[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

[[Page 1524]]

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

[[Page 1525]]

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

[[Page 1526]]

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.