Cleveland Clinic CEO Speaks on Health-Care Reform: 'We May End Up Making the Problem Substantially Worse'

by Jeneen Interlandi

When President Obama wanted a first-hand look at how health care is delivered in America, one of the first places he visited was the Cleveland Clinic. One of the largest private medical centers in the world, the Cleveland Clinic is renowned not just for the quality of its care but its innovative administrative policies.  

But in an interview today with NEWSWEEK editors, Dr. Delos M. Cosgrove, a longtime cardiac surgeon and president and CEO of Cleveland Clinic since 2004, expressed frustration that the debate in Washington has narrowed. Sooner or later, he says, the nation will have to address not just coverage for all Americans, but the cost, access, and quality of care available—in part, he says, by controlling the growing burden of obesity-related disease. Excerpts:
 
How would you characterize the health-care debate taking place right now?
I think the conversation has morphed from health-care reform to insurance reform.

Is that a semantic distinction?
No, I don’t think it is. In the beginning we were talking about access, cost, and quality, and now it seems we are just talking about access and cost-shifting, because there’s very little in the program that seems to be going to reduce the cost of health care in the United States. If you give access to another 40 million people, there’s going to be more cost.

Isn’t more insured people a good thing?
Of course it’s a good thing that more people will be insured. I don’t think I’ve ever heard anyone say otherwise, but if we just add people to the list of insured without addressing quality and cost, we may end up making the problem substantially worse. And there’s little in the legislation that suggests an intention to attack the two areas that hold the most potential for reducing costs: the delivery system and the disease burden in the United States.

Tell us about the Cleveland Clinic and what you guys are doing, and if it’s scalable.
There are two things that we’ve done. The first is integration of facilities and doctors. The days of the stand-alone hospital being able to be all things to all people I think is gone—it winds up being a duplication of effort and duplication of cost, and it doesn’t engender high quality.

Our system is 17 family health centers going to eight community hospitals going to a very high-tech central campus. Each one is connected by two things: electronic medical records and a transportation system. So you try to get the right person to the right place for the right problem.

What would a public option mean for clinics like yours?
I think it depends on how it’s structured. You probably heard the cry from hospitals around the country when they said the public option is going to be priced at [Medicare’s rates, plus five percent]. Right now, Medicare underpays by about 6 percent of the cost of delivering care. So that would amount to us losing more money. We already lose money on all Medicare and Medicaid patients, and that’s 50 percent of our business.

How do you compensate for that?
We shift costs from the public to the private system. All hospitals do that. If you were 100 percent Medicare and Medicaid, you’d be out of business.

What are your biggest concerns right now, as Congress continues to wrangle?
My concern is that until you begin driving more people to an integrated system, you’re not going to enhance the efficiency of the health-care system.

The second concern I have is the disease burden in the United States. Right now 10 percent of the cost of health care in the United States is secondary to obesity, and that’s going up another $100 billion a year from smoking. I don’t think there’s any way to drive down the total bill without reducing those numbers.

What can Congress or the president do about [reducing disease burden]? Isn’t that the responsibility of doctors?

It’s clearly possible in the United States to drive cigarettes out of existence—tax them out of existence. Forty percent of premature deaths in the United States are from smoking, inactivity, and obesity. That leads to chronic disease, and that’s 70 percent of the cost. We stopped hiring smokers. We test every applicant for drug use and for nicotine, and we have not hired doctors just because they tested positive for nicotine. But we can’t do that with obesity. In fact, obesity is protected by the Americans With Disabilities Act.

Don’t you think heavier people can also be healthy? Shouldn’t emphasis be on diet and exercise, not so much on body mass index and a number goal?
No. We aren’t talking about 20 pounds overweight; we’re talking about obesity.

What is the role of the physician in [health-care reform]?
Doctors are not very vocal; [they're] apolitical by nature. The majority of them don’t even belong to the American Medical Association. They mostly focus on doctoring, and they haven’t ever united in a major way. Should they be more involved? Absolutely. But is this discussion right now about health care? Not really. It’s about payment and access.

Tell us about the president’s visit to the Cleveland Clinic. What was he most interested in discussing?
I was surprised. It wasn’t a photo-op. He wasn’t interested in seeing a lot of people; he really wanted to sit down and talk. He was very interested in our electronic medical records and in our efforts to measure quality. I think he was learning. He asked fairly penetrating questions about how we make it all work.

If Congress passes something, is it better than nothing?
It depends on what they pass. If it’s just access, we will be back in a few years dealing with cost, and it will be even worse. We need to step in and try to make some cogent points that are not emotionally based.

Unfortunately, Washington frequently gets reduced to soundbites, and I hate to see that happen to something as complicated as health care—“47 million uninsured” or “We have to save the economy” are soundbites. And this is a complicated issue. I have been a little surprised at the naivete of the people making the decisions.