Conversation about drug pricing

WEBVTT
Kind: captions
Language: en

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SALMAN KHAN: I'm here
with Professor Laurence

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Baker from Stanford
Medical School,

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and I'm hoping he
can at least start

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to get me to understand
something that I've always

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wondered about and worried
about a little bit.

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Let's say that I'm
some drug company.

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So let me write this down.

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So I'm some pharma
company, pharma company

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A right over here,
and let's say that I

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invest 10 years and $100
million in some drug.

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I get it through all
of the clinical trials,

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and it gets approved by the FDA.

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And let's say, just for sake of
simplicity, it cures disease x.

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Now once I get to
that point, I'm

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feeling pretty good about
myself as a pharma company.

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What happens next?

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I'm assuming that I'm going
to have to go to the insurance

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companies and maybe
Medicaid and Medicare

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and figure out how much
they're going to pay for it,

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but how does that
conversation even happen?

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PROFESSOR LAURENCE BAKER: Yeah.

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So you're going to
have a conversation

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with a bunch of different folks.

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In the US, we have lots of
different private insurance

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plans.

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We've got government plans.

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And you're actually going
to have conversations

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with Europe and with some of the
other systems around the world,

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because each system is going
to make its own decision.

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SALMAN KHAN: And they have
a different way of doing it.

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PROFESSOR LAURENCE
BAKER: They may some

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have similarities in the
way that they probably

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want to talk to you about.

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SALMAN KHAN: Does there
tend to be a lead system?

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Does it tend to be
either the Europeans,

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or does it tend to be the
private insurers in the US?

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Or do you just start all of
those conversations at once

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because there's so much
money on the table?

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PROFESSOR LAURENCE
BAKER: So there

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will be some strategy
your business is going

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to come to because it's
very hard to have all

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of these conversations
exactly simultaneously.

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So you'll talk to the US.

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You'll talk to Europe.

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And there are some
cases in which people

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have viewed the regulatory
processes in Europe

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as a little easier
for some things,

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so they may want
to start in Europe.

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But in other cases, if
you're looking at a drug

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that maybe some of the
national systems in Europe

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are less likely to
want to pay for,

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you might want to start
with the US, where

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there's a little
more flexibility.

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SALMAN KHAN: But the
general rule of thumb

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is all the money is in Europe
and the US mainly right now.

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PROFESSOR LAURENCE
BAKER: A lot of it.

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The Asian systems, some of
them are pretty sophisticated

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and using a lot of the
advanced drugs, too,

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but I think the
majority of the money

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is in the US and
Europe, North America.

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SALMAN KHAN: And between
Europe and the US,

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I guess I've always imagined
North America was maybe

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where the bulk of the money was.

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But is that the case?

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PROFESSOR LAURENCE BAKER:
The US, well, our health care

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system spends more than
everybody in the world,

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and it's true for drugs, too.

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We spend more on drugs here
than most other places.

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SALMAN KHAN: OK.

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So definitely if I'm
here, pharma company A,

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I want to make sure I
get this right in the US.

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PROFESSOR LAURENCE BAKER: Yeah.

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Eventually you probably
care a lot about the US.

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SALMAN KHAN: Part
of my investment

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that I made is based on
some understanding that,

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if I got all the
way through, that I

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would get some type of
return within the US.

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Will I necessarily
immediately go to Medicare

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because they're one of
the largest players,

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or will I go to, like we
talked about, Blue Cross Blue

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Shield or Kaiser or some
of these other players?

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PROFESSOR LAURENCE
BAKER: So Medicare

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is actually an interesting
one for drug prices

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because, historically, Medicare
has not been a big coverer

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and still isn't of a lot of
the drugs that you hear about.

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So Medicare does
not pay by itself

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for outpatient drugs, drugs
that you might take at home.

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SALMAN KHAN: Really?

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I always assumed
that-- they don't.

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PROFESSOR LAURENCE
BAKER: So Medicare,

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in its main pieces-- Medicare,
we call Part A, Part B,

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Part C-- so Part A and
Part B, let's start there.

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They tend not to cover, or they
don't cover, outpatient drugs.

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If you get a drug
in the hospital

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while you're hospitalized,
Medicare will pay for those.

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And so if you've
got a drug that's

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going to be primarily
used in that setting,

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you're going to talk
to Medicare about it,

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and that's going to
be an important piece

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of the conversation.

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But if you're talking
about an outpatient drug,

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you're talking to
many [INAUDIBLE].

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SALMAN KHAN: Now, when
we're saying outpatient,

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inpatient is you're
in the hospital.

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You're sick.

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You need, I don't know,
morphine right now.

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That's inpatient drug.

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PROFESSOR LAURENCE BAKER: Yeah.

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SALMAN KHAN: Outpatient is,
hey, you're going back home.

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Take this three times a day.

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PROFESSOR LAURENCE BAKER: Yeah.

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Somebody sends you
to the pharmacy

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to pick up the prescription,
and you take it home with you.

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That's going to be an
outpatient kind of drug.

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So Medicare doesn't cover that
in its main Part A and Part B.

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There's Medicare Part D, which
is a drug plan in Medicare,

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and that will cover a lot
of the outpatient drugs.

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And so there you'd have
conversations with them.

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But most of the
Medicare Part D plans

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are essentially
private companies

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that Medicare contracts with.

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So you're not really talking to
the government at that point.

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You're talking to these
private plans that

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have contracted with Medicare
to provide Part D care.

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SALMAN KHAN: So once
again going back

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to the crux of the question
of how are these drugs going

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to get paid for,
how are we going

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to determine the price at
which these drugs get paid for,

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it goes straight back
to the private plans

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again because they're
going to contract.

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Part D is going to say,
oh, you're Medicare Part

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D. We're going to
go to go to Aetna.

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We're going to go to some other
plan or whoever it might be.

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I don't know who it might be.

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PROFESSOR LAURENCE
BAKER: Whoever

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is offering those Part D plans.

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SALMAN KHAN: Whoever is
offering those Part D plans--

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and so it will ride off of
whatever that private party has

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already negotiated with
the pharma company.

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PROFESSOR LAURENCE BAKER: It
would be related, probably,

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to that.

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SALMAN KHAN: OK.

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So let's say that we have
some type of insurance.

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I'm running out of letters now.

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Let's call this insurance
company Y right over here.

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And I go have a conversation
with insurance company Y,

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and I'm like, hey,
this is a big deal.

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Disease x, you know it's
been killing people.

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I want $1 million per pill.

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PROFESSOR LAURENCE
BAKER: Yeah, and so those

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have been really interesting
conversations in the US.

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So there's some
bargaining back and forth

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between the insurance
company and the drugmaker.

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The drugmaker is going to
have spent a lot of money.

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You've got $100
million up there.

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SALMAN KHAN: Yes.

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I deserve to make at least $10
billion off-- I'm only kidding.

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PROFESSOR LAURENCE BAKER:
So there's a certain amount,

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to a certain extent [INAUDIBLE].

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SALMAN KHAN: It's called
anchoring in a negotiation.

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PROFESSOR LAURENCE BAKER: Right.

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You start with what
you think you can get.

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SALMAN KHAN: Yes.

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Absolutely, yeah.

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[?

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PROFESSOR LAURENCE BAKER:
Push ?] that number to get

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everybody's mind around, yeah.

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So in reality, it costs
well over $100 million

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to take a drug
through the trials,

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to do the development work.

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So they're going to be sitting
there with a number, at least

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internally, saying, we want
to get our $800 million,

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our $1.5 billion back from this.

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And so we're going to try
and price it accordingly.

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SALMAN KHAN: Because
it's not just

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the cost of that one
drug-- so what is the cost?

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Do you know that off the top
of your head, the average drug?

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PROFESSOR LAURENCE BAKER:
It's hundreds of millions.

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So there's the
development costs that

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go in that the pharma
companies aren't typically

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willing to talk a lot about.

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And then there's
the cost of getting

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through the trials and the FDA
approvals, which people say

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$500 million and up.

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They'll say higher
numbers sometimes.

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SALMAN KHAN: For one given drug?

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PROFESSOR LAURENCE BAKER: Yeah.

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SALMAN KHAN: $500 million.

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So it can be as high
as $500 million.

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PROFESSOR LAURENCE
BAKER: It can be higher.

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SALMAN KHAN: Can be
greater than $500 million.

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And so that doesn't even take
into the probability-weighted

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risk, that there's a
10% chance that it fails

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or a 10% chance that it works.

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So it's really, if you're
spending $100 million per drug

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and only 1 out of
10 of those drugs

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are going to get
to the end zone--

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PROFESSOR LAURENCE BAKER: Yeah.

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You'll see along the way.

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You won't spend a whole
wad and then find out.

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You'll find out in steps.

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So you'll have to spend
something to get there.

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SALMAN KHAN: I see.

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You'll stop.

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So even though on one drug, it
might be $100 million or $500

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million, they might have spent
another $300 million or $400

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million on drugs that
didn't go anywhere.

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PROFESSOR LAURENCE BAKER:
Plus their own development

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costs in the background.

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SALMAN KHAN: Plus their
own development costs.

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So if you try to fully load
the cost, it's a large number.

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PROFESSOR LAURENCE
BAKER: It's large, yeah.

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Right.

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Exactly.

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They're running
an operation where

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they've got to put in a
lot of money in up front.

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When they get a
success, they have

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to get enough out
of that one success

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to pay for the operation,
to keep things going

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for the next development round.

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So they're looking at
those kinds of numbers,

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and they're trying to figure
out in this negotiation what

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they can sell this for.

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And that's a back
and forth discussion.

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The insurance companies
have some ability

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to say what they're
willing to pay,

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but a lot of these
drugs, if they're

00:07:09.719 --> 00:07:12.260
doing the curing a disease that
people care about, the pharma

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companies have a lot of
ability to come and say, this

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is what we need to get for
this and set that price

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and be able to get
it for a while.

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SALMAN KHAN: So obviously,
the pharma company

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is coming here with
all of this investment.

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They definitely want
it to get covered.

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But the insurance company,
their incentive is they

00:07:24.640 --> 00:07:26.431
don't want to look
like, all of the sudden,

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this company that doesn't
provide the cure for disease x.

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Do insurance companies
ever walk away

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and say, well,
that's just too much.

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I understand you invested
all of this money,

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but we just can't do that.

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That's just crazy.

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PROFESSOR LAURENCE
BAKER: So it's

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a little bit of a mixed bag.

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The US doesn't
have a lot of cases

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where insurance companies have
really put their foot down

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and said, no, they're
not going to do anything.

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They're not going
to have anything

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to do with some new
drug that comes out.

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And some of that's
due to the existence

00:07:52.290 --> 00:07:53.630
of lots of different companies.

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So if five of the companies
say no but the next guy in line

00:07:57.070 --> 00:08:00.667
says yes, then the dynamic of
that in a competitive market

00:08:00.667 --> 00:08:03.000
is often that everybody else
will eventually come around

00:08:03.000 --> 00:08:04.290
and say, OK, we're
going to [INAUDIBLE].

00:08:04.290 --> 00:08:06.206
SALMAN KHAN: Someone is
going to do something.

00:08:06.206 --> 00:08:07.665
They might not pay
for it outright.

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The whole reason why we're
having this conversation

00:08:09.790 --> 00:08:11.770
is because there are some drugs
that seem reasonably priced

00:08:11.770 --> 00:08:13.186
to me, but there
are some that are

00:08:13.186 --> 00:08:15.290
like $30,000 a
pill or something.

00:08:15.290 --> 00:08:16.207
I made up that number.

00:08:16.207 --> 00:08:17.498
PROFESSOR LAURENCE BAKER: Yeah.

00:08:17.498 --> 00:08:19.490
So the cases, the
really expensive ones,

00:08:19.490 --> 00:08:23.019
are drugs that are
unique-- tend to be unique,

00:08:23.019 --> 00:08:24.810
at least to some extent--
cure disease that

00:08:24.810 --> 00:08:27.226
gets some high profile, so
people are worried that they're

00:08:27.226 --> 00:08:29.215
going to die if they
don't get this drug.

00:08:29.215 --> 00:08:30.840
And of course, they're
still on patent.

00:08:30.840 --> 00:08:32.375
That's another
feature of all this,

00:08:32.375 --> 00:08:34.750
where you get the high price
for a certain period of time

00:08:34.750 --> 00:08:36.020
until your patents run out.

00:08:36.020 --> 00:08:36.710
SALMAN KHAN: And
then the generic--

00:08:36.710 --> 00:08:37.309
PROFESSOR LAURENCE
BAKER: And then generic

00:08:37.309 --> 00:08:37.640
comes in and the price--

00:08:37.640 --> 00:08:38.760
SALMAN KHAN: Can make them
for the cost of the pill,

00:08:38.760 --> 00:08:39.350
which is--

00:08:39.350 --> 00:08:40.340
PROFESSOR LAURENCE BAKER:
It drops dramatically.

00:08:40.340 --> 00:08:41.700
SALMAN KHAN: Pennies or dollars.

00:08:41.700 --> 00:08:43.200
PROFESSOR LAURENCE
BAKER: So how you

00:08:43.200 --> 00:08:45.430
get these things set
in a competitive market

00:08:45.430 --> 00:08:48.767
is an interesting question.

00:08:48.767 --> 00:08:50.350
One of things that
gets the brand name

00:08:50.350 --> 00:08:52.860
drugs to be a little cheaper is
competition within the class.

00:08:52.860 --> 00:08:54.710
So if there is two or three
drug manufacturers who

00:08:54.710 --> 00:08:56.450
have something that will
basically do the same thing,

00:08:56.450 --> 00:08:59.110
that will tend to take the edge
off the $30,000 a pill kind

00:08:59.110 --> 00:09:02.261
of situation and get you down
to more reasonable prices.

00:09:02.261 --> 00:09:04.427
It won't get you all the
way to generic pricing, but

00:09:04.427 --> 00:09:04.565
[INAUDIBLE].

00:09:04.565 --> 00:09:06.010
SALMAN KHAN: It
just seems to me--

00:09:06.010 --> 00:09:08.385
you just mentioned that very
few insurance companies have

00:09:08.385 --> 00:09:09.540
ever walked away from this.

00:09:09.540 --> 00:09:12.479
If you ever have a negotiation--
buying a used car--

00:09:12.479 --> 00:09:14.520
where one of the two
parties is not walking away,

00:09:14.520 --> 00:09:15.630
then it doesn't seem
like there's actually

00:09:15.630 --> 00:09:17.273
a hard, serious negotiation.

00:09:17.273 --> 00:09:18.390
Am I getting that wrong?

00:09:18.390 --> 00:09:20.294
PROFESSOR LAURENCE
BAKER: Yeah, I

00:09:20.294 --> 00:09:22.710
don't know all the ins and
outs of all these negotiations.

00:09:22.710 --> 00:09:24.340
There's lots that goes
on in these things.

00:09:24.340 --> 00:09:26.506
But I think that one of the
things that people would

00:09:26.506 --> 00:09:30.510
say about the US is that when
a drug manufacturer comes up

00:09:30.510 --> 00:09:33.830
with fairly unique,
on-patent drug

00:09:33.830 --> 00:09:37.000
that does some tangible good,
that they more or less can

00:09:37.000 --> 00:09:39.170
set the price that they
want to get for it.

00:09:39.170 --> 00:09:41.350
And they're going to make some
calculation, because they could

00:09:41.350 --> 00:09:43.530
set a high enough price that
everybody would say forget it.

00:09:43.530 --> 00:09:45.160
So they're going to try
and figure out something.

00:09:45.160 --> 00:09:47.070
But they're trying to
get as much as they can,

00:09:47.070 --> 00:09:49.300
and they get some leeway for
at least a period of time

00:09:49.300 --> 00:09:49.580
to name that price.

00:09:49.580 --> 00:09:51.038
SALMAN KHAN: So
they'll get leeway,

00:09:51.038 --> 00:09:53.730
and I guess there's some
range of reasonableness

00:09:53.730 --> 00:09:54.720
where it's like, OK.

00:09:54.720 --> 00:09:57.340
Yes, you've done something
amazing for humanity.

00:09:57.340 --> 00:10:01.140
You're going to get a 35%
return on your investment,

00:10:01.140 --> 00:10:03.432
but that shouldn't be a 300%
return on your investment.

00:10:03.432 --> 00:10:04.723
PROFESSOR LAURENCE BAKER: Yeah.

00:10:04.723 --> 00:10:06.859
I don't know at what point
the US would ever walk

00:10:06.859 --> 00:10:08.900
or the private insurers
will ever walk from this.

00:10:08.900 --> 00:10:10.950
I haven't seen it
really happen, and I

00:10:10.950 --> 00:10:13.520
think drug companies are pretty
sophisticated about trying

00:10:13.520 --> 00:10:14.978
to figure out what
price they think

00:10:14.978 --> 00:10:17.856
they can make work and get that
as high as they can get that.

00:10:17.856 --> 00:10:20.160
SALMAN KHAN: So
I guess I'm still

00:10:20.160 --> 00:10:23.414
unclear to see who's making
out here really well.

00:10:23.414 --> 00:10:24.830
PROFESSOR LAURENCE
BAKER: This has

00:10:24.830 --> 00:10:26.521
been a really
interesting debate.

00:10:26.521 --> 00:10:28.270
Pharma companies put
huge amounts of money

00:10:28.270 --> 00:10:28.978
into these drugs.

00:10:28.978 --> 00:10:31.430
And once in a while, they do
some really useful things,

00:10:31.430 --> 00:10:32.640
and they get high premiums.

00:10:32.640 --> 00:10:33.893
There are other people
who argue that some

00:10:33.893 --> 00:10:36.110
of the things that they're
getting high premiums for

00:10:36.110 --> 00:10:39.060
aren't really valuable
enough or somehow we've

00:10:39.060 --> 00:10:41.762
been told we need a
drug that, if we had it

00:10:41.762 --> 00:10:43.720
to our own devices, we
would never have come up

00:10:43.720 --> 00:10:44.830
with the fact that we need it.

00:10:44.830 --> 00:10:47.080
And so what's the real
value at the end of the day?

00:10:47.080 --> 00:10:48.420
And I think that's one
of the debates we're

00:10:48.420 --> 00:10:50.110
going to have in this
country for a little while.

00:10:50.110 --> 00:10:52.110
The industry has been
coming up with new things,

00:10:52.110 --> 00:10:54.510
and they're going to
keep trying to do that.

00:10:54.510 --> 00:10:57.280
We want to, from a social
standpoint, from a policy

00:10:57.280 --> 00:10:59.510
standpoint, try to make
sure that things we're doing

00:10:59.510 --> 00:11:03.100
are really valuable to society
and not copies of other drugs

00:11:03.100 --> 00:11:05.440
or not inventing a disease
that didn't need a solution

00:11:05.440 --> 00:11:06.710
and then solving the problem.

00:11:06.710 --> 00:11:08.100
And sometimes we
worry that maybe we're

00:11:08.100 --> 00:11:08.975
getting some of that.

00:11:08.975 --> 00:11:11.480
And I think that's the challenge
for the US health insurance

00:11:11.480 --> 00:11:13.210
system, for the
regulatory processes

00:11:13.210 --> 00:11:15.665
to try to guide the
innovation and guide

00:11:15.665 --> 00:11:17.700
the purchasing of these
things to really create

00:11:17.700 --> 00:11:18.845
the most value for society.

00:11:18.845 --> 00:11:19.850
It's been a challenge.

00:11:19.850 --> 00:11:20.820
It's going to be a challenge.

00:11:20.820 --> 00:11:22.645
We have the challenge, because
we have tremendous opportunity

00:11:22.645 --> 00:11:22.960
with new drugs created.

00:11:22.960 --> 00:11:25.050
SALMAN KHAN: So your gut
sense is there probably

00:11:25.050 --> 00:11:32.080
are some drugs out there that
they're doing really well,

00:11:32.080 --> 00:11:33.960
well above and beyond
the investment cost,

00:11:33.960 --> 00:11:34.834
but it's hard to say.

00:11:34.834 --> 00:11:36.665
It's really on a
case by case basis.

00:11:36.665 --> 00:11:37.280
PROFESSOR LAURENCE
BAKER: Yeah, I

00:11:37.280 --> 00:11:39.870
don't think you'd want to make
a generic statement about all

00:11:39.870 --> 00:11:40.980
the drugs that have
been discovered.

00:11:40.980 --> 00:11:42.250
Some of the things that
we've put out there

00:11:42.250 --> 00:11:43.990
in the last couple
of decades are really

00:11:43.990 --> 00:11:46.114
important drugs that are
going to do a lot of good.

00:11:46.114 --> 00:11:48.500
And I think there are debates
about some other ones where

00:11:48.500 --> 00:11:50.800
maybe somebody's been able
to be clever about marketing

00:11:50.800 --> 00:11:52.885
and sell it, and we're less
sure that it's [INAUDIBLE].

00:11:52.885 --> 00:11:54.100
SALMAN KHAN: And that,
actually, marketing-- I

00:11:54.100 --> 00:11:56.650
don't want to make this
conversation too long--

00:11:56.650 --> 00:11:59.186
but some people bring up that
the drug companies, they say,

00:11:59.186 --> 00:12:00.810
look, there's a lot
of investment right

00:12:00.810 --> 00:12:01.637
over here on this.

00:12:01.637 --> 00:12:03.845
And so they have to get some
reasonable return on it,

00:12:03.845 --> 00:12:05.780
and that seems to make sense,
especially when you probability

00:12:05.780 --> 00:12:07.090
weight it and all of that.

00:12:07.090 --> 00:12:09.370
But they spend a significant
amount of marketing

00:12:09.370 --> 00:12:10.930
as well, on actual marketing.

00:12:10.930 --> 00:12:13.020
You watch the nightly
news, most of the ads,

00:12:13.020 --> 00:12:13.780
you're going to
see a drug company.

00:12:13.780 --> 00:12:16.363
They do the physician dinners,
and they do all of their things

00:12:16.363 --> 00:12:17.317
like that.

00:12:17.317 --> 00:12:19.775
That seems to undermine that
argument that all of the money

00:12:19.775 --> 00:12:21.457
is going for R&D.

00:12:21.457 --> 00:12:22.790
PROFESSOR LAURENCE BAKER: Right.

00:12:22.790 --> 00:12:24.290
If you just totalled
up the dollars,

00:12:24.290 --> 00:12:27.750
I'm not sure what the
numbers would come out like,

00:12:27.750 --> 00:12:29.956
and honestly, the
pharma companies

00:12:29.956 --> 00:12:31.830
aren't really excited
about telling everybody

00:12:31.830 --> 00:12:34.500
all of the details of their
businesses for good reason.

00:12:34.500 --> 00:12:36.109
So absolutely,
there's a huge amount

00:12:36.109 --> 00:12:37.150
of marketing [INAUDIBLE].

00:12:37.150 --> 00:12:38.770
SALMAN KHAN: You spend a ton
of money on the marketing.

00:12:38.770 --> 00:12:40.430
And then you get
the consumer here

00:12:40.430 --> 00:12:42.170
to put the pressure
on the insurance

00:12:42.170 --> 00:12:45.220
companies and the doctors to
say, hey, you better cover

00:12:45.220 --> 00:12:46.489
that, or I'm asking for that.

00:12:46.489 --> 00:12:47.780
PROFESSOR LAURENCE BAKER: Yeah.

00:12:47.780 --> 00:12:51.070
There was a time
within my memory

00:12:51.070 --> 00:12:53.770
where we weren't allowed
to do direct to consumer

00:12:53.770 --> 00:12:55.650
marketing, where the
laws prohibited that.

00:12:55.650 --> 00:12:57.795
And the change came around,
and now we're allowed to do it.

00:12:57.795 --> 00:12:59.100
And it's really changed the
way that drugs are marketed.

00:12:59.100 --> 00:13:00.140
SALMAN KHAN: And I
have found that weird

00:13:00.140 --> 00:13:01.889
because, if these are
drugs that are meant

00:13:01.889 --> 00:13:04.802
to be by prescription, which
means that it should be

00:13:04.802 --> 00:13:06.343
a doctor's judgment
on whether or not

00:13:06.343 --> 00:13:08.509
you should get the drugs,
why is it being advertised

00:13:08.509 --> 00:13:10.480
on the nightly news
to a general audience?

00:13:10.480 --> 00:13:11.350
PROFESSOR LAURENCE
BAKER: Right-- a general

00:13:11.350 --> 00:13:13.516
audience who doesn't
understand all the ins and outs

00:13:13.516 --> 00:13:15.790
of the drug and whose
doctor may or may not

00:13:15.790 --> 00:13:17.290
want to take the time to
explain it all to them.

00:13:17.290 --> 00:13:17.870
SALMAN KHAN: Exactly.

00:13:17.870 --> 00:13:19.380
But then they'll go to
the doctor and say, please

00:13:19.380 --> 00:13:20.170
give me this drug.

00:13:20.170 --> 00:13:21.845
And then the doctor, it's easier
for them to say, well, sure.

00:13:21.845 --> 00:13:22.015
Why not?

00:13:22.015 --> 00:13:22.670
PROFESSOR LAURENCE BAKER: Yeah.

00:13:22.670 --> 00:13:24.050
No, I think a lot
of doctors would

00:13:24.050 --> 00:13:25.920
express a certain amount
of frustration about that.

00:13:25.920 --> 00:13:26.690
Their patients come in.

00:13:26.690 --> 00:13:28.460
It's hard to have the
conversation in a short period

00:13:28.460 --> 00:13:30.680
of time, so it's easier
just to give them the drug.

00:13:30.680 --> 00:13:31.967
SALMAN KHAN: Fascinating.


Blue Cross and Blue Shield

WEBVTT
Kind: captions
Language: en

00:00:00.330 --> 00:00:02.080
SAL KHAN: I'm here
with Dr. Laurence Baker

00:00:02.080 --> 00:00:03.600
from Stanford
Medical School, who

00:00:03.600 --> 00:00:05.640
specializes in
health care policy.

00:00:05.640 --> 00:00:09.220
And I have just a
very basic question.

00:00:09.220 --> 00:00:12.240
We see these Blue Cross and
Blue Shield all of the time.

00:00:12.240 --> 00:00:13.740
And sometimes they're
used together,

00:00:13.740 --> 00:00:14.750
sometimes they're
used differently.

00:00:14.750 --> 00:00:16.210
And it just seems
confusing to me.

00:00:16.210 --> 00:00:19.332
What are these things, and how
are they related to each other?

00:00:19.332 --> 00:00:20.915
DR. LAURENCE BAKER:
So they're related

00:00:20.915 --> 00:00:22.248
in some really interesting ways.

00:00:22.248 --> 00:00:24.480
They go way back in time.

00:00:24.480 --> 00:00:27.564
So Blue Cross and Blue Shield
began as separate things.

00:00:27.564 --> 00:00:28.980
Let's see if I can
get this right.

00:00:28.980 --> 00:00:31.550
Blue Shield was
started by doctors

00:00:31.550 --> 00:00:33.100
who wanted to set
up a health care

00:00:33.100 --> 00:00:36.180
plan to help their
patients get coverage.

00:00:36.180 --> 00:00:38.480
SAL KHAN: Kind of a
preventative shield

00:00:38.480 --> 00:00:40.050
to help things from
getting to you.

00:00:40.050 --> 00:00:40.550
Right.

00:00:40.550 --> 00:00:40.650
Right.

00:00:40.650 --> 00:00:40.750
Right.

00:00:40.750 --> 00:00:41.110
DR. LAURENCE BAKER: Yes.

00:00:41.110 --> 00:00:42.970
So that was started
a long time ago.

00:00:42.970 --> 00:00:47.200
These both go back, Blue Cross
and Blue Shield, to the 1930s,

00:00:47.200 --> 00:00:48.880
really, they're getting started.

00:00:48.880 --> 00:00:52.306
Blue Cross was started
by the hospitals,

00:00:52.306 --> 00:00:53.930
separately from Blue
Shield originally,

00:00:53.930 --> 00:00:55.530
and they got together
later as a way

00:00:55.530 --> 00:00:57.530
to help patients get
coverage for hospital care.

00:00:57.530 --> 00:00:59.654
SAL KHAN: And I guess the
cross because once you're

00:00:59.654 --> 00:01:02.190
in the hospital, you might
get a little religious.

00:01:02.190 --> 00:01:02.860
DR. LAURENCE BAKER: Exactly.

00:01:02.860 --> 00:01:04.970
I mean, I'm not sure that's what
they had in mind originally,

00:01:04.970 --> 00:01:05.690
but--

00:01:05.690 --> 00:01:07.650
SAL KHAN: And what
about the blue?

00:01:07.650 --> 00:01:08.590
DR. LAURENCE BAKER: I don't
know where the blue comes from.

00:01:08.590 --> 00:01:10.320
SAL KHAN: Is that just a color
that makes people feel good,

00:01:10.320 --> 00:01:11.740
it's like a health care color?

00:01:11.740 --> 00:01:12.760
DR. LAURENCE BAKER: I think it
must be a health care color.

00:01:12.760 --> 00:01:14.230
SAL KHAN: Red would
be inappropriate.

00:01:14.230 --> 00:01:15.854
DR. LAURENCE BAKER:
Let's go with blue.

00:01:15.854 --> 00:01:17.210
You're not bleeding with blue.

00:01:17.210 --> 00:01:18.876
SAL KHAN: Blue is--
you look at the sky.

00:01:18.876 --> 00:01:19.690
OK.

00:01:19.690 --> 00:01:20.650
And so what happened?

00:01:20.650 --> 00:01:22.790
So, I do see these
words used together.

00:01:22.790 --> 00:01:25.110
So these were separate plans.

00:01:25.110 --> 00:01:26.660
Doctors created
the Blue Shields.

00:01:26.660 --> 00:01:29.040
Hospitals created
the Blue Cross.

00:01:29.040 --> 00:01:31.040
DR. LAURENCE BAKER: And
then they grew over time

00:01:31.040 --> 00:01:31.810
and changed.

00:01:31.810 --> 00:01:33.290
So they got started in the '30s.

00:01:33.290 --> 00:01:37.340
They were around through the
'40s and the '50s, '60s, '70s,

00:01:37.340 --> 00:01:39.610
and so a couple things
happen along the way that

00:01:39.610 --> 00:01:42.260
starts to make things
confusing a little bit.

00:01:42.260 --> 00:01:46.300
One is that they're operating
in every state, to some extent,

00:01:46.300 --> 00:01:47.040
independently.

00:01:47.040 --> 00:01:49.932
So, states regulate health
insurance in this country,

00:01:49.932 --> 00:01:51.390
or have a lot to
do with regulating

00:01:51.390 --> 00:01:52.765
health insurance
in this country.

00:01:52.765 --> 00:01:54.640
And so, every state
had its own laws.

00:01:54.640 --> 00:01:57.270
And as a result, the Blue
Cross and the Blue Shield plans

00:01:57.270 --> 00:01:59.870
in different states grew
up in different ways.

00:01:59.870 --> 00:02:01.980
So what you come down
to today is really

00:02:01.980 --> 00:02:04.290
different plans in
every state because

00:02:04.290 --> 00:02:05.730
of this history of development.

00:02:05.730 --> 00:02:07.460
As states develop
their laws differently,

00:02:07.460 --> 00:02:09.550
the plans would evolve
in the different states.

00:02:09.550 --> 00:02:10.000
SAL KHAN: I see.

00:02:10.000 --> 00:02:12.583
So this is just to give myself
a kind of a framework of what's

00:02:12.583 --> 00:02:16.050
happening, is that pre-1920s,
early 1930s, there really

00:02:16.050 --> 00:02:17.240
weren't health care plans.

00:02:17.240 --> 00:02:18.270
DR. LAURENCE BAKER:
Not to speak of.

00:02:18.270 --> 00:02:20.870
SAL KHAN: The physicians said,
hey, we want a way for people

00:02:20.870 --> 00:02:24.060
to see us without having
to-- some way for them

00:02:24.060 --> 00:02:26.260
to be paying a little bit
every month or every year,

00:02:26.260 --> 00:02:27.801
and that if something
were to happen,

00:02:27.801 --> 00:02:29.150
they could see the doctors.

00:02:29.150 --> 00:02:31.061
The hospitals kind of
had the same model.

00:02:31.061 --> 00:02:32.810
But they did it
differently in every state

00:02:32.810 --> 00:02:35.190
because the state
is the regulatory--

00:02:35.190 --> 00:02:36.820
DR. LAURENCE BAKER: The state
especially-- well, in the '30s,

00:02:36.820 --> 00:02:38.040
there weren't a lot
of state regulations

00:02:38.040 --> 00:02:38.750
about health insurance.

00:02:38.750 --> 00:02:39.700
There wasn't health insurance.

00:02:39.700 --> 00:02:40.150
SAL KHAN: Right.

00:02:40.150 --> 00:02:41.230
DR. LAURENCE BAKER:
But as states evolved,

00:02:41.230 --> 00:02:43.563
as the health care system
evolved, as the plans evolved,

00:02:43.563 --> 00:02:46.770
it grew separately in
slightly different directions

00:02:46.770 --> 00:02:47.430
in every state.

00:02:47.430 --> 00:02:49.420
So that led to the
formation really of,

00:02:49.420 --> 00:02:52.210
you see Blue Cross of Tennessee,
or Blue Shield of Florida,

00:02:52.210 --> 00:02:54.089
or Blue Cross Blue
Shield of Michigan.

00:02:54.089 --> 00:02:56.630
They're all different, because
they're all in their own state

00:02:56.630 --> 00:02:58.671
environment and they've
all grown up differently.

00:02:58.671 --> 00:03:01.060
SAL KHAN: So, normally--
these kind of are brands.

00:03:01.060 --> 00:03:02.800
We've all heard of
them in that way.

00:03:02.800 --> 00:03:05.450
But normally, a brand
means something.

00:03:05.450 --> 00:03:08.350
It means more quality,
or less quality,

00:03:08.350 --> 00:03:10.080
or some type of
spin on-- you know,

00:03:10.080 --> 00:03:12.630
Apple means fun
consumer experience

00:03:12.630 --> 00:03:13.690
or something like that.

00:03:13.690 --> 00:03:16.850
But in this case, if I'm
hearing you correctly,

00:03:16.850 --> 00:03:18.620
if there's Blue
Cross of California

00:03:18.620 --> 00:03:21.740
and Blue Cross of
Texas, they have nothing

00:03:21.740 --> 00:03:24.364
to do with each other, or very
little to do with each other?

00:03:24.364 --> 00:03:26.530
DR. LAURENCE BAKER: So they
all had their start kind

00:03:26.530 --> 00:03:28.238
of together in the
'30s, and then they've

00:03:28.238 --> 00:03:29.560
all grown in their own ways.

00:03:29.560 --> 00:03:32.500
But they've stayed
related, and some of them

00:03:32.500 --> 00:03:33.980
to greater extents than others.

00:03:33.980 --> 00:03:36.690
And so one of the things that
happened along the way was they

00:03:36.690 --> 00:03:37.614
formed an association.

00:03:37.614 --> 00:03:40.030
There's now something in the
US called the Blue Cross Blue

00:03:40.030 --> 00:03:44.570
Shield Association,
which is a I guess

00:03:44.570 --> 00:03:47.470
an association of a lot of
the plans in different states

00:03:47.470 --> 00:03:50.240
that allows them to talk to each
other, to try to work together.

00:03:50.240 --> 00:03:51.615
SAL KHAN: And this
is an umbrella

00:03:51.615 --> 00:03:54.000
for all of the Blue Cross
and all of the Blue Shields.

00:03:54.000 --> 00:03:56.740
So that's why we hear them
used so frequently together.

00:03:56.740 --> 00:03:57.550
People say Blue
Cross Blue Shield.

00:03:57.550 --> 00:03:58.340
DR. LAURENCE BAKER: Yeah.

00:03:58.340 --> 00:04:00.390
So there's two reasons
you hear that together.

00:04:00.390 --> 00:04:02.260
One is the
association that tries

00:04:02.260 --> 00:04:04.294
to work with plans
from both groups.

00:04:04.294 --> 00:04:05.710
The other is that,
in some states,

00:04:05.710 --> 00:04:07.870
over time, the two got
together and actually became

00:04:07.870 --> 00:04:09.074
one health insurance plan.

00:04:09.074 --> 00:04:10.990
So there are states where
the health insurance

00:04:10.990 --> 00:04:14.290
plan is Blue Cross and
Blue Shield of a state.

00:04:14.290 --> 00:04:16.540
And there are other states
where they stayed separate.

00:04:16.540 --> 00:04:19.190
So, we're here in California,
where Blue Shield and Blue

00:04:19.190 --> 00:04:21.389
Cross have historically
stayed as separate plans.

00:04:21.389 --> 00:04:23.680
But there are some states
where they're the same thing.

00:04:23.680 --> 00:04:25.638
And then you'd hear Blue
Cross and Blue Shield.

00:04:25.638 --> 00:04:29.180
SAL KHAN: So if someone tells
you Blue Cross of state x,

00:04:29.180 --> 00:04:31.560
that just means to you
health insurance plan.

00:04:31.560 --> 00:04:34.602
There's nothing else that you
can really take from that.

00:04:34.602 --> 00:04:36.310
DR. LAURENCE BAKER:
So, once upon a time,

00:04:36.310 --> 00:04:38.143
you may have been able
to take more from it.

00:04:38.143 --> 00:04:40.477
But these days, it's
possible for them

00:04:40.477 --> 00:04:42.060
to vary in quite a
few different ways.

00:04:42.060 --> 00:04:44.930
Some of the Blue Cross
and Blue Shield plans,

00:04:44.930 --> 00:04:48.260
especially the Blue Cross plans,
have become for-profit plans.

00:04:48.260 --> 00:04:50.560
So, historically these
were always nonprofit.

00:04:50.560 --> 00:04:51.290
But in the last--

00:04:51.290 --> 00:04:52.470
SAL KHAN: So Blue Cross
especially, some of them

00:04:52.470 --> 00:04:53.760
have gone for-profit.

00:04:53.760 --> 00:04:54.760
DR. LAURENCE BAKER: Yes.

00:04:54.760 --> 00:04:56.760
I think, in both
cases, but Blue Cross

00:04:56.760 --> 00:04:59.774
is the one that I pay
more attention to.

00:04:59.774 --> 00:05:01.034
SAL KHAN: Right.

00:05:01.034 --> 00:05:02.450
DR. LAURENCE BAKER:
So they may be

00:05:02.450 --> 00:05:05.060
for-profit or
not-for-profit plans.

00:05:05.060 --> 00:05:07.710
They may act in similar ways.

00:05:07.710 --> 00:05:10.630
And they do, because at least
the ones in the association,

00:05:10.630 --> 00:05:13.091
tend to act with some
similarity from place to place.

00:05:13.091 --> 00:05:14.590
SAL KHAN: And just
to-- because I've

00:05:14.590 --> 00:05:15.810
explained this all
the time about even--

00:05:15.810 --> 00:05:17.185
Khan Academy is
a not-for-profit.

00:05:17.185 --> 00:05:19.560
A not-for-profit is an
entity, it can, in theory,

00:05:19.560 --> 00:05:22.030
charge revenue-- Khan Academy
doesn't-- but it could charge

00:05:22.030 --> 00:05:22.280
revenue.

00:05:22.280 --> 00:05:23.946
But there's no owner
of the organization

00:05:23.946 --> 00:05:25.790
who can become rich off of it.

00:05:25.790 --> 00:05:27.460
It's owned by the public.

00:05:27.460 --> 00:05:30.030
While a for-profit
has shareholders,

00:05:30.030 --> 00:05:32.090
and it can be bought
and sold, and it

00:05:32.090 --> 00:05:33.674
can issue dividends,
and all the rest.

00:05:33.674 --> 00:05:34.715
DR. LAURENCE BAKER: Yeah.

00:05:34.715 --> 00:05:36.720
So, historically in
America, most health plans

00:05:36.720 --> 00:05:38.480
were not-for-profit entities.

00:05:38.480 --> 00:05:42.520
They couldn't take
money that they earned

00:05:42.520 --> 00:05:44.750
and give it out to people
who might be the owners.

00:05:44.750 --> 00:05:46.080
They'd have to be reinvested.

00:05:46.080 --> 00:05:46.330
SAL KHAN: Exactly.

00:05:46.330 --> 00:05:48.260
DR. LAURENCE BAKER: In fact,
even in the early days of Blue

00:05:48.260 --> 00:05:49.801
Cross and Blue Shield
in some states,

00:05:49.801 --> 00:05:51.860
they were treated as
quasi-public entities.

00:05:51.860 --> 00:05:52.070
SAL KHAN: Right.

00:05:52.070 --> 00:05:52.170
Right.

00:05:52.170 --> 00:05:52.620
Right.

00:05:52.620 --> 00:05:53.340
DR. LAURENCE BAKER:
And they've kind of

00:05:53.340 --> 00:05:54.673
grown away from that a bit more.

00:05:54.673 --> 00:05:56.655
But there's this
history, especially

00:05:56.655 --> 00:05:59.010
with Blue Cross and Blue
Shield, of very not-for-profit,

00:05:59.010 --> 00:06:00.650
public-spirited entities.

00:06:00.650 --> 00:06:03.140
When you get to for-profit
plans, which we really

00:06:03.140 --> 00:06:05.260
didn't have in the
US in a big way

00:06:05.260 --> 00:06:07.600
until maybe the
last decade or two,

00:06:07.600 --> 00:06:10.050
where we've seen
some conversions.

00:06:10.050 --> 00:06:12.760
These are situations where
the plan can act explicitly

00:06:12.760 --> 00:06:15.536
as a profit generator for its
shareholders, for its owners.

00:06:15.536 --> 00:06:17.286
SAL KHAN: And some are
now publicly traded

00:06:17.286 --> 00:06:18.460
and they're on the
stock exchange.

00:06:18.460 --> 00:06:19.800
DR. LAURENCE BAKER: They may
be publicly traded, yeah.

00:06:19.800 --> 00:06:21.840
SAL KHAN: And so when
we talk about some

00:06:21.840 --> 00:06:23.510
of them becoming
for-profit here,

00:06:23.510 --> 00:06:25.350
it's that literally--
I don't know,

00:06:25.350 --> 00:06:28.822
the license to use the name
either Blue Cross or Blue

00:06:28.822 --> 00:06:30.280
Shield, or maybe
some of the assets

00:06:30.280 --> 00:06:33.100
of the former not-for-profit
are somehow transferred,

00:06:33.100 --> 00:06:34.979
or I guess a
for-profit buys them.

00:06:34.979 --> 00:06:37.270
DR. LAURENCE BAKER: So we
had a series of these things.

00:06:37.270 --> 00:06:38.311
We call them conversions.

00:06:38.311 --> 00:06:41.700
And when the company converted
from being a not-for-profit

00:06:41.700 --> 00:06:43.329
to a for-profit,
there were a lot

00:06:43.329 --> 00:06:44.870
of states in which
those conversions,

00:06:44.870 --> 00:06:47.780
or situations in which
they happened, where

00:06:47.780 --> 00:06:52.880
the public, the
government, somebody

00:06:52.880 --> 00:06:57.810
compelled the for-profit
entity in the conversion

00:06:57.810 --> 00:06:59.234
to create a public good.

00:06:59.234 --> 00:07:01.150
So there are some
foundations that now exist--

00:07:01.150 --> 00:07:01.984
SAL KHAN: Oh, I see.

00:07:01.984 --> 00:07:03.566
DR. LAURENCE BAKER:
In the conversion,

00:07:03.566 --> 00:07:06.170
they allowed a transfer of a
not-for-profit to a for-profit,

00:07:06.170 --> 00:07:08.670
but you had to create something
valuable for the public.

00:07:08.670 --> 00:07:10.400
So some of the things
that we see now

00:07:10.400 --> 00:07:11.983
in states, some of
the big foundations

00:07:11.983 --> 00:07:14.200
that exist in health care,
are conversion foundations

00:07:14.200 --> 00:07:15.711
around the for-profit
conversions

00:07:15.711 --> 00:07:16.960
of Blue Cross and Blue Shield.

00:07:16.960 --> 00:07:17.750
SAL KHAN: I see.

00:07:17.750 --> 00:07:20.446
But when we see things like--
I think it's, I always get

00:07:20.446 --> 00:07:22.320
confused between Blue
Cross and Blue Shield--

00:07:22.320 --> 00:07:24.910
but I believe Anthem has a
kind of a-- Let me see here,

00:07:24.910 --> 00:07:26.545
Anthem was a Blue--

00:07:26.545 --> 00:07:28.490
DR. LAURENCE BAKER: Blue
Cross in California.

00:07:28.490 --> 00:07:35.060
So, Anthem is a company
that is a large company that

00:07:35.060 --> 00:07:39.590
has Blue Cross, I think mostly
Blue Cross or all Blue Cross

00:07:39.590 --> 00:07:41.902
affiliates or entities
in different states.

00:07:41.902 --> 00:07:43.360
I think there are
14 or 15 of them.

00:07:43.360 --> 00:07:46.700
SAL KHAN: So these are
for-profit Blue Crosses

00:07:46.700 --> 00:07:48.020
if they have Anthem with them.

00:07:48.020 --> 00:07:49.490
DR. LAURENCE BAKER: I
believe that's correct.

00:07:49.490 --> 00:07:50.150
SAL KHAN: Right.

00:07:50.150 --> 00:07:50.510
Right.

00:07:50.510 --> 00:07:51.010
Right.

00:07:51.010 --> 00:07:53.156
And is there any, I guess
in how they operate,

00:07:53.156 --> 00:07:55.030
from a consumer point
of view, any difference

00:07:55.030 --> 00:07:56.988
between a for-profit Blue
Cross or Blue Shield,

00:07:56.988 --> 00:07:59.200
or is there anything
that we can tell?

00:07:59.200 --> 00:07:59.610
DR. LAURENCE BAKER:
So, that's actually

00:07:59.610 --> 00:08:00.780
a really interesting question.

00:08:00.780 --> 00:08:02.321
There are people
who've gone to look,

00:08:02.321 --> 00:08:03.860
and they've tried
to sometimes find

00:08:03.860 --> 00:08:05.700
some evidence for differences.

00:08:05.700 --> 00:08:07.096
There are a few
studies out there

00:08:07.096 --> 00:08:08.720
where people can find
some differences.

00:08:08.720 --> 00:08:10.330
But there's not
a lot of evidence

00:08:10.330 --> 00:08:11.959
that they behave
really differently.

00:08:11.959 --> 00:08:13.750
At the end of the day,
they have to compete

00:08:13.750 --> 00:08:16.190
in the same marketplace for the
business of the same companies

00:08:16.190 --> 00:08:17.160
and the same people.

00:08:17.160 --> 00:08:19.260
And if they behaved really
obviously different,

00:08:19.260 --> 00:08:21.757
if one was obviously way
better than the other,

00:08:21.757 --> 00:08:23.840
the market would sort out
who's going to win this.

00:08:23.840 --> 00:08:26.290
And the market has allowed
both types to exist.

00:08:26.290 --> 00:08:28.880
So, there are certainly
differences in the written

00:08:28.880 --> 00:08:31.850
charters, and maybe
differences in the preferences

00:08:31.850 --> 00:08:34.454
in the stated
ideals of the people

00:08:34.454 --> 00:08:35.620
who run these organizations.

00:08:35.620 --> 00:08:38.219
And that might make a
difference in some cases.

00:08:38.219 --> 00:08:40.010
But it's hard when you
get it all together,

00:08:40.010 --> 00:08:42.280
and you really go try to do
national data or something

00:08:42.280 --> 00:08:44.030
to find a big
difference between them.

00:08:44.030 --> 00:08:45.404
SAL KHAN: So the
big picture here

00:08:45.404 --> 00:08:47.660
is, as much as I've
looked at health care

00:08:47.660 --> 00:08:49.952
plans even when were trying
to figure out for employees

00:08:49.952 --> 00:08:51.993
at Khan Academy, which
health care plan to choose

00:08:51.993 --> 00:08:52.630
and which not.

00:08:52.630 --> 00:08:53.680
And I've stared, oh,
what's the difference

00:08:53.680 --> 00:08:55.220
between Blue Cross
and Blue Shield?

00:08:55.220 --> 00:08:57.053
There's actually very
little I can tell just

00:08:57.053 --> 00:08:58.240
by looking at those brands.

00:08:58.240 --> 00:08:59.400
I would really
have to dig deeper

00:08:59.400 --> 00:09:00.700
into the actual
health care policy.

00:09:00.700 --> 00:09:02.750
And that's going to be
different from state to state,

00:09:02.750 --> 00:09:04.958
and some will be for-profit,
some will be not-profit.

00:09:04.958 --> 00:09:07.690
Even that's not enough to tell
you a general rule of thumb.

00:09:07.690 --> 00:09:09.460
You really just have to look
at the health care plans.

00:09:09.460 --> 00:09:10.830
DR. LAURENCE BAKER: You have to
look at the health care plans.

00:09:10.830 --> 00:09:12.420
And it's Blue Cross
and Blue Shield.

00:09:12.420 --> 00:09:14.020
But there's other
plans out there.

00:09:14.020 --> 00:09:15.590
There's Kaiser around here.

00:09:15.590 --> 00:09:17.520
There's Aetna, and
Cigna, and other plans.

00:09:17.520 --> 00:09:20.360
And they can vary
from state to state.

00:09:20.360 --> 00:09:22.710
And even within, you
can see variations.

00:09:22.710 --> 00:09:25.550
So, Blue Cross in California,
Blue Shield in California,

00:09:25.550 --> 00:09:27.480
might offer some different
types of choices.

00:09:27.480 --> 00:09:30.190
So, if you said, I've
got a really nice plan

00:09:30.190 --> 00:09:31.060
from Blue Cross.

00:09:31.060 --> 00:09:33.685
And I look at another state, and
you look at a Blue Cross plan,

00:09:33.685 --> 00:09:36.185
it might be that you're just
looking at a less generous one,

00:09:36.185 --> 00:09:38.184
where there is another
one that you can look at.

00:09:38.184 --> 00:09:40.710
So, you even have to look within
a company at the specifics.

00:09:40.710 --> 00:09:42.876
SAL KHAN: Definitely when
we go from state to state,

00:09:42.876 --> 00:09:45.380
it would be weird to have
brand loyalty to some of these.

00:09:45.380 --> 00:09:45.730
DR. LAURENCE BAKER: It would.

00:09:45.730 --> 00:09:46.260
Yeah.

00:09:46.260 --> 00:09:46.880
You know Blue
Cross Blue Shield--

00:09:46.880 --> 00:09:48.500
SAL KHAN: Because they're not
going to be the same thing.

00:09:48.500 --> 00:09:49.310
DR. LAURENCE BAKER:
They have this history

00:09:49.310 --> 00:09:51.320
of being public-spirited
entities, and some of that

00:09:51.320 --> 00:09:52.260
persists to this day.

00:09:52.260 --> 00:09:53.968
So maybe that's
something to think about.

00:09:53.968 --> 00:09:55.970
But in a general sense,
there are so many things

00:09:55.970 --> 00:09:57.386
that they could
vary on that you'd

00:09:57.386 --> 00:09:59.770
want to be very careful
with any choice you make.

00:09:59.770 --> 00:10:02.500
And know that it could really
vary across state lines.

00:10:02.500 --> 00:10:04.050
SAL KHAN: Interesting.


Inflammation

WEBVTT
Kind: captions
Language: en

00:00:00.183 --> 00:00:02.099
SALMAN KHAN: I'm here
with Dr. David Agus, who

00:00:02.099 --> 00:00:05.239
is a professor of engineering
and medicine at USC.

00:00:05.239 --> 00:00:06.030
DAVID AGUS: Um-huh.

00:00:06.030 --> 00:00:08.400
SALMAN KHAN: And we're
looking at pictures here

00:00:08.400 --> 00:00:10.340
of things that seem
very different to me.

00:00:10.340 --> 00:00:13.210
What is the
commonality right here?

00:00:13.210 --> 00:00:15.420
DAVID AGUS: The commonality
is inflammation.

00:00:15.420 --> 00:00:18.570
So inflammation can be manifest
by a runny nose in a cold

00:00:18.570 --> 00:00:20.190
or getting the flu.

00:00:20.190 --> 00:00:23.170
It could be manifest by
an infection in your toes.

00:00:23.170 --> 00:00:25.140
It could be hitting your
head playing football

00:00:25.140 --> 00:00:28.130
or hitting your arm when
you fall playing a sport.

00:00:28.130 --> 00:00:30.055
All of those can
cause inflammation.

00:00:30.055 --> 00:00:31.430
SALMAN KHAN:
Because inflammation

00:00:31.430 --> 00:00:33.780
has a certain meaning
in everyday language.

00:00:33.780 --> 00:00:35.280
At least when I
imagine it, it means

00:00:35.280 --> 00:00:37.210
something that's
swollen and red.

00:00:37.210 --> 00:00:38.960
But here, we're talking
about inflammation

00:00:38.960 --> 00:00:41.410
in more of the medical
or the scientific sense.

00:00:41.410 --> 00:00:43.960
Things are swollen and red
because of inflammation.

00:00:43.960 --> 00:00:44.710
DAVID AGUS: Right.

00:00:44.710 --> 00:00:46.510
SALMAN KHAN: And so
what is inflammation?

00:00:46.510 --> 00:00:48.590
It isn't just
swollen and redness.

00:00:48.590 --> 00:00:52.060
I mean, the football player
isn't getting swollen and red,

00:00:52.060 --> 00:00:52.560
or is he?

00:00:52.560 --> 00:00:55.060
DAVID AGUS: So inflammation is
when your body senses danger.

00:00:55.060 --> 00:00:56.650
So when something
is wrong, whether it

00:00:56.650 --> 00:00:59.510
be an infection, whether it be
trauma in the case of football

00:00:59.510 --> 00:01:01.840
players, whether it be
a cold, your body senses

00:01:01.840 --> 00:01:04.860
danger and sends in
its frontline soldiers,

00:01:04.860 --> 00:01:06.840
which are the immune
cells, in order

00:01:06.840 --> 00:01:08.890
to fight whatever's causing it.

00:01:08.890 --> 00:01:10.890
So if it's trauma, the
immune cells go in there

00:01:10.890 --> 00:01:13.730
and they help rebuild the
tissue that's damaged.

00:01:13.730 --> 00:01:15.320
If it's a bacteria,
they go in there

00:01:15.320 --> 00:01:17.210
and they try to take
away the bacteria

00:01:17.210 --> 00:01:19.640
so you can get over
that cold or that flu.

00:01:19.640 --> 00:01:22.919
And so that whole process
we call inflammation.

00:01:22.919 --> 00:01:23.710
SALMAN KHAN: I see.

00:01:23.710 --> 00:01:24.240
DAVID AGUS: It's
a danger process.

00:01:24.240 --> 00:01:25.390
SALMAN KHAN: So it's
the immune cells

00:01:25.390 --> 00:01:27.931
going to the sign of danger to
either fight the danger itself

00:01:27.931 --> 00:01:29.094
or repair the aftermath--

00:01:29.094 --> 00:01:29.760
DAVID AGUS: Yup.

00:01:29.760 --> 00:01:30.630
SALMAN KHAN: --of the danger.

00:01:30.630 --> 00:01:32.250
So that sounds
like a good thing.

00:01:32.250 --> 00:01:33.666
DAVID AGUS: It's
an awesome thing.

00:01:33.666 --> 00:01:35.950
The problem is, your
body, all of us, we

00:01:35.950 --> 00:01:38.149
care about what happens
today, not down the road.

00:01:38.149 --> 00:01:38.940
SALMAN KHAN: Right.

00:01:38.940 --> 00:01:40.565
DAVID AGUS: And this
is one of the take

00:01:40.565 --> 00:01:43.970
home points that astonished me
when I start to think about it,

00:01:43.970 --> 00:01:47.470
is that nature,
evolution, selects out,

00:01:47.470 --> 00:01:49.710
for who has good kids.

00:01:49.710 --> 00:01:51.270
And that's what
evolution is about.

00:01:51.270 --> 00:01:52.480
It's about having children.

00:01:52.480 --> 00:01:53.230
We call progeny.

00:01:53.230 --> 00:01:53.980
SALMAN KHAN: Right

00:01:53.980 --> 00:01:56.190
DAVID AGUS: It's not
about what happens

00:01:56.190 --> 00:01:58.920
when you're 80 years
old or 90 years old.

00:01:58.920 --> 00:02:02.350
And so inflammation is
fantastic about dealing

00:02:02.350 --> 00:02:04.260
with today's ramifications.

00:02:04.260 --> 00:02:06.460
The problem is if you
get the flu today,

00:02:06.460 --> 00:02:08.820
your risk of cancer and
heart disease a decade

00:02:08.820 --> 00:02:10.512
or two decades from now are up.

00:02:10.512 --> 00:02:11.970
SALMAN KHAN: If I
get the flu once?

00:02:11.970 --> 00:02:13.280
DAVID AGUS: If you
get the flu once.

00:02:13.280 --> 00:02:13.820
SALMAN KHAN: Really.

00:02:13.820 --> 00:02:15.210
DAVID AGUS: So those
five, six days--

00:02:15.210 --> 00:02:15.520
SALMAN KHAN: You're worrying me.

00:02:15.520 --> 00:02:17.061
DAVID AGUS: --when
you feel horrible,

00:02:17.061 --> 00:02:19.020
your inflammation
is through the roof.

00:02:19.020 --> 00:02:21.570
That's having ramifications
down the road.

00:02:21.570 --> 00:02:22.944
SALMAN KHAN: Right.

00:02:22.944 --> 00:02:25.110
I mean this is already
getting a little scary for me

00:02:25.110 --> 00:02:26.050
because I've had the flu.

00:02:26.050 --> 00:02:28.180
So I already feel a little
worried about my cancer risk.

00:02:28.180 --> 00:02:29.015
DAVID AGUS: I can tell
by looking at you.

00:02:29.015 --> 00:02:29.500
[LAUGHTER]

00:02:29.500 --> 00:02:31.208
SALMAN KHAN: You can
tell by looking at--

00:02:31.208 --> 00:02:32.450
[LAUGHTER]

00:02:32.450 --> 00:02:35.550
And the symptoms that we get
when we have the flu or a cold,

00:02:35.550 --> 00:02:38.360
these are actually-- it's not
the virus that's-- the virus is

00:02:38.360 --> 00:02:40.095
causing the inflammation,
which is causing the symptoms.

00:02:40.095 --> 00:02:40.420
DAVID AGUS: Yeah.

00:02:40.420 --> 00:02:41.378
And that's what's wild.

00:02:41.378 --> 00:02:44.130
Is that when you get a virus,
your immune system attacks it

00:02:44.130 --> 00:02:45.730
and you get a fever.

00:02:45.730 --> 00:02:48.720
I still don't know
why we get fevers.

00:02:48.720 --> 00:02:51.020
It's one of those things
where the-- we call them

00:02:51.020 --> 00:02:53.940
the cytokines, which are
proteins the immune cells make

00:02:53.940 --> 00:02:56.160
to send out and get
more reinforcements

00:02:56.160 --> 00:02:57.470
and tell the body what to do.

00:02:57.470 --> 00:02:58.860
It causes a fever.

00:02:58.860 --> 00:02:59.980
Is a fever good?

00:02:59.980 --> 00:03:01.030
Is a fever bad?

00:03:01.030 --> 00:03:01.870
I don't know.

00:03:01.870 --> 00:03:04.430
We take Tylenol
to lower a fever,

00:03:04.430 --> 00:03:05.940
but is that a good thing?

00:03:05.940 --> 00:03:08.460
Nobody really has looked at
the long-term ramifications.

00:03:08.460 --> 00:03:09.970
They look at short term.

00:03:09.970 --> 00:03:11.742
But how does it affect
a decade from now

00:03:11.742 --> 00:03:12.700
what's going to happen?

00:03:12.700 --> 00:03:13.660
We just don't know.

00:03:13.660 --> 00:03:14.060
SALMAN KHAN: Wow.

00:03:14.060 --> 00:03:14.420
Wow.

00:03:14.420 --> 00:03:16.295
And what you're saying
is that the reason why

00:03:16.295 --> 00:03:18.960
we have inflammation
is, yeah, something

00:03:18.960 --> 00:03:19.960
has happened to my body.

00:03:19.960 --> 00:03:21.366
I have some trauma, some injury.

00:03:21.366 --> 00:03:22.990
And you were saying
this to me earlier,

00:03:22.990 --> 00:03:24.989
you might have to run
away from a lion tomorrow.

00:03:24.989 --> 00:03:27.252
So fix Sal or fix
David up right now,

00:03:27.252 --> 00:03:29.210
so that he can run away
from the lion tomorrow.

00:03:29.210 --> 00:03:34.540
But in the wild, I might
only live to 40 anyway.

00:03:34.540 --> 00:03:37.109
So why even worry about whether
that person might get cancer

00:03:37.109 --> 00:03:38.650
if they get to 40
or 50, once they're

00:03:38.650 --> 00:03:39.510
past the age of reproduction.

00:03:39.510 --> 00:03:39.820
DAVID AGUS: Eactly.

00:03:39.820 --> 00:03:41.530
The body has to
choose priorities.

00:03:41.530 --> 00:03:44.580
And the priority clearly is
today rather than tomorrow.

00:03:44.580 --> 00:03:47.770
And so an amazing study
was done in that we

00:03:47.770 --> 00:03:50.390
gave patients what
we call a statin.

00:03:50.390 --> 00:03:53.790
So statins were
drugs-- S-T-A-T-I-N.

00:03:53.790 --> 00:03:56.410
They were drugs that were
developed because they blocked

00:03:56.410 --> 00:03:57.930
the synthesis of cholesterol.

00:03:57.930 --> 00:03:58.360
SALMAN KHAN: Right.

00:03:58.360 --> 00:03:59.670
DAVID AGUS: And
we thought people

00:03:59.670 --> 00:04:02.010
with higher cholesterol,
particularly the bad one called

00:04:02.010 --> 00:04:06.000
LDL, those people have a higher
incidence of heart disease.

00:04:06.000 --> 00:04:07.810
So if we block the
synthesis, we're

00:04:07.810 --> 00:04:09.060
going to affect heart disease.

00:04:09.060 --> 00:04:10.580
And what do you know, we did.

00:04:10.580 --> 00:04:14.220
A dramatic effect, we lowered
the death from heart disease

00:04:14.220 --> 00:04:15.230
with these drugs.

00:04:15.230 --> 00:04:15.420
SALMAN KHAN: Right.

00:04:15.420 --> 00:04:16.690
So it seems like they worked.

00:04:16.690 --> 00:04:17.050
DAVID AGUS: They worked.

00:04:17.050 --> 00:04:18.950
Then a company, or
a very clever group,

00:04:18.950 --> 00:04:20.890
did a trial where
they gave people

00:04:20.890 --> 00:04:23.740
with normal cholesterol
these drugs.

00:04:23.740 --> 00:04:26.630
And they had a dramatic effect
in that it delayed heart attack

00:04:26.630 --> 00:04:28.860
and stroke by almost
a dozen years.

00:04:28.860 --> 00:04:29.600
SALMAN KHAN: Wow.

00:04:29.600 --> 00:04:31.683
DAVID AGUS: And it reduced
the incidence of cancer

00:04:31.683 --> 00:04:32.922
by about 40%.

00:04:32.922 --> 00:04:34.380
SALMAN KHAN: So
cancer, something--

00:04:34.380 --> 00:04:35.530
I mean we don't
associate cholesterol--

00:04:35.530 --> 00:04:36.540
DAVID AGUS: Totally different.

00:04:36.540 --> 00:04:36.920
SALMAN KHAN: Wow.

00:04:36.920 --> 00:04:38.836
DAVID AGUS: So it turns
out these drugs, which

00:04:38.836 --> 00:04:42.090
were the biggest drug in
terms of sales we've ever had,

00:04:42.090 --> 00:04:44.660
worked by lowering inflammation.

00:04:44.660 --> 00:04:47.540
So their effect in heart disease
wasn't by lowering cholesterol.

00:04:47.540 --> 00:04:49.235
It was predominantly by
lowering inflammation.

00:04:49.235 --> 00:04:49.550
SALMAN KHAN: Right.

00:04:49.550 --> 00:04:49.800
Right.

00:04:49.800 --> 00:04:51.300
DAVID AGUS: And the
effect on cancer

00:04:51.300 --> 00:04:52.554
was by lowering inflammation.

00:04:52.554 --> 00:04:54.720
In fact, do you remember
when the swine flu came out

00:04:54.720 --> 00:04:55.980
a couple years ago?

00:04:55.980 --> 00:04:56.250
SALMAN KHAN: Right.

00:04:56.250 --> 00:04:56.749
Right.

00:04:56.749 --> 00:04:58.560
DAVID AGUS: So if you
got the swine flu,

00:04:58.560 --> 00:05:00.737
the only thing that
protected you from your lungs

00:05:00.737 --> 00:05:02.820
collapsing and going on
what we call a ventilator,

00:05:02.820 --> 00:05:05.450
a breathing machine, was
being on one of these statins.

00:05:05.450 --> 00:05:06.370
SALMAN KHAN: Because it
would stop the inflammation.

00:05:06.370 --> 00:05:07.630
Because the swine flu
people were dying from

00:05:07.630 --> 00:05:08.921
is the inflammation going nuts.

00:05:08.921 --> 00:05:09.725
DAVID AGUS: Yeah.

00:05:09.725 --> 00:05:11.100
SALMAN KHAN: This
is fascinating.

00:05:11.100 --> 00:05:14.345
So the people who are
dying of heart disease,

00:05:14.345 --> 00:05:15.720
is it necessarily
the cholesterol

00:05:15.720 --> 00:05:16.553
that's killing them?

00:05:16.553 --> 00:05:19.030
Or is the inflammation
that's causing cholesterol?

00:05:19.030 --> 00:05:20.604
DAVID AGUS: Well, I think
it's this chicken and the egg

00:05:20.604 --> 00:05:21.104
phenomenon.

00:05:21.104 --> 00:05:21.630
That's it.

00:05:21.630 --> 00:05:23.870
The inflammation allows
cholesterol to deposit--

00:05:23.870 --> 00:05:24.360
SALMAN KHAN: I see.

00:05:24.360 --> 00:05:25.080
DAVID AGUS: --and they together.

00:05:25.080 --> 00:05:25.360
SALMAN KHAN: I see.

00:05:25.360 --> 00:05:25.860
I see.

00:05:25.860 --> 00:05:32.550
So it's really the statin
affects inflammation, which

00:05:32.550 --> 00:05:35.420
then reduces cancer by
stopping the inflammation

00:05:35.420 --> 00:05:36.240
and stopping the--

00:05:36.240 --> 00:05:36.585
DAVID AGUS: Exactly.

00:05:36.585 --> 00:05:36.700
SALMAN KHAN: --cholesterol.

00:05:36.700 --> 00:05:38.880
DAVID AGUS: One of those
problems we have a biology,

00:05:38.880 --> 00:05:41.970
in medicine, it's
what you can measure.

00:05:41.970 --> 00:05:43.619
And so I can
measure cholesterol.

00:05:43.619 --> 00:05:44.410
SALMAN KHAN: Right.

00:05:44.410 --> 00:05:45.868
DAVID AGUS: I don't
really know how

00:05:45.868 --> 00:05:47.640
to measure inflammation well.

00:05:47.640 --> 00:05:50.340
So while we can make these
association in big studies

00:05:50.340 --> 00:05:53.990
when we look back, if I had a
metric, if I had a blood test

00:05:53.990 --> 00:05:56.320
or something to look
at for inflammation,

00:05:56.320 --> 00:05:57.839
I can optimize things.

00:05:57.839 --> 00:06:00.380
SALMAN KHAN: Can you not measure
just the amount of cytokines

00:06:00.380 --> 00:06:03.260
and other inflammatory
type of things

00:06:03.260 --> 00:06:05.219
that become increased in
your-- does it happen?

00:06:05.219 --> 00:06:06.260
DAVID AGUS: You're right.

00:06:06.260 --> 00:06:08.220
But are different
types of inflammation.

00:06:08.220 --> 00:06:10.830
So some inflammation can
be good, some can be bad.

00:06:10.830 --> 00:06:12.630
Some can be really causal.

00:06:12.630 --> 00:06:14.490
Some could be a
little bit causal.

00:06:14.490 --> 00:06:16.390
And so we're putting
them all into one basket

00:06:16.390 --> 00:06:18.040
now, which is inflammation.

00:06:18.040 --> 00:06:19.710
The key is to
start to tease them

00:06:19.710 --> 00:06:22.360
out and be able
to modulate them.

00:06:22.360 --> 00:06:23.334
You can develop a drug.

00:06:23.334 --> 00:06:25.750
But then you have to optimize
it for a particular purpose.

00:06:25.750 --> 00:06:26.130
SALMAN KHAN: Right.

00:06:26.130 --> 00:06:26.360
Right.

00:06:26.360 --> 00:06:28.734
DAVID AGUS: So these were
optimized to lower cholesterol.

00:06:28.734 --> 00:06:30.090
And they do that very well.

00:06:30.090 --> 00:06:33.130
They also lower inflammation
and they work beautifully

00:06:33.130 --> 00:06:34.190
in that regard.

00:06:34.190 --> 00:06:36.682
But how do we optimize
that going forward?

00:06:36.682 --> 00:06:38.140
What it also means
is that when you

00:06:38.140 --> 00:06:39.806
look at your lifestyle
and my lifestyle,

00:06:39.806 --> 00:06:41.730
we have to limit inflammation.

00:06:41.730 --> 00:06:43.810
So what are the easy
ways to do that?

00:06:43.810 --> 00:06:46.120
One is, which I think
should be mandatory things,

00:06:46.120 --> 00:06:47.274
like the flu shot.

00:06:47.274 --> 00:06:48.065
SALMAN KHAN: Right.

00:06:48.065 --> 00:06:50.060
DAVID AGUS: So
again, the flu shot

00:06:50.060 --> 00:06:53.700
will certainly delay you
from having or prevent

00:06:53.700 --> 00:06:54.690
from having bad flu.

00:06:54.690 --> 00:06:56.700
SALMAN KHAN: That's good today
and good today and tomorrow.

00:06:56.700 --> 00:06:57.046
DAVID AGUS: And tomorrow--

00:06:57.046 --> 00:06:57.392
SALMAN KHAN: Yeah,
yeah, yeah, yeah.

00:06:57.392 --> 00:06:59.725
DAVID AGUS: --because it
limits heart disease and cancer

00:06:59.725 --> 00:07:00.660
down the road.

00:07:00.660 --> 00:07:01.870
That

00:07:01.870 --> 00:07:04.000
SALMAN KHAN: I had no clue
that the flu-- I thought

00:07:04.000 --> 00:07:06.410
it was just a nice thing,
avoid a week of sneezing,

00:07:06.410 --> 00:07:07.350
and you know.

00:07:07.350 --> 00:07:10.460
But the flu shot, you can
actually reduce your cancer--

00:07:10.460 --> 00:07:12.760
DAVID AGUS: And heart
disease down the road.

00:07:12.760 --> 00:07:15.110
And we have to think
long term as a society.

00:07:15.110 --> 00:07:16.443
SALMAN KHAN: What about statins?

00:07:16.443 --> 00:07:20.250
I mean it seems like-- these are
drugs like Lipitor and Crestor.

00:07:20.250 --> 00:07:24.030
I mean would you-- I mean no one
should take our medical advice

00:07:24.030 --> 00:07:25.370
based on a thing in video.

00:07:25.370 --> 00:07:26.120
DAVID AGUS: Right.

00:07:26.120 --> 00:07:28.770
SALMAN KHAN: I mean are
people taking it just

00:07:28.770 --> 00:07:31.250
for heart disease or are people
taking it more broadly now?

00:07:31.250 --> 00:07:32.041
DAVID AGUS: Listen.

00:07:32.041 --> 00:07:34.390
I mean I'm a believer
that these drugs have

00:07:34.390 --> 00:07:36.610
such a profound
effect on cancer,

00:07:36.610 --> 00:07:39.530
heart disease, stroke,
potentially Alzheimer's,

00:07:39.530 --> 00:07:42.610
that you should consider taking
it to prevent these diseases.

00:07:42.610 --> 00:07:44.930
And again, we're giving
no recommendations.

00:07:44.930 --> 00:07:46.997
But what I say is
you, your parents,

00:07:46.997 --> 00:07:48.830
they should talk about
it with their doctor.

00:07:48.830 --> 00:07:51.010
And so why shouldn't
I be on this drug?

00:07:51.010 --> 00:07:51.225
SALMAN KHAN: Right.

00:07:51.225 --> 00:07:52.558
And there are some side effects.

00:07:52.558 --> 00:07:54.467
But they're easy to test for.

00:07:54.467 --> 00:07:56.550
DAVID AGUS: Test for, and
then they're reversible.

00:07:56.550 --> 00:07:57.060
SALMAN KHAN: Right.

00:07:57.060 --> 00:07:57.135
OK.

00:07:57.135 --> 00:07:57.830
So you're not going too--

00:07:57.830 --> 00:07:58.360
DAVID AGUS: So
with anything, you

00:07:58.360 --> 00:07:59.810
got to do a risk and a benefit.

00:07:59.810 --> 00:08:00.320
SALMAN KHAN: Right.

00:08:00.320 --> 00:08:01.095
DAVID AGUS: And you
have to look at you

00:08:01.095 --> 00:08:02.990
and say am I high
risk for X, Y, and Z?

00:08:02.990 --> 00:08:05.820
If you are, what can
prevent or delay it?

00:08:05.820 --> 00:08:08.000
The name of the game is
not treating disease,

00:08:08.000 --> 00:08:09.340
it's preventing disease.

00:08:09.340 --> 00:08:09.720
SALMAN KHAN: Right.

00:08:09.720 --> 00:08:10.240
Right.

00:08:10.240 --> 00:08:11.899
Now, this is fascinating.

00:08:11.899 --> 00:08:13.690
Well, I might talk to
my wife about getting

00:08:13.690 --> 00:08:14.990
some-- well, no advice here.

00:08:14.990 --> 00:08:17.234
Everyone should talk
to their doctor.

00:08:17.234 --> 00:08:19.390
DAVID AGUS: By the way,
another great medicine

00:08:19.390 --> 00:08:21.390
to reduce inflammation
is called aspirin.

00:08:21.390 --> 00:08:23.276
SALMAN KHAN: Aspirin,
I've heard of that.

00:08:23.276 --> 00:08:23.630
DAVID AGUS: Yeah.

00:08:23.630 --> 00:08:24.160
It's a hell of a drug.

00:08:24.160 --> 00:08:25.970
Again, there are side
effects to aspirin.

00:08:25.970 --> 00:08:27.370
It can affect bleeding.

00:08:27.370 --> 00:08:29.870
But at the same time,
it's a dramatic effect

00:08:29.870 --> 00:08:31.119
by lowering inflammation.

00:08:31.119 --> 00:08:31.910
SALMAN KHAN: Right.

00:08:31.910 --> 00:08:33.289
And that is its
main side effect.

00:08:33.289 --> 00:08:35.820
I mean it's this age-old drug.

00:08:35.820 --> 00:08:36.700
It's a blood thinner.

00:08:36.700 --> 00:08:41.526
So if you get a cut or you bleed
while you're taking aspirin,

00:08:41.526 --> 00:08:42.400
you might bleed more.

00:08:42.400 --> 00:08:42.820
DAVID AGUS: Right.

00:08:42.820 --> 00:08:43.919
Blood thinner is a funny term.

00:08:43.919 --> 00:08:44.830
I'm not quite sure
what it means.

00:08:44.830 --> 00:08:46.645
I keep taking paint
thinner when you see it.

00:08:46.645 --> 00:08:47.030
SALMAN KHAN: Right.

00:08:47.030 --> 00:08:48.410
That's kind of how I imagine it.

00:08:48.410 --> 00:08:50.000
DAVID AGUS: It binds
to the platelets

00:08:50.000 --> 00:08:51.640
and blocks them from activating.

00:08:51.640 --> 00:08:53.330
It stops them from
working really well.

00:08:53.330 --> 00:08:54.450
SALMAN KHAN: So it's
more anticlotting.

00:08:54.450 --> 00:08:54.940
DAVID AGUS: Right.

00:08:54.940 --> 00:08:56.620
And platelets are one of the
key components of clotting.

00:08:56.620 --> 00:08:58.140
And they certainly affect it.

00:08:58.140 --> 00:08:58.440
SALMAN KHAN: Right.

00:08:58.440 --> 00:09:00.231
So your blood will have
the same viscosity.

00:09:00.231 --> 00:09:01.440
It just won't clot as easily.

00:09:01.440 --> 00:09:02.272
DAVID AGUS: Exactly.

00:09:02.272 --> 00:09:04.610
And you could certainly
paint a wall with either one.

00:09:04.610 --> 00:09:06.110
SALMAN KHAN: That's
a little morbid.

00:09:06.110 --> 00:09:06.610
All right.

00:09:06.610 --> 00:09:08.790
Well, thanks a bunch.