Everybody Pays the Doctor

...In 1908 about 28 percent of the beds in a stated group of general hospitals were in wards of ten beds or more...

...He suggests the principle of mass production and competition as a way out -mass production by the coordination of services in clinics and hospitals and competition among clinics and hospitals to effect maximum service at minimum cost...

...Wilbur's Committee...

...in other words to accommodations which average from $3.00 to $5.00 per day as distinct from the old ward accommodations below $3.00 and the expensive private rooms which ranged from $5.00 up-mostly up...

...Flat-rate charges for certain classes of cases have been adopted by some hospitals in order to lessen the unpredictability and unevenness of hospital charges...

...Hospital beds have increased from 421,000 in 1909 to 890,000 in 1928...

...He believes that not only should the healing business be made profitable but that "We should find a way, if possible, even to make our hospitals profitable...

...Under the best of circumstances lower medical charges cannot be expected upon any other basis than a more efficient organization of the medical service of the country, or upon the basis of charitable or state subsidy...

...The number of physicians to 100,000 population is greater in the United States than in any other country...

...The investigation to date indicates that there is a vast amount of lost motion in the present-day practice of the medical profession and its attendant services-hospitals but partially used, nurses averaging not much more than half-time employment...

...their offices, office help, expensive equipment are only partially used...

...The average American, typified by the person of moderate means, will not willingly accept charity even when extended in wholesale, nor is there any sound reason why he should accept it or why the medical profession should be saddled with the necessity of offering it...

...In some respects the most significant development has been in the extent to which the hospitals of the country have joined in the movement to provide service for persons of moderate means...

...The number of physicians in each clinic ranges from five to thirty-five although two groups are larger...

...In other words there is increasing recognition of the fact that the interests of all concerned are best served when the cost of illness is regarded as a unit...

...There are not many such institutions now in operation, probably one hundred and twenty in all...

...He also suggests another form of mass production in the use of credit unions to spread the cost of illness...

...Most of these systems are based upon investigation of the patient's financial position and general credit including information not only as to salary or earnings but also information as to unemployment, debts, size of family, other illness in the family and similar factors...

...Filene advocates...

...Many hospitals also have adopted systems of financial adjustment to ease the burden on patients...

...and a concentration of medical service in the form of clinics or similar organizations which will reduce overhead and employ all of the physicians all of the time and at the same time will afford more satisfactory medical service, will do much to reduce present costs and at the same time work to the benefit of the medical practitioner...

...the remaining portion are in proprietary hospitals, mostly of small size...

...However, the distribution of physicians is inadequate...

...People of moderate means are no more to be satisfied with medical service on the basis of the practice of twenty-five or even ten years ago than any one else...

...The survey conducted by Dr...

...The Committee on the Cost of Medical Care has found that the number of physicians has not been increasing as rapidly as the population although the number of dentists has increased more rapidly than population and the number of nurses still more rapidly...

...Nevertheless the various agencies which have been studying this problem and the relation of the average citizen to the world of medicine have accomplished much during the past year...

...Some of them have introduced systems of flat charges for certain services and meet the needs of patients of moderate means in other ways...

...The Massachusetts General Hospital of Boston, for example, is now building a "hospital for people of moderate means" which is to contain 300 beds arranged in wards of nine cubicles, four-bed wards, two-bed, semi-private rooms and single rooms...

...they are badly distributed geographically with an oversupply in the larger cities and great areas in rural districts without adequate service...

...With the increase of data on which to base actuarial calculations the principle of insurance will doubtless be given increasing application...

...Deferred payment or instalment basis of payment has been introduced by some hospitals...

...Clinics, health centres and similar institutions have increased from about six hundred in 1910 to about six thousand in 1926 and have been greatly on the increase in the past three years...

...The most common type of adjustment of charges, however, is the reduction or remission of such charges...

...The proportion of beds in semi-private rooms increased from about 10 percent in 1908 to 23 percent in 1928...

...For this situation the physicians and the hospitals are responsible...

...Nearly all hospitals of the larger sort have made at least some change in the service offered, mostly in the direction of providing accommodations between the private room and the general ward...

...Edward A. Filene of Boston, that adequate medical care should not only be within reach of all but that the medical business should be profitable, to the implication in the query of Professor Niles Carpenter, a member of the staff of Secretary Wilbur's Committee on the Cost of Medical Care, as to whether or not under the best of circumstances and with all the proposed reforms in hospital management and professional charges the average person of moderate means could pay for his hospital care...

...nor should they be...

...Out of these general conditions two movements are to be noted...

...There is also something in the Filene idea of mass production-another name for coordinated service in a medical plant employed to full capacity...

...They demand, and should have, such care as the most modern methods and latest developments in the science and art of medicine can provide...

...To the question: "Can the patient of moderate means normally pay for his hospital bed, his 'extras,' his special nurse and his physician out of his own individual income...

...Development in clinic services has been especially rapid in the past few years and indeed in the past few months...

...even most physicians themselves are only partially employed...

...Some hospitals, at least, believe that he can and have set out to give him service on this assumption...

...over one-quarter is provided by non-profit organizations for public service...

...While the increase has not been as rapid as the increase in population the improvements in transportation, the growth of office practice and other changes have counterbalanced the decreased ratio...

...Primarily these group clinics are not organized to reduce the cost of medical service, but their economic result is that through the saving of overhead and on the use of equipment and in the prevention of other losses they are in a position to reduce costs and usually do so...

...he offers no answer but the non-committal reply that "It may be that he can...

...The first is the increasing development of group practice among physicians in clinics or similar organizations and the other is the increasing attention on the part of hospitals to the needs of patients of moderate means...

...In some cases the physician's fee is strictly limited by the hospital and in a few instances the hospital acts as agent in collecting the fee of the physician, thus unifying the cost of the illness...

...These clinics, in short, are in a position to enter upon that competition for maximum service at minimum charges which Mr...

...In 1928 only 7 percent were in such wards...

...It is also clearly established that in spite of large doctor's fees in many cases and almost universal high cost of hospital service the average medical practitioner is underpaid, the average nurse receives no more than a living wage when yearly income is considered while the average hospital, even a hospital with considerable endowment, has difficulty in maintaining its financial solvency...

...Group insurance already is practicable while the extension of practical insurance to communities is well within sight...

...In short, the chief change in hospital development has been in the way of providing vastly greater accommodations of semi-private rooms at the expense of the large ward system...

...He believes, with an increasing show of reason, that an effective organization of hospital facilities and other medical agencies in the United States...

...A preliminary survey of various private group clinics in the central West and on the Pacific coast was conducted by C. Rufus Rorem in preparation for a thorough survey now being undertaken by Dr...

...With the exception of the services of the pay clinics -usually attached to hospitals or other institutions and in which charges cover the cost of the service including remuneration for the physicians-and the movement among hospitals to provide special accommodations for persons of moderate means, both of which movements in time may become important factors in the reduction of the cost of medical care it must be admitted that the great problem of what is to be done as to adequate medical service, including preventive service, for the great mass of the people of the country at rates they can afford to pay remains unsolved...

...Seventy percent of all hospital service in the United States in 1927 was rendered by institutions controlled by federal, state or local governments, such institutions including the large governmental hospitals for mental, tubercular and other groups as well as large general hospitals...

...Of the entire hospital-bed capacity of the country considerably over one half is provided, by the federal, state or local governments...

...Filene believes that doctors generally are not receiving anything like sufficient pay for their services, while at the same time the public as a rule is paying far too much for the services it receives, and that while the art or science of healing has made great strides the "business of healing" has made none...

...expensive equipment duplicated and idle much of the time...

...EVERYBODY PAYS THE DOCTOR By GEORGE E. ANDERSON IT IS only natural, perhaps, that with incomplete data on which to reason there should be wide diversity of opinion in current discussion of the burden of the cost of medical care in the United States...

...The larger cities are greatly oversupplied while many rural districts are relatively undersupplied-some of them with practically no supply at all...

...It is expected that on this basis the hospital will be self-supporting except as to capital charges...

...To most of the efforts so far made to reduce medical charges to suit the purse of the patient there is the ever-present and highly obnoxious objection that they partake of the nature of charity...

...The diversity of ideas ranges all the way from the opinion of Mr...

...Most of the clinics are located in states west of the Mississippi with Minnesota and Texas leading in the number of institutions...

...In 1927 South Carolina and Montana had only seventy-one physicians per 100,000 inhabitants while California had 200...

...From the economic point of view the essential feature of these group clinics is the joint participation of the physicians in the services afforded and in the income of the group, the financial arrangements varying, of course, with various groups...

...Undoubtedly better hospital management, proper accounting in hospitals, the provision of more standard and less luxurious accommodations, closer union of hospital and physician in unifying the cost of illness, arrangements for the payment for medical care in instalments when necessary, and better cooperation between the profession generally and the health authorities to prevent the incidence of illness or to prevent serious development of initial illness-all these will serve to reduce the present burden of illness...

...Professor Carpenter raises his query after a special study of hospital service for patients of moderate means...

...there is no coordination between the service of the general practitioner and the specialists-in short, the catalogue of medical faults is a long one...

...From the standpoint of the patient the advantage lies in the service of general practitioners and specialists in one coordinated service...

...On the other hand the actual cost of medical service in most communities is so high that persons of moderate means can face it only with the alternative of a crushing financial burden or the acceptance of a charity which galls them...

...Niles Carpenter indicates that out of 132 hospitals reporting on future plans, 120 include special provisions for people of moderate means while twenty-one reported that they contemplate new construction primarily designed for the use of such patients...

...The rates are to vary from $6.50 per day for single rooms to $4.00 per day for cubicles, the floor nursing to be so imprpved as to do away with the necessity of special nurses in most cases and all the existing laboratories and other facilities of the parent hospital to be placed at the disposal of patients while staff fees are to be limited...

...Among the facts disclosed it may be noted that there are something like five million people in the United States ill all the time, most of whom do not receive adequate medical attention at any price, while there are something like a million and a half people employed in the care and prevention of illness including 143,000 physicians, most of whom are employed but a part of their time...

...Inasmuch as charges for special services in most hospitals run about 30 percent of the average hospital bill the innovation in Boston is of high importance...

...Modern medical practice, however, rests upon scientific diagnosis and scientific diagnosis under any circumstances is expensive...

...The Committee on the Cost of Medical Care, now well into the third year of its five-year program of investigation, has developed considerable data as to the incidence of illness and extent of physical and mental defects in the country together with a review of the present medical facilities and particularly something as to the movement for adequate and satisfactory hospital service for patients of moderate means...

...The question is one not only of the high cost of medical care but also one of the cost of high medical care...

...A change also is noted in the way of closer cooperation between the physician and the hospital in their financial relations with the patient...

...a better organization of the medical profession with an abandonment of many of the archaic rules of professional ethics which now hamper reorganization...

...But the fundamental question of whether adequate medical service for all the people of the United States in the future is to depend upon public subsidy or charity or can pay its own way is yet to be solved...