Health Care for the 21st Century

The topic this morning is Healthcare in the 21st Century. And I want to start out with a disclaimer. Given the rapid change that's occurring in healthcare it's almost impossible to predict with certainty the future of healthcare. I know that if somebody asked me when I started my medical career in the sixties to predict what medical will look like in the year 2000 there's no way I could have predicted all the changes that would have occurred and what medicine in 2000 would have looked like.

When I was an intern and a medical student, peptic ulcers were something you treated surgically. Now we know that peptic ulcers are caused by bacteria and can be treated with an antibiotic. We couldn't have envisioned magnetic resonance imaging, CAT scans, the onset of diseases like AIDS and SARS ‑‑ just very difficult to predict with certainty the future of medicine. But what I'd like to do this morning is talk about some of the things I see as shaping the medical landscape over the next several years.

In order to predict what medicine may look like in the future it's important to understand where medicine has come in the United States over the past decade. And if one goes back to the turn of the century ‑ entering the 20th Century ‑ in fact, the epicenter of medicine in the world was not in the United States. If one warranted ‑ had the most advanced training or education in medicine ‑ if one wanted to see the most advanced research and education or the most advanced clinical activities in medicine, one went to Germany or France. Indeed, medical education in the United States was pretty abysmal. There were 157 schools of medicine, schools of medicine educate doctors. Almost all of them were proprietary, that is, they were run for a profit. The professors lectured for the fees, only lectured for the fees that they got from the students. There were no laboratories. Medicine was taught only in the classrooms. And the entire length of medical school was four months. And if one could afford to buy a degree ‑‑ or purchase a degree one got a degree in medicine. There were no licensing requirements.

Around the turn of the century a few schools, the University of Michigan, Harvard, Johns Hopkins, University of Pennsylvania, understood the poor medical education in the United States and made a commitment to advance medical education. And in this context they formed a contract with society. They said to society, “We promise you the highest quality and most advanced medical education in the world.” And society said in turn, “If you deliver on that promise we will afford you certain rights and privileges, like the right of self-governance, high place in society, et cetera.” And indeed, that started around 1900. Abraham Flexner was commissioned by the Carnegie Foundation in 1908 to assess the state of higher education, including medical schools in the United States and Canada. He published a scathing report in 1910 called the Flexner Report which pointed to the deplorable conditions of medical education in the United States. He also pointed out schools that exemplified the best in medical education, like Hopkins, Michigan, Pennsylvania, and Harvard.

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And gradually things changed. The number of medical schools decreased from 157 to well under 100. Proprietary medical schools were done away with. Licensure came into being. The length of medical school went from four months to four years. Laboratories were introduced. And the whole quality of medical education really changed, and with this medical care and medical research. And this led to the preeminence of the United States in medical education.

Over the past year there have been several landmarks. The National Institutes of Health that Senator Hutchison referred to, the federal agency that funds biomedical research was established after the 1940s. During the Second World War was the beginning of employer-based insurance. The War Labor Board during the Second World War said it was unfair for companies to compete by offering higher wages, that is, because of the labor shortage they said it was unfair for companies to woo employees away from another company by offering higher wages. And they standardized wages companies could pay. But they didn't say any thing about standardization of benefits. So what companies did to attract employees was to provide insurance, particularly health insurance, as an inducement to move from one company to another. And this was the beginning of what's called employer-based insurance, which is the foundation of how medical care is financed in the United States

In the 1960s Medicare and Medicaid were created: federal and state programs to provide healthcare to the elderly, Medicare, and to the poor, Medicaid. Because of rising cost of healthcare in the 1980s it was thought that medicine , the cost of medicine, should be left to the marketplace. That will decrease the cost. Managed care was introduced; HMOs were introduced, and it soon became clear that this was a failed experiment because medicine just does not obey or respond to normal market forces.

And then the human genome was sequenced around the turn of the century, entering the 21st century. But, again, just as there was tremendous uncertainty and trouble at the turn of the 20th Century I submit that there is similar uncertainty and potential trouble as we move into the 21st century.

Now, what are some of the trends that I see as shaping the landscape for medicine over the next several years? Well, one is increased cost of healthcare. I don't see anything on the horizon that over the next, certainly over the next ten years is going to stem the near double-digit yearly increases in the cost of healthcare. And I'll have more to say about this, all these points in a minute.

There will be an increased focus on quality and outcomes, what I refer to as consumerism. That is, those who use healthcare will want to have more to say in terms of the affordability of their care, the accessibility of their care, and the quality of their care.

There are tremendous changes in the demographics which will change medicine. We are becoming a more diverse society. We are becoming an older society. By 2020 just under 20 percent of the society will be over the age of 65 and 25 percent of society in the nation is underrepresented minorities. That's closer to 50 percent in Texas. There's going to be tremendous impact of increasing technology on medicine. The world of medicine is flat. Globalization is having tremendous impact on medicine, not only in the practice of medicine but in education and research.

And, finally, there's increased self-responsibility for health. Individuals are interested on finding out on their own about diseases, about treatments, et cetera, and using that information to treat their own issues.

What about this issue of cost? In 1970 the total cost of healthcare in the United States was roughly $73 billion, $348 per year per capita?, 7 percent of the Gross Domestic Product. Fast forward to 2002: 1.5 trillion, over $5,000 per year per capita. This year it's closer to $6,000 and 14.8 percent of the GDP. And 2010 is predicted to be 2.7 trillion, 17 percent, and over $8,000 per capita per year. This has had dramatic effects on the cost of health insurance, the monthly premiums that employers and employees have, and it's led to a rising increase in the number of individuals who are uninsured. Because they lack health insurance their health status is poorer than those individuals who do have health insurance, and they can't access healthcare like those individuals who do have health insurance can access healthcare.

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The number of uninsured in the United States now is roughly 46 million individuals. That number is equivalent to the number of individuals in the total United States that are covered by Medicare or Medicaid. We are the only developed country in the entire world that has this issue: a significant percentage of our population can't get the healthcare they need and deserve simply and solely because they lack health insurance.

If we pay this much, is the quality of healthcare in the United States better than it is elsewhere? And, sadly, the answer is no. If one looks at metrics like longevity, birth weight of individuals, et cetera, we don't rank in the top in categories, but we're somewhere in the middle. We are the most expensive in the world. Switzerland, which is the next highest country, has healthcare costs which are roughly 60 percent of what they are in the United States. Now, interestingly, although other countries like England, Canada, Switzerland, et cetera, have healthcare costs that are less than the United States, the rate of increase in those countries is now very similar to the rate of increase in the United States. So although the healthcare costs start out lower they are seeing double-digits rates ‑‑ yearly rates of increase similar to those seen in the United States.

Demographics are going to have a very important influence on the practice and education of medicine. We are becoming a very diverse society, but the demographics in the medical profession don't mirror that. If we say 25 percent of the Americas are underrepresented minorities, only 6 percent of physicians in this country are underrepresented minorities. I submit that we cannot conduct medical research, we cannot educate in medicine and we cannot provide medical care to a diverse population unless we have a medical workforce that reflects the diversity in that population we are committed to serve.

There's another interesting phenomenon that's going on, and that is individuals in the medical workforce are changing in terms of their demographics. It used to be that physicians predominated in the medical workforce, and that is quickly changing. There's been a 37 percent increase in physicians over the last ten years, but a 200 percent increase in physician assistants and nurse practitioners. So the ratio of non-M.D. health professionals to M.D. health professionals is rapidly increasing. And this is going to have an important effect on how medicine is practiced, and I submit could have a beneficial effect on the practice of medicine.

There has been only one new medical school in the United States established since the mid-1980s. And in the same time there have been many more new programs in nursing, allied health sciences, and physician assistants established. While there's only been one new medical school in the United States established since the eighties, there have been 15 new medical schools established in countries that are offshore in the United States educating physicians outside the United States.

So it's becoming clear that physicians are no longer the epicenter of the medical workforce. And this will have an important effect on how medicine is taught and how it's practiced. More and more it's becoming clear in this increasing sea of non-M.D. health professionals that there needs to be a team approach to the practice of medicine. The Institute of Medicine, in a report in 2003, stated the following: “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team emphasizing evidence-based practice, quality improvements approaches in informatics.”

And this is an approach that we have taken here at UTMB because we do have four health-related professional schools and it is occurring elsewhere ‑‑ that is, it takes students in medical school, nursing school, allied health professional school and have them educate together so they can learn early on how to practice as part of a team.

The technology is also going to have a very important impact. At noon you're going to hear from Glenn Hammack about the concept of E-Health and telemedicine. Since 1994 UTMB has been developing this concept of telemedicine ‑‑ that is, using telecommunications to produce healthcare at a distance. We have developed a very sophisticated system now so that we can do everything at great distances that you can do sitting face to face with a patient except touch the patient. You can examine the eyes, ears, nose, mouth, listen to their heart. You can use various types of scopes to look at various orifices, et cetera. But you can do just about everything you can do sitting face to face with a patient except touch the patient. Indeed, we deliver healthcare in the criminal justice system to incarcerated individuals hundreds of miles from UTMB using telemedicine, to businesses located several miles from UTMB, to a clinic in Nacogdoches for children with special needs, to imaging care clinics in two contiguous counties, to drilling platforms in the Gulf of Mexico, to cruise ships as they cruise in various parts of the world. And we are responsibility for the delivery and healthcare to 3,500 scientists on the South Pole, and we do it from this building.

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So this is just one example ‑ and there are many others ‑ of the impact technology will have on the delivery of healthcare.

As I said, the world of healthcare is flat, borrowing Friedman's terminology, and there are several examples of that. Many institutions now provide magnetic resonance imaging and computerized tomography scans and x-rays during the day. They digitally transmit those to India at night, where it's daytime in India. They're read by individuals in India. The reports are sent back in the middle of the night to the United States. And in the morning the physicians or whoever else has access to those x-rays. So I'm indicating the flatness of the world in terms of medicine and the impact of technology. One-third of the graduates of residency training programs ‑ a residency training is training that occurs after medical schools for individuals in various specialties ‑ one-third of those graduates now come from non-U.S. medical schools. As I indicated, while there's been one new medical school established in the United States over the last 20 years there have been 15 new medical schools established offshore, and India sees a great opportunity in increasing its ability to educate physicians.

The global spread of emerging infectious disease, beginning with AIDS then SARS. Five years West Nile moved from the Middle East to England and then spread across our 48 contiguous states in the United States. Perhaps the most dramatic example is SARS: six months, 30 countries showing how fast these infectious diseases, which are normally constrained to one small area of the world, can quickly become worldwide scourges requiring that we in the United States think of medicine not just in the United States but, indeed, globally.

They mention that there is increased personal responsibility for medicine. And going online to look up symptoms, diseases, treatments, diagnoses, et cetera, is just one example. In 2001 62 percent of individuals using the internet were looking at health-related topics. In 2005 it's 80 percent. If you look at the top three online activities the highest is e-mail. The second is research in products and services before purchase. But the third is looking for health and medical information. More and more people are coming with information that they read about or get online about their issues. This has led to a term called cybercondriacs, where individuals go online and then think they have the symptoms that they read about.

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So these are just some examples of the things that I think will shape medicine in the future.

Now, are there things we know for sure? Well, I think there are. I think that there are some things we know will increase. One is the cost of healthcare. As I said, there's nothing that I can see over the next five or ten years that is going to have a dramatic effect in decreasing the rising cost of healthcare. This will lead to an increase in number of uninsured and an increase in what's referred to as health disparities. These are disparities in health, particularly access to healthcare, that is simply related to differences in gender, differences in geography, differences in ethnicity ‑‑ and also results in differences in health outcomes that is simply related to such differences and differences which don't have anything to do with the state of health, but have to do mainly with the economics and the impact the economics has on the access to healthcare.

We definitely will see an increase in the role of non-physicians in the provision of healthcare, physician assistants, nurse practitioners, and others, people from public health backgrounds, et cetera. There definitely will be an increase in the quality and safety of healthcare.

There clearly is going to be an increase in complex ethical issues. Stem cell is just one obvious example, there are many others. There's going to be an increase in the portability of the health record, that is, your ability to take your health record from one provider or one entity to another and have it transmitted to follow you as you traverse the medical system. There's going to be an increased emphasis on chronic diseases because chronic diseases create the bulk of disorders that impact on the cost of healthcare.

There's going to be an increase in population-based medicine. What I mean by that is how can you take a finite amount of health dollars and do the most good for the largest number of individuals as opposed to using it to treat only an individual when that treatment may not be most appropriate. And there's going to be an increased focus on wellness, not simply disease intervention, but how can you maintain health and working with individuals in a responsible fashion to maintain their wellness.

There are also some things I think we know will decline. Universal access, well, there isn't universal access now, but access to healthcare will continue to decline as the number of uninsured continue to rise because the cost of healthcare continues to rise.

There will be a decline in practice variations in medical areas. Practice variations are variations in the practice of medicine which have nothing to do with quality and outcomes, but simply have to do with things like differences in geographic location or differences in the way individuals providing that healthcare were trained. For example, treating an individual aged 65 years in Sun City, Arizona, is about one-third the cost of treating that same individual in Miami for the same disease with no differences in the quality of treatment and no differences in the outcome. That is a practice variation. Or you can go into two cities that are 50 miles apart and find tonsillectomy rates that are three times different in those two cities and not occasioned by any difference in the quality or the outcomes, but simply are related to differences in geography and differences in training.

There's going to be a decrease in the ratio of U.S. physicians to non-physicians as more non-physician health professionals are educated, unless there's a dramatic change in the number of U.S. physicians that are educated. And I think with this we're going to see an influx of more individuals who are trained outside the United States.

There's going to be less government support for medicine. This includes research, education, and clinical service ‑‑ simply occasioned by financial constraints. And, sadly, there's going to be a decline in the influence of the medical profession on the environment and within which they're working. I think the medical profession ‑ and I'm referring to any health professionals - have lost credibility over the last several years because of things like quality issues, errors in medicine, practice variations, rising cost of medicine, blatant issues of fraud and abuse, etc. Also Failure to implement rapid changes and things like portability of the health record so that others are stepping into that void and making those changes. So I think unless something changes there will be less of an influence of the medical profession on the environment in which they work.

There are some wildcards that could dramatically change medicine in this country. One is the political will for universal access. Right now there is very little political will for universal access, mainly because there's very little economic wherewithal to do it. If that changes because of some calamity or because of some change in the political landscape that could have a dramatic change in medicine, much like the same change that the implementation of Medicare and Medicaid had on medicine in the 1960s.

Another wildcard is changes in the medical workforce and the way medicine is practiced. I think that we have a great opportunity to look at how medicine is practiced here in the United States, to use more non-M.D. health professionals, and I submit to do it in such a way to decrease the cost of medicine while at the same time increasing access and quality.

A bioterrorist emergent infection calamity could have a dramatic effect on medicine, much as the way polio, SARS, et cetera, the potential for avian flu, which we'll hear more about this afternoon, could have and has had.

The influence of payers, those who pay for healthcare, either through insurance or other programs, whether that be the federal government, state governments, employers, or whatever ‑ the influence they are willing to have on the choice individuals have in terms of where they receive their healthcare, the quality of that care, et cetera, could have a tremendous impact on medicine.

And, finally, the extent to which medicine embraces globalization. Globalization medicine is rapidly occurring, and if American medicine doesn't understand that, embrace it, and become part of it, it could have a dramatic effect on medicine. And, conversely, if it does it also could a dramatic effect on medicine. We have a single worldwide curriculum for educating physicians. It's no different in England than it is in Germany than it is in the United States. We could have single worldwide licensure requirements for health professionals. We could do a lot if we embrace the global community and a lot for the health of the world.

So, in my view, medicine over the next short term is going to be for the haves and the have nots. What I mean by the haves is for those who can afford to access medicine, medicine will be of the highest quality, it will be safe, it will be outcomes based, it will be led by a team of health professionals ‑ maybe not led by a physician‑‑ and healthcare will be received not in the traditional settings like a clinic or a hospital, but in some other settings.

For those who can't afford medicine access then healthcare is going to be episodic, it's going to be uncoordinated, it's going to occur in traditional settings like the emergency room or traditional hospital, and it's going to be aimed not as wellness or prevention, but going to be aimed at disease intervention.

The real wildcard, in my view, is will the United States maintain its dominance in health? As I said, just 100 years ago the epicenter for medicine in this world was not the United States, but it was France and Germany. Is the next epicenter for healthcare going to be India or China? And that, to me, is a possibility for this century.

But if the health professional, much as it did at the turn of this century, reaffirms its contract with society to provide the most accessible, most affordable, highest quality, most advanced medicine for all then I submit the United States will maintain its dominance. Thank you very much.

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Question and Answer:

Dr. Romo: Good morning, Dr. Stobo. And let me commend you on your great work that's being done. I'm Ricardo Romo, president of the University of Texas San Antonio. And I had a chance to hear a fabulous presentation by Dr. Stobo on Katrina and of preparation that was phenomenal. I wonder if you could just share a few things on us on how this institution was a model for how to prepare for pending disaster.

Dr. Stobo: Ricardo is referring to what we had to do in response to Hurricane Rita, and let me back up a little bit. In August of this year, at the request of the Governor, who asked a lot of institutions, particularly health-related institutions on the coast, to evaluate their hurricane preparedness plans. We will have to re-evaluate ours. We have six hospitals on this campus. For the past 114 years when there's been a hurricane, we have not evacuated the hospitals. We have discharged our most well patients, kept our sickest patients in the hospital, and hunkered down, so to speak, to provide care to those patients with about 1,000 to 2,000 employees.

In August we started to rethink that, whether we should evacuate the hospital, and then Katrina came. And it became clear that we need to seriously think about evacuating a hospital in the face of a Category 4 or Category 5 storm. So we said in August, well, we have six months to do this. So let's put together a plan that we can look at in February. And, of course, then Rita came and we had just about started on the plan, so we didn't have a plan.

And that Sunday when it looked like Rita was coming into the Gulf we started to put our team together. On Monday and Tuesday, when it became clear that it was going to be a very dangerous storm and was going to be headed for the Texas coast, we started to make plans to discharge our non-essential employees and our students, those individuals who aren't required to maintain and provide services on the campus. And then when it looked like it was even going to be more dangerous on Tuesday night we decide to, indeed, evacuate the patients in our hospital. We had roughly 440 patients in the hospital, many of whom were extremely sick because the wellest patients had gone home. And these are individuals on respirators, babies in incubators, the elderly, et cetera.

So with the help of the state and the county and the city we began Wednesday morning at eight o'clock in the morning with access to 90 ambulances, 40 helicopters, and five fixed-wing airplanes to evacuate our patients. That at eight o'clock on Wednesday we had one patient left in the hospital.

We had never done this before in 114 years, so we didn't have a plan. But it just points out what people can do when they roll up their sleeves and come together under great leadership, Karen Sexton, who was our incident commander , come together to do special things for a very special population - the patients we're committed to serve.

Then the next day we let all the employees - we had about 1,000 employees - who wanted to leave to do so, with the exception of the ones that we had to maintain here to keep services open. We kept our emergency room open all through the storm. And we evacuated, using two C-130s, about 250 employees to a shelter in Fort Worth. So Thursday night it was pretty lonely. We had about 400 employees, and Friday we just battened down and waited for the storm. Fortunately, it was much less severe than we predicted. But it was a pretty stressful and busy six days. But we were pleased that we were able to remove our patients and the majority of our employees from harm's way and pleased that we didn't have as much damage as was originally projected.

And, to me, it's a great example of what I refer to as a productive community, that is, a group of individuals who come together, and, irrespective of titles, positions, or where they are in institutions, understand that everybody can make a difference and work together as a team to do something pretty extraordinary. Thanks, Ricardo.

Audience: Good morning, Dr. Stobo. In 2003 when Congress passed a prescription drug benefit plan under Medicare one of the things that Congress also did was to create health savings accounts. And you mentioned as part of the future growth and consumerism on the part of patients making choices, both as to the price and utilization in terms of their healthcare. Obviously, the incentives are different than if all you have to pay is a $10 co-pay and the insurance company, some faceless, nameless organization, is paying for perhaps duplicative tests or maybe even unnecessary diagnostic tests.

So what I wanted to ask what you foresee for the future when it comes to the transparency of pricing of medical care. I know in California and elsewhere there have been some experiments with requiring hospitals to publish the list of their most commonly provided medical services. And I think people have noticed. I mean, there's been a wide disparity, an interesting disparity. But it gives consumers more information with which to make a choice based on outcomes and pricing and that sort of thing. And what impact do you think that will have on the rise of increased costs of medical care, the growth in the costs you predicted?

Dr. Stobo: Well, sir, I think that that could have a beneficial effect on the cost of healthcare, and I think we will see that. We've talked about that here. For example, if you come into our clinic for a test you don't know how much that test costs until you get the bill.

And the start of employee-based insurance in the 1940s was a good thing, but the downside of that is you're not responsible for the cost outside of a co-payment. Somebody else is paying for it, so we collectively as a society have not been attentive to the cost and have not made decisions on the basis of cost in the past.

But I think the financial pressures are going to force that issue and make that happen. I think it's going to happen at a state level. The states cannot afford to continue to support Medicaid to the level that they have supported. And pharmaceutical costs are a big part of Medicaid expenditures , not the most and not the biggest, but perhaps the most rapidly increasing. So I think we'll see a lot more transparency in pricing of pharmaceuticals, services, tests, et cetera, and also in providers. And that's where the influence of payers could come in.

If a large employer says to its employees: “Look, you go to Provider A because we have followed outcomes, we have followed indicators of quality, and we know cost. And putting those things together ensures a value added. We think Provider A is where you go. Provider B is almost as good, but not as good. So if you go to Provider A the co-payment is $20. If you go to Provider B the co-payment is $50. If you go to Provider C the co-payment is $100.” And use that type of leverage to direct its employees to a specific provider.

Now, they have been unwilling to do that in the past for a couple of reasons, labor unions are resistant to that and also for liability issues. You force me to go to Provider A, I had a bad outcome, and that's because you made me go to that individual. But I think we will see that more and more. And it's going to be a cost issue and affordability issue. Look what's happening in General Motors, for example, Delta Airlines. You can right on down the list. And talk about globalization? We're losing our global competitive edge because of the cost of healthcare and the impact that has on the cost of what we produce.

Audience: A few years ago there was a story about a physician coming down and giving a lecture. And he prepared his lecture and prepared slides and giving his anecdotes of special patients and so forth and put this all together after a long time, went down to one of the medical schools. He came down and went to a beautiful room like this with 120 students supposed to be in there. He was surprised because there were only six students sitting in the front row. And he thought, “Gosh, somebody must have spent a lot of money telling everybody that I was a lousy doctor and not to come listen to me.”

Turns out that this was the policy. The students paid the other six students to record the lecture. And all they had to do was memorize the thing and they never had to come to class until the final exam. If they passed the final exam they went on. Is that still the policy?

Dr. Stobo: That was common. Let me tell you a little anecdote. There was a story where a guest lecturer came into a classroom and looked into an auditorium like this and there were five students. And one of the students came up and put a tape recorder on the podium and he began his lecture. And what was happening was the student would then take that, transcribe the notes, and sell them to the rest of the students. So the next day he came in, turned on a recorder, and left the classroom, and it just gave his lecture.

I think medical schools throughout the country are looking at better ways of educating students, particularly in terms of this concept of lifelong learning, educating them so that they can out and continue to educate themselves. Because what you learn in four years of medical school rapidly becomes outdated. And so you need to learn how to keep up with all the information, the reams of information that comes along.

One approach that was started in Canada and came to the United States in Case Western and one that we have actually taken up here and at other schools is to go to small group sessions. So we have for just under half of our lectures, small groups where there are eight to ten students who work together in a problem-based approach. They're given a problem by the instructors and mentors not given a lecture and not lectured to. Then the students go out on their own working together to try to solve their problem.

Rather than teaching anatomy or histology or, biochemistry in a didactic fashion you present those students with a problem that includes anatomy, histology, and biochemistry. But they go out and, with some direction, learn that on their own. Now, we think that is going to be better in terms of this concept of lifelong learning and gets away from the large amphitheater type of lectures. More and more medical schools are experimenting with approaches like that to obviate or get around the very thing that you mentioned, which is pretty static and objective and not very dynamic.

Audience: How long does that last?

Dr. Stobo: Well, it goes through four years all through four years of medical school. There's a question up here.

Dr. Nicholas: I appreciate your very good analysis of our healthcare situation. You paint a fairly gloomy picture that we've inevitably going to have a decreased access and an increased healthcare cost.

You're well aware of the studies that have been done in several states that show that they're not totally unrelated. Particularly, you've said they've been done twice in California. The recent study in California showed if you initiated total healthcare for everyone in the state of California you would significantly decrease the total amount of money spent in California. The plan being considered, according to the Lowen study, shows that actually they would spend $8 billion less in healthcare costs by including everybody under healthcare. My question is, is Texas looking to get any kind of study like that?

A group of experts from Texas Tech, A&M, and UT were put together to research the issues of access and cost, and particularly the issue of uninsured individuals who don't have or have far less access. We've spent the last year-and-a-half analyzing the issues and proposing solutions. And one of the solutions I think that we're pretty unanimous on is there should be more experiments done, more demonstration projects. They'll look at different ways of addressing issues related to quality, cost, and access. And then out of that hopefully you could develop best practices.

So the short answer is, yes, in Texas we are doing some of that. Barbara Brier, who's here, has been working with what's called a three-share program, which addresses the health needs of the working uninsured where the employer pays a third of the premium, the employee pays a third of the premium, and then we use other state or federal funds to cover the remaining one third of the program. This has been started out in Wisconsin, is in a couple of other cities in the country too. And in those cities where that program has been initiated it does increase access, increase quality, and actually decreased cost. So we do need more experimentation.

Dr. Nicholas: Doctor, just one question about this employer-based reimbursement system in the United States. Is there any other developed country in the world that has the employers bearing as much proportionate of the healthcare cost as the United States?

Dr. Stobo: To my knowledge the answer is no.

Audience: South Africa is the only other country that does it.

Dr. Nicholas: And South Africa has found a way to cover its uninsured recently.

Audience: Yes.

Dr. Stobo: So the answer is South Africa has one. But are they as predominant?

Audience: No. With the change in government there they're moving more to a federal system. They're the only country.

Dr. Nicholas: Has anybody looked at the cost, the globalization cost that is, the lost business opportunities of American business trying to compete with countries that have a different funding system?

Dr. Stobo: Well, all I know is there have been anecdotal stories. You know, for a $10,000 car, for example, $1,200 of the expense of that car is related to the healthcare cost. But you can see what's happening to various companies that have to go into bankruptcy because it cannot afford the obligation to provide the healthcare costs to its retirees. So, although I don't know of any formalized study, I'd say it has a pretty dramatic impact on the global competition and will have more of an impact as global competition increases.

Lawrence Wright: Dr. Lawrence Wright from Austin. I understand that this school has just opened up some sort of partnership in Austin which is the largest metropolitan area in the country without a teaching hospital. What kind of entity is it going to be? Is it going to be a medical school or what do you foresee in your extension into Austin?

Dr. Stobo: Well, the question relates to our activities in Austin. We actually have been involved in educating students and residents in Austin since the early 1960s. And, because that has felt so good to us and worked so well for us and provides a high quality education, we in the late 1990s started to increase activities there by increasing the number of students and now the number of residents that we're responsible for, but receive their training in the Seton Hospital system particularly Brackenridge in Austin.

We also have been very fortunate to increase our partnerships and programs with the University of Texas in Austin in terms of research partnerships. And we also have a combined what's called M.D./Ph.D. program with UT Austin, where individuals can get an M.D. degree and a Ph.D. degree, not at the same time. It takes a little longer, but it's a combined program. Our idea is to continue to look at these relationships on a programmatic by programmatic basis, and where it makes sense to build on them, continue them, and enhance them.

We are not coming lightly into this thing, we want a medical school in Austin in five years. First of all, medical schools are extremely expensive the way they're constructed right now. This is politically a very hot topic. And there are probably other places in Texas that need to have a medical school before Austin. But that's not our goal. We are very good at developing partnerships, probably because we're on a barrier island. Having a partnership with Austin to enhance our educational goals in a mutually desirable and satisfactory fashion just makes sense to us and is something we're going to continue.

Let me say, we would not have been able to evacuate our patients if it weren't for the relationship we have with Seton. Seton took 170 of our 225 patients that had to be evacuated by ambulance or air. And we did not have that relationship preceding our Rita we would not have been able to do that.

Patricia Keck: Patricia Keck from Laredo, Texas. You showed us a time line from the 1900s to the present. If you were looking at that time line in the 1900s I would say your medical school classes were primarily young men, whereas now there's a wonderful gender balance. How do you see that the change in gender balances affects medical education and medical practice?

Dr. Stobo: Well, that's a very good question, I'm glad you reminded me. The point that's being made is, if you go back to the 1900s there were very few women. There were very few women in medicine in the 1960s. In my medical school we had forty students and only three that were women. Now, the majority – fifty-one percent of individuals in medical school are women. That is going to have a dramatic impact on practice. In my view I think a beneficial impact. But I think that we can see in general, in part occasioned by the increase in number of women going in practice, a greater interest on lifestyles in practice than on how much money can you earn, et cetera.

And so I think that is one of the impacts that we will see continue to happen as the proportion of women in medicine increases. If it weren't for women going into medicine the number of medical students in this country would decrease dramatically over the last several years. And some specialties, obstetrics and gynecology, ninety percent of the individuals in residency training in that specialty are women. So women are having a profound and important effect on the medical educational landscape and will have a profound effect on the practice of medicine.

The dean of our school of medicine is a woman. I think there are probably half a dozen women deans out of the 125 medical schools that exist in this country.

Senator Krueger: Bob Krueger, New Braunfels. Thank you for a superb presentation. I'd just like to ask, as you see the proportion of healthcare provided by physicians declining in comparison with physician’s assistants and other kinds of medical developments, how do you see the relationship of these medical providers to physicians changing? Will physicians continue to be the king on the heap or will others be allowed to make decisions for themselves and so forth?

Dr. Stobo: Well, my own view, and it's not necessarily a popular view with my colleagues because I am a physician, is that the world of physicians, say, in 2020 will be much different and the role of physicians will be much different than it is now. I think they will be geographically localized to very special areas. They will be involved in very special parts of medical treatment. For example, they will be involved mainly, or they'll play an important role in medical research.

But I think the role of physicians will change. So they will not necessarily be the leader of a team or the epicenter of how healthcare is delivered. But they will be involved in very specialized diagnostic procedures and very specialized therapeutic procedures. And other health professionals will play a role, say, in other parts of the delivery system. Now, I happen to think that that can be done in such a way that really advances the quality of medical care and decreases the cost.

George Whittenburg: George Whittenburg from Amarillo. I would like to revisit an issue that Senator Cornyn has addressed. Seems to me to be a fundamental problem in the whole cost of medical care that there's no point of sale accountability. Let me use an analogy. We've all heard the story about the people who go to lunch. And I'm going to say the doctor says, “Well, here, let me pick up the tab because I'm in a such-and-such tax bracket and I can deduct such-and-such.” But the insurance executive says, “Well, no, let me pick it up because I provide healthcare insurance and I'm on a cost-plus.”

The insurance companies are the ones who pay the bills. The patient goes in and can't even find out what it costs. And even if he can find out, he or she cannot find out what it's going to cost someone without insurance you can't find out because there are insurance contracts. And if you ask your doctor what is something going to cost the doctor doesn't have any idea. He's going to have to turn it over to somebody else. And it seems to me that divorcing the decision making or the accountability from payment in the decision to get a particular procedure is something that is a fundamental flaw in our system.

Dr. Stobo: Well, I agree with you and I think that's what Senator Cornyn was saying. And I go back, it stems from the concept of employee-based insurance. Because the individual who receives the healthcare pays very little of the total healthcare bill and the payment is so small, there was no incentive for you and I as patients, for example, to understand the cost. Somebody else was paying for it. And there was very little incentive on providers because decisions weren't made on cost to provide the cost of services they were providing.

George Whittenburg: But even those conscientious employees who know that it ultimately costs the employer and takes dollars out of the system and may reduce what an employee makes who wants to find out and make rational decision, not just with respect to the co-pay

Dr. Stobo: Right.

George Whittenburg: But with respect to the total cost and what can be done, there's no way to find out?

Dr. Stobo: Well, again, that's what Senator Cornyn was getting at. That is increasing. I mean, you can go into a thick book now and look at UTMB and find out what UTMB does in terms of certain quality indicators. Does it give aspirin for individuals who come in with myocardial infarctions? And you can also get the cost of certain procedures. So gradually that information is being made available. There's going to be more and more emphasis in the future on making that information available and more and more people are going to be making choices based on that information.

Right now that's not the case. In a couple of studies, one in New York and the other in Pennsylvania, when the outcomes of procedures were made available to the public in terms of mortality or morbidity, choices of the public were not made based on those parameters. They were not paid attention to. Now, the interesting thing is who did pay attention to it was hospitals. And hospitals instituted changes in those procedures to decrease the mortality and morbidity outcomes in certain procedures. And, again, it was a competitive issue. But consumers didn't make choices based on that. But I think that's going to change in the future.

Dr. Capper: I'm Dr. Robert Capper from Fort Worth. There are certain aspects of the escalating cost of healthcare that you didn't touch on in this wonderful presentation. We're looking at a population in the United States where sixteen percent of our children are obese. The incidence of diabetes is increasing twenty-five percent over the last decade. All of these patient-induced conditions lead to escalating need for and cost of healthcare, in addition to obvious increasing cost of technology. Are we addressing that in our system other than occasional headlines in the paper?

Dr. Stobo: Well, not adequately. But I think that we will start to address them more. I think more and more individuals or entities or payers of healthcare, including the federal government, are trying to develop incentives for individuals to take more responsibility of their own health in a beneficial way, patients with diabetes, for example, patients with obesity. And I think we'll see more of that as it is realized the enormous cost that those two conditions add to healthcare. And in terms of globalization, you know, obesity is not an epidemic that's present in just the United States. It is a global epidemic.

Audience: Doctor, I was interested in one of the comments that you made because it applies equally to a lot of professions, especially as in my profession of law where the demographics of the profession do not nearly equate the demographics of the population. And you alluded to that in the medical field as well. Do you have any ideas, any ways that we can increase the demographics of the professions to more equally equate the demographics of the state?

Dr. Stobo: Well, first of all, let me just reiterate, your observation is absolutely correct. As I said, about six percent of practicing physicians are underrepresented minorities. About ten percent of physicians in training are underrepresented minorities. And that's been constant since the mid-1990s. Despite the fact that organizations like the Association of American Medical Colleges and others have tried to make a change in that, it has been painfully slow.

And it's not because there are fewer baccalaureate-trained underrepresented minorities in the pipeline. In fact, the number of baccalaureately trained underrepresented minorities has increased, but the number, the percentage, going into medicine has decreased. So medicine is losing its market share of a diverse and capable workforce.

This preceded my coming to UTMB, but they worked very hard at UTMB, not by saying we need to get our numbers up, but by saying that we attract a special student here at UTMB. Students who come from disadvantaged backgrounds, whether economically disadvantaged or educationally disadvantaged, and want to go into medicine for passion reason, they do it with a passion, with the idea of going back into the communities and either through research, education, or clinical service give back to the communities.

Many of those are underrepresented minorities. And so we have had programs where we have mentoring programs, counseling programs. Individuals will come up spend a summer with us or, in some cases, a year. Some are taking special courses so that they can increase their educational level to be more competitive with their counterparts. And thirty-four percent of our medical students are underrepresented minorities. We were the number one medical school in the continental United States a year ago in terms of Hispanic medical student graduates.

So the answer is, yes, there are things that can be done. It takes a proactive approach to it, an approach that goes far beyond just a desire to get the numbers up. Because I can tell you that if you do it just by getting the numbers up, you will take a reasonable proportion of underrepresented minorities into the first-year medical school, but you'll lose them between year one and year four.

Audience: A problem that I think the system has to look at that is becoming more and more of a problem I've been in practice 47 years at this point. I graduated from this institution in 1951. When I first started out my malpractice insurance was $75 a year. Last year it went up to $39,000 a year. Now, I have never been sued. I've never been in court. I've never had a court situation, so that's no reason for it to go up. Some of the neurosurgeons have to pay $120,000 in malpractice insurance before they can even open up their offices. You're losing a lot of the older doctors because they say this is like General Motors, they can't afford to pay that high a price for malpractice insurance and stay in business. Unfortunately, this is a business. We have to pay our employees. I pay $1,600 a month for healthcare for my employees. And you're losing a lot of older people because they say we're just going to retire rather than continue with this.

Dr. Stobo: Well, I agree with you. You haven't been sued because you've had good medical training obviously. But you're absolutely right. The high cost of medical malpractice is having an impact on the cost of medicine. But, more importantly, it's having an impact on the access to medical care. There are places in the state where obstetricians just won't practice because of the high cost of health insurance or neurosurgeons won't practice. And, therefore, you can't get those services in that part of the state.

Now, in terms of the overall healthcare cost it's not the number one driver or the number two driver, but it's up there among the top five in terms of cost, depending on how you calculate it. Other than just the direct cost of the malpractice premium there are other things that health professionals will do because of their concern of over being sued or because of their liability things that they otherwise wouldn't do which are duplicative, shouldn't be done, added necessary cost to the healthcare, et cetera. So you're correct.

Dr. Lockrdige: My name is Lloyd Lockridge of Austin, Texas. And some years ago, only about three, I had what they call a heart flutter. And the doctor said that you can do this or you can do that. And one thing you can do is to have an ablation. Well, that was a wonderful thing. Some years prior to that I served with a man who's here I think, named Mark McLaughlin, and a man who's no longer here, named Mark Martin of Dallas, on a commission. There were about ten doctors. They had something called informed consent that the Legislature had adopted. And our commission was designed to address that and see what forms might be established. Half the doctors on the commission were mad as hell that there was this to go through. They didn't understand it and so forth. So we worked on that for two or three years. Now every time I or any member of my family goes to a hospital we get these informed consent things.

Now, relating that to some of what's been said, I happen to have Medicare. I'm very grateful for it, but I have no idea what anything costs. I never see a bill. It used to be that when a member of my family would be coming out of the hospital they'd ask how we were going to take care of this. When you see what Medicare does to the $25,000 overnight hospital bill for my ablation. The doctors and the healthcare providers start having to say to the patient, “Look, if you do this procedure it will cost somebody $25,000. If you take medicine the rest of your life it will be whatever the medicine costs.” Where are we going with this? And does that have anything to do with this subject?

Dr. Stobo: Well, the answer is yes. I'm going to ask Ron, do you want to say a few words? Ron's thought a lot about this in his role as director of our Institute of Medical Humanities and his interest in medical ethics.

Dr. Carson: Well, you mentioned informed consent. I mean, the purpose of informed consent is as the terms suggest, asking you as a patient for your permission to undertake a procedure. It's something that usually happens informally. Sometimes a piece of paper needs to be signed, but the piece of paper is really only worth the conversation that went on before informing the patient and asking for the patient's permission.

As far as costs are concerned, I think Dr. Stobo touched on that a little while ago. We're making progress in educating medical students, and particularly residents, about the cost of care. And patients are, if you look at that percentage of patients who use the internet looking things up, are finding out what things cost and are going to become much more demanding, if you will, regarding the cost of care as well as the quality of care.