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                  Office of the Press Secretary
                   (Charlotte, North Carolina)
For Immediate Release                               April 5, 1994
                     REMARKS BY THE PRESIDENT
                    Montgomery County Hospital
                       Troy, North Carolina

11:04 A.M. EDT

THE PRESIDENT: We just completed kind of a brief tour of the hospital and talked about -- I met some of the nurses and patients and people who work here. We talked a little bit about the physician shortage in this county; a little about the problems with delivery of babies and the high rate of teen pregnancies, low birth weight babies, relatively low number of prenatal visits. We talked about some of the reimbursement problems of Medicare and Medicaid and the problem that this hospital has at the emergency room as they take everybody whether they have insurance or not. And I think that's a fair summary -- and I met the wonderful, dedicated people. So why don't you lead off.

Q Thank you, sir. I want to let Mr. Bernstein give us an overview of Montgomery County medicine and how it relates to the rural problems overall.

THE PRESIDENT: I think it would help for the press that are here, just the first time you speak if you would say your name and why you're here.

Q I'm Jim Bernstein, and I'm the director of the State Office of Rural Health. We've been in business for 20 years, working to try to get better health care in the rural areas -- Montgomery County is a really fine rural community and it's very typical of, I think, a lot of rural America. Some are poor, some are wealthier and they look a little different, but they suffer from a lot of the same problems. And you went through most of them.

But we have -- and North Carolina has lots of community -- we are one of the three largest rural states in the country right now. Half of our county -- there are still professional shortage areas. Twenty years ago we took a little different approach to how to deal with rural health care. We decided to sort of vet the local communities with whatever resources we can and let them run their own show; and what we've created is a community corporation. And over time -- we've got about 90 different communities now. Hopefully, the 91st has put together a leading citizens' group to sort of take charge. And they own and operate the whole system, and the state provides a lot of technical assistance and some funding money. They've put many millions into it over the years -- into getting it going; recruited about 1200 physicians for these communities.

I think that everybody welcomes and applauds you in what you're going to do for us in health reform, especially our rural communities. They are, of course, very concerned about how things are going to affect them, and really believe that this universal approach is mandatory for them to be successful. If you do a piece-meal approach of pulling people in, we're concerned that the wealthier, urban areas will suck up -- because the demand will rise there, but it will stay the same in the rural areas -- all the physicians, the nurse practitioners and everything will be bid out -- not only -- won't go there -- but they'll be bid out to go to the urban areas. So we think it's imperative that we don't do universal coverage in a piece-meal way; that we do the whole thing so that everybody's entitled. Otherwise, we see another urban-rural discrepancy happening. It's happened in the past.

We think our approach of building up infrastructure in the rural areas will mesh with the managed competition, because then there will be somebody to deal with plans out here that's got it together. Otherwise, we're a little concerned they might just tick off their -- So, we're happy we've taken this 20-year approach to dealing with our rural problems that way.

THE PRESIDENT: Thank you very much. I also think -- I was reminded on the tour that North Carolina actually has a program to provide subsidies for the malpractice premiums of -- practitioners who deliver babies and do things that -- in rural areas that they normally wouldn't do in urban areas -- is that right?

Q Yes. We have a lot of incentives in place in the state; one is that one. Another one -- state hasn't done which is really good -- Arkansas might do it, I understand -- is that we pay our residents more money if they'll go into rural areas and give them higher salaries. And then we do the usual things, like loan repayments, things like that. And we have, also, a statewide area health education center program trying to bring continuing education to keep people current in Troy and places like that.

THE PRESIDENT: That's very important. In this plan, I just wanted to mention this, because I think it's important. As the Congress debates this whole health care issue, the things which get the largest amount of attention as they would expect, are how to provide universal coverage and whether you can maintain choice and quality with universal coverage.

And a lot of these big questions -- but what a lot of people don't know is that in rural America, even if you cover everybody, a lot of folks still don't have adequate access to health care, and there's a real doctor shortage out there. And no matter what happens, I hope the Congress will leave in the provisions of our plan, which have -- one, would expand the national health service corps by 7,000 doctors over the next eight years; two, would give physicians who go into underserved rural areas a tax credit of $1,000 a month five years to six -- and, three, would allow a much bigger, faster write-off of equipment -- medical equipment that doctors might bring into rural areas. So I think those three things will really help to reinforce what you're doing.

Q Mr. President, Dr. McRoberts is one of our three practicing family physicians in the county. Our ratio of family practice physicians to population is almost one to 8,000.

THE PRESIDENT: One to 8,000 -- and what's the recommended ratio?

Q Well, to qualify as a health profession shortage area, it would have to be about one to 3,000 -- correct?

Q one to 2,000.

THE PRESIDENT: One to 2,000 is what you should have, right?

Q Yes.

Q What we should have. And I have 8,000 active patients in my practice right now.

THE PRESIDENT: Eight thousand?

Q I have over 8,000.

THE PRESIDENT: When was the last time you slept?

Q Well, actually, I did sleep last night. Somebody else was on -- Dr. Heinz had that pleasure last night, so -- anyway, but it is difficult to just get call coverage here. The other two physicians are just as overtaxed as I am. I average -- well, in flu season, which we've just finished, I averaged working 100 hours to 110 hours a week, and that was from January through March. And then we're kind of taking a breather now, and things are a little bit easier, and I work about 80 hours a week. And that's direct patient care.

I don't ever go home feeling like I've finished my work. There's always something that's not done. It's either records that's not done or a couple of phone calls that I haven't returned, or a couple of H & Ps that I've gone and seen the patients, but I haven't done the paperwork yet, or whatever. And you always feel like you're robbing Peter to pay Paul. And that's probably the most unsatisfactory part of it, is that there are so many people there who need you to be someplace where you're not. And, yet, whatever I'm doing always seems important to me at the time. It's kind of an unhappy situation.

But I love the area. My heart is in rural medicine, and I think that the physicians who go to rural areas who stay there do so because, probably most of them are from rural areas to begin with, and they used to live in small towns. But you sort of get bonded with your patients here. I know I've got 8,000 patients, but I know who they are. They're not just the lady with severe rheumatoid arthritis, or the guy with congestive heart failure, or the baby that was born last week that we had to transfer out. We know them by name, we know their faces, we know their mothers, we know their grandmothers.

I've been through the loss of a child with one young mother and now she wants me to deliver her next baby. You can't leave. I mean, it's like leaving your family. So I think that that's a big part of why doctors stay in rural areas when they come here, is because of just personal commitments and --

THE PRESIDENT: What's the most important thing that could be done to make your life easier? More doctors?

Q More doctors. I mean, definitely. We are at such a critical shortage of doctors right now, with only three family practitioners. And our draw area, the population that we draw from is about 28,000 people.

THE PRESIDENT: And what would be more likely than anything else to generate more doctors in this area? What could be done by the --

Q I don't know. That's the big question mark -- what will it take to get doctors to come here . I think you have to look for things like loan forgiveness, certainly, or low repayment programs for the residents that are coming out. Because that way you can get fresh, young blood, you know, people that aren't tired yet.

THE PRESIDENT: It doesn't take long to get that way --

Q This sounds a little trite, because it's a big question. But for 30 years we've awarded high-tech people and health professional people and basically didn't pay primary care people. And I know money is not the single most important thing, but it is important. And so, if the reform plan could move to reverse that, somehow the incentives would be not only loan

repayment and stuff like that, but somebody who worked here could make as much money as somebody who worked -- even if it had to be paid more to get to that level than in Charlotte -- he would be in a better position. Because our physicians get paid a whole lot less out here -- a whole lot less -- than they do in Charlotte.

THE PRESIDENT: Well I think, for one thing, if you start in medical school, under our plan, we would shift the allocation of internships and slots more toward primary care physicians, so you'll have more people in that business and they don't have to go where the market is.

Secondly, I think, we know the national health service -- who just got cut way back. So if you put another 7,000 doctors out there, it will make a difference, because that's a way to pay your medical school. And then the way the tax credit works is that it will, in effect, increase the income of every doctor and the other -- by $12,000 a year. That's what $1,000-a-month tax credit is. And even though -- even if people just come in here in five-year cycles, that's a significant amount -- that's a big commitment of your professional life; you can keep going that way.

Q Mr. President, one of the things that we have done in Montgomery County recently is formed a group of citizens to put together a not-for-profit corporation, which intent and mission is to try to recruit physicians into our area. And what we're trying to do is create an environment where we can get six, eight family practice doctors. I think a lot of us lose sight that family practice doctors is a specialty. And to create this environment so Dr. McRoberts not on call seven nights a week, they don't have to work every weekend. If we can get recruited six, seven doctors, they can rotate call -- They can go home and have quality family time, which is a real major concern that we have for our physicians -- and I know they have for themselves -- because working 100 hours a week, there aren't many hours left to spend with your family.

Beth Howell who is our director of nursing, faces a lot of the same problems that we face on the physicians' side in recruiting nurses into our area. Hospitals are not run, nor will they operate, without well-educated, practiced nurses. And I'll let Beth --

Q I'm Beth Howell, and I'm the director of nursing here at Montgomery Memorial. My association with this hospital began many years ago in 1957, when I was actually born in this hospital. And my mother was a nurse here for 41 years. I began my nursing career here as a new graduate. I started out as a staff nurse, and have been involved in education for the staff; and am presently involved in nursing management. And, as Mr. Scott alluded to, one of the primary issues that I deal with on a day-to-day basis is the recruitment and retention of the nursing staff. It's very difficult to compete with the larger facilities who are able to offer more competitive salaries and benefits. There's more opportunities for professional growth in those facilities. And frequently, what I hear is that larger facilities are reluctant to hire new graduates.

We hire new graduates. We invest our time and our resources into training them. And then, frequently, within six months to a year, suddenly the larger facilities want to hire these seasoned professionals, and so they leave our facility. So we're continuously training.

In small hospitals, nurses have to be very versatile. We have to cross-train so that they can float from one unit to another, and they have to have a variety of skills. Continuing education is very important so that they can maintain their competency level and their skills. And about the closest resource for continuing education is 45 miles away. These

programs are often expensive, and it's also very difficult when you're already short-staffed to free them up so that they can go to these programs.

It's very important to my staff and to me personally to be able to provide quality patient care. These people that we take care of day to day are the same people that we see in the grocery store; we sit beside of them in church and they're our friends. They're our families, and we feel like we have a personal stake in their recovery.

THE PRESIDENT: How many more nurses do you need? I mean, just for example.

Q I would like to have five additional registered nurses.

THE PRESIDENT: And where are most of them trained? Most of the RNs you get here?

Q In the local community colleges.

THE PRESIDENT: And is there one -- where's the nearest one?

Q We have one -- we actually have two that are within 20 miles, and another one that's within 40 miles.

THE PRESIDENT: So that's not a real problem --

Q Right.

Q Retention is the problem. The nursing staff turns over a lot, just like she was saying.

THE PRESIDENT: I'd be interested in your feedback on this. The only thing that I know of that's in our bill that would help is there's also -- as I say, we felt that the quickest way we could deal with the income disparity -- I mean, we can't go in and sort of change the economics of every community in the country, but you could give a federal tax credit. And a credit is not like a deduction, it's a dollar-for-dollar deal. And so there's a $500-a-month tax credit for five years for nurses, too. And I think that will almost close most of the gaps. I mean, that's $6,000 a year. That's probably about what the gap is early on.

Q Is that just for health profession shortage areas?

THE PRESIDENT: Yes. For shortage areas. But you could qualify.

Q Thanks. (Laughter.)

THE PRESIDENT: I mean, nobody can work 80 hours or 100 hours a week forever. You burn out. You can't do it.

Q That's right. (Laughter.)

THE PRESIDENT: That's what I tell all of the young people at the White House with their -- energy. At some point, you stop working smart and you start working stupid. When you work hard, you just can't -- there's a limit to how much anybody can do.

Q Mr. President, Dr. Craft is in pediatrics. He came through our facility when he was in his resident program and worked in our emergency room for a short period when he was doing his residency. So I think that Dr. Craft probably has some comments that he cold address and shed some light.

Q I'm Hugh Craft. I'm a pediatrician. I practice now in Roanoke, Virginia, although I'm a North Carolina native. And I work at a teching hospital that serves as a referral center for a rural community very much like Troy, facing really the same types of problems. The communities are different, but the problems that the hospitals in the communities face are very similar. I take care of -- probably a third of the patients I see every year are children who are referred in from smaller hospitals. Many have not had adequate primary preventive care services, have diseases that resulted in inadequate immunizations. I think the things in your plan, the focus on preventive care, I think, is critical, and I think it will have a big impact on the health of children.

I think universal coverage will also. We have a two-tiered system and we need to have a one-tiered system so that patients are patients and providers are reimbursed at one level for everybody, and that's not an issue when the patient comes into the provider's office.

One of the things that we do that I think is helping our smaller communities, we do a lot of outreach education in the hospitals. We'll go out to the emergency room, a nurse and myself, and do programs in the hospital so the staff won't have to leave, and we can conduct the programs there at no cost. Part of our mission is teaching, and that way, can raise the level of skills to providers who take care of children.

Sick kids will often first show up at the door of a hospital like this hospital, or small hospitals in southwest Virginia, and how they're taking care of theirs is really critical to how they're going to do more things for our hospital. So think the new focus on preventive care, universal access and the rural health initiatives which I reviewed a couple of nights ago I think will really help in the rural areas.

We train a lot of family physicians who go out into small rural communities, and they're facing the same kind of problems that Dr. McRoberts faces here -- long hours, isolation from professional colleagues and I think there are a lot of things in your plan that will address those problems.

THE PRESIDENT: One of the things -- you mentioned the area health education concept, which I think has really done wonders in rural America, all over the country. But one of the things that we have tried to do in this plan which we haven't talked about this morning is to provide some funds for electronic hookups, with really great access to technology so you can have almost instantaneous and continuous contact with medical centers around the country. I think it isn't quite like being there, but it will go a long way toward bridging the gap that exists now.

Q Yes, I think it will. They have to put primary care doctors on the front line, literally, in instant contact with specialists when they have the patient in their office or in the hospital who need some help.

Q Well, you know, we had a sample of that here for a short period of time. Remember when we had -- and we were hooked up with the University of North Carolina at Chapel Hill, and they used to give us instant consultations on fetal monitoring strips on pregnant women who we felt like there was abnormality here that might be fairly serious, and we wanted to have a perinatal consultation. And they sold it to several different hospitals in the state, and we were one of the hospitals. And we didn't use it frequently, because most of our mothers are stable, luckily.

But, anyway, when it ended up that they took it out because other hospitals used it even less frequently than we did, and we were their last customer. So they felt like they couldn't justify the cost of it. And they called us up and asked us what

we thought about it, and we said, well, we love it. And we didn't want to turn ours in or sell it back or anything. But they came and took it away from us, anyway, because they discontinued the program. And that was really unfortunate, because that provided us with a great service for -- well, about a year or so, wasn't it, that we had that?

Q There's one other issue besides just training with technology -- advanced technologies to get from the large center to the small center. It's actually providing sites with physicians and nurses to be trained in rural areas, which is going -- something we'll have to do about -- will have to be done about modifying the way you reimburse those places, because they're not paid to train physicians. I'm with the college of medicine at East Tennessee State University that's dedicated to turning out primary care physicians, and does a good job, and they brag about turning people out in small communities in underserved areas.

But I also share the same -- almost 17 years of experience with Dr. McRoberts in a small community in southwest Virginia prior to doing that chore, and prior to teaching. And in those long years -- when I only went for two years -- in the national health service corps -- and could not leave that community for the very same reason she described. I never had a lot of help from universities that are subsidized for their subspecialties so well, and expect rural communities to go there for their care.

The access issue of first access, geographic boundaries and economic boundaries are essential problems in rural areas.

Medical schools have a lot of supply-side thinking to them. They've got the technologies, they've got the subspecialties, they're in here for the things that rural areas afford the patients to use these technologies. There must be a reorientation to the actual demands of those communities and what needs to be trained there, and how you go about training those with creative and innovative ways that they're doing in Roanoke, our own medical school has tried to put physicians in smaller communities for their training -- much more of their training. I think it is real regional emphasis.

Jim Bernstein and his organization has helped many communities all over this state, but he's been able to work with each medical school regionally throughout the state, and I think that focal factor -- the university, in its regional mission and accepting that mission across state lines many times, to get people there to be trained, besides just emphasizing technologies and telephone line and access in technology, there doesn't seem to be -- and people must be exposed to these places.

THE PRESIDENT: You know, this has been a source of real controversy, by the way, in the medical community, as you know, because we are only -- of all of our graduates from medical school now, only about 15 percent of the family practitioners, and in most other major nations, about half the doctors are family practitioners -- maybe slightly over half.

So in our bill, we propose over a five-year period to change the mix of medical school slots that the federal government subsidizes -- and, as you know, they're heavily subsidized -- to get to a point where about 55 percent have to be in family and general practice. And I met the other night with all the teaching hospitals in the Boston area to talk about how quickly that can be done, because as you pointed out, they're all sort of geared up and wired to their specialties and subspecialties and all that, and that's sort of where the money is. But I just thing that we have a very compelling obligation to spend the taxpayers' money at the national level to try to remedy what is a blooming horrible crisis.

We're here in a little rural area, but there is a shortage of family practice doctors in a lot of the major urban areas of the country. So I think it's not just the training setting, you actually have to get the med students into those slots, and we're going to have to change the subsidy ratio.

Now, again, this is something that almost never gets discussed in the larger debate about health care. But unless we're prepared to do what it takes to guarantee that we educate our young people in sufficient numbers to be family practitioners, all the economic subsidies in the world won't get them out there because they won't be there -- people won't be there. And I think that's one thing that's very important that the American people know that, that with all of the doctors we have, we actually have a shortage of family practitioners nationwide, and it's going to get worse unless we change the economic incentives for the next year.

Q Mr. President, this is a wonderful discussion, and I know that you have other commitments that you must attend to today, and we could sit here all day and all night --

THE PRESIDENT: I'm having a good time.

Q carrying on these discussions. And it is wonderful for us to have the opportunity to sit down and discuss with you. I'd like to thank you for visiting Montgomery Memorial Hospital and in speaking to our patients and our citizens, and to let you know we think that we're doing the right things in Montgomery County to deliver the best medicine we can, quality medicine to our citizens. But the problem is much larger than we are. And we are hoping and working for a payment system that can allow us to operate and serve our citizens.

I believe one of the doctors said earlier that when we see a patient they normally haven't been to a doctor and they're to a stage that if they need hospital care it's normally extended hospital care. So we're working to those -- we realize that the problem is much larger than we are and we are working very hard in our community to do what we can do. But we need the help from the Congress. We need the help from --

THE PRESIDENT: How much uncompensated care do you do here every year, do you know? Just people who show up at the emergency room that are uninsured.

Q I would say it would be about 50 percent in the emergency room. Probably, what --

Q Uncompensated care or less than total compensated care is better than 50 percent in our hospital.

Q That's true, our hospital, too.

THE PRESIDENT: So that goes back to the first point you made, that universal coverage is a big deal and if people want medical care to continue in rural America, and forget about the taxpayers and anything else, this hospital could pay more --

Q That's right.

THE PRESIDENT: -- to pay the nurses more, to pay other people -- to offer incentives to doctors to come directly if you had compensated care. And you'd have a -- if you had a better array of services then because it was compensated, you could take better care of the pregnancies and everything else.

It all comes back to this universal care thing. We cannot be the only country in the world that can't figure out how to provide basic coverage to all its citizens. We can't justify this any longer.

Q Thank you very much, Mr. President.

THE PRESIDENT: Thank you all. I'm glad to see you. Your father has been educating me about these things for years and years.

Q He's tried to figure it out.

Q Mr. President, why is it worth it for you to come here and talk to just such a few people when you have already basically done this before -- you asked a lot of these same questions before.

THE PRESIDENT: Because it's obvious to me that these things come in waves -- I mean, the American people are thinking about it again now, and it's very important that we deal with some of these horrible health problems. Most people lobbying on Capitol Hill will be lobbying against universal coverage in one way or the other. But these folks who are out here giving health care know we've got to have it.

I also think it's very important to emphasize a lot of the things that are in our health care program that are not controversial on their face, but they could get lost unless we emphasize them. For example, all the incentives for people to come out here and become family practitioners.

And so the debate, in a funny way, is just beginning. We're getting all this work in subcommittees; we're getting things going forward. All the surveys show an interesting dichotomy. They show that support for our plan goes up and down based on what they heard about it from interest groups or in paid ads; but that if you tell them what the details are in our plan, then more than two-thirds of the American people support all the specifics.

So what I'm trying to do is to get out here and highlight these real-world experiences that these doctors and nurses and other health care providers have so that we can focus the attention of the American people and the Congress on solving the real problems, not the rhetorical problems.

Q And get this on local television.

THE PRESIDENT: Well, yes, that's the idea.

Q Mr. President, are you losing public relations battle, Mr. President?

THE PRESIDENT: No, I think we're winning it again now. And we're getting real movement in Congress. But I think we don't have the ability to raise the kind of funds or do the kind of nationally organized advertising that has been done by some against the program. And, inevitably, a lot of the national organizations may get more publicity than local ones do. But when you get out here and you go beyond the rhetoric and get down to the details and the real-life experiences of these folks that are out here trying to take care of America, then the compelling case for reform, for universal coverage, for guaranteeing health security for all Americans, and getting the funds in here to these rural hospitals and providing more family doctors is overwhelming. And so I think we just have to keep hammering this home, not just on local television -- I'll be grateful if you put this story on national television tonight. (Laughter.)

Q Thank you, Mr. President, we appreciate you being here.


END11:38 A.M. EDT