Reinventing Government Event with Health Care Financing Administration

Old Executive Office Building
Washington, D.C. July 11, 1995


SECRETARY SHALALA: Thank you very much.

Mr. Vice President, Mrs. Clinton, this is an exciting day for us, but it's part of a continuum of improvements. With the Vice President, we announced some regulatory change in the FDA, and today, we have some additional contributions to make.

Walt Whitman once said, nothing happens unless first a dream, and our dream for every American has not been abandoned, and that is a quality health care system at an affordable rice in which each American has access to. And our leader in that effort is the First Lady of this country, who has led us with passion, with eloquence, and with strength, that this country has not seen before, and I'm very pleased to introduce her to you today:

the First Lady, Mrs. Clinton.


MRS. CLINTON: Thank you. Thank you very much. Thank you.

Thank you so much, and welcome to this event. I'm delighted to be here with so many physicians and nurses and health care professionals, and concerned citizens, who are committed to the work of making sure our health care system is both efficient and provides high quality health for all Americans. I'm delighted that the Vice President can be here with us today, and particularly pleased that he's able to be here, because that means his mother is doing so well in Tennessee --


MRS. CLINTON: -- so it's a special pleasure.


MRS. CLINTON: Last year, when we began the health care reform efforts, I think all of us agreed that, although American has the highest quality health care in the world, that the system that finances that quality health care is too complicated and too expensive. That while we boast of the most talented and dedicated health professionals and advanced
research institutions, those professionals and institutions have been overburdened by
paperwork, red tape, and needless regulation.

As part of our work on health care reform last year, we looked for ways to simplify the health care system, and we did so within the context of overall health care reform. We are here today in large part because of your ongoing commitment to that simplification effort. Both the individuals here in this auditorium, and the organizations you represent, have consistently worked with us to try to insure that we could eliminate the obstacles that stood in the way for the provision of quality health care.

We owe a particular debt of gratitude to Secretary Shalala, and Bruce Vladock [PH], the Administrator of HCFA, for having taken so seriously, over the last two-and-a-half years, the concerns of practicing physicians, of nurses and hospitals, of technicians, of others who are on the front lines of our health care system. And we are delighted to have with us a group of physicians and nurses and others, the National Health Policy Council, that, under the leadership of Dr. Steve Gleason, has worked continually to make our health care system both more user and more provider friendly.

At the same time that the overall efforts in health care reform were ongoing, the work of Vice President Gore's Reinventing Government initiative began looking at eliminating unnecessary regulatory burdens in all areas of government. The announcement today represents the perfect marriage of these two efforts, one step in an ongoing effort to free doctors, hospitals, and other health care providers to do what they were trained to do, and to enhance the quality of our health care system, not by micromanaging, but by measuring results.

Hospitals today, as many of you know, hire more administrative staff than medical staff, simply to handle the avalanche of insurance forms and paperwork that comes from both the public and private sectors. Doctors and nurses spend hundreds of hours each month on administration. That's time that has not been spent at the bedside of a patient, or with a child who needs a check up, or diagnosing an illness.

I will never forget talking to a nurse last year who said that she had gone into nursing to care for people. If she had wanted to be an accountant or a bookkeeper, she would have studied that, and gone to work handling paper. Instead, after training to be a nurse, she spent nearly 50 percent of her time filling out forms.

Even worse, many of you have made -- or watched the institutions where you work make difficult decisions to hire more bookkeepers and clerical people while laying off nurses and medical technicians. That is a very foolish and unnecessary choice, that no physician, hospital, or nursing home should have to face.

We can make a significant start on simplifying the health care system by improving how the federal health programs do business. In recent months here in Washington, the health care debate has centered around the need to reform Medicare and Medicaid, and to get spending under control.

Everyone agrees that those programs can be improved. That was a large part of what we proposed during health care reform. Everyone agrees that federal health spending is growing too fast. Over the next five years alone, almost 40 percent of the growth in federal spending will come from the rise in federal health care costs. They are growing faster than GDP, faster than overall inflation, faster than almost any other item in government spending.

But as the President has said over and over again, there is a right way and a wrong way to slow the growth in Medicare and Medicaid spending. The proposals that are currently being iscussed by the majority in Congress to take deep Medicare cuts to pay for tax breaks for the wealthiest Americans is the wrong way. Their Medicaid block grant proposal is also the wrong way. Under the current proposed block grant scenario, seven million children and nearly one million elderly and disabled Americans would lose coverage, and millions more would risk losing vital services, like nursing home

Instead, as we begin the debate about how to control health care costs, we need to remember that Medicare and Medicaid have lifted millions of Americans out of poverty and have helped millions more manage to pay for desperately needed health care services.

The right way is to improve and strengthen these programs and make them more efficient. That's why the President proposed a budget that reaches balance in ten years, but that has half of the Medicare and one-third of the Medicaid savings that are in the Republican plan. That's why the President's budget takes only the Part A cuts needed to strengthen the Medicare Trust Fund rather than playing on fears about the insolvency of the fund to slash Medicare spending to pay for other non-medical

And, as the President has consistently said, he will take these Medicare and Medicaid savings only in the context of health care reform. That's why his budget proposal takes the first steps toward reform, by making the insurance markets fairer. By helping workers who lose their jobs pay for health insurance, and making insurance more affordable for small businesses and the self-employed. By giving states more flexibility under Medicaid while protecting coverage, and by giving Medicare beneficiaries more choices and investing in new Medicare benefits and long term care.

As an important part of these reform efforts, there are also changes that the
Administration can make in the federal health care programs right now, changes that will improve these programs, and improve your ability to work with these programs. We can simplify the system and regulate the right way, without compromising quality.

In the past two-and-a-half years, we've made progress. HCFA has simplified the forms and statements that Medicare beneficiaries get each month. They have improved the system for processing claims. They have taken the real first steps toward making quality standards more sensible, and the enforcement of these standards more
flexibility, just to give you a few examples.

The reforms that the Vice President will outline today are part of this ongoing process. In addition, this afternoon, I will be speaking at a meeting convened by the Koop Foundation on health information infrastructure needs, and there, we'll be able to announce that the Vice President and the Secretary of HHS will be working to try to make sure technological developments are readily available to our health care professionals to expedite treatments, diagnoses, and to also deal more
efficiently with the payment side of our health care system.

I know we can build on the work we've done so far, and I know that all of you will continue to be our partners in helping us learn how to do better what is really the most important part of the health care equation. How do we protect, enhance, and support the relationship between the patient and the health care provider? How do we make sure physicians are able to give the care they were trained to give? How do we insure that nurses are there taking care of patients and not filling out forms? How do we make it possible for technicians to provide more and better care, instead of just standing by, making sure that regulations from either private insurance companies, or the public sector are fulfilled?

This relationship between health care professionals and the White House and HHS, not only here in Washington but throughout the regional offices, will be doubly effective if it is joined hand in hand with people working in communities across the country. We hope, with your help, that you will not only take the message of what we are attempting to do here back to your organizations and communities, but that you will continue to be our partner in identifying unnecessary and burdensome regulations, so that we can work together to simplify and improve our health care system.

It is now my honor to introduce a physician who has been of great assistance in helping us get to this day by bringing the messages from many, many physicians, nurses, and others to the attention of HHS, the White House, the Vice President's REGO
initiative, and who, along with all of you, has been a stalwart partner in making sure we don't just talk the problem to death, as it has been for decades, but begin to try to act to solve the problems you have helped to identify.

Please join me in welcoming Dr. Steve Gleason.


DR. GLEASON: Thank you, Mrs. Clinton, for that gracious introduction, but it should be me, and in fact, all Americans, thanking you for your courage in tackling these important health issues. You've been a champion for paperwork reduction, for patient choice, for preserving Medicare and, of course, for the uninsured. In reminding us that we are, indeed, our brother's keeper, you have provided moral balance to the health debate.

And I believe bureaucracy reduction is, indeed, a moral as well as fiscal issues.
Highlighting that point was the herald event that transformed me into a health care activist.

Frustrated by many conflicting rules and regulations that seemed to be coming from all different directions, I, like many other physicians, tended to address the problem in 1986 by arguing with colleague in the doctor's lounge, an exercise that was supposed to effect change.


DR. GLEASON: But in reality, it just reinforced our anger and our political ineptitude, for which we physicians are famous. But when my father went into the emergency room saying that he was sicker than he had ever been, I found the need to find better ways to effect change.

In their attempt to get preadmission paperwork approval, the nurses and physicians and the emergency room staff were struggling with the fact that his chest x-ray, EKG, laboratory data, and vital signs were all normal. In spite of complaints of pain from my normally stoic father, he appeared on paper to be perfectly healthy. It took many hours before we were able to gain the approval to proceed with surgery for what ended up being a ruptured bowel and septicemia.

Following surgery, he went into respiratory arrest, was on a ventilator for the better part of three months before he died. During the short period when he was off the ventilator, I stayed with my father almost night and day, discussing with
him life in general. But one particular night, his curiosity led us to a pressing question: why was it that physicians who were charged with the health of a nation couldn't affect and streamline the process by which patients are admitted to the hospital? It was one of his last clearly spoken thoughts.

That's why this initiative is so critical to me. Unnecessary bureaucracy, I believe, diverts time and money away from patient care and at times delays important procedures. Reducing paperwork and health care is, I believe, a moral as well as a fiscal issue. The number of regulations and rules concerning health care are similar, in some respect, to Winston Churchill's definition of history: History, Mr. Churchill said, is just one damn thing after another.


DR. GLEASON: And the regulations which have been promulgated on consumers and providers of health care over the past two decades have often been confusing, and certainly, at times, conflicting in their purpose. It has seemed that some Republicans and Democrats have been out of touch with this country's founding
ideas. Thomas Jefferson -- the first Democrat, I might add -- fought against government
oppression and eloquently defended individual liberty and tolerance.

Burdensome regulations can have a fearsome repressive effect on the quality, creativity, and fiscal good sense necessary for great medical care. By creating a myriad of regulations and forms, each one designed to protect the very few, government has, at times, created a tremendous burden for the vast majority.

It is therefore notable, and refreshing, that this Administration is willing to tackle the
issue of reinventing government and regulatory relief. I'm pleased to be here today to participate in this announcement as part of the Administration's ongoing efforts.

I have the job of highlighting just one small piece of the array of recommendations which the Vice President will soon review. And I should add, Mr. Vice President, that we appreciate very much your efforts to move us into the next millennium. Your work on our behalf to reduce unnecessary bureaucracy and develop new technologies is appreciated more than you know.

The pile that you see before you represents physician attestation statements.


DR. GLEASON: They really are. That's what they are.


DR. GLEASON: For those of you unfamiliar with this wonderful form, it was designed during some previous Administration to do several things. It was designed as an additional summary sheet of the diagnoses in the medical case. This form, of course, is in addition to a fully complete discharge summary that already has such information. It was designed to legally bind the physician by requiring an attestation, or truth oath, concerning the accuracy of the dictated discharge summary.

Under Medicare law, some thought this made it easier to put pressure on physicians to dictate accurate medical records. We later found out, of course, that the regular discharge summary suffices fully for that activity.

In the end, the only result was that it added more work to the physician day, most costs in the medical records department, and effectively delayed hospital payments by an additional thirty days. This was mainly trying to track down physicians to do the forms, I might add.


DR. GLEASON: This pile of paper represents a number of attestation statements signed, in a single year, by a single middle-sized community hospital in Iowa: Mercy Hospital in Iowa, in Des Moines, Iowa. This particular pile of attestation statements represents 11,127 discharges, which represents one full year at Mercy.

Nine hospital medical records staff spent 6100 hours in one year to prepare the forms. The forms required an additional 927 hours of physician and physician office staff time. Total hospital and physician costs per year for this effort, at this hospital, was $158,000.00. When Mercy's numbers are extrapolated to the entire nation, this form creates $136.8 million in unnecessary expense, and $6.1 million hours in unnecessary paperwork, not to mention the significant delay in Medicare payments to hospitals.

Eliminating this form is a very important step on our road to recovery from bureaucracy. It helps return physicians to the bedside, and cuts bureaucracy-related costs. And this represents only one of many different kinds of forms which consume 20 to 30 percent of our health care professional's work day throughout the

I cannot leave today without offering two further thank yous. First is to Secretary Shalala for initiating this particular effort; Bruce Vladock and HCFA for the monumental effort they've given to making HCFA a customer-friendly organization and addressing these administrative hassles.

Standing next to Bruce, I feel a little bit like the fly in Longfellow's famous line, "And so we plow along, the fly said to the ox."


DR. GLEASON: You're waiting to see if I was going to say, Vladock was a big ox, right?


DR. GLEASON: I've been on -- I can't talk, right? I've been on this diet. I call it the Bill Clinton diet. Every day, I jog two miles and eat five Big Macs.


DR. GLEASON: Don't tell him I said that.


DR. GLEASON: Anyway, HCFA is, indeed, the force plowing through this mound of paper, and we thank them for that change in direction.

I also want to thank those of you in the audience, most of whom have been instrumental in bringing this important work to fruition, and thank you very much, Mrs. Clinton, for allowing me to share in this announcement. I look forward to working with the Administration in the months to come on this effort.

In caring for patients, it is always wise to apply a little common sense. The same is true about government. No individual has dedicated more time and more effort to insuring that our government's rules and regulations make sense than the Vice President. His work on reinventing government is transforming the way Washington works.
It is my pleasure to introduce the Vice President of the United States, Al Gore.

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