of the u.s. senate. on weeknights watch key public policy events and every weekend the latest nonfiction authors and books on booktv. you can see past programs and get our schedules at our web site, and you can join in the conversation on social media sites. >> next, rosemary gibson presents her thoughts on the future of medicare and argues that the health care industry, more so than the public, is dependent on the $600 billion of annual medicare spending. this program is a little under an hour. >> for today is medicare and where we're headed and what it means for you and your patients. today in washington, d.c. the obama administration is preparing to release its federal budget proposal tomorrow that will have changes proposed for the medicare program. you might think, well, i'm not over 65, although some in the room may be over 65.

what does medicare have to do with me? in fact, medicare has a role in the lives of all of us including residents. the president's proposal will be yet another ongoinge de o fturef medicare. both democrats and republicans have proposed raising medicare's eligibility age from 65 to 67. others have proposed that seniors buy in to the health exchanges that will be coming online during the health care reform. and others have proposed eliminating fee-for-service medicine in medicare entirely and having everyone enroll in a private insurance plan. these are proposals on the table hotly debated. i wrote the book "medicare meltdown" to help the public understand what's going on behind the scenes, the debates that dt show up in the mainstream media. here's why medicare matters. there's 50 million people who are covered by medicare for their health insurance today.

this hospital and every hospital depends on medicare for a substal portion i revenues. for those of you who are residents in training, you may not know that medicare pays your residency stipends. it pays for faculty salaries. it makes residency training possible. all of us pay for medicare, and we'll all be covered by it, so it's something that we all have in common in the united states. here's a graph from the congressional budget office from a couple of years ago, 2007, that projected historical -- using historical trends in medicare spending where are we headed. in 1996 about 2.5% of our gross domestic product was spent just on medicare. and at -- if those historical trends continue, by 2082 we'll be spending 25% of the country's gdp just on medicare.

from that same congressional budget office report, and, by the way, these graphs were tucked away in an appendix on the last page and haven't seen much light of day, but i think it's important for the public to know this. total health care spending, if historical trends continue, by 2082 as a country we'll be spending 99% of our gdp just on health care. and so this is why there's urgency around medicare and health care to find some mechanism to limit how much we spend. and that's the purpose ofthe book "medicare meltdown." and it focuses on the business aspects of medicare, because not only is medicare an entitlement for senior, it is also big business. and be that's a powerful force driving the trajectory of health care and the kinds of care that patients receive. if that respect -- in that respect, it shines a light of aspects of medicare that we don't read much minute. more of the news i read now is

blooerg and other business news t findut what's happening in health care. the book examines where the money comes from are to pay for medicare, where it goes, who's getting it and what they're doing with it. and i believe the public has a right to this information because we're all paying for it from our paychks and those who are on medicare from the premiums that they pay. and once again we look at the outsize influence of the health care industry on medicare. it is, indeed, an entitlement for seniors. it's also the largest federal entitlement-based industry in the united states. let's talk about the size of medicare. if medicare were a country, it would be the 20th largest economy in the world. it's enormous. medicare spends $560 billion in 2011 for 50 million people. and this dollar amount is more than the size of sweden's economy and double the size of ireland's economy.

just medicare as one portion of health care. so no matter whether democrats or republicans prevail in shaping medicare's future, turns out medicare will become very crowded by 2030. every day 10,000 boomers sign up for medicare, and 33 million more people will be on medicare by 2030. this number is equivalent to adding the current combined populations of austria, hong kong, israel and switzerland to the medicare program. hospitals, doctors, nurses and the entire delivery system are and will be under increasing pressure to take care of everyone, and are we ready for it. medicare pays for residency training, pays for almost all of it. it pays the cost of your sty pends, it pays for teaching physicians' salaries and other expenses. and with pressure on the federal debt, graduate medical education is certainly under the budget microscope like many other

things. your residency training is fued by $9.5 million in funding from medicare, that's a combination of state and federal money, and once again it's being closely scrutinized. i'd like to do three things this morning; identify where the money from medicare goes andow it's being used, second, discuss the impact of the incentives in the program and what it means for patients and their physicians meaning many of you, and i'd like to make the case for limits on medicare spending to sustain this program for current and future generations. for those of you who are young people in this room, you want to count on medicare and insure that it's there for you. so, first, where does medicare's money come from, and how's it being used? 1965 medicare laid e foundation for the establishment and growth of the health care industry. in the past 50 years, we've seen an explosion in biomedical

advances, dramatic innovation in therapies and surgical procedures and tremendous successes in the management of diseases that were once fatal. and medicare has also changed the u.s. economy in unprecedented ways. here's two graphs on international spending on health care from 1980 to 2007, and i'll just direct your attention to the graph on the right. these are total health expenditures as a percentage of gdp for a number of developed countries. and you'll see that the united states, it's the black line, is way out aad of al the other countries. but once again this has enabled innovation and the application of wonderful health care services to millions of americans who have benefited. who pays for medicare? many it turns outay we for medicare. all of who work pay for medicare from a 2.9% payroll tax deducted from your paychecks. if you look at your pay stub, you'll see this amount deducted

every paycheck. you also pay foredicare from your federal income tax that you pay, and seniors over 65 pay premiums and co-payments. this is a reader comment to the new york times in response to a column written by paul krugman. the reader wrote: >> in fact, that's a myth. here's the truth. 44% of medicare spending is paid for by federal income tax revenue. so medicare does contribute to the federal debt, because the federal government does not collect sufficient money from the taxes and other sources to pay all of its medicare bills and has to borrow money and pays interest on that debt. so, yes, medicare does add to the federal debt.

this means that when bills are sent to medicare, theal fed vernment doesn't have the money to pay all of them, and it borrows money from places like china. and the u.s. federal debt exceeds $16 trillion. and that's an enormous sum of money and growing. most people think of medicare as an entitlement for seniors, and it is. but medicares also big business. health care businesses and facilities rely on medicare for $560 billion in annual revenue, the amount that medicare spends in a year. in 1965 there hea care companies listed on the fortune 100 list. today there are 15 health care companies that are on that his and are dependent on medicare and other sources of funding for their revenue. and these interests have a ov the future of medicare.debate there's a debate, for example, over whether medicare should be privatized to move from fee for

service to private health insurance plans. already medicare is partially privatized. most people don't foe that. % of sniors,rhaps some people in this room, belong to a private health insurance plan for their medicare coverage. in "medicare meltdown" i predict this trend will continue. health insurance companies certainly want customers, as be as they can, and certainly the 33 million new baby boomers who will be enrolling in medicare between now and 2030. let's talk a little bit about medicare waste. the institute of medicine at the national academy of sciences estimated last september that 30% ofalth ca spending, including medicare, is lost to waste. that might be from administrative costs. we were talking earlier about the cost of billing. it's an enormous sum of money. unnecessary treatment and, of course, fraud and this amount of medicare waste, believe it or not, $170 billion, is the size of the entire

economy of new zealand. and all of us are paying for it from our paychecks,or our premiums. here's a narrative from a very conscientious doctor who tried to cut medicare and other health care waste in his hospital. he's a very dedicated pediatric neurosurgeon that i've had the pleasure of knowing from my work in health care. he heard a talk in washington about how physicians should be good stewards of health care resources, so he took that missive seriously, went back to his hospital and asked the cfo to bring someone in to help tell him how much all the supplies in his operating room cost because he never knew. so the cfo sent over a financial person, and they went through all the inventory in this surgeon's work r. and what they -- or. hat they found was $700,000 worth of supplies. 10% had expired and had to be

thrown away. $70,000 worth thrown away. and he said i only needed $295,000 of that $700,000 worth of supplies that were needed. he was astonished. he had no clue. he said the sutures that the hospital was buying, i could buy them for $35,000 less, and so he encouraged the hospital to buy the less costly product. he was very eager to tell the ceo that he thought he'd discovered a gold mine for the hospital, that this would be a way that the hospital could save lots of money and keep that money for patient care and other things. so he set up a meeting with the ceo, and he did a back of the envelope calculation about the millions of dollars that he believed the hospital could save if they could purchase supplies and equipment much more cheaply. and it turns out he hit what i call the brick ceiling, the noncompetitive, nontransparent, quote, market for hospital

supplies and equipment. this is a $200 billion market that accounts for 8% of total health care spend, and in the 1980s, this market received an anti-kickback extension from congress. what started out as a costco model where people can buy volume of services less exnsively ha turned into one of the most expensive ways possible to purchase anything on the planet. recently, i asked him how things were going, and he said i went to buy a piece of ultrasound equipment, and i went online and found it for a certain price. and i realized that the hospital d to pe it through its own channels and paid a hundred times much what he could find on the internet for that piece of equipment. i'd like the discuss the impact to have the financial incentives in the medicare program and what it means for patients and their physicians. we are in medicine, as i'm sure that you see here at st. peter's

and every hospital around the productivity.e age of, quote, researchers at the mayo clinic surveyedore than 7,000 doctors, and 46 had at least one symptom of burnout. demands for more productivity, quotas are one factor in doctor burnout and in unhappiness. some of you may have seen the "60 minutes" segment that aired months ago. there were employees of a hospital based in arkansas, a for-profit institution, and they were expressing deep concern about the quotas they had to admit patients frhe er into the hospital to keep the revenue growing. "60 minutes" reported on this hospital system that allegedly pressured its er doctors to admit more and more patients regardless of medical need in order to increase revenues. the er director reportedly told the er doctors, i've been told

to replace you if you don't meet your numbers. ia toe aple, when physicians tiom t er, the hostile computer system would send a message questioning the physician's decision. physicians were concerned about nonphysicians telling physicians whether or not to admit patients to the er. here's a document reportedly from that hospital, and if you see the names of physicians are over at the left, a on the right are goals that the physicians were expected to meet. one of the goals that the hospital set for the physicians was that the percentage of patients over 65 who should be admitted to the hospital from the er was 50%. so half of all medicare patients who showed up in the er, the physicians were expected to admit them to the hospital. and there were also testing guidelines that you seee. that meant that every patient who was admitted to the hospital there was a series of testing guidelines that physicians had to follow, so the hospital could

continue to bill. and as you can see on the right-hand side, physicians were pan measures.r complianceit american medicine. this is what's happened to i'm sure it's not the medicine that dr. kirschner would have wanted to have seen. and what about the patient? what about the person who shows up in the emergency room? who expects that they're getting good care? when they're admitted to the hospital, they may think that thai getting good care, that they're being well taken care of when, in fact, the attention is very different. quotas in productivity in medicine are becoming morean more pervasive around the country. once again patients may think that they're getting good care. in fact, they don't know that they're being placed at risk by being admitted to the hospital; the risk of infection, complications from diagnostic tests without any benefit. and also financial burden. the annual hospital deductible for medicare is more than $1100.

and plus they pay a 20% co-pay for every day that they spend in the hospital. so patients are placed at risk, and they're also paying for it. this is the new medicare. the hospitals being investigated for these practices, and the fbi estimates that up to 10% of the money that medicare spends each year is lost to fraud, roughly $60 billion. and meanwhile, the talk in washington of raising the entitlement, raising the eligibility age for medicare so extraordinary in light of all of this waste. and by the way, this amount of alleged fraud from -- as quoted by the fbi, is equivalent to the lifetime contributions to medicare from about one million middle income seniors every single year. this is part to have waste in med -- of the waste in medicare. as the business of medicare grows, so does the ri o dual loyalty. facilities that have questionable cultures that put

finances ahead of patients create challenges for the ethical physician. for-profit facilities have a primary legal duty to yea physician who practices in organizations like that, he or she recognizes that his or her license requires that he or she has a primary duty to the patient, and there's an inherent conflict if that. in that. here's an example overuse from theedicare program. dr. richard deo from oregon health sciences university has, for decades, done extraordinary research about back surgery. he published a study in the asion op efthe american medal complex $80,000 back surgeries on people on medicare. he looked at medicare billing day from the from 2002 to 2007 for various forms of surgery, and there's a link to the article if you'd like to take a look at it. he overall rate of

surgery did not increase, he reported, the percentage of cases in which the complex procedures were used climbed from 1.3% to nearly 20%. and these -- if use of these more complex, more expensive approaches were correlated with a higher rate of complications, a greater risk of death and more than three times greater hospital charges. this was a topic that i discussed in the book, "the treatment trap," about the overuse of unnecessaryan unnecessarily complex tests and procedures. so the result is that the surgery that has no proof of added benefit went from a rarely-performed procedure to comprise nearly 20% of surgeries of that type increasing the risk to patients and increasing medicare spending. so we've created a system in medicare where more better, and the most expenseoff way possible of doing things is how we do business in health care today.

one of the reasons, the medical device makers have heavily promoted the devices and materials used in more complex surgeries which itself can cost $50,000 per operation. an editorial noted that the surgical fees can be ten times more for the more complex surgery with more complications. so we pay more and are getting less. here's a conclusion that i draw in "medicare meltdown." seniors' entitlement to medicare is not why medicare headed over a fiscal cliff.health care indus entitlement to medicare's money is what is driving medicare over that fiscal cliff. as dr. qatari mentioned, i spent a number of years working to bring paltive medicine into the mainstream, so i grew familiar with physicians, nurses, social workers and others. hospice is a medicare benefit.

it accounts for just a small peentage, just 1% of total medicare spending. yet its trends are a microcosm of what's happened to medicare overall. hospice care in the united states began as a charitable patient-centered effort by florence wald who was the extraordinary former dean of nursing at yale. and she and other colleagues, physicians and nurses went to capitol hill and advocated and testified on behalf of making hospice a medicare benefit. in the 1980s, inform, d -- in fact, hospice did become part of the medicare program. hospice is paid on a per diem basis. just 25 years later, half of all hospices have become for-profit, and hospices have settled with the justice department for enrolling people in has possess care who are not dying which is fraudulent use of medicare. the largest for-profit hospice in the u.s. has been under

federal investigation for fraud. a former manager accused the hospice chain of enrolling people who are not terminally ill. the parent company is roto-rooter plumbing. hospices spend money to defend these claims. they hire lawyers to do this. where does that money come from it comes from hospice revenues. where does that money come from? if you're paying payroll taxes from your paychecks, you're helping to subsidize the cost of defending the indefensible. and the reason i wrote this book, it was for the public to see the connections between the money that you pay, the money that we all pay, where it goes, who's getting it, how it's being used so we can use our democracy, be informed, and advocate for reforms that really help patients and their physicians. in 2012 of january, the department of justice had a lawsuit against an arkansas-based hospice operating in 19 states. according to kaiser health news,

hospice employees went door to door in public housing projects to find people they could label terminally ill and enroll them. this is all part of the prtivity and quos. get more,morend do the most complex things possible. this is what's happened to this wonderful program started with great intentions called medicare. nurses were instructed to chart negative in the medical record even when patients were stable or improving to justify the hospice be continuing to ref $150 per diem. and patients forgo curative care when they're in hospice. nonclinical senior managers were involved in many decisions on when patients should leave hospice. one of the most extraordinary things i learned was how private equity full-terms are investing in hospices. private equity is used to bring working capital to organizations to help sometimes turn them

around or expand them. it also have been useful to wring market and managing expertise toteis t ue have to ask is what value added does private equity bring to a labor intensive activity? the most limiting fact for hospices is lack of enoughs. and for an interintersurprisehi. for those who are supportive of bringing the market to pear in our health care, it's important to bear this principle in mind. treasured be an exchange where both parties benefit. we have to ask the question, all of us, what are patients? and all of us who pay for medicare receiving in return for money being taken. the public is compelled to ask what is the benefit to the patient. if we break down total spending,

we can break it down by price and volume. when i was here last time, i mentioned this study that we reported in the journal of internal medicine about the variation and costs of charges in california for the treatment of of an uncomplicated appendectomy in 2011. the price range was enorms, to $1500 to $182,000. and the researchers took out the outliers. these are for patients only who spent up to three days in the hospital. so the outliers were removed. the public couldn't find out which hospital had the lowest rates and which had the highest rates. and, by the away, we recently published the fact that senator mccaskill, a u.s. senator, went for a knee replacement operation. and beforehand she called three hospitals to find out how much it would cost, and she said she couldn't find out. she said i'm a u.s. senator, and

i couldn't find out how much it would cost. and for those of you who read the time malignant zien -- magazine article. i think what the impact of that is we're seeing more and more members of the public who are urging and wanting information on price. in fact, democrats and republicans have introduced legislation in congress calling for price transparency and health care. at any rate, back to this charge in california. the median charge buzz $33,000. compare that the incoming capita of california of $42,000. an enormous sum of money. and i wet a 65-year-old medicare beneficiary from kentucky. he went into the hospital for one night for a procedure which he did not name, but i would suspect the -- and he was floored by the hospital charges which were $244,000 for one

night if hospital which is the cost of of a house in his commitment. >> medicare, fortunately, paid only $18,000, but till that's equivalent to the per capita income in his community. he wrote a letter to the editor in his local newspaper about his experience, and i later learned the editor received a call from the hospital requesting the paper not publish such letters in the future. what we need is more public discourse on these important issues, not less, if we want to change the status quo. a challenge that we face going ahead is how do we engage patients to insure that they get the care they need and not the care they don't? i gave a talk to a group of legislators last summer in new jersey. these were legislators at the state level from all up and down the east coast. and i was talking about the overuse of ct scans. and after-- and the um pact of

radiation exposure. and a state legislator who was the speaker of his state assembly came up afterwards and said, you know, i go to my doctor every three months. i get a chest x-ray every time. i'm not sure why. i don't have anything wrong with me. he thought he was getting good care. but there is no reason that he would know any different. so all of us as members of the public have to be aware. i said to him, well, what -- after hearing this talk, i said what are you going to do? i'm going to ask him why am i getting all these chest x-rays, that's the right thing to do. think of the cumulative radiation exposure that he had. i was delighted to hear that steven weinberger from the ark cp came to talk about choosing wisely, an extraordinary important initiative in the medical community that's -- where the specialty societies are identifying the top five things we should be doing less of, and i'm also deleted to hear that dr. qatari is integrating

it into the residency program here at ft. peter's. but what's the next step? i think we have to go for the bigger ticket items, the overuse of heart bypass surgery. these are life-changing events for patients, and we know from what physicians have said in a report in 2008 under the us auspices of the national quality forum that these big ticket proceed juries are overused. it's interesting to note, however, that overuse was taken off as an explicit priority of the national group called national quality form. that happened not long ago. it's interesting why it happened, and it's unclear why it happened, but one can imagine the very powerful forces that don't want overuse on the national agenda. it's going to be up to the public to put it back on the national agenda. i had the pleasure of working

with and associating with very progressive and thoughtful colleagues in medicine and other healing professions. i'd like to share this e-mail that i received from a patient safety colleague. i received this e-mail just a few week ago, and i thought, i'm coming to st. peter's, i should tell you about this. here's what the e-mail said in part: >> what i took away from this is tt

moment of awakening, that moment of realization of what's really going on. how do we keep that awake ping alive and have more people wake up? that's the beginning of when we can see things change. i've worked in many fields in health care, end of life care, overtreatment, and none of these are exactly enticing topics. [laughter] and so they can be challenging to bring to the public debate. but here's a quote from schopenhauer, a 19th century philosopher, who said: >> i've seen this in the course ofe discussions on patient safety around medical errors for decades and decades and decades. we could never talk about the fact that we harmed people.

and that is has changed. we've been to open up. and as dr. qatari mentioned, the acme will be p coming and talking about patient safety. because as young residents, you deserve a good learning environment, because that's when you'll learn to become good doctors. it's interesting that president obama used to talk about overuse. in a speech he gave to congress in his first term, he mentioned it, that we need to curtail overuse. but i don't hear president obama talking about overuse anymore as a factor in reducing medicare spending. so once again it's going to be informed members of the public who will have to put it back on the agenda. citizens will have to be the ones to correct the misallocation of resources because it will not self-correct. while preparing for talk, i was thinking about what are some of the solutions, and i was in

princeton, new jersey, a couple of weeks ago walking along nassau street, and there was a bookstore. and there was a quote in that book store about how democracy -- to fix our democracy, we need more democracy. we need more informed citizens who are aware of what's going on to serve as a countervailing influence, a check and balance in the system. i think the biggest challenge we face is that health care companies whose primary duty is to shareholders, they have to demonstrate increased revenue and profitability. they have to do that as a condition of their corporate statutes. and this drives price and volume up. and this reality is in direct conflict with our needs as families, as employers, as state and federal governments to do the exact opposite. here's a quote from charles prince, the ceo of citigroup, in 2007: we'll keep dancing until the music stops. that was a theme in "the battle over health care" book.

one of the renowned capitalists of our time, jon vogel, was the founder of vanguard mutual funds. and he describes what he calls the pathological mutation that has gripped wall street in his book, "the battle for the soul of captain limp." he said what's happening is money can't be made honestly, then what's happening is we're cheating. and i believe we have a battle waging for the soul of health care. of we have that same pathological mutation gripping it to the dismay of ethical physicians. and the fallout from the pressure, older adults on medicare are marmed by preventable -- harmed by preventable events. 75,200 medicare beneficiaries in hospitals die of preventable harm. and that was a topic i brought out in the book "the wall of silence." so where do we go and what do we do? i've proposed in "medicare meltdown" that we need to have a

conversation about setting limits on health care spending and medicare spending. here's the, how much of the average social security check is needed to pay today for medicare part b and part d premiums and can co-pays. in 2010 a person who earned an average wage throughout his or her life and retired in 2010 paid 27% of their social security check just for medicare part b and d premiums and co-pays. that's an enormous sum of money. when medicare was started, it was only 6%. there was only part b back then. but look where it's headed. when i'm old, look how much it's going to be. for those of you who are young residents, look how much you'll be paying from your social security check. and now there's a debate in washington to reduce the cost of living adjustments in social security. so what do we do about that? there's a wonderful line from the great law of the iroquois:

>> in health care we have to consir the impact of our decisions for our generation and the next generation, because we don't have seven generations to wait. from the medicare trustees report: >> they have projected that medicae funding for hospital care will run out in 2024. they'll be able to pay only 90%. so should we have some limits to health care spending? what do you think? is it time? if you think about it, every system has limits. every family has a budget. every business has a budget. every government has budget. a country can't function without red lights. how did this all start? it happened because of how medicare was designed almost 50

years ago. there's no limit on how much hospitals and ore provider -- other providers can bill medicare. there's no market mechanism or regulatory structure to place limits. this was the chief design flaw of medicare when it was enacted in 1965. it's called the open-ended entitlement. what do you think? should we change it? do we need to install some red lights? just last week medicare officials had proposed an ambitious effort to limit hospital spending so it grows no faster than the overall economy. it would use maryland's unique rate-setting system to keep hospital spending from growing at roughly half its recent rate of increase. in the state of massachusetts, the state legislature and governor agreed to legislation that capped total health care spending both private and public so it would not grow faster than the overall economy. what do you think? should we do that?

and even in congress and the white house both president obama and members of congress, paul ryan, have proposed limiting average medicare spending per beneficiary to gdp growth at 0.5%. we don't hear much about that. but both of them have proposed limits, because they know that trajectory that we're on. what do you think? should we have limits to how much we spend? the health care reform law had proposed ap independent advisory board, it'd be set up with 15 members appointed by the president, confirmed by the senate, and members would recommend ways to curb medicare spending. it was based on the base realignment and closure commission. we had to close a lot of military bases. it's very hard for elected officials to make those decisions to close a military base in their own constituency, so they ceded that responsibility to experts, and congress had to agree or disagree. that was the model used for the

independent payment advisory board. it cannot change medicare raise premiums, cut benefits, and if congress doesn't like the recommendations, it doesn't have to agree with any of them. but what happened? it was repealed in the u.s. house of representatives. claims of rationing and government interference in the doctor/patient relationship were made. is that what the opposition was really all about? was it about the interests of patients? or was it about the interests of not being able to continue to see revenue growth. i propose in "medicare meltdown" that the real opposition was the health care try's desire to move any impediment to what they have to do as a condition of their doing business which is to keep doing business. and also the industry has tight relationships with members of

congress and didn't want to take that away and give it to nonelected officials. but, again, remember congress still had the final say. so for the public watching this on c-span, the main message here is that the public's entitlement to medicare, in my view, is not what is causing medicare to fall over the cliff. yet the debate that we're having in washington is putting the onus on older adults, raising the eligibility age, increasing premiums. the health care industry's sense of entitlement to medicare's money, i believe, is what is driving medicare over the cliff. and as you listen to the medicare debates in the coming months and years, this is an issue that you might want to keep in mind, and you can decide for yourself what you think. for residents in this room, for the young physicians, what does the future look like? well, this gives you the reality of the overall context in which you're working. you should also know that there are many extraordinary places in

this country where you can practice good medicine. and you'll have to go look, and you'll have to find them. but they're out there. i was just in maine last week giving a talk, and i met some of the most extraordinary young physicians who are practicing medicine the way good, ethical physicians like dr. kirschner would have wanted young people to practice medicine, to have a career like that. it is possible. but you'll have to go look for it. in closing, i'd like the remind us of why we're all here, what medicare was established for, and it's about the patient. and this is a quote that i took from mahatma gandhi, tweaked a little bit. and here it goes:

>> thank you very much for all thed you do for patients who come to this hospital. it's noble work, it's not easy work, but it's work worth doing. thank you. [applause] we have ten minutes for questions and comments. and, please, come to the microphone which is over here. >> [inaudible] the mic is not on? i'm in cardiology practice for many years. i was very surprised about --

[inaudible] hospice. i have a patient who -- i'm a little bit emotional, so give me the time. i had a patient who i have been taking care of for the last many years, and the doctor come to me, and she says that i can't take care of her. i want my mother to be put in hospice. so i say, well, your mother is not dying. so she said, well, i want her to be in hospice. what i say? as far as i'm concerned, the criteria is you have end-stage cancer and you can't take care of yourselves, you're going to die within six months or something like that. so she left. about two weeks after that, patient, i got a form to sign a form to acknowledge that the patient has been already

enrolled in hospice. so i had absolutely no role. they bypassed me. and now they want my rubber stamp, and i did not sign. in spite of that, she's still in hospice. so the question is, what -- no. if this is going on, what the future? i mean, so i think your point is well taken about hospice. i was surprised myself, too, and i told somebody after that incident that this is one of the biggest fraud going on in medicare now. >> right. >> because if they can bypass me and enroll a patient in hospice, then you can imagine what can go wrong, what can happen. thank you. >> thank you, doctor, for sharing that.

i can't imagine what kind of position that you were placed into, asked to put a patient in hospice who was not likely and should not have been placed to need hospice care and should never have been placed in it. i can't imagine what that's like. and i, too, was stunned when i saw what had happened to something that started out as a mission and became something else. and the reason i wrote this book is so people can understand what's really going on. and that this is what's happening in manager as important as hospice -- in something as important as hospice care. there's a saying in india that you might know. if you have a big pot of rice, all you need is one grain to see if the pot is cooked. if this is happening to 1% of medicare, what's happening to the rest of it? thank you for sharing that. and i believe what we need is more of the public to be aware so we can have a countervailing influence and set up a checks and balances system. but people don't know.

we have to start telling them. >> [inaudible] and i don't know who -- [inaudible] >> yes. >> a person who has never seen the patient -- >> the person's never seen the patient made the decision. >> [inaudible] >> and you've been taking care of the patient for 20 years. thank you. yes, sir. >> thank you for an excellent talk. just going to make two comments. one, i'm an oncologist in practice for 20-plus years, more than that. my experience at least has not been the type that, you know, you had mentioned, but anytime you make anything for-profit, things will change, and the priorities will change. tell me what your thoughts are on the t.r. reid's book healing of america where he talks about the fact that he goes to six different countries, seven different countries, looks at different models and comes back with the fact that you cannot have a health care entity that

are for-profit. once you hitch your wagon to wall street, in some form or another, you've sold your soul. >> well, i think a main point of writing "medicare meltdown" is to show how the influence of our capital system has entered such profound decisions between doctors and patients, has affected how physicians practice medicine. and we need to be aware of it and say what do we do. the only thing i can come up -- because, you're right, the system will keep doing what it's doing because that's what it's supposed to do. and the only checks and balances i can see is setting limits on how much we can spend and then within that we as a society have to figure out how do we have best use of those resources, reduce overuse, improve prevention, keep people healthy to use it for the right reasons? so i agree with you with that underlying trajectory that's causing great challenges in our health care system. >> what do you think with the united kingdom's --

[inaudible] national institute for -- [inaudible] excellence? which is a different issue altogether. >> with i think we do need to have a conversation about whether we pay for things that work or don't work. the public expects it. why are we paying for things that are not effective? i talk to physicians who sit on the fda's approving committee, and the, fda's approving drugs that are actually less effective, have worse outcomes, more risks than drugs that are perfectly fine and already on the market. why is that? because we have to keep doing the innovation thing. you have to keep the business churning. you have to keep producing it so you can say to your shareholders, this is what's in the pipeline, new drugs. but are they any better? so i think n.i.c.e. is right in that respect. the only side the public heres is, oh, my god, this is interference. this is actually good medicine. this is good for you. so i think we should absolutely do it. and we have that with comparative effectiveness research. and the industry, you know,

behind the scenes screamed that this was government getting involved in medicine. well, we should have people who know good science determine whether patients should be getting this treatment or that treatment. that's good medicine. we should be doing it. yes, sir. >> hi. [inaudible] primarily teaching. there was an article a few years ago called the perfect storm of overutilization which had several suggestions about what might need to be done among, if you will, were theville villains they identified as the pharmaceutical industry. and with the mass rate of thoroughness, we teach overutilization. >> yeah. >> i think we as people who are responsible for the next general ration of physicians must -- generation of physicians must keep in mind that there's a limit when -- [inaudible] there's more than that. tort reform is an important part of it too. all of these things are things which cannot becched

overnight, but i think have to be addressed by people like you and the government as well. >> i agree about the storm of overutilization. but i've come to the conclusion that we will only get serious about it if we set some limits, and we have to make choices. otherwise i think we'll keep doing what we're doing. and thank you for trying to educate the next generation on good care, what you need and helping people get what they need, not what they don't. yes, sir. >> [inaudible] i'm a urologist, and i frequent this hall every tuesday morning, and nice to hear you again. >> thank you. >> it seems that solution is already at hand. of but in the construct of give me a place to stand and a big enough stick, i'll move the

world is what you -- [inaudible] we need to get some sort of empowerment in this regard to implement some of the things you already identifying. but the message doesn't reach. >> right. >> in its entirety. of that's the thing. if a solution has a, b, c up to z, if some of the things are omitted, the solution will not work. >> i -- >> empower the patient to take care of this thing right from the start is what we must be thinking. >> i agree that progress is very, very, very slow. we started overtreatment, a discussion in this country, about that. came onboard to move that very quickly. i be i think the only way we're going to take out seriously is if we have limits on how much we spend so we can make decisions on what's best for the patient, what's not. and the only way to do that is

to let the public know about where we're headed. and that's why i included those graphs in the "medicare meltdown" book. if we keep doing what we're doing, we'll be eating grass and picking berries. i grew up in suburban new york, and the grammar school i went to closed in part because of budget cutbacks. why? because their health care spending for their employees in this 30,000-population town keep going up, so they closed the school last year, two schools in the school district. this year they're laying off 15 teachers. why? because their health care expenses went up 27% in one year. so i think the public's getting the message about price transparency, but we need an organizing principle around it. i think that's part of it, and then the next step is setting some limits on how we can spend, how much we can spend as a society. thank you. >> thank you, dr. gibson, for this talk. my name is ely kirschner, i'm

jack's son, and i'm the medical oncologist. what i wanted to talk about was i enjoyed how you explained how medicare is breaking the bank. but what you didn't really talk about is the whole mathematical system in this country and how the myth is that we provide the best medical care in the world. which i think is one of the biggest myths that we hear coming out of washington. we can provide the best medical care for individuals, but as a system it really is failing. >> right. >> and, but one of the pieces of information that i think is very interesting is that the health care for people over the age of 65 is better in this country than most other countries if the world, and that is because of the system of medicare which is, essentially, a universal health care system. and the one thing you didn't talk about was the problems with private health care. and it seems to me that that's as big a piece of the puzzle as medicare and the failings in medicare. do you have any comments on

where we should go with medicare in the future? and should it be expanded? >> well, you know, the reality is we're spending enough money on health care in the united states to cover everybody and to provide really good care and to send a rebate check to every citizen in this country. we'd have better outcomes, lower cost and better health. we can do that tomorrow. and we have to, we have -- abuse of these wonderful systems, and so we have to correct the misallocation of resources. what you're talking about is population health for even. keep it simple. you and i talked before this got started. let's keep it simple. and you're absolutely right. let's not make it so complex. i went online to see what it's like to choose among 30 competing health insurance plans for people on ped care in my commitment. -- medicare in my community. i couldn't figure it out. we've made it so complex in the name of choice. i think we've been sold an illusion of choice. what we need is simple. all of this is so basic. as you as physicians know, the

patient at the bedside, let's take good care of them, and let's not lose sight of that. and it's going to be patients and the public who will have to be the checks and balances of the system that we've sort of been asleep at the switch for 20, 30 years. it's gotten out of control, and it's time for us to the take back our health care. thank you for your questions, and thank you for the legacy of your father's work. and i think with that we'll conclude this session. thank you all for coming today. [applause] >> you're watching booktv on c-span2, 48 hours of nonfiction authors and books every weekend. >> we are at the annual conservative political action conference in washington, d.c., and we're here with marji ross, president and publisher of regnery publishing and conservative imprint based here in washington. booktv viewers may recognize ms. ross who was with us last year for a long conversation

about publishing. how are you doing, marji? >> i'm great. happy to be here, happy you're here. >> great. let's talk about a couple books you have coming up. first off, former lieutenant governor, "beating obamacare." >> this is a terrific book. it's our first bestseller of 2013, so we're very excited about that. we released this book, "beating obamacare," as an original trade paperback because we wanted to make it an accessible handbook, a sort of consumer's guide to what people can expect. you know, a lot of people talked about what was going to happen when obamacare was actually starting to come into effect. well, now it's here, and we've got to live with it, we've got to deal with it. so betsy is an expert in this area. she's former lieutenant governor of new york. she's one of the few people who's read the entire bill, and she goes through it in a very common sense, easy-to-understand -- i was very impressed when i remember reading the manuscript, it was a

very easy-to-understand explanation of what actually is in the bill, what these different, um, laws are, what the rules are, what you can expect with these different exchanges, how it's going to affect people in their paycheck, in their withholding, in their, um, insurance coverage that they get at their job. so it's just a very practical guide for consumers to find out what they're facing. >> and this is regardless if you're a conservative or liberal. >> actually, it is. she is not a fan of the law, but she walks you through in a very practical sort of consumery way, what do you need to do to navigate this. >> okay. next book here, david her sanny, obama's "four horsemen." >> this is our newest book out. as you can see, it's rather apocalyptic, and that's the message here. i think a lot of the books that are out, have come out in the past few months have talked about america at a crossroads or america at a point where we have

a big decision to make. david harsani, who is a terrific writer and spokesperson, basically says we've crossed that point. it is too late to avoid some of the disasters that we're facing, so now we've just got to buckle down and figure out how to get through. >> and the last week you have, you're -- book you have, you're holding a galley right here. >> this book is not even yet out, but this is our next big book coming in april, and it's called "the ultimate obama survival guide." this is a terrific read. it's very fun. it's also very pact cam. so the first -- practical. so the first part of the book tells us all the terrible things we're facing under a second term of barack obama, and the second half of the book is a very practical survival guide. everything from how to buy gold coins to how to stock your house with food and water to how to buy a gun and what ammunition to

stock up on. he's got, he's covered all the bases in a very, very entertaining way, and you'll be scared, you'll be amused, and you'll be prepared. >> so couldn't help but notice all three of these books deal with obama's second term, and there is kind of an understanding that for conservatives this is something that they're going to have to live through. so how did you go about acquiring these books in such a short period of time? because you weren't really aware of who would win the election. >> that is a terrific question, and that is something that we struggled with and talked about a lot in the second half of last year and, obviously, it's something that our current events publishers have to deal with. but particularly for regnery, because we focus on only conservative political books, that's our niche, and we know every four years it's going to be an interesting challenge to try to publish into the beginning of a new presidential term. especially when you don't know, as you never do, whether it's

going to be the incumbent or someone new. in some cases it's going to be someone new no matter what. and so what we did was we tried to sign up books that were very practical and talking about what people needed to do to survive and thrive kind of no matter who was in charge. and then we knew that once the election was over, we would pivot one way or the other in the positioning of the book and even the titling of the book or the subtitling of the book depending on who won. ..