q&a with toe because euro -- toby c osgrove. cosgrove,ek, toby discusses his 25 years of the cleveland clinic and medicine. us an overview of what the cleveland clinic is. practicea large group with 3200 positions. we have facilities in cleveland. main campus.

we have facilities in las vegas, toronto. we have an outpatient facility in fort lauderdale. we have a big commitment in abu dhabi. we are running a hospital in abu dhabi. it is the largest hospital in the uae. it is a big project. biggest project of its sort that americans have ever taken on overseas. >> you have been ceo since 2004. how many heart operations have you done? >> what kind? doing coronaryt bypass. then i started doing ipass valve

surgery -- valve surgery. surgery andou leave go to the administrative side? event and is an epic you have to stand there all day long. athletes wear out. i see a lot of surgeons come to the end of their career and stop when their athletic abilities deteriorate. i want to stop before that happened. i was not rated hang up my spikes completely. to hang up my spikes completely. i saw some opportunities and went and did them. theirdecessor announced retirement and i threw my hat in the ring. >> if you could name one thing that you have done since 2004, what would it be? washe best thing i did

focus on why we have a health care organization. was, we arepeech going to put patients first. i handed out buttons that said that. that is our norstar. star.th whether you are an administrator or working, we are all working for the patient. >> we will get back to some of your past. the cleveland clinic has been mentioned many times because of the new health bill that comes into effect on october 1. i want to show you a speech the ted cruz of texas made. he mentioned you. of this bodyrs might say, well, these are hard times. everybody is struggling.

maybe the cleveland clinic is just responding to the economic challenges. who is to say with the cleveland clinic is doing has anything to do with obamacare. is,, the answer to that who's to say? the cleveland clinic. for the cleveland clinic said, to prepare for health care reform, cleveland clinic is transforming the way care is being offered to patients. money was going to be cut from the clinic's annual budget. you want to talk about direct job losses, go to cleveland. go to those working at the cleveland clinic and depending on the cleveland clinic for health care. is one real manifestation of the train wreck for obamacare. >> what you think?

>> we have to understand what is going on across the country. we have gotten ourselves into a situation where we knew we had to change health care because it has gotten so expensive. it is consuming 18% of gdp. is eating into education and other social programs that we want to have a need to have. expensive than any other country in the world. harness that inflation rate. we have to control it and bring it down. we have to remain competitive. we have been at this a long time. this, is a process that started several years ago. we have begun to make health care delivery more efficient. example,for consolidated services in hospitals. we have closed a hospital that

two 2000-bed from hospitals. foronsolidate services rehabilitation and cardiac surgery. for pediatric, as well. and, for trauma. we consolidated services from five trauma services -- centers to three. . this is been a long process. is that a loton of things are coming to a head that we have concentrated on. we have concentrated on purchasing in the last two years. we took money out of purchasing the last two years. we have illuminated redundancies. so that youocks and

cannot order redundant labs tests. have put in block so that you cannot order redundant labs tests. we know that we are going to get paid less. companies are paying is less. medicare is paying is less. sequestration had an effect on hospitals. the amh funding is decreasing. to decrease our costs further. all this goes into trying to change our health care. it is not one single thing that did it. it is not one program. it is a whole series of things that we're doing. starting back 5, 6, 7 years ago.

these changes are so significant, in terms of what we're going to get paid. we now have to be more stringent. that as what led to offering people early retirement. >> did you expect, after you made this announcement, that the obamacare connection would be made? >> actually not. qualityoncerned about and looking after our employees. , we areur caregivers not buildings, we are people. my concern was for people. how can we make the transition more graceful, if we have to do it. or, how do it loosened the fact. the effect. loosen

i had a nine month schedule the that i do every quarter and we televise to all of our locations. i explained to the organizations what is going on and what we are going to do. i never thought that this is something that would become a political football. this was concerned about delivering great care. >> how many employees you have? >> we have 43,000. peopleave offered 3000 early retirement and we expect that we will get six or 800 people -- 600 or 800 people to take that. we do not know what the long- term implications of that will be. we are poised, if we have to do it further, to reduce.

>> how is it that you are nonprofit? >> we are a $6.5 billion is a and. organization. we are non-profit like every other hospital. there is no shareholders and there are no bonuses. goes back residual into the organization and doing research. >> you pointed out that there is no tenure at the cleveland clinic. explain why you say that and what difference that makes. >> that is a good point. all of us are salaried. we have no financial incentives. i can say, you need a heart operation. about whether or not i think you need it or not. that is a wonderful feeling to

be able to say to a patient that you are not doing it for your financial benefit. all of us are salaried. we have annual professional reviews. eachyear, we sit down doctor and go through how they are doing. they tell us what they think they need from the organization. it is a wonderful way to get feedback. is the way almost every business in the country works -- it is the way all most every business in the country works. >> the more heart surgery you do, the more you bring to a hospital and the more money that comes in. >> that is correct. the direct relationship is not there. example, if -- for we need you to help us with our

transplant program, we don't --t you to give up the fact we don't want you to not think about what the institution needs. it couldbe clinical, be research, it could be a combination of those. they could be business. all those things go into how we decide to pay people. -- the fact that we do not have tenure, i think it is a wonderful thing. tenure, frankly, allows us to say to people that they are not fitting into an organization and not contributing. thank you very much for service. it is time ago. -- it is time to go. had to take to

operations that your member, what would you pick? >> surgeons do not remember the successes. they remember the failures. euler more for failures in the successes. learn more from the failures than the successes. those failures stand out in your mind and you replay them. failure? a >> somebody dying. happen?ften did that >> less and less. cardiac surgery, when i started, was in its infancy. one day, we lost five children. it was terrible to come back the

next day and do it again. , mortalitya resident rates were double digits. my whole career was trying to morbidityrtality and down to one percent or less. link obligations and the -- the plications and stays in the emergency room have gotten better. >> when did you decide to put that on your website? >> i became -- about 25 years ago, i became the chairman of cardiac surgery. cardiologist see the patient and make the diagnosis to refer them to die -- to surgery. i thoughtportant --

it was important to explain what the implication from surgery was. we had a report where we as cardiologist to come. we stood up and report the results of bypasses. cardiologist would ask is for results a week and put them in a booklet. they want to intelligently tell the patient the risk. , let's distribute this nationally. we think that every time you look at the results, you find something you can do better. improvement,teady looking at all the things that are not as good as they should be. when i became ceo, i said, let's do it for everything. let's do it for cardiac surgery and dermatology.

the cardiac surgery is pretty easy. people either make it or they do not. you count the results pretty easily. a lobbych harder and other specialties. take dermatology. what is quality dermatology? a dermatologist cannot just tell us that they are a great dermatologist. show us a metrics. show us some numbers. so, i set the metrics. you have 17 or so i'll come books. each year, they get more sophisticated. we talk about the good, the bad, and the ugly. a wonderful is thing. transparency and quality did not happen in medicine until 15 or 20 years ago. >> whose decision was it to put your tax form on the website? >> that is part of our transparency.

but when did that start? >> i do not remember. >> i want to show you the former vice president talking about cardiology. mr. cheney. >> i got a call from the cleveland to -- clinic. they're putting on a conference on innovation in cardiology. they said they had all the suppliers coming and so forth. they had a lot of the doctors coming. they decided that they needed a patient. somebody said, let's get cheney, david -- he has had everything done to him that you could have. this gave us the idea that you can tell a story of the 40-year miracle that has happened with heart disease in this country through my story. way to connect

what went on in his life and all the heart operations to obamacare? >> i think it is hard -- first of all, i was there and heard on described what had gone during that time. he had an artificial assist in him. it put things in perspective. we know, 50 years into development of an artificial , that he lived on the basis of that research while waiting for a heart transplant. amount oftremendous investment over time and improvement. i hope that we will continue to do that kind of research going forward. it is an important aspect for all of us.

cancer,it is the heart, we need to continue to have those sorts of missions. if you look at economic medical centers across the country. country, have a tripartite mission. their educating and taking care patients. -- they are taking care of patients. >> how much federal money do you get a year? >> we get about $70 million. but what for? >> for research. hit?ve you been >> we have been flat over the last several years. -- thataid that are

there are 27 thousand pages of regulation -- 27,000 pages of regulation in obamacare. what do they say? >> i am dyslexic. i have not read them all. outline continuing to how they are going to set up these care delivery systems and how we are going to pay. >> what would you have done if you had been asked to write this bill? >> one of the things that we we havend is that access in the bill has done a great job providing access to insurance coverage so that people do not wind of just going to emergency room. that has been a process that is ongoing. but, we took the cost out.

there's only two ways that you can take the cost of health care. you make a more efficient delivery system. we are on the way to that. we have to reduce the burden of disease. we have to take care of ourselves more. exercisend obesity and are factors in driving up the cost of health care. 10% of accounts for health care costs in the united states. we are facing a synonymy of obesity across united states. we had a deal that. -- we have to deal with that. that was left alone in the bill. this is about taking care of yourself. society, from

food manufacturers, to ,ducators, to food providers understand that we need to understand that there's an epidemic of obesity and we need to make a change. >> you had a board meeting and you took this to the board. what did you tell them that the impact was going to be on the cleveland clinic? time, been over bringing the board along so that they understand. through the financial projections for the cleveland clinic as a result of all the things that are changing and not just one thing. everything that changing across health care. we had toze that reduce our expenses substantially going forward.

>> anybody get salary cuts? >> we have not cut salaries. we want to keep people who want to stay in are good workers. we want to continue to pay them well and at a competitive rate. foray competitive rates everybody who works the cleveland clinic, relative to what they do. you -- what would you say to insurance company about what they do that you don't like? ceos of theking to insurance companies last night. i said, it is important that we figure how to work together better and pulled the friction out of user transaction between the two organizations. we send a bill for somebody who is had a delivery, they have somebody who checks the bill out. we have somebody who checks if

they have paid us. would be nice to say, let us figure out how much it costs and who is going to pester delivery? to pay us forg delivery? that would take the checkers out of both ends. >> there is a television personality that played a role -- or maybe you played a role in .is life, his name is dr. oz >> i walked in the door and he said, what are you doing? said, i have tickets to the cleveland indians. he took me to the indians game. he talking about life. he asked what i was going to do it at the clinic -- what i was going to do at the clinic.

level, you can see was a division chair and became the head of the figuretion, a towering in medicine, to take somebody did, thatt like he something i want to impart to people. >> i think the first time i came ran awas the time i casualty staging location in 50-106 andre we had wounded troops in everyday. 50-100 sick and wounded troops in everyday. i would touch them. i would shake their hands. i recognize the difference that

a personal connection makes. you learn these things as you go along. that is one of the things i remember. >> when were you in vietnam? >> right after the tet offensive. >> what is the impact on your life? >> i learned lots of things. i learned the horrors of war. there is no such thing as a good war. arrived, we watched a firefight the hospital. and, i learned a lot about the world and people. i learned about medicine and the military. they have a transportation system. a helicopter would pick you up in the field. they would stop the bleeding and splint you're wound. you can go to a hospital and get the most sophisticated care.

to be evacuated to japan or the philippines. could be a fact way to japan or the philippines. we took that idea and set up a transportation system. we do not think that all hospitals can be all things to all people. we think that you have to move the patients the right thing for the right time for the right care. we have helicopters and ambulances. we moved about 20,000 patients a year to the right locations for the right care. we concentrate people with .imilar problems at a location it is called the practice of medicine. the more you practice it, the better you get at it. >> what service was it? >> at the time of the vietnam got commissioned out

of medical school. and i after residency went into the air force. >> what did you think of the war? know, the war was -- the human effects of award horrible. r are horrible and hard to understand. it is hard to understand the reporting of it. i, before he was killed in a car wreck, used to talk about the war a lot and how we had different perspectives. d it.ported

it was difficult to understand from anyone position. >> did you change her mind about the war in the last 40 years? >> i don't think i did. enthusiastic about united states getting involved overseas. >> what part of that conversation would david, one of our early guests, remember? how did you to differ? >> he was into the bigger picture and very upset about u.s. involvement there and people who were there. he was very vocal about its. . was a little more confused i was very concerned. i ran a clinic for the vietnamese. >> the university of virginia

said yes. >> thank goodness. being a c- about student, how did you get into the university of virginia? >> they treated me very well, great education, and i am internally appreciative. >> you've gone on to run the cleveland clinic. how many patients do you see here? >> we see multiple millions. >> you did 22,000 operations as a cardiologist. go back to education. why did those 12 turn you down? >> i went to williams college. i was not a great student at

williams college. i frequently talk about french. i never heard a word of french in my life, so i thought, i had better learn the wedding which. i found -- learn the language. i found out i could not do french at all. oui, and iaid oui, we and couldn't find it. it turned out i had 3-d minuses and a d. i worked very hard, but the language i had to do was very difficult. i'm not surprised most medical schools didn't take me. the interesting thing is going back and looking at this and understanding i am dyslexic, i realized dyslexia is a gift.

i think about things differently. i look at things differently. if you look at the writings on professor is probably the expert. would say she finds dyslexic people more creative as they think differently. >> what is the first thing that tells you you are dyslexic, and why did it take 32 years to find out? >> i never heard the word before i was that age, and people didn't recognize it as a defect or a learning disability at that point. i just thought i was not very quick. >> how did you know?

what did you see that we didn't see? >> i cannot tell you that. i wound up with a bunch of patents. differently than other people do to do that. i have a daughter who is dyslexic. the same way. she has become a fashion designer following a difficult academic career from age four college.ay through >> are there different experiences? >> very painful to read. have ever read a novel. >> how did you do reports? >> i work at it. i find a quiet place where there is no distraction and righttrate, take notes,

in the margins, read it slowly. it's very painful. >> you know what the system is. you have to get good grades. is there something wrong with that? >> we have to think about letting people who have that extra diagnosis have extra time, because they are not dumb. they are just slow. a lot of the reading can be changed into tapes, so there is a lot of accommodations that can be made for people who are dyslexic. i've been involved with chuck swabbed, who is also dyslexic. he and i have talked with a inch of admissions people colleges about times tests and bringing people who are dyslexic to come in. they can be productive members of society.

>> go back to the obamacare issue. go back to 2009. >> the reason i visited the cleveland clinic is they have been able to drive down costs any other health care system out there while maintaining the best quality. when i asked how did you go about doing it, they started this thing in 1921. doctors who are part of the cleveland clinic get paid a salary instead of being paid a fee for service. people don't feel like they are losing money out of pocket. they just don't feel they are getting a salary. have anyone else do what you have done?

for service? >> we are seeing that happen. it's interesting how this has come about. we are seeing consolidation of health care. we are also seeing doctors want to be salaried. the unitedors in states are salaried, and if you look at people graduating from medical school, they would preferred to be salaried rather than going and being self- employed. it is a major shift. people are coming closer to the type of care where you work for the hospital. practice.roup we are hospital with employees. >>, and the buildings do you have on campus? >> we have 160 acres on the main

campus. >> how many doctors? or 2000 physicians. >> how do you approach -- are only the harvard doctors getting in? >> no. coming to worky in cleveland is a great filter. people are not coming to go to the beach or go skiing. they are coming to cleveland because they are interested in working there. that's a great filter. there becauseing they want to go to work and they want to work in the service system we have. that's a great service for us. they look at people who are really concentrated and driven about deriving great health care

and great quality. toy probably aren't going get paid as much. just to give you an example, was doingrted out, i about 500 heart operations a year, and i was getting paid 50 or $60,000. been therefter i had i was offered another job to make a million dollars. i stayed at the cleveland clinic he does i like that environment and the teamwork that went with it. >> how many doctors were there when you started? >> it has grown a little. 140. >> how many of your patients are from ohio? >> we draw them from a six , and the rest of them from a five state area around that.

five percent come from overseas. >> how do you deal with it? who can come? >> anybody can come. it is the largest number of medicaid patients in the state of ohio. we take everybody. the lawyers are getting $1000 an hour in this town. their rates keep going up. a are not salary, and you have something called malpractice. how much of that $6,000 the year goes to malpractice insurance? werer malpractice costs $60 billion. we work very hard at bringing them down. have done several things to

bring them down. one thing we say is when we know we have a problem with the patient, we go up to them and say, we have a problem. really sorry. we will do everything we can to make it right. second we open the medical records for everybody. we say, these are your records. you can read it anytime you want. we sign anybody up for electronic medical records when they visit. we want everybody and gauge. if you take away the secrecy of what is going on, and if you take away the fact you might be hiding some tank, it does begin -- hiding something, it does decrease the number of lawsuits. >> do you have any idea how many lawsuits you have? for hiringsponsible

in cardiac surgery. i must have hired 30 on the staff, and there were all the residents and fellows who came to work there in the hundreds. we have about 1800 residents and fellows in training at any one time, so we are a very large organization. >> of somebody comes in front of you, what is your criteria in terms of whether or not you hire someone? >> i think you look for a number of wings. -- a number of things. i think you look at somebody who has had training. interpersonal communication is a big part of that. >> how often do you look at the grade point average? >> almost never. >> why? >> because by the time they come to us to be hired they have gone from college and medical school

to a residency. portionnerally the top of their class, and i don't care if they are number one or number 15 or 20. top applicants. >> if you are predicting what the world will look like in five years based on this new law that comes on october 1, what would you tell people? understand this is about the economics of this country. duty toa patriotic reduce the cost of health care in the united states and keep the quality first class, so there are going to be a number of things that are going to change. who you are going to get your insurance from is probably going to change.

who you are going to see. >> good or bad? >> i think it is a good thing. it allows everyone to practice at the top of their capabilities. work. should do nursing we are going to bring in a new workforce. the people who look after you are going to be different. are different. chronic diseases have gone way up. iq diseases have gone way down. you are going to see more people treated as outpatients instead of inpatients. you have seen that happen already with surgery going to outpatient from inpatient. you have also seen people with chronic disease are going to be treated as an outpatient and

from home. to see more home care. where you are going to be treated, who is going to treat you, and the type of diseases you are going to be treated for is going change. >> what percentage comes from medicaid or medicare? >> medicare is about 20%. .edicaid is about 15% >> in five years what will those percentages be? >> i think we both inc. there is go -- think there is going to be a bigger percentage in 10 years. 70% will be government pay, medicare or medicaid of some sort. who pays. just that's the demographics of the country. >> what will that impact be on

you? >> it is going to depend upon what happens to the payment systems. there is no medicaid. they haven't had a medicaid expansion. we think it makes sense from an economic standpoint to get that past and also in terms of a humanitarian standpoint to get that bill passed. i hope it happens soon. >> what about those sitting in this country bu? have had a lot of complaining. people are saying it is the worst thing. it's going to bring this country down. president obama says it's going $25,000 ar bill by

year. where do you come down on this? know.don't we are in the process of changing. bill, and perfect there probably has never been a perfect goal written. en.bill writt i don't think we can tell you what it's going to mean. we have so many fact or is going on. if the population going to continue to age? we going to find new ways to treat people? i don't know the answer to this. i know there is going to be a major change. newow there are going to be

ways to treat people and care for people, but i think the quality will go up, and health care in the united states will deliver great care like it does now. >> why is it so much more expensive than it is overseas? >> one thing is we have put our people atn treating the end of their lives and very sick, cancer, heart disease. in the last 20 years we have given down the debt from heart disease by 27%. from heart disease by 27%. a lot of places have put their on prodigal care for example. a great example is what happened in china after the second world war. the life expectancy was in the high 20's, primarily from

disease and starvation. health they doubled it. look at russia they see life expectancy going down because of alcoholism and suicide, etc. there is a lot of difference in where people put their money. had a national system. every hospital was built as standalone. it is much different from london, for example. besides thentry united states and the european union has the best medical system? ex-pats a tough one. i think everyone of them has something you admire.

-- >> that's a tough one. i think everyone has something you admire. jobany has done a terrific in putting emphasis on primary care in england. i think you try to look at the best you can find in various countries. >> why is the cleveland clinic opening and abu dhabi hospital? >> i'm glad you asked. thatan interesting story goes back to 9/11. 359/11 we were seeing patients a month, particularly from the middle east, for heart surgery, and they went to five in two weeks. that started us on an opportunity to say, could we do something that will meet these

patients at other places. we met in saudi arabia and with other members. there were about 60 or 70 countries who approached us about doing a facility in the country, and we said, there has to be five criteria. one is we had to have a stable country. there had to be a stable property. i was not going to invest in another country. there had to be financial return. delivert we had to value, and i thought that was going to require a long-term relationship. we were there to transfer our culture. abu dhabi fit all those

criteria. >> how many beds? building one that will have 500. >> you mentioned patents. how many have you received over the years? >> 30. i designed a ring that holds it in place. >> what year? >> that must've been almost 20 years ago. >> how did you invent that? >> i know one of the things is they have leaflets that come together like this. >> where is that valve? >> in the middle of the heart, on the left side of the heart. these leaflets come together like this, and they are held together on a reading.

-- ring. the blood goes outwards. people were using a ring that was rigid at the time. i know the heart is not a rigid structure. i thought, what we want to do is ring thatreading -- flexes with the heart, which would be more physiologic. i tried a number of things. i tied it down. tiedpends on how tightly i it or not. i remember -- have you ever seen an embroidery hoop? you take it off, and you have an

embroidered handkerchief or something like that. i thought, that's what we are going to do. pieceou have a flexible with a measured reduction. everyone use that now? >> it's probably one of the most used in the world. >> what was your day like? what time did you start? >> he operating room started at 8:00. i would get there at seven and get home after seven. >> how many would you do a day? >> i have done as few as two and as many as six or seven. >> what would you advise patients to have a hard problem? what do they most often worry besides death? that.rybody worries about

the second thing they worry about is strokes. at risklooked at who is of a stroke, who is at risk of dying. what their risks are, and we tell them in a matter of fact way about that. probably the other thing is people don't want to go to war with somebody they don't know. they think they are going to war, so you talk to them straight, and they appreciate that. thing is we give classes to people who are going to have heart surgery, because it used to be everybody used to be terribly anxious. they thought, i am the only one this is going to happen to. you take 10 or 15 people and put them in a class and say, here is what is going to happen to you. grouphey think, it's like therapy. it's a common effect on people. >> you were born in 1940.

at makes you 73. how long are you going to do this? >> i'm going to be here for a couple more years or until something happens to me and the board of trustees says it is time to move on. >> you talk about obesity. what do you personally do? >> i use an elliptical, and i watch what ie. >> how have you seen it change? upstate new in york. i don't remember anyone weighing hundreds pounds. that beganly saw how to change. go back to the depression and world warg home from

i or world war ii. they don't look like our population now. >> what caused it? i think you only have to look at how plentiful food is and how people have begun to look at -- you used to drink coke out of the little bottle. now you get it out of half- gallon jugs. it has changed. food has become cheaper, more plentiful, and people don't walk or exercise as much as he used to. about the heart that you want the public to know ? >> it is an amazing organ. it's incredible. if you take care of it, it is going to serve you for a long time.

>> what has happened over the years with heart transplants? become -- >> we have had great long-term results. probability has little changed. people eligible for transplant and only a fraction get it. >> will there ever be a chance artificialcompany heart? >> that has been the holy grail. we have been searching for that for a long time. we are getting closer and closer. i think we're going to have better results with partial heart than a totally artificial heart. >> wordy you walk the lines with politicians left and right? the linedo you walk

with politicians left and right? >> i am not a politician. what i am trying to do is look after a group of people, provide them great quality health care, and make the organization fiscally sound so they can produce that sort of result. >> thank you very much. >> my pleasure. >> for free transcript or to give us your comments about this --gram, visit us at q&a.org q-and-a.org. british laborext,

party leader and millet and addressing party leaders at their annual conference. liband addressing party leaders at their annual conference. later, another chance to see q&a with dr. tony cosgrove thomas president and ceo of the cleveland clinic. we will discuss the likelihood withgovernment shutdown thomas mann and norman ornstein. after that we will continue our series on the health care law and health exchanges set to open for enrollment on tuesday. then a discussion with peter coy about the limit on the debt ceiling, how the issue has been handled in the past, and what potential consequences might the for not raising the limit.

beginning at 7 a.m. eastern on c-span. u.s. chief operation officer wears a few hat. is the budget for the executive ranch. it covers the agencies of government and the department of defense to formulate the budget every year. the second thing is through the act we have, the u.s. chief information officer has the authority to set policy. the visionary view of government and driving back forward as part of what we u.s. chief third, information officer, a