atlas recently published about 50% of health care cost comes in the last two years of life. and guess which state leads the way in the atlas report? ? new jersey. >> it's new jersey. >> okay. >> can you comment on, you know, care at the end of life. the cost of the end of life and how the new health care reform would address that? >> well, as you know, there was an attempt to put a provision in the reform law that would allow

medicare to pay for a conversation between a doctor and patient about, you know, serious issues that could -- about a life-limits illness. suddenly we have the term called death panels that cropped up that took the provision out. the intention of that provision was to recognize that when patients are seriously ill, and it was commented earlier seven minutes is not enough time to talk to your physician when you're facing a life. limiting illness. the intent was to create a space and time what i call the sacred conversations about what peoples choices are. what is important to them. so we tried it it was for political reasons, i believe taken out. you know, i spent twelve years at robert johnson foundation to

bring health care into the mainstream of the health care system. it started when a major study came out that was published showing how poorly we care for people at the end of life. and so we launch a major initiative and we started to help hospitals and physicians and nurses establish care programs in their hospitals. which is a good thing. people can get the care they want. so the early form of shared decision making. while it has taken off and we have a specialty -- [inaudible] the question remains how come ended end of life care cost keep going on? what's there to stop it. on the other side of the equation or families are deeply troubled about what they see their loved ones going through. it's a manifestation we don't know what to to stop. we don't have a mechanism to

stop it. that will rely on physicians, future generations, i would love to hear your thoughts on what to do to make sure people get the care they need to benefit them. we have public expectations. we have an overuse problem. if you turn on grays admatty. we feed the public more is better. there's a cure for everything. the television show, "house" every test can be and should be done. we have created the environment for the public to believe more is better and how do we begin to reverse that? that's what the choosing windsly campaign does. one thing we should stop doing is chemotherapy after so many rounds. i can't agree with you more. it's very tough politically to do. a lot of first time i heard

patients and families describe what they see their loved ones go through in terrible terms. almost like post-traumatic trees they experience because of the expensety. medicine desire to want to do good also we need the wisdom to know when to stop. consistent with a preferences ever patients and families. thank you. >> i think there is a -- problem not a -- is there any reform on the actual cost of -- like, it's impossible to get your brain around the cost of medicine because it costs $33 ,000 but you get two. what does it cost if a hospital can sustain itself based on what they get? what does it actually cost? >> i think it's a great question. and i would hope that 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 need to be good stewards of resources. and so he went back home to the hospital, and he asked the financial people to go through the inventory with them in the operating room to find out how much all those things cost. he had no idea. it turns out there was -- he was surprised. there was $700 ,000 worth of supplies and equipment in that inventory. 10% of it was expired. he wilgded it down saying i only need $29 5,000 worth. enormous savings. that's just one operating room in one hospital. so then he went to the ceo and said, imagine if we did this system wide and call late they

can save billions of dollars. just by asking a simple question. when you prescribe a drug for your patient, when you do a test, you don't want to be done on the basis of price. but just being aware of how much these things cost. we have done -- remotely by the default. let just do it. we all need to be good stewards of resources. simply asking the question and now we're seeing more price transparency begin to come out with the blue book. they have no idea, they think they're going to pay $1500 for a cool on that's new guarantee we see prices come down. i think it's asking the question, simple question how much does it cost if is a place to start. . hi. >> my name is [inaudible] i'm a medical student from a university. and my question has to deal with

more about medical education and the cost of it. go one of the probably the most expensive medical school in the country and that kind of goes with what doctor earlier when coming out of medical school we're a high amount of debt that kind of changes, you know, the opinion of the students, what field should go into. how am i going to sustain myself in the future? and pay off my debt and have a good living? so what is, already changing the way we get our loans, subsidizes i think they have taken some of it away this year. what is being done about that? also 32 million -- more medical schools are opening up. how are we able to provide and sustain for the cost of education and producing one physician more and more i feel requires like a lot from society. college, medical school and

training. so your thoughts on that? >> thank you for asking your question. i think we should ask the same issue what does it cost to train and why does it cost that much? on what basis do we decide that it should cost -- it in fact costs that much. i think what we have with medical education, we have the college cost going up and health care cost going up. we have the perfect storm of health care and education coming together. you fall in the middle of the storm. you and other medical students. i don't think there is any answer for that health care reform law has provisions if people want to go into primary care and work in underserved communities. it's not an answer. health care reform did not fix that. thank you. we have one final comment. >> yeah. [inaudible] i'm a neurologist.

i sympathize with the medical student's plight. the current education system and that burden they have doesn't lend them into primary care at all. this is what we need. and so the system has to be secured in a way that should be incentive enough or some sort of relief from the -- [inaudible] education in the system. otherwise we will wind up importing doctors specifically geared for primary care. i think that is the avenue that the country will have to take. >> i think that's what happened to -- [inaudible] it's the lowest paid of all the specialties i believe within medicine. and 40% of fellowships are unfilled. as i understand. t that and other factors. foreign national medical graduates come in and do the

fellowships. they may not have the -- [inaudible] health care reform fixed part of it. there are many other things that need to be done. it needs to be put on the agenda. thank you very much for all you do and the care you provide. [applause] >> every weekend booktv offers 48 hour of programming focused on non-fiction authors and books. watch it here on c-span2. >> several years ago when the queen was at one of the yearly garden parties making her way through a crowd of nearly 9,000 people and greeting a selection of guests, she was asking such standard questions as have you come far? when one woman looked at her and said, what do you do? [laughter] several days later, at the friend's birthday party, the queen described the exchange and

confessed, i had no idea what to to say. it was the first time in all the years of meeting people anybody ever asked her that question. any job in writing "elizabeth the queen" was not only to explain what she does, but to tell what she's really like. and take the reader as close as possible to elizabeth the human being. the wife, the mother, and the friend as well as the highly respected leader. today i'm going talk first about what was it was like to write about queen elizabeth. and second i'd like to share you some of the many surprising discoveries i made about the queen. because she is the the best known woman in the world. people feel as if they know her. but the real woman is very different from the woman in velvet. this is my sixth biography. all of them about larger than

life characters. there is no one like the queen. she lives in her very own remarkable world. other heads of state have come and gone, elizabeth is the longest serving leader in the world spanning 20th and 21st century. she is the 0th monarch of the 1,000 year history. reigning over the united nations of england, whales, scotland and northern ireland along with 15 realms and 14 overseas territories. she is the second monarch to celebrate a diamond jubilee marking 60 years on the throne which is a milestone she will reach on february 6th. the only other was the great, great grandmother whose celebration was 115 years ago. in 1897 when she was 87 years

old. elizabeth will soon turn 86 is still on the throne in september 2015, she will surpass vict or it ya's reign of nearly 64 years. between the two of them, victoria and elizabeth have been on the throne for 13 -- 124 of the last 174 years and symbolized longer than the four man that were kings between the reigns. elizabeth is always surrounded by people. but being queen makes her a solitary and singular figure. it is crucial for her to keep a delicate balance at all times. if she seems too mistiers you, she loses her bond with the subjects. if she seems too much like everyone else. she loses her mystique. he doesn't carry a passport or have a driver's license although

one of her cousins told me that she drives like a bat out of hell on the roads of the country estates. she can't vote. she can't appear as a witness in court, and she can't change her faith to roman catholic. because of her hereditary position everyone around her including her closest friends and family bow and courtesies when they greet her and say to her. she was trained by strict nannies who prevented her from being spoiled she was trained from childhood to expect the -- a friend of mine told me about the time when then princess elizabeth came to visit the family castle in scotland. he playfully threw her on to a sofa. the father, the 12th earl took him by the arm, punched in the stomach and said don't you ever

do that to royalty. the princess didn't mind my friend toll told me that was in the structure in which she was brought up. how does a biographer particularly an american penetrate the royal bubble especially when she was head for the last sixty years not granting interviews. it wasn't too different from the way i approached my other books which was to turn to those who knew her best for insight and information. i a long time bio. i have visited britain frequently over the past three decades. i have made a a lot of friends. some of whom who helped me on my book in princess diana. why started researching the queen's life i went back to a group of key sources who agreed to help me again and introduce me to more people who knew the

royal family. they also served as my advocate the in getting cooperation to buckingham palace. my book on i diana had been fair to the royal family and particularly to charles. so the senior staff at the palace briefed queen and gave me the green light. as a result i had access to the inner circle of close friends and advisers. the queen has disciplined herself to keep her views and emotionals under wraps in public, those close to her shared with me some of her fascinating opinions and feelings what worried her most about prince charles when the marriage to i did man that was falling apart. a what would became if she physically or mentally incapacity and even politically sensitive opinions including one hot button issue she discussed with an american ambassador. her friends explained the secret

of her screenty and courage and they sized her up sometimes in unusually perceptive ways. monte roberts the california horse whisperer was one of the most unlikely friends told me that the queen gave him good advise she shows an incredible ability to read intention just like a horse does. with the assistance of the palace, i was also able to watch the queen and prince phillip in many different settings at the parade at windsor castle while presenting honors at buckingham palace and one after annual garden parties. i received a personalized invitation on white -- embossed in gold with with the queen's crown announcing that the lord

chamberlain had been commanded be her majesty to invite me. everybody got that. watching the queen at that garden party make her way along a line of people. i was struck by the measured pace. the lord who was senior official at buckingham palace later told me she moves slowly to absorb everything that's going on and just take as much in as she can. i also marveled at mastery of brief but focus conversations. and her storedy stance. a technique she once explained to the wife of one of her foreign secretaries by lifting her evening gown above her angle and saying, one plants the feet apart like this, keep them parallel, make sure your weight is evenly distributed and that's all there is to it. as i observe the queen overt

course of a year, i accumulated impressions that help me understand how she carries out her role and how earnestly she does her job with great discipline and concentration in every situation. she is not just a figure head. and she has an em pressive range of duty every day except christmas and east easter she spends hours of reading the government boxes. they are delivered, they are red lettedder boxes that can only be opened by four keys. she reads them in the morning and at night and even on weekends. one of her close friends told me about th time during one of the queen's visits when she was -- must you madam her friend asked? the queen replied, if i miss once, i might never catch up again. mary who is the youngest

daughter of the queen's first prime minister winston churchill told me when elizabeth was 25 years her father had been impressed by the attentiveness she always paid attention to whatever she was doing. it's hard too imagine the amount of information that the queen has accumulated over six decades, and she has used in exercising her right to be consulted, to encourage and to warn when she meets with government officials as well as senior military officer, clergy men, diplomats who come her. the fact there's knob else there giving them a feeling they can say what they like. the most important encounter of these encounters have been the weekly audiences with the 12 prime ministers. consider the trajectory from

churchill who was born in the 19th century and served in the army of her great great grandmother queen victoria to david cameron the current prime minister who was born three years after the youngest child prince edward. she actually glimpsed the first of her -- for the first time her future twelfth prime minister when he aspiredded at age eight in the school production of toad of toad hall. probably her most fascinating relationship was with margaret thatcher and in the course of our reporting, i gained some great insights into how that relationship worked and some of which contradicted the common view. the queen cousin not have executive power but she does have unique influence. in her role as head of state, she represents the government officially at home and abroad

but she also serves as head of nation which means that she connects with people to reward their achievement and remain in touch with their concerns. two decades past the normal retirement age she still does something like 400 engagements a year. traveling around the united nations to cities as well as tinny hamlet. charles was served as private secretary to both john major and margaret thatcher told me that the queen knows every inch of this country in a way no one else does. she spends so much time neating people she has an understanding of what other people lives are like. she understanding what the normal human condition is. she's also spend an extraordinary amount of time honoring citizens and members of the military for great service. in sixty years, she has coniferred more than 400,000

honors and awards and given them in person over 600 times. people need pats on the back sometimes she has said, it's a very dinghy world otherwise. traveling with the queen was particularly valuable especially the overseas royal took took to bermuda and trinidad. she was 83 years old at the time and the program called long days of meeting and greeting. her stamina was impressive. matched only by 88-year-old prince phillip. whenever they go off on a trip together like that, the lord channel leer blin accompanies to the airport and phillip turns around and waives at him and says, mind the shop! i got a real sense of how much sync they are with an export choreography sort of like fred astair and gingers roberts. i saw aspects of him that

contradict of characteristic. he watches the queen intently to see whether she needs any assistance. i once saw him bring a little child over to greet her. he often spots people in the crowd who can't see very well and walk them up to give them a better advantage point. when the queen needs a boost, he's thralls with a human more aside don't be some sad sausage. on the last night in trinidad, i also witnessed a close range what i heard about from several people that the queen doesn't press pyre even in the hottest temperatures. the british high commission was he'sing a garden party in the hill top home an steamy evening that everyone incoming me was dripping from the heat. but after an hour of lively conversations with some 65 guests, the queen walked very

closely by and there was absolutely no moisture on the face. one of her cousins who traveled in the tropics with her explained to me in her own way that the queen's skin does not run water. [laughter] and that while it may look good, it does make her uncomfortable. i saw further evidence of this a year later on a july day at ground zero in manhattan when the temperature hit 103 degrees. and one of the women, the queen spoke to said to me afterwards. we were all pouring sweat she didn't have a bead on her. that must be what it's like to be a royal. during the trips, i was able to see the buckingham palace machinery on the road. to get to know the senior officials and get a feel for thes atmosphere around the queen and the way the household has changed in the early days when it was run entirely by

aristocratic men. as i stood in the lobby of the hotel the masters of the household pointed to half dozen footman one of whom who was a woman dressed in navy blue suits. see sam over there, he said, he has a master's degree in pail yen tolings. he was a far cry from the stereo type of abby. >> you can watch this and other programs online at booktv.org. now joining us on booktv is scot who is the publish of penguin press. we want to find out the new titles. i want to start with the "pate yarnlg." s a enextraordinary story. ted ken city before the death reached out to -- among other things and gave him an extraordinary offer. he gave him exclusive ax excess

to the ken city family papers the paper of his father which had never been shared with any biographers. there was no strings attached. there was no family review. david spent years on this book digging through the archives, digs pass the mit and started from scratch. one of the things the papers allowed him to do is hear the kind of closer to the emotional core of joseph kennedy because joseph kennedy letters had never been used. crucially david was able to follow the money. the kennedy family fortunate has been a black box. and david's able to put together exactly how joseph kennedy did it. hollywood is a big part of the a story in the way that hasn't exactly been understood before. we know about wall street. we know some of the myths some are more true than we thought.

others less so. and i think in the ended why ted kennedy we can't ask him now, why ted kennedy -- he saw in carnegie sort model of the father's wife. somebody who made a great fortunate relatively early and spent the rest of the life figures out ways to do good or do things with it. of course in joseph kennedy's case the things he didn't was help make the son president. that piece of the story how joseph kennedy was involved in the son's assent and ultimately the son's election to president. it's fascinating. there's news breaks in the book. >> a book coming out as well? >> it's the auto biography. a memoir of state craft. it's for a man that has a reputation of a diplomat. it's nicely unvarnished. no secret he had issues with the

bush administration over iraq. there's no secret he had issue with the state of israel over lebanon innovation. in sense what is point i can't about the book there is a lot in about it what e i had tried to fail to do. the limitation the power. what i think is quite moving to and not really openly expected is this is also reminder how much of the u.n. actually does do to improve the lives of billions of people around the world in a way that is really off the radar screen and his account what the organization does and its role in the world today, it's an argument for in a sense. it can't do and at end of the day, it's a great stateman with great power on the world stage with some of the most dramatics issues of the time telling stories about people. telling stories about events. telling you the true thoughts

about the great characters he's had to work with. >> so both mr. nah saw's book coming out in the fall of 2012. >> that's right. this book after the election kofi's book before the election. right around the u.n. annual meeting in new york city. >> nobel prize winner? >> his long awaited memoir of the war whicher to his country nigeria apart in the late '60s was a scar that runs through his life. he's never talk abouted it or written about it. the book is in part a coming of age and coming of age for himself as a writer and his country. and u [inaudible] it shows the hope, the promises for the young country and how tragically hope turned into hatred and how the civil warrer to the country apart and set it

on a aligned course. . it's a beautiful book that is in part about the role of a writer in being a voice of conscious. what is the artist role committed? what is it to stand up and sort of, you know, speak for those who won't speak or can't speak. he has done that since the first novel quality things apart." it's in high schools all over the country. it sold 80 billion copies since the publication in 1959 through to the memoir which is a magnificent capstone to the great career. >> how did it health. >> he's in the mid 80s. he's in a wheelchair. his brain is still as strong as ever. we're going be careful with the time. many time would like to do things with him that fall around

the publication. we have to be careful and limited. what we will do, i hope, we'll bring down the thunder and great a great sense of 0 scags. >> finally a former "washington post" writer tom who is familiar to a lot of viewers on c-span has another military book coming out. >> he does. it's in a way kind of the cull man nation of 25 years in covering mt. military. it's called the generals a study in military command from the world war ii to the present looking at the art of the general. what is is it to be a general. what differentiates generals from not so great generals. one of the things that provoked the book in 2005 tom was called a staff ride in sizely going over the world war ii battle grounds. some officers and they were telling tom the sorry of the battle and tom was struck by the fact that the general who lead the innovation initially in

sicily was fired two weeks later by omar bradley. this story tom heard just literally months after a essay by an army counselor rocking around the military. today in 2005, a private suffers more grief for losing a rifle than a general losing a war. being a general is really hard and should be expected that many people fail at it. that command is famously hard. the american military had a tradition of firing generals and there wasn't any shame in it. and the military has completely lost that tradition. generals are essentially only fired by the president for political reasons. he wanted to understand what happened to the culture. he follows from the generals from world war ii to korea to iraq and afghanistan to the gene yolings and looking at whats to

be a general and why is that what's going to ysh i i can't read the whole thing for you. basically said, you know, this is exactly what the book we need. we need as an institution to ask yourself about the question about the leadership and how we hold our leadership accountable. and this is the book about how organizations need to hold themselves accountable their performance or else they stop becoming effective. it's a book about the american military. it's great military history. it has a lot of ramifications. anyone who works in the organization that needs to improve or die, basically. >> we have been talking with scott moyers who is publishers of penguin press. ..