The Path to More Effective, Affordable Healthcare with Dr. Delos Cosgrove

As former President and CEO of the Cleveland Clinic, Delos Cosgrove, MD, was responsible for a $5 billion health care system encompassing twenty-eight different institutions. He cares passionately about patient care and patient experience and has undertaken major reorganizations within his company to improve clinical services. He has also initiated major programs to improve wellness among patients, employees and communities.

SPEAKING.COM: You mentioned in a recent interview that healthcare spending makes up almost 20% of the US economy. How does that compare to other developed nations and what is driving those costs?

COSGROVE: The cost in the United States is up substantially to 18-plus percent moving toward 20%. In comparison, in the most high cost European countries, healthcare spending makes up 11 to 12% of the GDP.

This cost is being driven by a number of things. One is the fact that we spend much more on healthcare and much less on social programs than other countries. When you look at the combination of social and medical costs, the United States actually ranks about fourth, but when you break that down, the percentage spent on healthcare significantly outweighs the percentage spent on social programs.

Additionally, what we have in the U.S. isn’t really a system, but rather a whole series of independent healthcare delivery organizations, so we don’t get the efficiency of national planning or even local planning.

In addition to these factors, the expectation of care in the United States is higher than expectations in many other countries.

SPEAKING.COM: What is unique about the Cleveland Clinic that makes it a model for other healthcare organizations?

COSGROVE: First of all, the Cleveland Clinic is a non-profit physician-led group practice made up of 3600 physicians. We are all salaried with one-year contracts, and annual professional reviews. To the best of my knowledge we’re the only organization that has all of those characteristics. As a result of those characteristics, financial incentives are removed. For example, I’m a cardiac surgeon. Whether I did someone’s heart operation or not didn’t affect my financial status at my job there.

That’s further demonstrated by a study from a number of years ago which looked at where the costs were lowest in the last 18 months of life in Medicare patients. It turns out that the Mayo Clinic and the Cleveland clinic were one and two in the lowest costs, and both of those have employed physicians, so it’s a unique model and it has been extraordinarily successful in our organization.

SPEAKING.COM: Why do you believe that group practices provide better and cheaper care?

COSGROVE: One of the things we’ve recognized is that hospitals that are run by physicians have a higher quality than hospitals that are run by administrators. I think it’s a matter of emphasis, that physicians really know what to emphasize in order to drive quality. I am a major believer in physician leadership and that we need to continue to improve the quality and the number of physicians who are going to be leading.

SPEAKING.COM: You took the reins at the Cleveland Clinic in 2004 and led it until 2018. What are the biggest changes you saw during your time there?

COSGROVE: The Cleveland Clinic saw a substantial growth over that period of time, becoming the first American hospital to go full tilt internationally with our facility in Abu Dhabi, a facility in Toronto, and the start of a facility in London.

Simultaneously, we saw enormous changes in healthcare with an increasing emphasis on going from a fee-for-service model to being paid for value, a change that I think is going to continue over time. So there has been a huge growth in the Cleveland Clinic and the direction in which it’s directing its services.

SPEAKING.COM: The Cleveland Clinic had taken about 700 million out of their costs during the course of two to three years. How were you able to achieve that without sacrificing the quality of care or conditions for employees?

COSGROVE: We actually took almost a billion dollars out of our costs over that period of time at a $9 billion organization because we felt we needed to do that in order to make care affordable. This effort was led by physicians. We’d planned on taking about 25 million a year out of our cost and have stuck pretty much to that.

We did it by looking at every aspect of our organization; there were no sacred cows. We began to benchmark ourselves against other institutions by various administrative areas, and also by various clinical areas.

At the same time, we’ve seen quality improve, and we have not seen a decrease in employee engagement over that period of time nor have we seen our reputational score or patient satisfaction scores go down. In fact, all of those have gone up.

SPEAKING.COM: What are your thoughts on universal healthcare or Medicare for All?

COSGROVE: Interestingly, Medicare for All is now being touted as a major campaign issue in 2020, but I think that it is unlikely that it is going to come to fruition for two reasons.

First, if you look at Medicare for All, it is going to cause a major disruption of the federal budget. Considering that currently almost 50% of the healthcare in the United States is paid for privately and by employers, that would be an enormous shift and a substantial increase to the federal budget.

The second thing is that traditionally people have been reluctant to make major changes in healthcare over the years, and I think pure inertia would prevent having such a huge change happen in the United States, over the period of just the next two years. However, I do think that we’re going to get there incrementally over time. We’re now seeing at the Cleveland Clinic that 62% of our patients are Medicare-Medicaid or no pay, and that’s going up 1% to 2% per year. We are gradually moving in the direction of government pay, but I find it highly unlikely that Medicare for All will happen in 2020.

SPEAKING.COM: What are some ways healthcare groups can use big data to improve the quality of care and lower their costs?

COSGROVE: We as an industry have an enormous amount of information coming at us from all directions, from 3 billion base pairs in every human genome to the 5,300 medical journals putting out over 800,000 articles per year. On top of that, we are seeing health care double every 1.5 years, so we’ve got to figure out how we are going to deal with that.

The opportunity with that data is as we move from the art of medicine to the science of medicine we’re putting numbers behind things. That helps us analyze and begin to gain a new recognition of healthcare issues and the best way to treat patients. In turn, we should be able to reduce the cost and improve the quality at the same time.

I think the first step is going to be this data going to the Cloud. As more and more people put their data in the cloud, that will increase the opportunity for interoperability, something that health care has greatly been lacking and a factor that’s plagued it for a long time. So I see enormous opportunity with big data.

SPEAKING.COM: What is your advice on how caregivers can improve their communication skills and empathy skills?

COSGROVE: We recognize that one of the biggest complaints that we have is regarding communication, and it has been perpetually a problem. We looked at various ways to improve communication and eventually decided that each one of our physicians needed to spend a day in a course on communication. With that, we’ve seen the quality of communication rise and the engagement of doctors with their patients improve, so I think that communication skills certainly are something that can be significantly improved with education and emphasis on it.

Empathy is a more difficult topic. There is a raging debate and vast literature right now focusing on whether empathy can be taught and it would appear that the older the individual is, the more difficult it is to teach empathy.

I think you have to continually raise the awareness of how important empathy is in our industry. One of the things that has served as an aid across the entire field is a formative video that was made here at the Cleveland Clinic. It has now had several million views worldwide and really speaks to empathy and the importance of empathy, particularly in the care giving situation.

SPEAKING.COM: How can healthcare leaders help prevent burnout in their medical staff?

COSGROVE: Burnout is the result of a number of things that have come into play in healthcare recently. The first is the loss of autonomy and moving from the individual to a team approach.

The second is the loss of the insistence upon quality and the measurement of quality, which physicians per se, were not used to but now has become a regular part of the industry.

The third issue is the electronic medical record which people are now spending an enormous amount of time working on recording data.

Finally, the explosion in data has become overwhelming for many physicians.

One of the things that we have tried to do is help physicians in particular, deal with the amount of busy work that they need to do. We’ve hired a pharmacist to do refills. We have hired scribes to help them with their individual history and note taking. We have used technology and Dragon, which is a voice recording, and Medics which is a distance scribe using Google Glass.

We’ve also recognized that physicians often feel isolated so we’ve created social programs for them and we have listened to them very carefully in a multiple tone setting.

The same approach has been implemented across our entire caregiver organization; we’ve use the same tools with nurses, technicians and everyone involved in the care, since the stresses on healthcare providers are enormous right now. The burnout rate among physicians is 50%. Happily it’s substantially lower than that at the Cleveland Clinic, but it’s something that we need to deal with and understand on a regular basis.

My hope for the future is that the electronic medical record is going to be streamlined. The best way to probably do that and help physicians the most will be with natural voice recognition, and several tech companies are currently working on that.

SPEAKING.COM: Is there anything else you’d like to share about improving and lowering costs for healthcare in the United States?

COSGROVE: I think that new technologies are going to help us substantially. We’re going to see an increasing consolidation of healthcare delivery systems. The fee-per-service model is going to move to a value-based one. As that happens, you’ll see new technologies employed and a shift in emphasis on trying to keep more people healthy, out of the hospital and out of healthcare.

It would also be great if we saw a little assistance from government in terms of helping us with epidemics such as diabetes, smoking and opioid addiction, all of which can be improved substantially by legislative activities.

To bring healthcare speaker Dr. Delos Cosgrove to your organization, please contact Michael Frick at: Mike@Speaking.com