System. Shes interviewed by david blumenthal, president of the commonwealth fund. Host hello. It is a pleasure to be here with you. I want to congratulate you on an incredibly readable in a thorough review of our problems in the Healthcare System and proposals for a solution. I have a ton of questions for you based on my background in the physician as a policy analyst and of course, also as an occasional patient. But first, i would like to ask a couple of question for context. The first one is why did you write this book and why did you write it al . Guest i worked on a series for the new york times. My first stop in that it was actually at the Commonwealth Club to learn a little bit more about the Healthcare System andd how it had gotten so very expensive. Then during that series, we solicited in love stories through social media. At the end of the series two years later, i had a kind of wow of patient stories and people that were smart just havent been able to make the system work. Which nobody seems to like right mow. And by understanding that, you can we get to a better place. We have seen so many efforts that reform. Everyone agrees it needs to be reformed but as we see on the hill today, we are still arguing. As you mentioned, you are a physician and i am a physician. We both went to Harvard Medical School and traineded in internal medicine. You went on to become a journalist. How did that come about . Guest i dont want to say by accident but i love writing and i did a lot of freelance writing on the side and in the early 90s i was working in an emergency room in new york and i felt the Health System wasnt working for people who were poor or uninsured. It was largely working well for people like me who had good insurance. There was something called the Clinton Health repoform and the times asked if i could like to write about it. I thought i would be a journalist for a few years, that will pass and i will go back to being a physician and it didnt and i didnt and here i am 20 wreerz years talking about the same issue. The system has spiralled out of control without Getting Better results were patients. Host before we get into the substance, one of the special things about your book is the way you ground it in stories. Stories about doctors, stories about patients, hospital administrators, you have lots and lots of stories. They are all very detailed. How did you get all those stories . What caused you to take that approach for this book . This is something i learned from years of journalism. My first story was about bone Marrow Transplant stories. I realized it became a mission to write about how whatever i wrote about affected real people. Even when i covered Climate Change i would get a nice family who has been impacted by Climate Change. I have read a lot of Health Policy book and stories and read the stories about the Million Dollar bone Marrow Transplants and i think the way most readers see those is they say that is really terrible or i dont think the policy, that story is heartbreaking but i hope i dont get that kind of cancer or i hope i dont insist on everything at the end of life. What i tried to do in the book is make the connection between acronyms and the things that go in washington and this is an issue that plays out on our wallets, bodies, in our living rooms and kitchen. The people in the bock, i was fortunate in the age of social media, most of the people came to me and said i want to share my story. They were tremendous volunteers and vehicles making readers and helping readers to understand this is about you. Also, they are great characters. I often feel like i want to have dinner party or club of everyone in the bock because they were fun, interesting, thoughtful people to talk to. I hope as readers read their stories they are compelling and absurd but i think they drive the narrative in a way that i hope will get people to understand a lot more about the kind of back end policy and economics without suffering through the kind of diagrams and the charts that are, you know, i read because i am a Health Policy wonk but most people dont an appetite for. Host and doctors are about their patients stories. Guest one thing that truck me at the end, like many of us who watched Health Reform i repeated the phrase a hundred times about we are looking for patient centered Evidence Based care and at some point i stepped back when researching the book and thought wait a second, what other kind of health care could there be . This is about patients. If it is not patientcentered and Evidence Base it is terrible care. What i learned in researching the history is too often the finances are on the front burner and the patient centered and evidence are on the become burner and that is the shift i would like to see. Host sure. So, you said about this book, organizing it in a doctorally way. You started talking about describing the problem and what we call taking a history of the present element and office and diagnose and then offer therapy and those are the way doctors go about organizing their interaction with patients and their problems. I would like to take a viewer through those three segments if you will. Maybe you could start by describing the problem. What is the american sickness that presents itself to you . I was an er doctor so the chief complaint is high prices. It is high unfordable prices and unfordable health care. I dont think anyone, republican, democrat, libertarian, independent, would disagree with that. Host how did we get to those high prices . What is the diagnose, if you will . Guest this is where the history of present illness has to fool itself out. I think what i realize as i was digging into that is this is kind of a classic case of, you know, the road to hell is paved with good intention. Each step of the way over thealist decades you see to new decade come in that was a good the last idea and then it gets preverted as how p perverted how can we make money off this a lot of peoplet got Health Insurance and that is not to say Health Insurance is a bad thing. That was partly because health care was getting more expensive. There are historic reasons that i dont want to go in but we end up with people alet of people medicare or employerbased insurance. For those who were lucky, your employee paid your premium and you had little in the way out of of pocket cost. What happens if you are entrepreneurial and business minded under that setup it feels like nobody is paying. So in my dads day, an office visit would cost 10. Once it feels like no one is paying it becomes 100 or 200 and then around the 80s and 90s Business People start coming into the health care and say what could you charge for that . When it was just the physician in this office, or her office, he was thinking what is reasonable for health care . When the Business People start coming in and sometimes it is as bold and direct as consultants from mckenzie being hired by hospitals and the consultants come in and they are not medical people. They dont know the best treatment were your liver failure or your phenomena. They are thinking how can we squeeze more money out of the system and make it more efficient. And the answer over and over again is the easy answer you just bill differently. You do the same thing you have been doing all ong but you can charge more because it feels like nobody is paying. You suddenly see charges coming in which were 200 may be 2,000 and then you see layers of administrators and va coming in. Many of the ceos were pormer chief physicians, medical people without much business training, and hospitals were not very efficient. But somehow the kind of we ran over a boundary where business became primary and the Business People became primary and the medicine secondary. They get resentful and they think here i am doing all this work. I am doing this surgery. I am seeing the patients and i am looking at this layer of 20 administrators with mbas who are all making a million a year. I want more. Not all physicians do it but many get in the entrepreneurial spirit and many are angry they are being judged not by how well they take care of their patients but how much revenue they generate, how much money they are generating from the hospital and they start being compared with fellow physicians and this is the logic of business. Who is generating more revenue and maybe you will get a bonus if you generate a lot of revenue and so once again, i think you see the values of business which are efficiency, revenue generation, revenue maximize, and our my infection rates low. Hospitals know more about the rbu and billing cycle than they know about if infection rates. I was pretty shocked this week when i saw that centers for surgeries have widely varying in the complication rates. And the centers know what the complications rates are, patients cant know them. Now, that seems crazy to me. If we are asked to be a good consumer we kind of deserve that information and it is our health afterall. Lets mover on to talking about what you are already beginning, i think, to deal with and that is the treatment, the solution to some of these problems. As you pointed out, some of them are valuebased. You had a lot of suggestions. One of things that i think is special about your book the extent to which you spend time prescribing things for the system and people. Can you say a few lines about how you think you ask go about reversing the problems you described. I think if we wait for a solution from washington we may be waiting for a very long time. I want to say i think the Affordable Care act i always have to say it did really important thing for our health care in that it covered people with preexisting conditions at a reasonable cost which is in the balance, it covered 20 more million people, it put an emphasis on value and what is good for patients back in the bullseye, and i think it changed the notion of should government think of this as its responsibility to get good, Affordable Health care. I think many patients are at a Tipping Point where they cant afford this anymore. I hear from people spending 2030 of their income on health care. More than food, more than housing. They are not going on summer have vacations. I tragically hear from people who are leaving the u. S. Because there is someone in the book who has type one diabetes. She is a grad student and only looking for jobs outside the u. S. Because even with good insurance she is worried she will not be able to afford her disease and i think that is not just an american sickness that is an american tragedy. What i do with the book and aim to do is help people understand there are solutions. There are step by Step Solutions as we see the Health Care System got to be where it is in a kind of step wise fashion. Likewise, we can start reeling it back in a step wise fashion. Part of that is what individuals can do. So, Little Things that they sound silly maybe but they do work. I became the bill trouble shooter for everyone in the newsroom fe new york times. I ivise used a lot of these thing and gotten a lot of bills reversed and reduced and muigated. One thing i feel people and you i seen patients, you know how this works, it is uncomfortable for doctors when patients do this but when i go see my physician when he says maybe we should get some blood tests, i feel okay and not because i am a former physician, but because i am a patient and i believe it is pai right to say, well why . Because as you and i both know when doctors are ordering test, the test are a long check sheet and you are just going down the sheet. I think the question now should be why . How is it going to change my care . That requires a lot little mind shift. My mom knows to the doctor and she said i like her but she didnt even order a blood test. As patients we have to say maybe the answer is to wait and not jump in all the time. But when it is time to jump in, then i say to my physician the computer is programmed to send my blood test order to the hospital lab. No, can you please send it to lap corp or quest, the two commercial labs i know in my network because lab core and quest may charge 10 for the same lab test a hospital would charge 500 or 1,000 and we know they are both putting tubes of blood into a machine that spits out numbers. Likewise, i think we can say to our physicians if i need an xray of my knee which of the dozen centers will boo a good xray at a reasonable cost. We know most doctors dont have that information. But i think the more patients ask the more they will have that information. It will send a message we care and we paying for that. V with my 5,000 deductible plan. It matters to me. Host so this is an important theme of your book. You do put a lot of the burden of containing and cost reducing prices and also deciding what you are going to get and where you will get it on the consumer. I was struck by the recommendation people review the papers they were asked to sign without looking at them to make sure they are not being referred do doctors and hospitals who will thought be paid by their Insurance Company because they are out of network as i said. I had the picture of a patient on a stretcher clutching his chest and having to go through that paperwork or running down the list of drug prices or lab tests saying i dont want you to dothese and these things because they are not covered. It it is a burden to put on patients but this is where we find ourselves. This isnt the ultimate solution but the alternative is like someone in the book being lulled in on the stretcher for an emergency and the Business Manager comes through saying we need your credit card before we can proceed with your surgery and she said i am naked and i dont have my wallet and the Business Manager said do you know someone we can call and get a credit card number so we can proceed. There are lots of parts of medical care that are not emergency situations. Yes, it is unfair and yes, it is a burden. But if we tont take the steps the system doesnt eform. The ultimate goal isnt to write in. If you go to an innetwork and you run Hospital Systems and that is extra work. The goal isnt to say this was the final answer but to push the providers who were not paying attention to do so. It is unfortunate this has fallen into the patients lap and on the back of sick people who should not pea thinking about how they are healing and into the the laps of doctors who should just be thinking about what is the right thing to do. But physicians spend a lot of time dealing with the system. I have to fill out paperwork and do preauthorization for a drug that is a hundred years old unless they start walking i think that is going to get worse and worse. Host and this relationship between nurses and patient patients and physicians and patients has been based on trust. That is an important part of the therapeutic and healing relationship. None of those even those trained in medicine are in a position to make positions about our own care. What is left of trust in our Health Care System . I hope it isnt lost anyone who reads the book can see many of the best sources are physicians who are distressed and want to keep that connection with their patients. I think it has been diluted. Some of that may be needed and it not realistic to think you could spend an hour with the patient but this kind of notion that doing things more efficient will result in good care. One example that is minor but telling. So much has been replaced with technology. Telemedicine, we will give avenue everyone an ipad and it will be better. Electronic records. All of those things could be useful tools but they have been used as a substitute for that face to face interaction which is so crucial to trust. I was just hearing about a program to give patients in hospice ipads. Home hospice ipads. That is kind of great at some level if it is used for certain things but instead of a nurse coming by and holding someones hand and talking to them which is what a lot of people need in home hospice that is just diluted everything that is so precious to me about health care and what patients really want. It shouldnt be the primary goal of health care. As you and i are speaking the house of representatives is deeply engaged in the future of the Affordable Care act and government and policy at the National Level and underlying that discussion is a big philosophical question about whether health care is a market good and whether it should be ruled by Market Forces or some other mechanisms. As i read your book, i sometimes felt like we could solve our Health Care Problems through free market sources. I think what we have seen as the answer is probably not. At the beginning of the become, i put somewhat tongue and cheek rules of the dysfunctional Health Care Market where if you think of health care as a business proposition, that the market will solve, you get to crazy places like, you know, a life time of treatment is pr preferable to a cure. I am not saying for a second anyone thinks that but that is where market force puts you. Type one diabetes is a wonderful example of this. It is a chronic illness which great treatments now, better insulin, pumps, monitors, peoples lives are much, much better than they were 2030 years ago but that has come at a huge price. If someone came along tomorrow and said we can cure diabetes with a cheap, old drug what would happen in the industry with tens of billions . There is an example i bring up in the book, a researcher at mass general who is working with very old vaccine to see if that will cure type one diabetes. It may or may not; right . It is early stages. But she cant get pharma funding which is who we trust to fund the Drug Development because they look at this and say great idea but if it works you killed our market. I think the notion Market Forces lead us to a rational place in health care doesnt work. I mean that is the simplest way i can say it. I think why is that . It is because a market depend ons a lot of forces that just not only dont exist in health care but they cant exist in health care. I mean you need to be able to make a choice; right . When you are lying on the stretcher, you are in a gown with your appendix burst, you are not in a great position to do that. Mostly doctors are choosing forest. You can work with your doctor to chose better but as we see now the choices are often rather limited unless you are willing to fly to another city. Many cities have had so much health care consolidate there are choices. Likewise, where there is hospital consolidation and all the studies show that leads to higher prices after a point, not better care, the ftc will occasionally come in but their philosophy is well, if a concern hospital cornered all the cancer care in a concern part of florida and this happened the answer is the market will work. How will it work . Maybe an oncologist will say they are getting high prices in florida so we will open a clinic. Takes time for a doctor to move a practice and establish a patient pool. It may take 35 years and what happens to the people with cancer in the meantime . Look at the price variation we see for medical procedures. The same test that cost 30,000 in run city like a Knee Replacement might cost 150,000 in another and 13,000 in france. How can this possibly function as market . I think what we have seen as we look around the world and that is why i look at other countrys Health Systems is there is no place where it worked. There is always some degree of price regulation or national, you know, some systems chose a more governmentbased approach, socialized medicine, canada, the uk, others chose a single payer where there is a lot of private hospitals and doctors in japan but one payer and rates a set at a national registration. Others have a marketplace broached but even there, like in switzerland, there is a degree of price regulation. You cant just let the market decide because this market is going to decide what our market has decided which is prices will rise to whatever anyone will pay and someone will always pay a lot. Host you do have a series of recommendations for the Public Sector as well. You are recommending that the Public Sector require prices be published. What we in the Health Policy world call Price Transparency. You are recommending Insurance Commissioners which mostly work at the state level be much more aggressive in negotiating what the industries do and you are recommending drug prices be nugauche negotiated. You are pore sympathetic to government than the prevailing political consensus seems to be. Can you a little on the practicality to be recommendations tach recommendations. They are more a mau menu of opt. There are lots of differents options and we are choosing none of the above. I think no one of those things is a solution. You know, there is some people that go the answer is Price Transparency and then the market will workism i am not saying that is an answer. I am saying we will have to try to be consumers, at least we deserve that. It happens in other countries. In frances there are practs on doctor walls and in france it is a right to have a binding estimate before you go in the hospital. I dont think that is a solution in and of itself what it is what patients deserve to know if we are paying part of the bill. It is one of those areas where if the hospital i had my colonoscopy had to write we are charging 11,000 they wouldnt charge that much. A lot of these prices are in the darkness. I think we ask whatever too little in the end. We have too little state Insurance Commissioners and i didnt know much about this. Tay are either elected or appointed. They do have a lot of control or at least the big pulley pulpit to make insurance works better for citizens. So, you know, just the tiny example, we all know insurance directies and studies in our own experience are horriblely inaccurate. Or there is this innetwork but motta not taking new patients. Or you go to a provider in your network but this for therapist isnt in your network. So Insurance Companies can be more consumer advocates instead of Insurance Industry proproents. Do we pressure your government to stand up for someone that will stand up for the patients . We dont think of having the same rights in health care as we do for shopping for groceries or a car and i think that is cra s crazy. You look at a state like california that has an activist insurance commissioner in david jones. Has he solved the problem . No. But has he made it better . Yes. He doesnt have a lot of legal tools but he can make a lot of noise and certainly has. Host so we touched on the Affordable Care act a little bit earlier. This is absolutey a critical time for that law. Some of the issues that are front and center in the debate going on today issues like whether insurance should have to cover certain things or whether Insurance Companies have to challenge more or less the same amount. Those two issues are very much under debate. From what you have learned in your study of the u. S. Health care system, does it leave you with opinions about ongoing debates or observations . I cannot allowed to have opinions but i can tell a couple stories everyone should think about. I started my pain till it hurts series before the aca series game into effect. I interviewed many people that year who were uninsured because they had a preexisting condition and couldnt afford insurance and at some price in some cases couldnt get insurance. That included preexisting conditions were as minor as having had an abnormal pap smear or needing an asthma inhaler. If i had not had employerprovided insurance i would have been in that pool because we all have some kind of history. So, i think likewise, if we talk about we are going foopull out essential health benefits. In those days, insurance policy didnt have to cover Maternity Care. Most people didnt realize it but many policies didnt. I interviewed a young woman who discovered once pregnant her policy didnt cover Maternity Care. People can say consumers have to be better shoppers but Insurance Companies are hard to read through. She went about shopping for her Maternity Care and did it as a rational shopper. Cedes give me a ballpark. My husband and i willing to pay. In the end they came back and said it will be between 5,000 and 45,000. This is the preaca shopping were health care and no essential benefits. Stuff happens in health care you cannot predict. So to allow people to say i am fought going to cover pregnancy because you know i dont want to get pregnant or i am a guy, so i am not going to i dont want to have to pay for Prostate Cancer . That doesnt work and it leaves people out in the cold at a moment in their lives when i dont think anyone in the country wants to say we will not treat your cancer or we will not say you can come into the hospital to have your baby. That doesnt work. You know, i think health care is something that you have to think about holistically and it is hard to think about selfishly because you may be healthy today and really sick tomorrow. One of the aspects of the Affordable Care act that doesnt get much attention but you touch on in your book and actually suggest or that Insurance Companies would do more of it, the Affordable Care act promoted the socalled bundling of payment or the changes in the way we pay. There are a lot of folks who believe that is part of the Affordable Care act which is not under debate right now and we have a lot of bipartisan support is an important addition to the fiscal scene in health care. Can you say more about that reforms . Part of the way the prices got out of control is the phenomenon of unbundling. It is what used to be allincluded but now you are paying for a bed, drink, priority boarding. In health care, that happened exponentially. You are having a baby instead of being Maternity Care now is the most motrin, the heating pad, the delivery seat. I had one wonderful patient whose a physician and she thought i am not going to buy this unbundling thing. She came to the hospital ten minutes before delivery, brault her heating pad, motrin, decided to keep or newborn in the room and was charged a newborn rooming infee and lactation consultancy which she didnt need. This motion of Rebundling Services and it has become a novel thing but in fact it is how care was done a long time ago and how care is done in most other countries. It is a really smart idea and taken to the extreme it is the hmo concept where all the patients care is paid for by Annie Jacobson annual fee. Medicare did interesting pilot projects with bundling knee and hip surgery. And in california they have reference pricing saying hospitals, doctors and all people involved in the care, we will give you a price we know is reasonable. Where you can get a good hip or Knee Replacement and you guys figure out how you will divvy it up. That is your problem not ours. In california, where medicare is done, i think the price ranges we know 20,000 and maybe 35,000. That is way less than most fee for Service Hospital bills where you are being build for each component of the nee, the skroo screes the oxygen you got after surgery, being three hours of Recovery Time because the Surgical Team was having dinner the last hour. So it a wonderfully sensible concept that has worked well where it has used hospitals woo were trying the medicare model. Most of them found there was a lot of stuff they were doing for hip and Knee Replacements tat didnt add much to the care. For example, the longperiods of inpatient rehap or physician therapy on a hip replacement. When they were told they would not be paid separately for it, they discovered it doesnt change the outcome. And in europe, they have never done ps because they knew it didnt change the outcome and some of the better hmos they dont do that because it doesnt change the outcome. It was an ex experiment that was headed for policy under the Affordable Care act. I know the new hhs secretary has expressed his dislike of this concept so i dont know where it will go but it is the kind of thing we should be, if, you know, as guardians of our health care dollars, we and our physicians should be enthusiastic and there is also this narrative of if there is a fixed price maybe someone will be skimping on our care. And i think what we see in our Health System and what i have learned is there is no such we do that is excessive that because it is paid for not because it is good for health. We could eliminate a lot of tat. I dont think we will get to the france level of Health Spending or germany level of Health Spending tomorrow but we can poptart start turning this expensive ship around and we need to or otherwise we will all end up bankrupt. Host let me turn to hospitals as charity. Hospitals as nonprofit entities. The Affordable Care act increases requirements for hospitals, nonprofit hospitals, to report on the Community Benefits. The charitable benefits tay offer in return for their tax deductible status. Pane people around the United States volunteer or donate to their hospital as charity. You have striking things to say about hospitals and private industry. One thing about writing the book and doing this series that gets under my skin is i go to a hospital in new york, get the bill and the first thing that comes in the mail is you know we are so happy you liked the service, want you consider a donation. And i am like ak. I donate to charities but these pal aces, piefb tar hotels, pane of them dont feel like charities at the moment. That is not to say there are not hurting hospitals. Hospitals that may not are a good payer mix can dont have the healthier krientel who are willing otonate art or time in rural places. Tay are really struggling to stay a float. We see a lot shutting down because they dont have a Good Business model. We hear we have to emergency room because not a lot opeople coming in. That is not why we keep them open. We key them open because people might be sick and there might be an injuring. But we end up with a lot of weird decisions. Again and again people say i get all these requests asking for money and you know the Hospital Executives are saying medicare doesnt pay them enough, medicaid doesnt pay enough. The first thing i say is walk into the lobby of your Teaching Hospital and tells me it feels like a poor suffering place. I am sorry, i know we have both been involved in wealthy Teaching Hospitals but hospitals today look like fivetar hotels. You know, i spoke to one trauma tr woo wanted peto come look at their zen garden. I am like this is a weird priority. Some hospitals mow hire Hotel Executives to improve the customer appearance andtail advertise thigh high thread count sheets and great meals. I think it is great. I dont think hospitals have to be like prisons. Bui think we patients have to wise up to wauz important. What are hospitals doing. Do they feel like charities i recommend aerobic within look at the 99 tax form of the local hospital and look how much the executives are paid. The highest paid executive in most cities the ceo of the local hospital. And i dont know want anyone going broke on health care. I dont think you have to take a vow of poverty but i dont think most hospitals need the top 20 administrator paid over a million year and when they say health care is really comp calculat calculated. My immediate answer is the Ford Foundation is difficult to and they operate in many countries and the ceo of the forwad compa doesnt make as much money. I think the aca did something important and that is one of the things i am afraid of what will go on. The reporting of what the husband is doing to get the tax break. What are you doing to benefit the community in the way of charity care . I think that was transparency and never defined. What is the level we want. What is the kind of Community Benefits we want to merit that tax break . As communities we can take that next steps. There have been local merits with sued hospitals to take away the tax extempt status. If hospitals are not really serving with what the Community Needs like cheapererates or rem remediated moldinvested husing maybe you can better use the tax dollars. Apple giving away a lot of computers each year but it doesnt make them a charity. We have to define the bar we expect these big Healthy Company do is deserve a tax break. Long answer but i think it is something every mayor or city council should be looking at. Host your book takes on the whole a pretty negative view of our Health Care System and you know, you are phoenixed on its problems. Are there any good parts of health care in the United States . Anything that we should feel good about as citizens . As patients . As taxpayers . Well, i can there are many, many fw people in the system. I run a Facebook Group and there are 9,000 people in the grup and they talk about getting at the promise land of medicare so they dont have to deal with the expensive bills. I think it is true there are some kinds of treatment we get first. That narrative that we hear over and over again. Yes, drugs often come to the u. S. First. They often come to the u. S. First because they are far pricier here and it makes sense to market them commercially here because you set a high bar for the price in the rest of the world. Also bringing us new drugs and treatments use to bad results. The overuse of expensive treatment. Great new machines like the proton bean therapy which was invented for a small segment of patients who could not be treated but there are dozens in the u. S. And they are used on many patients who dont need them and wont benefit from them. I think, yes, we get them first, and yes for people who really need them, that is great. But then there is this kind of defusion to places where these treatments are not useful. Also, i think the flip side of that is treatments that are not useful, we sometimes dont see in this country because there is not a business model. One of my kids was at princeton at the meningitis b and there were vaccines in australia, canada, england and other countries but it had never been marketed in the u. S. Because it was clear it would be used in a limited way for outbreaks on college campss and it wasnt worth going through the whole fda process. We get some treatments much quicker and there are others which eventually that vaccine did arrive in the United States but it was only after the cdc and the fda jumped through a bunch of extraordinary hoops after, i think it was close to a year that vaccine arrived. I love my doctors. I am proud of the care we get. In this book, you will not find anyone unhappy with results of the treatment but they are unhappy about the cost and the burden put on them and i think that is where we have to focus our energy and our research, too. Yeah, it is more efficient have to a heart surgeon running two operating roomas rooms at once that what you want . To me that is not medical research. That is Business Efficiency research and i am not sure there is a medical case for even trying to do that. So, we are nearing the end of the hour. It has been terrific listening to your description of the book and i highly recommend the book. It really personalizes a lot of these issues we all feel. There is much more we could talk about. I am looking forward to seeing what you do with your reporting going forward. Any comments on what you have planning to do next based on what you learn . I am editor and chief of Kaiser Health news which is a nonprofit. And i think what i am trying to do in that role is continuing it look at why economic theories of health care dont work on the ground, what makes our system expensive and what we can do about it. One thing we havent talked about very much is the area of drug pricing and why we are not doing what everything within else in the world does which is to negotiate at a National Level. Medicare prohibited from doing that. There are bipartisan support every time there is an epipen crisis we should allow medicaid to negotiate or allowed for controlled imports or reference pricing with canada. Those dont go anywhere and i think the reason they dont is lobbying. We are looking more at how lobbying affects the health care we see in the usa today. So stay tuned for that. Host great. It has been a pleasure. Wish you luck with your book and Kaiser Health news and look forward to talking with you in the future. Thank you very much. It is good to be talking to you again. Take care