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(6) The authors' investigation concerning sickness expectancy.-In the investigation here described, data were collected from over 400 sickbenefit associations, covering, in the majority ofinstances, an experience of three years, have been collected. These data consist of records of disability due to sickness and nonindustrial accidents for which cash benefits have been paid under the various regulations of the associations, and afford this kind of sickness experience among over threequarters of a million wage earners engaged in many different industries and occupations. The collection and tabulation of the information have not been completed, but it is possible, for purposes of illustration, to present some preliminary figures for groups of wago earners who are members of one or two types of sick-benefit funds. It should be kept in mind that any conclusions suggested by these statistics ought to be regarded as tentative for the reason that more complete data covering a larger sickness experience are yet to be compiled.

More trustworthy information, it is believed, will be afforded when certain inquiries now under way are completed and when the systematic reporting of morbidity among wage earners is begun. An effort is now being made by the United States Public Health Service to collect such statistics of disability as are at present available in the experience among employees of industrial establishments.

For presentation here the disability records of those sick-benefit associations which pay no benefits for the first three days of sickness, or for illnesses of less than four days' duration, have been selected because a similar provision has been included in the health insurance bills that have been introduced in various State legislatures. Data for 22 of these associations have so far been collected. They include approximately 150,000 members, for the great majority of whom a three years' (1914, 1915, and 1916) experience is available, which makes possible a consideration of 463,714 years of exposure of membership. The regulations of the associations, however, are not uniform with respect to the maximum length of the period for which benefits can be paid; for this reason the statistics are presented accord

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1 It may be noted that the members of the 20 associations were nearly all males, the females constituting a negligible proportion, and, so far as could be ascertaincd, were adults of the usual wage-earning age period. They were employed in a variety of industrial plants and in various occupations; their sickness experience, however, is not large enough to permit of accurate indications of the influence of occupation. Since industrial accidents are not included, and since the members are fairly well distributed among different occupations in the groups presented in the table which follows, the occupational factor may be disregarded for the purposes of this illustration. To a considerable extent the members are a selected group; some of the associations require applicants for membership to pass a physical examination and to be under 45 years d' age, and nearly all had provisions which operated to exclude casual laborers from their membership. The possible influence of administrative methods and practices upon the sick rate is more difficult to determine; the possible effect of the amount of the cash benefit, however, may be disregarded for purposes of approximation, since, for the most part, the cash benefits provided ranged between one-third and one-hall of the wages. * Years of exposure of membership were ascertained from the records of the associations by securing the average memberships for each month in each year and computing the average ycarly membership by dividing the total of the monthly membership by 12.

ing to groups of associations having the same or nearly the same maximum benefit period. The statistics follow:

TABLE 2.---Sickness and nonindustrial accident statistics of 22 establishment sick-benefit

funds having a three days' waiting period, for 1914, 1915, and 1916: Classified according to length of benefit period.

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1 By "years of exposure of membership" is meant the number of members for whom a 1 year's sickness and nonindustrial accident record was obtained. The approximate number of persons who were members of the funds can be obtained by dividing the years of exposure of membership by 3.

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It will be noted that, ag may be expected, the waiting period being the same for all associations considered, the average days of compensated sickness per case tends to increase according to the maximum length of the benefit period, and determines the trend of the average days of sickness per member. The importance of the length of the benefit period in determining the amount of sickness for which benefits are to be paid under a system of health insurance is thus suggested. The sickness experience covered in the foregoing statistics is too small to afford definite indications of the experience under any given benefit period except, probably, for those associations having benefit periods of 52 weeks or more. For those six associations, with 440,691 years of exposure, we have a rate of 8.8 days of sickness per year per member.

The sickness expectancy for associations having a maximum benefit period of 26 weeks is, however, of especial interest because some of the health insurance bills introduced in State legislatures contain a similar provision. Unfortunately, until the data obtained are more completely tabulated and adjustments made for varying waiting and benefit periods, our statistics are rather meager. The rate of 6 days of sickness per member per year and of 392 cases of sickness per 1,000 members per year for the group of associations having benefit periods of 23 to 26 weeks appears to be conservatively low, especially when it is compared with the indicated experience obtained in several recent "sickness censuses" in the United States, to which reference has been made, and with the experience of the German

1 If the average annual case rate of 477 per 1,000 for the entire group of 22 associations included in the foregoing table be used as possibly a more accurate base, the days of sickness per member per year 4 associations with a benefit period of 23 to 26 weeks would be 7.3.

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sickness insurance system during the five years prior to the war. With similar waiting and benefit periods, the German experience for the years 1909-1913 showed an average of 8.4 days of compensated sickness per member per year. This was a considerable increase over the rate in 1900 and in years prior, which was about 6 or 7 days.?

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While the increase was in some measure undoubtedly due to changes in the provisions of the sickness insurance law, it can be interpreted at least partly as an indication of improvements in the medical care of the sick, of the placing of a greater emphasis upon "medical inadvisability to work” rather than on actual “inability to work” as a principle in determining the return of disabled workers to em. ployment, and of a clearer realization of insured persons as to their rights under the insurance system. It would therefore appear that all of the increase can not be attributed to malingering. Without venturing to assume that conditions affecting the health of German wage earners before the war were comparable in all respects with conditions in this country or that the German sickness rate is any guide to the sickness expectancy here, it seems reasonable to have under consideration the probability that the expectancy of sickness which is to receive cash benefits under State or other health insurance laws in the United States will be larger than that indicated by the experience of existing sick-benefit funds, especially if an adequate medical service is afforded.

Probably a conservative estimate of the total amount of sickness which will require medical service under the proposed health-insurance measures would be something between 8 and 9 days per insured person.

This includes, of course, the first 3 days of sickness and sicknesses lasting less than 4 days for which medical service must be

1 The following table presents the German sickness insurance experience for the years 1885, 1890, 1895, 1901, and 1905–1913 (compiled for the years indicated from Statistik des Deutschen Reichs: Die KrankenVersicberung):

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

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