Healthcare Could Be a Lot Better

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I.  Identify and Frame the Issue:

Healthcare in the United States, often called ‘the best healthcare in the world,’ could be a lot better at lots of things. In the year 2000, the Institute of Medicine published a report called “To Err is Human,” which said to lots of lay people what professionals had known for a long time - which is that our system is ‘maddeningly inconsistent and unreliable.’  The estimate was that we kill about 98,000 people a year in mistakes in hospitals. And most of us who’ve had a family member in a hospital have seen something go wrong.  When it goes wrong it’s not usually because the professionals didn’t care, or weren’t smart, or weren’t working hard. It’s because the system has not adopted the same systems of reliability, predictability and assumption of perfection that we have in many other industries. You heard about the airline pilot who goes around with a checklist and a flashlight before the plane takes off. It’s only in the last five years that surgeons have started doing the same thing in operating rooms. So the fact of the matter is it’s not a very good service industry from the standpoint of quality. And from the standpoint in service, I ask you to consider there is nothing you do that you did the same way 20 years ago, except your interaction with the healthcare system. You don’t shop the way you used to, you don’t communicate with your friends and family the way you used to, you don’t bank the way you used to, but even though our hospitals and clinics have new fancy machines that buzz and whir and go bing in the night, the basic infrastructure of our interaction with this service industry is pretty much the same way it was in 1955.

 

II. Underlying Facts and Prevailing Thoughts (Examine Current Paradigms, Assumptions and Facts):

Everyone is an expert on healthcare right? Because you all have either experienced it, experienced it as it used to be or as your flawed memory of it used to be, or you have strong positions about how it ought to be.Healthcare means many different things to many different people. It is impossible for me to say anything of substance that will not annoy or offend someone.

So let’s talk about what we mean when we say healthcare. What is healthcare?

  • Healthcare is a social compact that goes back as long as there has been mankind, that we should gather together to care for the ill and the injured and reduce suffering. There is no religion that does not have as part of its origin and part of its tradition the coming together to care for people, and part of what we expect governments to do, society to do, is to find mechanisms to care for people. That’s why there’s a St Luke’s Hospital, and a Sinai Hospital, a St. Catherine’s, a Daughters of Charity, a Sisters of Mercy – that’s where that comes from.
  • Healthcare is also a professional calling. If you a doctor, or a nurse, or a dentist, or a social worker, or a lab technician, if you’re a professional, you’ve sworn an oath, not just to do a job, but to put the interests, like other professionals, of your patients or your clients above your own. That’s part of what it means to be a professional. And that’s part of why we appeal rightly, today, even in the midst of all this turmoil and chaos, for physicians and nurses and others to heed that calling of their profession even when it may not serve them economically.
  • Healthcare is a source of employment for non-professionals. In fact, if you look at labor statistics for the last 10 years, the only sector of our economy that has consistently added jobs is healthcare. In many towns healthcare is not only the largest employer, but often the only employer where people with a high school degree can go and find a job that has benefits is the local hospital. And so as is so often the case, we have a system whose policy dimensions are often influenced as much by the interest of the workforce in that sector as they are the people whom that sector serves. I used to run a foundation in California – whenever the legislature would come up with the idea for a new medical school, the dean would come to me and ask me to give them millions of dollars, and I would say why do you want a medical school in Riverside? And in fact, the local fathers wanted a medical school because they had dreams of employment – a biotech startup in ecology that was going to follow the hospital. So it’s a big driver of employment in our country. It is a source of economic activity and profit. If you own a Standard and Poor’s 500 Index fund, you own a lot of healthcare stock. It’s the source of construction jobs and pharmaceutical jobs and doctor jobs and the people who make the machines and the people who build the hospitals, in fact, it’s why a friend of mine says the 'Order' that he now sees most prominently displayed in healthcare is the 'Sisters of Sustainable Competitive Advantage.' So healthcare is about 1/7 of the economy. A lot of people are making a lot of money in healthcare. It is therefore a political football. You heard from Chuck Todd, you heard from our speaker yesterday about how the Congress works – it is no surprise that it’s a long standing political football in Washington and in every state capitol because it serves all these other functions. Any of you been to Japan? Any of you seen Kabuki? Basically, the discussion about healthcare in Washington is like Kabuki. It’s stylized ritual where everyone has a mask on and is repeating the same moves they’ve made for a thousand years, going through this elaborate dance with each other. It’s a political football because it’s a seventh of the economy and accounts for lots of jobs. It’s something that people feel deeply about – it is all of these things. And that’s part of why healthcare is so difficult because we have a difficult time figuring out how to frame it.

Should we apply a market test or a moral test to healthcare? Do we want it to run like any other business? Do we want it to be cutthroat competitive, live or die, Darwinian survival of the fittest? Or it is a social calling where we should support every hospital, every place that has someone’s mother’s name on it, because it was the object of their philanthropy whether we need it or not? It’s part of why it’s so difficult because it serves all these functions.

But for most of us, it’s a service industry. For most of us we see healthcare as a place where we go to get a service. And when you strip aside all the hallowed meanings that healthcare has, it’s a service industry to most of us. Unfortunately, not a very good service industry.

So what is a paradigm? A paradigm is a world view underlying the theories and methodology of a particular scientific subject. Here are the seven paradigms that are changing:

  1. Our healthcare system used to be focused on curative things. That is to say for millennium, doctors would sit in their office and wait until something bad happened. And when it happened, they would try to fix it and send you back out, and then wait until something else bad happened. Because of the progress of our biomedical science, we now know the patho-physiology of disease. We know that patients who have hypertension for 30 years will have kidney failure, and so we’re trying not to send them to the nephrologist when they have kidney failure; we’re trying to control their hypertension so they never get to see him, or the cardiologist, or the ophthalmologist, or all the other ologists that you will wind up going to. But our ability to do that is because we now understand the progress of disease in the way we didn’t used to. That’s why we control your lipids – not because your lipids are bad for you inherently, but because if we don’t control your lipids you’ll wind up in an operating room 20 years from now.
  2. Healthcare used to be provided by individual providers. How many times have you heard some politician say this should be between you and your doctor? Bullshit. Modern medicine is a team sport. And increasingly, we will be cared for by teams, with divisions of labor. It turns out nurses do a better job of educating newly diagnosed diabetics about their disease than doctors do. And they call a lot less. And believe me, money is an object. So increasingly, all of us will get our care not from our doctor, but from a team of professionals, each of whom has a role to play. The pharmacist, trust me, understands drugs than I do. Understands interactions and complications better than I do. The pharmacist is the one you want to talk to about that.
  3. Our care used to be based on eminence, now it’s based on evidence. So you used to do things based on what the old professor who taught me way back with gray hair said, or what they said if they were on the faculty of Emory or Vanderbilt or Harvard. Now we say, you know what? Old Doc Jones told me that, but we now have 70,000 patients and the data suggests that Old Doc Jones was wrong.
  4. Our care used to be hospital dominant. When I was in training we used to put people in the hospital to give them two units of red cells, for Christ’s sake. To give them two liters of fluid they’d laugh you out of the medical society if you put tried to put someone in the hospital to give them fluid now. So it turns out that most of the things that even five years ago you needed to be in the ICU for, we can do at home. You can take people’s blood pressure, you can take their oxygen saturation, you can monitor their weight, you can do all sorts of stuff in the community and more and more, people will get their care at drugstores, in WalMart, at home, and not in hospitals.
  5. Our care used to be exclusively biomedical and in America, in part because of our successes, increasingly our care has to be both biomedical and psycho-social. If you look at the diseases of developed countries they are not infant diarrhea, they are not cholera, they are not malaria; they are diseases of obesity and smoking and too many Ding Dongs and not enough treadmills. How you change that? There is no pill to get people to stop eating Ding Dongs. It is a biomedical/psycho-social set of interventions which our healthcare systems in a developed country increasingly has to be competent at.
  6. We used to be paid for volume – every time you do an operation – ka-ching – every time you get in the hospital – ka-ching. Hospitals used to be paid if they screwed up and the patient came back in a week for something they should have done while he was there. No more. So if you think about that, in the old days, hospitals didn’t care if they screwed up – every time they came back – ka-ching. Now they’re not going to get paid again. Now they care very much about getting it right before they send the patient home. They care about making sure the patient has an appointment before they leave. That the doctor knows the patient who was in the hospital is coming out of the hospital. Changes things completely. Paid for value.
  7. And we used to presume that patients were passive – you should do this. Now in fact, sometimes they’re passive-aggressive. Often they don’t do what we instruct them to do – we call that non-compliance. But our system was based on the presumption that doctors decided and patients complied. Increasingly, patients are both patients and consumers. And depending on how your benefits are arranged, you increasingly have choices. I’ll give you an example: in Northern California, in one market, the price for a hip replacement ranges from $15,000 to $80,000. Those are true numbers. And let me tell you that no matter what the $80,000 hospital says, there is no objective information, scientific information, that their patients are sicker or that their care is any better – trust me on that one. So Safeway now has a benefits designed that says to its employees, if you need a hip replacement – we’ve studied the market in our area, prices range from $15,000 to $80,000. The old days of managed care they would have said you have to go to the $15,000 hospital and nobody liked that. Now they say, go wherever you want. You can go to the $80,000 hospital. And take $65,000 with you because we’re only going to pay $15,000. So all of a sudden, as you can imagine, the volume is starting to drop in that $80,000 hospital. Hospital administrator is calling orthopedic surgeons and saying what happened to our admissions? And he’s saying, well I don’t know. Their admissions have gone to the $15,000 hospital. So patients increasingly are acting not just as passive patients but as patients and more active consumers of care.

So, this is again to remind you to be careful. All the things I just said – preventive care, working in groups – this is the recommendation from the Committee on the Cost of Medical Care. The committee recommends that “medical service, both preventive and therapeutic, should be furnished largely by organized groups of physicians, dentists, nurses, pharmacists, other associated personnel; such groups should be organized preferably around a hospital for running a complete home, office and hospital care; should encourage the maintenance of high standards; should the training of physicians should give increasing emphasis to the teaching of health and the prevention of disease; the social aspects of medical practice should be given great attention.” This is the Commission on the Costs of Medical Care from 1932. So as I said, be careful of gloom and doom prophecies; in some ways there’s nothing new in any of this. As they once said about 'America Will Try'; we eventually get to the right answer after we’ve tried everything else.

 

III. Who should address the issue?

About a month ago my wife and I were in, actually two months ago, we were in Cambodia. Anyone here ever been to Angkor Wat? A mile from Angkor Wat you can stick your bank card in a hole in the wall and get US currency from your bank account. I guarantee you can go to the hospital where you were born and you’ve been seeing the doctor twice a year for 50 years and if you have a problem go in the ER and they’ll say are you on any medications, do you have any allergies, like they’ve never seen you before. So think about it, in this industry which in some ways in its clinical manifestation is so highly technical, in its basic interaction with us as service people is like something from the 1950s. When do you go to the doctor? On the doctor’s schedule, right? What other service industry has institutionalized a waiting room? What other service industry says to its customers, our time is more important that your time? So in its basic infrastructure you have this mismatch between the technical miracles we can do, and the way in which the industry is organized.

I was privileged to chair another committee of the Institute of Medicine, it was called “Best Care at Lower Cost.” Let me just tell you aside from its Chairman, its members were really smart. CEO of a health plan, CEO of a hospital, a former astronaut, a distinguished health care economist from the University of Chicago, a cardio-vascular surgeon, a pharma executive, a nurse, an expert in consumer relations, these were, as they say, ‘serious’ people. And our report concluded a couple of things that you need to know. The first is that we waste an awful lot of money in healthcare. About $760 billion a year. For those of you who think its all fraud and defensive medicine, I’m here to tell you it’s not. It’s mainly unnecessary services, inefficiently delivered services, missed prevention opportunities. Our healthcare system, for all its genius, is not well or systematically organized. And here’s the consequence of wasting all that money. When the Medicare program was begun in 1965, the House of Representatives projected that in 1990 it would cost $12 billion. In 1990 it actually cost $110 billion.  By 2013 it cost $492 billion. Now for those who believe in markets, the reason there is a Medicare program, is by 1965 there was no market that could solve the problem of how older people could afford an insurance premium that was actuarially correct, given the consumption of healthcare that older people have. That is why we have a Medicare program. It’s not to say it couldn’t be better, that it could adopt more market principles, but that’s the reason we have Medicare. And it’s always amusing to see who will show up at a town hall mad as hell with a sign saying, "I want to keep the government’s hands out of my Medicare program." Excuse me??

So here’s another way to look at the cost of healthcare. This is the difference between how much healthcare has gone up in the last decade and how much everything else has gone up. The bottom line is how much inflation has taken out of our pockets in the last decade, the top line is what healthcare premiums have done. This is why healthcare is not affordable for individuals, for companies, or even for governments anymore. So the fact of the matter is, for those of you my fellow physicians in the room, we have an industry that has been so successful in some ways that it has priced itself out of the reach of people who need it. So if you think that the idea of universal healthcare is a socialistic thing invented by Barack Hussein Obama, this is a picture of Richard Nixon. In 1970, Richard Nixon called a special joint session of the United States Congress and proposed universal healthcare in America paid for by an employer mandate. Nobody called him Stalin at the time. At the time that he proposed that, a Blue Cross Blue Shield high option for a federal option was ?? of the then minimum wage. By 2009 it had become 115% of the minimum wage. So when I say the healthcare has increasingly priced itself out of the people who need it, this is what I need. Some of you here are fans of Paul Ryan, some are probably fans of Paul Krugman. There are not many things tht Paul Ryan believes that Paul Krugman also believes, but one of the few things they both believe is that the cost of healthcare has to be dramatically contained. They may disagree about how, but they don’t disagree about whether. So, the other thing our Committee considered was the problem of complexity. Which illustrates once again that many of the problems of our system, as in other areas of American life, are the consequences of our prior successes. If you ask us why are we obese, it’s because the American industrial agriculture system has succeeded in reversing the constant search by humanity for a way to produce enough calories to survive. So we now produce calories so cheaply and are so free of physical labor, that we’ve created whole industries to work off the calories that we can afford to consume for free and never work off. Similarly, many of the problems in our healthcare system are the result of our previous successes. Complexity is among them. Anybody here a physician, I know there are at least a couple. What’s your specialty, sir? Nephrology. If you were to sit down on Monday morning at 9 o’clock and read just nephrology articles, and you break for lunch at 12 and go back at 1 and work ‘til 6, and you do that 6 days a week, at a month you’d be a month behind. These are the consequences of our successes.

A 79 year old patient who has osteoporosis, diabetes, hyper-tension and COPD, not an unusual constellation of problems for a 79 year old, might be on 19 different medications. If you are a primary care doctor taking care of Medicare patients, you interact with up to 200 different doctors in the course of a year. We have more choices for prostrate cancer, for breast cancer, for arthritis, for every chronic disease that we ever had, and if you ever are unlucky enough to work in the ICU of a hospital you will have 180 different discreet activities a day. These are all good things in some ways. The complexity is a result of our success, and yet we have to have new ways of managing this complexity. And that’s just a beginning, because what’s coming – when I talk about the future of healthcare I know some of you thought I was going to talk about whizz-bang machines and pills that have cameras and fancy diodes and yea, there’s a lot of that coming, but there’s even more Buck Rogers stuff coming. There is amazing stuff coming. So if you think it’s hard to manage the information now just imagine what it will be like in 10 years.

So, here’s my summary of a long report with lots of serious people. The past half-century has seen unprecedented knowledge generation and technical innovation in biomedical science and there’s much more to come, but our systems for choosing, training, deploying and paying the workforce and organizing their work have not kept up with the biomedical science. In the end, it’s the biomedical science that has driven all this. We have more drugs, more procedures, more machines, and it’s a good thing but we haven’t kept up with the science. So, anybody know what the SOAP notes are? Remember SOAP notes? For those who are not docs, everybody his age and mine was trained with SOAP notes. Subjective, Objective, Assessment and Plans. That’s what you wrote down when you saw a patient. The SOAP notes system was created by a guy named Dr. Larry Weed, and he recently published a book with his son which has a terrific quote which summarizes that this ‘michigas’ better than I could possibly do. Dr. Weed said, “Any system of care that depends on the personal knowledge and analytical capabilities of a physician cannot be trusted.”  This is the guy who taught physicians how to be physicians. So don’t take it from me, take it from Larry Weed.

All right, so now healthcare reform, how big a deal is it.  Well, in the words of Vice-President Biden [off-screen slide] – not my words – his words, not my words, his words. And it is a big deal. The irony is that the Affordable Care Act was developed in part to reduce the variation across the country in your access to health insurance if you were poor, or if you happened to work for an employer that didn’t offer health insurance. And it turns out now that depending on whether your state expands Medicare or not, has an exchange or not, the variation is actually worse. So I live in a Yes/Yes state, California, the great state of North Dakota is a Yes/No state, the great state of Utah is a No/Yes state, and the great states of Texas and Florida, which between them have about 60% of all the uninsured people in the country, are both Hell No states. Now don’t get me wrong, these decisions have consequences. I know we have someone in the room who runs the Volunteers in Medicine clinic. These are people who suffer because they do not have a way to pay for their healthcare in a way that most people in this room don’t worry about that. Don’t worry about being pauperized, don’t worry about losing their life savings if they’re in a car accident. So whether or not you have health insurance has real consequences, has clinical consequences, has financial consequences. And as I hope I’ve illustrated, through no fault of their own, we are now in the situation where the average American cannot afford the average health insurance policy. Even with insurance – this is a graph from my former colleagues at the Kaiser Family Foundation [off-screen slide] – if you have insurance through the Exchange, and you qualify for insurance, it is likely to be catastrophic insurance. Now don’t get me wrong, that’s a good thing. It’s a good thing to be covered for a catastrophic event, but it is not the same thing as paying for a visit to a doctor, paying for ampicillin if your kid need it, paying for an ER visit, these are policies with very high deductibles. And just look at this arrow – these are people who are 100 to 250% of the federal poverty limit, that’s about $58,000 for a family of four, and the left arrow here are people who have a policy with $1,200 single or $2,400 family deductible. What this graph shows is a majority of people don’t have 2,500 bucks in the bank. That may seem hard to believe for some people in this room, but there are a lot of American families who are working families that don’t have $5,000 in the bank should they need it for what is essentially a catastrophic policy. So the problem of the affordability of healthcare doesn’t go away even if you’re covered.

In addition to the reform you see in the newspaper, there’s a lot of stuff going on. Everyone is now clear that costs have to be contained. And frankly, even people in the profession, people who run hospitals, doctors, health insurance companies, everybody’s on board - something’s gotta give. There’s lots of consolidation going on. I suspect there are people who here on the boards of your local hospitals. If you are, you’re either buying a hospital or being bought by a hospital, or thinking about merging, thinking about running for cover. Everybody’s trying to get bigger – it’s all in the name of clinical integration and it’s mainly about market power. The bigger you are the higher prices you can charge. There’s discussion about moving from volume to value. Hospitals operate on the same economic principles as hotels. They would like their beds to be full, and they would like you to get expensive procedures or room service while you were there. You get paid every time the bed is full – if you’re a doctor, you get paid when the turnstile turns, even if the turnstile need not turn.

So, what are the other things that are going on? Fancy word – disintermediation of professionals. Those slides I showed you before - travel agents, tellers, librarians – there’s enabling technology that allows us to do things as lay people in those fields that we used to have to pay professionals to do. And the fact is, there’s the capacity to do that in much of medicine as well, and the democratization of health information. All of the people who work in this hotel now carry around with them a medical library [showing personal cell phone] that you and I used to have to have an admission card to the local medical society and it would take us hours. So as in so many other fields, the internet has dramatically changed the asymmetry of access to information in healthcare as well.

 

IV. Possible Solutions (Discussion Points):

4 Courageous Conversations.

First, are we going to have universal coverage of people, or are we not? You all know we are the only developed country in the world that hasn’t figured out some system by which everybody has some basic level of coverage against financial ruin and access to healthcare. Germany, France, Spain, Canada, Singapore, Taiwan, Japan – very different systems, very different histories, but they’ve all figured out a way. And sometimes universality, as in for instance mandates, as opposed to the idea that this is not freedom; that one should be free not to participate in the system. I will only say there’s no such thing as universal, voluntary anything. Not taxes, not military service, nothing. So if the notion of freedom is that you should be free to abstain from this basic societal compact about how we provide some basic, minimum, civilized level of coverage, in the richest country in the history of the world, then you and I have a different notion of the word freedom means. Note, however, I will say that in the couple of instances where it turns out that having money was life or death, we’ve done workarounds. Some of you will be old enough to remember when dialysis was invented. And when having money was life and death. We didn’t do a universal system but we did a workaround. We said okay, n stage real disease we’ll put you on Medicare, so we won’t let you die on the streets. So we kind of evaded this issue. We did it again frankly with AIDS. The combination of Ryan White funding and ADEP funding – for AIDS patients having these drugs is the difference between life and death. We couldn’t get ourselves around the notion of universal care but we did a bunch of workarounds that mean, frankly, if you have HIV in this country you pretty much can get access to the drugs you need to survive. But what’s coming is more and more instances – we can now cure Hepatitis C – there are going to be more and more instances where we can cure leukemia; where having the money to pay for the drugs or the surgery is the difference between life and death. Our capacity to do workarounds will get increasingly stretched. So we’re going to have to have a conversation about what it means to have universal anything; whether people can opt out.

Second courageous conversation: What we in the business call ‘scope of practice.’ That is to say, do you get to do stuff because your credentials say you can do it or because you can do it effectively. When I was in training, the diagnosis of strep through (are there any pediatricians in the room? God love them – they’re out dealing with snotty, feverish kids). When I was in training, the diagnosis of strep throat required somebody like me who’d been to school 15 years.  You had to feel the nodes, look in the throat, talk to the parents, take the temperature, send something to the lab, wait for 24 hours… now the diagnosis of strep throat can be made in 2 minutes for 2 bucks by a high school graduate. We don’t let them do that because it wouldn’t be ‘safe.’ Just like if we let librarians decide who could use Google I’m sure none of it would be ‘safe’ for us to use. So we’re going to have to decide in a country where increasingly we can’t afford the system we have, do we let people do things only because they’re credentialed and therefore can fight in the legislature? What happens is in the legislature is that dentists fight the dental technicians, the dental technicians fight the dental assistants, and doctors fight nurses, and nurses fight EMTs.  In my home state, in California, an emergency medical technician is licensed to put a tube down your throat and save your life if you’re dying, but it’s illegal for him or her to take your blood pressure at a screening fair. What?? I mean this goes on throughout medicine. In New Hampshire you can get a whooping cough vaccination in a drugstore, in Vermont you can’t. It goes on throughout medicine. We’re going to have to have a conversation: are we doing this really to protect people’s incomes, or are we trying to build a system in which people can practice effectively, no matter what their license is?

Third conversation: End of life. Are we going to do whatever the doctors can do, or are we going to do what patients want? This is a tough one. It’s a tough one. One of the more shameful episodes in recent American health policy is the characterization as death panels of a proposal to actually pay doctors to have a conversation with patients about how and where and when you want to die. We’re all going to do it folks. There’s no reason why people should be getting chemotherapy in their last 2 weeks of life. And my colleagues, doctors, often blame it on patients and, frankly, they mean well but they don’t understand. I’ll give you an example: a colleague of mine named Steve Padilack, who teaches doctors how to care for dying patients, and palliative care gives this example. You’re in the room with the family of a dying patient, and you go to someone and say would you like us to do everything for your mother? Well what answer do you think you’re going to get to that? No, not my mother, oh no, skimp on her case. So of course the family says Yes, Doc, do everything, and then you say you see, the family made me do it. As opposed to, what are you hoping we can do for your mother? For which the answer is we hope you can keep her comfortable, we hope you can keep her cogent so she can talk to us. And these are tough conversations, let me tell you. My experience has been outside the political echo chamber of Washington. There’s really broad agreement among doctors and people generally that they’re really doing this the wrong way. But it’s a conversation that we all need to have; we need to have them with ourselves, with our families, with our doctors, with our clergymen, with our hospital systems about why we spend so much time and effort flogging people towards the end of their lives in ways that ironically – interesting study that shows when you compare people in late stage cancer in usual care versus palliative care, which is sometimes described as ‘giving up,’ not only did they have a better life in palliative care, they actually lived longer because we weren’t poisoning them with our efforts to flog them with chemotherapy. Touchy conversation, but one we need to have.

And lastly: Big Data. Walmart knows more about our patients than we do. Google and Amazon know more about what our patients are interested in, scared of… see, so our healthcare system may know how tall you are or how much you weigh, they may know something about your “race,” whatever that is. But do they know how risk-adverse you are? Whether you were an early adopter or a laggard? In other words, do they know things about you that are in the domain of your ‘behavior?’ So we have a struggle to figure out how much of that is permissible to have in healthcare because frankly, it would be a tremendous boon to the healthcare system to have deeper, richer understanding of our patients in ways that are outside their interaction with the medical care system, and yet we are understandably a little scared about the notion of everybody having all our information about us.

I have one last example that should make us a little ashamed of healthcare. Anybody know who this is? [off screen slide] Gary Loveman. Gary Loveman is an economist, used to be on the faculty of Harvard Business School. The CEO of Caesars Palace. Once heard Gary Loveman say there are 3 things that can get you fired at Caesars Palace: sexual harassment, stealing money, and running an experiment without a control group. Any of you who’ve been to Caesars Palace or one of these institutions has one of these: it’s a loyalty card. You think it’s to keep you coming back; it’s to gather information. Turns out Caesars Palace has studied hundreds of thousands of their customers, and they know that if you come there on Friday and in the course of the weekend you lose 200 bucks, you say Honey I had a great time, let’s come back next week. If you there on a Friday and you lose 200 bucks on Friday, you say Honey, I had a terrible time, I’m never coming back to this hell hole ever again. So what happens is when you put your card in the slot machine it knows you’re down $150 and someone will sidle up to you and say, Gee, how about tickets to a show? Celine Dion? Maybe a nice meal at Picassa? And in the end you wind up losing your 200 bucks but you say Honey, I had a great time, let’s come back next week. So how scary is it that the casino industry knows enough about you to predict the future and change it, and we in healthcare are still left with our patients coming in saying Oh please Mrs. Jones, please take your medicine, please eat less Ding Dongs and get on the treadmill. So think about what we might be able to do if we had deeper, richer understanding of our patients in a way that these algorithms at Amazon have, and yet it’s a little spooky, I know it’s spooky, but we’re going to have that conversation because just telling Mrs. Jones louder to take her medicine is clearly not going to work.

All right, I’m almost done. Here’s where I tell you what I told you. Part of the reason healthcare is so difficult for us is it’s like the old Aesop’s fable on the elephant and the blind man. Whatever part you feel it’s different. If you’re an investor healthcare is one thing, if you’re a nurse it’s something very different. So our society has to deal with this phenomenon which is simultaneously many different things to us as individuals and to different interest groups. I talked about the problems of cost and complexity and the difference between the headline reform and the quiet reform that’s going on every day. I talked about the 7 paradigm changes that you’ve written down by now. And I talked about these 4 courageous conversations I think that we all can begin to have in the course of our lives with ourselves and our families and our providers and to the extent that we’re in a positions of responsibility in healthcare systems with those organizations as well.

And I want to end with this picture that I took on the beach this morning about 6:30. It’s a terrific sunrise, terrific sunrise. I have a patient who’s 71 years old. He’s had AIDS for over a decade. Just had his hip replaced successfully, walks his grandchildren to school. He’s on one pill once a day for his HIV. It is a miracle. It’s a miracle. When I was an intern, my first night on call I admitted 4 young men to the hospital with this bizarre protozoa infection that no one had ever actually seen in real life, and people in San Francisco and places even like Hilton Head were dropping like flies. It was a holocaust. The fact that a 71 year old man is on one pill once a day – I’m a general internist, I’ve got to go back and worry about his prostrate, and his lipids and his kidney function, all that - that’s my problem, not his. How did we get there? The market, the private sector, did not discover the HIV virus. The HIV virus was discovered by people working with lots of money and attention from the National Institutes of Health with your tax money and mine. They discovered the virus, they identified it, they identified how it worked, and in the process we learned a lot about virology that’s benefitting us every day and lots of other fields of other medicine. But then it was the private sector that took that information, developed the drug, tested it, made sure it was safe, developed other drugs, combined them in one formulation, made them safely, repeatable, without defects, distributes them around the world. But you know what, it was then the government that took deliberate and bipartisan action to make sure that my patient could afford that drug, because the market was not going to do it for him. So that’s kind of the genius of American healthcare: the roles of both the government and the private sector. And I’m actually quite optimistic about the future because there are more miracles coming, if we can only get this balance right. My patient is the beneficiary of unimaginable progress in the biomedical arena and frankly in the social arena as well. And so, if that’s an appetizer for next year, you’re welcome to it. Thank you very much for your time.