Address to the AMA
Chicago, IL, June 13, 1993
Thank you very much, Mr. Speaker; all of the members of the House of Delegates, the officers and trustees of the AMA, and all whom you represent. It is an honor for me to be with you at this meeting and to have the opportunity to participate with you in an ongoing conversation about our health care system and the kinds of constructive changes that we all wish to see brought to it.
I know that you have, through Health Access America, and through other activities and programs of the AMA been deeply involved in this conversation already, and all of us are grateful for your contribution. I'm also pleased that you invited students from the Nathan Davis Elementary School to join us here this afternoon. I know that the AMA has a special relationship with this school, named as it is for the founder of the AMA, and that the AMA participates in its corporate capacity in the Adopt a School program here in Chicago. You have made a real contribution to these young men and women. And not only have you provided free immunizations and physicals and lectures and help about health and related matters, but you have served as role models and mentors. It is very important that all of us as adults do what we can to give young people the skills they will need to become responsible and successful adults. And I congratulate you for your efforts and welcome the students here today.
All of us respond to children. We want to nurture them so they can dream the dreams that free and healthy children should have. This is our primary responsibility as adults. And it is our primary responsibility as a government. We should stand behind families, teachers and others who work with the young, so that we can enable them to meet their own needs by becoming self-sufficient and responsible so that they, in turn, will be able to meet their families and their own children's needs.
When I was growing up, not far from where we are today, this seemed an easier task. There seemed to be more strong families. There seemed to be safer neighborhoods. There seemed to be an outlook of caring and cooperation among adults that stood for and behind children. I remember so well my father saying to me that if you get in trouble at school, you get in trouble at home -- no questions asked -- because there was this sense among the adult community that all of them, from my child's perspective, were involved in helping their own and others' children.
Much has changed since those days. We have lost some of the hope and optimism of that earlier time. Today, we too often meet our greatest challenges, whether it is the raising of children or reforming the health care system, with a sense that our problems have grown too large and unmanageable. And I don't need to tell you that kind of attitude begins to undermine one's sense of hope, optimism, and even competence.
We know now -- and you know better than I -- that over the last decade our health care system has been under extraordinary stress. It is one of the many institutions in our society that has experienced such stress. That stress has begun to break down many of the relationships that should stand at the core of the health care system. That breakdown has, in turn, undermined your profession in many ways, changing the nature of and the rewards of practicing medicine.
Most doctors and other health care professionals choose careers in health and medicine because they want to help people. But too often because our system isn't working and we haven't taken full responsibility for fixing it, that motive is clouded by perceptions that doctors aren't the same as they used to be. They're not really doing what they used to do. They don't really care like they once did.
You know and I know that we have to work harder to renew a trust in who doctors are and what doctors do. That is also not unique to the medical community. Just as our institutions across society are under attack and stress, all elements of those institutions are finding that they no longer can command the trust and respect, whether we talk of parents or government officials or other professionals -- police officers, teachers -- that should come with giving of themselves and doing a job well that needs to be done.
But focusing this afternoon on those concerns that are yours -- what has happened with medicine, what is likely to happen -- we need to start with a fundamental commitment to making the practice of medicine again a visible, honored link in our efforts to promote the common good. And the way to do that is to improve the entire system of which you are a part. We cannot create the atmosphere of trust and respect and professionalism that you deserve to have, and that many of you who are in this room remember from earlier years, without changing the incentives and the way the entire system operates. That has to be our primary commitment. If we do not put medicine and those who operate within medicine in the forefront of the respect they deserve to have, no matter what we do to the system on the margins will not make the differences that it should.
As you know, the President is in the process of finalizing his proposal for health care reform, and I am grateful to speak with you about that process and where it is today and where it is going. I had originally hoped to join you at your meeting in March in Washington, D.C. And I, again, want to apologize for my absence. I very much appreciated Vice President Gore attending for me, and I also appreciated the kind words from your executive officials on behalf of the entire association because of my absence.
My father was ill and I spent several weeks with him in the hospital before he died. During his hospitalization at St. Vincent's Hospital in Little Rock, Arkansas, I witnessed firsthand the courage and commitment of health care professionals, both directly and indirectly. I will always appreciate the sensitivity and the skills they showed, not just in caring for my father, not just in caring for his family -- which, as you know, often needs as much care as the patient, but in caring for the many others whose names I will never know. I know that some of you worry about what the impact of health care reform will be on your profession and on your practice. Let me say from the start, if I read only what the newspapers have said about what we are doing in our plan, I'd probably be a little afraid myself, too, because it is very difficult to get out what is going on in such a complex process.
But the simple fact is this: The President has asked all of us, representatives of the AMA, of every other element of the health care system, as well as the administration, to work on making changes where they are needed, to keeping and improving those things that work, and to preserving and conserving the best parts of our system as we try to improve and change those that are not.
This system is not working as well as it did, or as well as it could -- for you, for the private sector, for the public or for the nation. The one area that is so important to be understood on a macronational level is how our failure to deal with the health care system and its financial demands is at the center of our problems financially in Washington. Because we cannot control health care costs and become further and further behind in our efforts to do so, we find our economy, and particularly the federal budget, under increasing pressure.
Just as it would be irresponsible, therefore, to change what is working in the health care system, it is equally irresponsible for us not to fix what we know is no longer working. So let us start with some basic principles that are remarkably like the ones that you have adopted in your statements, and in particularly in Health Access America. We must guarantee all Americans access to a comprehensive package of benefits, no matter where they work, where they live, or whether they have ever been sick before. If we do not reach universal access, we cannot deal with our other problems.
And that is a point that you understand that you have to help the rest of the country understand -- that until we do provide security for every American when it comes to health care, we cannot fix what is wrong with the health care system. Secondly, we do have to control costs. How we do that is one of the great challenges in this system, but one thing we can all agree on is that we have to cut down on the paperwork and reduce the bureaucracy in both the public and private sectors.
We also have to be sure that when we look at costs, we look at it not just from a financial perspective, but also from a human perspective. I remember sitting in the family waiting area of St. Vincent's, talking to a number of my physician friends to stop by to see how we were doing. And one day, one of my friends told me that, every day, he discharges patients who need medication to stabilize a condition. And at least once a day, he knows there is a patient who will not be able to afford the prescription drugs he has prescribed, with the result that that patient may decide not to fill the prescription when the hospital supply runs out. Or that patient may decide that even though the doctor told him to take three pills a day, he'll just take one a day so it can be stretched further.
And even though St. Vincent's has created a fund to try to help support the needs of patients who cannot afford prescriptions, there's not enough to go around, and so every day there is someone who my friend knows and you know will be back in the hospital because of their inability either to afford the care that is required after they leave, or because they try to cut the corners on it, with the net result that then you and I will pay more for that person who is back in the hospital than we would have if we had taken a sensible approach toward what the real costs in the medical system are. That is why we will try, for example, to include prescription drugs in the comprehensive benefit package for all Americans, including those over 65, through Medicare.
We believe that if we help control costs up front, we will save costs on the back end. That is a principle that runs through our proposal and which each of you knows from firsthand experience is more likely to be efficient in both human and financial terms. We will also preserve what is best in the American health care system today.
We have looked at every other system in the world. We have tried to talk to every expert whom we can find to describe how any other country tries to provide health care. And we have concluded that what is needed is an American solution for an American problem by creating an American health care system that works for America. And two of the principles that underlie that American solution are quality and choice.
We want to ensure and enhance quality. And in order to do that, we're going to have to make some changes, and you know that. We cannot, for example, promise to really achieve universal access if we do not expand our supply of primary care physicians, and we must do that. And you will have to help us determine the best way to go about achieving that goal.
I've spoken with representatives of our medical schools, and we have talked about how the funding of graduate medical education will have to be changed to provide incentives for the training of more primary care physicians. I have talked with representatives of many of the associations, such as this one, about how continuing educational opportunities could help even mid- career physicians, once we have a real supply of primary care physicians who are adequately reimbursed and adequately supported, how they might even go back into primary care.
We have also very much put choice in the center of our system so that we will have not just choice for patients as to which plan they choose to join, but choice for physicians as to which plan they choose to practice with, including the option of being part of more than one plan at the same time.
Now, as we work out all of the details in the many proposals and its parts that must come together, I am not suggesting that you will agree with every recommendation the President makes. I don't expect any group to do that. In fact, I suppose that if everybody's not a little put out that means we probably haven't done it right. But I do hope and expect that this group, as with other groups representing physicians and nurses and other health care professionals will find in this plan much to be applauded and supported. And I also believe that given the complexities of the problem we face, it would be difficult to arrive at a solution that was universally accepted.
But the reason I have confidence that this house, the AMA, and others will be supportive of the President's proposal is because we have benefited so much from what you have already done and from the involvement of many of you and others around the country.
Again, contrary to what you may have heard scores of practicing physicians served on the working groups that were studying health care reform. I am deeply grateful on a personal level that members of the AMA's leadership spent invaluable time coming to meeting after meeting, day after day sharing their ideas, reacting to ideas at the White House. And, of course, in the course of that we learned we had many common goals and objectives.
We will not only stand for universal coverage, but in addition the following: community rating so that we can assure all Americans they will be taken care of -- (applause); eliminating restrictions based on preexisting conditions so that every American will be eligible -- (applause); a nationally guaranteed comprehensive benefits package that will emphasize primary and preventive health care as well as hospitalization and other care -- (applause); the kind of choice and quality assurances that we will need to have to make sure this new system not only operates well during the transition but gets a firm footing as it moves into the future and we will therefore be emphasizing more on practice parameters and outcomes research so that you, too, can know better what works.
One of the great interesting experiences I have had during the past months is as I've traveled around from state to state is having doctors coming up to me and telling me that they need more information; that all too often the information they receive doesn't come to them in forms that they believe are practical in their particular context. And what we want to do is by working with organizations like yours is be sure that the quality outcomes and the kind of research that will done will be readily available to every practicing physician in the country.
We also believe that it will be essential to continue medical research and to use the breakthroughs in medical research, again, not just to alleviate human suffering but to save money, because you know better than I that often times a breakthrough in research, a new drug, a new procedure is the quickest way to take care of the most people in a cost-effective manner. So we will continue to support medical research.
All of these principles arise from the same common assumption -- that the status quo is unacceptable. And it is not really even any longer a status quo because we do not stand still, we drift backwards. Every month people lose their insurance; every month you have more micromanagement and regulation to put up with; every month our health care system becomes more expensive to fix.
I know that many of you feel that as doctors you are under siege in the current system. And I think there is cause for you to believe that, because we are witnessing a disturbing assault on the doctor/patient relationship. More and more employers are buying into managed care plans that force employees to choose from a specific pool of doctors. And too often, even when a doctor is willing to join a new plan to maintain his relationship with patients, he, or she I should say, is frozen out.
What we want to see is a system in which the employer does not make the choice as to what plan is available for the employee, the employee makes that choice for him or herself. But if we do not change and if the present pattern continues, as it will if we do not act quickly, the art of practicing medicine will be forever transformed. Gone will be the patients treasured privilege to choose his or her doctor. Gone will be the close trusting bonds built up between physicians and patients over the years. Gone will be the security of knowing you can switch jobs and still visit your longtime internist or pediatrician or OB/GYN.
We cannot afford to let that happen. But the erosion of the doctor/patient relationship is only one piece of the problem. Another piece is the role that insurance companies have come to play and the role that the government has come to play along with them in second-guessing medical decisions.
I can understand how many of you must feel. When instead of being trusted for your expertise, you're expected to call an 800 number and get approval for even basic medical procedures from a total stranger.
Frankly, despite my best efforts of the last month to understand every aspect of the health care system, it is and remains a mystery to me how a person sitting at a computer in some air- conditioned office thousands of miles away can make a judgment about what should or shouldn't happen at a patient's bedside in Illinois or Georgia or California. The result of this excessive oversight, this peering over all of your shoulder's is a system of backward incentives. It rewards providers for over prescribing, overtesting, and generally overdoing. And worse, it punishes doctors who show proper restraint and exercise their professional judgment in ways that those sitting at the computers disagree with.
Dr. Bob Barrinson, one of the practicing physicians who spent hours and hours working with us while also maintaining his practice, told us recently of an experience that he had as one of many. He admitted an emergency room patient named Jeff. Jeff suffered from cirrhosis of the liver and --. Dr. Barrinson put him in the hospital and within 24 hours received a call from Jeff's insurance company. The insurance company wanted to know exactly how many days Jeff would be in the hospital and why. Dr. Barrinson replied that he couldn't predict the precise length of stay. A few days later the insurance company called back and questioned whether Jeff would need surgery. Again, Dr. Barrinson said he wasn't yet sure.
And what was Dr. Barrinson's reward for his honesty and his professionalism? He was placed on the insurance company's "special exceptions" list. You know, that's a list of troublesome doctors who make the insurance company wait a few days or a few weeks to determine the bottom line on a particular patient.
From that point on, the insurance company called Dr. Barrinson six times in two weeks. Each time he had to be summoned away from the patient to take the call. Each time he spoke to a different insurance company representative. Each time he repeated the same story. Each time his role as the physician was subverted. And each time the treatment of the patient was impeded.
Dr. Barrinson and you know that medicine, the art of healing, doesn't work like that. There is no master checklist that can be administered by some faceless bureaucrat that can tell you what you need to do on an hourly basis to take care of your patients; and, frankly, I wouldn't want to be one of your patients if there were.
Now, adding to these difficulties doctors and hospitals and nurses, particularly, are being buried under an avalanche of paperwork. There are mountains of forms, mountains of rules, mountains of hours spent on administrative minutiae instead of caring for the sick. Where, you might ask yourself, did all this bureaucracy come from? And the short answer is, basically, everywhere.
There are forms to ensure appropriate care for the sick and the dying; forms to guard against unnecessary tests and procedures. And from each insurance company and government agency there are forms to record the decisions of doctors and nurses. I remember going to Boston and having a physician bring into a hearing I held there the stack of forms his office is required to fill out. And he held up a Medicare form and next to it he held up an insurance company form. And he said that they are the same forms that ask the same questions, but the insurance company form will not be accepted by the government, and the government form will not be accepted by the insurance company. And the insurance company basically took the government form, changed the title to call it by its own name and requires them to have it filled out. That was the tip of the iceberg.
One nurse told me that she entered the profession because she wanted to care for people. She said that if she had wanted to be an accountant, she would have gone to work for an accounting company instead. (Laughter.) But she, like many other nurses, and as you know so well, many of the people in your offices now, are required to be bookkeepers and accountants, not clinicians, not caregivers.
The latest statistic I have seen is that for every doctor a hospital hires, four new administrative staff are hired. And that in the average doctor's office 80 hours a month is now spent on administration. That is not time spent with a patient recovering from bypass surgery or with a child or teenager who needs a checkup and maybe a little extra TLC time of listening and counseling, and certainly not spent with a patient who has to run in quickly for some kind of an emergency.
Blanketing an entire profession with rules aimed at catching those who are not living up to their professional standards does not improve quality. What we need is a new bargain. We need to remove from the vast majority of physicians these unnecessary, repetitive, often uneven read forms and instead substitute for what they were attempting to do -- more discipline, more peer review, more careful scrutiny of your colleagues. You are the ones who can tell better than I or better than some bureaucrat whether the quality of medicine that is being practiced in your clinic, in your hospital, is what you would want for yourself and your family.
Let us remove the kind of micromanagement and regulation that has not improved quality and has wasted billions of dollars, but then you have to help us substitute for it, a system that the patients of this country, the public of this country, the decision- makers of this country can have confidence in. Now, I know there are legal obstacles for your being able to do that, and we are looking very closely at how we can remove those so that you can be part -- (applause) -- of creating a new solution in which everyone, including yourself, can believe in.
In every private conversation I've had with a physician, whether it's someone I knew from St. Vincent's or someone I had just met, I have asked: Tell me, have you ever practiced with or around someone you did not think was living up to your standards? And, invariably, the answer is, well, yes, I remember in my training; well, yes, I remember this emergency room work I used to do; yes, I remember in the hospital when so-and-so had that problem. And I've said, do you believe enough was done by the profession to deal with that problem and to eliminate it? And, invariably, no matter who the doctor is, I've been told, no, I don't.
We want you to have the chance so that in the future you can say, yes, I do believe we've been dealing with our problems. It is not something we should leave for the government, and, certainly, we cannot leave it to the patient. That is the new kind of relationship I think that we need to have.
Finally, if we do not, as I said earlier, provide universal coverage, we cannot do any of what I have just been speaking about because we cannot fulfill our basic commitment you as physicians, us as a society, that we will care for one another. It should no longer be left to the individual doctor to decide to probe his conscience before determining whether to treat a needy patient. I cannot tell you what it is like for me to travel around to hear stories from doctors and patients that are right on point.
But the most poignant that I tell because it struck me so personally was of the woman with no insurance; working for a company in New Orleans; had worked there for a number of years; tried to take good care of herself; went for the annual physical every year; and I sat with her on a folding chair in the loading dock of her company along with others -- all of whom were uninsured; all of whom had worked numbers of years -- while she told me at her last physical her doctor had found a lump in her breast and referred her to a surgeon. And the surgeon told her that if she had insurance, he would have biopsied it but because she did not he would watch it.
I don't think you have to be a woman to feel what I felt when that woman told me that story. And I don't think you have to be a physician to feel what you felt when you heard that story. We need to create a system in which no one ever has to say that for good cause or bad, and no one has to hear it ever again.
If we move toward universal coverage, so therefore everyone has a payment stream behind them to be able to come into your office, to be able to come into the hospital, you will again be able to make decisions that should be made with clinical autonomy, with professional judgment. And we intend to try to give you the time and free you up from other conditions to be able to do that.
One specific issue I want to mention, because I feel strongly about it -- if my husband had not asked me to do this, I would have felt strongly about it because of the impact in my state of Arkansas -- we have to simplify and eliminate the burdensome regulations created under *CLEA -- (applause) -- a well-intentioned law with many unintended consequences that have affected not only those of you in private practice but public health departments like ours in Arkansas around the country.
But again we need that new bargain. You have to help us know what should be eliminated so that we then can just focus in on a very small part of this whole situation and eliminate the rest of the regulations that were thrown on top.
So those are the kinds of issues in which we think we can make it more possible for you to practice in a more efficient, humane, better manner. We also believe strongly that we have to emphasize preventive care. And we have to provide a basic policy of preventive care. And we have to be sure that all of you and those who come after you into medicine are trained well in medical school to appreciate the importance of preventive care.
Much of what is now considered outside the scope of mainstream medicine is crowding in. Many of us in this room I know exercise, try to watch our diets, do things to try to remain healthier. And yet often medical education and medicine as it's practiced does not include those new kind of common-sense approaches to health. We need to be a system that does not take care of the sick but instead promotes health wherever we can in whatever way we possibly can do it.
And finally, let me say that we will offer a serious proposal to curb malpractice problems for all of you. But let me add that it, too, must be part of this new contract. In order to do that and to do it in a way that engenders the confidence of the average American, we must have organized medicine standing ready to say we will do a better job of taking care of the problems within us.
I have read or tried to read everything I can find about all of this. And you know as well as I do there are studies all over the field. It depends upon who writes it and who it's written for and the like. But we know there's a problem. We know we're going to deal with it. But one of the stark statistics from these studies is that all too often the largest number of malpractice suits is brought against the same physicians on a repetitive basis.
Now, it may be that for some that is an unfair accusation, and we need to deal with that through reform. But for others, you need to weed them out of your profession if they cannot practice to the quality that you expect your fellow colleagues to practice to. So we will propose serious malpractice reform, and we will have to look to you to help us make sure that the problems that will still flow from people who should not be making decisions will be eliminated. That way we can give confidence back to you as a profession, that you will not be second-guessed or unfairly called into court. And we will give confidence to the public that they will be protected insofar as humanly possible. So that is what we will have to look for when we come forward with that.
Now, reaching consensus on all that should be done and putting it into a piece of legislation and moving it through the Congress is not going to be easy. There will be many groups that will nibble at the edges of it, not like the whole idea of it, want to continue to the status quo. But if we do not have the courage to change now, if we do not move toward a system that once again gives you back your professionalism to practice prudent, practical, intelligent medicine again; if we do not move toward restoring the dignity again to the doctor-patient relationship, and that encourages young people to become physicians because they want to participate in that wonderful process of healing and caring, then the entire society, but most particularly medicine, will suffer.
The reason we are doing any of this is because of children like those who are here from Nathan Davis. Most of us in this room are at least halfway through. (Laughter.) And most of us in this room have sat in dozens and dozens of meetings just like this. We've sat and listened to people tell us what was wrong with health care or what medicine or with whatever, and we've talked about the problems at least seriously since the 1970s. And we've produced proposals like yours for Health Access America.
But while we have talked, our problems have gotten worse, and the frustration on the part of all of you and others has increased. Time and again, groups, individuals, and particularly the government, has walked up to trying to reform health care and then walked away.
There's enough blame to go around, every kind of political stripes can be included, but the point now is that we could have done something about health care reform 20 years ago and solved our problems for millions of dollars, and we walked away. Later we could have done something and solved our problems for hundreds of millions, and we walked away.
After 20 years with rate of medical inflation going up and with all of the problems you know so well, it is a harder and more difficult solution that confronts us. But I believe that if one looks at what is at stake, we are not talking just about reforming the way we finance health care, we are not talking just about the particulars of how we deliver health care, we are talking about creating a new sense of community and caring in this country in which we once again value your contribution, value the dignity of all people.
How many more meetings do we need? How many alerts? How many more plans? How many more brochures? The time has come for all of us, not just with respect to health care, but with respect to all of the difficulties our country faces to stop walking away and to start stepping up and taking responsibility. We are supposed to be the ones to lead for our children and our grandchildren. And the way we have behaved in the last years, we have run away and abdicated that responsibility. And at the core of the human experience is responsibility for children to leave them a better world than the one we found.
We can do that with health care. We can make a difference now that will be a legacy for all of you. We can once again give you the confidence to say to your grandsons and granddaughters, yes, do go into medicine; yes, it is the most rewarding profession there is.
So let's celebrate your profession by improving health care. Let's celebrate our children by reforming this system. Let's come together not as liberals or conservatives or Republicans or Democrats, but as Americans who want the best for their country and know we can no longer wait to get about the business of providing it.
Thank you all very much.