Prevention, efficiency critical: Noted doctor says physician assistants will have greater role in care

Dr. Delos M. “Toby” Cosgrove, left, president and CEO of the Cleveland Clinic, speaks about health care innovation and reform during a discussion with Dr. Robert F. Asbury last month at the Clayton Opera House. Justin Sorensen/ NNY Business

With health care costs ballooning and anxiety about the Affordable Care Act mounting, hospitals should focus on more effective care delivery and campaigns that target smoking and obesity.

That was the message that Dr. Delos M. “Toby” Cosgrove III, Watertown native and president and CEO of the Cleveland Clinic, gave last month to a packed Clayton Opera House during an interview with Dr. Robert F. Asbury, a physician in Rochester who served with Dr. Cosgrove during a residency at Massachusetts General Hospital.

The Cleveland Clinic is a $6.2 billion health care system consistently ranked as one of the four best nationwide. Under the leadership of Dr. Cosgrove, who joined the clinic in 1975 and became chairman of the department of thoracic and cardiovascular surgery in 1989, the clinic’s cardiology program was ranked first nationwide for 10 consecutive years. Dr. Cosgrove has performed more than 22,000 operations, filed 30 patents and published nearly 450 journal articles.

He attributes some of his success and interest in patient care to being an undiagnosed dyslexic until the age of 34, an experience which taught him persistence and a different way of looking at problems, as dyslexics tend to be more creative thinkers. But it did cause him to have an “absolutely horrible academic career” and nearly fail his first year of undergraduate work at Williams College.

“I just thought I was dumb,” he said. “But I think dyslexia was a huge advantage. I never would have gotten through college if not for plain plugging.”

Serving as a surgeon in the U.S. Air Force and as chief of the U.S. Air Force Casualty Staging Flight in Vietnam taught him the importance of hospital transportation systems and the value of physician assistants. He was in charge of a 100-bed hospital treating 75 to 100 patients per day with only one other doctor, 11 nurses and “uncounted” assistants.

This system “allowed everyone to practice at their level of ability and it worked terrifically,” Dr. Cosgrove said.

Hospitals in the Cleveland Clinic’s system, which includes more than 75 northern Ohio outpatient locations, are similarly specialized based on what he called a “FedEx for patients” that moves them around to the right places. The main Cleveland Clinic treats a higher level of illness than any facility in the country; one-third of its beds are intensive care.

Reliance on physician assistants will be key in hospitals nationwide, Dr. Cosgrove said, when the Affordable Care Act exacerbates a physician shortage expected to reach 98,000, half in primary care, in the next 10 years.

At the Cleveland Clinic, with 80 physician assistants and 12 surgeons in cardiac surgery, physicians can focus solely on their role and not tasks such as changing dressings, thus improving the quality of care, he said.

“We’re going to see a major change in who gives care and where it happens,” he said.

Small disruptions to the system, like those happening now with the rise of pharmacies doing more primary care, are the catalyst to future innovations, he said.

The U.S. health care system isn’t currently an integrated model; it lacks a way to move people through a cycle of care between home, hospitals, outpatient clinics and rehabs. Implementing a better delivery system and reducing the burden of disease are the two ways to reduce costs that have escalated to 18 percent of the country’s gross domestic product, the largest percentage of any country in the world, Dr. Cosgrove said.

Initiatives to tackle both of these issues at the Cleveland Clinic include group visits of patients with the same disease, fewer unnecessary lab tests, yearly contracts and reviews of physicians to determine salary, less wasteful use of surgery tools and improved same-day access to physians.

Hospitals also need to look at consolidating services like finances, information technology and purchasing, he said. In the past year, there have been 170 hospital mergers; 60 percent of hospitals nationwide are now part of a system, he said.

“What you’re going to see is hospitals all over the country coming together in one large group,” he said.

To reduce the burden of disease, the Cleveland Clinic stopped hiring smokers, removed all fried food from the cafeteria and placed a premium on exercise. As a result, staff members’ weight has decreased by 400,000 pounds collectively and the percentage of people who smoke in the clinic’s county has declined from 28 percent to 15 percent over five years. Though he said he initially received criticism for his smoking initiative from those who thought it was overstepping the bounds of an employer, today 6,000 businesses nationwide ban smoking.

“You can make a difference,” Dr. Cosgrove said.

He said he is disappointed that the ACA includes few provisions for such initiatives to keep people healthy, given that smoking, obesity and lack of exercise drive 70 percent of chronic disease and 70 percent of health care costs.

But Dr. Cosgrove said it’s too early to determine the impact of the federal health-care overhaul.

“I guarantee it will be different,” he said, calling the changes a different way of administering health care. “I don’t think immediately the cost will go down. But there’s no question it had to change. The current system is unsustainable from a cost standpoint.”

The Cleveland Clinic has teamed up with Community Health Systems—the second largest for-profit health care provider in the country. Dr. Cosgrove said the partnership makes sense because CHS is trying to create an efficient model, and his clinic’s focus on driving quality through transparency must be efficient to be the successful value-based health care model of the future.

“We hope the hybrid helps us to both become more efficient and help spread our model of care,” he said.

In response to a question from the audience about his work with autism, Dr. Cosgrove said that he is “deeply concerned” about higher incidences of both autism and Alzheimer’s disease. One in 88 live births today is an autistic child, he said, alarming considering he knew few autistic children growing up. The number of people over the age of 65 with Alzheimer’s is expected to increase by 40 percent over the next 12 years, to 7.1 million, according to the nonprofit Alzheimer’s Assocation.

But he said he has reason for cautious optimism, as the two areas of innovation that have seen huge progress and have widespread implications for the future are neurological diseases and genomics. With an enhanced ability to understand and image the brain, treatment for these neurological diseases, as well as for diseases like Epilepsy and Parkinson’s, can greatly improve.

“There’s enormous potential to understand how the body works and how effective drugs are,” he said of advances in genomics.

Leah Buletti is a staff writer for NNY Magazines. Reach her at 661-2381 or