    [Public Papers of the Presidents of the United States: William J. Clinton (1993, Book II)]
    [September 17, 1993]
    [Pages 1523-1526]
    [From the U.S. Government Publishing Office www.gpo.gov]

    Remarks at the Children's National Medical Center
    September 17, 1993

        The President. Thank you. Well, Dr. Beard, I promise to free you of
    the paperwork if you will promise not to use your free time to run for
    President. [Laughter]
        Mr. Brown and Ms. Freiberg, Dr. Beard, to all of you who helped to
    make our visit here so wonderful today, I want to thank this Children's
    Hospital for bringing us together this morning, for giving us a chance
    to see some of your patients and their parents and their friends and to
    witness the miracles you are working. I want to thank Ben Bradlee and
    Sally Quinn for calling Al and me and telling us to hustle more money
    for the hospital.
        In my former life, when I was a Governor, my wife and I worked very
    hard for the Arkansas Children's Hospital. Some of you know it's one of
    the 10 biggest hospitals in the country, and every year we finished
    first or second in the telethon, even though we come from a small State.
    There's a lot of grassroots support for people who are doing what you're
    doing.
        We built a tertiary care nursery at our hospital with State funds,
    the first time anything like that had been done. And I have spent
    countless hours in our Children's Hospital at home with my own daughter,
    with the children of my friends, sometimes their last day, sometimes
    their best day. And I am profoundly grateful to you.
        I think the people in the press and maybe some others might have
    wondered today why in the wide world we would come to a children's
    hospital, with all of its gripping, wonderful, personal stories, to have
    an event about bureaucracy and paperwork. After you listen to a nurse
    say why she couldn't care for a sick child and a doctor plead for more
    time to be a doctor, maybe you know. There is an intensely human element
    behind the need to reform the system we have.
        When we were upstairs and Dr. Grizzard and Ms. Mahan were showing us
    some forms, we looked at four case files that they said had $14,000
    worth of work in them that were absolutely unrelated to the care of the
    patient. The doctor said he estimated that each doctor practicing in
    this hospital, 200 in total, spent enough time on paperwork unrelated to
    patient care every year to see another 500 patients for primary
    preventive care--times 200. You don't have to be a mathematical genius
    to figure out that's another 10,000 kids who could have been cared for,
    whose lives could be better.
        People say to me, how in the world do you expect to finance
    universal coverage and cut Medicare and Medicaid? Let me say first of
    all, nobody's talking about cutting Medicare and Medicaid; we're talking
    about whether it doesn't need to increase at 16 percent or 12 percent or
    15 percent a year anymore. And it wouldn't if we had some simplification
    so people could spend the time they have already got on this Earth doing
    what they were trained to do.
        I've got a friend who is a doctor that I grew up with who happens to
    live in the area, who calls me about once every 3 months to tell me
    another horror story. And the other day, he called me and he said, ``You
    had better hurry up and get this done.'' He said, ``You know, I'm in
    practice with this other guy. We've got all of these people doing
    paperwork. Now we've hired somebody who doesn't even fill out any forms.
    She spends all day on the telephone beating up on the insurance
    companies to pay for the forms we've already sent in. We actually had to
    hire somebody to do nothing but call on the phone.'' He said, ``I'm lost
    in a fun house here.'' [Laughter] He said, ``I went to medical school to
    try to practice medicine. Now I've got to hire somebody who does nothing
    but call people on the phone to pay the bills

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    they're supposed to pay, after I've spent all this time filling out
    these forms?''
        People complain about doctor fees going up. I'll give you one
    interesting statistic. In 1980, the average physician in America took
    home 75 percent of the revenues that were generated in a clinic. By
    1990, that number had dropped from $.75 on the dollar to $.52. Where did
    the rest of it go? Right there. Most of it went to forms.
        Now you know, when we were up in that medical records room, we saw
    all these forms. We were told that by the time the room was done, the
    room was already too small because the paper kept coming faster than you
    could make space for it in this hospital. A lot of you are nodding about
    that. Now they have records flowing on into a room that is beneath us in
    the garage, and these files are still growing at the rate of 6.5 feet a
    week.
        We know, of course, from what Dr. Beard and Ms. Freiberg said,
    that's just some of the story. There are departments in this hospital
    that spend all their time trying to satisfy hundreds of different
    insurers. There are 1,500 in America, by the way. No other country has
    that many. This hospital I think deals with over 300. Each of them want
    a slightly different piece of information and in a slightly different
    way; so that even if you try to have a uniform form, it's not uniform by
    the time you finish customizing it.
        How did this happen? Hospitals like this one treat people who are
    most vulnerable, weak, ailing, and in pain. To make sure that sick
    patients were getting the best care, Government regulators and private
    insurers created rules and regulations, and with them came forms to make
    sure you were following the rules and regulations. To make sure doctors
    and nurses then didn't see the patients that were getting the best care
    too often, keep them in the hospital too long, or charge them too much,
    there were more rules and regulations and along with them, more forms.
        As more and more insurance agencies and private companies got into
    the business of selling health insurance--and as I said, there are now
    more than 1,500 insurers in this country; no other country in the world
    has anything like that many--each of them had their own forms and their
    own different list of what they would cover. And so what are you left
    with? Instead of all this paper and all these medical forms assuring
    that the rules are followed and people get healthy, we're stuck in a
    system where we're ruled by the forms and have less time to make
    children and adults healthy.
        When doctors and nurses are forced to write out the same information
    six different times in seven different ways just to satisfy some distant
    company or agency, it wastes their time and patients' money, and in the
    end, undermines the integrity of a system that leaves you spending more
    and caring for fewer people.
        Just think about the patients. I don't know if you've read the
    stories in the morning paper about the people we invited to the Rose
    Garden at the White House yesterday. We invited about 100 people who had
    written us letters. We let 15 of them read their letters. They are part
    of the 700,000 letters that my wife and her group have received since we
    started this health care project. And they were all saying more or less
    the same thing: We want coverage. We don't want to be locked into our
    jobs, preexisting conditions shouldn't bankrupt families.
        But there was one gentleman there from Florida, Jim Heffernan, who
    told us that he is a retiree on Medicare who spends his time working in
    hospice programs with people who are much sicker than he is. And he
    talked about how all the regulations, the reimbursement forms, all the
    complexities sap the energy and the morale and the vitality of the
    people that he was trying to help. He describes mountains of paperwork
    that older Americans face. He told how he now volunteers his time
    helping these patients to decipher their forms instead of helping them
    to feel better about their lives and think of something interesting to
    do every day to make every day count.
        The biggest problem with all this, of course, is the waste and
    inefficiency. We spend more than 20 cents of every health care dollar on
    paperwork. And after about 4 years of studying this system, long before
    I even thought of running for President, I got interested in this at
    home, and I've tried to honestly compare our system with systems in
    other countries. And it appears to me that we spend about a dime on the
    dollar more than any other country in the world on bureaucracy and
    paperwork.
        In a medical system that costs $880 billion, you don't have to be a
    mathematical genius to figure out what that is. What could we do in this
    country with that money? How many people could we cover? How many things
    could we

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    do? How much more preventive care could we do to lower the long-term
    cost of the system? How many more children could we care for?
        In the last 10 years, our medical providers have been hiring
    clerical help at 4 times the rate of direct health care providers. That
    is a stunning statistic. They spend resources that should go into care
    on other things.
        What we want to do with this health security plan is to do away with
    all of that, to streamline the rules, reduce the paperwork, make the
    system make sense, and do nothing to interfere with the private delivery
    of care system that we have now. And we believe we can do it. We think
    we can do away with the different claims forms, with all the confusing
    policies, and put the responsibility for measuring quality where it
    belongs, with you on the front-lines and not with examiners that work
    for Government or the insurance company thousands of miles away.
        Here's how we propose to do it. First, we want to create a single
    claim form, one piece of paper that everyone will use and all plans will
    accept. We've already started moving in this direction now. There are
    some standard forms used by Medicare and others that are aimed at
    cutting back on all this craziness. But as you know here at Children's,
    a single form is no good if every insurer uses it differently. You might
    as well have different forms.
        So we will now introduce a single form which we have a prototype of
    here today. I've got one here, or you can see one here, a single form
    which would go to every hospital, every doctor's office in the country,
    which would deal with the basic benefits package and which would replace
    that and worse. Think of what that will do. Think of how many hours it
    will free up for all of you.
        Now, when we do this, that won't be enough. We'll have to
    standardize how the forms are used, building on what has been done in
    other contexts in private industry, building on what we know from the
    professional associations in health care. We'll ask doctors and nurses
    and health care plans to decide together on what information absolutely
    has to be given to guarantee the highest quality and most cost-effective
    care.
        Secondly, in order to make this form work, we'll have to create a
    single comprehensive benefit package for all Americans. We'll allow
    consumers of the health care, the employees and others in our country,
    to make some choices between the packages. But it will essentially be
    one comprehensive package. No longer will hospitals and doctors have to
    keep track of thousands of different policies. No longer will they have
    to chase down who has which insurance and what's covered under what
    circumstances. If it's covered, it's covered no matter who you are or
    what plan you're in, no matter whether you have a job or whether you
    don't. It will simply be covered.
        It will simplify your life. And it will also provide security to the
    American people who worry that if they switch jobs, they'll lose their
    health care coverage, or it will be so different it will take them 6
    months to figure out what's covered and what isn't. They won't have to
    know--the American people won't--enough jargon to fill a phone book just
    to come down here and see you. It will mean that more of the money we
    all pay for health care will go for health care and not bureaucracy.
        And finally, the Government will try as hard as we can, and I say
    that because I've found as President I have to work extra hard to change
    the culture of the Government when I want to get something done. But our
    rules are going to be that we are going to rebuild the trust between
    doctors and hospitals and patients and the Government that is funding
    some, but by no means all, of the health care.
        Federal programs, let's face it, are a big part of the paperwork
    problem. We will simplify and streamline Medicare reimbursement and
    claims processes, and we'll refocus clinical laboratory regulations to
    emphasize quality protection. And we will reduce a lot of the
    unnecessary administrative burden that the National Government has put
    on them now.
        If we do this right, those of you on the front-lines will spend less
    time and money meeting the paperwork requirements, and more time and
    energy treating patients. You'll face fewer crazy rules and regulations,
    worry less about which insurers cover what, have better tools and
    information to help actually protect people and promote quality, rather
    than constantly having to prove you've done nothing wrong.
        You'll hear a lot more about this proposal in the weeks ahead. As
    the debate evolves, I want to tell the people about these children,
    these brave children I met upstairs, about the wonderful people who are
    caring for them, and about how they deserve the opportunity to care

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    more and spend less time with paper and forms.
        I value what you do here at this hospital and what people like you
    do all over America. If the American people really knew what nurses and
    doctors have to go through today just to treat people, they would be up
    in arms, they would be marching on Congress, demanding that we do
    something to solve this problem.
        I hope that, by our coming here today, we have made a very real and
    human connection between these magnificent children and all of the
    wonderful people who care for them and this awful problem represented by
    this board up here. If we move here, it means more for them. And that's
    why we came here.
        Thank you very much.

    Note: The President spoke at 10:20 a.m. in the Atrium. In his remarks,
    he referred to Lillian Beard, M.D., Washington, DC, pediatrician; Debbie
    Freiberg, R.N., pediatric cancer nurse; Michael B. Grizzard, M.D., vice
    president for medical affairs; Michelle Mahan, vice president of
    finance; Ben Bradlee, vice president at large, Washington Post; and
    author and journalist Sally Quinn.