toward working out satisfactory plans, and insist on their inclusion in all the bills proposed in any State legislature ?

Turning now to the discussion of the plans for providing medical and surgical treatment, and the methods of payment, the following have been proposed:

1. The establishment of a panel upon which any licensed practitioner so desiring may register. From this panel insured persons are allowed to select their physician, subject to the right of the physician to refuse under certain regulations.

Payments to be made on a capitation or fee basis, or a combination of both.

2. Contract physicians employed on an annual salary basis, or a capitation basis, from which number the insured persons are allowed to select.

3. District physicians, paid on part-time basis. 4. Combinations of numbers 1, 2, and 3.

The success or failure of any of these plans will, of course, depend largely upon their administration. Two plans for the organization of the administration have been proposed; one, with an administrative board composed entirely of employers and employees, with an advisory medical committee; the other, with an administrative board composed of a chairman, employer, and employee directors, together with a medical director and a health director, with an advisory medical committee. It would appear obvious that in the administration of medical and health matters, medical and health men should have an active part in the management instead of only an advisory authority. The State should have representation through the selection of the chairman and the health director, and physicians should insist on having proper representation on the local and district boards which are to administer the medical benefits, and not be satisfied with an advisory position.

As to the plans for proviqing medical benefits, it seems to be conceded that free choice of physicians must be provided wherever practicable. Whether this will always provide the best medical service is a question, but the demand of individual freedom in this matter is too strong to be limited, even though the individual may at times exercise this freedom of choice to his own detriment. Furthermore, the efficiency of a physician's treatment would be seriously affected when attending a patient who did not prefer his services. Much may be said in favor of freedom of choice. It would avoid a disturbance of the time-honored relation of the family physician to his patients. With the right to change doctors at will, physicians would still have operative all of the present incentive to please their patients.

It would be through the method of payment that an opportunity would be afforded to take the premium off of sickness and place it indirectly upon health. By fixing the payments on a capitation

basis, the physician would receive the same amount per patient per year, whether his patients were sick or well. This would indirectly result in making the healthy patient the most desirable to the physician. Under this system there might be some patients left over who had been refused by all of the physicians as undesirable on account of the frequency of their demands on the medical attendant's time. This, however, is liable to occur under any system of free choice. If the number of these left-over patients is small, they may be allotted pro rata. If the number is large, a salaried physician may be employed to attend them. Surely when the patients have the power to change physicians at will, the physician will have the same incentive as he now has to please and render his best service. Further"more, he will realize that by doing everything possible to keep his patients in health his work will be reduced. On a visitation basis of payment the physician who had sickly patients would have the better income, so that there would be no indirect financial incentive to keep his patients well; on the contrary, the more visits he made, the greater his income. This plan of so much per visit would probably be too expensive for the insurance system, unless in making up the annual budget a fixed amount were allotted for the payment of medical benefits. Such an allotment of a definite amount per insured person would really be equivalent to capitation payment, as it would limit the payment to a fixed amount per capita. It would, however,

, have the defect of putting a premium on the sick patient.

In this discussion of plans for providing adequate medical and surgical relief, the remuneration of physicians must be presumed to be adequate, else the conditions are liable to be worse under health insurance than they are now. For this reason it might be provided in the organic act that the rate of remuneration must be adequate, and provisions made for a commission to fix the rates. Furthermore, if members of the families of insured persons are to be included " in provisions for medical benefits, the rates should be fixed according to the number entitled to medical benefits and not according to the number of insured persons. Obviously, the physician who is to furnish medical treatment to an insured person with wife and child is entitled to three times more than he would be if he is only to furnish it to a single insured person with no dependents, for, as stated above, the sickness expectancy of women and children is very probably as great as that of men in the wage-earning age group.

Before leaving this question of medical benefits it should be stated that it is not just to oppose a proper health insurance bill on the ground that it means cheap contract practice, with all of its known evil

. Contract practice can not be objectionable if the physician is paid enough so that he will not have to slight his work in order to

make a living

Contract practice is in successful operation in this country in many government services, and in many large business establishments. Furthermore, based on a capitation payment, where there is competition for patients, the contract practice is likely to prove satisfactory, provided always that there is no opportunity for cutting the rates of payments. Methods of Adequate Prevention of Sickness-Plan for Making Sickness Insurance

Actually Health Insurance. The foregoing discussion has related to sickness insurance as a relief measure. If it is to be enacted on the grounds of a health measure and is really to be health insurance then ample provision should be made for the preveniion of disease. It is not sufficient to create a financial incentive for the reduction of the sickness rate. Definite provision should be made for preventive machinery. Some of the existing State health departments are too inefficient to be depended upon. They should be strengthened, to meet the needs in this field, If millions of State funds are to be expended for health work, surely these funds should be spent to prevent disease, and not simply for relief.

With the appropriations for “health insurance” running into millions of dollars annually it goes without saying that legislative bodies will not materially increase the appropriations for their health departments. Owing to this fact there is a decided probability of sickness insurance acts endangering the very existence of State health departments by absorbing all of the funds available for health work, Our statesmen and lawmakers must therefore be careful that proper and ample provisions are made for health machinery in any sickness insurance act.

No provisions have been made in any of the insurance systems of foreign countries for coordinating them with the health agencies; though to a limited extent provisions are made by some for disease prevention and medical research. The English experience has been such that the ministry of health bill now pending provides for the transfer of the national insurance system to the health department.

We should profit by this experience and make ample provision for disease prevention through existing State health agencies. All proposals for health insurance in this country should therefore be carefully scrutinized and all sections providing for disease prevention amended so as to definitely place these functions under the jurisdiction of the health departments. Otherwise there will be duplication of work, confusion of administration and waste of funds. The weightiest of the arguments presented by the proponents of health insurance are based on the probable effect it will have in preventing disease. The question then would seem to be whether existing health


agencies shall be utilized or new agencies created. Surely some plan can be worked out whereby existing health agencies can be coordinated with health insurance systems and obviate the necessity of creating new machinery. Even if new machinery were created it would be unwise to create it to work independently, so that, after all, existing health agencies would need to be coordinated with the new system.

The general outlines of a plan for coordination were approved by the Annual Conference of State and Territorial Health Officers with the Public Health Service, May, 1916. This plan proposes to utilize the medical referees in carrying it into effect. It is proposed to have these appointed by the State, and commissioned to act as referees for the health insurance system and as health officers for the health department, under the jurisdiction of both agencies.

Following out this general outline, a scheme of organization has been suggested which, it is believed, would work out satisfactorily to both. It is pretty well conceded that medical referees will be required in every locality to see and keep in touch with each sick person in order to certify to his disability prior to the payment of cash benefits. Experience has shown that it is not right to impose the duty of signing the disability certificate upon the physician treating the case. Since the medical referee is considered necessary in the scheme of sickness insurance, and since his duties as referee will require him to pass upon claims in which three parties are interested, viz, the insurer, the insured, and the treating physician, it would appear but proper that he be employed by the State. The additional duties required of him as health officer would not interfere with his usefulness as referee; in fact, they would add to his efficiency and clothe him with the authority of the health department. Such authority would make of him one unit in the health machinery for the health insurance system. :- The organization proposed would be about as follows:

1. Make the State commissioner of health an ex officio member of the State health insurance commission.

2. Detail a medical director from the State health department to assist the commission in supervising the administration of the medical benefits and to act as health advisor and director.

3. Detail district medical directors from the State health department to aid in the administration of the medical benefits in their respective districts.

4. Detail from the State health department a sufficient number of local medical officers to act as medical referees and to sign all disability certificates, and to perform such other duties as may be authorized by law or regulation.

To give some idea of the size of such a corps, it may be tentatively estimated that it would require one medical referee to every 4,000 insured persons.

In a State with 1,000,000 wage earners, this would mean 250 local medical officers giving their entire time to the study of the health of the insured persons. This, of course, would be in addition to the medical treatment furnished by the panel physicians.

The objection could not be offered that such a corps would be too expensive, for it must not be forgotten that all the measures now advocated provide for medical referees. The only additional expense incurred by this plan would be for the medical director and the district medical directors.

Even.if the expense of the whole corps were an additional expense, the cost would not be prohibitive because the medical referees would more than save their salaries in the disallowances of unfair claims. Furthermore, while an estimate can not be made of the amount to be saved by the work of these health experts, it is safe to say it would be many times more than the sum of their salaries.

At first glance this plan has been considered by some to be impracticable because they thought it gave too much authority to the health departments. It, however, does not add to the authority of health departments, it only extends their field of usefulness.

The duties of the referee as related to the insurance system would be to see and keep in touch with the sick insured, to certify to their disability, to advise with the treating physician, to advise the insuring agency as to measures calculated to shorten disabilities, and to prevent disabilities among insured persons.

The duties of the referee as related to the health department would be almost identical with the above, with the additional duties of sending duplicates of morbidity and mortality reports to the department, and advising as to any assistance he may need for research into the causes of sickness in his jurisdiction.

For the proper performance of these two sets of duties he would be responsible to each department. But under the organization proposed, a referee would receive State appointment, subject to duty anywhere within the State, so that it for any reason his services were not locally satisfactory he might be shifted to another locality; in fact, there should be a limit to his tour of duty in any one locality to prevent him becoming too thoroughly identified with the local politics or other conditions which might give a bias to his decisions or actions.

The plan has been criticized owing to the fact that it does not place employment of the referee under the control of the local insuring agency, one of the parties interested in his decisions as referee. It would scem obvious that a referee should not be employed by one of the parties at interest. Further criticism has been made that the treating doctors would not submit to supervision by a representative of the State health department. It is hard to understand

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