provided. With a sickness expectancy of 9 days per insured person per year, the physician with 1,000 insured persons on his list might expect to have 20 to 40 of these constantly sick. That would mean making some 20 to 40 professional visits a day, though a certain proportion will be office visits. This estimate applies only to insured persons; if the families are to be included in the medical benefits and if the average family consists of wage earner, wife, and child, the amount of medical work would be increased at least 200 per cent, for it may be safely estimated that the sickness expectancy in the family is at least twice as great as for insured persons.

Methods of Providing Adequate Medical and Surgical Relief.

The question of adequate medical relief has become a serious economic problem. The advances made in medical science, the new discoveries, the refinements in technique of diagnosis and treatment, have added to the seriousness of the problem, until now it is often stated that only the rich and some of the very poor are able to obtain the latest and most up-to-date medical and surgical treatment.

For the general practitioner the question of rendering his best service is becoming more onerous. The examination which he is now equipped for carrying out requires so much time and patience that it becomes a question of increasing his charges to where the cost is prohibitive for the man of ordinary income, or doing his increased service at the old rate of pay and finding that he is not able to earn a decent living for his family.

The physician, when he faces this situation, must decide to confine his practice to the well-to-do, to drop back into the old method of a hurried and inadequate service for a large clientele, or to render his best service to all and content himself in his poverty with the knowledge that his life is worth while.

In another sense an important underlying cause of the present medical and surgical service inadequacy is an economic one. The income of the physician is dependent upon the misfortune of his friends. When his friends are not sick the doctor's income stops. In other words, when his friends are without income they have the further burden of a doctor's bill. This is, to say the least, economically unsound. If the practice of medicine is to be on a sound economic basis the cost of sickness should be met during the period of employment, when there is an income. The problem, then, is to furnish an adequate medical and surgical service to the wage earner, the cost to be met during the period of employment. To guarantee that it be within the reach of all employed persons, provision must be made for the continuance of a substantial part of the income during sickness, else many will not be able to stop work even when sick.

Under present practices of the medical profession there is a premium placed on sickness. That is to say, the patient who is sick often, or for long periods, is worth much more to his doctor than the patient who is seldom sick. This should be reversed; the premium should, in so far as practicable, be placed on health. With a premium on health payable to the doctor, it goes without saying that it would be an added incentive to him to keep his patients well, and to cure them as quickly as possible when sick. The question, then, is as to the practicability of working out some plan by which all of the good features in present practice may be retained and at the same time add an economic incentive as a further inducement for the doctor to keep his patient well.

If health insurance is to come, and changes in methods of medical practice are to be made, certainly the opportunity is an extraordinary one for placing these practices on an economically sound basis, and for making "sickness" insurance actually a "health" insurance.

It should be thoroughly understood that adequate medical and surgical relief is not possible without adequate pay. Any plan which proposes to reduce the average net income of the physician will surely fail to provide adequate relief. If, as is often stated, a large proportion of the people are not receiving adequate medical treatment, the readjustments made necessary in order to provide proper treatment for all insured persons would very probably mean an increase in the average net income of the physicians. Surely no plan should be countenanced which will make matters worse.

In this connection it is well for physicians to consider the experience of foreign countries under sickness insurance, and the experience of this country under workmen's compensation laws. In Germany, the plan of administration of medical benefits which led to the "doctors' strike," would hardly offer inducements to us to copy the German plan. In Great Britain, the plan has been the subject of much criticism, mainly because of the incentive to malingering, and delays in payments, and methods of payments to the physicians. After the British law had been in operation for something more than a year, Mr. Lloyd George made the statement that there had been an average increase in the annual income of the physicians of $750 occasioned by the act, and that 22,000 of the 25,000 physicians in England had registered on the panels. The experience in this country under workmen's compensation laws is too well known to need discussion here. That this experience has not been satisfactory is mainly the fault of the physicians themselves. They sat quietly by while the laws were being enacted and made little effort to have the proper provisions incorporated into these acts. The question naturally arises, Shall the physicians spend their time and money fighting these proposed measures, or shall they direct all their efforts

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 providing 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 prevention 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 in

surance 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