Our speaker today is Dr. David Song. Dr. Song is the Cynthia Chow Professor of Surgery, the Vice Chair of the Department of Surgery, the Chief of Plastic and Reconstructive Surgery. In addition, Dr. Song is the Associate Dean for Continuing Medical Education here at the University. David is an internationally recognized expert in plastic surgery with additional training in reconstructive microsurgery. He specializes in breast reconstruction and oncoplastic surgery. Dr. Song has pioneered several techniques for the repair and reconstruction of chest wall defects and has been involved in clinical trials relating to these procedures. For his outstanding achievements in 2008, Dr. Song received the prestigious Arthur G. Michelle Award from the Breast Cancer Network of Strength. Crane's Chicago also awarded Dr. Song the 40 under 40 executive recognition. Additionally, Dr. Song serves on the Board of Medical Aid for Children of Latin America, an organization that provides free surgical care for children with congenital deformities. Dr. Song received his MD from the University of California at Los Angeles, his MBA from the University of Chicago Booth School of Business, and completed his residency at the University of Chicago. Today, Dr. Song will speak to us on the topic of the future of surgery under the ACA. Please join me in giving a warm welcome to Dr. David Song. It's always great to talk about the future because there's no data. And I'm not used to giving talks without having firm data that's scientifically rigorous, that's been tried and tested. So this is sort of a little bit outside my element. So indulge me for the next 45 minutes and I think the future of surgery under the Affordable Care Act will look like. Some controversial topics in here. These are based on my musings over the last four years, a lot of discussions with my economist friends that I golf with every Saturday, including the likes of Gene Fama and Steve Levitt. So some of these ideas have been bounced around on the golf course for the last four years. And so hopefully it'll come to fruition. So there is some validity, it's not just my own imaginations. Here are my disclosures. And I do want to also say that my views expressed are not necessarily shared by those of the Department of Surgery, the Dean's Office, or the administration or the hospital. I want to make that very clear. I'm going to go over a few things. Really talk about the state of confusion and transition currently. Talk about price transparency and what that means and how that's coming about and how that'll affect us. Talk about cost control on an individual surgeon level. And then talk a little bit about how surgery and medicine may be organized in the near future or should be organized. And then finally talk a little bit about some of the work that Alex Langerman and we are doing in Oak Creek. So if you look at the left, everyone looks at Obamacare and say this is wonderful. It's really how could a first world nation not have coverage for our populace? But if you look on the right side, you get a completely different view of what the Affordable Care Act looks like. I want to make it very clear that I don't want this talk to be political. It's just a matter of presenting ideas and what I think will be crystallized into how surgery will be performed in the future. This is a funny thing. There's a lot of confusion here and I think even at the governmental level there's confusion as to what's going on. And so this is a slide that somewhat resonates. And I think the state of confusion and the fog of confusion is starting to dissipate. So how is surgery done today? Well, if you come to the University of Chicago and you have breast reconstruction surgery by me or one of my colleagues, there's a bill. And this entire bill that is paid for by your third party carrier is divided up into the institutional side, what the insurance company pays the University of Chicago for the ICU care for the ORs, for the nurses, for the sutures and such. Then there's a professional side of what we as surgeons get paid. Of course, if you talk to a surgeon, this side is too small and if you talk to the institution, this side is too small. And if you talk to third party payers, that side is way too big. And so there's this dynamic conflict that's going on currently. So what's happening now is that CMS is shifting the risk away from the hospitals and to the doctors and physicians. So 10, 15 years ago, I didn't have to think about this stuff. I just walked into work and did the surgery and used the stuff that I wanted to use and didn't need to think about how our outcomes are going to be or what is quality and that's something that's changing rapidly. So this is a slide that if you remember nothing else, hopefully you'll remember this slide. It's like crossing the crevasse. Currently we're over here. Right now the more I do as a surgeon, the more I get paid. The more surgical procedures that I do, the more remuneration that we receive as a hospital. It's tied to our work RVUs and I'm seeing Andy Switek over there who we are very aligned here in 2014. There are a few quality measures. Now, this quip's coming about and there's all kinds of things that are starting to blossom. Even plastic surgery has its own registry. But because of that, there's an incentive to do more. Meaning that when a patient comes to see me, the first thing on my mind is, when can I schedule the patient for surgery? And I realize when I take a step back and think about this as not just an economist, but as a human being that perhaps not everyone needs surgery. And so what happens is that the remuneration that we receive in the high-end top growth service lines helps to cross-subsidize the entire medical center in many ways. In the future, what the Affordable Care Act is going to accelerate and the velocity of this acceleration is going to increase now and tomorrow is it's all about population care, which helps to reduce fragmentation. EMR in many ways is going to in 10 years tell us what's efficient, what's working and what doesn't work. And that's perhaps how it's going to save over $19 billion a year. There's going to be a premium on quality. And quality measures are really going to be at the forefront of everyone's mind. I'm going to talk a little bit about that towards the end of my talk. And then government payers are going to take a prominent role thus incentivizing not the realm of do more, get paid more, but perhaps doing less to create better health and value for the population that we take care of. And that's going to be accelerated. I don't know if you can see that from back there, but by bundled payments and this whole concept of pay for performance is really going to help to accelerate our crossage of this crevasse. This is another busy slide, but I want you to focus right here. Currently there's a whole set of employers now that are self-insured and that is rising. And so what's happening is large companies like Walmart, school systems, Lowe's, McDonald's are now self-insuring their own population. And so what that does, it sort of flip-flops the incentives that are currently happening and perhaps realigns them with global health of their population. What does that mean for us as surgeons? Well, that means that perhaps, and this is a bit controversial, insurance companies will no longer be needed. What if Walmart came to the University of Chicago and said, Dear Dean Polanski, we want to make sure that University of Chicago is our preferred provider for X, Y and Z service lines and we will negotiate with you directly because we're basically paying it. And then Blue Cross can just be the third party adjudicator of that process. Novel concept. This is sort of a back to the future of the 50s and 60s where patients paid for the services that they received. What does that do? And I think over the last three or four decades insurance companies and the whole idea and the concept of insurance has been perverted. You know, if you think about car insurance, there's all types of different products that you can buy and health insurance is the same way. And so when someone else pays for your insurance, the person that's not paying doesn't own it. And so what happens is it's similar to going and leasing a car for a week. If Andy Switek and I are going on a golf trip and I'm leasing a car, well, I'm not going to care if he spills coffee on the seat. But believe me, if he was in my car and I'm driving to our golf retreat in my car, I'm going to be really upset that he spilled coffee. Similar with health care. When a self-insured entity pays for their workers to have health care, I think that you're going to start to see alignment of both health population management and this whole concept of value-based health care delivery. So the whole purpose of this slide is to show you that's happening currently and the velocities of that are increasing. So let me segue into price transparency. And I think if you think about price transparency in terms of hotels.com, priceline.com, GEICO, and nationwide insurance, you go on to insurance website or you go on to, if you're flying to Hawaii for a holiday, you can go in and punch in your dates and outspits kayaks, you know, five different choices. But we don't have that in health care. If you think about all the industries that occur in the United States, some of these efficiencies that leverage technology that help to make things more efficient and unveil price obfuscations just don't exist in health care. And I think we're at the dawn of a new age of price transparency within health care. And let me tell you a little bit about that. These are funny slides, but they have a lot of meaning because when you go and get your hip replaced at the University of Chicago versus Northwestern versus Rush or UIC, the hospital bill is completely disparate. And I'll show you some data here. This is a California study just on routine appendectomies. People have seen this before. But if you go to one hospital that's as low as $1,500, all in, if you go to another hospital that's as high as $182,000, why? The reason why is because they can. And I'll tell you what happens when you start to reveal and peel the onion away, the layers of the onion away from price obfuscation, there are going to be some winners and losers in. And we'll talk a little bit about that. Here's another study showing that not just appendectomies, but cabbages at different hospitals in California have such a disparate way of charging and pricing for what they do. More data in the Pittsburgh area show that no matter what you charge, the payments aren't too disparate. And I think if you look at the Chicagoland area, and God forbid one of you or your family members requires heart surgery, well, if you came to the University of Chicago versus Rush versus Northwestern, you would see a dramatic difference in the price of what you're paying for or what the charge is to the insurance company. So we're on a dawn of a new era where I think companies like Castlight, just as a quick show of hands, who in this room has heard of Castlight? Raise your hand. Okay, stay tuned because these type of companies where they're collecting all types of healthcare bills and revealing what people pay for is the first step towards price transparency and is really the first wave of the price line.coms or the kayaks, if you will, of healthcare. So what that does is, let's say you live in this zip code and you want a primary care physician or you have a sore throat or you need a colonoscopy, you'll type in your zip code and you'll type in who charges what and how much you'll actually pay for it with your deductible on your current insurance plan. That's an extremely powerful tool because imagine if you needed left-toe surgery and your network was narrow and you went on there and said, okay, I need left-toe surgery. I can choose between Dr. Chin, Dr. Sigler or Dr. Song. Well, Dr. Sigler is going to charge $50,000 and Dr. Song charges $2,000 and Dr. Chin charges $200. And if you pair that with outcomes data, that's the next step and I'll talk a little bit about that in the future. Well, guess what? You're going to raise your hand and say, what's so special about Dr. Sigler? He's very special to me, but he may not be the best left-toe surgeon. So this is what CASTLIGHT and they just went public about two months ago and this is a complete wave of the future. And as I disclose, I'm an advisor for Health Engine, which is similarly a vehicle for price transparency but with an added benefit of actually negotiating with providers with their excess capacity to be able to provide quality care at a lesser price that's totally transparent. So if you think about it as hotels.com for health care and things that are high in capacity, because if we used 99% of our OR time, well, this type of vehicle is irrelevant. But if we're at 60 to 65% of our capacity, well, there's 35% of capacity that can be utilized for a less price, a contracted price. So think about an airline. When you take off from Chicago to Orange County and all the seats except for five are not filled, well, if you actually go on on a Tuesday night after midnight, or I think it's right before midnight, it's the cheapest prices because that's when they do inventory. So vehicles like this are starting to pop up and I think we are once again on the dawn of a new era of price transparency that we've had in virtually every other services in the United States except for health care. So with that price transparency becomes a responsibility of the providers to think about costs. So what does something cost? Well, if you go to Nordstroms and you want to buy a tie, the person that purchased the tie for Nordstroms paid a wholesale price to a factory in Malaysia. And the Malaysians paid a... you can go down the supply chain and think about exactly what people paid for. But in health care, it's extremely confusing. So I did a straw poll because once again, we have no data. I don't know if maybe most of the people in this room are too young to remember this, but there's a game show called The Price Is Right and I know it's in its different innovation, but one of the favorite games is you put a commodity up there and you had to guess the price between a certain range. And of course, some people were good at it and some people who were horrible at it. So I did this with our surgeons and I asked surgeons in the surgical waiting room, hey, Dr. Langerman, how much does a surgical staple cost and how much does a 3-0 vical cost? And I did this across about 20 different surgeons and I got answers between $18 and $182. Jason probably knows the exact price and he can tell me who won or not, but that is the basis for this cost confusion because we, as the providers, the consumers of these variable costs don't even know how much they cost. So what happens? It goes back to the analogy of renting a car versus owning a car and we don't have the accountability on our side of surgeons. I promise you this is the only slide I'm going to show from business school, but if you look at the variable costs out here, the higher you go and the more you use, the profit margin goes down and your contribution goes down. And in this era of efficiency and managing expenses and managing price transparency, coupled with cost control, this is extremely important. So how are we going to get there? Well, the vehicle, if you remember back to my slide of the crevasse and the accelerator being bundled payments, this is what's going to happen. Instead of the current situation of profis, institutional immuneration and there's that dynamic conflict, well, there's going to be this whole concept of bundle care where, and this is happening already and actually our old dean, Glenn Steele, at Geisinger Health is one of the first people to really do this on a systematic basis for coronary artery bypass grafting. So he went to this third party adjudicators and said, look, we're going to take care of your patients with coronary artery disease and we'll take $40,000 all in and we'll take control of that. What happens there is now the risk is shifted from the insurance carrier to actually the provider and the institution. So how does that work? Well, if there's a complication, the hospital eats it. If there's a mismanagement of variable costs of things that Jason has to buy for our ORs, the hospital eats it. So what happens then is how is this remuneration going to be doled out to all the different parties involved from radiology to health care services to the support services, nursing, ICU, and so on and so forth. And that's really going to be the big work that institutions will have to do, I think, in the near future when things are really moving towards bundle care. Because once again, this shift is happening rapidly and the risk of health care is now being placed upon the providers and institutions as opposed to a third party payer. So what happens to our income? Well, I think as surgeons, we're starting to see government payers pay nine cents on the dollar for what we do. Now let me pause for a moment. There's a few surgeons in the room and I'm going to say something a bit controversial. I think that if you look at and normalize data of surgeons and surgical services globally, that the United States, the costs of what we do and the remuneration of what we receive for the same services is markedly higher. We're talking standard deviations higher than our closest neighbors. One of my good friends was skiing in the Dolomites and just this past winter and he went down a double X run and had a tibial plateau fracture. So instead of flying out here and he has the means to fly wherever he wants to go, one of his friends that was skiing with him was a German surgeon that knew some of the Italians that got him into a private clinic, fixed his knee, his tibial plateau for all in $7,500. We're talking including the implant costs, including the hospital stay, which was three days, medicines and surgery. I can tell you the hospital bill for a tibial plateau fracture, probably in the Chicagoland area, all in close to $90,000. Anywhere between $60,000 to $90,000. So what's happening here? And I want to save that conflict for our discussion, but unless we do something as surgeons and as leaders within a medical institution, the income will be anticipated on a downward trend. I think we need to figure out what to do with it. This is actually a slide that Jason will look at and know, but these are real life, ongoing things that we're doing and managing our variable costs. Here are estimated savings for things like hip and knee, neuro fixation, and so forth, and how we're actually being stewards of some of these things that are high ticket items. This is a real slide, and I've taken the offending companies out to save them, but you can see for something just like a biologic, which is a skin substitute, the prices can be markedly different. This is a real slide. Everything was set for me in mid-December of last year to figure out how to consolidate and pick. Now we're not asking to pick based on just price alone, but we're looking at pairing price and aligning that with our outcomes, and this is something that we need to do more of and continuing to own as surgeons. The days of, hey, give me three of those and two of these and let's see what sticks are really long gone. So what will be the drivers of efficiency in the future? First and foremost, we have to understand what things cost. As surgeons, like I said, when I did that straw poll, there's a huge variability of what things cost. If I asked any of you how much does a gallon of gas cost, you can within three to ten cents know and tell me exactly how much a gallon of gas or a gallon of milk will cost, but in surgery, with things that I use every day multiple times a day, that data is not clear. So with that data, by unveiling that data, we as surgeons have to be better at managing our variable costs. I can't tell you how many times. I'm going to pause for a moment and give you real-life vignettes of what happens in surgery, and these are some of the things that Dr. Langerman is studying through Opry and how stress perhaps is correlated with higher use of variable instruments that are disposable. So let me give you an example. I'm going to pick on Dr. Angelos because he's always so calm and smooth and collected, but there may be a day when there's some extra bleeding coming out of his incision after doing a thyroidectomy, and the nurse had walked out of the room because she was getting the dressings for Dr. Angelos. Dr.  But now the nurse comes back in with all the things that he wanted for the dressings, and Dr. Angelos is yelling and screaming at her, which he never does. Where's my suction? I need an extra yank hour because it fell on the ground, and I need an extra fibrin sealant and a hemostatic solution, this little powder that costs hundreds if not thousands of dollars. So she rushes out of the room, oh my gosh, Dr. Angelos is really pissed. I've never seen Dr. Angelos pissed. So instead of grabbing one hemostat, which costs thousands of dollars, she grabs two because she doesn't want him to be upset. And then comes back to the operating table and knows if Dr. Angelos is really upset, opens two of these. Dr. Angelos, meanwhile, while she was out, got control of the bleeding with good surgical technique. Everything is common cool, the video is working again, and we don't need the surgical statin anymore. So what happens? The nurse did her job, and the nurse is trying to please Dr. Angelos, do the right thing for the patient, and opens up things that costs hundreds if not thousands of dollars that goes untouched. This happens thousands of times a day, every day in the United States. So we have to figure out how to control that. I'm going to show you a real life example of that, how to partner with hospitals to make sure that the efficiencies of what we do in surgery not only translate into great patient care and safety, but cost-effective patient care and safety that really equates to value. So I have this idea that right now there's this whole concept of work RVUs. The more you do, the more it's tied to compensation. But in the future, there may be something called relative cost units. And you want them to be diametrically opposed to your relative value units, Andy Switek may have a sheet that opens up and says, Dr. Song's relative value units are really ticking up, but so is his relative cost units. And we're going to have to tie that to his compensation because what you want is a divergence of work units versus cost units. And I think that once you define that inflection point and can normalize that, stay tuned because I really think that this is an opportunity for forward-thinking universities and medical centers to trial and think about not just RVUs but RCUs. And this applies across the spectrum of health care delivery, not just in surgery. Surgery just happens to be easy to pick on because we have got high variable costs. So this is a real-life picture probably, I don't know, six months ago. I consider myself a very prudent, parsimonious surgeon and I'm very aware of this and I'm actually the one given this talk, but this is quite hypocritical and this is my remains of the day. This is the title that I came up with with Alex and these are all the instruments and things that were opened but not touched at the end of the case. Not just the beginning, at the end of the case. So we're doing a study right now as how much we're actually wasting. You can see here this bioptics monitor, that's $780, contracted price. This is a specialized glue and surgical tape, probably a couple hundred bucks, $120, something like that. A couple of stapler, sterile strips. A light mat, which I love to use to give light into deep crevices. That's probably, I don't know, at least $150. All in total, I think this was about $680 to $700, something in that ballpark. And that's for someone that, in my opinion, I think I'm very parsimonious. My wife will say that I'm cheap. But I'd like to use the word parsimonious and that's me. So think about what happens hundreds if not thousands of times a day, every day in the operating rooms in the United States. Which translates into huge opportunity for us to manage proactively how we deliver high quality care. Which equates to value. Because we know that the dollars are shrinking. We know that the costs of what we use are increasing. And we have to figure out how we can do it better. And that's why guys like Jason, I'm glad you're here, are going to be pivotal in partnering with us to figure out how to deliver this change management correctly. So I had this concept at the end of the case. So in surgery what happens at the beginning of the case when Dr. Angelos does a parathyroiderectomy, he walks in and says, this is Mr. Jones. We're going to do a parathyroiderectomy, re-implantation, no allergies. Beta block was taken today. And this is actually a checklist that we have to go through. And at the end of the case, before he leaves, he has to do what's called a debriefing. So the debriefing goes something like this. Okay, I just performed a parathyroiderectomy, a radical nectisection and the tying off of the carotid artery. It was a complicated case. And the patient's going to go to the ICU and the disposition is challenged and discussed. Well, I think that's a perfect opportunity for us to introduce what's called a surgical receipt. So at the end of the case, instead of going and saying, because if you go to the store and if I ask Dr. Segal, hey, here's my credit card. Go to Whole Foods and buy your family a week of groceries. Guess what? It's going to be hundreds if not thousands of dollars. I would like to think so, because all the great wine he's going to pick. But if he used his own credit card, it would be a fraction of that, because he's going to pick what he needs. So how about if we pair up and align the data of what we use in surgery with what our outcomes will be? Imagine a day when Dr. Angelos does a debriefing and without going granular, the screen on the dashboard flashes green, yellow or red. Green means that he's within the norm of parathyroidectomy surgeons across the country and the costs are right within one or two standard deviations, maybe one standard deviation. Yellow, something happened, it creeps above that and two statins were opened and he actually used two statins and maybe that's a variability that is acceptable. But then if Dr. Angelos comes out of surgery and that screen flashes red, every single case, someone's going to make a call and say, hey, Dr. Angelos, look, I just want to show you the last 20 cases that you've done, outcomes are good, but why is it that you cost the hospital $122,000 and Dr. Grogan does it for 12? The length of stay is the same. The current laryngeal nerve is always protected and it's never cut. The patient outcomes are the same. Help us understand that. So I think there's an opportunity for us to pair the debriefing with what we spend in surgery. First of all, we have to unveil what things cost because people just don't know, including myself, what things actually cost in surgery. I'm going to talk about the ethics of that later and really tie it in in our discussion. But moving on to how things are going to be organized, we talked about price transparency. We talked about cost control on an individual basis and I want to finish up with a few things and I think things will change on how patients are accessing our healthcare institutions. So right now, this price transparency and information velocity, I think is going to enhance and empower patients to have greater choice. We know it as of today. I mean, things like airline flights and car services have become a commodity and I dare say it to distinguished colleagues like Dr. Sohn, but surgery, because we've gotten so good at it, may become commoditized. Of course there's individual variations of complexity and indexing but things that we do in surgery may become commoditized and in medicine itself. And with that commodity and price transparency and information velocity will lead to greater patient choice and it's happening already in virtually every other industry that we can think about. So if you make that available publicly, which is happening already and then make cost data available, you're going to start to see that we need to reorganize ourselves. Here's what happens right now. If a patient has breast cancer and I'll use breast cancer because it's a very complex set of touch points for surgeons and physicians and radiologists and imaging and nurses that we actually have something called nurse navigators that help a patient navigate through who they need to touch as far as healthcare. So there's surgery, there's oncology, there's radiation oncology, pathology. I didn't even list the six or seven others but we all currently work in silos. We may have these things called multidisciplinary teams but each of us is our own cost center and our own revenue center. So we are doing what we need to do to minimize rents for what we do in surgery. Oncology will do the same for oncology and radiology and so forth. So we are basically working in silos and the patient has to figure out how to manage these silos for themselves. So what does that mean? I think it's stuck here. So instead of having nurse navigators they have to be their own navigators.  I have to go to the University of Chicago website. There's nothing that says breast diseases necessarily but I have to figure out for myself because my friend told me that I should probably get a mammogram. Then after I get a mammogram well that's going to go to the pathologist and I have to figure out and make sure I talk to Dr. Hussein to make sure all the margins and what type of tumor that I have. Then after that I have to be aware enough if the navigator is off for the day to figure out that I need a surgeon after Dr. Jaskoviak. Then upon that the patient has to figure out well, I may need chemo, I may need reconstruction and this is all the onus is on the patient. Now if you back up to the last slide I showed you because of information, price transparency, cost control that I believe is going to happen that is going to be open to the public. So we have to organize ourselves better and what I think is going to happen and I think what should happen is we should be organized as based at forward thinking institutions where a patient will understand that if they have a disease of the breast or breast cancer that they click breast cancer and all our providers and I hate to use the word provider because as a physician I didn't go to provider school I went to medical school but this is how third party payers think about us and this is how the public may think about us this is how we're going to be organized and I think this is how we should be organized. Some may say hey we are organized that way some may say that the Cleveland Clinic is doing it because a website shows it that way but I can tell you that unless you pair up cost centers and revenue centers that way instead of the current way we're doing it within silos it really doesn't work that way where the money is is how we should be organized and where the money is is how we're going to have to be organized. So what does that mean? So right now if you came to the University of Chicago these are rough, rough, rough estimates these are make-believe numbers this is what a patient is going to pay but in the future with bundled care at the University of Chicago Blue Cross Blue Shield or Walmart or McDonald's will say you know for Miss Jones we're going to give you $33,000 and you guys figure out how you're going to be organized and how you're going to dole up that money because now the risk is on you guys and that's what's going to happen. So I think what needs to happen that cost centers will have to be blended the bundle care concept will be the norm the bundle payment to the hospital system or the ACL will have to be what we have to manage per member per month type of payment model may be the norm who knows but that's what's going to happen in my opinion and then for the hospital it's going to be an overall break-even game instead of a profit margin because right now the reason why we can do all these things is that certain payers will pay us 20x of what other payers will pay us and that's how we cross subsidize so in the era of bundled payments we're really going to have to be efficient and manage our cost because the revenues will slump and then because of that I think we can make that up by doing more efficient expeditious quality care because the more you do the better at it you get and the more efficient you get I mean when I used to do a DIEP flat for breast reconstruction 10 years ago it took me 12 hours to do it today I did one a couple days ago it took me about four and a half so it is possible to do more to do better and my outcomes I think are better than they were 10 years ago and then finally the whole concept of who pays for the complication so if someone has a breast cancer complication after touch points of all these different services then who pays for it well I think that the risk will be shifted on us as well as the provider as the institution because now the insurance companies and the self-insured who gave you $33,000 for patient X that's what we're going to give you and we have to figure out how to manage ourselves better so what would the departments of the future look like these are just my made up names but it may be a department of breast diseases where the cost centers and the management is all within that department of breast services the chair may be a breast surgeon the faculty may be a plastic surgeon radiologist and an oncologist and pathologist all revolving around breast diseases a lot of this is happening in Europe as we speak heart and basket disease the chair may be a cardiologist with all these people as faculty members right now they communicate and they have multidisciplinary teams we're not under the same cost center department trauma and extremity care and so forth you can start to see that if you think about patient forward ways of delivering efficient quality valued health care we're going to have to change as physicians and as leaders particular in surgery so I believe change is inevitable the current fog of confusion is dissipating and it'll continue to clear up we're going to have to cross that crevasse to this value based health care side and it's going to be expedited by risking transferring risk to providers and institutions it's going to be an incentive to manage our population and our zip code as opposed to fee for service model insurance exchanges will ensure more people but reimbursements will be lower so let me stop for a moment and talk about the ethics of how this may plan out if you think about what's happening in Canada and in the UK there will be some sort of rationing it's a bad word rationing of health care is a really bad word here in the United States but these are the vehicles that are going to help implement that rationing if it's called rationing it may be called a wait list or it may be called a to be continued type of list but health care will be rationed price transparency I believe is going to be the norm because it's happening already patients will be able to click online and know Dr. Song costs X Dr. Angelos costs 2X and Dr. Siegler costs half X and we'll be able to choose and pair that with quality data outcome measures will be front and center we have NISQIP right now we have all types of data that's available for institutions a SEAR database but there will be databases that are forward facing like Yelp or Angie's List or Castelight will have that vehicle for you to go on there and say well Dr. Siegler did 3000 left-toe surgeries last year and his surgical side infection meanwhile Dr. Chin did 2200 and his infection rate was 5% by the way Dr. Siegler costs half X so I think you're going to start to see that paired up with patient facing data cost control on an individual basis I believe will be the norm and within our lifetime within our era in practicing surgery here at the University of Chicago Jason will have a way of figuring out how to pair that data with what we do it's very unsavory to think about but it has to be the case for us to continue to make a margin to fuel our mission then opportunities I think opportunities and feedback for individual growth and improvement will make us better faster stronger and it's all about performance enhancement so let me take the next few minutes to talk about some of the cool things because I hate to always end on a downer I mean I give these talks at our major international societies and our national societies and literally all the surgeons in the room their faces turning red they're about to hurl their leftover sandwich at me and I have to remind them I'm just the messenger and these are just my thoughts and quite frankly one of the things I actually put up there is as a disclaimer I hope I'm wrong I never like to be wrong but in this instance I would love to be invited back five years from now to the McLean Center and say who I would love to eat crow up here and say my title will be how wrong was I we're still in the fee for service in fact we've gone back to the fee for service model and insurance payments are Obamacare's repealed and things are not just back to old business but you know the good old days I don't think that's going to happen but I would love to be invited back if that does and I'd be the first one to say how wrong was I but I have to remind myself that surgery and surgeons in particular I'm safe to say this because I am a surgeon it's hard to change what we do because there are rules around repetition and how we were taught and how our mentors were taught and so forth and so to try to break that culture is very challenging especially in surgery so I do want to end on a high note so opportunities so if you think about what we do in sports and even in video games there's all kinds of sensors that allow you to be better at what you do who play how many golfers in this room alright if you've ever hooked yourself up to a swing machine you'll understand that what you do this is a horrible golf swing notice my head is dipping down there's a little sway in what I do and my hips are not rotating but they're swaying this is after multiple attempts at sensors and speed and this and that and the other but I thought to myself wait a minute I'm doing this for my golf game I'm not going to do this to my profession so let's show you a great swing this tighter woods and you can see that his head doesn't move this is not digitally enhanced is unbelievable because he doesn't move his head doesn't move at all he's rotating around the core of what he does this has relevance bear with me this definitely has relevance and you can see that at the top of his swing his club is parallel to the ground and pointed in the right direction and look at what happens when he releases head doesn't move at all there's no sway in the hips it's an uncoiling of power 320 yards straight down the middle now what if I told you that that was his swing in 2005 and he's changed it three times since three times and that's Tiger Woods because as a professional is what he does and what he wants to achieve before his fateful accident by his wife ex-wife is as a professional what he wants to do is become better and he's changed his swing since then three times so what are some of the opportunities what can we do this is courtesy of Philippe this is what we're doing right now under Dr. Lagerman's guidance and OPRI performance research institute to make sure that we can apply some of the things that we used to fix my golf swing which is beyond repair to do things in surgery better, faster, more efficiently safely and the economies of motion I'm going to show you a slide here this is a 3D rendering of what our posture looks like that's me right there it's my assistant how can we organize ourselves better as a team for greater outcome greater patient comfort greater surgeon comfort and here's some of the things that we can do this is Sam Fuller he's not here today but I think I have his permission to show his image this is me, look at his neck his neck is bent and flexed for hours on end and if you've ever spoken to a surgeon that's 50 years old or more they invariably have cervical neck or lumbar problems, maybe not Peter but I can tell you that most of my colleagues in plastic surgery because we wear loops and headlights by the time we're in our late 40's or early 50's at the prime of our career we've got problems and so how can we fix that because if you're operating like this and you're uncomfortable and you're doing a microanastomosis of a 1.2 millimeter vessel, well I think you're going to be better if you're like this and more comfortable and relaxed so how can we improve ourselves it's a matter of first of all getting the data becoming more efficient understanding what we're using in the operating room to then translate into better outcomes so how does that work? Atul Gawande talked about a surgical coach and that's a fine idea but it's not necessary I can't hire Butch Harman or Tiger Woods Swing Coach I would love to and have him see me every time but what we can do is leverage our technology we can watch film for immediate feedback and using sensors to say hey, wait a minute you're bent over too much your neck is crooked and if you continue to do that you're going to get cervical neck discarnation we've got to be more ergonomic and more efficient I believe this will translate into patient safety because as a surgeon if I'm operating for 8 hours and I'm not comfortable I know at the end of the case that I could have done something better I think as surgeons in the room if I'm comfortable and stress free as much as humanly possible then things will be efficient things will be safer and things will be more cost effective so it also adds to surgeon safety and I'll end with a real life example of this there's a very famous plastic surgeon who's a hand surgeon that at two years ago he gave this keynotes address to our society and the first slide he showed was not like the next ray of someone that was 90 years old with degenerative joints there's no actually joint spaces at all in this patient's neck and spine and the next slide is it showed that it was himself it was the sea spine of himself he's practicing and living with chronic pain because of the things that he didn't do early on in his career so for those young surgeons in the room and for those not so young surgeons in the room we have to be more efficient and we have to think ergonomically of what we're doing because I believe it translates into patient safety and our safety so a new dawn is upon us I think there's a lot of opportunities there's incredible change and the velocity of that change even within my lifetime as a physician is like at 120 miles an hour and it's going to get faster and we have to be responsive to that and partner with our hospital partners to make each other to be better and I want to leave you with this slide so thank you very much happens to fall in line with what happens as we develop an integrated care system which is now labeled accountable care organization it smacks of heresy in an academic medical center that is set up in academic departments that have traditionally been very strong and my question has to do with how are we going to de-emphasize academic departments and develop accountable care along the way with your price transparency and value structure all of which I think are very important Cleveland Clinic has done it they've virtually eliminated the traditional department setting everything up by service lines but how do we go about doing that here at a place that has a culture of working in silos without very much horizontal integration to begin with that's a great question first and foremost we're not alone if you look at any university of St. Elsewhere academic medical center it's very much built upon departmental prominence departmental profitability departments are lauded for research dollars and profitability so it's a culture that I think has to change unfortunately it will change because of how healthcare is changing Cleveland Clinic is the forefront of this and they're really the leaders of this but even to this day Cleveland Clinic their cost structures and their revenue centers are not blended some of their programs are and they're moving that way but this is a real shift and you want to call me a heretic believe me I've been called a lot worse for giving this talk because it is something that if you divorce yourself as a surgeon and look at it purely from a perspective of service as a business this model that we currently live in is archaic and I think that the public is going to demand more the price transparency and cross structure is going to mandate it and I think that we have to respond so the change is going to be very difficult and I think there's still a sweet spot I think there's a way to be able to reorganize our departments blending our cost structure without sacrificing the research and the educational mission there's definitely a way we just need to figure out I mean we can figure out how to transplant a kidney and transplant we can easily figure out how to reorganize ourselves it's just a matter of coming to the table having very frank discussions and figuring out the win-wins particularly as it pertains to patient care I think when we do that and we sort of check our egos at the door and think about what's right in this new environment we will find win-wins that will give us greater prominence and not necessarily just departmental prominence so that's hopefully my prediction and I'd like to be right on that one because there are many institutions that we know of where the department of left-toe surgery is extremely prominent internationally and yet the departments of medicine or surgery are not and so if we can reorganize ourselves better to be more efficient and to be to deliver that care in a more cost-effective way there will be room for that margin to help feed the missions that make us what we are two quick questions one, it seems to me that bundling payments actually incentivizes the physician to do the least amount possible at potential risk for the patient which I'm not sure is an ideal situation for us to get into so I wonder if you comment on that and then the other is do you suppose the expansion of insurance to folks on the south side might change the university's calculation that providing trauma care is financially feasible? Let me focus on the fact that bundle care may actually expedite a two-tiered system of healthcare it's happening already if you look north of our borders if you look at the UK any place with somewhat of this nationalized system has a two-tiered health system the answer to your question is yes and no I think yes it will help to ration if that's the word healthcare so I'll give you an example of what I mean by that so right now we at the University of Chicago are trying to do everything humanly possible to increase patient flow particularly in breast reconstruction let's say well I went to Vancouver as a visiting professor and their biggest problem believe it or not is they have too many patients their average wait time for an elective breast reconstruction was 8 months so they're trying to figure out how to stop the doors so it's completely flip-flop so what has happened in Vancouver is there are these private clinics that cater to people with means and I don't say this with any judgment at all I just want to tell you what's happening is a two-tiered system will evolve and it continues to be involved if you look at the data on primary care physicians the average number of primary care physicians with a concierge in practice 10 years ago was 3% now I think it's like 13 or 14% and rapidly rising there's a whole group an organization like the AMA calling American primary care concierge physicians association or something like that and that's rapidly increasing so you're starting to see a lot of that play out as far as you know care I mean that trauma discussion is probably not relevant to this talk but I think that you're going to start to see that academic medical centers will start to expand their focus of what we can do more efficiently and better what is the future of the telemedicine pro and cons cost-effective yeah so the future of telemedicine so you know we have to define what telemedicine really means does it mean individualized patient interaction does it mean feeds to teach does it mean a combination of both so I think that's already happening now I mean webinars are the norm our conferences are you know closed through the internet being broadcast to all the people that want to subscribe I think that meetings of the future are going to be more let based on internet and web based as opposed to actual sitting down and shaking hands so it's happening already you know there's companies right now that are especially in aesthetic medicine that are doing consults via Skype and closed circuit type of services so it's happening already it's just a matter of how do we keep it safe how do we keep it compliant and how do we make sure that patients really are getting what they're asking for so to answer your question it's happening already I think a huge educational agenda of mine as the associate dean for CME leverage that whole learning online and personal professional management and growth so that's happening already thank you for superb talk the question that I have is you started to talk about the catch 22 of cost containment if you do more you make more if you do less you make less I have control as a surgeon over my cost I can send a bill and I have control over it I have no control over the hospital costs I have no control over the pharmaceutical costs I have no control over the device costs it seems to me and I'd like to get to your suggestion of how we could have more impact on the hospitals, pharmaceutical companies device companies to all work together get those costs under control you know I think it starts with really leveraging transparency and understanding that that's right around the corner and so you know imagine if you find a jason at your hospital and you sit down and say look let's figure out how we as an organization can do things more efficiently more cost effectively with better outcomes well I showed you my own personal slide how much money I'm wasting and I think if I walked into your operating room at the end of the case you'll start to realize oh my gosh I didn't realize my nurse opened up five of those urethral catheters and I think that that starts there and if you align goals with the institution well that margin that you either save can be deployed for everyone's benefit so I think it starts with partnership and that's one of my summary slides is to make sure that we I mean let's face it in this new era we have to have partnerships you're seeing massive consolidations in healthcare as we speak you know cadence healthcare aligned now with Northwestern and all these different healthcare systems and why because they're trying to gain more economies scale for everything that they do and so we have to do that on an individual basis and I think there's huge opportunities for us to do that so I would start there and I would start involvement with you know I think Jason and I talk probably more than most surgeons and administrators talk on the hospital side and I think there's that type of dialogue can be dramatically improved and the volume turned up a little bit how could we impact on the device companies pharmaceutical big article today hepatitis C they have a drug now it costs $84,000 for treatment well how many people can afford that and how many of these devices can we afford to use under cost containment I was wondering do you have any ideas of how we can impact on device companies and pharmaceutical companies right so this is slightly off topic but I can talk to you I'm the vice president and treasurer of our society and one of the things that we're creating for the American side of plastic surgeons is an entire medical service organization and GPOs so we are pooling risk and we are pooling negotiating power across multiple different individual practitioners to say that if you need a stapler or a widget that we're going to go and negotiate en masse not just one surgeon or a group of surgeons but 4,000 surgeons to the companies and believe me if you're Johnson & Johnson and 4,000 surgeons come up to you and they're 80% of your business they're going to listen as opposed to four surgeons come up to you say hey you're basically relegated to talking with the rep so there's opportunities for us and I think for you in our organizations to think about en masse or negotiations with device companies and with pharmaceutical companies and I think imagine if all the hepatologists in the country got together and said look we're going to use your drug but now we've got 22,500 hepatologists that want to use your drug we can't pay $84,000 but here's what we're going to pay we're going to pay $8,322 guess what that company is going to say so I think there's power in organizations I sound like a labor union guy but I think that we have to understand and leverage that we are not alone and the era of individual practitioners is long gone and I took out a slide because I thought I'd run out of time but there's data showing that in 2008, 71% of all physicians in the country 71% were somehow employed by a hospital system now it's probably about 78% and eventually the era of the individual practitioner is probably over for these reasons that was a really great talk so thank you very much just a question for you and I love your thoughts I was recently visiting professor in Massachusetts so what they're very concerned about is the tiering of medical centers so medical centers are placed into tiers and depending on what tier they are patients are told that you can go to whatever hospital you want but if you go to tier one you pay this deductible if you go to tier two you pay a greater deductible and most of the academic medical centers are at the higher tier because the cost of providing care in an academic institution is often much higher and so I'm wondering your thoughts about that is that what we're going to see nationally and if so how as surgeons can we address that role to play and what tier we might be that's a great question so recently I think it was in the Wall Street Journal looking at either Forbes or Wall Street Journal looking at even Texas which is almost like a different country how they're organizing their networks so MD Anderson used to be in everyone's network in Texas now I think they're only a part of 13 and that's MD Anderson so it's happening as we speak and they're trying to trying to answer the question that you just posed I don't know what the right answer is I think that what we have to do is to think creatively so you can imagine University of Chicago having partners that are not necessarily under one federal tax ID number perhaps and I'm just making this up but those are ways that we can capture patients leverage this highly specialized quaternary care at the same time somehow fit into some network and I think people are thinking about that creatively as we speak but I think that's got to be the answer and I know people in MD Anderson are also thinking on that level as to how to to grow their roots without growing their cost structure David thanks so much wonderful what do you think the impact of this new system will be on surgical innovation and surgical advances that's boy that is such I have a whole another talk mark on that particular I do and so here's what I think I think that coupled with what's happening on the healthcare national landscape the FDA has become a barrier in many ways you're starting to see a lot of clinical and human trials and device makers go abroad you know there's multinational companies so so some of the things that I've done in clinical trials are now we used to do them here in the states we used to have our own animal lives what they're doing now is innovating in Costa Rica because they have access to old world primates and no FDA so then they're getting a CE approval before they get the FDA approval that's what's going to happen it's happening right now as we speak in hot beds like India where cost structure is so low and the FDA really doesn't exist and on the nefarious side of things if you want to look at it through that lens there's no IRB or Helsinki doctrine of human experimentation is probably a little loose there as opposed to we are here we're probably on the other end of the pendulum so I think you're going to start to see innovation occur outside of the United States and the hegemony of surgical innovation that was always our purview may may be slowly slipping away now having said that things like OPRI and what Alex is doing on an innovation level on a different side of being efficient cost effective and it's a whole other field of discovery I think we're well poised to take advantage of that Thanks Dr. Song I really enjoyed that talk so you mentioned the debrief as a way to give feedback to surgeons as one of probably many ideas that could be used to change the culture of a surgery department but then you mentioned the role of an academic center taking initiative in this new possible era of bundled payments trying to align surgeons to understand the cost of their operations what they do but there are debrief costs that come with having residents in the OR and trainees in the OR such as increased time maybe increased resources but eventually the responsibility of that surgery falls to the attending surgeon so for me as a trainee and for my classmates how do you reconcile the initiative that an academic center needs to take with all these changes and the role an academic center has to train doctors Couple that with the 80 hour work week it becomes more of a challenge I was recently the program director until I fired myself for Julie Park it's a challenge it's a greater challenge today than ever before to train residents we're limited in how many hours we have them for there's a greater burden placed on people like Peter and I to do more of the things that residents used to do and so it becomes an incredible challenge to train residents now the benefit is I didn't have 3D virtual imaging 12 years ago right so I think you're going to start to see an uptick in simulation I think you're going to start to see an uptick in virtual surgery and planning our conferences are more robust than ever before so that may not necessarily replace surgical training but I'm afraid of that too this is what I talk about on our board level we're starting to see a generation of surgeons that have been trained under the ADR work week and I will say this is not necessarily backed up by evidence but a lot of my peers will say wow these weren't the same type of products that we were producing 15 years ago you know people talk about that 10,000 hour rule to become an expert and we're slicing away on both ends and so it becomes harder and harder as a trainee so what I tell my residents is before the risk was on they asked to teach you how to operate because we had no regulations you can stay here 140 hours a week now the risk is on you to make sure you get that knowledge and so from day one one of the things that I tell my residents is look we have only six years and 20% less hours to train you with you've got to figure out how to supplement that by being present always by asking the hard questions about how efficient in the way you absorb knowledge you know here's a great example of how efficient people can be when I trained you know email was just starting to come about I mean if Dr. Siegel asked me a question on rounds I better have remembered it or I'd have to go to Courard look it up in the stacks after rounds and figure out what the answer was nowadays you ask a medical student and they'll correct you and they'll say it actually says this on Google that time sync of what I had to do to train myself is gone so perhaps that is a way to become more efficient in how we train our residents and that's the only way to do it because you're right because Peter and I and Alex were forced to do a lot of things that I used to do as a resident I mean my pager goes off probably just as much as the intern some days and that's just the way it is you know moan about it all we want or we can decide to figure out how to make that more efficient and better for our residents so it's a great time to train as a resident because of all this technology I think the opportunity and the risk is now on you to say look I own my six years of residency in plastic surgery I better figure out how to turn out at the end of this journey of proficient surgeon whereas it was almost de facto that you did back in the old days and it's one of the takeaways I had was that planning is really important and just tearing out of Gwande's page out of his book Experienced Judgment Planning it seems like some of the themes that you've thrown out that planning is deficient and we need more information aside from information sharing between EMRs what are the implications for better, stronger earlier evidence-based patient assessment and review and better clinical decision making at the front end is at a state level before you decide to operate on the patient great question so I'm going to give you another story is Russell Reed here in the room so Russell Reed is our craniofacial surgeon when he takes care of kids that are born with misshapen heads and he does a big operation called craniovolt surgery where with a neurosurgeon he peels back the scalp basically takes the bone off re-arranges it and puts it back on and the planning of surgery was done because of the knowledge you sat with a guy that used to do it for 30 years and that's how you train so about 5 years ago there's a company in Colorado where you can actually send the CT scan to and they'll give you a model of it so you can actually do the model surgery before you walked into surgery now Dr. Reed just brought a 3D printer last year and he does it himself so before every vault case he prints out on the 3D printer a model of the patient's skull sits down with the resin and plans out the cuts it gets even better there's a company that allows you to with 3D imaging and with the rendering of the after result it can give you cutting guides so the cutting guides are sterilizable you put it right on the bone I mean even I can do it you just saw right where it says 1, 2 and 3 it's like paint by numbers and the results are better than before than just using your eye so the simulation part of what we're talking about and this is intuitive I don't know if you're a physician or surgeon but this is intuitive to the new generation of resins I mean for me it's kind of like wow that's cool and they're like what are you talking about I got a 3D printer at home and so it goes back to the question that he asked how are the resins going to get better so the planning stage will be ready shoot aim now it's aim, aim, aim, aim ready and then shoot maybe half a bullet and I think that's what's happening with surgery that's clearly what's going to be happening with medicine because of these EMR is going to accelerate that and I think that I'm seeing that in real time in surgery right now with my own division going from CT scan and sort of eyeballing it to then sending the CT scan to a company that the patient had to pay for to then now we have a 3D printer to then we send that 3D printer with these cutting guides and now anyone can do the surgery it's fascinating thank you for a wonderful talk absolutely fabulous as surgeons we're trained to take care of patients and we own our patients and sometimes to a fault we take care of our patients and keep going full throttle to the last breathing moment but the American Board of Surgery now sponsors fellowships in palliative medicine as surgical services we tend not to refer to palliative medicine because it's counterintuitive to us the way we were trained and it's giving up but sometimes the 93 year old the aerogenosis doesn't need a valve replacement it just needs comfort care and the head neck patient, cancer patient who's demented in a nursing home doesn't need a radical neck, he just needs comfort care when in surgery will the pendulum begin to shift for us thinking about palliation is not getting up but actually honoring patients' preferences and understanding that some of the things that we do are not necessarily indicated because we can do them so who passed away last year was one of my professors in business school, he gave a talk two years ago and his data showed that about 85% of our GDP in healthcare spend is spent within the last five years of life so I wouldn't be here talking about this if we as a society could figure out how to diminish that this is why President Obama talks about South Korea as being a model healthcare system I'll tell you why it works there because it's one culture, one people you can sway social norms by a miniseries that the government says hey I want you to make a miniseries on end of life care make it attractive to die at home so when you go when a 92 year old goes to Asan Medical Center with aortic stenosis the surgeon will say hey Mr. Kim a lot more blunt way, look you're 92 you had a great life, why don't you go home and die it sounds a little bit better in Korean but basically that's what happens you try telling that to Mr. Jones up the street you're 92 and the family says we want a great great granddaddy to have that surgery to come out alive and to make it to 100 so once again, I wouldn't even be given this time we wouldn't even have this whole series on the ethics of the Affordable Care Act if we as a society could somehow figure out how to curb 85% of our healthcare costs in the last five years of our life I don't know how to do that and this is an ethical question that probably Dr. Siegler has been thinking about for years as a disparate society we've got and this is what makes us great and this is what makes us in my opinion weak at the same time because we've got my best friend is Muslim and my wife may be Christian and my sons may be a fundamental Jane and we have all different norms of what's right and what's wrong and we have to respect that and that truly is what makes our country so great but then we pay for it on the end of life care I mean who dies at home anymore nobody they die on your operating table because you've tried to redo the aortic stenosis on a 99-year-old so boy if you can figure that out then we can go back to innovation and think about really cool stuff maybe some of your residents should get it right but once again we could really titch up palliative medicine to a whole other residency if you will it doesn't change social norms within one small zip code you've got variabilities of what end of life means in South Korea it's really sort of one norm I mean it's almost shunned when you take your great grandfather to the hospital for a 93-year-old great grandfather they wouldn't even go to the hospital the doctor would come and say he's got a aortic stenosis let's make him comfortable and die at home and that's honored and that's respected and that's the norm here it's completely flip-flop so we could do all kinds of palliative care residencies and fellowships and what have you but until we change if we ever change our societal norms we're never going to get there and it really goes back to what Fogel talked about if we really want to decrease 18% of our GDP we're doing it the wrong way the biggest lever is to figure out how to fix the end of life care so David you talked about the challenge of changing the way that different departments or groups are organized and I wonder if you can prime both your business hat as well as your ethics hat and if you think first of all bundle payments you have that picture of the dollar bill and how the dollars are currently divided but think about what kind of criteria or process you would use to figure out how that dollar should be divided up among a new really organized system as well as it's still related but if you take the broader populace perspective so ACO for example where it's not just a bundle payment but then you have potentially a fixed capitative budget how do you do that same process about deciding about preventive care and populace management so what type of criteria and process would you use given the difficulty of buying and change I'd give 100% to the surgeons you know it's a really great question and I think that we'll have to have better metrics I introduced a new concept of relative cost units I think we have to think about that we have RVUs, you have RVUs Dr. Siegler and I have RVUs, it's accepted whether we think the methodology is right or wrong it's accepted I think we have to figure out a relative cost unit because we can't think about revenue without thinking about expenses and the bottom line income statement has to balance that out there's a side of me talking there has to be some sort of way to measure effort, cost and then ultimately the bottom line so it's going to be formulaic and you know this is going to be heresy but I think surgeons are probably going to come down the primary care physicians probably should go up preventive care physicians and organizations should be subsidized by what we do because then it prevents some of the things that are happening and in the mix there's going to be once again this two-tiered system where people are just going to bypass all that and say I'm 93 and I want my third aortic valve replacement that's always going to happen this is America I was approached by a private equity firm to think about creating top end hospital in the Bahamas away from all this where Peter Angelos we would hire him for three months if Jeff Matthews let him to come down there and operate for two and see his patients for the third month with his family patients fly down how awesome would that be they fly down to the Bahamas get their thyroid taken out and make sure that they're all healed they go home Peter makes six times what he does and then comes back and still becomes a professor of surgery and runs the ethics and so forth and that will happen but how do we bundle and how do we divvy up that dollar that's diminishing I think there has to be a transparent methodology that everyone can recognize and appreciate and respect and call it relative cost units call it whatever you will but we have to create a mirrored system along with our views to do that David you sounded pessimistic when you were talking about the future of the surgery patient relationship is there a future for it? absolutely and let me be clear this is not necessary pessimism it's just the realities of what I'm seeing and when I've hearing I've been given this talk and very interested in this for the past four years in my opinion the opportunities are in outcomes and enhancing that patient-surgeon relationship because that's where value is created so whether that's expressed through a second tier system or whether that's expressed through the current system that has to be the norm because patients are going to demand it and it's going to be transparent and you can go to health grades which is not very good because it's all patient-reported and it could be bogus but there will be measures and there's going to be a Yelp or a Angie's List type of thing that pairs your surgical site infection data or your outcome data or your length of stay data your complexity index with your doctor patient satisfaction and a metric of that so it behooves us as surgeons in particular and I say this because I am one once again that we need to enhance that relationship on a much broader scale that's enriched leveraging things like perhaps telemedicine I mean all my patients get my cell phone and my email that's unheard of right people think I'm nuts and my wife hates it but you know that's that's how you provide value and quality of health care in this very confusing state that we're in right now so please don't misinterpret that pessimism is not necessarily pessimism it's just what I'm seeing from a different lens that was built around business school but the realities of what we see now are tremendous opportunities for physicians to enhance that. Following up on Dr. Siegler's question you said that you'd be delighted if five years from now you could come back and give a talk and say well I was totally wrong with my talk now but a lot of what you've talked about sounds pretty good I mean value, transparency honesty efficiency, emphasis on outcomes so what are the parts of the current system that you're afraid we're going to lose and what are the parts of this future vision that you talked about that you're afraid of? So when I say that I wish I could come back and say I was wrong I think I'm speaking mostly to the surgeons in the room because there are going to be clear winners and losers it's a zero sum game of health care dollars that are actually shrinking so I give and I think the days where cardiac surgeons were making two million dollars I mean those days are long gone so that was the audience that I was speaking to. Now having said that there is this ethic and I sort of brought it up in one of my slides but there is this whole side of rationing health care that's going to be upon us you can call it whatever you want but it's still going to be rationed it's going to be like Canada it's going to be a maneuver where someone waits eight months for their care and people with means are going to be able to come down to the University of Chicago and get it done people without are going to have to wait eight months if you remember a few years ago the Prime Minister of Canada came actually to the Mayo Clinic for his mother came to the Mayo Clinic for her health care as opposed to staying in Canada and waiting eight months so when I'm saying that I hope I'm wrong is right now if you have insurance access to health care virtually immediately I mean the speed from even if you're indigent and don't have insurance we have some of the best health care for indigents in the world in our county system and even our patients that we treat here and that access probably will be titrated down a little bit so there's two groups of people that I'm talking to in particular when I say boy I hope I'm wrong because there are a lot of barriers to patient care that are going to be ahead of us because of this there's a lot of good and let me be clear on one final statement is I think 50 years from now sociologists and historians will look back and say this was a wonderful thing Affordable Care Act and what President Obama did was historic and was something that was long overdue for this country now in the process it's pain there's a lot of change and change management is very difficult and there's norms and there's you know there's the far right who thinks that you know I showed you that picture and that's from one of the Republican websites so I think we have to figure out how this is going to play out but for the short term run I think once again the surgeons in the room were probably at the brunt or the tip of the spear as far as change goes and that tip can be bent in multiple different ways so let's thank Dr. Sung for a terrific thoughtful talk