 Just let a few more people come in now that they hear my voice coming in from the outside. I'm Francisco Gonzales-Corana, the Dean of the Medical School. It's my real privilege to welcome you to the 11th annual Frank Bryan, Jr. Memorial Lecture in Medical Ethics and tell you a little bit about the lectureship. Today's presentation highlights the Center for Medical Humanities and Ethics efforts to provide opportunities that foster critical thinking and ethical decision making for our entire community. This year, we have chosen to hold the Bryan Lectureship in the month of February in recognition of Black History Month. We plan to continue to honor Black or recognize Black History Month in this way in the future. The Frank Bryan, Jr. Memorial Lecture celebrates the life and memory of a greatly admired medical leader in an outstanding human attorney. Dr. Bryan graduated from the University of Texas Medical Branch in Galveston in 1956. He was a third African-American to receive a medical degree in Texas. To us, it is astonishing to believe that only three African-Americans had become physicians in Texas by then. He fell within my lifetime and certainly a few of us in the front row. He was also the first Black intern and the first Black physician at the Robert B. Green Memorial Hospital, which was located where the new building, the RBG, which many of us go to, outpatient offices are. After services in the Army, he opened a family practice clinic on the east side and was known by many as San Antonio's father of medicine. Dr. Bryan kept his personal phone number in the phone book so that his patients could reach him. There are still a few students in the back, so for them a phone book is something that used to come thick. They would put it in your doorstep and you would look at it in small type. But it's the equivalent of having the patients have your cell phone, which very few physicians do. He used to take time to know each of them, something that we re-emphasize nowadays as we know that medicine is not just about medications or treatments, but also about the social context. His former students, who are now practicing physicians, recall his patients and his desire to help anyone, regardless of their ability to pay for his services. For many of us, it is a fitting tribute to know that a person with high moral standards, a pioneer for equality in healthcare, and one who cared about leadership doing what is right, will be honored and remembered in this way. Dr. Bryan was a dynamic force in San Antonio, especially though not exclusively in the African American community. We're proud to honor him with this annual lecture. Dr. Bryan believed in giving back to his community, and that such giving was really the purpose and the privilege of education. We're especially honored to have with us today his wife, Mrs. Gloria Bryant. Thank you for joining us and for the privilege of allowing us to continue to use his name in this way and so commemorate his life. Dr. Berger will now introduce our speaker for today. Dr. Gonzalez for joining us here. Welcome again to our 11th annual Frank Bryant MD Memorial Lecture in Medical Ethics. This lecture is made possible through the generosity of the Salinger Foreland family via their endowment, and also by a newly established but growing endowment named for Dr. Bryant that will allow us to continue this memorial in perpetuity. I'm Dr. Ruth Bergren, Director of the Center for Medical Humanities and Ethics, where we teach ethics and professionalism while nurturing empathy and humanitarian values. I have a few housekeeping details. Elizabeth Rosenthal is a correspondent for the New York Times, and she discloses that she has no relevant financial relationships with any commercial interests related to the planning or implementation of this activity. To receive continuing medical education, including ethics credit, please complete the electronic evaluation and statement of attendance. You can access these via the QR code, which is on the back of your program, or you can visit our website at texashumanities.org and follow the links to the Frank Bryant Lecture. Following this presentation, there will be a light reception in the foyer. There will also be a time for questions. If you prefer not to come to the microphone, you may write your questions on an index card and have those cards passed forward to me, and I will read them if they're legible. As I mentioned earlier, Dr. Rosenthal is a senior writer at the New York Times who also trained as a medical doctor. She spent much of the last year working on an in-depth series on health care costs and pricing. During 20 years as a reporter and correspondent for the time, she's covered a wide variety of beats. From health care to the environment to general reporting for six years in China, she's a frequent contributor to the New York Times Sunday Review section. Her many journalism awards include the Asia Society's Osborne Elliott Prize, the Beat Reporting Award from the Society for Environmental Journalists, and multiple citations from the News Women's Club of New York. She's been a pointer fellow at Yale, a Ferris visiting professor at Princeton, and an adjunct professor at Columbia University. She received a BS in biology from Stanford, a master's in English literature from Cambridge University where she was a Marshall scholar. She holds an MD from Harvard Medical School. She trained at New York Hospital in internal medicine and worked there in the emergency department before becoming a full-time journalist. The presentation this evening is titled, Medical Prices in the U.S., A Problem We Can't Ignore. Please note that we are accompanied here tonight by now cast, San Antonio, and that this presentation will be available on the Internet following this presentation here today. Please join me now in welcoming Dr. Elizabeth Rosenthal. Well, thank you everyone for coming. Thank you for having me to give the Brian Lecture this year, and I'm really happy to see this issue is being considered an issue of medical ethics as well as economics and healthcare. I think too often medicine is divided, siloed into too many different areas. I had a wonderful talk with medical students at lunch, and I hope to broaden the discussion here and look forward to your questions. Anyway, as you heard, my name's Elizabeth Rosenthal. I've spent the last year writing this series, Pain Till It Hurts, which will keep going. People say how long, and I always say, till this problem is solved. I don't know if my editors will have that patience, but I'm hoping at least we'll have a start. So anyway, it's a pleasure to be here to talk to you all. And I should say, I want to start off this talk by saying in terms of relevant financial interests, I have some, we all have some, because my healthcare premiums have gone from nothing to about $700 a month that I pay for my family. My out-of-pocket costs are going up. My co-pays, when I get a medicine, are going up. My country has this huge deficit, which is essentially a healthcare deficit. I mean, one of the most amazing statistics I've heard this year is if the United States spent as much money as the second largest spender on healthcare, which is Switzerland, we would now have an excess, not a deficit. So I think solving this problem is about individual pocketbooks, but also about our national future and how we want to allocate our resources. So in a country with 40 million uninsured, we've talked a lot about the Affordable Care Act the last couple of years. And I think it's the right first step to get as many people as we can insured. I say that's, you know, hooray to that. But it's really a crucial second step now to figure out our cost and pricing problem. Because if we get everyone in this country insured and continue to finance healthcare and pay for healthcare and price healthcare the way we're doing, we're going to be even more broke. And it's not going to be affordable. The Affordable and Affordable Care Act will be a myth. I mean, already, you know, the one example that I came across in doing this series is the issue of hip replacement. You know, the need for joint replacement over the next 20 years is projected to increase by 300%. I'm a runner, so I will probably be in that, you know, in the hospital waiting for mine. But if we're all paying $50,000 for a hip replacement, we're in trouble. Likewise, you know, we really need to think about what's happening to individuals. I'm sure, as I mentioned, I'm facing higher deductibles. Everyone is facing higher deductibles. The Affordable Care Act policies, many of them, have $6,300 deductibles for their policies. That's not going to feel so affordable to some people when they're suddenly hit with that bill. So, you know, and many of our policies now, I don't know about the ones you're seeing here in San Antonio, but certainly the, I like this part because I'm still on a union contract. The New York Times executive insurance policies now require a 15% out-of-pocket co-pay, not a set co-pay. If you're paying 15% co-pay on a $50,000 hip replacement, you're going to think about it one way. If you're paying 15% out-of-pocket on a $10,000 procedure, it's going to feel really different. Many countries, not countries with socialized medicine, with fee-for-service medicine, have percentage co-pays, but that's manageable because the total pricing is much less. So, you know, we started off the series, and I'll tell you a little more about the gestation of the series with this chart. You can see pricing in the U.S. compared to pricing in other countries. And, you know, what you see is everywhere you look, everything you can possibly look at in our system, we pay far more for. And I know some people will say, well, yes, it's just the bills. These are not bills. These are all paid charges. Everything I show you is going to be paid charges, unless I tell you otherwise. And in fact, this chart, we were kind of new to this world of health care pricing when we were making this up. A few things, the colonoscopy charges are, for the U.S., are underestimates because they don't include, for example, the anesthesiologist fee. So, these are not, in other countries, these are bundled charges. I don't know about the $35 in Canada, but these are mostly bundled charges. Here, charges are mostly very unbundled. So, these are not complete charges. You know, certainly the angiogram, that's the physician fee, not the hospital fee. You'd be really lucky in the U.S. if you could get an angiogram for $914. So anyway, this series started because I'll tell you a little bit about my history with it. As you heard, I'm trained as a physician. My father was a physician. He was a pediatric oncologist at Mount Sinai Hospital in New York. And so I come from a medical family. I became a doctor because that's what people do in my family. And I loved it while I was practicing medicine. But I left medicine, never thinking I would leave for good. I'd always been a writer on the side, and I left medicine during the effort, the President Clinton's effort at health reform to cover health policy and health payment at the New York Times. And kind of never went back after that failed because there were other assignments, and two kids intervened, and I always thought I'd go back, but didn't. And I guess what happened to me while I was overseas, because we took some overseas assignments first in China and then in Italy and then in France, was that I saw how other countries did medicine, and that left an impression on me. Not so much while I was overseas, but when I got back to New York in 2006, I think it was, I was 52, and hey, I needed my first colonoscopy. So how many lectures start off with people talking about their colonoscopies, but here I am. So I went to my internist who I adore and said, he said, you need a colonoscopy. And I said, okay, where should I go? He said, well, you could go to my colleague down the hall, but you're going to face a pretty big out-of-pocket expense because your insurance probably won't cover the anesthesia, and he does it at the hospital, so you'll be facing copayments for hospital fees. And he said, but you know, it's a pretty standard screening procedure. So why don't you call your employer and see who's in network? Find a way to do it in network. So I was fine. I called New York Times, say, how do I do this in network? And remember, I'm kind of new to this new world of American medicine, and I'm old enough that I'm running into things that I actually need from the healthcare system. And they say, oh, well, all the hospitals are in New York or in network. So just call a hospital and you can have it done through their colonoscopy screening service. You know, I'm kind of trying to be a good consumer. I think cancer screening, memorial Sloan Kettering, I'll sign up there. So I call Sloan Kettering. I say, do you do screening colonoscopies? And they're like, sure. So fine. I schedule it, you know, go through the whole very unpleasant prep. And, you know, walk into Sloan Kettering, which is part of the New York hospital system where I trained. So I knew the system. I knew the hospital. I knew some of the doctors there, including, weirdly, it turned out, the guy who was doing my colonoscopy. But, you know, I was a little surprised because when I walked in, I seemed to be going to the ambulatory surgery center. And I was getting a wristband and I was getting what seemed to be kind of a pre-admitting physical. And I, you know, I didn't think too much of that. I thought, all right, you know, it seems a little overboard for this, but that's fine. And then, you know, I get into my gown, have my cap on and get wheeled into an operating room, you know, with nurses all around and anesthesia equipment. And I'm thinking, again, it seems a little overboard, but fine. I have my colonoscopy. It's fine. I'm thinking, you know, I don't pay a penny. And I'm thinking, as too many Americans do, oh, great. It was free, right? Free. That's the problem. And it seemed really free to me until two months later when I got my explanation of benefits, which, because I'm kind of a healthcare wonk, I open. And I see that my insurance company has been charged over $13,000 for this really unremarkable procedure. I think, somewhat naively, this must be a mistake. So I call my insurance and they say, oh, no, you know, look, it's really good. We know that $13,000, $14,000, that's a lot. Don't worry, we bargained it down. You can see, we only paid $8,900. And I think, that's still crazy. So I say, look, there was an hour of recovery room. I'm like, yeah, but I didn't need a recovery room. You know, well, you know, there was actually some blood work drawn. I didn't need blood work, you know. So anyway, after wasting a lot of my time on the phone, you know, life goes on and I'm not paying. And I think, okay, you know, not my problem. And leave it at that. But it still kind of haunts me. So part of what I wanted to do with this series is to start this discussion about costs. Because I didn't feel like I could talk about this. You know, and this, I don't know how many of you saw this. It was a recent article in the New England Journal, which I am thrilled to see because I think this is bubbling now in the medical community of cost as a side effect. You know, we talk about a lot of side effects from different things we do, but we don't talk about cost. Now, I had good insurance that would get me a colonoscopy. From that first story, well, and I'll tell you, I'm getting one step ahead of myself, but a lot of people don't. And I'm hearing from a lot of people who, before the Affordable Care Act said colonoscopies had to be free to patients, which they are, were not getting colonoscopies because they were really expensive. And I've also heard, as I'm sure you've heard from a lot of patients who checked to see that their doctor was a network. And so they thought that part would be paid for, but then suddenly are getting bills from facilities and anesthesiologists that they didn't consent to, that they didn't know were going to exist and are really struggling with those. So more about this idea later, but that was the start of the series. So I want to talk later about, you know, solutions that we'll talk about that at the end. But first of all, I wanted to talk about what, what, how the beginning of the series. It had a very humble beginning, which is I knew this, I wanted to do a series on health care costs. My editor said to me, we want you to, why don't you write about the Affordable Care Act? And I said, no, I think it's a great first step, but I want to write, do a series about costs. And they thankfully gave me a green light and said, tell us, tell us how you want to do it. So this was kind of a little open, open for business post. This was from our well blog. I did a little post, and I don't know how many medical students are in the room or college students. It was about a study that was done by a medical student during her summer job and in a lab. And basically what she did was she called 200 hospitals across the United States as part of her project and said, I have a 62-year-old grandmother who needs a hip replacement. She's not Medicare age. She doesn't have insurance, but she's, she's, she's well to do so she can afford to pay for it herself. How much will it cost? Does anyone have any ideas of how, how many hospitals could tell her that? You know, even after, she was persistent, you know, she called back many, many times and really wasn't able to get an answer. About 20% could give her a ballpark after repeated calls, repeated calls, maybe 40% could give her a ballpark. But as you'll see from our next little video, ballparks can be pretty broad. And we're telling everyone, oh, be a good consumer of healthcare. And the question I like to ask people, because I think we should all be better consumers of healthcare, is how you can do that in a world where nobody can give you a price. And how you can do that in a world where not even for the most part physicians can get a price of the things that they order. You know, when I, if I'm an internist and I refer to my, a patient for a bone scan, do I know what that's going to cost? How can I know what it's going to cost? And I know everyone will say, well, in our, in our complicated system, you know, insurers pay different things. So it's impossible to say, and yes, that's true. But I think we need to get some costs out there. And I think merely publishing costs, posting costs, I believe, you know, I trained at Sloan Kettering. I think it's a great place. But I believe no hospital would put up a cost of $13,000 for a colonoscopy. They just wouldn't. So I think there needs to be some rationalization. You know, most hotels have rack rates, very few people actually pay them, but that's not an excuse to never have the rack rate. So anyway, it will be a good exercise to get people talking about this. So now I'm going to have to do a little bit of, sorry, this is, I'm doing videos as well as, so here we go. So I want everyone, I want to show you this video of one of the patients who participated in the series. And, okay, before I do that, I want to say that first little post that I did about, are we okay? Okay, okay. The first little post that I did about that issue of trying to find out the price for a hip replacement, we just put a little comments tag on it because I wanted to find out is there enough interest for the series. That little post was up for about two hours. And we put a little query saying, have any of you experienced issues of medical costs recently with hip replacements or other procedures? In those two hours, we got 512 comments, not just on hip replacement, even though that was what the original query was about, but on people who were having, what, sorry. It's on extended desktop. Do you want, do you want, can this play? You can, I have the PowerPoint so we can take it over. Oh, so what do I do? You can go back to your PowerPoint and it's about it. This video won't show, it's on extended desktop. Oh really, I showed this before though. I showed this today. It'll play only on the main side. Excuse me, well I really want you to see this video if I can. Do you want me to do something? I think it just needs to be on extended desktop. Well I'll tell you a little, do you want to play with this for a second while I keep talking? I'll tell you a little, I mean because this has really been the really fascinating thing about this series for me, is those first 512 comments produced the next two stories, produced the patients who volunteered their time to be the topic of a New York Times article. These are not people who are exhibitionists. I mean they're not people who want their medical issues splayed across the front page of the New York Times. But they really felt like it was an issue that was important and they gave, she's one of them, this woman who I'm trying to, the video I'm trying to show. Is it because I, do you want me to reload it? I can do it straight off the website if you want me to do that. Okay, sorry about this everyone. That's still not going, huh? It's on the PowerPoint still. Back to the PowerPoint. Sorry about this everyone. You want me to unplug the PowerPoint for me? I mean it's just going to bring it back up. Let me see if it comes back up. It's just coming up. This is taking priority. What happens if, because there are several videos that some of them I have to show. The minute we plug this up it's going to do this. Sorry. Get that down, minimize that, tabs up there. So you can't see anything up there that's on the desktop? Because it's on the, this is on the, on the, it's on the wrong side of the desktop. If I could track this whole thing. Oh, great. All right. Phew. We got pregnant and it was sort of after we stopped trying but you know we were so elated and we called the hospital and I said, well can you give me ballpark? I think the range was from 4,000 to 45,000. I don't know what to expect in any way but I also don't want to make choices based economically instead of what's best for me and my baby. And so that's really scary. Even yesterday I was just talking to my mother because we started childbirth classes and they're saying oh you can use the bathtub or you could use the ball and my mother says totally innocently well how much does the bathtub cost? If you get an epidural how much is that going to cost? And I don't want to think about that in my childbirth. I want to do what's best for the baby. The hospital they're really trying to help us and the doctors are really wonderful. It's just we're trying to make it work in a system that doesn't work. So that is, now how do I get? That is Renee Martin who was one of the people who commented in response to that first post. She was five months pregnant when she answered that post and I followed her through her pregnancy. And I want to tell you all my kids are now 19 and 21. If my kids turn out like her and her husband I will be ecstatic. My kids are two. They're both 32. They've always worked. They've always made sure they had health insurance. Renee is now in a master's program in medical ethics at Vanderbilt and applying to medical school. Her mom is a doctor and his dad is a doctor. So that these people couldn't make the system work for them to me is, you know, it shows how problematic it is. I'll show you now what her charges ended up being. You know, good news. She had a healthy baby in June. These were their charges. I understand these are charges at the hospital where her father-in-law is on staff as a pediatrician. Well, you can look. And the thing I notice about this is look where the money is. The obstetrician's charges, the obstetrician who followed her from the first prenatal visit to postnatal care is not particularly, is not the big number. You know, all of those were negotiated down somewhat. The hospital had a, quote, unquote, charity care program. So they paid about 60% of those charges. They are not poor enough to qualify for Medicare because they're both employed. She, ironically, her husband's insurance did cover pregnancy, but she couldn't get on her husband's insurance policy because she had had an abnormal pap smear three years prior, which was considered a preexisting condition. So they wouldn't insure her, okay? So this is a system in trouble that is not working well for almost anyone. These are the charges they did pay or had paid already by the time their child was born. So again, you know, they may, you know, the problem is partly that if you look at them through the experience of American medicine, that looks okay. You know, ultrasound 1191, maybe that's reasonable. One of the people who answered happened to be, have a German wife who does billing and coding in the German system. The charge for ultrasounds there is about $200. Okay, so, you know, again, we're talking big differences. Okay, so we started, it may be partly because of my own experience, but we started our series with colonoscopies. Partly because the goal of this series, often when the New York Times and other publications cover healthcare, they talk about healthcare pricing. They tend to focus on the, you know, half million dollar cancer drug or the hospitalization that costs $200 million, I mean, $2 million. And my thing was to kind of get more people engaged on this. I wanted to focus on medical encounters that everyone could relate to, that no one was going to say, wow, that's shocking, but I hope I never get that, I need that drug. So, you know, we started off on the things that we thought that everyone needs. So we started off with colonoscopy, the most expensive screening procedure recommended for every American. And, you know, what I found is, you know, let's just look, the first five entries are relating to the woman who was the subject of that story, a woman who, you know, amazingly agreed to have her colonoscopy dissected for our readers. And hers was not remarkable, particularly remarkable, and that's the thing too about this series. I didn't pick, I could have picked much more expensive ones. I picked ones that seemed to reveal what most of the people, most of our readers were experiencing. So, Deirdre Yappolatter was her name, she's 64. She went to, you know, the facility fee, she had an outpatient, she had her colonoscopy an outpatient surgery center. Facility fee, 2910 anesthesia, 2400, gastroenterologists, again, you know, less than the anesthesiologists. Total 6,400 paid about 4,000. She didn't pay a penny. She was happy at first, until she started looking at her bills. Now, the two numbers below I think are instructive because they're another patient's bills, a woman named Maggie McKen who's in her, who's in around 50, who for different reasons needed a colonoscopy, two colonoscopies, it was about, they were about three months apart. And actually the more complicated one was the cheaper one. The in-office one, I mean was, the more complicated one was the one in office. The first one was the screening colonoscopy at the hospital, 914284. There was a lesion that was found there that they biopsied but decided they should take off. So the gastroenterologist said, come back, I want to take it off. And they scheduled the second one in the office, not because anyone was, you know, it was like so many of the decisions we make in American medicine. It was related to, oh, it was good for her to do a Thursday. And on Thursdays, the doctor was in the office rather than at the hospital. And there you go, look at the big difference in the pricing. And that's part of the message too and why I'm going around wanting to talk to medical students and physicians and patients. Because a lot of the decisions we as patients and doctors say, yeah, why don't we just do this? We have to start understanding there's a cost to, why don't we just do this? That there is farm done. So that was, now why did it cost so much? And I think this is, I'm just, you know, for consumers in the audience, for doctors who may not have thought about this particular specialty. The reason it cost so much and the reason the gastroenterologist's fee was less is because in this case the gastroenterologist also owned the facility in which this was done. So basically this was a gastroenterologist in the suburbs of New York, gastroenterology group. You know, no one says they're bad doctors, everyone had a good experience there, their patients like them. But a few years ago, they decided 10 years ago it was good for them to open an ambulatory surgical center. Now literally if you get off the elevators on the fourth floor of this office building, to the right is the doctor's offices, to the left is the ambulatory surgical center. They used to do the colonoscopies to the right where you couldn't collect a facility fee. Now they do them to the left where you can and that has increased the price of their colonoscopies dramatically. So why not open a center? Why do we think it's not a good idea for doctors to own facilities to which they refer? Here's an example. And Medicare and insurers to fight back against this part of the problem and part of the suffering for doctors is they say, look we know you guys are all doing this so what are we going to do? We're going to reduce your fee. We're not going to give you that much because we're assuming that all of you guys are making money on facility fees as well. But if you're the doctor who is still doing these colonoscopies in your office in a cost-effective way, you're going to be in trouble because your fee is going to be cut by a lot. So that was one thing. The anesthesia, you know, $2,400 for an hour of anesthesia for, and we're not talking, you know, intubation and major, we're talking propofol. In a lot of the world, propofol is given by the doctor who's doing the colonoscopy. Now you may argue, and I think it's a discussion that needs to be had, how much safety, if any, does it add to have an anesthesiologist standing there? You may add a friend of mine who's an economist at Yale, who saw this article and said he doesn't like a lot of, he's a, you know, type A person. He didn't want to lose time to propofol. He said, I want to see what this is like to have it done without anesthesia, as is often done. He said it was great. He said he's going to wreck, I don't know that I would go that route. I want propofol for mine. But you know, I think the problem is that, and if you do it, if you have a colonoscopy at the VA, the VA will not pay for anesthesia like this, and they won't pay for, you know, they will do it in the most cost-effective way. I think the problem is the financial incentives lead us to do it in the least cost-effective way, the most costly way possible. So no one is saying that this is a bad test. We want everyone to get colonoscopy screening. I don't know if we need them as much. I mean, I have seen really amusing letters that patients sent me as I was working on this where people would have a colonoscopy and, you know, a year later, as if this was like a six-month teeth cleaning, you know, we want to remind you that it's time to schedule your next colonoscopy. And people are, you know, they want to do the right thing, and they try to do the right thing. Another thing I was mentioning, you know, on colonoscopies, the number of colonoscopies that are done, there's a geriatrician in the UT system who does a lot of studies on the overuse of colonoscopies in the frail elderly. To say this is a preventive procedure that's always a good idea, you know, for a frail elderly person to do a clean-out, to detect a possible early colon cancer, let's think about whether that makes sense and why we're doing that. So anyway, moving on from colonoscopies, because each of these examples shows a different issue in our healthcare system. There's Renee Martin again. Her issue was childbirth. I frankly didn't even realize that childbirth was an issue. I had my babies, you know, 20 years ago when I remember the issue was do you pay for a TV in the room or not. You know, what I learned is that the cost of childbirth in the U.S. has tripled since 1995, tripled. My last kid was born in 94. And people say to me, and you know, maternity care used to be a money-loser for hospitals. Now we're in a world of, you know, fancy birthing-in suites. Oh, here's your free champagne, all private rooms. It is, again, very test-intensive, very technology-intensive. Not that that's a bad thing. There are two high-risk pregnancies, but it's used kind of rote. And the rate, as a result, the C-section rate in this country is much higher than it is elsewhere, as is the rate of preterm induction. So, again, we have to think about why are we doing these things. You know, people like to say, again, oh, those bills don't reflect anything real. That's just, you know, the insurers never pay that much. These are paid amounts on average for childbirth in the U.S. versus other countries. And again, they don't include private doctor's fees. So these are hospital fees in the U.S. in other countries, they're bundled payments. So we're paying a lot more. And the question is, are we getting a lot more? You know, the problem is that all the studies have shown that even though we pay more and we get more stuff done to us, we don't have better results on average. So we have to think about that. Next, I wanted to mention one more thing because it's a nice anecdote on the pregnancy care. One of the, I've had some of my most interesting responses from physicians who are upset about this. And one of the people in the pregnancy story was a doctor named Marguerite Dwayne, who's a family practitioner in Washington, D.C. She was upset, she's at Georgetown. And she was upset about the cost that her first two pregnancies had generated, the bills. She has good insurance, so it wasn't really about the out-of-pocket expense. So for her third child who was born last year, she decided she would like do it, you know, basically bring everything with her. So she turned up at the hospital two hours before delivery. She brought her motrin, she brought her heating pad, she brought the donut that you're given to sit on. She brought diapers. She had her baby stay with her in the room, thinking, okay, those nursery charges are really offensive to me. And when she got her bill, you know, it helped a bit. She got her bill. It was $8,000. And she discovered that it actually costs more to have the baby with her in the room than it costs to have the baby in the nursery. So, again, let's think about what we're paying for. This is Mike Schopen. Now I'm going to want to play another video. But like, sorry, I'll give you some advanced warning. Do you want to set that up? We'll just do that real quick. Okay. Michael Schopen, just to give you some background, he, there, you have to reduce this. You have to minimize that. And this is, this one, it's that one. So Michael Schopen, he's now 67. And he, he had a bad arthritis of his right hip after a sailing accident when he was younger. He's an architectural photographer, has always been insured. But when he needed a hip replacement at the age of 62, because he really couldn't work anymore, he did not, his, his hip was considered. I needed a hip replacement. And I started looking into it. So I'm going to load it again. I can have to close it and open it again. Just get it back on. No, it's, it's over there now. Yeah. Yeah. But anyway, you know, in terms of talking about medical consumers, Mr. Schopen was the best medical consumer I've ever encountered. When he realized he needed a hip replacement, he, and I don't want to play it. You don't want to play it? Well, yeah, I do, but not. I want to wait one second. You want to play around with that while I talk? I'll charge you. Okay. So he, he is, he was a great medical consumer. He called, he was living in Seattle. He called Swedish hospital, said, what's the hospital charge going to be? They, and he pushed, he, they gave him a range. They said it's probably going to be about $100,000. He found an orthopedist who he liked. He got a charge from the orthopedist. As you may or may not know, generally hospital charges exclude the artificial joint that's often paid separately. So he did a lot of research, figured out what kind of joint he wanted, and found a friend who worked at Striker and arranged to buy his joint for a wholesale price of $13,000. You know, that's, that's a good, for those of you who don't follow artificial joint pricing, that's a good price for an artificial joint. But when he added those all up, you know, he, he's a photographer. He didn't have, he had savings, but he was nearing retirement, and he decided he would look overseas. Let me see if I can do this. I'm sorry, I'm really sorry. But can you get it? Can we start it now? Even if we can, even if we have the junk around, it would be good to... Oh, anyway, I'll keep talking in the hopes we can get this going, because it's really quite... I needed a hip replacement. Thank you. And I started looking into what it cost to have it done. It came to $112,000. $112,317. She's in San Francisco for the hospital. You know, I'd heard about having surgery overseas. Basically, the price was $13,660 for everything. The surgery, the rehab, the flight over and back, two people, crutches, medication to take home with me, everything. This is not the prosthetic. This is not the anesthesiologist. This is not, you know, anybody who actually did anything. This is just the hospital bill. Total cost of hip surgery in Belgium, including everything, cost just about $600 to $700 more than the wholesale cost of just the prosthetic device in the United States. The good thing about my knee surgery was getting my mobility back and getting my life back. And it enabled me to start horseback riding at $68,66, which most people don't start horseback riding at $66. And I couldn't be doing that without the joint. I bought a new board, new snowboard, new boots, all this stuff because I'd given it up years before because I couldn't. And started riding again. I was pretty cautious for the first year just because I was scared of falling. But this past year, I taught 26 days on the mountain. I mean, I'm stronger than I've been in a decade. So, you know, the good thing, of course, is that, you know, the good thing, of course, and you'll note with both patients, they're really happy with the outcome. The joint replacements changed people's lives. But why did they cost so much? That's what was the cost difference. Why did those joints cost so much more in the U.S. than in Europe? And, you know, again, there are five companies that basically make most of the joints in the world. I discovered in doing my research that three of them are in a little town in northern Indiana called Warsaw, Indiana. You know, if you were an economist, I think you might say, well, this is a kind of monopoly situation. The joint makers, they don't really have to fix prices because everyone in that town, you know, it makes marriages when one person works for Striker and the other works for DuPuis. So, you know, it's in everyone's interest to keep them high. And they can do that in this country because we have no, the medical profession, hospitals have no collective bargaining power. Why are those joints cheaper in Belgium? Why does it cost $4,000? This is the exact same joint. It's definitely a joint made by a U.S. company. Some of them may be manufactured overseas, both there and here. It's because the Belgian government says, what's a joint? How much should we pay for a joint? What do we think it's worth? And they set prices. They say, this is what our system will pay for this artificial joint. And guess what? You know, the companies say, okay, fine. Well, you know, we'll take that. This is what you're offering. But we don't have anything like that. So instead, every hospital, every group of orthopedists is left to their own devices to do this kind of negotiation. And individually, they don't have that much negotiating power against just a few companies. Complicating that even more. I mean, the more I looked into this, the more you realize how business decisions really guide this. The joint makers make a big effort to, they want to be in teaching hospitals because I'm sure there are some, I hope there are some orthopedists in the audience. You know, orthopedists tend to learn on a particular device. They get comfortable with that system. A striker device uses different tools to get put in than a device from another company. So the device makers want to be in the hospital. They want the residents to get used to their system because when those residents go out into the world to other hospitals, they're going to say, this is the joint system I want to use. And the hospital directors, by and large, are going to have to say, yes, because once you've trained, it's like, you know, me with my Mac and somebody else with the PC. I know how to do things on this. So you're not going to tell me when somebody's life is on the line while they're on the operating table, switch to this other system which you're not as familiar with. So, you know, there's this whole world of trying to create and maintain brand loyalty, which is very effective. So most hospitals have to stock every brand. Now, the good thing is that a few orthopedic groups and a few hospitals are saying no to this and trying to work around it to say, we're not going to stock every brand. We're going to pick two brands and everyone's going to have to learn to use them. Now, there may be a little learning period in there. So that's important to know. They're also saying, which I think is a really interesting tactic, even if your joint is not on this bill, we're going to break that as in our bundled hospital bill. We're going to break it out. We're going to let you know how much we had to pay to get that joint, because if they were paying 20,000 bucks for that joint, they want the patients to know that because they don't want the patients blaming the hospital. Now, a lot of their contracts with joint makers say that they're not supposed to reveal prices. That's been a big thing in medicine. Prices are secret. They're trade secrets. But I think more transparency at every level would help, because now what happens is another part of why these devices get so expensive. One business person from the industry told me between the manufacturer of the device and going into a patient, there are 14 steps, 14 transactions that take place. There's the salesman for the company. There are device brokers in between. There are warehouses that store devices. Every hospital or many hospitals has someone who negotiates joint prices. When you get to the operating room, there's often someone from the company in the operating room assisting. And every person takes a cut. And so by the time we end up, we end up with much higher prices than everywhere else. Okay, so that's the joint replacement story. Again, this one we wanted to do on... I wanted to do a segment on prescription drug pricing. Huge problem in the U.S. for across many illnesses. I had wanted to focus mostly on... Originally, I thought I would focus, and this is going to sound really weird in retrospect, on this little tube of antibiotic ointment called BactraBan. Many of you know it. It came into use when I was a resident. It was a great thing then. It's very effective. But I was really surprised that 30 years later, this stuff was A, not over-the-counter, like Neosporin and B, was being charged at $60, $70, $80 for this little tube. So fortunately, I went to our programmers and said, well, what kind of medicines are our readers complaining about? Because at this point, we had 20,000 comments, which is really phenomenal. I like to say it's more than Nate Silver got during the last election. So this is a really important issue to our readers. And we had a lot of complaints about inhalers. I don't know how many of you use inhalers or our physicians who prescribe them. But again, I was shocked. This was something I had had at Mild Asthma earlier in life. I'd used a Ventolin inhaler. I remembered it being $10 if that. And now, suddenly, something that looked very much like a Ventolin inhaler, which now had a little dial on the back. That was the innovation. Or some of the combo inhalers were retailing for $150, $200, $300, $350. So even if you have pretty good insurance, those copays are really going to add up. So the next piece was specifically on asthma inhalers, and now I'm going to need my next, the best graphic in the history of New York Times. We'll see next. So I'm going to keep talking while I have to download the... It's this one. No? No, no, no, it's this last one. Is it anyone? Yeah, sorry. Yeah, now it's gone. Can we get down a little bit on that? That's it. It's a graphic. I need to click on it. Where can I click them? Click there. Okay. So, okay. This is what we decided to look at what we pay for medicines versus what other countries pay for them. And again, I want to emphasize these are manufacturers suggested wholesale prices. So this is the exact same medicine. This is not what's being billed. This is what the manufacturer is suggesting. It would be sold to pharmacies for it in different countries. So that's the... Cubar, that's a steroid inhaler. And Advair, do you know about that? This is one of the most expensive, the most widely used combination inhaler for asthma. A great drug. Many people told me that their asthma was terrible before they were on Advair. And I first heard about this from a person who commented on the first story who said this is like one of those first world problems. He goes to France each summer to buy his Advair because that's how he finances his vacation. That's how much money he saves. So here you go, Advair. Again, now people in France don't actually pay this because their pharmacy is covered. But this is what the manufacturer is suggesting or is selling to pharmacies for. Rhinocort, how many of you are on Rhinocort or use it, it's a common nasal spray, great for allergies, very commonly used, sold over the counter for... Oh, sorry, for five or six dollars in much of Europe. You know, I see occasionally... I live up near Columbia. I see occasionally people going into the pharmacy looking for Rhinocort and wondering why they can't find it on shelves and being shocked when they learn how it's sold in the U.S. Augmentin. Again, I was a little obsessed with this because Augmentin came into being while I was in medical school. It was an incredible innovation when it was first present because it made amoxicillin useful again. And it was what was considered expensive in those times, maybe 30 bucks for a 10-day prescription. Now, Augmentin, here you go, okay? One of the things I learned is that there is generic Augmentin, but generic Augmentin is not cheap. It's just 10% cheaper than brand Augmentin. You would think that generics would drastically reduce price and they do in some markets with some drugs when there's enough competition, but often generics just result in a slight reduction of price. Colchris, anyone? Colchicin, one of the oldest drugs known to medicine. Let's look at this one. This one's really impressive. So what happened with Colchicin? Why did this...? I mean, and those of you who practice medicine will know that Colchicin, until a few years ago, was incredibly cheap. It was pennies. But really what happens in the U.S. is drug pricing is determined largely by patents and the U.S. Patent Office and the FDA. And they each do their job fairly narrowly defined. They do what they're supposed to do according to their mandate, which is not to think about prices. So the U.S. Patent Office merely has to say, is it new to extend a patent? So what works for drug manufacturers is... sometimes there are wonderful new medications, but sometimes there's just minor tweaking of an old medication that allows for extended repatting. So when those... my little Ventolin inhaler got a new dial on the back saying how many meters, how many sprays were left in the canister. Again, it's useful, but it led to a new patent. So it meant that that inhaler could be sold for $150 instead of $5. With Colchicin or Colchicin, what happened is... And again, you know, it's the result of good intentions. The FDA said, look, there are some of these really old medicines that we don't have good safety studies on. We don't have the official drug trials we would want. So they said, you know, good idea. Okay, if there's a drug manufacturer out there that's willing to undertake the safety studies we have for more modern drugs for Colchicin, and this is a drug that's been used for centuries. So it's not like anyone thought there was some, you know, major skeleton in the closet. They could get a new patent on the drug. So some enterprising entrepreneurs said, sure, I'll do those trials, has a patent on Colchicin that I believe lasts for 10 years, and that company can charge what it wants now in the United States. So again, you know, the Patent Office determines if something's new. The FDA determines if something is safe and effective, but no one, as in many other countries, is thinking, is it worth it? Is it better? Is it really better than what we have already? The example I like to point out, which is to me most telling, because I heard about this from a lot of my gynecologist friends this summer, is there was a very popular birth control pill called Lowestrin24, I believe, that was about to go off patent this summer, or it goes off patent in 2014. So last summer, the drugmaker that makes Lowestrin pulled it from the market and reintroduced it in a chewable form. Chewable birth control pills? Sorry, but most people who are of that age know how to swallow pills. It created havoc because the old pill was no longer available. The new pill was much more expensive and the young women who were taking it weren't sure, they didn't particularly want to chew their oral contraceptives and didn't know if it would work if they just swallowed it. So anyway, this is the kind of stuff that goes on and I'm going to try and speed up because I know we're running late. The next one I wanted to talk about was hospital costs and I really didn't want to go into inpatient costs because every inpatient stay is so different. They're complicated. I didn't think I could bear dissecting a hospital bill. So we decided to just look at something simple like stitches and an ER. And this was one of the kids whose mom came forward and said, oh, my kid had stitches last week and I was really upset by the bill. He's in East Lansing, Michigan. His stitches cost over $3,000. I got a very amusing note from the hospital saying, that's impossible, but I had every patient. Before I used someone in the story, I insist on seeing the bills. We had the bills. And it's a combination of things. So the little girl who got glue, it was $2,100. And I've since gotten letters saying, wow, that was a good deal because my stitches were $15,000. So it's all over the map. And of course, in fairness to hospitals, they're not paid for a lot of things they do. There's tremendous cost-shifting, but it's often very irrational cost-shifting. So the girl who got the glue, this two-year-old, she was treated in California. And because California is unique in the United States in that it requires hospitals to file their charge masters and make them publicly available, I went to California Pacific Medical Center to look at how hospitals determine prices. And I want to point out that California Pacific Medical Center, you know, again, I didn't pick a hospital that I think is doing something illegal or widely off the mark. I think they're just really good at doing this. They're really good at the business of medicine. And so this is part of their charge master. I think it's really interesting for doctors and patients if they can get their hands on one to look at it because you see how these bills add up. You can see how a bill for a few stitches ends up being $3,500 because every component of it is charged separately. You can see the gauze. You can see the suture material. You can see the lidocaine. You can see the glue, you know, what it's charged. And the charges are often, you know, as we see when we hear about the, you know, $35 Tylenols. Pretty surprising. You look here. Radiology services, just look at a few. A CT without contrast, $3,000. That's a lot for a CT. And EKG, $300. You know, I guess when I'm speaking to doctors, I always encourage them to look, to ask wherever they practice to see the charge master, to see what's being billed on their behalf and to see what things are going to cost. You look at lab tests on charge masters. They're high, you know, for a lot of hospitals, and I guess a lot of you know this, labs are like the kind of drinks at a restaurant. They're the profit centers. So, you know, I always remember now somewhat with some horror when I was a resident and everyone who was in the hospital, we would order a CBC with DIFF every day and electrolyte panel, you know, two standard blood tests for hospitalized patients. You add those together at CPMC and you end up with over $500 a day in lab tests that probably no one is looking at. So, you know, again, it's the why not and reflexive stuff that we do that I think we have to start thinking a little more about. Again, you go to the cost of a hospital day in the U.S. versus other countries. You know, we're way out there. Not all of our hospitals, there's a wide range. You know, the academic medical centers tend not to be the ones at the top of this chart. They're somewhere in the middle. But we're paying a lot more and these, again, are costs, not prices. I want to show you a picture first and then I'm going to have my last multimedia thing. The hospital in Belgium where Mr. Schopen had his surgery done. Very highly ranked hospital, but it doesn't look like any hospital you would see in the U.S. And he, in fact, said to me, he'd arranged this surgery. He flew over there with his partner and he said they pulled up in front of the hospital and his first reaction was, oh, my, I made a big mistake. I better run away. His father had just died at New York hospital where I trained. So he had been used to that being his model of a hospital and he went in here and he was like, where's the Starbucks? Where's the coffee in the lobby? Where's the private room? There's none of that. And so I think part of it, part of the change is not just for hospitals and doctors. It's we as American patients have to kind of refocus what we care about in healthcare if we want to get our money's worth. You know, I have so many friends who go into hospitals and go, oh, it was such a great place. There was free coffee in the lobby, you know, because that's what consumers respond to. No, it's this one. So again, you know, when people say, why are the prices so high? It's all of us. It's the consumers, too, who expect things that maybe aren't really essential to healthcare if we want healthcare for everybody. Now I've got to scroll down on this. Yeah, it's great if you can. Oh, no, wait, I have to clear this if you're doing it this way. So to think about this a little more, you know, I always try and get people with my writing to think about their assumptions and their values and what they're paying for. We designed an online quiz called Is This a Hospital or a Hotel? So we invited our readers to choose. We don't have to go through the whole thing. You can look at it online if you want. What do you think, hospital or hotel? Yeah, you're correct. This one, that's a hotel. Here we go, hospital. That's Baylor. So let's see, this I hope is a hotel, but yeah, that's a hotel. And I want to point out these are not, you know, these are five-star hotels. This, I'd say that's a hotel. Yeah. This, I know, it is Mount Sinai Medical Center in New York. So high-thread count sheets. But anyway, you get the point. You know, this could go on and on. But I think, you know, are we paying for the things that really yield good care and how can we communicate that to consumers? Yeah, I just want to go back to the PowerPoint. Yeah, it's done there. So anyway, you know, we could go on and find different examples of this. The last story which I know raised a lot of hackles among physicians was about how certain specialties have monetized their treatments over the last two decades. It focused primarily on dermatologists, mostly because their incomes have gone over the past two decades, or 25 years from on-part to primary care doctors to now, to a point where at many hospitals if they're on salary, they are now making more than some of the neurosurgeons. And I always try and point out to my colleagues that, you know, neurosurgeons spend 10 years in training and deal with a lot of middle-of-the-night emergencies. Dermatologists don't. So I understand that certain specialists have a really difficult lifestyle, a really challenging lifestyle, and go through years and years of training and face high malpractice rates. But I also like to point out that the specialty that probably has the worst lifestyle and the highest malpractice rates is OBGYN, and the OBGYNs are not particularly well-paid in many communities compared to some of the... what we called when I was in medical school, lifestyle specialists. I know anesthesiologists are not the same as dermatologists in that sense. They work a lot in the night. But I do want to raise the question of physician income and physician salaries because we're at a point in our healthcare debate where everyone says we need more primary care doctors. We need to reward people for going into primary care, and yet medical students come out of medical school with an average of $156,000 of debt, and they are not going into primary care. So if we believe that, we really need to figure out a way to rearrange our salary scale. In other countries, orthopedists make more than primary care doctors, but not five times more, not three times more. So I think we really have to evaluate how we value different parts of our healthcare system differently. The other thing I want to say to doctors always is when you look at hospital bills, and this has been pointed out to me many times, and this is certainly true, the specialist fee is generally a very small part of that hospital bill. But it doesn't help to just point that out. It helps to... Doctors need to be more proactive, and that's why I say, price as a side effect, cost as a side effect. We need to feel responsible for the pricing and the payments and the cost and the economic pain. We create, even if it isn't directly because of our fee, because we set the cascade in motion. So to kind of say, well, I didn't charge that much for the surgery, it's the artificial joint, which costs $25,000, but what can I do? I feel like it's incumbent upon all the different parts of the medical community, including the doctors, to be part of that debate. Fortunately, and I'm going to... And now I'm seeing much more of that happening. I've been really heartened that the Medical Society of Wisconsin recently took out a full-page ad in a lot of their local media calling for payment reform, now not a single payer, of course, and I don't think that's a solution. There are many solutions to this, but one of them is not keeping on doing what we're doing now, which leads us to bankruptcy individually and as a country. They had a lot of interesting ideas. Require insurers to spend 95% of their revenues rather than the 80% we now do on patient care. Require hospitals to justify their new building board. Do we really need all private rooms in a hospital? Do we really need the new wing? They took issue with medical advertising. When I was training, you couldn't advertise prescription drugs on television. Now you look at the news channels and who are the advertisers? They're hospitals, mostly not the best hospitals. If I was being completely candid about this, and it's things like testosterone gel, not God's work. So I think we need to really rethink how our money is getting spent. Should we be regulating... I mean, we are now not allowed to buy drugs from overseas. Again, technically, that's for our own protection. Recently, the state of Maine said to its employees and its residents, go buy in Canada. It's fine. That immediately will bring down our drug prices. I don't know. I hear over and over again. I've heard from a lot of people in South Texas going to Mexico to buy medications that they couldn't afford in the U.S. I heard from a doctor in Tucson, Auntie Venom. I don't know how much you guys use that here, but I've heard from one patient who had what he called... Maybe this is a Texas thing, a little rattlesnake bite. In New York, there's no such thing as a little rattlesnake bite. He described great treatment he got with Auntie Venom, left the hospital shortly thereafter, and he said... A couple of days later, I realized why everyone was being so nice. I was billed $135,000. Over the border in Mexico, the vial of Auntie Venom is $30 a vial I hear. I think we have to bring drug prices into control. That chart is funny, but it's also a stand. I was pleased to see Maine doing that. I've gotten some really interesting calls, one from a doctor named Abil Manji who is head of the cardiac transplant program at Yale who said they're now trying to actually cost out their procedures. What does it actually cost to do a heart transplant? What does it actually cost to keep someone in cardiac intensive care so that they can justify what they do and see where they could cut down those costs? I think all of these exercises are really interesting and I hope they will move forward and I hope doctors will be central to this process because one thing I feel like I do know is that drug makers and insurers who are where the really high salaries are, there's an article coming about that, by the way, they're not really caring about your patients the way you are. So take the lead. And I'll stop there and we can do questions. Thank you so much Libby for that excellent journalism. We're sorry about our technological glitches here, but it was worth the wait. So at this point I know there are many experienced people in our audience that represent different walks of our medical lives in San Antonio and I'm sure that some of you are working on some questions. You may either head to the microphone that's in the central aisle as I see Jerry Winiker doing now or you may give your question on an index card to Melanie or Stephanie. Alright, Jerry Winiker. Thank you Dr. Rosenthal for your talk tonight and for bringing these costs and price issues front and center to American consumers. I practiced medicine for almost 40 years here in San Antonio, the last 20 as a geriatrician. As a geriatrician taking care of patients 65 and over, I was basically, although I was in private practice, I worked for America's single payer system, which is Medicare. I think any of us that have Medicare or have loved ones on Medicare realizes that that works pretty well as an insurance program. Now there are also issues of cost with Medicare for the long run, but I'd like to point out that in Medicare as a physician, Medicare set my fees every year and for the last 10 years, basically, there really hasn't been an increase in physician fees. And yet, I believe that the program worked well for my patients. It often occurred to me about this great debate we're having about the cost of health care in America as if the federal government in the Medicare program could set my fees as an independently practicing, privately practicing physician my entire career. Why is it so such an anathema to think that they couldn't set other fees, the cost of drugs, the cost of procedures, the cost of hospital stays? I realize politically it's a difficult issue, but let's face it, it's working. The system is working for an awful lot of people, almost 50 million Americans. The system is working. So what is the difference? What is keeping fee setting in other areas of medicine, the way it's done for doctors under Medicare? What is keeping that from being done? Thank you. That's a good question. There are a lot of things that we take for granted, like America wouldn't accept Medicare for all. It wouldn't accept a single payer. You can't regulate. Regulation is a problem. I don't know. What I do know is that America doesn't like the way things are working now, and what I do know is that if you had a choice of Medicare or etna setting your rates, you might choose at least a federal program that was dealing uniformly with everyone rather than deciding, we've got a lot of bargaining power here and not much there. Medicare does set doctor fees. It does set bundled fees for hospital stays, too, but it was taken as a given in our political system that that wouldn't work, although I do point out to people, and I'm not proscriptive in this series. I don't know. I do think there are lots of different kinds of answers, and at the moment we do none of them. I would point out, too, that we regulate a lot of things that are essential in our world. We regulate electricity, you know, rates. That's not set by the free market, and more than that I would point out that there is no real market in healthcare at the moment, so what do we expect to set prices? I mean, we get exactly the prices our system is designed to create, which is whatever the market will tolerate. And I think a lot of... I've heard from a lot of individual providers who are now saying that Medicare is often their best payer because if you're an individual in private practice in New York, you have no bargaining power against the private insurers, and they're getting now $45 an office visit. So, you know, what we're doing is it makes no sense. It doesn't get us the outcomes we want and it's not sustainable, so... That was a very complex question with many complex answers and room for a lot more thought. Let's take one of these questions from the card and then we'll move to Dr. Yusatin. I think this maybe comes from one of our students in the audience. You mentioned there are harm side effects to cost. With regard to training cost-conscious clinicians, how do we help medical students and residents to think and practice cost-effectively when the system itself seems inflexible to cost-conscious efforts? Well, that's a great question. We were talking about this this morning a bit. You know, I think medical students and people in medical training are in a great position to start the cost discussion. I think cost is a side effect to me, that it should be part of every patient visit. And I know both doctors and patients hate that. We want to say, oh, it doesn't matter. We're just going to do the best thing for you. But that's not realistic because the patients are going to get those bills a month later, two months later, and not be able to pay them. So I think we have to talk about it more and talking about it more means preceptors talking to their students. I said to the students this morning, I think medical students, you have a little more time. You should be asking every patient what's your insurance like, trying to get from your doctor, the doctor you're working with, how much is this likely to cost this patient? Can the patient afford it? I think it will raise consciousness for everyone, of course. And I think there should be courses in medical school, which I certainly didn't get, about how much does this... Why do things cost what they do? We take a lot for granted, and if you look at other countries, there's no reason why things have to be done the way we're doing them and we're not doing them. Look how much administration we have in American healthcare. Old studies say 3,000% more. You call the Curry Institute in France, they're not a shabby hospital. They look kind of shabby, but they're not... If I call them and ask a question, I want to know... I want to speak to an administrator. They'll say, we have four. Which one do you want? The head of nursing, the head of... They don't have these layers and layers and layers. If I call a hospital in Germany and say, what's your facility fee for a colonoscopy? Everyone's scratching their heads. What do you mean? You can't do a colonoscopy without a room. It's part of the procedure. So the way we build things is... It's irrational. Sorry. Libby, thank you so much for bringing all these issues to the forefront, because I deal with this every day in my practice, and as I was listening, I could think of a thousand examples of how I'm so frustrated by all these cost issues. One particular example that I saw in the last year was that I was on a global health trip with the center, with medical students. We were in Guatemala. We bought the Bendizol for $35, and I was just curious to know how much that same medicine would have cost if we bought it in the United States. I looked at my Hippocrates and I did the calculation. It would have been $10,000 if we had brought that medicine from the United States instead of bought it in Guatemala. Students were saying, maybe we need to bring it back and sell it to fund our education. There's a new way to pay for medical school tuition. It's truly insane, but another aspect are these drug shortages that are happening now where generic medicines that my patients have counted on are completely unavailable. The other thing is that some of the medicines that I've used that are generic and would like to continue to use have actually gone up in price by tenfold in the last year. That was actually recently an article in one of the medical journals showing how generic prices have gone up for a particular set of generics. The pharmaceutical industry is clearly not responsible for providing what our patients and our society needs. How do we change that? Well, I mean, in a way I don't think you're going to do that anyway but some kind of regulation or national pricing. I just don't personally see that happening even though I'm not. I don't see how we can get that market that's so broken to work. I mean, part of the way the market approach might be to really change how we do anti-trust law and collusion practices. What's happened in the world of generics which I, again, I've found out so many shocking things in the course of researching these articles is that many generic drug makers are actually bought by brand drug makers. So if I make a branded drug and I buy the if I make brand augmentin I own generic augmentin am I really going to price it very low? No, of course not. The other thing that's happened is and there are a number of lawsuits ongoing about this but pharmaceutical firms have a lot of lawyers who look very carefully at whether they are breaking the law is that a number of brand manufacturers will pay generic makers not to produce or to keep their drugs off the market that's legal. It's legal but not what anyone intended. So as long as we let that kind of stuff go on and as long as we say sure, changing it from a pill to a chewable counts as a new product I think we're really going to be in trouble. Now, I know is this big government? I don't think so. I think this is just you know, you either have to control price or you have to make a market that's really a market and it's not a market now and patients are really suffering. I think the word that came to mind for me was not big government but piracy when I saw the pills that you could get in Saudi Arabia compared to the pills you could get in the United States. Listen, we have lots of wonderful questions and the discussion could go deep into the night but we have a reception waiting for you all in the back and what I'd like to do now is to first of all once again, thank Dr. Rosenthal I know that we're all looking forward to reading your additional posts in The New York Times. And also I should say for doctors and patients who have anything they want to say, I'm E. Rosenthal at nytimes.com I'm interested this series has grown out of hearing from readers and you know, for everything I know about there are 10 that I don't so please feel free to contact me. And I want to close with the thought that Dr. Frank Bryant believed deeply that health care should be accessible to all regardless of their ability to pay regardless of the color of their skin regardless of their religion or their ethnicity and the high cost of medical care that all of us are facing today threatens those values for each one of us and so we are grateful to the Bryant family for again, permitting us to perpetuate the legacy of Dr. Bryant and his values we're grateful to our supporters in this community that allow us to begin these kinds of dialogues in San Antonio and so please join me one more time in thanking Dr. Rosenthal and we're adjourned.