 On behalf of the McLean Center and the Center for Health and Social Sciences, David Meltzer, David, raise your hand there, and I welcome you to this fourth lecture in our 2018-19 series on improving value in the U.S. healthcare system. I now have the pleasure to introduce Dr. David Hyman. David and I go back quite a ways. We met when David was an undergraduate here at the University of Chicago, from which he graduated in 1983. I then knew him when he was a student at the Pritzker Medical School, from which he graduated in 1991, and along the way he took a law degree at the law school in 89. Partly, Professor Hyman is a professor of law at Georgetown University and is the author of two books. One is called Medicare meets Mephistopheles, selected by the U.S. Chamber of Commerce as one of the top books of 2007, and this past year, this year, with co-author Charles Silver, David has written Overcharged, Why Americans Pay Too Much for Healthcare. Today, Professor Hyman's talk to us will be entitled, the same as the book, Overcharged, Why Americans Pay Too Much for Healthcare. Please join me in giving a warm welcome to David. So thank you. I actually decided to put up on the slide the title of the series that Mark has organized, which has a series of wonderful speakers, plus he included me. So I want to talk a little bit about improving value in the healthcare system in the context of the book that we published about four months ago. And I think it's purely a coincidence that I'm here on Halloween with the intention of scaring you all about some likely future changes. But before we get to that, let's start with some sort of definitional complications of thinking about the problem of value in healthcare rights. So the first question is, are we going to focus on inputs or outputs? Healthcare providers, for a variety of obvious reasons, have historically focused on inputs. Patients are not necessarily so fixated on inputs and often are focusing on outputs, but they may well have other issues they're concerned with. Another way of thinking about the problem of value is outcomes achieved per dollar spent. B school types will say this. This is actually a quote from Warren Buffett, price is what you pay, value is what you get, the obvious possibility of a disjunction between the two of them. The interesting operational question is, who gets to decide what counts as value and whose views on that subject actually count? And I've just listed a laundry list of possibilities here. Me, meaning the individual patient or your doctor or a range of other possibilities with government in its regulatory hat and also its payer hat. One of the important realities of modern American healthcare is the government as both purchaser and regulator of healthcare services. But the interesting issue, a recent survey that was done out of Utah pulled patients, doctors, and sort of administrative types. What do you think are the important measures of value in healthcare? And the striking thing was the most frequent answer among patients turned out to be low out-of-pocket costs, which if you're an economist is stupid. And if you're a patient may well make perfect sense in the world in which you don't really know whether the care is good or not. But you can definitely tell how much it's costing you after at least all of the bills have come in. The other complication in talking about value in healthcare is an agency cost problem, right? Milton Friedman memorably observed. There's sort of four different possibilities when money is being spent. You can be spending your own money on yourself, your own money on other people, other people's money on yourself or other people's money on other people. And this sort of straight little simplified four-part box shows the changes in the way that people behave and the way in which they think about what they're engaged in, including on the question of value. And one of the obviously important realities of healthcare is for many people, most of the time they perceive they're spending other people's money on themselves. And many healthcare providers perceive that they're spending other people's money on other people. And you should understand that those disjunctions are going to make a difference in how the agency cost problem are going to play out. So, you know, it's always, you can put a lot of words up and lawyers and law professors use lots of words. It was memorably said by one of my colleagues, we know that a picture is worth a thousand words. We just prefer the thousand words. Rather than do that, I thought I'd put up a very stylized formula for thinking about the problem of value in healthcare. And we can argue about the specifics. I'll come back to this at the very end. But the core idea here, which you can operationalize at either an individual or a population level, is you should sum up the total amount of high-quality good care, subtract out the not so good and affirmatively bad care, and then divide that by the sum of whatever it is that's being spent to purchase it. So this sort of is a different way of formulating the Warren Buffett observation. But in a way that sort of focuses the mind on the value question, because the bigger the numerator is, the higher the value is, the bigger the denominator is, the smaller the value is. And you've got sort of different action points that you can think about operationalizing to improve the value of the healthcare system, which was, of course, the focus of this entire series. So Mark mentioned earlier, and I'll just show you the obligatory cover of our book, Overcharge Why Americans Pay Too Much for Healthcare. It may be a little hard to see, but the backdrop is a medical bill with very high numbers on it, which is the reality for people who get quite ill. And even those who are not quite ill, if they're out of network or uninsured, they're going to encounter very large bills being sent to them. And you can see the website for the book at the bottom where we have a variety of additional materials. So the organization of the book, just talk about very briefly, and then I'll tell you some stories from the book that illustrate some of the value problems in the American healthcare system. So part one is about what we think the problem's reform should have fixed. There are 14 chapters, and they cover, I don't want to say soup to nuts, but many, many aspects of the healthcare system where there are sort of horrible problems that you can appear and document and pay for because we get what we pay for in healthcare and we don't pay in ways that it seems to me are designed to maximize the value of the care. We actually had a pre-publication reading of an early draft of the book at which Dr. Meltzer was kind enough to show up, and he gave the single best blurb for the book, which he, for reasons that will become obvious, declined to put in print. But he said, David, I felt like taking a shower after I read your book, which I thought was a nice thing, actually, because it paints a not very flattering picture of a significant chunk of the healthcare system, everything from sort of the most unbelievably criminal conduct engaged in by marginal characters to mainstream players who figure out ways to game the system and take the taxpayers and private insurers and patients for large amounts of money. And then the second part of the book pivots and focuses on, well, okay, if these are the problems, what should we do about them? And you can see on the screen the range of subjects that we're covering, more on that shortly. But I thought a good way to motivate this is to remind you all of some of the real human cost of the value problem in the American healthcare system. So this is somebody who was filling up the car with gas since the gas kicked back and the nine-year-old girl got splashed and her eyes were burning. And so they ran off to the emergency room and the emergency department said, the sink's over there, go rinse yourself out. But not before getting the billing information to send them an $800 bill while providing really no meaningful medical intervention. You don't like gas. How about bee stings? We've got a $12,000 bill for an emergency room visit. These are obviously people who are out of network. And so if they perceive it's an emergency, they're not going to be able to spend very much time finding an in-network provider. But for reasons I'll actually talk about a little later, emergency departments, it's quite common to encounter an out-of-network ER doc, even though the hospital itself is in network, which is a sort of striking phenomena. These are some tourists who came to the United States to spend a weekend in San Francisco. The baby fell off the bed in the hotel, wouldn't stop crying. They took them to the local very high-quality hospital named after a prominent tech executive who started a company that's named Namebook or rhymes with Namebook. And the baby got a nap and a bottle of formula, which the hospital was good enough to provide, but they sent a bill for $18,000, which they cut to basically zero after it got some major press attention. This is a school teacher in Texas. School teachers actually have very good insurance relative to much of the rest of the population. He had a heart attack. He got a bill for $150,000. The insurer paid $50,000 and the hospital said, thank you very much. We're now going to pursue this teacher for the balance for the $110,000 again until it got press attention, at which point they accepted, I think, about $350, suggesting something about the real price that they were willing to accept for the bill and the real cost of producing these services. But of course, many of the people who get these sorts of staggering bills don't come to the attention of the news media. And this is not a particularly good way of dealing with this problem. A recent example, actually from last month, a pharma CEO undeterred by the bad press that Martin Shekreli got said it's my moral requirement to raise drug prices by 400%. I think he's clearly auditioning for the next Martin Shekreli role in front of Congress. And then there was something that just came out today. Utah will pay for public employees that have high-cost drug prescriptions to get on a plane, fly to San Diego, ride a bus into Tijuana, get their prescriptions filled, and the insurer will cover all of those costs, plus give the employee $500. And they're still net ahead to filling the cost of that prescription in Utah. Now, Jack Wenberg years ago had this example where he said, look, if everybody in Miami agreed to get their health care in Minnesota, we could buy each and every one of them every Medicare beneficiary. We could buy each and every one of them atop of the line fully loaded Lexus, and the Medicare program would still come out ahead. This is exactly that. But for public employees in a deeply conservative state, this is an indication that I think we're getting closer and closer to the breaking point, at least for pharmaceutical pricing, if not for broader health care pricing. So now let me talk about a couple of bad apples that are profiled in the book. This is Dr. Jacques Roy, who was a primary care doc in Texas. At least that was his title. In reality, he was a certification machine for home health care. He just would sign his name on a piece of paper, and then the Medicare program would get billed, often large amounts of money. He was the number one certifier in the entire United States. Most physicians do 50 maybe of these per year. He did 5,000 in a single year, 11,000 over a six-year period. And the striking thing was when they finally figured out there was a problem, they suspended him, and he said, thank you, I'll sign up under a different name and keep doing it. He finally got convicted and sentenced to prison, at which point he stopped doing this. But you should not assume that the Medicare program will be aggressive in dealing with people like Dr. Roy. There's a long history of them paying for services rendered by dead physicians to dead patients. That's the sort of level of scrutiny that the Medicare program often has engaged in in deciding whether to pay the bills. Now Dr. Najam Azmat, who was nicknamed Dr. Hazmat by the federal prosecutors that finally had to deal with him, he was a surgeon. He took a two-week-end course on stenting, and there was a hospital in Georgia, the Citillo Regional Medical Center, who after they lost the people who were doing stenting hired him to handle it all for $600,000 a year. He wasn't very good at it. That's an understatement. There was a sort of wake of death and destruction in his wake, including wrong-sided stenting, which is hard to do. And then he did it actually to a professor of radiology at Duke University, not a good person on whom to do that. The federal investigators ultimately found more than 30 patients who received worthless care, poor care, or unnecessary care. And that's not counting the people who needed care who suffered severe injuries. And the hospital didn't really seem to care very much because they had somebody who was stenting and generating revenue. And the nurses rebelled, and one of them asked a hospital administrator, what's it going to take to stock Dr. Asmott? And the administrator said essentially, even if he kills somebody as long as the billings are good, that's really what we're focusing on. He was also licensed in three states, even though he lost his privileges ultimately at Citillo and had lost his privileges at other places and bounced around doing other things, including running a series of pill mills. It took two of the states a long time to yank his license well after he had done all of this. The third state only yanked his license after he had been arrested and held without bond for several months for running a pill mill and engaging in healthcare fraud. And that was only because a newspaper ran an article that said, why hasn't the state yanked his license? They finally got around to doing it. So a remarkable picture of indifference, both on the part of the hospital administrators and also on the part of the states, the licensed physicians. Now let me talk about a slightly different problem. Whatmecular degeneration is a problem that can cause blindness in the elderly. And ophthalmologists discovered that you could use Avastin, a drug that was developed for cancer treatment of colon cancer. And you can tell that because it comes in 100 milligram doses. And they'd subdivided and inject small quantities into people's eyes. And they had huge beneficial results. The company that manufactured Avastin decided that they were selling it at too cheap a price. So they decided to come up with a different product called Lucentus, which comes in much smaller doses. And you can see the price per dose. These are the ophthalmologic dose amounts below. Now if people were spending their own money, they would obviously say, give me the $60 one. But what you will discover if you look at Medicare billing records is many ophthalmologists enthusiastically started using Lucentus. There were probably several reasons for that. But it's not an accident that the way in which Medicare Part B pays for drugs and pays for physicians to dispense those drugs creates a big incentive for physicians to pick the more expensive drug rather than the less expensive drug. And that has real consequences for patients because they bear a 20% copayment for drugs that are dispensed through Part B. That's a problem. But it's not the problem I want to talk about. The one I want to talk about is Dr. Melgen, who's described on the book, a very prominent Florida ophthalmologist. He saw more than 100 patients per day. He was running a mass production line for seeing people and giving every single person more or less who came through the door. Lucentus, whether they needed it or not. And the Medicare program figured out there was something wrong. And in around 2011, they demanded that he pay back $9 million that he had been overpaid for dispensing Lucentus in 2008 and 2009. Dr. Melgen wasn't happy about it, but he wrote them a check for $9 million. And then he proceeded to keep billing the Medicare program. $21 million in 2012. He was the number one biller in the entire United States. You know, a world record for health care spending. He sort of slackened off in 2013. He was only the third highest biller in the entire Medicare program. The Medicare program just kept cutting him checks until finally, the Wall Street Journal actually did some litigation to get access to information about high billers, published an article about them, and then the Medicare program, which indicated it was simultaneously investigating him, started to crack down. Overall, Dr. Melgen was actually engaged in quadruple billing. I can talk about that in the Q&A if people have questions for the Lucentus. And he took the Medicare program for a conservatively estimated about $135 million over eight years. But he used some of that money when he got into trouble with the people who were the program administrators to make large campaign contributions to his favorite senator, not from Florida, but from New Jersey, a total of $1.1 million. And Menendez and his staff repeatedly went to bat for Dr. Melgen. And I'm going to pick on Senator Menendez. But in fairness, I want to tell you this is a bipartisan phenomena. It applies in the House, in the Senate. Many health care, many representatives view themselves as representing the interests of the people in their district. And making campaign contributions is a good way to get in the door and have your voice heard. So let me just give you a brief example of one of the arguments that were made. This is an argument where one of Senator Menendez's staffers called up someone who worked for the Medicare program for CMS. And this is the argument that he gave as to why they should just keep writing checks. Bad medicine is not illegal. Medicare should pay these claims. So one federal employee is telling another federal employee, just keep the money trained flowing. It's not your problem, whether it's good or bad medicine. We need some other strategy, apparently, to do that other than the way in which Medicare pays for things. Now let me talk a little bit about surprise medical bills. This is some recent polling from a Kaiser Family Foundation survey. Left side is sort of very concerned. Right side is not at all concerned. And unexpected medical bills are the number one concern on this list of things, many of which are health related, but certainly not all of them. People are not all that concerned about food or rent or mortgage compared to unexpected medical bills and their health insurance deductibles. And there's some good reason for them to be concerned. So I've got a movie that I'm going to try and show. And we'll see whether it actually works. And if not, there we go. My name is Paul Davis. I'm a retired family physician. A couple of years ago, my daughter, Liz, was experiencing some severe back pain. And so she consulted a physician. He determined that she would be eligible to have an operation to fix her back. And she underwent the procedure successfully. When she was discharged home, she was given a prescription for a pain pill. She had an insurance, and it paid for almost all of the operation, except for a deductible. Then the physician ordered a urine drug screen. She never was given the results of that test. And so she basically forgot about it. About a year after the operation, she got a call on her cell phone and was told that she owed $17,850 for this urine test. When I found out my immediate reaction was, this is fraud. This is price gouging of incredible magnitude. I was the program director for the physician assistant training program here at the local university. For $45, we did background checks in urine drug screens on our accepted students. There is actually no way that what they did was worth the amount of money that they charged my daughter. They tested for things like valium or Xanax, $2,975. Methadone, which was $850. One of the most amazing things on here to me is they did skeletal muscle relaxance, $1,200. All of these things just outrageously overpriced and aren't even really necessary. Not a routine post-op practice. My biggest concern was my daughter and her husband and what something like that could do to their credit rating if they did not settle this bill somehow. And so I paid $5,000 to these people to settle this bill. The lab's attorney said that their pricing is consistent with the industry. And I was just livid that these people would have the nerve to charge this amount of money for this service. In Carol's book, Overcharge, they are pointing toward solutions that have a high chance of working. Until I read the book, I was very much in favor of a single payer system because I don't think I really understood that over insurance is shielding us from the market forces that ought to be at work. Even though I'm retired, I believe in the principles of what the medical profession is supposed to stand for. People are being overcharged throughout the country. And I hope that the ideas in the book gain traction. OK, so let's go back to the presentation. And I'll talk more about a surprise medical billing, where we see it, and why we see it. As I said previously, when we were talking about the case out of San Francisco, hospital emergency departments are a very common location for people to get surprise medical bills. Let me actually just ask, how many of you have either gotten a surprise medical bill or know someone who has? OK, so this is an indication of the prevalence of the issue. Now these are facilities where this is a nicely done study that came out just over a year ago, where they looked at the likelihood of a patient at the given emergency department getting an out of network bill. And what you see, the x-axis is basically time. And the vertical point where there are dashes right underneath the x-axis are where the hospital switched the ER staffing company that it was using. And what you see time and again is a sudden and dramatic increase in the likelihood of someone going to that emergency department receiving an out of network bill. And the key point is the likelihood of out of network was zero or close to it prior to the switch. So you know what the baseline is of the likelihood of out of network. And the causation is clearly a result of the emergency department staffing company choosing to be out of network and the hospital choosing to contract with an ED staffing company that's out of network. And you're looking at rates ranging from 33% all the way up to 100%. This is about the ED staffing company and the hospital's contracting decisions. Hospitals are able to solve this problem. That's why the rate was zero before they switched. And ED staffing companies are choosing to be out of network quite deliberately because they've decided that they can make more money by doing it that way. And the key thing, I think, to recognize here is that every other business has managed to figure out how to solve the problem of preventing surprise bills. This is the auto body shop in Champaign that I used to go to. I had four kids who were driving. So I became quite familiar with the auto body shop. I never once got a surprise bill from the guy whose job was to put the bumper on or to paint the car. There was a sort of package all in pricing. The body shop had figured out how to solve this problem, but the health care system seems to have had some difficulty. We have seen some legislative action, but it doesn't really address the core incentive problem. Instead, it's an after-the-fact mandate. And so again, the argument in the book is all of this is attributable to the way in which we've decided to pay for health care. Now, I mentioned Martin Chacrally earlier. Everybody's heard of Martin Chacrally, right? Described as having the most punchable face in America. And he became the face of Pharma Greed for raising the price of Daraprim from $13 to $750. Now, in the scheme of American health care spending, this is not a drop in the bucket. This is not even a teeny part of a drop in the bucket. There are a total of 5,000 Daraprim prescriptions written per year. The more important point is that Chacrally was following in a pathway that had been established for him by lots of other pharmaceutical companies, both branded and generic. And you can see listed some pretty dramatic price increases. The first cohort are all drugs that have been generic for decades, long been available. And we see dramatic price increases, often because the Food and Drug Administration has not approved an alternative supplier of this drug and is unwilling to allow importation from other countries when prices rise. But we see the same phenomenon, branded drugs, the complete uncoupling of our pricing system from the performance of the larger economy. And an important part of the reason for that is, again, our reliance on open-ended insurance reimbursement, where whatever the provider, sometimes hospitals, sometimes individual physicians in the context of out-of-network, most of the attention has involved pharmaceutical companies, sets whatever price they want, knowing that the insurer is going to pick up most of it, sometimes all of it, and knowing that open-ended reimbursement, especially if it's coming from the Treasury, is not subject to the same constraints that apply to ordinary people if they had to come up with the money right now out of their own pocket. This does not suggest that pricing games are exhaustive of the kinds of bad behavior that you see. This is a reputable company. This is Walgreens, Illinois-based company, very successful company. Someone came to them and said, you know, you're dispensing Zantac, a long generic drug, and you're dispensing it in tablet form. But the tablets are subject to a very low price cap. If you just switch everybody to capsules unilaterally without telling them or asking them or asking anybody's permission, you can add $75 million to your bottom line nationwide. And look, this is what happened in Florida. Basically, the prescription rate for tablets fell off the cliff, and the rate for capsules skyrocketed for a period of several years, and then it plummeted again. Anybody want to guess why it plummeted again? Somebody filed a whistleblower lawsuit alleging that this was health care fraud, and Walgreens decided that this was fine as long as no one was paying attention. The book has this lengthy catalog of fraud, waste, and abuse, and you find it everywhere you look involving every type of provider, ranging from the sort of scum of the earth kinds of bad people that we actually do see, giving you a couple of examples of really bad people. These are not the worst people in the book, but they're up there. The mob is actually involved in taking money from the health care system as well, but any provider you can imagine has been involved in these sorts of problems. Now, what about price transparency? In normal markets, we actually see a high degree of price transparency. We do see price transparency in some small parts of the health care system. This is actually a price list from the Walmart Care Clinic. They don't do everything by any stretch of the imagination, but one of the things they do is tell you up front, here's what we're going to charge you. And free parking, not a long wait. These are important attributes for people, especially people who are cash constrained. Now, my father lives in the Western suburbs of Chicago. He's 90 years old. He's on Medicare. He's seen by the DuPage Medical Group. This is probably pretty hard to see, but they sent out to all of their patients this form. And what it says is here's what you should know it will cost if you go to on the top. Our same day appointment or after care, average cost is $70. Second row is a video visit or an e-visit, and it lists the prices in the far right column. The immediate care center, a little more expensive, but not huge. And then at the bottom, the emergency room, average cost $2,300. Now, we can argue about whether those numbers are spot on or not. It's obviously going to depend on what problem you actually have, but this is a lot more information than most patients have accessible to them. Now, I do quantitative empirical work, so I wanted to show you a little bit, actually, some new results involving quality transparency. I had data on Illinois licensed physicians and their medical malpractice records and their disciplinary records. And so I identified the absolute worst doctors in Illinois. The bottom 0.25% judged by the frequency of paid medical malpractice claims plus discipline. You had to have both, and not just one of each. You needed one or more paid claims and three or more disciplines, or three or more paid claims and one or more disciplines. And this is not disciplined by your local hospital. This is the state licensing board has decided to sanction you in some way. And then we matched them with 191 control physicians on all of the attributes that you can see, but they had completely clean records, no paid medical malpractice claims and no disciplines. And the question I was interested in is, well, what kind of information is available online to ordinary patients about these physicians? And we used four physician ranking websites plus everybody's favorite Yelp. And so the first thing that you discover when you do that is the coverage is not great. In terms of those 191 physicians in our bad docs pool and our control, we basically don't get higher than 60% having information that's accessible online about them, whether the information is good, bad, or indifferent. Yelp is the worst, down around 5% to 9%, but the average is high 30s, low 40s. So if you're looking for information on health care providers, you don't get great coverage looking online, even if you look at all of these. What about patient satisfaction? So the control docs who have completely clean records, that doesn't mean they're great. It just means that they haven't had either disciplines or medical malpractice paid claims in their past. And you can sort of see the number of stars. This is out of a five ranking. So I teach in a law school. This is B plus performance. That was supposed to be a joke. But 3 and 3 quarters to 4 is the average. And if we're picking up something meaningful in our online rankings, and if the paid malclaims and disciplines have some impact on the patient's assessment of quality, you ought to see much lower numbers. That's what you would expect to see. And what you actually see is the numbers are a little lower. Not very much. This is not promising news about the availability of our very sophisticated information technology to provide accessible information to patients about quality of care. And we can talk during the Q&A about whether I pick the right measure or not. But these are not good doctors. I think you ought to at least concede the far right column to me on that. OK, so why is our health care system so dysfunctional? And now I'll pivot to the second part of the book. Our argument is that the way in which we've chosen to use insurance, rather than using it for catastrophes, we use it for everything. And everyone perceives that they're spending someone else's money. Now, we've seen some changes of late with high deductible health plans, which have had some interesting consequences. But the difficulty is people's expectations about how their health care ought to be delivered and how much they care about the price of it are greatly influenced by whether they're facing no cost at the point of service. Staggeringly high costs are somewhere in between. And again, the price at which the exchanges take place are influenced by the provider's knowledge that insurance is on the other side of the equation. That's why our list prices have climbed steadily, much faster than the rate of inflation. The second complication is we see political control of health care spending. Depending on whether your team is in power, you might feel differently about this. But you should recognize that elections are what they are. And so other people will be in charge of the system. And so you might want to think carefully about how much political control of health care spending we actually want. We also see all sorts of regulations that have an impact on the health care system, tax subsidies, mandates on what insurance has to cover, and significant limits on market entry. And disruptive innovation in other industries has been the most important driver of both innovation and value improvements, higher quality at a lower price point. But we don't see nearly the same amount of that in health care. For most new entrants, their first question is how can I get reimbursed for what I'm doing? Where reimbursed means by the Medicare program or by private insurers. They don't perceive the patients by and large as being their customers. The political economy of health care is affected by these dynamics. Our argument in the book is that medicine corrupts politics and regulatory policy. When the government is the major purchaser of health care, health care providers respond by trying to capture the political and regulatory environment. And that's not a condemnation. It's just a statement of fact about the way these things have worked. Plenty of examples in the book. The flip side, of course, is that politicians don't necessarily know very much about health care, but they know what voters like. And so they will compete with one another to offer solutions which may or may not map on to what we think is high quality care. An important reality is if you look over time, although the price of health care and our spending on health care has climbed dramatically, the share of it that's born at the point of purchase by the patient has dropped precipitously. So between 1970 and 2016, we start with patients bearing 34% of health care spending at the point of purchase, dropping to 10%. Now, why did that happen? Because we decided we wanted to insulate patients from the cost of care by, among other things, extending to them, often heavily subsidized insurance. Everyone thought that was a good idea, but what it did was it unleashed an inflationary spending spiral in health care where, again, providers, by and large, view insurers, and the government as their customer rather than the patient. So what should we do? So this has cut off the bottom of it. And so this is actually a cartoon from the AARP magazine. And I'm not sure why it cut it off. So I've spoiled the cartoon, but the caption is unhappy hour at the health reform cocktail party. And these are a bunch of people standing at the bar who are complaining about various aspects of the health care system. And they have real complaints. These are issues that are deeply important to people, particularly if they're worried about their ability to afford the health care system. So what do we have to suggest to them? Well, we think the important point here is we should stop focusing on extending coverage and start focusing on making health care cheaper. Because if we do, it'll be cheaper to extend coverage to all of the people that we'd like to do it for. Whereas extending coverage and not paying attention to the cost just is like throwing gasoline on the fire. It becomes more and more difficult to continue to pay for the coverage that you've decided to extend. We think you should encourage market entry and competition. There are a bunch of examples in the book of ways in which that's had an impact. We think self-pay rather than open-ended reimbursement is the way that we should be pushing. This is not a condemnation of health insurance. We think there's an important role for health insurance. It's the role we see for insurance in all other sectors of the economy, which is covering catastrophic outcomes that have a low probability of actually happening. We also have some suggestions about how to deal with pharmaceuticals. And somewhat interestingly, we find ourselves on the same page with Bernie Sanders on how you should deal with the branded pharmaceutical issue. Generic pharmaceuticals, we think, have much more to do with market consolidation and decisions that the FDA has made. We think we should exploit federalism. Different states have different preferences. And if one state wants to do single payer and another state wants to do medical savings accounts, as long as they're spending their own money, it's not at all obvious to us why that's any business of anyone in any other state. We think we should fix the tax subsidies by making health care cheaper. Tax subsidies inherently end up causing health care to be more expensive because it's cheaper to purchase and obtain health coverage than it should be. And we should subsidize people who are in need, but not by giving them coverage, but by giving them money and letting them choose to spend that money as they see fit. And for those of you who would be inclined to say, well, that's a bad idea. You should note that our entire social security system is built on this framework. We don't choose to provide the elderly with housing and food. Directly, we give them money and let them make their own consumption decisions. So let me close with talking a little bit about single payer. Mark, how much time do I have? Five more minutes. OK, so let me talk a little bit about single payer because that's usually the pushback to the arguments in the book. And we have a chapter in there on blind alleys and lost causes, which we identify single payer as both of those. And we recognize that's not a universal assessment. But a couple of observations about single payer. The first is, if you think single payer is a good idea, you ought to think hard about which version of single payer shows up. So Medicare single payer is very different than Medicaid single payer is very different than the VA, just to pick three examples from within our own borders. Second, the usual argument for single payer in the form of Medicare for all is look how low the overhead is. We're not wasting money on administration. The book has several pages on this. It's actually a terrible measure for system performance because it's picking both the wrong numerator and the wrong denominator. Happy to talk about that during the Q&A as well. It will also result in very high on budget costs. The sort of standard estimate, I think, for the proponents is $33 trillion in new spending over 10 years. That's 18 to 20% of GDP. Keep in mind our overall tax rate currently is about 20% of our GDP. So you're talking about a very dramatic increase in the amount of money that's flowing through the government. Also, keep in mind a lot of that money is currently being spent by individuals on private health insurance. So you're substituting it from one part of the economy to the other. But the reality is, although I think advocates are very keen to increase taxation and government spending for accomplishing this, it's not at all clear. The voters are, we've got three states that have taken serious looks at single payer and all of them have gagged at the price tag, the first two in the form of legislation, the third, Massachusetts. Don Berwick ran for governor on a platform of we should do single payer. These are all, by the way, deep blue states. This is not Texas deciding it doesn't want single payer. Another way of framing this was put by Chuck Blayhouse, who was the public trustee for Social Security and Medicare. And what he points out, and I won't read this to you, but you can read it for yourself, is you might think that it's a plausible bargain to try and switch the entire healthcare system into the government side of the ledger. But it's worth asking yourself, would Americans be willing to do that if it involved the sector of the economy other than healthcare, like food? Where the claim for affordability is premised on your ability to take 40% of current spending out of the system in order to pay for the coverage expansion and to pay for the increased intensity of services that people are gonna get if they're facing zero out of pocket costs. And I'm not gonna presume to answer this question, but it's at least worth framing it in the context of something other than healthcare. And if the answer is people wouldn't do this for food, but they should do it for health. I think you need to come up with some arguments about why health is so different that people would be willing to take this particular deal. So the next question is well, okay, fine. But single payer seems to work everywhere else, so it ought to work here. And we have two responses to that. One is this long ago article by Stuart Altman and Mark Rodwin. We have neither competitive markets nor optimal regulation. What we have in this country is a rotten version of both of them. And so you need to explain why we'll, by getting rid of the former we'll actually be able to fix the latter. We put it somewhat more pointedly in the book that relative to other countries, our government is uniquely subject to pressure from special interests. And it also often behaves as though it is run by idiots. My office is down the hall, down the street from Capitol Hill and I have lots of evidence to support that last sentence. So let me close. This is actually a figure that U.E. Reinhardt sent out in one of his Christmas cards where he was pointing out, actually let me set it up in this way. The often given explanation for why we don't have universal coverage is that Americans are sort of uniquely selfish people. And if only we were willing to sort of step up, then we'd be able to do it. Now, Reinhardt's observation in this figure is, gee, maybe the cost of healthcare has something to do with the extent to which we're generous. That is, we're looking at a very different supply curve. Even if we have the same demand as other countries for universal coverage, our ability and willingness to fund it are influenced by the price point that we're facing. And the summary that I actually give of this article is Americans aren't selfish. We are the most generous people in the history of mankind. We're willing to pay for our healthcare system no matter how much it costs, not for everyone, but we just keep paying, right? So don't say we're selfish. We're actually sort of remarkably generous. So let me return to the value in healthcare framework. And this is actually a quote from Don Burwick where he indicated that when he stepped down as acting head of CMS, that 20 to 30% of health spending yields no benefits to patients. That means we're not doing very well on either the numerator or the denominator. And this is a target-rich environment for improving. And let me close with the important observation that no matter how good our intentions, they are not a substitute for doing good policy. I'll stop there and I'm happy to take questions. Thank you. Everything you said is true. You can stop there. Yes, but it's like a telescope. It depends which side we are looking. From one side, the thing looks much larger and from the other side, much smaller. Now, we calculate the cost we pay for healthcare, but we seldom calculate how much it costs to give the healthcare. A day in a hospital costs 2,000 for a bed and it costs 4,000 for an ICU bed, 4,000 down. Now, we have a lot of social problem which enters into medicine. Crime, as you mentioned in there. Everyone who has an accident, a simple accident, comes to the hospital without insurance. That cost is 100,000. Who pays for that? So hospital cost is a lot different and depends. So you say, for example, that person paid $18 for coming and get a band-aid. It's a lot like having a cup of tea in your neighborhood may take 10 cents at home, 10 cents, but if you go to a rich hotel, it gets $15 because of the service and mankind involved in this, we do not really calculate it. Now, you talk about my practice. Some years ago, I calculated, I paid $300,000 for my practice and my colleagues in Indiana paid 50 and Wisconsin 40. I don't think we practice any worse than those. So these social problems are not really problem of a healthcare or problems that has to be cared elsewhere. Okay, so a couple of quick responses. You've raised a bunch of different issues, right? So one which is important is we don't actually know what the cost of many things that are done in the healthcare system are because by and large, we don't have the cost accounting that's necessary. And so the price tag at which that bed is built out bears no obvious relationship to the actual cost of production, okay? And that's part of the reason why we actually see new entrants coming in at very different price points, including the Surgery Center of Oklahoma, which is a full service hospital that has dramatically lower prices and fixed prices in a manner that's quite different than many of the fine hospitals in the city of Chicago. So I think, you know, because we've chosen to price things on a per diem basis, okay, it's very expensive for the first day in the hospital, but the price, the cost of production actually goes down over time, right? The second day for a mom who gives birth is much less expensive in a production cost function than the average billing that we're doing, right? We Reinhardt actually wrote an article that said how much does it cost for a cup of jello emphasizing the point that the price for the first day ought to be very different than the price for the second day, but hospitals have chosen to price their services on a per diem basis. And that's why the Medicare program, approach this as a, gee, we have a per diem problem. Let's move to a flat price rather than continuing to fight with you about how many days people ought to stay in the hospital. That's the first point. The second point is you're right, the lots of social problems come to hospitals and to other healthcare providers. And if we as a society want those problems to be taken care of, there's a way in which we can fund that, which is taxing ourselves and then paying healthcare providers to do it. We shouldn't expect them to be in the redistribution social insurance unless they choose to, in which case they should face people who are spending their own money, right? So the difference in tea pricing in the hotel versus the diner versus your own home, the key point is that in all of those settings, the customer is facing the price and paying for it with their own money, as opposed to going back to my agency cost example, spending somebody else's money and not only worrying about their incremental cost. With regard to malpractice, I'm happy to talk to you about the several, you know, there are probably 25 articles that we've written on this subject. The best evidence on defensive medicine is that it's a relatively small piece of the healthcare pie. Indiana has, and I've actually done a lot of work on Indiana, Indiana does have lower prices. It also has a cap and a patient compensation fund, which is very different than Illinois, which has enacted caps three times only to see them struck down by the Illinois Supreme Court. So if you have a beef about that, it's not with me, it's with the Illinois Supreme Court. But I'm happy to talk to you more about what we do know about medical malpractice because we know a lot more about that than any other aspect of the civil justice system. Other questions? Yeah, just wait till she brings the microphone. Uwe Reinhart in the early 2000 made his famous paper saying it's the price stupid. And it's pretty clear that the biggest problem in the system and the cost of the system is the prices. I guess I'm not following where your suggestions are going, where it's gonna do that. What kind of market entry is going to reduce prices? Are you suggesting more physicians in the market, more hospitals? What are you suggesting? It's a great question. So, and I agree with you, I actually cut out the slides that involve cross national comparisons because you heard from Ashish Jha about two weeks ago and Uwe Reinhart's done some work and other people have obviously done work. So the obvious question is, okay, what's gonna cause prices to come down? Well, the reason why prices are so high is because healthcare providers perceive that the person who's buying it from them has an unlimited budget, okay? And a significant, the reason why we see out of network bills that look the way that they do is because starting at a higher price causes the in-network provider to pay a bigger share of it. And if they're on the other hand facing someone who's spending their own money and there are enough of them in the market, then the model of the sky's the limit for pricing and I'll negotiate at the back end starts to break down, especially if they're alternative providers of the services. And with regard to where our other provider's gonna come from, we actually talk about retail medicine as an important driver of market entry. Obviously not for intensive care unit services, but we shouldn't have a situation where intensive care units are out of network compared to the rest of the hospital. And we actually have examples of that as well, right? We ought to stop playing pricing games on the sell side, but the motivation to do that is incentives driven off of the buy side. David. I want to just do a little heart on your description, which I read a little bit as saying if only people were more sensitive to price, the markets would be better policed and the incentives would be better aligned. And I understand that for sort of people who are not high utilizers and sort of the retail side of it, for most of us who are pretty healthy most of the time, maybe, and I think the argument can be made against that. But a very large fraction of healthcare expenditures are incurred by a very small fraction of people who incur very high expenditures. And so my question is, how do you envision that working? How should we, if this is the prescription, be creating incentives, that incentivize economizing on care when people are very, what are the structures that you think would work? And to the extent those structures are familiar one, what's your read on the evidence that they actually do work? Sure, great, great set of questions. So you are absolutely right that a small share of people are responsible for a massively disproportionate share of healthcare spending, right? So, I mean, we can talk about the specifics, but I think they're well known to everybody. The important thing to recognize is that's not unique to healthcare. If you look at the fire insurance, a relatively small number of people get catastrophically wiped out. So the presence of that concentration is not an indication that we don't have mechanisms for dealing with that. Then the follow on is okay, well, maybe there's some gradations that we should worry about. And the first cut is obviously people who have chronic illnesses who are high utilizers versus people who have catastrophic medical expenses but may or may not have chronic illness unless it's at the end stage of the chronic illness. And I think you wanna think separately about those two types of people. Remember, I didn't say we had anything against having people buy catastrophic insurance. And catastrophic insurance that's gonna be more hard-nosed about this because people will be buying it with their own money as opposed to obtaining it in a way that allows them to pretend that my employer is footing the bill rather than myself. So the next observation is we see high prices for some healthcare patients. That's a volume effect, times a price effect. On the volume effect, the issue is, well, did you actually need all of these things that the healthcare system has decided to deliver to you because it runs on autopilot? Maybe you do, maybe you don't. Who should be in the business of deciding that? That was my first slide about who should be assessing value. And on the price side, I think the, again, the impact of less use of open-ended third-party payment is gonna end up affecting prices. We're actually seeing this already, not helpfully, in the back-end negotiation over out-of-network bills. So the urine movie that I showed you would happily took $5,000, but they were busily sending out bills for $18,000, which, as the lawyer indicated, was industry standard. But we don't see that, again, in any other sector of the economy. So the question I would come back to you is, well, maybe healthcare is different, but is it so different that it's dysfunctional this way when it hasn't been this dysfunctional previously? And we don't see any obvious strategies for fixing it that don't, I mean, we, meaning Charlie and I, don't see obvious strategies for fixing it that it will rely on top-down government regulation. We're trying to deal with it in a way that maximizes the value patients get when we think they are the best judge of what they should get, in combination with the physician that they trust. I guess if you're right about that, then you would expect the private market to look better than Medicare, for example. Is there some incentives there? And it's not a... It's not an obvious, yeah. No, no, I... I know that that's where the efficiency really is. In fact, it's kind of the opposite in the U.S. So part of the problem with Medicare is it's, you know, you get shadow pricing because the individual insurers correctly perceive that the employers are their customers rather than the individual patients. So I agree with you that the private market is by no means a model of efficiency. And, you know, some of the conduct we're describing victimized private insurers, not just public insurers. I guess what I'm thinking is the problem here is you don't have one bad incentive. You have a bunch. You have an infinite number of them scattered over so many different parties. And so you sort of imagine implementing some of these market-based solutions. And you still have some incredibly powerful parties. You do. You do. And the question, I'm trying to make progress on a hard problem. I'm not suggesting it's an easy problem, right? When you dig yourself this deep in a hole, it takes a while to get out of it. Other questions? Hi, thank you. Sorry if this is a bit off topic from what you're talking about. But one thing that's interesting is the electronic medical records. So usually in most industries, technology actually makes providing services more efficient. Turns out in health care it seems that people have actually wasted a lot of time and physician hours and there's probably lost value through the EMR. So I don't know if you have any suggestions on how that can be improved or whether there's some more value to be had in that regard. Yeah, you can tell the story over and over again with any number of innovations in health care. The part of the health care system where technology works is the billing department. It's sort of is seamlessly effective at sending out bills with very high numbers. The reason why we've lagged in adopting EMR and there's actually a chapter in the book that talks about it and talks about the way in which the health care providers actually held up the federal government to say, we won't adopt electronic health records unless you pay us to do it, which again is not the way in which we see other sectors of the economy behaving. And then guess what? If they were paying for it, they decided to attach certain terms and conditions and then the people who were buying it were not focused on what was actually best for patient care let alone what would be an effective system. They were focused on regulatory compliance. It's in a microcosm, it's not off topic at all. It's exactly the same problem. In terms of a fix, I junk your current system because it's the source of immense dissatisfaction. I hear less now about physicians quitting because of medical malpractice premiums and more about them quitting because of the electronic health records, which is not a promising sign. And then the difficulty is, I think in all fairness, federalism offers a solution to this as well. Rather than trying to mandate a top down standardized, you must do it this way. Let's do some experimentation. I think in fairness, we do want reciprocity of record exchange and interoperability. And so standard setting organizations are an important part of that. And again, I keep saying this, other sectors of the economy, why is it that healthcare is so different? Are you saying you support government? No, standard setting organizations are not government. Okay, and I don't have any brief against government as long as it does a good job in areas where it's constitutionally authorized. This is not an anarchist scheme. Standard setting organization, that government is this organization. Why don't I talk to you offline about it? There's a long established, I mean the reason why electrical plugs look the way that they do has everything to do with a standard setting organization. Any other questions? So it's always thought-provoking to listen to you speak. So did I have the right mix of fun and inflammatory stuff? You did, you did, it was good, it was a good mix. And I enjoyed it. So you gave us a story of how broken our medical system is. And actually my conclusion from what you said is that the problem is that greed is the driving force. And that you can't legislate greed away and you can't privatize greed away. So we have to choose between two evils to try and come up with a healthcare system that actually accomplishes the goals which are to meet the needs of the population of patients that are being served to try and maximize their health and well-being. So you talked about some of the problems with single payer and you said, well, we can't possibly accomplish it because we have too many other problems in our system. You said more than that, but that's at least part of what you said. What are examples? Is there an actual set of examples of privatized healthcare systems that actually have the health outcomes that the single payer systems have accomplished? So let me start with the greed point. So do you have a cell phone? I do. You do. Do you know who makes it? You don't know and you don't care because it works, right? But how many of you have iPhones? Okay, do you think Steve Jobs was greedy? Do you think the people who worked for Apple were greedy? Everybody's greedy, right? The issue is to basically motivate them to turn that in the interests of someone other than themselves, right? So I won't quote you, Adam Smith, but you know the quote about, and we can do Milton Friedman or we can do Gordon Gekko. It sort of all depends on which version would most inflame you before you go off to rounds. But greed is a dominant reality of the human experience that you can't say it seems to me that we can't do it this way in healthcare because of greed when phones seem to work, production of clothes seems to work, buildings seem to go up, cars seem to drive along the street, et cetera, et cetera. So the difficulty is not the presence or absence of greed, it's incentives that encourage people to serve their own interests rather than the interests of their patient. And if there are ways of doing that that involve government action, then that's just fine. If they're superior to, then there are circumstances where there would be, right? So you think about externalities and you think about monopoly and you think about public goods and all of those are justifications for government intervention, okay? But I think you should get away from the proposition that there's a group of virtuous, non-greedy people out there that we can rely on to run our system or to deliver healthcare services. Okay, then on the, what's my case study example? So you're not gonna find one in the United States because we have Medicare, Medicaid, a variety of systems and pretty aggressive state regulation that in many states chills market entry because it's serving the interests of incumbent providers. In terms of do I have a model of this particular approach that we're detailing, the book talks about Singapore as a proof of concept. Now Singapore is obviously much smaller than the United States. It's ethnically diverse, but not as diverse as we are. I mean one of our small states has a population that's at least twice that of Singapore and we're not, obviously Singapore has some governance problems that we're not recommending either. But the core point is there are ways in which other countries have experimented that we might wanna think about learning from and that's part of the reason why I think federalism is a good approach. If Vermont wants to do a single payer let's let them do it and see what happens. But I think that's the point is that there are lots of experiments going on to try and achieve the approach to healthcare delivery. But right now I would say that in the world single payer is probably the most successful approach to healthcare delivery on a national basis. So look we can argue about the significant variation among countries and what their single payer looks like as well as the variation in which their delivery system looks like. You also find as it happens unhappiness everywhere you look, everyone's looking for somebody else. There's no perfect outcome. Well that's an important concession, right? And I'm not again suggesting the common approach is to say we should just do Germany, right? Or we should do France or the really aggressive people want to do the UK. Many more people want to do Canada just because it's close and you can visit and they have good croissant and Montreal and so on. It all must be connected. Truthfully, I don't care which of those individual states do but I think trying to do a top down solution for the whole country didn't work and can't see how it's gonna work. We've suggested one pathway, we're open to others. Yeah. I wonder if you could go back to the point you made about the, you have to go back to the slide. Okay. The Yelp ratings and the Yelp ratings and the generally poor correlation between information and real quality in healthcare and talk about how you think that affects the viability of a market driven. That's a real problem, right? The reason why I showed you the results is because I'm trying to fairly present the problems not just with what we're doing currently but the limitations on our ability to do it. If there's a problem with price transparency or quality transparency, it seems to me there are two possible strategies. One is to say this proves that we can't rely on availability of information to drive markets and so we should have some other strategy that will involve varying degrees of top-down regulation. The other is to say we have a market failure problem, there's informational asymmetry, the current market isn't providing it, why is that happening and what can we do to fix it? And I'm very much in the second camp but the reason I presented you the results is to say, these are really bad doctors but they look pretty much the same to people who are unsophisticated and if you're concerned about quality of care, that ought to scare the heck out of you. Right? So do you have a solution? I'm thinking I should go and give all of those doctors that I know are bad one-star ratings and enlist you and your friends to help me. Well, you know, I did the work, they're bad, right? These are not, you would not send your mother there, right? And you ought to worry about other people's mothers going to see them. What I didn't show you by the way, right? It's easy to say, oh, those are just doctors. I used the same data in the interest of time I left off this slide. I used the same data to construct the portfolio of physicians with privileges at about 130 hospitals in Illinois. They had to have at least 100 physicians on staff for me to include them because I was worried about, you know, obviously small cell problems. And then I just did a scatter plot and it turns out these doctors are not evenly distributed throughout hospitals in Illinois, right? There are a half a dozen hospitals that are awful, truly awful. And four of them are within easy driving distance of us right now. There are two others that are downstate, okay? My suspicion is if you went into the emergency department and you asked people, do you know that the average physician here has a likelihood of having a paid malpractice claim of 0.6, six, you know, half of them basically have a paid malpractice claim and about 10% have disciplines. None of them would know, right? They ought to be put out of business, right? And I'm not suggesting, I'm not suggesting that good doctors go there and become bad. I think the much more likely outcome is this is where the bad doctors end up. And again, if you had a bad car company or a food manufacturer that was delivering product that was unsafe, we'd close it down in a heartbeat. But here we take, oh, even a bad doctor is better than no doctor, not always. So I think that's actually an important role for regulation because the example of the doctor who was licensed in three different states and one of them didn't take away his license until he was in jail. For healthcare fraud, multiple months of running a pill mill, that doesn't suggest the state's doing a particularly good job. We ought to get them to do a better job. Please. So I would agree with you on some points. But my counter argument to you would be that I think patients want insurance, okay? I actually work in the insurance industry. I'm a physician, I've been a physician reviewer for years and I can certainly say, based upon my experience, I've seen a lot of bad medicine practice across the country. But I would argue, so what I'm asking you is how are you going to convince the average person that they should pay out of pocket and just have catastrophic health insurance? Because I can tell you, even when I do peer-to-peers now with physicians for certain things, the physicians will tell me frankly, it's like, I know this person doesn't need it, but they want it and they've asked me to call you. So I'm doing that. Well, I'm glad I got the concession that you agree with some of it, which is a fall off from Daniel's agreeing with all of it. But I would expect some diversity of views on those issues. Second, I think the healthcare system is succeeding in pushing us in this direction anyway, right? The reason why we're seeing high deductible health plans, which put patients at risk for a first dollar spending is because the healthcare system has almost succeeded in pricing itself out of the reach of most Americans. And so people's desire for insurance is not surprisingly driven by the high prices that they're facing, but those high prices simultaneously make the insurance, open-ended insurance increasingly unaffordable. And we actually, prior to the enactment of PAPAC of the Patient Protection and Affordable Care Act, we were seeing indications that people's willingness to buy insurance was starting to drop, which suggests again, when people are facing the costs, what they tell you they want and what they actually do are potentially two quite different things. And so I actually, I agree with you that patients express the interest in I wanna have this, but if they actually had to foot the bill at the time of purchase, maybe their views would be different. Maybe not, but enough of them would be, right? There's a recent survey that was done, surveys have their own set of problems that indicated that 40% of patients would switch pharmacies if the price of the drug was $10 different, and 75% would switch if it was $25 different. Now again, that's cheap talk, right? You know, we should look at what they actually do. But there is a price at which people will say, yeah, my kid going to college is more important than my having this additional test. But one of the other issues is, and I think they've shown this in people who have these high deductible health plans, is as your example shows in the Yelp, people don't know where to go for information to find out who is the good doctor, who's not the good doctor, whether this procedure is needed or not. So unfortunately, what's happened is, people have to pay these high deductibles, but they themselves are not able to search out and find out what is the best place for their care. Mm-hmm. Yeah, I agree. This is a sort of dovetails with the point that I made earlier. That's an informational problem that we ought to be fixing rather than just saying this is a problem. And so we should try and come up with some measures and make them broadly available so we don't have people looking at Yelp to try and pick their bad doctors. So. Hi, thank you. I have a question as it relates to the quality versus cost of care and specifically your comment about the cell phone. Speak louder. Yes. Okay, specifically your comment about the cell phone with the quality versus cost of care. My question is, so half of all personal bankruptcies in this country aren't the result of an unpaid phone bill, but rather the results of an unpaid medical one. So let me interrupt you right there. That's actually a misstatement of the findings of that study, right? That study found, we can leave aside, there's actually several studies which find differences depending upon the measures. They used an overbroad measure of bankruptcy. And what they found was that using that overbroad measure without a control group of people who had the same amount of bills to see what they actually did. Looking at a file of people who filed for bankruptcy, so you're actually selecting on the observable which is a problem as well. They find that lots of people, close to 50%, had medical bills, okay? 100% of them had bills for food, but we don't blame their food bills for help for their bankruptcy, right? So I'm sorry, let me let you continue, but this is a sort of common perception that's not in fact, I think a complete statement of the findings of the study. So please go on. Yeah, I appreciate your perspective, thank you. My question is, how are we able to provide care for our patients when that care becomes prohibitively costly? Forgive my stutter. When that care becomes prohibitively costly, how are we able to actually provide them with quality care? One example I think of is aging. You know, how at a certain point we will all need that long-term care in some capacity, so how are we able to actually provide that for our patients? So the implicit assumption in your statement is that if you can identify a need, then it's the job of the healthcare system to provide it. And again, we don't think about anything else in that fashion. And the question you ought to be asking is what are we either individually or collectively willing to pay for, for ourselves and for other people? And then how we go about delivering that is downstream of that decision, right? The standard trope is I can identify a problem and that implies the obligation for a solution. And I don't actually share that view. And I think lots of people don't share that view. If going back to the Uri Reinhart figure, if the price point for healthcare was a lot lower, we'd be able to do a lot more for a lot more people. And that's why our argument is we should be focusing on price volume, not so much, mostly price for reasons that we've already heard. And then we'll have lots more money to spend on all of the problems that you can list. Okay. I wanna thank you for coming back to university and for giving us wonderful talk. Thanks. Thanks very much. Thank you.