February 22, 2010 — President Obama originally laid out three goals for health care reform: increasing access, improving quality and decreasing costs.

Roughly 90 percent of the 2,000-odd pages in the two bills passed by the House and Senate deal with insurance reforms and improved access, but less than 10 percent of the bills deal with improving quality or controlling costs, one expert told a University of Virginia audience on Friday.

While the bills deserve an "A" for improving access, they get a "C" on improving quality, Dr. Delos M. "Toby" Cosgrove, president and chief executive officer of the Cleveland Clinic, a $4.6 billion health care network, said at the Darden Health Innovation Symposium.

The current bills will do very little to control costs, he said, and their "dirty secret" is that costs will increase significantly in coming years, driven by three factors: a growing population, an aging population, and continuing improvements in health care technology that will enable us to do more – and spend more – to treat illness.

On top of those factors, he added, if health care reform succeeds in improving access, the influx of new people served by our system will push up costs even further.

Above and beyond the costs of health care benefits, businesses pay at least twice as much – seven times as much, according to some estimates – in the costs of poor health, including worker productivity losses due to absenteeism, early retirement and chronic disease, said symposium organizer Elizabeth Teisberg, a professor at U.Va.'s Darden School of Business, a leading expert on health care strategy and policy and co-author of "Redefining Health Care: Creating Value Based Competition on Results."

Controlling the skyrocketing costs of health care will require major innovation and redesign of our current health care regime with "a strategy that moves us toward chronic health, rather than chronic disease," Teisberg said.

Friday's symposium brought together two leaders of that redesign: Cosgrove and Tim Brown, president and chief executive officer of the global design firm IDEO.

Perhaps the biggest key to controlling health care costs will be confronting the burden of disease, Cosgrove said. Three preventable conditions – smoking, obesity and lack of activity – cause 40 percent of premature deaths, 70 percent of chronic disease, and 75 percent of all health care costs.

"We can no longer figure that we can live any kind of lifestyle we want and then, when you get sick, expect to be taken care of," he said.

The Cleveland Clinic, comprising the namesake main hospital complex, nine community hospitals, 14 family health and ambulatory surgery centers, and satellite campuses in Florida, Toronto and Abu Dhabi, has taken a number of innovative steps to deal with all three of those conditions.

Summing up the 22,000 surgeries he had performed over his career as a cardio-thoracic surgeon (he earned his M.D. from U.Va.), Cosgrove said, "All I've done is operate on complications of smoking." So he decided to make the Cleveland Clinic a non-smoking enterprise.

They offered free smoking cessation programs and nicotine patches to all employees and the surrounding community. Noting that the average smoker each year takes two weeks worth of smoke breaks and costs an average of $3,000 more than nonsmokers in health care costs, he said, three years ago the clinic stopped hiring smokers, including doctors. Employee drug screenings now test for nicotine as well as other banned substances. The clinic stepped up politically to lobby the Ohio legislature in support of a ban on smoking in public places.

In the Cleveland Clinic's surrounding community of Cuyahoga County, Ohio, smoking rates have fallen from 28 percent of the population to 18 percent, a drop that "probably saved more lives than I did in my entire career," he said.

Next, the clinic attacked obesity and inactivity, starting by removing soda and candy bars from vending machines, removing fryers and trans-fats from their cafeterias, and labeling the calories in all foods served in the cafeterias. Hospital staff were encouraged to exercise, with free access to gyms, yoga, Curves programs, and the like.

In the first year of the push against obesity, clinic staff lost a total of 140,000 pounds. "We probably have another 2 million pounds to go," he added.

When the clinic partnered with the local YMCA to offer a free weight-loss program to the local community, 25,000 people signed up.

"It shows the pent-up demand for such opportunities," Cosgrove said. Such programs also signaled to both Cleveland Clinic staff and the surrounding community that they needed to look after the health of the community, not just the sickness, he said.

Cosgrove created a stir after he was quoted in a New York Times article explaining that "we don't hire smokers and if it wasn't illegal, I wouldn't hire obese people either."

With 50 percent of Ohioans projected to be obese in 2020, "we can't afford anymore to become the fattest nation in world," he said. "We have to deal with the epidemic of obesity that is sweeping the country. This is going to be a long, hard process."

The obesity epidemic has been a source of embarrassment for Americans, he noted, but the controversy created by his comments at least pushes the issue into the open for Americans to begin talking about it, a precondition for confronting the problem. Americans always get to a better solution as a nation, he said, when we can talk openly about embarrassing issues.

The problem of obesity, like smoking and inactivity, won't succumb to a future pill or vaccine, said Brown, the president and CEO of IDEO and the symposium's second keynote speaker. It requires changing our behavior, which is powerfully influenced by the design of our built environment, as Brown outlined with a humorous example.

When authorities at Schiphol Airport in the Netherlands added a life-sized picture of a fly in basins of the restroom urinals, "misses" were reduced by 80 percent, simply because the fly gave men something to aim at, Brown explained.

Similarly, IDEO designed a simple tabletop telemedicine interface, allowing elderly patients to respond daily to simple questions about whether they were following prescribed routines like taking pills, eating regularly and doing exercise. The interface also allowed the health care provider to remotely monitor a patient's deviation from prescribed behavior before serious consequences arose.

Patients with the telemedicine interface were hospitalized 60 percent less than those without it, according to a study by the Veterans Administration, Brown said.

"There's a lot of room for design to make us healthier and reduce health care costs," he said.

We already live in a modern world in which everything around us is designed, he noted. But in the past that design has usually had goals such as promoting more consumption or spending, goals that often run counter to promoting healthy lives.

"The system around us encourages us to consume all sorts of things that aren't healthy for us, not just physically unhealthy, but unhealthy in many ways," Brown said.

The burden of resisting that unhealthy behavior "tends to fall on all of us as individuals, and dealing with these complex issues as individuals is almost completely overwhelming," he said. "We have to deal with it as communities, as a society."

The symposium made it clear that huge changes are needed to right the ailing U.S. health care system.

"Innovation is the only long-term solution to high-quality, affordable health care," Teisberg concluded.