Okay so let's get started. My name is Marshall Chin and on behalf of the McLean Center for Clinical Mental Ethics welcome to our next session on our yearly series on the ethics of health care reform. So we're very fortunate today to have a speaker from the outside Dr. Steven Schroeder who is a distinguished professor of health and health care at the University of California at San Francisco. Dr. Schroeder has a very interesting background. He grew up in El Cerrito, California which is a working-class community on the East Bay in Northern California. Went to Stanford for undergraduate, Harvard Medical School and then the Boston City Hospital for its residency in internal medicine. Also spent a couple years at the Center for Disease Controls Epidemiology Intelligence Service. He started his career in Washington DC at George Washington University in academic journal internal medicine and he was just like as we know from ethics you know Dr. Siegler is the father of clinical mental ethics. Dr. Schroeder was one of a group of about 12 people who were really the fathers of academic journal internal medicine. He was really found in the field and eventually become the president of the Society of General Internal Medicine. He then went to UCSF in San Francisco and there he built one of the premier divisions of general internal medicine which to this day remains one of the top divisions of general internal medicine and really was fundamentally and really creating the the division as an example of clinical folks who did great clinical care, great research and great teaching which again what was a new concept back there in the 70s. In 1990 in 2002 Dr. Schroeder was the president of the Robert Wood Johnson Foundation and many accomplishments. I'll just point out four that have been lasting. One was the major initiative in tobaccoization. At the time then that there were the major decreases in smoking within our country. There was also then a major role the foundation played in the expansion of childhood health insurance the CHIPRA program and so again fond enough for bringing millions of children into the world of health insurance. He also was the person at the foundation that that did what we take so much for granted now but was really one of the first to basically incorporate health as well as health care in the work of foundations doing work trying to improve population health and then finally he made major in rows in a variety of diversity programs designed to increase diversity of the US health care workforce. Dr. Schroeder then went back to San Francisco and he's been really a major player in the national stage. He's been on numerous important committees so of note particularly for this talk he was for years a member of the US Prospective Payment Commission which advises Congress on physician payment issues. He has numerous honors till this mention one that at the ripe old age of 43 he was elected to the National Academy of Sciences Institute of Medicine. So that's Dr. Schroeder's CV. I'll just tell you a little bit about Dr. Schroeder the man. I've known Dr. Schroeder for almost 30 years now that he's been one of my mentors since my first year of medical school and what I can tell you is that he's maybe one of the top two or three people I've met in my lifetime in terms of his ability to be a great listener. This very empathetic, sensitive, caring, great instincts in terms of being able to size people up and figure out what they need and how to be responsive. A great bedside manner. He's one of these doctors that can get away with actually sitting on the bed of the patient and talking to them in a very natural way. And I just, some of us are saying that he's the man with the highest integrity, the highest ideals, someone that has been a great role model for thinking about how you can try to make impact on a wise societal basis while also treating people, individuals with dignity and respect. Dr. Schroeder? Well, Marshall, thank you. That's hard to live up to that kind of an introduction. And I'm very pleased to hear it's wonderful. One of the benefits of going, of getting older in academic medicine is you watch your former students flourish. And Marshall just said I was a president of SGIM. He is the incoming president of SGIM.  And I have a very full day here today. I've met some fascinating people. And I've got a quote when President, and so this is a city of presidents now, right? And I got a quote, President Kennedy, when he got an honorary doctorate from Yale, he said, now I have the best of both possible worlds, a Harvard education and a Yale degree. So I'm going to say now I have the best of all possible worlds, a UCSF faculty position, a Harvard education and University of Chicago t-shirt that Mark just gave me. But what I'm going to talk about today gets into the ethics of how money gets spent. And as you know from my title and as you know, actually prior to coming in here, we spent a lot of money on health care and there's a lot of criticism that we don't get the value from it that we should get. So I'm going to take a quick poll. How many of you here think the United States has the best medical system in the world? Okay, so not many of you. I would say I would raise my hand which might shock some of my left-wing friends, except to say for people like me, it is the best. I'm insured, I'm knowledgeable, I know where to go. I'm living in San Francisco where the quality is very good. But most people would say no. How many people have, for the younger ones, parents or for the older ones, spouses who are happy with their current medical care? Yeah, and I am too. And that's one of the reasons why it's been so hard to get health care reform because most people are worried they're going to give up something that they really like. For those of you who are active clinically here, how many of you are active clinically at UC? Okay, for those, how often do you see instances where medical resources were wasted? Often? Same thing at UCSF. Finally, do you think that specialty income potential has a major role in medical student career choices of what specialty they choose or what kind of an area they choose to practice in? Yeah. Okay, so here we go. We spent a lot of money, almost 18% of GDP, almost $3 trillion. The next highest country is either France or maybe the Netherlands, but they're about 12%, so much, much lower. And most of the others are less than maybe even 10%. People talk about why don't folks, you know, what's so big a barrier to getting covered by health insurance? Well, the annual premium in 2010 for a family was 15K. And there are a lot of people for whom an extra 15K and that's pre-tax money is going to be tough. We get poor value for the health dollar. I'm going to show you some data on that. And it's interesting as I've been watching this and I've been working on this issue really since the 1970s. You see fads. Every couple years there's a new fad, a new quick, painless way to lower the costs, to lower the amount of money we're spending on health care. And the more recent ones are let's get an electronic medical record in every place. That'll do it because when someone comes to the ER, we won't duplicate x-rays. On the other hand, you'll slow up what a doc does by 10% to 20% and actually lose money. Or pay for performance. Or let's judge different technologies based on what their payoff is going to be. All those are reasonable things to do, but by themselves they don't have a chance in lowering our rate of rise of health care spending. And what they really show is that the fundamental drivers of rising health care costs are at the guts of our political system. So it's pharmaceutical industry, device and insurance industries, hospitals, doctors, unions, and patients. And we don't want to get at those. So this just shows you what's been happening in 2012. I think the data were about 17.7. Whether it's going to get here or not, I'm going to show a slide later to show that there's been a flattening of spending for health care. Whether that's going to keep going or not, I don't really know. But you can see that it's really come up. And when I was starting work in this field, which Tim, I'm going to show you from my observations of waste, we were at GDP of about 7%. And economists were ringing their hands saying, oh my God, it's going to hit 10%. And it did. And it barreled right through it. So Harvey Feinberg did the Shattuck lecture a couple of years ago. And you can see the U.S. in red. There was a laser pointer here at one point, and now it's gone. But I'm not sure that I need it. You can see in red at the top was the U.S. We were clustered around other places in 1960 and we're not now. So when you put it there, okay. Thank you. And just do that. Right. Okay. And you can see some of the other countries which we kind of compare. They're all going up, but we're going up much, much faster. And Harvard Business School has noted this. And they talk about the U.S. value, U.S. health care value shortfall. So here we are. Life expectancy, one proxy measure for outcomes. Obviously not the only one. Health care spending. And here we are as this huge outlier about in the middle to the lower third of the pack of the wealthier countries in terms of how long people can expect to live, but out of line in terms of how much we are spending. So I'm going to now go through an analysis of why we spend so much more than the other countries. And this is personal, but it's a distillation of reading the literature and knowing it pretty well, working in the system, working in ways to try to change it. Others might parse it somewhat differently, but I think this is pretty much mainstream. So I'm going to raise a number of theories. Are we expensive because we have more doctors per population? No. We're actually in the lower half of the European MD supply. So we don't have all that many doctors. But where we stand out is the proportion of our physicians who are specialists are off the chart in comparison to others. Most of the other countries have 40, 50, 60 percent of their physicians are in primary care. Ours is much, much less. Is it that people working in healthcare make a lot of money compared to others? Yes. It's not just high-earning surgeons. It's the nurses. It's the respiratory therapists. It's everybody. It starts with the CEO. So I just read recently that the CEO of the University of Pittsburgh Medical Center, which is a very strong and very, very big, makes $6 million annually. When I started out in healthcare, directors of hospitals were called just that. Now they're called hospital CEOs. So we've monetized and made healthcare into a business and we pay well for it. And we pay a lot more for people up and down the spectrum in hospitals and in healthcare compared to other countries. Is it that we have more hospitals? No. We actually have fewer hospital beds than most developed countries. Do we stay in the hospital longer? No. We actually discharge them faster. So they leave our hospitals sicker and quicker. But we have a much higher proportion of ICU beds and I'm going to come back with a story on that. And we do a lot of costly stuff, whether it's heart surgery, dialysis, oncology care, imaging, you name it, we do much, much, much, much, much, much more of it than other countries. And this is why I think Marshall asked me to come today. How we pay doctors is a big reason. Remember that doctors only get about 20% of the healthcare dollar, but they account for another 60% by deciding whether someone's going to get a medication or whether they're going to go into the hospital or get something else. So incentives facing doctors are pretty critical. So how did I get interested in how doctors get paid? Well, as Marshall mentioned, my first job was as medical director of the George Washington University HMO. And we started pretty small and our specialists were capitated. That is, they got a fixed sum of money for caring for a relatively small number of patients. They felt they could do that. But just to make sure they weren't going to get the short end, they submitted bills under fee for service and they would calibrate those. And then next year, when we were going to get what their, what the capitation rate was, they could reflect on what the experience was. I was familiar with billing in general medicine, but not with some of the radiology and the surgical techniques. And I was flabbergasted because I knew that some of the procedures didn't take much time. And yet the amount of income that they were charging was so much more per hour of time than what my colleagues were getting, that it really piqued my interest. And then when I went to UCSF five years later, we did some studies to sort of demonstrate that. So let me show you this one. This was a study in medical care that my colleague John Shostack and I did. And what we did is we used the common fee for service payment model in the mid-70s in California. We constructed four hypothetical practices of general internals. The first three were solo and the fourth was a four-person group practice. And we escalated the amount of procedures to be done for new patients and follow-up visits when we went from practice A to practice D. And we decreased the amount of patients that were going to be seen by five percent each. So model B saw five percent less than model A, model C saw five percent less than model B, model D saw five percent less than C. And what we did with model A, all the lab tests and EKGs and stuff were farmed out. Somewhere else got the revenue, but the model A practice didn't get all the overhead to have to pay for it. And we cost it out what it would take to do EKG, to do chest x-rays, to do stress tests, and in the final one to do a multi-channel chemistry test. And you can see that model D, which sees 15 percent fewer patients than model A, has net revenue. This was in 1975, excuse me, in $76 of three times as much as model A, showing that even in humble general medicine, if you do stuff, technology, lab procedures, it has a much higher profit margin. And that, of course, is still true today. Then we did a study saying, how did this happen? And we traced through the history of usual customer and reasonable charges, how physician panels got started and all that, and we published this in the Blue Shield journal. So to keep on with this, I'm interested, as having been on in active medicine much of my life, how the opportunities that I gave you a chance to talk about in our poll, how they influence what young doctors do. And have you heard of the road to happiness? So this is a big buzzword at matching time that residents know that radiology, ophthalmology, anesthesiology, dermatology, and if you're English, emergency medicine, have are the dream specialties. Why is that? High income, shift work, you're not burdened with caring for people with chronic illnesses, and you can go home early. And so that's the road. I've heard my doctor's sons, I have a son who's a cardiologist and one who's a pediatrician, have heard them and their colleagues talk about specialties and the reality's medical practice, that I've served on some boards of hospitals and I've watched my sons as they deal with the business aspects of the medicine. And they're both, by the way, extremely happy being doctors and it was the right kind of career for them. One of the things that hospitals are doing now, they're kind of selectively buying up practices. Cardiology is the best case for this. They're buying up practices of cardiologists, so now probably 75% of cardiologists who used to work independently are working for a hospital. Why are they doing this? Why the hospital is doing it? There are different rates of paying for cardiac procedures. So if you do an echocardiogram or an EKG or a stress thallium test in your private practice cardiology lab, you'll get one X payment from Medicare or from private health insurance. If you do it in the same procedure in a lab owned by a hospital, but it could be that same lab, the hospital just bought you out, you'll get three to four X. And so the doctors gain, the hospitals gain, the payers lose, the patients lose. So the National Commission, I'm going to have to get that out of here, which I should have done, sorry, to hold up. National Commission for Doctor Payment Reform was an outgrowth of the Society for General Medicine. And here it is. And I'm going to tell a little bit about how that got started. So the then president was Harry Selker. And Harry under the Clinton, Planning for Clinton Healthcare was very worried about ethical mark consequences of capitation payment, which are things like what Kaiser has, where you get a bundle of money to take care of patients, and it's assumed that you'll take care of them well, but you have a financial incentive to do less. And and Harry was really worried that was going to surface one more time. And he said, I want you to do a commission. I want you, Steve, to chair as a former President of Michigan, and someone's written about it, to chair a commission, which which lays bare the ethical conflicts inherent in bundling or in in capitation. And my answer was Harry, their conflicts of interest in every way that you pay doctors fee for service, salary bundling, I won't take your narrow ambit, but if you if you will widen the viewpoint of what we're going to do, I will do it. And he said, fine. So our game plan was, we just didn't want something that was a sit on the shelf. We didn't want a predictable general internist say pay us more, which is kind of predictable. So we wanted the membership to reflect a broader group than just general internist. We want to document that would be terse and would would get a longer life. We wanted to be independent from the sponsoring group. We didn't want them to have veto power over it. And we want to focus both on federal payment but also on private health insurance. And most of the commissions and groups doing this have mainly focused just on federal programs. So in planning for this, we estimated now when the Institute of Medicine does something like this, and I've been on several committees and chaired a couple that the island was done.  They have a large staff. They do a review of the data. They bring the membership in of the committee three or four times. They work on drafts choosing about 1.5 million. We figured we could do it cheaper. We can do it for 800,000. And we then went knocking on doors. And we got a very, we got some funding, 195,000 from Robert Johnson Foundation and 25,000 from the California Health Care Foundation. And that was it. So then we had to figure out, do we cash it in? Do we say can't do it? Or should we try? So we tried. And we did it as sort of a short track. We I had a half time staffer. I served on a pro bono basis and probably spent about a quarter of my time during the year doing this. One of the virtues of being old is your days aren't as busy as they used to be. And we only had one face to face meeting. And actually, it was the first one was canceled by Hurricanes handy. So this we had to reschedule that one. And we did pay for a consultant to help us with the with the roll out. So here are the members. Underline means a member of SGIM.  So I was the chair. We got Bill Frist to be the honorary chair. Why Bill Frist? Because he's a doctor knows the stuff and he swings writer than our IGHER than most members of SGIM most academic general internists are pretty much left of center. And so we wanted the credibility that he would bring in. In fact, that turned out to be a wise choice. Troy Brennan, a physician who's chief medical officer of CVS. On a side note, partly as a as a result of this work, I got to work with Troy to roll out the decision by CVS to not sell cigarettes and pharmacies. And there was an article in Jamma that you might have seen on that. Let's give it to let's give it to you. Susan Suzanne Del Banco, who used to be the head of leapfrog, and is not a lawyer or a doctor, but just whip smart. Tom Gallagher, who's an ethicist that Mark probably knows who's the University of Washington. Jerry Kennett, who's a cardiologist. So we want to get someone whose ox is going to get was probably going to get bored, gored because he cardiologists, as I mentioned, really benefit from higher prices for procedures. Richard Kravitz, who is a very smart internist UC Davis, and is a co editor of the Journal of SGIM. Lisa Lats, who's a physician working for a managed care company, Wellpoint health health insurance company. Dr. Kavita Paytell, who was a former Robert Johnson clinical scholar, was working in the White House at the time of the ACA. And is now at Brookings. Meredith Rosen Slal, who's an economist at Harvard School of Public Health. Amy Woodcome Slammer, who's a lawyer and who's an advocate, and Steve Weinberger, who's the objective vice president for Merritt College of Physicians. So it was weighted towards doctors, but not only doctors and gave wasn't entirely kind of a predictable commission. And here it is pretty slim. Nice graphs. If I can find a couple about how much specialties make and that sort of thing. And I can actually, I can pass it on, I can pass it around. So and we also Dr. Frist and I, I should say Senator Frist and I think that's his kind of preferred title. Now, maybe it's Dr. Had a simultaneous sounding board in the New England Journal of Medicine with a title phasing out fee for service payment, which is a major part of what we did. So I'm going to go over the recommendations of the commission, sort of briefly. Number one, phase out fee for service over time. Why? Because it's inherently inefficient. That is, it pays you for doing more. And the way the values are structured, it's pro technology. So if I'm a GI specialist, and I have a patient with also colitis who's on a flare, I can spend a lot of time talking to that patient, figuring out what his compliance with medications are, what his diet has been, what stress has been, and I'll get a two figure income, or I can pass a scope in the same amount of time do a biopsy, and I'll get a three to four figure income and or payment. And both are equally valued. So the incentives are to do more costly things. Number two, the transition won't be easy. So start with testing models over a five year period with the look to by the end of a decade, most fee for service will be gone. Number three, and this there was some contention on the committee over this one. Some of the people, the theoreticians, people who thought, you know, we're writing about this, so it's going to happen, said, don't worry about changing fee for service, because it's going to be gone. It's going to be the dodo bird. But others of us, and I was one of them said, uh, it's resilient. It's like Rasputin. You know, you can keep putting daggers in him, but he's going to keep going. So let's fix it while we're changing it to because we're going to need to keep recalibrating those formulas. For all payers, Medicare and the private health insurers, let's update the annual let's update the annual fee rise for so called E and M services, which are characteristically underpaid. Now, we didn't say E and M services only for primary care. So this was a decision our commission made. We said, we're going to link common cause with endocrinologists, infectious disease specialists, psychiatrists, oncologists, cardiologists, people who have a choice of doing an E and M service or technology. So we're not just going to be special interest leaders for us. But let's freeze the updates for these procedure codes unless we can prove that one procedure is undervalued. And I've never seen evidence of any of that. Then let's do away with this kind of charade that I mentioned. An echocardiogram should cost the same whether at least if it's an outpatient echocardiogram, whether it's in a hospital or in a doctor's office. Don't create these incentives to buy up practices and game the system. Also, in the private market, health insurers get lobbied. So a powerful hospital in Boston can get, as I heard yesterday, three times as much money for C section as a less powerful hospital in Boston, because that group has market share and they'll threaten to pull out of the out of the private plan. So let's have transparency. And let's give similar prices for similar services. These are sort of motherhood and apple pie six, seven and eight. One is fee for service contracts should include a way to measure quality. And people have been talking about that for a long time. Measure is saying it is not as easy as doing it. But there has been progress made in trying to measure quality. Then there's a problem with small practices, especially in rural areas. They don't benefit from all the consolidation that you can in a city like this, or in a state like ours. So we should let small practices form a relationship that's virtual to give them a chance to harvest some economies of scale. And then when we move from fee for service, let's focus on areas with the high potential for costs and quality savings and particularly people with high cost chronic illnesses. There's a risk when you do this that health care systems will game it by getting easy by sort of cherry picking, picking patients who are not as demographically at risk, patients whose diagnosis are easier. And so let's make sure we can adequate adjust for risk. Let's make sure we're committed to payment. Let's make sure we have quality measures. Do you all know what the SGR is? The Sustainable Growth Rate? You've probably heard about this. This is something that was put in by Congress in 1997 to try to rein in doctor costs and then they check and out. So this was to say a physician, if spending for physicians under Medicare was more than the cost of living increase, then they're going to take it out of what they're going to pay the doctors for Medicare the next year. In 2002, imaging went through the roof. And so actually Congress cut back doctor payments by 4.8%. They never did that again. So each year, they waived that penalty. And now it's up to something like 25%. And this year, once again, Marshall, our correspondent, he was saying, it's going to happen. It's going to happen. I said, I'm not so sure, Marshall. It didn't happen. They kicked the can down the road. Once again, they said, we're not going to do that penalty. We said, let's get rid of this.  And what it does is it penalizes all physicians. And yet it assumes that an individual physician can make any difference. So we said, let's get rid of SGR. And then the problem is, what do you do with the federal budget? Because although health care spending has been going down in this, the foregone revenues at one point were 200 and something billion, they're down to 138, maybe somewhat less now. And where do you get that money from? And the Republicans wanted to take it out of welfare programs, and the Democrats didn't. And so that's why you can't get it. Both parties now say SGR is a farce. Let's get rid of it. But neither one is willing. They can't get a consensus on where they recoup that money. And the final recommendation is on the Resource Value Update Committee, which is based right here in Chicago at the AMA. And this is the one that sets or recalibrate surprises for new and old kind of procedures. And the criticism of it is that it's built like the Senate, not the House. So Wyoming has equal votes with California. People in Wyoming like that. People in California don't. So the plastic surgeons have an equal vote to the family docs. So there are much more representationists coming from, especially as you do a lot of health care procedures. It's one thing. And also the issue is voting isn't transparent. Now, now the collective vote is published, but individual votes aren't. And then finally, we said, let's wean CMS. CMS was adopting like 95% of the recommendations of the right. And we said, let's wean same way. There are other ways you can get these data. So what was the feedback to our commission? Well, when it got set up, our communications people had a press conference that said this, this, this is going to get set up. I thought it was non news. But because it's such an inflammatory issue, it's big news. And then all the groups wanted to get a member on it. So the nurses and neurosurgeons, you name them, they all wanted to have a seat on the commission. And we said, send us your input. But it's, it's, it's fixed. We can't give more. Some of the members of our society, although it didn't raise money, it's interesting, Harry and I raised the, raised the money. But they were worried that Senator Frisk was going to be a stalking horse for a really conservative surgical influences. In fact, Senator Frisk pushed us to do more. So he had that worry didn't turn out to happen. And then they were worried about lack of basic control over what the recommendations are going to say. And there was a last minute really blow up over that turns out they liked it. But they were worried they wouldn't have any control over. And what our our answer was, it's going to be more authentic. If it represents the broader kind of membership that there is. And as I mentioned, we decided not to make it a primary care versus everybody else, but let's balance the scale better, which, which impacts all, all physicians. So we then when the report came out, our communications people scheduled for myself and for some of the other members of the commission trips to Capitol Hill, both to the House and House and the Senate, and leaders and even one member of both parties. And basically they said, it's great. It's great. Tell us how to get there. And of course, if you're working with money from a foundation, you're prohibited by the IRS from writing any, any legislation. And so but they wanted to get they also want to know with the SGR, where what we thought about getting the 138 billion two days before we went around the Hill, the Steven Brill magazine came out. All you see this $1,000 or whatever it was for a time on all pills. So the the outrageous pricing of hospitals for services.  So there was a dog that hadn't barked on this. Normally, when a negative piece is going to happen, the involved lobby knows in advance and goes on Capitol Hill and tries to kind of modify it. American Hospital Association never showed up on Capitol Hill over this. They just didn't do anything about this. I was only had a few comments, but not not much. So we came at a good time because people were worried about pricing. We also went to the major private health payers. And again, they said, looks great. But they many of them said, Well, we're not the leaders here. We're not the top dog. We're going to wait and see what CMS is going to do. And both the AMA and Marine College of Physicians said the Ruck isn't really that bad. We just ought to tweak it a little bit. Most other people didn't didn't like it. So Marshall asked me to put in the slide an update on the SGR fix. And once again, Congress working on it this I wrote that a couple weeks ago, since then Congress said, We're not going to do it. We're not going to we're not going to penalize doctors. So it's what they call kicking the can down the road. People have multiple versions of what the update was going to be. It's liable to be very small in the future because of concerns about budget and about Medicare. And the major roadblock, as I mentioned, is how to get the money. I got connected with a cardiologist friend of our son, David, who's up at Oregon Health Sciences. His name is Eric Strecker. Eric Strecker and I worked with him on a previous article, which I didn't want my name on. But then he asked me if I would do this. So he took the risk of antagonizing his cardiology colleagues and making the kind of following argument. As we phase out fee for service, if that happens, if Rasputin finally dies, we're still going to need relative value units. Because if we go to bundled payment, let's say the Mayo Clinic gets $20,000 for bypass surgery. And that includes all the care of everybody, the anesthesiologists, the heart surgeons, the cardiologists, the primary care doctor, the clinical pharmacist, they then have to figure out how to divide that fee. And so the divvying up of the pie is liable to retain the relative value units so central to fee for service medicine. And so what Eric did, and then I helped him with it, and he asked me to be a co-author, and he probably did 95% of the work, is the gist is that the RVU's relative value units are liable to stay around. And thus we need to reform them because as I pointed out, they're very distorted. And so this is what he proposed, and I've shrunk this from the paper, that currently smoking cessation, subject really dear to my heart, which is why it came up first, the current RVU's range from one to 3.2, kind of dependent on how much time you spend five, 10 or 15 or more minutes. And he would up that, he would up it from one to three, to four to six. Starting new evidence based treatment for congestive heart failure or atrial fibrillation, a similar up. Population management, supervising telephone based care management of congestive heart failure or coronary artery disease, which would be a big part of a capitated system, currently gets no RVU dollars. And he would propose that you get 20 for every 50 patients. So making it more worth, worth their while. Then he got into, he started goring the cardiologist's stocks. So an ST elevated a QMI having a stent. So these are all what how much you pay for stents. If you do it, as it's ST elevated a QMI unspecified 12.6 units either way. If the door getting in the door of the ER to the balloon is less than 60 minutes, he would double it. But if the afford is the authorized usual care score, this is a cardiology committee. I've forgotten what the acronym is. But these are authorizations of if it's seven to nine, in this clinical condition, it is really worth doing. If it's four to six, it's equivalent. It's one to three, the evidence is that you shouldn't do it. So he was saying, if you have chronic stable angina, and the score is seven to nine, and you do the stent in an approved lab, he go from the current 11.2 to 14. If you do it in equivocal circumstances in an approved lab, you cut it in half.  The idea here is you still get paid to get paid a lot less. So you're taking away the incentive for doing a marginal kind of a kind of a procedure. Same thing with an implantable cardiac defibrillator can see that the higher score in an approved lab goes from 15.2 to 19. That the medium score with an approved lab cut in half. And you can see that it's cut in a quarter, if it's not a very good indication, and doesn't have an approved lab. So that was this paper and it came out in December of 2013. And to Eric's kind of surprise and pleasure, he didn't get beat up by his fellow cardiologists, they said makes sense. This shows you that even the last 17 years or so, there's been very little rise in what primary care doctors make big rise in dermatology effort hasn't changed. So why the increase? Well, I got quoted in a New York Times article saying that it makes no sense. I was paraphrasing George Bernard Shaw. But when I have a lot of sun damage, it's probably genetic. And it's also going in California. So I have a primary care dermatologist. He's really good.  In case you do a biopsy, takes 15 minutes, builds $650. And that's typical. And I commented on that. And I got a letter. And I was quoted on that in an article by Elizabeth Rosenthal. I got a letter from a Derm person saying, this isn't fair. And I said, Well, you know, that's what happens. He said it doesn't happen under Medicare, I said, but it does under private health insurance. So this just shows you the difference. I won't read them all. As you can see in the amount of hours worked is relatively comparable across those specialties.  You know, I think a cardiac surgeon or a neurosurgeon really deserves their skill. And there's there's extra training, and they should get more. But most other countries don't have this. And this difference is a direct function of the way we pay under fee for service. So United Health Group, which is I think the second or third largest health insurance company is in a transition here. And they've scaled us out. They let me use this graph. And this is the wave of the future. This is the degree of integration of doctors. So this is a solo practice. This is Kaiser. And this is level of risk. And we're on our way here. And different parts of the system are there. And different groups are there. But it's going to happen. The question is how quickly and where and when. And the idea is that they're going to try to put medical groups at risk for outcomes and base payment on outcomes to and there will not be incentives to keep doing more. Okay, so I did a long riff on fee for service. Now we're back to the question, the shorter synthesis of why does the United States spend so much more on health care? Practice style variations. Yeah, people get a lot more stuff in Florida than in the Twin Cities or in North Dakota. So there are big for and we even within a certain state there are real variations and the Dartmouth group has been major at showing this. It administrative cost. So if you're at the Toronto General, which is a thousand bed hospital, you go to the billing office in the basement, you got a grizzled guy in a lumberjack shirt who's sending who's sending bills to the province who will pay as asked. You go to the mass general same size. You got guys and stripes suits, tassel loafers, consulting algorithms, sending bills to 500 different health insurance premium companies and trying to figure out how to get the best payment. Health insurance companies in the United States have figured out how to delay your payment, how to pay you less. So a tremendous amount of the health care of the hospital dollar in the United States goes to managing health insurance bills. It's just empty calories. Malpractice talk to doctors. That's the number one thing. You know, I order all these tests because I'm afraid of getting sued. Well, the IOM and others have studied this, and they estimated a couple years ago that yeah, we spend about an unnecessary $54 billion a year. That's not chump change. But on a denominator of 2.7 trillion, it is chump change. And so if we fix malpractice totally, we'd be down from 17.9% to what 17% or something like that. So much, much, you know, it doesn't make much of a difference. Aging population, everybody knows that as we get older, people are more reliable to get health care because they get sicker and they get stuff done. And so that's a reason why we stand out. Well, in fact, because we have so many immigrants, our country is one of the youngest of the Western countries. So Japan, very, very old population, they're not bringing in immigrants. Scandinavian countries. So we're actually relatively younger. Patient demand. Absolutely. I had a sabbatical in London where we studied health care systems. And I had been reading the San Francisco Chronicle, which is a rag. I mean, it's just just a bad paper. But they almost every day, they'd have a front page story on some new breakthrough. And then when a breakthrough didn't happen, of course, it wouldn't show up. The London Times, which was a premier journal, the premier paper, didn't do that. And the patients in England elsewhere in Europe just had less expectations. I'm going to show a slide about that. So that's a big push. The economists say the reason we're there or a way to get us better is to have us be as competitive on cost as possible. Now, Europe doesn't compete on cost. So we didn't get there by lack of competition. But it may be one of the answers to bending the cost curve. We don't know yet. Low investment in IT. So now in England, every physician has an electronic medical record. And England spends or the UK spends about 7% of its GDP on health care. And people who don't know say, well, that's the reason. Well, they know they only put the EHR electronic record in two or three years ago. So they grafted that on to a low GDP. It might be that if we went to and if as we keep going to an EHR, we might generate some cost savings. So far, those haven't happened, even though we had tremendous federal incentives to spread the EHR. Fraud and abuse is a big issue here. We don't know how much of it is an issue over there. But clearly, we need to end this story today in the New York Times, which is very crude. I refuse to answer what the journalists wanted me to comment on it. I just gave her one sentence. I said, it's good for transparency, but it would open the doors to mischief. So, for example, if there's one person billing on behalf of a whole group in an inpatient clinic, it's going to make it look like that person is a robber. But this issue for more transparency is going to happen. And maybe it'll caution some folks. So unnecessary care. Why is people at the IOM did this study? Probably a two million dollar study. We could have done it cheaper. And you can see how they parsed out that about one third of our health care based on $2009 could have been vanished without any impact on quality. That's a big chunk. That would take us from 18 percent of GDP down to 12 percent. Getting there isn't easy. People worry about rationing in the United States and in Canada. And this is an interesting study showing coronary artery bypass angioplasty bypass and surgery on the carotid for the young old and the old old. And where we really stand out compared to Canada is in the old old. We do about eight times as much on those. I don't know what the right number is, but you hear anecdotes of people with profound dementia getting this kind of stuff, which to my view is probably wasted. So when we were living in England, supported by the Commonwealth Fund, we did a study of elderly English speaking people. And we asked this question, which should have to be a brilliant question. I didn't think of it. One of my colleagues did. If your personal doctor told you that you had incurable and fatal disease, would you accept that diagnosis or seek a second opinion? And you've got to love the Brits, right? It's well loved. Been a good year. It's been a good life. Let's have a cup of tea and prepare our will. And this must be Idaho or Wyoming or so. I don't know where those people are. So by world standards, I mean, if you look at cosmetic surgery or alternate complementary and alternative treatment, whatever, we just do so much more that because people in this country aren't prepared to die. Maybe that's good, but it's just a fact. And that clearly is a driver getting people to do more. And expenditures are asymmetric. You can really see here that the top 1% consumes about a quarter of all spending at top 5%, 50%. So management of these cases could clearly be helpful. So when I was in England, being a professor of medicine in the United States is no big deal. Being a professor of medicine overseas is a big deal. There are only two or three per academic department. So I would write from my base at St. Thomas's to teaching hospitals in Germany, France, Belgium, Holland. I'm coming over. I'd love to see your system. Can you take me on around and meet with me? So I'd be greeted by all the leadership. What does a professor of medicine in the United States look like? So they take me on rounds and the rounds, the beds on the regular wards look just like here at UCSF or Yale. And I say, take me to your ICU. Boy, was that different. This was in 1983. But boy, was that different. First of all, great big hospitals, ICU, 10 beds. The train wrecks weren't there. People weren't intubated. They weren't comatose. They weren't getting dialyzed. So I would say to my hosts, were the train wrecks? And they usually spoke English. And they'd do this long silence. They'd look down at their shoes and finally one of them would say, Dr. Schroeder, we trained at your, we trained at a hospital. We did a fellowship at Penn or whatever. God, we loved it there. The technology is so good. You're teaching so wonderful. Pause. But you don't know when to stop. And so I constructed this cartoon of pressures. The U.S. is in red and the Europe is in blue. From the patient in the family, referring to the general's physician, to the specialist, to the community hospital, to the ICU at the community hospital, to places like here, to the ICU here. We have pressures going much more, towards more than they had in Europe. And it's that constellation, I think, that adds to cost. So why can't we curb costs in the United States? Well, this is again a Schroeder synthesis. We don't like limiting choices. People from overseas are blown away by our grocery stores. How many different kinds of milk is there? Are there? How many different kinds of ice cream? Bread. We just have, we love choices. Power of the industries and the fact that our system of politics is so fueled by contributions. Power of the medical and hospital sectors and academic medicine, I might say, which does extremely well but is always crying that it's bleeding to death. New technologies which are priced high. The fact that our political system can't deal with these kinds of issues. It can't deal with global climate change either. We just don't do well with issues of controversy. So why not let the costs keep rising? Some people have said, boy, if you're sick or your family's sick, what better could you be than to get all the best possible medical care for them? And the answer is the opportunity cost. So if you haven't noticed, our schools aren't doing very well and they come from the same public dollar that healthcare does.  It's hard to be as competitive with other countries if we're spending for our products so much on health care for our workers.  Business is pushing back now, pushing more and more of the health care costs onto its workers saying we don't want to bear them. Cutting off previously covered benefits for people who used to work there. Biggest single source of labor disputes. Biggest single cause of personal bankruptcies. And of course pressure on public hospitals like your county hospital here. And then increasingly there's a consensus in Washington that we can't let costs which are so often funded by a public sector. We can't let them keep rising. And of course higher premiums mean more uninsured as people can't afford to give them. So I think I got this one headline on the final bullet. This will be the finding health policy issue for the next three decades. Maybe more. And I mentioned we have a system that's really in flux. So it's a wonderful opportunity to study what's going on now. I mentioned the volume of hospital practices. The insurers and employers are shifting costs to their patients. There's more of an attempt to pay for value. And I get at UCSF at least tremendous professional interest in reducing unnecessary medical care. So here's some examples of that. You heard of the Choosing Wisely campaign. American Board of Internal Medicine has asked each specialty to pick five procedures or things that it thinks are overdone. And mostly it's been plain vanilla. But some of them are done like SGIM said annual physical isn't needed. Which cuts off the income of SGIM members which is why it's an academic group not a practicing group I guess. Rita Redberg at UCSF was a cardiologist has trained. How many of you read JAMA Medicine? She has transformed what used to be the archives into and she calls it less is more and has periodic features on examples where doing more was bad. And Alan Schroeder our pediatric son has coined a group of studies called safely doing less where he has found clinical procedures where if you do less the kid actually do it does better like studying little girls with UT allies you don't need to do a vesicular urogram. Show that you didn't need to do that. And it caused discomfort and it caused trauma. So are we in the have we fixed this. Medical expenditures have been stable the past three years. In part is because the economy has it's gone up in other words it's gone up at the same rate as the cost of living which isn't much. A lot of people think it's because with so many people out of work are worried about being out of work they spend less. They don't do the discretionary things that call that are you have to do a cost pay or a cost share on. But part may be that the pressure is coming down from purchasers and patients. Some people think that the ACA may have stimulated this. And we don't really know you'll read a lot about it but we don't really know yet. So some wag once said our health care priorities are this we want the best. We want it right now. We want choices. We want someone else to pay for it. If we can't get it will sue. Most countries pick two or three of those. We picked all five hard to get a coherent policy out of that. So here's my final slide. I give similar talks like this at UCSF and last year one of the students said what would you recommend. I felt it was fair to put it on. So this year I put it on. So I would recommend just as our SM Commission paper said phase out fee for service payment to physicians but also recalibrate it prior to us being phased out. Palliative care and care at the end of life services to get that 1% is getting 27% of all the spending. Most people don't want to die in the ICU. And palliative care actually got its start by Chris Castle who was here. He's the head of the general medicine section. Now there's a section at Mount Sinai that actually Robert Johnson helped to start. Diane Myers on it. It's a it's a win win. People want it and it's it saves money and hospitals are beginning now there's thanks in part to her center. Most academic centers have a palliative care center. You have one here. I'm sure. And is it a good one? Good. Okay. You wouldn't say no. Regarding new technologies require evidence that they work in comparison to the one that you so it's easy to get imaging technologies that give clearer resolution. And often the clear resolution is 5 or 10% and the increase cost is 5x. And so require before they're paid for that they make a meaningful difference and then set the price reasonably. Case management for the for the hot zones for the high flyers for those people who keep coming in and out of the hospital. Often if you get someone a low cost person to just manage to make sure they take their meds you can prevent hospitalization which again is a win win and nobody likes to go in the hospital. So it's better quality of care and slower cost. And then finally the students like this one. Students are graduating only a couple hundred thousand dollars are often married classmates. If they're having a kind of debt which Europe doesn't Europe basically gives medical student education for free. We're making students take this burden on they're not going to feel very good about charity care and they're not going to feel very good about getting off the road to to a happy specialty. So that's the end of this talk. I think there's time Marshall for question and answer and again it's a pleasure to be here with you in Chicago. I got my mic so. There are provisions to stimulate accountable care organizations primary care medical homes pilot demonstrations. All those in theory can. Save money the demonstrations to date have not been terribly promising. The results of not been terribly promising. I think the fact that there is flux. And that insurers are worried about new people coming on the market. And the fact that. Part of the a C.A. included finding a trillion dollars in savings to pay for the expanded coverage. Has sensitized people to this. So I don't know the jury still I don't of course. The implementation of the C.A. has fallen so far short because of the Medicaid ruling and also that many states don't want to do it. So I mean one of this is a separate issue but one of the tragedies is there's only about 10 million now. Who are insured. We thought there'd be as many as 32 million. Thank you. Thank you very much. Thank you very much. Thank you very much. Thank you very much. Thank you very much. Thank you for excellent talking but it was a burden. Just recently the United State Bar Association had a seminar on reimbursement. Consensus along all the individuals vote said in 5 years it'll be consumer directed healthcare but the consumer would be given more where looking to direct their own health care educate them so they don't understand what kind of health care they're going to get. I'd like to hear your comments on that. Well, I think the social media and all the things that we know about the Twitter and the Facebook and all that means that people are much more knowledgeable and are much more able to understand choices and to ask for them. The problem is that the epidemiology is asymmetric. So the folks at Stanford know that their business school graduates are really good at this, but they're not sick. And the 1% that's consuming the 27% tend to be older. They may not be as literate on computers. They may be from lower SES status. They may not speak English as a prime language. So I'm not as bullish on that five-year estimate. I think it's going to happen. I think it's going to take a lot longer. Thank you. Excellent presentation. With the reality that if your commission's recommendations ever become a reality, they have to be filtered to the lens of the difficult track through interspace policies. What's the position of the AMA and the Hot American Hospital Association on your recommendation to present? They didn't say no. They didn't say yes. We asked them to sign off on it. They didn't do that, but they didn't say no. Number of different groups did sign off on it, but not as many as we would like. And change is hard, as you all know. You were talking about European countries. You were talking about the differences in medical care. So single-payer is different from how doctors get paid. Single-payer is just where the bank is. And so each of those countries then has to figure out how to pay their doctors. What it does do is it gives you the capacity. So I'm in general a big single-payer fan, but with a couple of caveats. It does give you the capacity to centralize things. It gives you much more of a capacity to cut back on spending and to calibrate the rates. But how about female reproductive services under single-payer? What do you think would happen under President Cruz? Were you sure you'd want to go that route? So we're not Canada. Canada is a parliamentary forum where if the party in power wants to do something, it happens. The United States, any group, can sort of cancel out stuff. So I'm probably a little less, in this country, of 340 million people with a political system that's basically broken, that is driven by financing. I'm not as enthusiastic about government control as I was a decade ago. So what Germany has is it has a fail-safe government program, but most people go through their buns, they go into private health insurance plans, but there's a safety net. And those plans figure out how they pay. So the paying of doctors is somewhat uncoupled from who pays, but for reasons I don't fully comprehend, part of it actually, I'll tell you, when Wilbur Cohen came to UCSF in the 70s and I asked him why did Medicare incorporate this usual customer and reasonable charge for paying doctors, which is so inflationary and so pro-technology. And he said, Steve, I made a mistake. I thought I could buy out the AMA. I gave them what they wanted and they still argued against, and he said, if I had to do it again, I wouldn't do it. Now, whether it would have gone through or not, I don't know. So they're peculiar. This is a very different country. I was speaking up in Canada just after the Clinton Health Plan failed and they wanted to know how it failed. And I had to tell them, and the Canadians just didn't get this, the United States fundamentally going way, way back doesn't trust government. The Canadians do trust government. So we have a very different system. Our constitution was set up differently. It works mainly. It doesn't always work. Thanks for speaking. You mentioned a little bit about how increasing the amount of quality metrics that people can view might change things. What do you think is most important about that in terms of helping payers or consumers down the road start to make the right decisions? How does that information need to be shared and what should be shared? It's a very important and complicated question. I'm not sure I can answer it fully. I'm not sure I have the expertise to, but let me try to. It's really easy to say let's pay more for quality and less for not quality. That then means you've got to look at evidence. And when I was practicing and there were guidelines that came out, I would often find to the frustration I had that the circumstances of my patient didn't fit in those guidelines. So I think the execution of paying for quality is not going to be as easy. They usually start with cardiac procedures and the one that Eric Stecker showed on that. And you could do that. So if the criteria are one through three, then you just don't pay much for a stent in those circumstances or a defibrillator. But there's so many varieties of how to pay and look at Alzheimer's care. What's quality in Alzheimer's care? So the measurement, it's wonderful for health services researchers because it's a way to keep studying and doing that. I think the premise that you've got to justify what you're doing that's going to be good is reasonable. It gets tricky. So if you're an oncologist, you've got a patient with stage four cancer and you're showing a failed two chemotherapies. There's some people who say you shouldn't offer a further chemotherapy. And others who say, well, you should do it but with a full knowledge that what the suffering is going to be. And what there often is is asymmetric disclosure of information. So for example, on prostate surgery, the literature before they began studying it was at the rate of complications of incontinence and impotence were really low. Well, when some interns start setting up, wow, it's a lot higher than the GU people said they were. So part of it is getting information, which I fully support. Part of it is sort of transparency. Part of it is transparency of cost. In this way, and it's interesting, the U.S. leads the world. We're doing more research on this stuff than other places do. But people tell you it's going to be easy, tend to be theorists who are not getting, are not in the trenches. And it's much harder to work at least in the way I think. Marcia Beaker, you're closer to this than I am. What do you think of the ease of using quality to drive patient payment? Well, I think it's challenging for the reasons you said, but I think you do have to link quality metrics, as well as financial incentives to have all the alignment right for you have the maximum chance of real well success. I agree in theory, how hard is it to do it? Challenging. A bit related to the last question is looking at the five sort of recommended strategies. At the end, I was struck by the third part about sort of the payment for technology and sort of being more critical around that. Something that seems so much further out in the future. Could you lay over sort of a time and optimism component to some of these? Do you see any of these as sort of legitimate, much closer, quick wins and others that maybe don't need the ten year time horizon and don't know how we're going to get there, but it's still preferred. So this is on very specific diagnosis and treatment technologies. How much hype is there? Is that your question? Yeah, I guess with specific interest on that one, but then also if there are others that you think are in the further route. So you've got that, remember that chain I showed where all the forces are to do more. And that really fuels innovation and to drive to do stuff and you've got cancer and you want to beat it and so there's a tremendous amount of stuff coming out and we have a system perfectly, so somebody once said, when you see a turtle on a fence post, it didn't get there by itself. And we have a system perfectly designed to be where it is. We have high consumer expectations. We have real propensity to sue. We have physicians whose incomes are really different. So an oncologist gets much, much, much more money from using chemotherapy from not doing chemotherapy. So the best meaning oncologist, if the situation is equivocal and there's a new drug out and he's going to get a lot more money for it, the incentive, the person's human, is to want to say, you know, let's try this. So imaging, oncology, all these, they keep coming out. And also that's what the papers, that's what the journals publish. So I'm amazed, I'll read articles in the New England Journal. I was on its editorial board for a long time. They publish articles on new cancer drug that extends live for two months. And that's a big deal.  I mean, I don't have cancer now. So maybe it would be a big deal for me. And the costs are $100,000 annually. So who's going to pay for that? So we're going to get into ethics at some point. Someone asked me, getting back to the kind of single payer issue, what would it take to get everybody covered by national health insurance? And I would say it's an economic, it's a catastrophe that we get a great depression, not a recession, and people lose their jobs and their health insurance, and that would spark it. Thanks for your talk today. What do you believe is the most productive way that physicians can become involved in policy change or begin to affect it other than simply voting for their preferred officials? And what way can they, as physicians, and as general physicians, not just people picked for humanities, contribute to health care overhaul? So that's a great question. What can individual physicians do? And I get that UCSF has a lot of very socially conscious students and residents, and they come to me all the time. Part of me, and I've sent some to work in Washington, I have to tell you part of me worries, because the climate in Washington is so poisonous now that I worry that an immersion in that climate is going to turn them up, but they don't seem to be. They're young and optimistic and they're going to change things. You can do it at a number of different levels. You can do, as Mark is trying to do here with his center, you can create a model in your own place, but then you got to make sure that the rest of the world knows about it. You can get active in politics. You can get active on the issues. You can work for non-governmental organizations. You can write. You can help your local newspaper cover this better. There are just a whole lot of different things. What faculty can do is there's a Robert Johnson Health Policy Fellowship Program where you can actually go to work on the Hill, often in the Senate, to actually see how bills get made. There's a former health policy, why don't you stand up? There's a former health policy fellow in the audience who worked for Senator Kennedy. Was it a good year? Great. So you can do that. You have to be nominated by your school. You can get jobs on the Hill. I've gotten UCSF medical students jobs at the Institute of Medicine to work on projects, so they can do it. You can work on the issues. You can make it your scholarly career as Marshall's done. There are lots of really different ways. One thing to do is find someone who you think is a role model and talk to them.  I'd be glad to send you my slide deck. Schroeder at medicine.ucsf.edu.  That's okay. Dr. Schroeder, I'm going to go back to when you were talking about innovation and your definition of it, because technology is an innovation, but there are low-tech innovations. Has there ever been a comparison looking at the ROI on something, for example, like a culinary clinic or the medication checks you mentioned in terms of the return on those labor-intensive steps and then the advancement to getting better outcomes compared to the newest breakthrough technology? I walk that divide between breakthrough technologies but then I do $12 doing just basic education and nutrition and I can see there's a better ROI. So let me answer that one first before I forget it and then you keep talking about it. So who funds studies of ROI? It's government and it's industry. They want something new and dazzling, using a thiozide for hypertension instead of a third generation, whatever is much cheaper. No pharmacy company is going to fund that. So it's very hard to get money to study low-technology ROI. The Kaisers of the world could do that but it doesn't. So the incentives on, as I watch faculty, is to do the dazzling new thing, the new buzzword, the new technology for which you can get money. And even our government programs tend not to do that. They like to do, now the big thing is the social media. A home visit. It's very low-tech ROI in selected categories. No one's going to fund that but it's very hard to get it funded. Your second question. We'll find it. It would be probably one with a lot of hits. I think that it would overturn some of the comments that come out of RAM. Second question goes to Dartmouth and their ANOVA and their comments coming out about innovation in primary care. What can you tell us that you think is really something that's exciting out of that group? On the Dartmouth? The ANOVA clinic where they take the innovations, they bring it to a consensus on which one they're kind of almost as stakeholders going to invest in and then roll it out and have it across the board. So you know more about it than I do. I can't tell you much. I know Tom Bodenheimer at UCSF, who was a resident with me, has been talking about redesign of primary care. He's written a lot on that. It's harder to do in smaller practices. It's easier to do in the Kaisers of the world. It's easier to do when you get fiscal incentives to save money for not hospitalizing people. People who asked me today in earlier meetings, is there a future to being a primary care physician? I think that there definitely is, but it's going to require being creative, using other health personnel, those sorts of things. Questions? That's all right. What role do you believe physicians should have in grassroots political advocacy for health care change? For example, there's an on-campus student group of the Students for Health Act pushing for an adult level 1 trauma center to be re-established at the center that a number of doctors have openly come out in support and in fact attended protests themselves. Do you believe that physicians should be involved in that kind of advocacy, or they should mostly stay in the background, you know, research-based dealings? I don't think it has to be either or, as I think they can be advocates and others. One of the issues challenging medicine as advocates is that there is no single organization that really speaks for them. The members of the AMA is about 22% now of all practicing doctors, a little higher if you add resonance. So most doctors link in with their specialist society, and whether it's the cardiologist or the neurosurgeon or the radiologist, when they go to Washington, they lobby for two things, don't cut our fees or please raise our fees and help us with malpractices. AMSA, American Medical Student Association, is probably the most progressive of any medical stuff, but they're gone. So the leadership keeps turning over. I think if I were to lobby as a medical student, I would look at healthcare tuition. And I think, I don't think it costs as much to educate a medical student as they say it does. And I think, tuition's are helping to subsidize research and faculty. But students can't organize because, A, they're gone quickly. And B, they're worried about being the squeaky wheel or the nail that sticks up is going to get hammered down. So there is room for advocacy. But structurally it's really challenging now. In the smoking world where I'm in, one of the reasons why smoking rates in the United States are down so low is advocacy from doctors. The rate of physician smoking is 1%. Portugal is 40%. China for the male doctors, it's 50%. So one reason we've gotten so much kind of support, one reason why conservative governors are willing to raise the tax on a pack of cigarettes is that the doctors and the groups like the American Cancer Society and the Lung Association, Heart Association Goans, they say this is the right thing you should do. So doctors can be very powerful in public health advocacy.  So it's harder to get a consensus and it's hard to speak with one voice. It was more like a tower of battle. Thank you so much for talking to us. It was really enjoyable. My question would be, what kind of ways do you see that the consumer demand could be tempered and the expectations could be lowered in the society? So whether there would be any financial incentives or disincentives that you're bullet number two of daily care would become more of a standard for thinking in society versus number five or six course of chemotherapy or number five or six month in the ICU? That's a great question. The question if you didn't hear it is, how can we alter consumer demand? And I think it gets back to the question, who has the question about innovation and all that? So I think it is going to happen and I think one of the things is education. There's asymmetric information now and where is palliative care taking off? It's taking off in the educated people and one of the sad things is that people of color are so suspicious of the healthcare system that they think that not doing everything is white man's attempt to cut back on what they should get. But just as smoking and fitness and statin start in the upper classes and they kind of trickle into lower, I think palliative care and I think knowing and being, the other thing that's a problem is being literate in numbers. So what is a 1% chance of cure or mean? What is a 10% chance of incontinence mean? But I think having access to real good data on what the risks and the benefits are and increasingly I think people are saying I don't want to do that. I don't want to have that. I know you've had speakers here who have made the choice not to seek a full-core price. I'm actually a little more bullish on that as a strategy but I guess it's going to take a very long time and it feeds against all the forces that I showed on that previous slide. So next week our speaker is Mike Kenning who used to work at the administration here at the University of Chicago and he's currently the Deputy Director for Planning and Reform Implementation at the Illinois Department of Health Care and Family Services. And he's even talking about challenges of implementing the ACA here in Illinois. But let's thank Dr. Schroeder for a very thoughtful talk.