In the face of challenges facing the entire healthcare industry, Cleveland Clinic CEO Toby Cosgrove this week delivered a message of measured optimism for the 90-year-old institution in his annual State of the Clinic address. The near future is going to be challenging, he said in an interview. "We have entered a period of change in healthcare that has only been seen once before, during the 1968 creation of Medicare." The Clinic's main challenges, Cosgrove says, are not limited to Northeast Ohio: population decline and unemployment, and decreased reimbursement for many services due to healthcare reform measures. "The bottom line is we have to do better with less," Cosgrove says.