I did 22,000 procedures, mostly cardiac surgery. I started out doing a lot of bypass operations and why did you leave cardiology surgery and go to the administrative side . You have to use your hands and stand there all day long. I have seen a lot of surgeons come to the end of their careers and not stop when their athletic abilities deteriorated. I wanted to stop before that happened. Toid not think i was ready hang it up completely. I did not know exactly what i was going to do. I had looked at some opportunities. I thought maybe i would go to the Cleveland Clinic. , the ceo announced his retirement and asked me to throw my hat into the ring. Thing to could do one improve the situation, what would it be . I think the best thing i did was focus on the Cleveland Clinic. My opening speech, i said were going to put patients first. I handed out buttons that said patients first. That is the thing that really unites us all, whether you are an educator or a Research Scientist or administrator or you work on the loading dock. I think thats probably the most important thing that happens. We will get back to some of your past. The Cleveland Clinic has been mentioned many times over the past several months because of the new health bill that comes in effect on october the first. I want to show you a little bit of the speech that senator ted cruz of texas made when he did his marathon speech. Lets let you break this down. Some members of this body might say well, these are hard times. Struggling. So maybe the Cleveland Clinic is to economicing challenges. Whos to say what the Cleveland Clinic is doing has anything to do with obamacare . Madam president , the answer to that is him whos to say . A spokeswoman for the cleveland prepare for to health care reform, Cleveland Clinic is transforming the way health care is delivered to patients. She added that millions would be cut from the annual budget. You want to talk about direct obamacare, goom to cleveland, ohio. Go to those working at the Cleveland Clinic. Go to those depending on the Cleveland Clinic for health care. That is one very real manifestation of the train wreck that is obama care. What do you think . You have to understand what is going on in health care across the country. We have gotten ourselves in a situation where we knew we have to change health care. Health care is becoming so expensive in the United States. It is starting to eat into things like education and other social programs that we want to have and need to have. Expensive than any other country in the world. To harness that and control it and bring the costs down so that we can remain competitive. We have been at this for a long time. It is a process that started several years ago. And how we begin to make our Health Care Delivery more efficient, for example we have consolidated services in hospitals. We have enclosed one hospital that was two miles from a 2000 bed hospital. Frankly, we consolidated obstetrics, for rehabilitation, for cardiac surgery, for pediatrics. , and for trauma. When we consolidated from five we sawcenters to three, a 20 improvement in mortality rates. So it has been a long process where we are trying to reform this. Whats going on right now is that a lot of the things are coming to a head that we have concentrated on costs in the last couple of years, for example things like purchases. Likeve done things illuminated redundancies. Cannotblocks in so you order redundant labs test and eliminated some 12,000 tests that would be redundant. We have been working on this all along. We know that there are things happening right now that we are going to be paid less by private and public players, Insurance Companies are paying us less, medicare is paying us less. Sequestration had an effect on hospitals, the nih funding decreasing has had an effect on our research, so we had to decrease our costs still further. All of this goes into trying to change how Health Care Comes together. Not one single thing did it we would not one single payer or program, it is a whole series of things we are doing starting back 5, 6, 7 years ago and the changes are so significant in terms of what were going to pay that we have to now be even more stringent. That is what led to people offering people early retirement. Did you expect that after you made this announcement that the obama connection was going to be made which more absolutely not. One of my biggest concerns was for the people that worked at the Cleveland Clinic. We are concerned about driving great Quality Health care and we are looking after our employees, because all of our caregivers are really what the clinic is. We are not buildings, we are people. My concern really was about those people and how we could either make that transition if we had to do it, or to reduce its effect. I thought it would have implications for the local Community Thomas and we reached out in many Different Directions to tell people what we are doing and why it was coming. I had a nine month schedule of meetings that i do every quarter where we televise it to all of our locations. I thought this is the time for me to stand up and explain to the organization whats going on and what were going to do as a result, and i did that. I never thought this was something that was going to become a political football. This was concern about delivering great care and letting those people do it. Will you reduce it to because of cutbacks question mark what we have offered is 3000 people we have offered early retirement. We expect we will get 600800 people to take that. We dont know exactly what the. Ongterm implications are we will have to wait and see. But we are poised if we have to reduce it further to do that in january. How is it that you are not profitable we are a 6. 5 billion organization and we are a Nonprofit Organization like almost every other hospital in the country. Stockholders, no shareholders, no incentives, no bonuses. Backf the residual goes into building the organization and doing the research and paying the employees. I read that there is no tenure at the Cleveland Clinic. What difference does that make is to mark all of us are we have nond financial incentives. I could look at you and say you need a heart operation. It would have no effect whatsoever on my back pocket. Its all about whether i think you need it or not. Tot is a wonderful feeling be able to say to a patient, i think you need something, and not have them worry that you are doing it for your own financial benefit. Salaried, andre we have annual professional reviews. Each year we sit down with each doctor and we go through how usy are doing, and they tell what it can mean for the organization. Its a wonderful way to get that feedback, and its the way almost every business in the country works except health care. , let me add a question however you are not tenured, but the more heart surgery you do, the more you bring to the hospital, the more money that comes in, the better off everybody can be. X that is correct. The direct onetoone relationship is not there. You are ae, if psychiatrist and we need you to help us with our transplant program, youre not going to bring any money to the Cleveland Clinic, but we dont want you thinking about the fact that you guys are Something Else rather than what the institution needs. We all get paid on the basis of our total contribution to the organization tom and the contribution might be clinical, it might be research, it might be education, it might be a combination of those. It might be management, mib business. It. Of those things go into dont haveat we tenure i think is a wonderful thing. Tenure frankly allows us to say to people, youre not fitting into the organization. Youre not contributing to the organization and thank you very much for your service and its time to go. When you think back on your career on those 22,000 operations, if you had to pick one or two that youll always remember, what would you pick . You know, this is this is tough thing to say for a surgeon but, the surgeons dont remember the successes. They remember the failures. And youll always learn more from those failures than you did from your successes, and you play them over and over and over in your mind. Happily, cardiac surgery over time became quite safe but those, those failures really stand out in your mind and you replay them and remember them even to this day. Whats a failure . Somebody dying. For a d. V. D. Copy of this in one day we lost five children. Terrible to go back the next day and try to do it again. When i was a resident, or talent he rates for accord ex were double digits. Was trying toreer get the mortality and morbidity of cardiac surgery to come down. Now were tally for cardiac surgery is one percent or less. And the complications and the stay in the operating room and the incisions and the quality outcome has gotten better and better over time. When you did you decide to put on your web site how many operations are held in the last year and how many people have died from . Yes, an interesting story because i became about 25 years ago, i became chairman of cardiac surgery. And we always work hand in glove with the cardiologists. Cardiologists see the patient and make the diagnosis and then potentially refer them to cardiac surgery. And i thought it was very important for the cardiologists to be part of the team and understand what the potential for outcomes for from cardiac surgery were. So we had at the end of each year, we had a report where we ask all the cardiologists to come and we all gathered and we stood up and we one after another reported the results of the coronary bypass or aortic valve replacement or mitral valve replacement, Something Like that. Then the cardiologists started to ask us for the results so we put together a little booklet that had all these results and so they could intelligently tell the patient, look, the risk of what im suggesting is this. And then we said, lets distribute it nationally. Because we think that every time you look at those results, youll always find something that you can do better and its a regular, steady improvement looking at all those Little Things that are not as good as they should be. So we put it out there and then when i became ceo, i said, lets do it for everything. Lets do it for cardiac surgery and for dermatology, et cetera now, the issue really was and cardiac surgery is pretty easy to give you the results. You know, people either make it or they not make it. And so you count up the results pretty easily. Its much harder in a lot of the other specialties. Take dermatology, for example, you know, what is quality dermatology . I mean i said to the dermatologist, you cant just tell us youre a great dermatologist. Show me some numbers, give me some metrics. So what i asked them to do is set up the metrics for their specialty. And so we now have 17 or so outcomes books that we publish each year to get more sophisticated and we should talk about the good, the bad and the ugly, but its transparency. Transparency is a wonderful thing. Transparency and quality and really didnt happen at all in medicine up until maybe 15, 20 years ago. Whose decision was it to put your 990 tax form on the web site . Thats part of our transparency. When did that start . I cant tell you. I dont remember actually. I want to show you some video of a former Vice President talking about cardiology, mr. Cheney. I got a phone call one day, and this is just before the transplant, from the Cleveland Clinic. And they were going to put on a conference on innovation and cardiology and care of Heart Disease. And they said, weve got all the suppliers coming, the makers of the devices and so forth. Weve got a lot of the docs coming, but they said, we decided we need a patient. And somebody said, well, lets get cheney. And he said, everything done to him, you can do to a heart patient, which was true. Up to that point, i havent had a transplant yet, but this gave us the idea that you can tell the story of that 40year miracle, really, of what happened with respect to our ability to deal with Heart Disease in this country, through my story, and my case history. Is there any way to connect what went on in his life in all the heart operations he had and heart attacks to obamacare and what will change because of that . I think thats hard i think. Well, first of all, i was there and heard him very eloquently describe and very personally describe what had gone on. At that point, he had a artificial assist in him. And just to put sort of the things in perspective, we know almost 50 years into the development of a artificial heart and left ventricular assist. He lived on the basis of that research for several couple of years waiting for a heart transplant. And, you know, that is the tremendous amount of investment over time and improvement. I hope that were going to be able to continue to do that sort of Research Going forward. Thats an important aspect for all of us. And whether its in heart or whether its in cancer or whatever specialty its in, we need to continue to have those sorts of missions. Now, if you look at Academic Medical Centers across the country, they have a Tripartite Mission as we do. Theyre educating people to they are researching and theyre taking care of patients. So we need to continue to do that and, you know, well have to see how that all works out over time. How much federal money do you get a year . We get about 70 million. What for . For research. Oh, the research money, thats how have you been . Nih money. How have you been hit in this sequester era . We have been flat over the last several years in the amount of nih money that we get for research and we get other moneys from other locations. You said that there are 27,000 pages of regulations that have come out of the obamacare bill . Yes. Has that ever happened in your life . Well, it hasnt happened in medicine. Thats about equivalent to what the irs does. What do they say . Well, ill be honest with you. Im dyslexic. I havent read them all. They are continuing to outline how were going to set up these types of care Delivery System and how are we going to get paid, et cetera. What would you have done if somebody had asked you to write bill differently maybe . I think well, i think one of the things that we understand is we had to have access and i think the bill has done a great job of providing access. Access to what . Access to insurance coverage, so that people, you know, dont wind up just going to emergency room but gets some sort of continuum of care along the way and thats been a process thats ongoing. But we know we had to take the cost out, and theres only really two ways that you can take cost out of healthcare. One is you have to make a more efficient Delivery System and i think were on our way to getting a more efficient Delivery System. The other one is we have to reduce the burden of disease in the United States. We cant that we have to take care of ourselves a little bit. And smoking and obesity and lack of exercise are very big factors right now in driving up the cost to healthcare. Obesity, for example, now accounts for 10 percent of the healthcare cost in the United States. And we are in the midst of a tsunami of obesity across United States, and that we have to deal with that. That was left pretty much alone in the bill and i would have liked to have seen more emphasis on trying to help educate people about taking care of themselves and helping all of society from food manufacturers to educators, to food providers to understand that we need to understand this epidemic of obesity and begin to make a change. After you analyzed those 27,000 pages and you had a Board Meeting and you took this to your board, what did you tell them that the impacts are going to be on the Cleveland Clinic in the future . Well, what we did is we gradually over time have been you know, at each Board Meeting, weve been bringing the board along so they understand it as we understood it. And then we have told them that weve gone through the financial projections for the Cleveland Clinic is a result of all the things that are changing, not just one thing but everything thats changing across healthcare and our financial projections for the future and, you know, we recognize that we had to reduce our expenses substantially going forward. Anybody get their salaries cut . We have not cut salaries and what we want to do is we want to keep the people who want to stay there and who are good workers and we want to continue to pay them well, at a competitive rate. And in fact, we pay competitive rates for doctors, for nurses, for everybody who works at the Cleveland Clinic relative to what they do. What would you say to an Insurance Company that you deal with all the time about what they do that you dont like that they do . Well, we talk to the Insurance Companies. In fact, i was talking it was the ceo of some of the Insurance Companies last night and i said, you know, its important that we begin to figure out how were going to Work Together better. We have to take the friction out of the gears of the transaction between the two different organizations and reduce that. For example, if we send in a bill for someone whos had a delivery, they have