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Social phases of the group health association movement in the United States

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Social phases of the group health association movement in the United States

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Content SOCIAL PHASES OF THÉ GROUP HEALTH ASSOCIATION MOVEMENT IN THE UNITED STATES A Dissertation Presented to the Faculty of the Department of Sociology University of Southern California In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy By Edward C• McDonagh May 1943 UMI Number: DP31689 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. DîssQrtaîion PwDiisring UMI DP31689 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 ex This dissertation) w ritten by ........MWARD.MGDpNAGH under the guidance o f h%3.. F a cu lty Comm ittee on Studies, and approved by a ll its members, has been presented to and accepted by the C ouncil on Graduate Study and Research, in p a rtia l f u l fillm e n t of requirements fo r the degree of D O C T O R O F P H I L O S O P H Y Dean Secretary Committee on Studies : ^ . . Æ t L Chairman "r Â TABLE OP CONTENTS CHAPTER PAGE I* -THE PROBLEM'AND DEFINITIONS OF TERMS USED .... 1 The problem •••••••••••• ........... 2 Statement of problem....................... 2 Methodology of the study ................... 3 Definitions of terms used..................... • 7 Group health association ................... 7 Social phases ........... 7 Social movement........................... 7 Rochdale principles •••••• ............. 8 Cooperative group health association .... 9 Proprietary group health association .... 10 Quasi group health association ............. 10 Public, state, or socialized medicine .... 10 Wealthy income group ....................... 11 Middle income group .......................... 11 Low income group . « 12 Relief income group ............. «.•••• 12 Forecast of chapters............................ 13 II. SOCIAL ORIGINS OF THE GROUP HEALTH ASSOCIATION MOVEMENT IN THE UNITED STATES ........... 14 Cost of medical care to middle c l a s s...........14 Search for low cost methods of obtaining medical services ............................ CHAPTER PAGE Origins in health insurance procedures and legislation......................... . 23 Workmen's compensation laws and procedures .. ............... ....... 33 Industrial clinics and welfare services .... 38 Committee on the Costs of Medical Care .... 47 Abstract of chapter ....... ............. 56 III. COOPERATIVE GROUP HEALTH ASSOCIATIONS ........... 62 Farmers* Union Community Hospital Elk City, Oklahoma . . . . . . . . . . . . . 64 Group Health Association, Inc. at Washington D.C. ................... 84 Greenhelt Health Association at Greenhelt, Maryland ...... ............. 99 Group Health Cooperative at Chicago Illinois......................... 117 Group Health Cooperative at New York City . . . . 133 Wage Earners * Health Association at St. Louis, Missouri . . . . . . . . . . . . . 140 Chapter summary............ 159 IV. PROPRIETARY GROUP HEALTH ASSOCIATIONS ...... 163 Ross-Loos Medical Group at Los Angeles, California................... 164 CHAPTER PAGE Trinity Hospital at Little Rock, Arkansas................. 191 Review of chapter ....................196 V. QUASI GROUP HEALTH ASSOCIATIONS ........... 199 California Physicians* Service ............. 201 King County Medical Service Corporation at Seattle, Washington . ................. 214 Medical Service Bureau at Atlanta, Georgia.............. 218 Summary of chapter............................ 223 VI. CORRELATIVE DEVELOPMENTS ASSOCIATED WITH THE GROUP HEALTH ASSOCIATION MOVEMENT ..... 228 Group hospitalization......................228 Group dental plans..........................242 Chapter abstract ..........................257 VII. A COMPARATIVE ANALYSIS OP THE ADMINISTRA- TIVE STRUCTURE, MAsfâGEÏÆENT, AHD OOHTROL OP POLICY OP THE THREE TYPES OP GROUP HEALTH ASSOCIATIONS OPERATING IN THE UNITED STATES .............................. 268 Structure and management....................263 Control of policy ........................281 Chapter recapitulation.............. 290 CHAPTER PAGE VIII. COMPARISON OP HEALTH PLANS IN FOREIGN COUNTRIES WITH HEALTH GROUPS IN THE UNITED STATES .......... '......... 295 Great Britain ....................... 296 Scandinvian countries .......... . . 308 Germany ...... ..................... 312 Union of Soviet Socialist Republics .... 314 India ....................... ............ 317 South America..............................318 Chapter review .................. . 320 IX. MAJOR CONTEMPORARY PROBLEMS AND VALUES OP COOPERATIVE AND PROPRIETARY GROUP HEALTH ASSOCIATIONS ......... 325 Major problems ................... 325 Major values ... ........................ 342 X. SUMMARY OF FINDINGS, RECOMMENDATIONS, SUGGESTIONS FOR FURTHER STUDIES, AND SOCIOLOGICAL IMPLICATIONS. OF THIS STUDY . . . 349 BIBLIOGRAPHY ........ ......................... 361 APPENDIX . ............................ 377 LIST OF TABLES TABLE PAGE I* Membership Dues Payable to Group Health Association of Washington D.G. ...........88 II. Membership Dues Payable to Greenbelt Health Association of Greenbelt, Maryland • . . . 102 III. Comparative Cost of Medical Services to Members and ïïon-members of Greenbelt Health Association ......................104 IV. The Comparative Cost of Medical Service to Group Members of Group Health Co operative at Chicago, Illinois ..........120 V. Comparative Cost of Medical Services to Group Members and Individual ^embers of Group Health Cooperative ^ew York City . . 135 LIST OP charts CHART PAGE I. Administrative Structure of the Ross-Loos Medical Group at Los Angeles, California , 264 II. Administrative Structure of California Physicians* Service................... • 267 III. Administrative Structure of Farmers* Union Community Hospital at Elk City, Oklahoma ....................... 271 IV. Administrative Structure of Group Health Association at Washington D.C. ..... 273 V. Administrative Structure of Group Health Cooperative, Inc. and Civic Medical Center at Chicago, Illinois............ 276 VI. Administrative Structure of Wage Earners* Health Association at St. Louis, Missouri .............................. 278 VII. Model Administrative Structure of a Group Health Association ............... 280 VIII. Comparison of Group Health Associations in the United States with Health Insurance in Great Britain and State Medicine in Soviet Russia............ 294 CHART PAGE IX* Socio-Medical Comparison and Summary of Health Groups Analyzed. . ............... 552 CHAPTER I THE PROBLEM AND DEFINITIONS OF TERMS USED The problem of how best to dispense medical care to the American people has been the subject of much social con troversy and conflict for the past several décades in the United States. The clash of deep-seated attitudes rooted in custom and tradition with modern medical innovations which threaten the security and status of the established institution of medical private practice has succeeded in focusing this problem in the public consciousness. Arguments both for and against various medical plans, as expressed by their proponents and opponents, have heightened public interest on the subject, and tangible evidence of newer methods of distributing medical care, in the form of group health associations, have crystal lized areas of attitudes and opinions of diverse groups of people. Lay and professional groups throughout the country have sought some means to meet their health needs and have been instrumental in fostering and developing organizations offering group health services through a system of periodic or pre-payment plan. They met with opposition, primarily, from the medical doctors through their professional organization, the American Medical Association. 2 Inasmuch as many group health associations have been in existence less than two decades, it has been possible in certain cases to observe with considerable clarity and accuracy the particular steps in their formation and their ensuing prob lems at each stage of their growth and development to date. The scholarly literature on this important subject is meager and scattered, a fact which constituted one of the academic hurdles of this study. However, sufficient primary sources and pamphlets came to the attention of the writer to circum vent this difficulty at least partially. I. THE PROBLEM Statement of problem. The primary aim of this disser tation is to trace the underlying factors in the development and functioning of the group health association movement in the United States. Basic to a thorough analysis and under standing of this central problem are the following questions, which constitute sub-purposes of the study: (1) what are the origins of group health associations? (2) what features characterize cooperative group health'associations? (3) what features typify proprietary group health associations? (4) what hallmarks designate quasi group health associations? (5) what related developments correlate the group health assoc iation movement? (6) how do group health associations contrast 3 with health, insurance schemes and plans of state medicine? (7) what do the attitudes of group health association members reveal and disclose about the group health association movement and the medical set-up in the United States today? (8) what seem to be the significant-social values and major problems of group health associations? Methodology of the study. A careful analysis has been made of the available literature pertaining to group health associations and related organizations in order to ascertain lay and professional thought on this topic. The following libraries were utilized for purposes of research and for the gathering of bibliographical materials: The Edward L. Doheny Jr. Memorial Library of the University of Southern California, The Los Angeles Public Library, Stanford University Library, University of California Library, Southern Illinois Normal University Library, and the Library of Congress. The librar ians in these institutions were helpful and courteous in locating literature and information pertinent to this problem* A second method used in this dissertation was to make a comparative study of the constitutions, by-laws, &nd espec ially the contracts of important group health associations. Most of these documents were obtained by requesting specimen copies from each health group from the managers of each particular group, who were, in nearly all cases, eager and 4 willing to cooperate in supplying the requested information. For the reader, a few representative copies of group health association contracts have been placed in the appendix of this study. A third method of gathering data was through correspond ence with the managers and leaders of group health associations. Specific information was obtained from administrators which would not otherwise have been available in group health liter ature. Questions asked were specific, on the whole, and thus did not involve a too extensive answer from the receiver. Cooperation from professional and lay members of the health groups studied, in so far as correspondence was concerned, was excellent. The utilization of the objective observer technique was a fourth type of methodology used to gather information for the study. Considerable factual information was collected on each of the contemporary group health associations before an attempt was made to interview and evaluate any health group. Thus, an unbiased and detached attitude in intern- viewing these group health members^ whether they were medical doctors, managers, or subscribers, was possible. An apper ceptive mass of factual information concerning each one of these group health associations was an important aid in 5 making interviews and observations more objective than would otherwise have been true. Several hundred interviews conducted by the writer, have thrown some light on the attitudes and reactions of subscribers, administrators, and physicians. It was noticed that physicians frequently showed more reticence than others in discussing^ the nature of group health associ- ■ i ations. However, the reserved nature of physicians, in a number of instances, may have been due in part either to the pressure which the American Medical Association has brought to bear on almost every medical doctor practicing in this country, or to an occupational attitude of medical doctors. Gasfe data of a representative nature were made avail able through the cooperation of persons who interviewed members of the three different group health associations studied intensively. These interviews were conducted along certain specific lines to insure greater validity of the findings. A written account of each interview was sent to the writer, and each case was scrutinized and evaluated, and the analysis incorporated in the dissertation. Nearly one hundred inter views with members of Farmers* Union Community Hospital were gathered by field interviewers. Approximately one hundred and fifty interviews and about one hundred ^ ’expressionnaires” were collected from subscribers * to Ross-Loos Medical Group. Interviewees represented the following occupations served by 6 Ross-Loos Medical Group: Southern California Gas Company, The University of Southern California, Los Angeles City School Teachers, Southern California Telephone Company, and the Los Angeles Police Department* Wage Earners* Health Association of St. Louis, Missouri was studied intensively by the writer* The collection of case materials disclosing the attitudes of members of group health associations constituted a fifth method of procedure* In order to attain a realistic xinderstanding of the at titude of the American Medical Association toward the inception and development of the group health association movement, the writer attended a phase of the trial between the Government and the American Medical. Association which was held in Judge Procter* s court in Washington, D*C*, during the month of March, 1941* The Journal of the American Medical Association has published a complete report of the statements and proceedings of the historic trial* A brief review of the outcome and findings of this trial has been undertaken in a later section of this work* A sixth type of methodology was to present the location of group health associations in the United States not only in terms of spatial concentration, but also in terms of temporal sequence* Such a graphic method indicates both the points of concentration of health groups and the date of origin of the 7 health, associations which are in operation at the present time. Again, this spatial-temporal map makes possible a more complete comprehension of the relationship which may exist between regionalism and the distribution of group health associations* II. DEFINITIONS OF TERMS USED Group health association. In general, a group health association is an organization with the following essential elements : (1) systematic or periodic payment of fees by sub scribers or potential patients for health services, usually on a monthly basis, (2) medical personnel provided on a group scheme, (5) centralization and pooling of scientific equip ment in one or more buildings* Social phase* This term is used to describe the social or interactional aspects of group health associations, including attitudes and opinions of members, and organizational develop ment and problems of health groups. Social movement* Doctor Clarence E* Rainwater has defined the term as a **mode of collective behavior occasioned by social disorganization or contacts involving intercommunica tion of desires, and manifested by an organization of social activities intended to accomplish a common object.He noted ^Clarence E. Rainwater, The Flay Movement(Chicagos The University of Chicago Press, 1922), p* 3* 8 four other significant characteristics which were common to movements as follows: (1) a series of events involving the adjustments to a social situation, (2) an extension of this series in time and space, (3) an object to be realized by means of the adjustments involved, and (4») a tendency toward attainment of that object, disclosed in stages in its develop- p ment and transitions in its policy and activities. The inability of a large number of American people to pay for adequate medi cal care was largely responsible for bringing about the social movement of group health associations. Rochdale principles. In 1844 an organization of Roch dale Pioneers formed a consumer * s cooperative which proved to 3 be successful. The principles which governed this weaver*s cooperative have become known as the "Rochdale principles." Because these cooperative principles have stood the test of time, it has been appropriate to qualify them as the cardinal principles. The Executive Board of the Bureau of Cooperative Medicine has pointed out the relationship between the Rochdale principles and cooperative medicine as follows: "From the standpoint of organization, the fundamental principles of con sumer cooperation apply; one member, one vote; no proxy voting. . p. 3. 3 Emory S. Bogardus, The Development of Social Thought (New York: Longmans, Green and Company, 1940), p. 383. 9 no political,, racial, or religious discrimination; open membership* These principles are the basis of democracy. It has not been possible for group health associations to return to subscribers a "patronage dividend" because of the nature and structure of health groups. Excess capital over operating expenses at the end of the year is turned generally into medical research or used for the purchase of medical equipment for the group health association, or the premium rate is lowered. Cooperative group health association# The essential principles of cooperative group health associations are; group medical practice, preventive medicine, periodic payment, and consumer control. In these health groups the lay members democratically control administrative policies and the physicians direct and supervise all medical problems and practices. It has been found advantageous to have a functioning division of labor and control between lay subscribers and. professional personnel. "No agency except an association of patients seems to be so motivated as to provide the proper relationship be tween the doctors and the purchasers of medical service. Let it be said, however, that under the cooperative plan, lay control ^Cooperative Health Association (Nev/ York: The Bureau of Cooperative Medicine, 1937), p. 25. 10 does not extend into the field of medical matters. These are exclusively in the province of the doctor." Proprietary group health association. In this type of health group a number of physicians pool medical equipment into a centrally located suite of offices and offer medical services on a periodic payment basis to a group of subscribers. Physicians in these health groups are owners, operators, and administrators. Thus, subscribers to a proprietary group health association do not have a voice in the formation of administrative policy. Quasi group health association. The American Medical Association has encouraged the formation within counties of a form of quasi group health association which incorporates periodic payments and a panel of names of all physicians in good standing in the local county medical society. Such health groups have been quasi because there is no pooling of medical equipment or medical personnel in centrally located offices. Some of these health groups have been created to prevent the spread of more thorough plans of distributing medical services. Public, state, or socialized medicine. Medical services that are financed by government funds are known as either ^Ibid,, p$ 25. 11 public, state, or socialized medicine.^ Medicine so dispensed has been more prominent in European countries than in the United States. The poor and relief classes even in the United States, however, have been recipients of a system of almost mass health, as practiced by public medical agents. The American Medical Association has waged a vigorous campaign for several years against the development and organization of state medicine on the grounds that such medical care did away with the "patient-physician relationship." Wealthy income group. Families with an annual income in excess of $10,000 have been designated as belonging to the wealthy income group. In 1928 during the period of "economic normalcy" there were only 2.7 per cent of the families in the United States with an annual income of more than $10,000, or about 783,000 families that might have been considered as constituting this aggregation#*^ Middle income group. This term does not necessarily mean the average income, but rather what the lay person defines Some writers have attempted to make a distinction between socialized and state medicine. For them, any form of group •medicine is socialized and thus group medicine that is financed by government funds is state medicine# Therefore, to them socialized medicine is the more inclusive terms. 7 Statistics compiled from The Ability to Pay for Medical Care, By Louis S. Reed. Abstract of Publication No# 25 of the Committee on the Costs of Medical Care, January, 1933, p. 4# IE popularly as the "middle class." Annual incomes between $2,000 and $10,000 generalize the earnings of the middle income class family. In 1928 there were around 42.1 per cent of the families in this classification. Hence, it is fair to consider this 8 group as almost an economic middle class. Low income group. Annual family incomes from $1,000 to $2,000 constitute the low income group. The lower half of this branch of society might be regarded as a "medical indigent class." In 1928 almost 41 per cent of the American families were in this income group. Since the year 1929 the number of families constituting the low income class has increased consider ably.^ Relief income group. A new class in society has been created in such countries as the United States with the pro longed period of widespread unemployment which was caused principally by the utilization of labor saving machinery and the financial crash of the stock market in 1929. It was necessary for the various agencies of county, state, and federal government to take an active part in providing relief to the millions of families that were the victims of unemployment. Inasmuch as the depression of 1929 has been unusually tenacious, this relief class has become an almost permanent aspect of ^Ibld.. p. 4. ^Ibld.. p. 4. 13 American culture. Medical care for relief class has been a serious problem. III. FORECAST OF CHAPTERS In Chapter II an attempt is made to depict the origins of group health associations in the United States. Cooperative group health association methods are discussed in Chapter III. A characterization of the principal features of proprietary group health associations is made in Chapter IV. An analysis of the methods of quasi group health associations is developed in Chapter V. Correlative developments associated with the group health association movement are presented in Chapter VI. The central purpose of Chapter VII is to present a comparative analysis of the administrative structure, management, and control of policy of the three types of health groups. Chapter VIII focuses attention on comparative health developments in foreign countries with health groups in this country. Major problems and values of group health associations are analyzed in Chapter IX. The final section. Chapter X, sets forth the findings and recommendations of this study. GHAPTm II SOCIAL ORIGINS OF THE GROUP HEALTH ASSOCIATION MOVEMENT IN THE UNITED STATES In this chapter an attempt is made to describe and analyze adequately some of the basic factors which seem to account for the process of social evolution or growth of group health associations in this country. Of particular interest is the fact that many of the historical factors responsible for the creation and maturation of health groups are still operating at the present time; hence, in a large number of instances, contemporary verification is possible on a number of points. Cost of medical care to middle class. One of the significant but somewhat paradoxical factors which accounts in part for the development of group health practices in this country is the economic fact that the low-middle income group has found it difficult to afford adequate medical services under a traditional fee-for-service type of medical care. Numerous writers and thinkers in the field of social health have observed that "Only the rich and the poor...get the best medical care; the rich because they have money, the poor be cause they have charity. Studies indicate that both rural ^William P. Foster, Doctors and Disease (New York Public Affairs Pamphlet, No. 10, 1940), p.1. 15 and urban low middle income strata have been unable to afford adequate medical care. The low income class feels that it has been discrim inated against regarding the matter of medical care. One Los Angeles citizen commented as follows on the subject of the Los Angeles County General Hospital: 1*11 tell you what I think about the County Hospital. Iti*s a beautiful set of buildings to have, but as for me, it.might just as well hot be here. Any Mexican can go in there looking hungry and he gets good care. But let an American go in and what happens? He can die while they go through a lot of red tape to find out whether he*s a pauper or not. How if you*re a * swell* from the West Side you don*t need to come to the County Hospital because you can afford to pay some high class doctor to take care of you. And if you want to, you can come to the County Hospital and pay a good fee and they*11 see to it that you get special attention. And as I said, a down-and-outer is always able to get free care here. But a wage earner like myself tries to work when he * s sick and when he can* t stand any more he scrapes up enough money to pay a regular doctor and hopes he gets well fast. And mind you, we taxpayers pay for these beautiful buildings, and yet we get nothing out of it at all. Believe me, I*d like to see something done about it, and the sooner the better. 3 The low middle income group finds itself contributing a rather large share of the cost of illness because the paying patient must compensate the physician for the bills that are non-collect- able and for his charity work. A number of socially minded ^Por a careful review of the problems of middle income farmers in California see "A Health Program for California Farmers," by Von T. Ellsworth. Medical Care, Volume I, Number 1, 1941, p. 34. ^Interview with W.A. 16 persons have been investigating the possibilities of reducing the cost of medical services and distributing the risk of un predictable medical fees among a large number of people. For some time, both .in the United States and in Europe, the low income group has experimented with the cooperative purchasing of various food commodities. There is evidence to support the view that cooperative consumer stores are becoming an integral part of the American culture complex. It is therefore a logical step and natural development that the principle of group or cooperative purchasing be transferred and applied to the purchase of medical and hospital services. It is also a significant coincidence that one of the foremost leaders in the cooperative movement in the United States, James P. Warbasse, is a medical doctor. Under his encouragement consumer cooperators all over the country have become aware of the possibility of providing medical services to a group of subscribers on a periodic payment plan. A group health association not only distributes the risk of the cost of a serious illness among a group of members but also lowers the per capita medical cost because of the saving involved in the pooling of costly medical equipment among a group of doctors. Frequently the low income person is restricted from taking advantage of so-called free clinics because of the social psychological stigma attached to patients who are without funds 17 and must ask for medical charity. Doctor Kingsley Roberts noted that there are millions of people in this nation who do not receive adequate medical care even though they are not ill-housed or ill-fed. ”There are those who are unwilling to go to a doctor’s office and ask for charity.**^ Search for low cost methods of obtaining medical services. The cost of purchasing adequate medical care has resulted in a very notable and conscientious search for ways, means, and plans that would make medical services available to the low income class. While it is true, as pointed out earlier, that the high cost of medical services alone does not necessarily argue in favor of group health associations,it is nevertheless probable that medical services can be dispensed with less difficulty through a distribution of risk program, which is an ^essential principle of group health medicine, than by fee-for-service medical practice. One of the earliest methods devised to reduce the cost of medical services to patients was the centralization of medical personnel and equipment in a suite of offices or even a building. Such a centralization of medical services was termed frequently and commonly, a clinic* The development of clinical medicine made possible a mutual or cooperative sharing 4 Kingsley Roberts, **The Place of Group Practice in the Future of American Medicine,” Journal of Medicine, May, 1940* 18 of medical knowledge and methods# It was discovered that it was becoming an impossibility for every medical doctor to have a first hand acquaintance with the entire fund of medical and scientific information; hence an epistemological advantage in group consultation and interstimulation of clinical practice 5 became evident# Prom an economic point of view, it was manifest that the average physician could not afford modern and costly scientific equipment for his office# In the clinic the medi cal practitioner has free access to scientific equipment as an aid in the diagnosis and treatment of medical illnesses# One of the most successful private clinics in the United States has been operated by the Mayo brothers in Rochester, 6 Minesota# Because the Mayo Clinic did not violate the so-called ethical code of the American Medical Association, it was not opposed and not severely critioized by organized medicine# Traditional fee-for-service and sliding scale methods were incorporated in the economic structure of this clinic. However, the unusual skill of the Mayo brothers as first rate surgeons was instrumental in creating for this clinic a national and famous reputation. The advantages of clinical medicine plus 5 For a good account of the development of modem medicine see the book by Bernhard F. Stern, Society and Medical Progress Princeton; Princeton University Press, 1941), particularly Chapter VIII. ^James Rorty, American Medicine Mobilizes (Hew York: W.W. Horton and Company, 1939), p. 259. 19 the great prestige of the Mayo Clinic have been significant factors in furthering the development of tendencies toward group health associations. Private health clinics, like the Mayo Clinic, even though they retained the matrix of conservative medical service distribution, nevertheless demonstrated to the American people the advantages of group medical association and consultation. Modern group health associations have taken the idea of centralized personnel and equipment from private medical clinics, but the criterion for payment of fees has been changed radically. Another effort to meet the problem of medical services was demonstrated satisfactorily by the United States Army in the first World War. Doctor Bertram Bernheim, Associate Professor of Surgery of Johns Hopkins University, significant ly remarked concering the nature of medical services of the United States Army in Prance during the international conflict: The one thing, though that impressed me most and gave me more cause for thought later was the effective medical and surgical service given the troops, and the high quality of it— once the doctors got themselves together. For here was full time medicine (and nursing) at its height I Every man was working on a salary basis* his pay check came in the first of every month whether he worked or not* There was no private practice; and the high and low, the general and the humblest private got the same treatment. It was superb, grand. There never was anything like it. Kobody, so far as I could see, loafed when there was work to be done. '^Bertram M. Bernheim, Medicine at the Crossroads (He# York: William Morrow and Company, 1939), p. 19. 20 Of interest to the sociologist was the fact that the irapracti- cability of medical individualism as carried on in times of peace became conspicuous in a time of great social unpheaval and military conflict. Because of the concentration of great numbers of persons in limited areas, some' method of organizing and conserving personnel and equipment became of paramount concern. A number of famous physicians in the United States have had personal contact with military medicine and have become leaders for reforms regarding methods of medical eco nomics. Because of the similarity between the United States Army medical services and group health services, managers of group health associations have pointed out the success Q of group medical practices even under military supervision. Urbanization has also indirectly promoted the evolve- ment of group health associations. Social scientists have noted that urban areas tend to centralize facilities of social living, particularly social institutions and services. Durkheim has pointed out that increasing density of population has been a major key in the development of a division of labor.^ ®The Selective Service Proclamation of the United States President, effective October 16,1940, tended to recruit many young physicians into the United States Army Medical Division. Many physicians today, as in World War Humber 1, will receive a first hand orientation of group medical practices and services. %ogardu3, op* cit., p. 421. 21 Urbanism facilitates the adoption of group health association principles# It is an important observation that with the exception of one group health association, the other health groups have been organized and developed in or very near large American cities# There is little doubt that urbanism has been an important factor in the historical development of modern medicine as the following sociologist notes so wells The shift of the western world from a predominately rural to ah urban society, and from a handicraft to an industrial economic order has profoundly influenced the growth of medicine. The aggregation of vast numbers of people into cities changes pronouncedly the patient’s behavior and attitudes, his susceptibilities to disease, his probable contact with an infection, and the nature of his nutrition. The industrial revolution, took place in the social setting of competitive enterprise, when the prevailing attitudes were hostile to any form of governmental regulation. Consequently, as modern cities grew, congested slum areas developed and most communities lacked proper sanitation and adequate water supplies# This situation raised challenging health problems with which both the medical profession and public health agencies had to cope, to prevent the cities from devouring their inhabitants. Advances in proper housing, in the disposal of garbage and waste, in the availability of a pure and adequate water supply, and in other sanitary measures have contributed in no small measures to the ability of medicine to extend the life of man, and to decrease the frequency and duration of his diseases. They therefore form a fitting and necessary background for the understanding of the success of modern medicine.^ A futile search for patent medicines in order to reduce the cost of medical service has been made by the low income ^Bernhard P. Stern, op. cit,, p.xv. 22 middle class. The trial and error practice of self-medication has been undertaken by many in an effort to avoids a ’ ’physician’s call fee” for seemingly unimportant illnesses. Patent medicines with almost ”cure all” claims have become well known to the American public through newspaper, radio, and outdoor advertising. It has been found that the poor spend, for medicine, a greater proportion of their total medical expenditures than do the middle and upper classes.^^Pharmacists have stocked their stores with thousands of patent medicines. Mr. James Rorty has remarked: ’ ’They don’t want to carry 142 different cough'-rernedies, 148 brands of liver pills, 30 mouth antiseptics and correspondingly burdensome stocks of ’ethical proprietaries,’ but the advertisers and the drughouse detail men oblige them to do so, that they may ’serve’ the public. Pharmacists probably have not wanted to sell worthless or harmful patent medicines, but many have been guided by the statement, ”If I don’t sell them patent medicines some other 12 druggist will.” The habit of self-medication has often resulted in tragedy. It was clear to a number of people in the United States that self-medication was not the solution to effective decrease of the cost of medical service. James Rorty, op. cit., p. 175. Ibid.. p. 179. 12 Personal interview, no. 2. 23 Origins in health insurance procedures and legislation. It was observed more than twenty-five years ago that the cost of illness does not fall evenly upon each person in the community, With this realization, efforts were made to place the cost of medical services on an insurance basis by certain progressive minded groups in the United States. Perhaps the underlying philosophy of health insurance revolved around a group of social principles aimed at circumventing difficulties which may be an ticipated before they occur. Certain cycles have been noted which point toward the fact that social living, especially when serious illness with its attendant monetary depletion occurs among the lower income groups, becomes a practical impossibility. The social phases of a vicious cycle recur repeatedly in this order, i.e., (1) an employed person becomes ill, (2) his income ceases at a time when his expenditures are great, (3) his lack of income makes it difficult or impossible for him to secure adequate medical care, which prolongs his illness, increases his poverty, and places him among either the unemployed or the un employable* The social principles involved to help alleviate this cycle are; (1) to assure cash benefits during illness, (2) to provide adequate medication during illness through med ical benefits, and (3) to carry on a preventive program of medicine. See I.M. Rubinow, The Quest for Soourity. 24 The American Association for Labor Legislation directed a vigorous campaign for the adoption of compulsory health insurance* Through the efforts of this organization com missions were appointed in eleven states to study the entire subject of compulsory health insurance. Of these eleven com missions, a majority of six urged the enactment of a com pulsory health insurance program. Two California commissions reacted favorably in 1917 as follows; .•.Legislative provision for a state wide system of com pulsory health insurance for wage workers and together persons of small income would offer a very powerful remedy for the problems of sickness and dependency in the State of California...Any Legislation on this sub ject should...provide (a) for a compulsory system...by non-profit making insurance carriers, (b) for a thoroughly adequate provision for the care and treatment of the sick, (c) for contribution from the insured, from industry, and from.the state.14 Because the California Commission indicated that there were certain constitutional limitations which would prevent the immediate inauguration of a health insurance program, it % recommended that the measure be simxtted to the electorate. The conservative medical group in California was successful in its fight against the adoption of a compulsory health insur- • ance bill and the people voted more than two to one against the adoption of a health insurance plan for California. Leaders ^^Report of the Social Insurance. Commission of California. January, 1917, p. 17. as in the fight for compulsory health insurance in California were bitterly attacked by certain physicians who used almost what might be considered underhanded methods to assure the defeat of such legislation. In 1919 a second California Commission on Social Insurance recommended a compulsory system of health insurance. The committee recommended; Experience in other countries has demonstrated the necessity of this. A purely voluntary system does not reach those who most need it; its overhead charges are necessarily larger, compulsory contributions from em ployers are impracticable, and it does not admit of free choice of doctors, nor of exemption from medical examination.1^ In spite of the two recommendations for a health insurance program for California, the people of that state did not command the enactment of health insurance legislation. In February, 1917, the first Massachusetts Commission on Social Insurance unanimously endorsed the principle of health insurance. The findings of this commission clearly pointed to the need for a system of health insurance as a 16 means to help solve the.economic burdens of illness. In 1918, however, a second Massachusetts Special Commission on Social Insurance negated the recommendations of the first commission and proclaimed compulsory health insurance to be a form of ’ ’class legislation” not worthy of endorsement. , p. 19. Abraham Epstein, Insecurity: A Challenge to America (Hew York: Random House, 1938), p. 449• 26 The New Jersey Commission of 1917 set forth the inherent weaknesses in various plans of mutual benefit associations and fraternal organizations. This commission advocated that ’ ’health insurance is a measure which gives great promise both of relieving economic distress due to sickness and of stimulating 17 preventive action. The New Jersey report further stressed that insurance legislation ought to provide medical care and health instruction which would lend themselves to a plan at 18 once curative and preventive# The principle of health insurance as an approved means of distributing the cost of sickness was suggested by the Ohio Health and Old Age Insurance Commission of 1919. It was thought desirable to include health insurance as a require ment for all employees, to be paid for by employers and employees in equal proportions. Administrative costs entailed by social legislation were to be met by the state. The benefits requested by this commission were rather comprehensive as may be noted in the following points: (1) cash benefits of 6 "L7 H^bort on Health Insurance by the New Jersey Commission on Old Age. Insurance and Pensions5 1917, pp. 18-20. ^^The State Conference of Health and Welfare, 1939, recommended a voluntary health insurance plan because it offered an excellent area for experimental legislation* For further information see report of the State Conference of Health and WeIfare. New Jersey, 1939, p. 68. 27 a part of the worker’s wages during a period of disability, (2) full medical care and hospitalization, (3) rehabili tation both physical and vocational in cooperation with existing state departments, (4) dental care, (5) medical care for dependents, and (6) a burial benefit for the worker* Private insurance companies fought the adoption of this piece of legislation because it would have competed with death benefits in so-called ’ ’life insurance” policies. A favorable report was tunned in by the first Health Commission of Pennsylvania which endorsed the principle of health insurance. This commission reasoned that it was the state’s responsibility to make immediate and adequate medi cal care available for illness cases and to prevent the financial burden of sickness from falling entirely on the person least able to bear it— the sick wage worker. Regard ing contributions to the program, it advocated some way of distributing the burden of sickness among all the wage 20 earners, industry, or the community as a whole. It has been observed that most of the commissions which made a detailed study of the needs for health insurance reported favorably; while those which rejected health insurance, with one exception had not made a study of the ISReport of the Ohio Health and Old Age Insurance Com mission, February, 1919, pp. 17-18. ^^Report of the Health Insurance Commission of Penn sylvania, 1919, p. 9. 28 PI needs of wage earners and health insurance. Apparently, the commissions with the most realistic understanding of the problems of the low income group were most in favor of the adoption of some form of health insurance. Although the Wisconsin Commission of 1918 had not undertaken any extensive study of the problem of health insurance, it reported that there was no demand for health insurance and purported that it ”saw no reason why sickness of the wage-earner cannot be fully met by diminishing sick- pp ness. This same commission stated further I We see no reason why sickness of the wage earner can not be fully met by diminishing illness, without attaching at the same time to this effort a complicated plan of insurance as contemplated by the proposed Health Insurance Legislation. Practically all the provisions of the so- called Standard Bill refer to the method of inaugurating the Insurance System and the question of the prevention of illness receives but little, if any consideration. We believe that prevention rather than indemnification is a better solution of the problem. It is surprising that such recommendations should come from one of the outstanding progressive states in the United States. It was granted by the Connecticut Commission of Public Welfare that there were some strong arguments in favor of 21 Abraham Epstein, op. cit., p. 451. pQ Report of the Wisconsin Special Committee on Social Insurance, 1919, p. 49. p. 49. 29 health insurance, but it declined to endorse such legislation because it was ’ ’experimental” and it would have necessitated 24 the expenditures of large sums of money. In Pennsylvania the American Medical Association made its opposition to the principle of health insurance extremely obvious. The second Pennsylvania Commission which reported in 1921 admitted that it had received representation and support from the American Medical Association. It was odd that both the State Chamber of Commerce and organized labor opposed health insurance legislation. The combined pressure of organized medicine, business, and labor was instrumental in influencing the second commission to negate the favorable suggestions of the first commission regarding the desirability of health insurance legislation for Pennsylvania. The majority opinion of the Illinois Health Insurance commission, after an extensive survey, declared ’ ’that its findings do not justify its recommending compulsory health insurance. This commission expressed the conviction that workers could provide themselves, with health insurance if they were to be more thrifty. A minority report which was written by Doctor Alice Hamilton and Mister John E. Ransom vigorously ^^Report of the Connecticut Public Welfare Commission, 1919, p. 16. 25 Report of the Illinois Health Insurance Commission, May, 1919, pp. 165-166. 50 criticized the majority report of the Illinois Health Insuramce commissions in the following manner: With reference to the point made in the majority report that compulsory health insurance has not been an important factor in the prevention of sickness, we would not claim that compulsory health insurance is intended as a pre ventive medical measure. Like many other forms of insurance it is not intended to eradicate the risk against which it offers.26 Evidently the majority report expressed a somewhat confused conception of the nature and role of health insurance measures. Previous to the^ development of the foregoing health plans which have been reviewed, the American Association for Labor legislation proposed a ’ ’Standard Bill” in cooperation with a committee of the American Medical Association. Sickness, accidents, and death benefits were provided for all employees earning less than $100.00 a month. A panel of physicians would have been set up to insure the free choice of physicians by subscribers. In several ways the medical administration and items under the ’ ’Standard Bill” resemble and antedate quasi medical groups now in operation in many states. The cost of such legislation was to be met by the combined contributions from state, employer, and employee. Specifically, the state was to contribute one fifth of the expense and the balance was to be shared equally by employers and employees. A medical 26 Ibid., pp. 172-173< 51 advisory committee was to take care of medical problems and a social insurance commission would have charge of administrative P7 duties. The outlook for group health insurance from 1910 to 1919 was rather encouraging and hopeful. For many years the Socialist Part carried in its platform a health insurance plank. In 1912 Theodore Roosevelt recognized the need for health insurance and its probable ’ ’voting appeal” to the extent that he included it as a plank in the platform of the Progressive Party. The' tendency toward health insurance had become quite significant when American political parties and politicians insisted on the inclusion of some reference to health reforms in their campaign literature. Professor Epstein reviews succintly the movement for health insurance as follows ; In 1916, the standard bill was introduced in the legislature of New York, Massachusetts and New Jersey. In 1917, twelve state legislatures considered the sub ject. The investigating commissions called two national conferences, at Washington in 1917 and Cleveland in 1918. Governors Samuel W. McCall of Massachusetts and Alfred K. Smith of New York were especially active in support of compulsory health insurance.28 In fact. Governor Alfred Smith of New York said to the Legislature, ”The incapacity of the wage earner because of 27 Abraham Epstein, op. cit., pp. 453-54. 28 ^°Ibid., pp. 454-55. 51 advisory committee was to take care of medical problems and a social insurance commission would have charge of administrative 27 duties. The outlook for group health insurance from 1910 to 1910 was rather encouraging and hopeful. For many years the Socialist Party carried in its platform a health insurance plank. In 1912 Theodore Roosevelt recognized the need for health insurance and its probable "voting appeal” to the extent that he included it as a plank in the platform of the Progressive Party, The tendency toward health insurance had become quite significant when American political parties and politicians insisted on the inclusion of some reference to health reforms in their campaign literature. Professor Epstein reviews succintly the movement for health insurance as follows: In 1916, the standard bill was introducted in the legislature of New York, Massachusetts and New Jersey. In 1917, twelve state legislatures considered the sub ject. The investigating commissions called two national conferences, at Washington in 1917 and Cleveland in 1918. Governors Samuel W. McCall of Massachusetts and Alfred E. Smith of New York were especially active in support of compulsory health insurance. In fact. Governor Alfred Smith of New York said to the Legislature, "The incapacity of the wage earner because of Abraham Epstein, op. cit., pp. 455-54. . pp. 454-55. 32 illness is one of the underlying causes of poverty. The enactment of a health insurance law, which I strongly urge, 29 will remedy this unfair condition.” Although the Davenports Donohue health insurance bill passed the Senate, On April 10, 1919, the New York Assembly failed to vote on the measure. Such a fate was met by health insurance measures in a number of states already reviewed. The health insurance movement had advanced far enough to prompt the comment that "compulsory health insurance in 1920 is in about the same relative position as workmen’s compensation for industrial accidents was, with regard to legislative adoption in 1910.”^^ Unfortunately, the develop ment of health insurance from 1919 was blocked by various vital forces. Professor Armstrong has noted carefully the interests that were opposed to the principle of health insur ance in the following manner: All the effort and interest that went into the social health insurance plans in the years 1913 to 1919 was buried by an avalanche of adverse propaganda fostered by a strange alliance of interests which illustrated the truth of the saw, ’Politics makes strange bedfellows,’ certain commer cial insurance companies, certain employers associations. Cited by James Rorty, op. cit., p. 75. 30 John A. Lapp, American Labor Legislation Review, Vol. 10, p. 27. 33 physicians and Christian Scientists. Of the four groups the first two were the most important politically as they were better organized, more experienced, and better heeled for battle. Another authority in the field of social insurance has observed critically that "From 1920 until 1932, when the reports of the Committee on the Costs of Medical Care began to appear, all public interest in health insurance seems to have disappeared. Despite the recommendations of the various commissions, nothing concrete was accomplished. No state, municipal, or other governmental agency in this country has in any way provided for, or aided any type of health insurance." One of the reasons for the tendency toward voluntary group health associations in this country has been the flat refusal of governmental units to have anything to do with compulsory health insurance. It is a significant fact that many of the states that turned down the idea of compulsory health insurance recommended experimentation with various voluntary health insurance schemes. Thus, the trend toward the development of group health associations was stimulated by the necessity for doing something about a health problem that the agencies of government had failed to solve. Workmen’s compensation laws and procedures. Another Barbara N, Armstrong, Insuring the Essentials (New York; The Macmillan Company, 1932), p. 371. Abraham Epstein, op. cit., p. 455. 34 factor behind the development of group health associations in this country has been the role played by the incorporation of insurance procedures necessary in connection with workmen’s compensation laws. The purpose of medical services, associated with compensation laws, were set forth as follows : "For a good many years there have been developing in large industrial establishments, medical services which had for their purpose the effective care of the employee, at first in order to carry out the requirements of the workmen’s compensation act, and later to improve the efficiency of the employee by dimin ishing not only injury, but illness* Workmen’s compensation laws which have been in effect in all states except Mississippi probably have been the major pioneering step toward a social insurance program for the United States. Christie has differentiated between workmen’s compensation and health insurance as follows ; These differences arise from the following facts. Workmen’s compensation is fundamentally compensating the workman for time lost and medical expense in curred because of injury or disease directly connected with the industry in which he is engaged. That is, it is a means of making industry responsible for the care of its employees when they are injured in its services. The insurance principle is quite secondary. Being compelled to care for its injured employees, industry either takes out insurance for this purpose in a % z Hugh Cabot, The Patient’s Dilemma, (New York: Reynal and Hitchcock, 1940), p. 155. 55 company that it believes reliable or it builds up a reserve fund through #iich it Insures itself. Medical care was definitely limited to illnesses resulting from conditions or factors related to hazards attending certain industries. Workmen’s compensation laws were, in the initial stages, designed mainly to provide cash benefits to the v/orker as a substitute for the precarious court awards under the common law and the liability statutes. Medical care was at first on a meager basis, if included in the plan. Some of the significant factors fostering the further development of medical services have been summarized by Marshall Dawson as follows * Observant public administrators and some private insurance medical officers were not long in learning, however, that adequate medical care, on the whole and in the long run was the most economical, because competent care reduced the periods of temporary disability and the incidence of permanent impairments.^^ On the whole, workmen’s compensation laws in the United States were modeled after European precedents. It may be worthwhile to review briefly some of the major problems in the evolution of workmen’s compensation laws. The employer under English common laws was required merely to exercise 54 Christie, Economic Problems of Medicine, (New York : The Macmillan Company, 1955T7 P- 114. Marshall Dawson, "Medical Care Under the Workmen’s Compensation," Medical Care, Vol. I, No. 1, 1941, p. 19. 36 "reasonable care" and to maintain his establishment of employ ment "reasonably safe."3b ^jo^ee grounds repeatedly resorted to by the employer to avoid paying the injured worker were "assumption of risk," "fellow-servant," and "contributory negligence." A tremendous interest in liberal labor reform between the years 1905 and 1915 in the United States were responsible for the enactment of scores of v/orkmen’s compensation laws. President Theodore Roosevelt went so far as to remark: It is neither just, expedient nor humane ; it is revolting to judgment and sentiment alike that the financial burden of accidents occurring because of the necessary exigencies of their daily occupation should be thrust upon those sufferers who are least able to bear it. When the employer starts in motion agencies which create risks for others, he should take all the ordinary and extraordinary risks involved. ^"7 A number of states appointed commissions to study the possib ility of enacting workmen’s compensation legislation. It was New York that adopted the first compulsory compensation law in 1910. The New York law was declared unconstitutional on the ground that it forced employers to pay compensation when they were not at fault. However, this difficulty was 36 For a critical discussion of the problems met in the evolution of an adequate "Workmen’s Compensation Law" see Gheipters XXXI and XXXII in Insecurity: A Challenge to America, by Abraham Epstein. Cited by E.H. Downey, Workmen’s Compensation (New York: The Gontury Company, 1924), p. 30. 37 circumvented by the introduction of the elective compensation law in order to avoid constitutional intricacies* In more detail Professor Armstrong shows : In consequence, the ’elective’ compensation Lttw was devised giving to both employer and employee the choice of either the new compensation system or the old damage suit arrangement, but penalizing the rejection of com pensation by providing that rejection by the employer deprived him of the right to set up his three ’defenses’ in the event of suit by his worker.38 In 1917 the United States Supreme Court gave its sanction to a compulsory type of compensation. All but seven of the forty-eight states had adopted workmen’s compensation laws by 1920. Medical services given under workmen’s compensation laws have utilized several important principles similar and in some instances almost identical with those of group health associations. There probably has been a definite transfer from the principle of prevention of accidents under work men’s compensation laws to the prevention of illness which has become one of the cardinal principles of group health associations. Leaders in industry realized that adequate medical care was more economical than insufficient medical care. Group health associations have come to realize too that adequate medical care, especially in the incipient 38 Barbara N. Armstrong, op. cit., p. 252. 38 stages of illness, lowers costs of illness. The causal and . parallel factors in the development of workmen’s compensation laws have been noted in the progress toward the establishment of group health associations. Industrial clinics and welfare services. Another point of origin of the group health association movement in the United States has been found in the welfare work carried on by industry. Dr. iîelvin James Vincent has thought that employers organized welfare services to appease the militant 39 attitudes of organized labor. Several widely known plans of industrial health have been analyzed in an effort to under stand the nature and character of medical services under the control of industry. Inasmuch as these industrial health departments have shown some of the adva-ntages of group med ical practices, they may be considered as factors in the development of health groups in this country. One of the first industrial group medical plans was put into operation by the Endicott-Johnson Corporation of New York in 1918. This corporation has developed its medical services to the point where it offers almost complete health coverage. Inasmuch as the corporation sponsored the medical plan in its entirety, employees were not required to contribute i — g g Melvin J. Vincent, The Accomodation Process in Industry (Los Angeles : The University of Southern California Press, 1930), p. 44. 39 financially to the health group* Endicott-Johnson has given complete medical service to 18,000 employees and dependent members of their immediate families, which opened the way 40 for care for more than 54,000 people* The range of health services made available to employees of this medical group has been one of the broadest offered by any group health association of its kind operating in the United States at the present time# Specifically, this health group rendered the following services: The services include all types of medical and surgical care, hospitalization. X-ray diagnosis and treatment, dentistry, and nursing* All types of diseases and con ditions requiring medical care, from prenatal service to the deathbed, are cared for. The services of the medical organization are available to workers in the event of industrial accidents* The local hospitals are used for the care of patients under a contractual arrange ment whereby the company pays rates standard in the community.4l Forty-one physicians, thirty-six of whom are on full time salaried basis constitute the health personnel of this corporation. The technical personnel of this health plan consists of the following: Our medical personnel consists of 5 general surgeons, 1 man doing chest surgery and 2 industrial surgeons, 3 internists, 2 otolaryngologists, 2 pediatricians, 2 ^^Correspondence with R.LE. of Workers’ Medical and Relief Department of Endicott-Johnson Corporation, March 27,1941. 41|jew Plans of Medical Service (New York: Bureau of Cooperative Medicine, 1940), p. 24* 40 ophthalmologists, 3 obstetricians, 1 gynecologist, 1 dermatologist, 1 pathologist, 1 roentgenolgist, 1 anesthetist and 10 men in general practice. We have 3 bacteriologists, 30 graduate nurses, 0 dentists, 6 dental hygienists and 6 pharmacists#42 In 1938 the average cost of service rendered on behalf of the 51,180 eligible persons was approximately $17.31 per individual# The total cost of the plan to the corporation 43 v/as $886,344. Once a worker had selected a physician, he was supposed to designate that physician as his family doctor. " Medi cal service centers were located respectively in Binghamton, Johnson City, and Endicott. These "Triple Cities", within a radious of nine miles of each other, have been considered to be ideally located ecologically^ A worker could go to any one of the foregoing mentioned medical centers. The choice of medical doctor was left to the discretion and judgment of the patient. In 1909 the Goodyear Relief Association of Akron, Ohio;,, maintained hospital services on a voluntary insurance non profit plan, and provided cash benefits during periods of illness for its employees.. In 1927 the employees of this '^^Correspondence with R.L#E# of Workers* Medical and Relief Department of Endicott-Johnson Corporation, March 27,1941 43%^ew Plans of Medical Service (New York: Bureau of Cooperative Medicine, 1940), pp. 24-25. 41 company organized the Mutual Hospital Benefit Association for the payment of hospital services which were not included in workmen’s compensation laws* This plan included the follow ing services 5 room and board, operating room service, anes thesia, laboratory service, blood transfusions, and X-ray 44 examinations• In February, 1933, the hospital association was consolidated with the Goodyear Relief Association# The association has designated the maximum amount of $250 for extended hospitalization within one year for any one disability. A plan for dependents of employees has been worked out which stipulates that under schedule A, dues of sixty cents a month for adults and forty cents for children were to be charged. A second rate, termed schedule B, exacted a slightly higher rates of payment for those who desired better accommodations. At the present time the Goodyear Relief Association is contemplating a change of policy from a system of weekly sick and accident disability benefits on a disability basis to the provision of these same benefits on a time basis, or, specifically, benefits for a certain number (still undetermined) of weeks per year. The details of the change in hospitalization . p. 44 42 regulations were as follows : We also contemplate changing our hospitalization plan for members from a disability basis to a time basis. At the present time under our members hospitalization plan, female members pay the same dues and receive the same benefits as male members. Our experience has been that female members use twice the hgppital service as do males, we therefore, have experienced a very heavy loss on our female members and we contemplate under the new plan to partially correct this situation, if not entirely* Their dues will be at least 50^ higher than male members for the same benefits...Our X-ray costs for 1940 were $20,411.00 It might also be well to add that thb dues for male members also need to be adjusted upward because we have experienced a loss on male members hospitalization oper ation. We mention this because we want to make sure that you are not misled by our apparent low cost of hospitaliz ation as the Regulations would lead one to thinlc. The loss we have experienced on members hospitalization over the last 10 years has been off-set in part by income we have received on securities our surplus has been invested in. We cannot hope to continue to receive the return we have had in the past on our securities on account of most of our securities having been invested in high yielding bonds which are being called at a rapid rate and we can not reinvest this surplus at a rate that will average over iM. When our new plan for members* weekly sick and accident benefits and hospitalization is completed we believe we will have a plan that will meet the changed conditions that we find ourselves in to-day, and one that will show a better balance between weekly sick and accident and hospitalization benefits than does our present plan.45 There are some 19,000 dependents of members participating in the Goodyear Relief Association. Apparently, there have not been any changes regarding dependent coverage. '^^Correspondence with H.L.M., Goodyear Relief Association, May 6, 1941. 43 The Spaulding Employees* Mutual Benefit Association of Binghamton, New York, has illustrated well the joint sharing of the costs of health services by employees and employers. It was first organized in 1930 for the specific purpose of paying cash benefits and providing medical care and hospitalization during an illness to the employees of Spaulding Bakeries, Inc. For administrative purposes the plant was divided into divisions and the principle was made that each division must have at least two-thirds of its eligible employees as members of the association. The company appointed a Board of Trustees, which has taken charge of the supervision of each division. Any employee in good health can become a member of this association. The dues vary with the income of the employee and are administered separately by each division. A member may receive cash benefits for medical care rendered by any physician in the community under the following schedule of fees5 $4 for house calls, $2 for office visits, including a maximum of twenty-five visits; cash benefits for surgical procedures, such as a $100 limit for major operations, a $50 limit for tonsillectomies. $3 per day is designated for hospitalization, which is not to exceed thirty days. In 1924 Stanocola Employees* Medical and Hospital ^^New Plans for Medical Care. (New York: Bureau of Cooperative Medicine, 1940), pp. 29-30. 44 Association of Baton Rouge, Louisiana was organized with an initial membership of 2,000 white employees. Seven physicians from Baton Rouge were selected by the members to act in the capacity of association physicians. At first medical services were given in the private offices of the physicians chosen, but in 1930 the organization purchased a building to be used for clinical purposes exclusively# The dues of the association were $3*00 a month, in addition to two assessments of $3.00 47 each normally levied during the year. This health group has developed to the point where it now has eleven full-time physicians on the medical staff; two surgeons, an eye, ear, nose and throat specialist, a pedia trician, an anesthetist, and six general practitioners. In addition to physicians the clinic personnel was composed of two graduate nurses, two non-graduate nurses, an X-ray tech nician, a laboratory technician, two registration and telephone clerks, one janitor, and a maid.^^ About ninety per cent of the employees who were eligible for membership were active members of the Stanocola Employees Medical and Hospital Association. Although membership was voluntary, it has been a membership rule that each employee ^*^Correspondence with F.H.B., Stanocola Employees Medi cal and Hospital Association, April 23, 1941. Pl^s for Medical Gare, (New York; Bureau of Co operative Medicine, 1940), pp. 55-66. 45 must purchase one share of stock, which may be paid in small installments. The money raised through the sale of stock has been expended for building alterations and equipment. Doctor Franz Goldmann points out that the important advantages of group medical practice are: (1) reduction of need for service through safety programs and preventive services for apparently well persons, (2) the even spread of risks through service for relatively large indiscriminate popula tion groups, (3) the economies resulting from group practice, and (4) the integration of preventive and curative s e r v i c e s *49 Another insight into the value of industrial medical oare is analyzed by Doctor C.B. Bray, Director of Medical Services of the American Cast Iron Pipe Company, at Birmingham, Alabama as follows : From thirty years* experience in providing adequate medical services for.our employee group, certain facts and conclusions emerge. First, our experience has shown that a program including the family rather than the worker alone is the best one. Second, we are able to provide our employees and their families with all the medical care they need at a reasonable per capita cost. There is no doubt that our families would be unable to buy the same amount and quality of medical care provided in our setup if they had to pay for it on an individual basis. Franz Goldmann, "Medical Care in Industry," Medical Care I: 312, No. 4, October, 1941. 46 . Third, our loss of man days through illness during 1940 was only 187 of 1 per cent. This proportion is less than half the national average of 2 per cent. In my judgment time lost from illness in the manufacturing industries of the nation would run considerably higher than this usually accepted average. Fourth, the number of days lost from accidents in our plant is only .73 of 1 per cent, far below the national average.•• Fifth, while it is not practical to attempt a presenta tion of this fact by statistical data, we feel that the working efficiency of our employees is increased to such an extent, in terms of units of production, that far more money is saved than the total cost of all our medical services. Sixth, we believe that the Immediate and continuous availability of adequate medical services to our employees increases their efficient working life span. Particular ly, is this true of the man who has reached the age where it is necessary to guard his health more closely. In the field of the prevention of chronic disease alone our medi cal service program is fully justified. The success of which these industrial and welfare health groups have experienced has demonstrated the possibility of group medical services upon a periodic basis. Financial costs and administrative problems have been objectified by these plans and group health associations have profited by the experiences of industrial health services. Industrial group medical plans may be considered rightly as socio-medical institutions augment ing the group health movement in this country. Bray, "An Industrial Medical Care Plan," Medical Care. I: 348-49. 47 Committee on the Costs of Medical Care. The famous survey and study of the costs of medical care in the United States which was started in 1928 has given added impetus to the group health association movement. The medical committee was under the directorship of Doctor Ray Lyman Wilhur, formerly President of the American Medical Association and President of Stanford University# The director of the research staff was Doctor I.S. Falk, an economist, #10 later became director of the health studies for the Social Security Board. He has written a large number of articles setting forth the advantages of group health and insurance plans. The following forty eight persons comprised the committee personnel: seventeen medical doctors, representing private practitioners; six persons representing public health; six members representing the social sciences; ten members, some physicians and dentists representing institutions and special interests; and nine members representing the public. The committee recommendations disclosed willingness to adopt a system of adequate medical care in almost any form or combination of forms. This eclecticism regarding types of medical plans was perhaps due to the diverse occupational backgrounds of the monbers who composed the committee. The broad implications of the final recommendations of the 48 committee may be noted in the following statement: The Committee recommends that the costs of medical care he placed on a group basis, through the use of in surance, through the use of taxation, or through the use of both these methods# This is not meant to preclude the continuation of medical service provided on an indiv idual fee basis for those who prefer the present method. Cash benefits, i.e., compensation for wage-loss due to illness, if and when provided, should be separate and distinct from medical services# However, in spite of its effort to adopt a satisfactory medi cal plan, the Committee failed, to recommend even one plausible plan for the American people because it was the Committee’s belief that regionally the United States was not homogenous enough for a unifed program of medical care. Professor Walton H. Hamilton, who was a dissenting member of the Committee, criticized scathingly the general recommendations on the following grounds : The document represents what all who have signed are willing to accept rather than what any individual would have written...It is, however, unfortunate that the spirit of tolerance, admirable as it is, should have been so largely indulged. Its manféstation in the treatment of resort to general but indefinite principles, the setting do\m of propositions in which the nouns give and the adjectives take away, are far too numerous. If the Com mittee were a formal agency, charged with the formulation of a constructive program, compromise would be justified as essential to action, but the task of the Committee is to study, to analyze, to investigate, and to report, it has no power to institute a single desirable reform; its labors can be converted into a better organization for ^^The Committee on the Costs of Medical Care, Medical Care for the American People, 1932, p. 120. 49 medicine only through its influence upon groups who have authority to act. This end, it seems to me, would have been far better served, by cleancut— and^even uncompromising — presentation of alternative programs* The majority of the Committee did not recommend a compulsory insurance system because of administrative consid eration as the following excerpt shows : There are also weighty administrative considerations against making health insurance compulsory as a general, program for the United States. Compulsory insurance abroad has depended for its administration largely upon organized groups of employees, such as unions or coopera tive societies...Such industrial and cooperative associations are not sufficiently developed in most localities in the United -States to include more than a small fraction of the population. It would be impossible, therefore, to use such organizations as the basis for administering health insurance. However, a minority of eight members of the Committee argued for the immediate adoption of some form of compulsory health insurance by stating the following facts# Most European countries, one after another, have gone from voluntary to a required system of insurance, but many of the evils of the voluntary systems are carried^ over: toc the’ .compulsory plan. Vested interests are built up under voluntary insurance which are very difficult to dislodge, even though they seriously hamper effective work.^^ . p. 120. . p. 129. 54 Ibid., p. 131. 50 While the conclusions and recommendations were neither very definite nor specific, it should not be overlooked that the findings pointed to the need for some form of group health association. This study objectively and scientifically revealed the shortcomings of traditional fee-for-service medicine. In the literature and pamphlets published by various organizations interested in group medicine the findings of this study as proof of the need for group medical care have been frequently cited* It was, of course, true that the need for medical care was pressing long before the study was undertaken. Neverthe less, this study has been a powerful force in manifesting the need for some form of group organization to challenge the problem of providing adequate health services for the American people* That professional and lay groups recognized the in capacity of persons belonging to a low income group to secure the purchase of medical care has probably been a significant factor in bringing about a closer -understanding between the medical doctor and the lay person. A brief review of some of the more significant findings of the Committee reporting on the costs of medical care revealed several economic factors which have encouraged the organization 55 of group health associations in the United States. Doctor Louis S. Reed, The Ability to Pay for Medical Care (Abstract of Publication No. 25), Chicago: The University of Chicago Press, 1933), p. 4. 51 Louis 8. Reed estimated that at least 75 per cent of the families in the United states received an income of less than $3,000 annually. It observed that the lowest in come group, under $1,000 spends a greater percentage of income for health servies than any other income group* "The percentage of miscellaneous expenditures devoted to medical care decreases significantly with ascending in- «56 come. " Regarding a decent standard of living, it appears that at Idast 10 per cent of the families in this country are living on a level below that which economists and social workers characterize as a minimum standard for decent and 57 healthy existence. In 1929, the American people spent about $3,656,000,000, or approximately $30*08 per capita for medical care* Of this amount, $2,885,790,000 represented the fees of patients, $509,500,000 was paid for by tax funds, $180,710,000 was met through voluntary contributions and donations, and nearly C Q $79,000,000 was borne by Industry. While In any one year the , p. 6. \Ibld., p. 7* Ibid*, p. 7* 52 majority of families of any income level incur comparatively small expense for medical care, it is true that a small minority have a great deal of sickness among their members, and are compelled to incur charges for medical service which amount to one-fourth, one-third, or occasionally even one- C Q half of the annual income* The unpredictability of sick ness has been an important factor in the utilization of the insurance principle as a cardinal element of group health associations. It was found that of all hospital cases among families with incomes between $1,200 and $2,000, 23 per cent received free care* These individuals might have been able to meet the costs of ordinary illness, but a serious .illness forced 60 them to accept charity* Undoubtedly, it was true that a part of the population was too poor to pay the cost of urgent ly needed medical care, regardless of method of purchase, even though the payment could be spread out over a long period of time, as by an insurance or pre-payment plan* On the other hand, "above these strata are many people who are unable to pay for the medical care they now receive, not because the average cost of that care over a period of years 63 is high, hut because the cost is so unevenly distributed."®^ The Committee report on the cost of medical care made a significant discovery regarding the cost of satisfactory medical care* It was estimated that the cost of furnishing adequate medical care would be approximately $36 per capita, per year, of which $10.70 would be necessary for dental care expenditures* Reasonably good medical care, with specific exceptions, could be furnished for $20 per capita. The minimum 62 per family per year would amount to about $82. The findings of this Committee on the cost of medical care and the extent of health services have been important factors in the development of the group health association movement in this country* The findings have pointed to the need for the formation of some kind of organization which could budget medical payments on a periodic basis and at the same time utilize the insurance principle as the keystone in the organizational arch of the association. Although the recommendations have been indefinite, the findings of the Committee have been selected by groups interested in group medicine as a barometric indicator pointing toward a need for group organization and administration of health services* ®hbid., p. 10, 62 Ibid., p. 11. 54 The literature of group health associations has made use of the findings of the Committee to enroll new members into health groups. One might almost state that the findings of the Committee have become educational ammunition for group health associations in the United States. A National Health Conference was called to order on July 18, 1938 by Josephine Roche, a socially-minded leader for health reforms. Leaders from the field of organized medicine and public health discussed various phases of the central health problem in America. President Franklin D. Roosevelt, in his message which was read by Miss Josephine Roche, said: "... The chief problems before you are, in a 63 real sense, public problems." In summation, the chief executive seemed to realize that the distribution of medical service to the American people was a matter to be handled by the public or by some form of group action. In no sense could his attitude be interpreted as one which would have relegated this problem to the types of programs ad vocated by the American Medical Association and its physician- members whose skeptical attitudes regarding group health have become well known. Later in the message, the President remarked: "The economic loss due to sickness is a very serious matter not only for many families with and without incomes. ®®Cited by Rorty, cit., p. 21. 55 but for the nation as a whole*Thus the President of the United States recognized the economic consequences of illne 88, The five planks or recommendations of this health program proposed by an Interdepartmental Committee of the United States Government and adopted by the conference were as follows: 1. Expansion of our public health, maternal, and child health service, with a special emphasis on preventing sickness# 2# Extension of hospital facilities, especially in .small towns and rural areas where free or low-cost hospital service is practically unobtainable# 3. Provision for medical care at public expense for the one-third of the population in the lower income levels unable to pay for adequate private care. 4. Measures for spreading the cost of medical care either by state systems of medical insurance, or further extension of state medical service with aid of federal subsidies# 5# Protection against the loss of wages during sick ness by insurance# The great social and medical importance of this con ference is well stated by Doctor Hugh Cabot, a medical director of a recently organized proprietary group health association 64 Ibid.# p. 21. 65 Beulah Amidon, Who Can Afford Health (New York: Public Affairs Pamphlets, No. 27, 193977 p . 29. 56 as follows: Here appeared for the first time--as far as X am aware— clear, unmistakable evidence that there were bodies of people who clearly saw the need and firmly demanded that the Government take a hand in applying the remedy. Here appeared authorized representatives of the great middle class comprising organized labor in both camps, various farm organizations, and many re presentatives of welfare bodies who saw the problem at first hand,... They voiced a profound conviction that here was a structural weakness in our civilization and they turned to Government with the demand that some plan be worked out and some remedy applied. Here is a ready-made pressure group which might easily stampede a political party in power into ill-considered, hasty, and even dangerous legislation.®® ^ Abstract of chanter. 1. The social group in society from which the group health association movement emerges centers largely in the low-middle income group because, on the one hand, this group could not affoiW to pay for tradition al fee-for-service medical care, which only the wealthy income class could purchase; while on the other hand, individuals in this group were not eligible for so-called "charity medicine," which by definition was limited to the relief class* Hence, efforts were made by the low-middle income group to adjust to this situation by mutually sharing the economic burden of illness through the utilization of the insurance principle in group health associations. ®®Hugh Cabot, The Patient* s Dilemma (New York: Reynal & Hitchcock, 1940), pp. 232-33* 67 2* The centralization of medical personnel in a suite of offices has manifested the advantage of certain important practices in the evolution of group health associations. Even in the provincial clinic the obvious superiority bf group consultation and centralized medical equipment attested to the trend toward coordination of special fields. Such private clinics as the Mayo Clinic demonstrated the importance of group medicine at the point of production even though a sliding scale was utilized in the method of payment. From a social psychological point of view, too, the prestige of the Mayo Clinic probably has been an immeasurable factor in aiding the inauguration of gi'oup health associations. 3. Certain medical practices of the United States Army in the First World War demonstrated satisfactorily the functional success of the payment of physicians upon a salary basis and the application of medical services to individuals upon a group basis. It seems that a "family physician relationship" was not a paramount prerequisite to good medical care . 4. The population shift from a rural community to an urban area augmented the development of group health associations. Specialization and division of labor are characteristic of urban society, and group health associations may be considered, sociologically, as a form of specialization. 58 6# Efforts of the low-middle income group to adjust on an individual basis to a social condition beyond their means to afford resulted in the indiscriminate practice of self-medication through the use of patent medicines. This practice revealed the inherent weakness of such substitutions for the scientific knowledge and care of a physician. Hence, attempts to institute some method of purchasing the services of a good physician at a lower cost to the individual became evident enough to excite the attention of both lay and pro fessional observers. Self-medication was realized to be but a feeble effort to circumvent the inadequacies in a fee-for- service type of medical care. 6. Forward looking leaders more than twenty-five years ago were eager to adopt a compulsory health insurance law in the various states of the Union. At first most of the state commissions endorsed the principle of health insurance, but a combination of pressure groups was successful in reversing the favorable recommendation of a compulsory health insurance measure through the formation of a "second commission for the study of health insurance." The upshot of this trend was the encouragement of various voluntary experiments with health insurance. The inability of the State to provide the low income group with satisfactory health insurance is indicative of a culture lag that might more accurately be described as 59 an American lag, especially when compared with other nations in a similar cultural stage. It was quite natural that the formation of group health associations followed, inasmuch as governmental units refused to enact a compulsory health insurance law. 7. Workmen’s compensation laws demonstrated the feasibility of the incorporation of the insurance principle in matters of health, especially illnesses due to industrial accidents. With the adoption of compulsory workmen’s com pensation laws a determined effort was made by American industry to prevent accidents, for it was noted that fewer accidents resulted in lowering the costs of workmen’s com pensation. A parallel was noted in the similarity between prevention of accidents under workmen’s compensation laws and the prevention of illness under a scheme of group health practices. 8. The welfare services provided by a number of progressive corporations in this country have served as stepping stones in the movement toward group health associations. Employees of many of these corporations have been the recipients of medical care upon a periodic payment plan and have benefited from the utilization of group medical personnel and equipment services. Probably considerable social imitation of the 60 methods and some phases of the structure of private welfare corporations have been incorporated in the various group health association plans* 9* The Committee on the Costs of Medical Care in the United States scientifically pointed out the deplorable maldistribution of medical services to the American people* It was noted that the recommendations of this Committee were not very specific nor definite* Nevertheless, the findings manifested the need for possible group action in the solution of the problem of health. Group health assocations have mentioned the findings of this Committee repeatedly as first rate evidence of an existing need for the formation of more health groups in the United States. Both lay and professional persons have realized the unevenness of the cost of sickness per person per year* 10. The National Health Conference of 1938 served to focus nation wide attention on health needs and voluntary and compulsory ways of meeting this need. Group health associations for the low income groups is one way of meeting this need and has been suggested as a means of meeting the social situation of inadequate medical care at the National Health Conference. 11. For coneoptional purposes the stages and transitions of the group health association movement are outlined in the 6X following manner: I. ORIGIN STAGE A# Medical indigence of the low income group B. Attempts to enact compulsory health insurance legislation 0, Failure of self-medication as a substitute for scientific medical care. II. CLINIC STAGE A. Centralization of medical personnel and equipment in private clinics B. United States Army in the first WorlAWar demonstrates that physicians can be remunerated on other than fee-for-service basis C. Industrial group medicine points in the way of voluntary group health associations III. GROUP HEALTH STAGE A. Founding of cooperative and proprietary group health associations in 1929 B. Group hospitalization plans, a cultural thrust G. Attempts in the direction of group dental plans D. Formation of quasi group health plans E. Interdependence transition: National Federation of Group Health Associations, National Conference of Group Health, and National Group Health Institute CHAPTER III COOPERATIVE GROUP HEALTH ASSOCIATIONS In several Instances the initiative necessary for the formation of health groups has come from the la^an rather than the physician. In this chapter a consideration of health groups which fuse some of the principles of both consumer and producer cooperatives is undertaken# Sociologically, the American Medical Association regards such health groups, designated as cooperative group health associations, as representing the first stepping stone to the "bureaucracy of state medicine." Cooperative health groups are characterized as deviates from the prevailing socio-medico folkways and mores centered around the American culture pattern of obtaining medical care. It is true that on the whole the health groups analyzed in this chapter may be viewed as constituting a greater deviation from orthodox fee-for-service medicine than most of the other forms of health groups analyzed, for in them the subscriber becomes an integral and inseparable part of the active health organi zation. Lay members in a cooperative group health association have a vital interest and control in the administrative policies of their organizations, and the underlying assumption in this type of health group revolves around the theory that 63 that the subscriber, a purchaser of medical services, has every right to bargain for the services he is to receive# It is, of course, well known that the purchase of medical care is quite different from the: the purchase of other commodities# The uniqueness inherent in the purchase of medical care is well expressed in the following statement: Medical care is an esoteric economic commodity concern ing which the buyer has no basis for critical judgment of quality or value. The patient does not know whether he should purchase a particular type of medical service and is frequently unable to determine whether or not the medical service has been satisfactory after its receipt. The physician, therefore, is judge both of the patient’s need for service whijh he has to offer, as well as of the time and conditions linder which it shall be purchased* Moreover, inasmuch as medical care involves life or death (or at least the risk of death), the patient frequently believes that only one individual practitioner holds the commodity which he needs. It therefore seems impossible to search for another purveyor of medical service, as he would do if ÿhe forces of economic supply and demand operated in medicineaas in the majority of business trans actions. The conditions surrounding the delivery of medical care are therefore unique and are unlike those which characterize ordinary economic phenomena, because there is but one buyer and one seller and because; the commodity itself is of priceless value if received#I The social psychological dependence of the purchaser of medical care upon the medical dispenser of such care is thus manifest# A system of health care in which the wish for health security is satisfied by the mutual confidence of patient and doctor 1.8. Falk, C# Rufus Rorem, and Martha D. Ring, The Economic Aspects of Medical Services (Chicago: The University of Chicago Press, 1933), pp. 2-3. 64 as cooperators in a socio-medical institution for the further ance of better health should not be overlooked# FARMERS’ UNION COMI^UNITY HOSPITAL The first cooperative health group was organized in the United States in 1929 by Doctor Michael A. Shadid# He was about to retire from active medical practice when he realized that there was a need in the community where he lived for the inauguration of a new type of medical care based on the social principle of cooperation# This pioneer cooper ator- physician contacted the farmers who lived near Elk City, Oklahoma, and explained the objectives of his plan to. them. The social situation is significant in the development of this type of group health association for the farmers of Oklahoma had had some realistic experience with the advantages of ■ I purchasing equipment and selling products through the utili zation of cooperative methods and principles. The transference of this same system to the consumption of medical services probably seemed like a logical and feasible plan to apply. Such a forward looking view on the part of these farmers has somewhat refuted the common notion that farmers are rugged individualists difficult to organize in behalf of their common interests. 65 Doctor Shadid raised sufficient capital in 1931 to erect a twenty-bed hospital by selling shares at fifty dollars each. By 1939 the hospital had been expanded so that it could accommodate eighty-five patients. The hospital is built of brick and features modern architecture. Subscribers to this group health association are entitled to the services of physicians, specialists, and nurses without charge for a period of twelve months. Some of the health services offered are; (1) free health exami nations, (2) free treatments, (3) free surgical operations, and (4) free general nursing. In addition to the foregoing, members are entitled to free X-ray diagnosis. Farmers’ Union Community Hospital is one of the few health groups which includes any form of dental services on a periodic or prepayment basis. As might be expected the conditions of alcoholism, drug addiction, social diseases, and mental disorders are excluded from treatment in this health group. Medical services are subject to about the same conditions of limitations as noted in succeeding group health associations discussed. Physical conditions which require hospitalization are treated in the modem Community Hospital sponsored and owned by the Farmers’ Union Community Hospital. This is one of the few group health associations that limits hospitalization of 67 of its subscribers to a single hospital. Because subscribers to this group health association pay lower membership dues than is customary in other health groups,, they are limited to fewer days of free hospitalization. In fact a charge of two dollars a day is required for room, board, and general nursing care in a semi-private room. A fee of five to twenty dollars is charged for anesthetic-operating service, v^ich is necessary in surgical cases. X-ray photography costs from two to three dollars,^ Payment of membership dues '" i n this group health association is on a quarterly prepayment basis rather than on the usual monthly payment scheme. The cost of health services varies with the number of dependents a subscriber has. An annual fee of twelve dollars is charged to a sub scriber without any dependents. A subscriber with ont de pendent is asked to pay eighteen dollars a year. A f^ily of four is charged twenty-five dollars annually for health protection. As previously mentioned fees are due quarterly in advance. Payment of a membership fee of fity dollars is required before any. hospitalization service is rendered. Home calls are subject to a dollar fee plus.a mileage charge Michael A. Shadid, Principles of Cooperative Medicine. p. 17. 68 of twenty-five cents a mile one way. Ambulance service costs one dollar plus ten cents a mile one way. Dental services are provided with a slight extra charge for the cost of materials used, i.e., twenty-five cents additional for a tooth filling and ten cents for the extraction of a tooth. ^A select group of five physicians constitute the medical personnel of this health association, each of whom is a graduate of an accredited medical school. Besides graduate nurses and technicians, two doctors of dental surgery are on the staff, which is an innovation not yet incorporated in other cooperative group health associations. Residents of Elk Gity who are not members of the health group obtain the services of group health physicians and dentists if they pay the usual fees customary in private practice. Democratic principles govern the administration of this health group. Members of the hospital meet once a year in their respective districts. One delegate is elected for every twenty members. At Elk City the delegates transact the annual business of the health plan and in the interim between annual meetings a board of trustees of seven men carries on the business of the group health association. The medical group is employed by the board of trustees. The Board elects a medical director who selects and employs the other physicians. 69 dentists, and nurses. The Board elects a business manager who in turn selects the business staff. A general pudget is turned over, to the medj.cal group which can be used as the medical staff think best.^ Inasmuch as this was one of the first group health associations, formed in the United States, it is understandable that it experienced a variety of problems in its effort to launch a cooperative health plan. The more’significant prob lems and difficulties surmounted by this health plan deserve special attention and thought. The medical director. Doctor Michael Shadid, personal ly piloted this health group through many perplexing problems. Initially, he was subjected to the organized opposition of special interest groups. In this connection the control role played by local medical doctors was one of vigorous and determined opposition to the formation and function of a cooperative hospital. One of the first steps taken by local physicians was to expel Doctor Shadid from the local medical society. He was expelled on the ground of practicing medicine in an **imethical manner.** Doctor Shadid has described in detail the technical points on which physicians, fired by the message of the American Medical Association, tried to p. 17. 70 revoke his license to practice medicine in the State of Oklahoma, in his hook entitled, A Doctor for the People. The social pressure brought to bear on Doctor Shadid made national headlines in some newspapers. It was necessary, in fact, for the Governor of Oklahoma-to intervene and prevent the revocation of Doctor Shadid*s license to practice medicine. Doctor Shadid did not mind the social ostracism #iich certain conservative cliques in the American Medical Association were applying, but he did have to protect his legal rights. In the first and incipient stages of this social movement social pressure and intentional propaganda were used as social control measures tp regulate if possible the develop ment of Farmers* Union Community Hospital, A functional division of labor has been attained be tween laymen and physicians. The following interview with a rural member of this health plan indicates that lay members have a sense of proprietary social unity about this group health association. One of the main things I like about our hospital is that we all own it. Doctor Shadid doesn’t own it, he only runs the medical angle and we run the business side of it, through our delegates. The hospital is just exactly what its name says it is, a ’Community Hospital.’ We poor farmers are proud that we could get together and have our own plant. Of course, I believe in public ownership if it is limited to a small group of people. 71 The doctors and nurses in the community hospital treat us as owners and patients and not as poor ignorant farmers who have no rights. We own the hospital and they treat us with respect.4 It is the administrative organization of this group health associations which aids in making the division of labor functional and actual. Physicians received compensation for their professional services even during the drought, which compared favorably with compensation for similar work before the^depression.^ Economic security for the physician, assured through periodic payments by members, helps to relieve the doctor of worries originating from lack of financial security. Many private physicians practicing in the surrounding area of Elk City were not able to collect their fees during the worst phases of the depression.^ It was inevitable that charity cases mounted as **dust bowl** conditions deprived farmers of crops. Physicians connected with this cooperative group health association are granted a month vacation with pay each year. Social-psychologically, vacation periods are quite important in helping to maintain personality equilibrium. Those engaged $Interview with H.O. ^Michael A. Shadid, op. pit., p. 20. ^Personal interview v/ith Â.W. 72 in occupations which place the personality under a great deal of pressure and responsibility find a vacation respite especial ly beneficial. Under fee-for-service medicine it is rare that -private practitioners leave their practices for a month’s vacation, no matter how badly they or their families need a change of locale and activities. Physicians who have a regular vacation period come back to their work feeling more enthusiatic about their undertakings, hence, vacations are one of the important intangible merits of this cooperative health group. The technical minutia of clerical responsibility has been removed completely from the professional services of the physician. Items involving overhead expense are also taken care of by a staff of trained office personnel. The medical doctor working for this group health association is free to devote all his attention to medical problems and find it unnecessary to split his attention between medicine and clerical work. Friendly cooperation rather than competition is the practice among medical doctors in this group health associ- ation. Doctor Michael Shadid remarks: The interests of the doctors are one, and they cooperate wholeheartedly with each other without any thought or jealousy or personal advantage, and we enjoy our relations professionally and socially, as 73 7 never under individual competitive practices." Cooperation between physicians becomes more apparent as medical knowledge advances.® It is a psychological impossibility for any one physician to have at his immediate command all the knowledge and judgment necessary in certain "abnormal" cases. Group consultation makes possible a sharing of medical information. In private practice it is the general rule to charge an extra fee for such consultation with another physician. The un ethical practice of "fee-splitting" has developed largely Q because medical doctors in private practice work as individuals. In a group health association group consultation is the rule rather than the exception and therefore "fee-splitting" is unheard of as a practice. In fact, on&of the cardinal principles of cooperative group health associations is the sharing of medical information and equipment to bring the best possible service to the member. Farmers’ Union Community Hospital provides a low income group with comprehensive medical services and hospi- alization at a minimum of expense to the subscribers* The *^Michael Â. Shadid, o£. cit., p.20. ®Por an intriguing treatment of the interdependence of medicine and related fields see Bernhard P. Stern, Society and Medical Progréss(Princeton?Princeton University Press,1941, p. 215é ^3ee Hugh Cabot, The Doctor’s Bill (Hew York? Columbia Press, 1935), p. 74 low cost of hospitalization is a source of appreciation as the following case notes : You ask me what I think of Doctor Shadid.^ s hospital. Well, I like it more than I thought possible. I was in a serious auto wreck last year and the first thought I had when I regained my senses was how grateful I was.for the hospital and its low fees. My arm was set and several stitches in my face were taken. The medical doctors and nurses were fine and friendly even though they were very budtyè I got all the care I needed. I was astonished when my bill was presented to me--it was so reasonable.^® Attitudes of confidence in the medical personnel are often evinced by subscribers. In the following case an attitude of health security is discernible: I am all for our hospital plan. We had a regular seige around here last winter of illness. I don’t right know what would have happened to us if we did not belong to the hospital association. I had pneumonia and was taken to the hospital and in a few days later my fifteen year old boy here had appendicitis and they brought him in and operated on him. Hext, my wife took a bad case of the flu and so she was brought in also. We were three of us there at the same time, almost what you mi^t say a family reunion in the hospital! As you can see, we just can’t praise the good care we got too much. The staff gives you good medical care and hospital service at a reduced cost. Where we would have gotten the money to pay for all this illness I am sure I don’t know if we weren’t members of the hospital association. H This same attitude of security and appreciation of the reason able charges is observed by another member; Last winter I was kicked.in the head by a horse and was ^®Interview with P.L. ^^Interview with D. J. 75 immediately taken to the hospital. I was there about a week and I thinlc that if it weren’t for the wonderful care Ï got X might easily have lost the sight of my right eye. The bill for all this care was only fourteen dollars. I, of course, think this coop hospital outfit very worthwhile. Years ago the closest hospital to me was more than twenty miles away. In those days we were without doctor’s care or hospital advantages* Since I am a member of the com munity hospital I don’t worry so much about becoming sick.12 To broaden the base of membership administrators of Farmers’ Union Community Hospital have permitted members to sell half a fifty dollar share to another person. The details and reason for selling a portion of a share is given by a member as follows: I sold half my fifty dollar share to my sister for the hospital association. The health group authorities are doing this so that more of us can take advantage of good care and be a shareholder in our own hospital. We are very happy that the membership can be enlarged for we think that even better services may be made possible to more people. Just a little while ago my sister spent a week in the hospital after an operation for some kind of a growth on her neck. The entire bill was only fifteen dollars. She sure liked the treatment she received for she claimed that they treat you like a friend at the community hospital. We are lucky to have such a fine health plan. If you could only understand the plight we were in before Doctor Shadid got busy* A number of cases reveal that a wish for health satis faction has been achieved to a remarkable degree. In the following case social insight into the details of why some Interview with O.L, ^^Interview with F.G. 76 subscribers are satisfied with the medical services of the health group is portrayed; Last winter I had my eyes treated. Doctors fitted me with good glasses which have stopped my awful headaches. Just a little while ago my baby boy was puny and didn’t seem to grow much. However, I took him down to the clinic and the doctors gave him some examinations and medicines. He has been gaining weight since then and I know that in a few more months he will be fatter. The more I visit the hospital the more I like it. For a few dollars a month my whole family is entitled to doctor’s care. No expensive doctor bills for us, not any more. Even non-members of this group health association have pointed out that the organization has been instrumental in reducing the fees of private medical practitioners in Elk City. A gas station non-member said: Since the health scheme started in 1929, the charges of private doctors have been cut down quite a bit. The health plan has been about the best thing that has ever happened to Elk City. I think Doctor Shadid has done a lot of good and has put our city on the map. I can cite an experience I had with an operation that will let you know how expensive local doctors used to be. A year before the hospital was organized I had a ruptured appendix that cost me over seven hundred dollars to be treated and if this group had been functioning then X would have been given good medical care sooner and at a price I could afford to pay. You mightn’t believe me, but I am still paying for that big doctor bill. I believe that every town ought to have a community health plan like we have here. Some of the people are now selling a part of their fifty dollar share to another party so that more individuals can take advantage of the health benefits.\ When I finally get my doctor bill paid I am going to become a member of Shadid*s plan. 14 Interview with Â.E. ^®Interview with C.L. 77 As might be expected some members have noted that their attitudes have changed from ambivalent or mild ap proval to positive preference. An example of shift in attitude toward this health group is uncovered in the follow ing case : At first I didn* t think so much of my membership in the community hospital. Our farm did not produce much and I naturally got behind in many of our bills including our payments to the hospital. My little baby girl became very sick and she was taken to the hospital and there received excellent care. We were treated with kindness and imderstanding in every possible way. They realized that my farm wasn* t producing. Now, I tell all my friends about our community clinic and how nice they were to me even though I had not been able to meet my monthly dues and fees. This year our farm is doing better and I feel that we will have a good crop so that we can catch up on our payments. An estimate of the social and economic value of a share in this cooperative group health association is noted by the following interviews: Some outsiders have asked me if I thought fifty dollars was too much for a share in the community hospital. Well, do you know what I tell them? I wouldn’t sell my fifty dollar share for one hundred dollars if I couldn’t buy another. Doctor Shadid is a wizard. There was some slight criticism sometime ago about the medicine costing too much but that complaint was looked into and adjusted satis factorily by the doctors and managers. Because of the treat ment and reasonable cost of services, I am sold on the idea . of group heal th. ^®Interview with D.S. Interview with T.A. 78 The practice of one of the essential principles of consumer group health, preventive medicine, is revealed in the following cases ; My children were given cold shots last fall by the clinic doctors for a very small fee. They had very few colds because of these cold shots. The doctors down there at the clinic are smart to treat you so you won’t get sick*^® Preventive medical practice is disclosed also in the follow ing statement; The doctors in our health group don’t mind you coming in when you think there is something wrong. They are frank in that they say it is to their advantage to keep you well. They don’t make any more money Just because you need treatments. If you wait too long before seeing the community doctors, they will bawl you out for not coming in earlier. We all think it is better to keep well by annual health examinations and treateents than to wait until a condition becomes hopeless.^® Another important feature of this cooperative group health association concerns the emergency and protective medical care which is offered to members. The following two cases unveil details of preventive medical practices : Not long ago while working in the big barn I ran a pitch fork into the instep of my right foot, I was taken Immediately to the hospital for first-aid treatment. One of the first things they did was to me tetanus serum to prevent blood poisoning and lockjaw. Each clinic treat ment was only fifty cents and the medicine was given at ^®Interview with W.N. 19 Interview with M.P, 79 20 one-half the regular price. The emergency and first aid treatments afforded to members and non-members are factors increasing community good will toward this group health association. The follow ing case discloses the importance of emergency care : My daughter, while washing clothes, was badly burned about the arms and face from scalding water. She was rushed to the coimnunity hospital and given immediate treatment. My girl said that she liked the doctors and nurses at the hospital a lot. We have all felt that the doctors are Interested in their business. I was grate ful to the hospital for such good treatment. It is certainly comforting to know that there is a good hospital close to our farm.21 A dairy farmer says : Our girl, age ten, had symptoms of pneumonia and T.B. They kept her there at the hospital a week after symptoms of pneumonia had gone. A careful T.B. examina tion was also given. The entire cost of the medical care and hospital service was only nineteen dollars. I think that Elk City is a better town sinèè the health clinic started.2^ Doctor Michael Shadid observes that there a significant relationship between the" acuteness of certain health conditions and membership in a cooperative group health association in the following manner: "It is worthy of note that our members ^^Interview with W.R. PI Interview with B.H. ^^Interview with RwB. 80 very seldom come to us with a ruptured appendix whereas 50^ of the cases of appendicitis that come to us from non-members of the association are ruptured. The former are on a periodic payment plan, the latter are on a fee-for-service basis. The importance of the cultural setting and social situation as factors promoting the cultural diffusion of the principles and concepts of cooperative group health associa tions is evident in the following case: There is no question in my mind but what the hospital association is a great benefit to Elk^ City and the surround ing community* About the only criticism I have heard has been in connection with the cost of drugs and medicine. Personally, X don’t think a separate charge for medicines ought to be required. It is a source of complaint. Did you know that Doctor B.C. McDaniel who was with Doctor Shadid has gone to Amhust, Texas? Amhurst is' a small town near Littlefield. Doctor McDaniel has organized a community hospital on almost exactly the same basis as the one in Elk City except that there will be no drug department. For Texas Doctor McDaniel’s cooperative hospital is the first of its kind. I heard' that it is scheduled to open around the first of September this year. He is selling the shares in about the same way -they were sold here. Farmers are serving as salesman. One of the big advantages that Doctor McDaniel is finding in Amhurst is that the entire community is aware of coops. , In that town there are two cooperative retail stores, two cooperative elevators, and two cooperative cotton gin mills, and now they are going to have a coop community hospital and health plan .24 23 Michael A. Shadid, op. cit., p. 29. 24 Interview with A.D.G. 81 In the foregoing case the social situation of a cooperative conmiunity seems to make for a ready assimilation and adoption of group health associations. There seems to be some reason for believing that there may exist a considerable transfer from cooperative activities connected with the purchase and sale of commodities to the organization and adoption of co operative group health associations. More light is thrown on this point in the following case; tt I think one of the reasons why our coop hospital has gone over so big is that we are used to cooperating. We farmers have been buying and selling equipment and crops through all sorts of coops. I think we caught on to the idea of coop doctors a lot faster than some of the city people who never bought a thin cooperatively. I guess you might even say we were ready for Shadid’s health idea,24 Members point out that they regard lay control as a desirable feature of the administrative organization of the health group. One member remarks: Our cooperative health plan is run by us. We actually own and control the plan. You see we elect one delegate for about every twenty members who in turn elect members of the board of directors. The board of directors takes care of money and helps in getting new equipment which the doctors need. The medical director. Doctor Shadid, takes care of running the clinic part of our health plan. We know nearly all the delegates and board of directors by their first names. In a small town like Elk City we get to know everybody and I guess that is why we have had 84 Interview with B.k. 8B for the most part good delegates and directors* We are completely free to criticize the organization and treat ment so all may hear. Some say the reason why we have so much control over the health group is because we own it and I guess that is correct. Il:have more confidence in our delegates- than in our so-called representatives in the State Capitol.25 The above case makes manifest that primary controls are functioning in directing and shaping the policies of the health association. In a small community such as Elk City the face- to-face relationship of members makes it possible for member, delegate, and administrator to communicate and interact with each other. Sociologically, these relationships are character ized by limited spatial and social farness. Farmers’ Union Community Hospital provides complete dental services at reduced costs as is noted by the following interview: We all like this hospital and doctor service very much. My little Mary, age five, was treated for trench mouth. The dentists kept her under care for more than six weeks. They made me bring Mary in twice a week for treatments. She was treated in such a way that it didn’t hurt much. The dentists told me how to be sure that she wouldn’t get this disease again. We like the dentists because they are so interested in your case and are glad to answer questions about teeth. The cost of treatment for my little girl was very cheap and reasonable.26 In the following case it is revealed that members ex press overt pride in their group health association and that ®®Interi^iew with W.T. ^®Interview with R.S. 83 some members remain in western Oklahoma because of the physical proxmity of the health group; My young girl cut her foot on a rusty barb wire. We took her right away to the hospital. She was given serum and treatment immediately. In just a short time her foot was well. To me it is a source of satisfaction to know] to know where to turn for medical help and just how much it will cost me. One reason, I guess, why we don’t want to leave this part of the country is because we mightn’t have a community hospital plan nearby. You know there aren’t so many group health hospitals in the United States. . I have heard that some of the members who^move away from here still keep their membership paid The only criticism mentioned by members of this group health association concerned the cost of medicine dispensed at the hospital. While this criticism is being met by appropri ate measures, the following case reveals what a member said; I guess the thing that irritates me most about the health group is that they charge you for all medicines the doctors prescribe. Most of us complain even though the doctors claim that the medicine is given at half price. I think that medicine should be included as part of the regular services. I don’t like any kind of ’extra charges.’ 28 Members of group health associations seem to be resentful to ward extra fees charged for particular types of medical services. Probably a slightly higher periodic payment could correct this criticism. From an analysis of attitudes and opinions expressed by members of Farmers’ Union Community Hospital a deep con- 27 Interview with M.Â.S. ^®Interview with T.C.P. 84 vlction in the social worth of this organization is revealed. This health group has been an instrumental factor in mitigating the problem of distribution of medical service to low Income farmers* An American sociologist relates the following im pression of Farmers’ Union Community Hospital in this way: "It is a worthwhile health plan with many problems* Its founder. Doctor Shaddd, is a worthy fighter, engaged in carrying on daily in behalf of the needy people of Western O k l a h o m a . "29 GROUP HEALTH ASSOCIATION, INC. AT WASHINGTON D.C. The term "group health association" probably was adopted first by :this health group* It is one of the largest and one of the most complete cooperative medical groups functioning in America. Although it has been giving medical services only since November, 1937, Group Health Association Inc. has developed to the point where, in 1940, a staff of four physicians, six nurses, a technician, and one pharmacist had become associated with the organization. Membership in this health group is limted to civil employees of the United States Government. An imderstanding of the wide variety of services offered to its members is attained from a brief enumeration of the 29 Personal correspondence with Doctor Emory Stephen Bogardus, June 12, 1941. 85 of the health aids offered by this health plan as follows : medical and surgical examination, and treatments at the clinic, at home, or in the hospital; laboratory tests. X-ray examinations at the clinic, eye examinations, short wave and ultra-violet therapy, surgical operations, house calls, obstetrical care, professional consultations, and ambulance service*^® The types of health services lA&iich this group health association do not offer are as follows; (1)...Treatment of industrial accident cases where treatment is provided under Federal or State Employees Compensation Laws to the extent of such provi sion; (2) Surgery of the brain and nervous system; (3) Any treatment after the time that Medical Director, in mental, tubercular, drug or alcohol addiction cases, recommends commitment to, or hospitalization in an institution.31 In addition to the foregoing limitations it ought to be pointed out that medical services do not include dental care, plastic surgery, correction of deformities and birthmarks, psychiatric treatment, and chiropody* These exclusions are similar to the limitations of other group health organizations investigated. Subscribers to Croup Health Association Inc. are 30 The Answers about Group Health, a leaflet published by the Group Health Association of Washington b* C*, September 1, 1940* ^^By-Laws of Group Health Association Inc., pp. 15-16, January, 1940. 86 eligible to twenty-one days of hospitalization for any one illness, with a maximum of forty-two days per year per sub scriber. Salient features of the hospitalization plan are as follows ; bed and board in a hospital, general nursing care, use of operating room or delivery room when necessary, services of an anesthetist, ordinary surgical dressings, and routine laboratory examinations. If a patient-member desires hospitalization outside the service area, or without prior authorization by the medical director, no more than fifteen dollars is allowed for the use of the operating room and not more than ten dollars is permitted for the services of an anesthetist. Hospitalization procured in this way is limited in time to the date of the patient’s discharge. A fee of two dollars for each "bread winner" subscriber and an additional fee of two dollars for each dependent is requested with each application. It is these fees that entitle the applicant and dependents to physician’s services and physi cal examinations which determine their acceptability as candidates for membership in this group health association* In the event the applicant is refused membership, the application fee is returned* However, if accepted, each applicant is asked to pay a ten dollar membership fee which covers all dependents, , p. 13. 87 to be paid in its entirety or at the rate of one dollar a month. ^^The ten dollar member ship fee is the applicant’s contribution to the growth and expansion of the health group and its facilities. However, if the applicant resigns within two years or leaves the territory, he has the right to transfer his membership to another person. The cost of expensive equipment is partially defrayed by utilizing a part of the membership fee for the purchase of such items. Periodic dues are payable at the first of each month. A family of three pays five dollars a month for health pro tection and treatment in this health group. The table on the following page makes manifest the rates which are charged for various types of membership. Dues are also payable on a prepayment basis. Members who pay their dues for a full year in advance are given a five per cent discount and those who pay their dues six months in advance are accorded a two per cent discount. In the event, that the m^bership is terminated, this group health association refunds the usual monthly dues up to the date of termination. A schedule has been worked out which covers fees for special medical and surgical services. A fee of one dollar is charged for the first house call in each illness. Any 3 3 The Answers about Group Health, p. 4. 88 TABLE MEMBERSHIP DUES PAYABLE TO GROUP HEALTH ASSOCIATION INC. MEMBERSHIP COST PER MONTH Single member or head of family................$2.20 Husband or wife................................. f 1.80 Child dependents under 18(one or more).........$1.00 Child dependents, 18 to 21 (each)............. $1.00 Adult dependents over 21 ( each) ........... $2.20 ^^ata for this table were compiled from By-Laws of Group Association, Inc., p. 7. 89 subsequent calls made at the insistence of an attending physician are not subject to a charge* A fee of twenty- five dollars is asked in each confinement case to meet the cost of hospitalization. Members reimburse the health group for the cost of services in connection with confinements and ailments present at the time of admission during the first ten months of membership. Chronic illnesses which develop within three years from the date of membership are subject to an additional charge. Each physician who is a candidate for a position with this health group is interviewed and his personal qualifica tions are examined carefully and reviewed by the medical director before he makes his recommendations to the Board of Trustees, who officially authorize all medical appointments. It will be pointed out elsewhere in this study that one of the weaknesses in quasi group health associations and in orthodox fee-for-service medicine is the problem of selecting a "good physician." Some of the advantages of selecting a doctor from a group of physicians who have been elected to the staff of Group Health Association Inc. rather <yû—' than upon random choice or hearsay evidence is frequently done in the selection of private doctors are : "The professional qualifications of doctors are much better known and determined The Answers About Group Health, p.3. 90 by their fellow doctors than by a laymen. Left to himself, the layman is as likely to choose a mediocre physician as a good one. Group Health’s medical staff is the result of painstaking analysis and review of the qualifications of several hundred physicians." Every medical doctor with a license to practice medicine is not considered equal to every other medical practitioner. An effort has been made by this group health association to refine partially free choice of physician to a good choice rather than a poor choice of a medical doctor. In 1940 the group health association had a staff which consisted of the following members : one medical director, one surgeon and proctologist, one pediatrician, two general practitioners, two specialists in internal medicine, one obstetrician and gynecologist, one urologist, one eye, ear, nose and throat specialist, one optometrist, six registered nurses, one X-ray technician, two laboratory technicians, 37 and two graduate pharmacists. The salaries paid to medical doctors employed by this organization compare favorably with the salaries paid by other health associations and by private physicians practicing in Washington D.C. Physicians employed by this group receive , p. 4. ^'^lbld« . pp. 3-4. 91 salaries ranging from tliirty-six iiundred to seventy-five hundred dollars a year. About thirty-three per cent of the physicians in private practice earn less than twenty-five hundred dollars annually which reveals that physicians employed by this health association are at least in the average physician income class. Administration of the health group is controlled and directed by eleven trustees, each of whom is elected by the general membership, while the remaining two are appointed by the Federal Home Loan Board, which sponsored the formation of Group Health Association Inc.Several standing committees are concerned with problems of membership acquisitions, mem bership relations, and public relations. A membership council meets once every three months with the Board of Trustees. One delegate for every twenty-five members constitutes the 39 advisory council. According to the annual report for the year 1940, the total number of members was 2,791, or a net increase of 408 over the preceding period. The total number of members and dependents served by th|s health group was 6,611 or an in- ^^Maurice Lev en. The Income of Physicians (Washington D.0.5 The Committee on the Cost of Wedical Care, Abstract of publication No. 24, 1932), p. 10. New Plans of Medical Service, pp. 25-26. 92 crease of 1,062 subscribers# Probably the membership turn over is remarkably low because the members are employed by the Federal Government. The financial condition of Group Health Association Inc# is sound, as the following statement for 1940 reveals: Operating results for the year show a net saving of $2,194. Net additions to our capital funds amounted to $5,664. We have more than $30,000 on hand in cash and U.S. Savings Bonds, and our êotal assets are roughly $50,000. With liabilities of $9,261, this makes our net worth at the end of 1940 $40,608. Of general statistical interest is the fact that the mean age composition in 1941 of the subscribers to Group Health Association Inc. is about thirty-six years. Sociologically, one of the clearest and novel manifes tations of questionable social controls has been utilized by the American Medical Association against the Group Health Association Inc* The social control techniques practiced most commonly by this medical association might be classified as combinations of intimidation and reprisal* Professor L.L. Bernard notes that "use of fear and intimidation and threats lies just over the borderline from force as a method of social ^^From G.E.A. News,' Annual Report of Group Health Association Inc. for 1940, issued January 1, 1941, p. 3. An estimate made by J.T., one of the officials of Group Health Association, Inc. 93 control* The American Medical Association has displayed op position to the development of this group health association. The District Medical Society of Columbia expelled one of the group health physicians from its organization on the ground that he was practicing medicine unethically* Because this physician’s standing in the local medical society had been lowered, he was refused hospital privileges in certain Wash ington hospitals. This action was the result of a threat which the American Medical Association held in abeyance regarding hospital ethics; namely, that hospitals which allowed physicians to use their facilities who were not members in good standing with their local medical societies might be stricken off the list of "approved" hospitals. This threat was so potent in its effect that hospital administrators regarded the omission of the name of a hospital from the list of approved hospitals compiled by the American Medical Assoc iation as so serious a blow as to amount to a "dire catastrophe," as one actually stated* Group Health Association, Inc. was the chief agency in bringing to trial and attempting to indict the four medical 42 L.L. Bernard, Social Control (New York; The Mac millan dompany, 1939), p% 152.' (See Chapter VIII of this work for a sociological discussion of intimidation.) 94 societies and twenty-one physicians for violation of Federal Anti-Trust laws. The health group was endeavoring to bring about some form of social accommodation with the American Medical Association. . Dr. Melvin J. Vincent has observed that one of the objectives of the social process of accom modation is to "enable persons or groups widely separated by social distance to carry on life activities within close spatial distance, and this in the face of the antagonisms which may exist because of the barrier of social distance. This group health association desired greatly to work out some form of adjustment whereby they could continue to make avail able health services on a periodic basis* The official list of societies and individuals involved in this famous trial is as follows : Case of the United States of America versus The American Medical Association, a corporation, the Medical Society of the District of Columbia, a corporation, the Harris County Medical Society, an association, the Wash ington Academy of Surgeons, an association, Arthur Carlisle Christie, Goursen Baxter Conklin, James Bayard Gregg Curtis, William Dick Cutter, Morris Fishbein, Thomas Allen Groover (deceased), Robert Arthur Hooe, Rosco Gening Lelant, Thomas Earnest Mattingly, Leon Alphonse Martel, Francis Xavier McGovern, Thomas Edwin Neill, Edward Hiram Reede, William Mercer Sprigg, William Jospeh Stanton, John Ogle Warfield Jr., 01in West, Prentiss Willson, William Creighton Woodward, Wallace Mason Yates, Joseph Rogers Young# 44 --------- 53---------- Melvin J. Vincent, The Accommodation Process in Industry (Los Angeles: University of Southern California, 1930), p. 4. 44 The Journal of the American Medical Association, llbî 2285, May 17, 1941. 95 One of the foregoing defendants wrote the following letter to a hospital director on December 21, 1936, as follows : "The intention behind the |knndt3 Resolution referred to was to smoke out from the staff of some hospitals certain men who were regarded as objectionable but whom the hospital felt a delicacy in removing. Signed, William D. Cutter. Apparently, the American Medical Association, through one of its officers, had selected strong words to serve as intim idating stereotypes in an effort to coerce hospital adminis tra tots to terminate the hospital privileges held by group 46 health doctors. Mr. John H. Lewin, prosecuting attorney for the United States Government, summed up the issue between Group Health Association, Inc. and the American Medical Association as follows: Did the defendants, the two cor porations and the eighteen individuals, plan together or plan to take action together to restrain and hinder the activities of this cooperative medical group association by: "American Medical Association on Trial," The Journal ÉÉ the American Medical Association, 116:1538, Apri1 "5, l94l. The writer of this study heard a part of the cross examination of Dr. W.D. Gutter in Judge Proctor’s District Court during March, 1941. Dr. Gutter admitted that it was his signature and dictation initials which apparently were signed on the letter, but he used a somewhat extraordinary defense for this, namely, that he did not write the letter nor read it, even though he signed it. 96 1. Enforcing rules and regulations designed to prevent doctors, including members of the defendant societies from Joining Group Health, or from consulting with Group Health, or having anything to do with it and 2. By inducing the private independent hospitals, other wise independent institutions, to Join with them in pre venting Group Health Association from having a chance even to get courtesy staff privileges at those independent hospitals. On the other hand, the defense attorneys for the American Medical Association claimed that the practice of medicine was not a trade and therefore did not come under the Sherman anti- trus t laws. The jury found the American Medical Association guilty of violating the anti-trust laws of the United States, but found the individual defendants not guilty. There has been some evidence that the American Medical Association was not satisfied with the verdict, for on May 2, attorneys for the American Medical Association were scheduled to submit to the District Court three motions with argument. "The motions are: a motion to set aside the verdict of guilty and to enter judgment in favor of the two corporate defendents. 2 a motion in arrest of judgment, 3 a motion for a new trial, ' ^7 «^ex»ioan Medical Association on Trial," The Journal of the American Medical Association, 116:2285, May 17, 1941. Ibid.. 116:2058, May 3, 1941. 97 One of the members of Group Health Association Inc. revealed the social accommodation reason why this health group was so concerned with the outcome of this trial as follows : All that G.H.A. wants from the American Medical Association is a chance to give its members good medical care without the constant interference of the A.M.A* and its antiquated ethics. If we should win the cuse, it will mean that cooperative health groups all over the nation may proceed to organize and develop without being threatened by the conser vative doctors* organization. An indictment against the A.m .A. will give us the * go signal.* Probably the greatest difficulty overcome in the development of the group health association movement was the attainment of the legal right to form and operate consumer controlled health groups. A number of medical directors and lay admin istrators have remarked that the verdict rendered in this historic trial could serve as an impetus to the further spread of group health associations throughout the TJrf. ted States. In other words, the social accommodation attained between conservative medicine and health groups would permit the natural unfoldment of cooperative health practices. Another related problem successfully encountered by this association has been to develop a functional division of labor between consumer control and medical control. 49 Personal interview with R.T. 98 Professor Kimball Young observes that "the most outstanding feature of the division of labor is not the separation of functions but the fact that it renders these functions interdependent in a society.Medical problems and services have been given over to a group of physicians; while adminis trative difficulties and policies are controlled and solved by a lay board of trustees who represent the wishes and desires of the subscribers. This division of labor makes it possible for the physician to devote all his time and energy into health activities rather than a combination of health and clerical activities. The problems with which this group health association has been confronted are similar to those met by other cooper ative group health associations in the United States. An official of this health group outlines contemporary prob lems as follows : 1. The provision of dental services (now being studied). 2. Health education (a class for expectant mothers has recently been formed). 5. Formation of regional offices to the Washington area. 4. The opening of the membership to persons no t employed by the Federal Government. * ' ' SO... ... Kimball Young, to Introductory Sociology, (New York: American Book Company, 1934), p. 405. Personal correspondence with M.S., February 8, 1941. 99 Dental services have been noted as a difficulty which has restricted the range of health services available to sub scribers to various health groups. An effort to broaden the base of eligibility has been observed in several group health associations* Probably this group health association is most widely known throughout the country because of the publicity which it received in the trial between the United States Government and the American Medical Association. From one point of view Group Health Association Inc. has become the spearhead in the group health association movement even though it has been in existence only a few years. Even novels written about the theme of state medicine cite this group health association 52 as a forerunner. GREEHBELT HEALTH ASSOCIATION AT GREENBELT, MARYLAND Greenbelt Health Association was organized by the people of Greenbelt as a voluntary, non-profit, cooperative health group in June, 1938. Greenbelt was built by the 52 For an interesting but biased account of the threat of health associations as an entering wedge for socialized medicine, see the novel by Frank G. Slaughter, M.D., That None Should Die. 53 An Ounce of Prevention and a Pound of Cure Throw Greenbelt, a pamphlet by GreenSeIt^eal€h Association Through P« 1* 100 United States Government as a resettlement project for low middle income families who were employees of the Federal Government, under the general supervision of the Farm Security Administration. The social activities and social institutions associated with the cooperative movement are conspicuous in the community patterns of this town. The following financial enterprises are conducted on a cooperative basis : a drug store, barber shop, notion store, grocery store, theater, and a credit union. It is little wonder that a cooperative group health association was founded in this area for the community patterns and social situation converge upon the cooperative principle. The health services offered by this health group are not as complete as by some of the other group health assoc iations reviewed. Medical services usually rendered by a general practitioner are included in the care provided by this health group. In other words, medical services are available to the point where a medical specialist would have to take charge of the case. No specific limitations are set forth except that a candidate for membership is subject to a medical examination. Membership is dependent upon the prospective subscriber’s health, which has to be such that he would be able to pass the health examination. loi Greenbelt Health Association operates l.ts.;0.wn hospital. Because this hospital represents the only institution of its kind in the county, medical doctors not connected with the health group have been extended courtesy privileges. Such a practice is almost a literal "turning of the other cheek" vtfhen it is recalled that many hospitals revoked hospital privileges to physicians connected with a group health assoc iation. On the whole, this hospital has been used for minor and emergency surgery, deliveries, and general medical conditions. The hospital is housed in an attractive modern building. Medical services are somewhat limited, hence, monthly dues of one dollar per single person are enough to meet expenses. This is an extraordinarily low fee if compared with other group health association plans. Upon joining the health group the candidate is charged a five dollar entrance fee, which is used to purchetse medical equipment. An arrange ment has been made in which the member may pay the entrance fee in one dollar installments. The following table. No. IX, objectively indicates the fees charged various members. In order to demonstrate the economic saving which a member would derive from participating in Greenbelt Health Assoc ia, tion, the following information has been made available in 102 TABLE 11®'^ MEMBER SHIP DUES PAYABLE TO 6REEKBELT HEALTH ASSOCIATION MEMBERS COST PER MONTH Single persons ................................. $1.00 Couples...........................................1.50 Families with one or two children 2.00 Families with three or more children..............2.25 54 Data for this table were compiled from information available in a pamphlet titled to Ounce of Prevention and A Pound of Cure Tbro%h Greenbelt. 105 Table III. Even a cursory glance at Table III reveals that the cost of medical care to members of the cooperative group health plan is about one-third the cost to non-members. The insurance principle applied to health care and hospital ization has objectively demonstrated its inherent soundness in the health groups thus far analyzed. Greenbelt Health Association has contracts with three medical doctors who had training not only in general practice, but each of whom had a specialty. Subscribers have rights to the services of specialists in the following fields: pediatrics, internal medicine, and general surgery. The medical staff also serve as public health officers for the community of Greenbelt. A registered pharmacist is employed as are graduate public health nurses. Because two of the medical doctors resigned not long ago, it has been necessary to elect two physicians to fill the vacancies. The reasons for the resignation of these two physicians will be discussed in another part of this analysis. The acting president of the Greenbelt Health Association reviews the qualifications and experience of the new medical appointees as follows; The Board of Directors of the Greenbelt Health Association is happy to announce the appointment of Doctor Mary Richardson and Doctor Clesson Richardson to join Doctor Joseph Silagy on the Association’s 104 55 TABLE III COMPARATIVE COST OF MEDICAL- SERVICES CHARGED TO MEMBERS AND NON-MEMBERS ITEMS MEMBERS NON-MEMBERS Dues.................................#647.00 .00 537 office calls.................. . 0 0........ #805.50 75 home calls. 28.50 . .... 150.00 6 deliveries 150.00 270.00 Supplies, injections 68.50 ...... 109.10 Laboratory examinations.......... .00........ 13.50 3 tonsillectomies.................. 45.00 75.00 1 appendectomy 45.00 80.00 Other surgery...................... 14.50........ 24.10 TOTALS #998.50 #1527.20 55 Data compiled from Ibid. (one month period) 105 medical staff. This action has been taken on the basis . of the recommendations of a special advisory committee including Doctor Mario Scandiffio, Medical Director of Group Health Association of Washington, and Doctor Fred. Mott of Farm Security Administration. Doctor Mary Richardson received her M.D. degree from ' Columbia University in 1923 and interned at Bellevue in New York City. From 1924 to 1929 she supervised a 115- bed hospital in Shanghai, China* In 1929 she married Doctor Clesson Richardson. Her post-graduate study has included pediatrics at Mount Sinai Hospital in New York City; gynecology and obstetrics in Lying in Hospital in New York: Tropical Medicine and Hygiene in Londong, England; obstetrics at Margaret Hague Hospital, Jersey City; and pediatrics and gynecology at Post Graduate Hospital, Columbia University. From 1932 to 1938, she practiced medicine, gynecology, obstetrics and pediatrics in South India hospitals. In 1940 she was chosen to pioneer a new hospital in Korea, but she was forced to evacuate Korea on instructions of the U.S. State Department. In the last six months she has been in charge of the health program of the National Youth Administration in Missouri, and it is from this position that whe will come to us. Doctor Clesson Richardson served in the Air Service Aeronautics prior to his study of medicine, and he received his medical degree from Columbia University in 1928. His surgical internship was served at the Polyclinic Post Graduate school and Hospital in New York City. His early experiences and study were in the Health Services Depart ment, Broad Street Hospital, New York City, and in London, England, where he received a diploma in Tropical Medicine and Hygiene and did post-graduate work at the Royal Eye Hospital. Prom 1932 to 1938 he was in South India, first in charge of a 125-bed hospital, later in charge of pioneering a 30-bed hospital. He tl%en had post-graduate work in general surgery at the Post Graduate School and Hospital of Columbia University, and post-graduate observation in the Los Angeles County Hospital. In 1940 he, together with 106 Doctor Mary Richardson and other Americans, started to pioneer a new hospital in Korea and was forced to leave by the Japanese. Prom January of this year to the present he served as a contract surgeon with the G.G.C., Ninth Corps Area in Pine Valley, California. The wish for new experience and mutual aid which Doctors Clesson and Mary Richardson have manifested by seeking broad academic training and attempting to organize a pioneer hospital in Korea can probably be transferred to another important pioneer medical project, namely, Greenbelt Health Association. Greenbelt Health Association is unique in that it is the only health group functioning in the United States which limits its services almost exclusively to citizens of this cooperative town. The ecological setting of this community facilitates primary group conditions between its citizens. In conversing with citizens of this community it is easily discerned that Greenbelters look upon each other as neighbors rather than nigh-dwellers. Social interaction between mem bers of this community is enhanced by, first the deliberate spatial planning of dwelling units and secondly, because these people enjoy approximately the same social and economic status by virtue of the fact that they share a common employer, the United States Government. The sociological setting of this community is important in understanding the values and 55 Howard C. Custer, Acting President of Greenbelt Health Association, Newsletter dated August 1, 1941. 107 m problems of Greenbelt Health Association. Preventive medicine is practiced by medical doctors employed by the health group. It is reported that during the year 1940, the three group physicians and the nurses received 6,055 calls in the office and made 1,673 calls on 57 members in their homes. In the following quotation specific information is set forth on the number of cases treated: While the ratio of office to home calls for members was approximately 3*5 to 1, the ratio for the doctors’ private patients was 1.6 to 1. This clearly emphasizes the preventive aspect of the Health Association’s plan. Non-members were much more inclined to wait until they were sick enough to warrant a call at home, while members apparently didn* t wait until they were ill in bed to call for medical attention. ^ Of the total number calls, approximately 225 were complete physical examinations, which are given at no additional charge. There were eleven major operations for members performed in the Greenbelt Hospital, and about 95 cases of minor surgery. During the year there was a net gain in membership of 65 members— a gain of 21^. At the beginning of the year there were 987 Greenbelt persons covered by the service, and as of December 31st there were 1,189. ® One-of the most serious obstacles met by this health group has been the organization of a group health association in a relatively small community. The total number of possible ÆÈÊ Bulletin, Volume II, No. 2, February 1, 1941, Greenbelt Health Association. , p. 3. 108 subscribers nas not been over 900, exclusive of dependents. It has been observed that with a larger number of members more equipment can be purchased and a lower per capita fee. charged* The number of subscribers definitely limits the type and cost of medical services available. It has been an interesting fact that the great social and legal conflict be tween'.; Group Health Association of Wash ington D.C. and the District of Columbia Medical Society was waged only a few miles away from this health group. One of the reasons why Greenbelt Health Association did not encounter the wrath of the American Medical Association is that the health group has limited its services to a community that is somewhat isolated from any other community. In a homogenous and isolated community it would be difficult for the local medical society to accuse health group doctors of unfair competition. As pointed out earlier this community has organized its own business and professional services. Greenbelt Health Association has not known the pressure and opposition of organized medicine to the same extent as other cooperative group health associations, largely because of its spatial location. However, a few special interest groups have attempted to stereotype the community of Greenbelt as an area where socialistic ideas are practiced, especially with regards to 109 "socialistic" or state medicine. One Greenbelter interviewed remarked: It is a curious thing, but some of our local real estate men have been most antagonistic toward the develop ment of our town. These real estate agents have claimed that the government has been pampering its employees by giving them such beautiful and attractive apartments to live in. Federal employees are working for the govern ment, but should not necessarily try to put the govern ment into medicine, grocery stores, credit unions, and housing it is claimed. We of Greenbelt realize that we are better off than many of our friends who earn more money than we do, but who are forced to live in D.C. With our cooperative health center we are assured good medical care at a low cost. It is too bad that more people have not had an opportunity to live amid such desirable surroundings. Greenbelt has cost the govern ment plenty, but it is better than anything the local ’fault finders’ have to offer or suggest.59 Dental services have been offered to subscribers of this health group at reduced prices. As we have observed not many health groups have been able to incorporate dental services in their plans. A schedule of fees has been worked out which, on the whole, lowers costs more than could be determined in other groups. Greenbelt Health Association has been experiencing several perplexing problems. Thus far it has not been possible to sell the idea of od mplete medical coverage to all the subscribers. An official of this health group re marks 2 "So far our educational work has not convinced members that they are better off paying for all their care by monthly ^^Personal interview with P.G. 110 dues* Many of them would rather pay dues for limited service and take thdr chanpes on the balance. It is unfortunate that the members who subscribe for only a fraction of medical services are running the risk of encountering medical bills that they could not pay* Partial coverage or insurance against high doctor bills prevents the health group from purchasing needed medical equipment and developing well balanced health services for all the members. A second problem relates to the hospitalization of its members when ill. At present subscribers of Greenbelt Health Association are endeavoring to devise a system whereby the insurance principle could be applied to the purchase of hospitalization, and thus spread the cost of hospitalization among a large number of members. This health group will probably have to inaugurate its own hospital plan independent of the Blue Gross Hospital Plan because of the inaccesibility of hospitals in Washington D.G., especially in conditions requiring emergency treat ment in a hospital. Another vexing problem which subscribers have faced is concerned with the inevitable fact that as medical services become more complete the cost of such services ^^Personal correspondence with S.H.W., January 28,1941. Ill must rise accordingly. Some of the subscribers are in doubt as to the advisability of increasing the coverage of medical services. One subscriber notes the behavior of one of the health group members as follows: Not long ago a member was suddenly taken ill just , after he had joined our health group. It was necessary for the medical staff to perform a very serious and complicated operation on this person’s stomach. After he had recovered from his illness he was one of the best boosters we had for the health group. However, the important thing about this case is that it wasn’t six months later until this subscriber had purchased a new expensive car. The automobile cost him so much that it was not possible for him to pay for his monthly health dues. He has dropped out of the association. It is just such cases as this one that make it hard for us financial ly and psychologically on our combined m e m b e r s h i p . A fourth problem which is common with most group health associations, relates to the spreading of rumors and gossip concerning the character of medical services rendered to members of Greenbelt Health Association. In a small community where primary group relationships and phenomena characterize much of the social life of the inhabitants it is understand able that some of the members of a health group may generalize particular incidents unduly. It has been necessary to call the attention of Greenbelt^ to the dangers of malicious gossip in the following manner: We hear of patients criminally neglected by our doctors at the hospital, ridiculous or inadequate diagnosis made ^^Personal interview with O.P. 112 by one doctor or another, and diametrically opposite remedies prescribed by two different doctors who happen to call on the same patient. Investigation has almost never bourne out any of these rumors, for our doctors never hesitate to call in specialists where they need assistance, and it is expected of doctors in a group health plan that they work together. Such gossip not only results in serious annoyance to members of our medi cal staff and the Board of Directors, but often makes the patients themselves of the objects of unwanted, misdirected, painful sympathy. We are sure that no Greenbelter desires to inflict rumors malicious or unjust on patient or doctor. The thinking citizen will at once refer all complaints or questions to any one of the numerous sources the Association pro vides, and then much of the unfair gossip will cease. A fifth problem relates to the serious disorganization and lack of ■understanding between lay subscribers and medical doctors, which has been a determining factor in precipitating the resignation of tv^o physicians from the medical staff of this health group. Before permanent replacement in the medi cal staff could be made a reorganization of the constitution was necessary. In order to attain a balanced perspective of the importance of this contemporary problem, a portion of a mimeographed newsletter is quoted as follows : It was obvious that we had reached a crossroads with the loss of Doctors Berenberg and Still* For some time previously the Board and doctors had been discussing changes in contract, since both recognized that the old contract with its unclear and outmoded provisions was a clumsy and friction-provoking instrument. The Legis lative Committee had been re-working the by-laws and ®®"G033lp,'* Bulletin. 11:2, March 1, 1941. 113 drawing up a new set of policies defining duties and responsibilities. The Extra Charges Committee had gone far enough in its analysis of the present rate structure to know that extensive revisions were necessary. We knew we were approaching the time for a reorganization, but we reached that point on June 1st much more suddenly than we had expected.^3 The central problems of reorganization and division of control between subscribers and medical doctors is stated in the following words : Our reorganization is now or probably never, and new staff members cannot be appointed until we know whether the Association or the medical staff will be empowered to engage them; until we decide upon a method of deter mining their remuneration; and until we know what sort of working relationship will exist between medical staff and Association.64 In the contract proposed by the Board of Directors on June 24, 1941, several provisions are set forth which are attempts to define and set the limits of consumer and medical control. The following sentences taken from the contract indicate the nature and extent of the physician’s rights and duties: "The physician shall render to the members of the Association all medical and surgical services which in the conclusive opinion of the Medical Director of the Association, the physician ^^Edward I. Weitman, President of Greenbelt Health Association, He^gietter dated June 24, 1941. 64 Ibid* 114 is qualified to render by training and experience.®^ The cost of fees and the right of the physician to engage in private practice in the surrounding communities of Greenbelt have been stated as follows: The physician, to the extent approved by the Medical Director and the Board of Directors of the Association, may engage in the private practice of medicine, provided that such practice does not interfere with the rendition to the members of the Association of the services herein set forth. The physician shall, at the end of each week, render to the Business Manager of the Association a state ment of the names and addresses of the private patients whom he treated during the week, and the amount of the charges* Charges for services rendered to non-members shall be subject to the approval of the Medical Director, and shall be at least sixty-six and two-thirds percent . (66 2/^fo) above the fees regularly charged to members for the same services by the Association.66 A statement concerning the conditions under which vacations and sick leave are granted has been summarized in the physician’s contract as follows: After this agreement has been in effect for a period of one (1) year, and each year thereafter during which this agreement is in full force and effect, the physician shall be entitled to three (3) weeks* vacation leave, with pay, which vacation shall be taken at such time as ^^0bntract Proposed by the Board of Directors. Green belt Health Association, June 24, 1941. ®®Ibid*, It is also pointed out that the method and manner in which medical services are to be rendered by the physician, in each particular case, shall be determined solely by the physician. The physician agrees, however, that if re quested by the patient or by the Medical Director, with the approval of the patient, that he will consult with the Medical Director and the other physicians of the Association or such outside physician or physicians as the patient or the Medical Director may select. 115 shall be approved by the Medical Director.,. The physician shall, in addition to vacation leave, be entitled to not more than three (3) weeks* sick leave, with pay, during any year in which this agreement shall remain in effect.67 The regulations governing the remuneration of physicians of this cooperative health group are stated as follows : The association guarantees that the physician shall receive as full payment for all the medical services which he renders to members of this association and to his private patients, during each month while this agree ment is in effect, the sum of three hundred dollars($300) or fifty per cent(50^) of the amount collected on his private fees, whichever is greater. This provision shall not be interpreted to prevent the physician from receiving additional remuneration for serving as Public Health Officer of the Town of Greenbelt# 68 The Board of Directors of Greenbelt Health Association has set forth in considerable detail its reasons for advising members to adopt the foregoing contract between the Association and medical doctors. Some of the most pertinent reasons for the Boards recommendation of the proposed contract were as follows : It places the financial and business-administration control in the hands of the consumer group where it belongs. Under the minority plan the consumer group is little more than a patient-getting body for the doctors. We do not see any reason why the consumer group which created the Health Association should relinquish its control just when the Association is coming of age. It frees the doctors from direct concern with business worries and responsibilities and permits them to concentrate °®nDld. 116 on their practice of medicine and their own medical organization. This is the fundamental "basis of co operative medicine. It binds the doctors’ interests more positively with those of the Association than the minority plan does. Under the minority plan the Association is not a too necessary appendage of the doctors* group. In fact, the liquidation of the Association might well be to the advantage of the doctor group under that plan, for with the dissolution of the Association the patients would stil]\jDe there but their bargaining power would be lost. it makes our rate structure, the schedule of dues and fees, a flexible instrument that the Association itself might change at its discretion in order to meet easily and promptly without protracted negotiations, the changing conditions or needs of the Association and its membdrs. Under the minority plan the Association would have no control over the internal financial or personal organiza tion of the doctors’ group. The way would be opened to exploit any incoming doctor for the benefit of the cont- troiling physicians who handle all funds. We feel strong ly that a much healthier relationship would be present among the physicians if no one of them could dominate the others in such a v/ay if each one had an independent con tract with the Association. The Board’s plan has positive approval of authorities who have been close to the immediate situations two doctors from our medical advisory board; Farm Secux^ity medical and legal staffs; our former pediatricians; physicians from National Youth Administration and the National Institute of Health; and a leading authority in the field of consumer cooperation. We are assured by these people that there is small danger of the charge of corporate practice of medicine or change in the status of our relationship with the county medical society under this plan.^9 Greenbelt Health Association represents the problems 117 and functions of a health group that is developing in an area dominated by cooperative social activities# At the present time it is passing through a period of social crisis and disorganization due to the friction between medical doctors and subscribers over fees and control of policy. With the appointment of Doctors Clesson and Mary Richardson to take the positions vacated by Doctors Berenberg and Still, the conflict between subscribers and medical personnel seems to have reached a state of social accommodation and adjustment. GROUP HEALTH COOPERATIVE AT CHICAGO,ILLINOIS In 1941 a consumer type of health cooperative was organized in connection with Civic ^edical Center of Chicago* Civic Medical Center has been rendering medical care to occupational groups on a prepayment plan for a number of years* The following services are available to subscribers to Civic Medical Center at no extra costs (1) diagnosis and treatment in all departments of the center; internal medicine, surgery, dermatolo^, allergy, .'cardiology, pediatrics, proctology, obstetrics and gynecology, ear;, nose, and throat, eye, urology, roentgenology, and physiotherapy; (2) consultations involving any or all departments were given; (5) major and 118 minor surgery; (4)medical eare, anaesthesia, operating room dressings, casts and ordinary medications in hospital; (5) all chemical and laboratory tests; (6) X-ray, electro cardiography and basal metabolism; (7) delivery and confine ment : pre-natal, natal, and post-natal care for pregnancy after one year of membership; (8) preventive care: periodic health examinations and immunization; (9) dental X-rays and diagnosis; (1Ù) ambulance service to the extent of ten patient miles in any one month; (11) mental cases, tuberculosis, drug and alcohol addiction and contagious diseases^{the isolation of which is prescribed by law are treated until Civic Medical Center prescribes confinement to an institution; &nd finally (12) a twenty-four hour telephone service prompt 70 attention to house calls. The medical services and health facilities offered to the subscribers of this health group are as inclusive and complete as any group health association operating at the present time in the United States. Certain medical services which call for institutionali zation are excluded from treatment. However, Civic Medical Center is the only health group reviewed which includes treat ment of the following conditionss mental cases, drug and alcohol addiction, contagious diseases and tuberculosis not needing 70 Prepayment Plan, Chicago: The Civic Medical Center, |194qJ, p. 5. 119 institutional care* Nevertheless, the service does not en compass treatment of brain and spinal cord surgery, ortho- 71 pedics, and neuropsychiatry* Medical services have been emphasized more than hospital ization in this health group. However, Civic Medical Center has made arrangements with several Chicago hospitals which have agreed to give hospitalization services to subscribers at nominal rates. In large urban areas members of group health associations can become associated with the Blue Cross Hospital Plan independently of the health group. On the whole the cost of medical service is comparable with that charged by similar health groups operating in the United States. Payments can be made on monthly, quarterly, semi-annual or annual bases, depending upon the arrangements made with’ f-the member or his organization# Table V reveals the fees for various types of membership in the health group. Non-group subscribers are subject to a three dollar 72 examination fee for each membër. The foregoing fees are not necessarily high considering the comprehensive medical care available. *71-------- Ibid., p. 6. 72 Ibid. , p. 4. 120 TABLE V THE comparative GOST OP MEDICAL SERVICE TO GROUP MEMBERS TYPE OP MEMBER COST PER MONTH One person only (single or married) ...........$2*00 Couple (man and v»ife) ..............5.00 Family, including all dependent children • • • 4.00 ^. 73 Ibid., p. 4. 121 Medical doctors employed by tiiis health group have been graduated from some of the leading medical schools in the United States. Each physician employed has been in practice _ ^ 74 twelve or more years. The following account reveals some thing of the broad training and wide interest of one of the organizers of Givic Medical Center: Dr. Lawrence Jacques, Civic Medical Center surgeon, is a native Chicagoan and graduate of the University of Chicago and Rush Medical College. After post graduate work in Vienna and interne service at County Hospital, he was associated for eight years v/ith Dr. H.M. Richter, one of America’s outstanding surgeons. He taught the same number of years at Northwestern Medical (SchoolJ A pioneer in cooperative medicine. Dr. Jacques helped td organize CMC six years ago. He is known to thousands of workers as the surgeon who testified before the La Follette Committee regarding the Republic Steel tragedy several years ago, and to thousands of others as the central figure in Meyer Levon’s Chicago novel. The Citizens. Dr. Jacques’ hobby is painting. His ’Bradford Street, Province- town,’ was hung in the recent Chicago artists’ snow at the Institute. The importance of having a select group .of physicians is of vital significance in aiding the lay member to make a "good" choice of physician. The social psychological and 74 Chicago Teachers Union Medical Center Plan Provided by Civic Medical Center, a leaflet published by Chicago Teachers Union, CL940^ 75 . "Dr. Lawrence Jacques," Group Health Journal, 1:5, May, 1941. 122 superficial personality traits have dominated the "fee-for- service" and "free-choice" of medical doctor under the traditional plan. The physician’s physical appearance and manner have in many cases been overemphasized and the knowl edge and skill of thé doctor neglected in selecting a medical practitioner* The weakness in unselected free-choice by the average layman is pointed out by Dr. Hugh Cabot as follows ; "While it is probably true that the average layman assumes himself to be able to select his physician, there is no field in which human judgment is so fallible, and in which 76 it has so little to guide it. " Professor Walton H. Hamilton makes the following observation and criticism of free-choice of physician; Although ’the personal choice of a physician’ is an excellent ideal, it does not, under current conditions, work well in practice. An old maxim, long known to every student of social philosophy, calls for a restriction of personal choice when ’the consumer is not a proper judge of the quality of the ware.’ The art of medicine is intricate ; the relation of the treatment of the sick to results obtained cannot be appraised by a layman; in medicine, almost more certainly than anywhere else, the patient has not the knowledge requisite for judgment. In almost every city reputable physicians will admit-- at least in private--that the competence of their fellows is not in accord with their respective reputa tions. Values are treasured long after they have begun 76 Hugh Cabot, The Doctor’s Bill (New York: Columbia University, 1955), p. 58. 123 to depreciate; and the idea of ’free choice* is much too individualistic to be easily surrendered. But its worth is to a large extent fictitious; and the expense and suffering which attends wrong choice and * shopping around* add greatly to the avoidable human costs of medicine* In this health group the member has free choice of a selected number of physicians who have been elected by medical doctors on the basis of medical competence. Free choice in this health group and other group health associations is likely to mean at least competent choice. Besides medical doctors, a large number of technicians and assistants are employed by this health group to facilitate medical efficiency of the health association. The group health cooperative was formed by a number of members of Givic Medical Center Wbo believed that a group of lay people could help sponsor such a health plan. Civic Medical Center probably has the most developed program of education of any group health association operating at the present time. The Group Health Cooperative has been endorsed and supported by the Civic Medical Center. An official of the Group Health Cooperative says : "At the present --------77-------- Walton H. Hamilton, Medical Care for the American People (Chicago: The University of Chicago Press, 1932), pp. 193-94. 78 Personal correspondence with V.E.S., Group Health Cooperative, Inc., July 19, 1941. 184 time the Center gives the Co-op $438.00 a month. We do certain things for the Center and also carry on a broad educational program. The Center has about 2,000 prepayment 79 plan members and the Co-op has about 130 members." There has been some evidence that if Group Health Cooperative proves itself as an integral part of the nedical center it will take a more active part in the formation of adminis trative policies of the Civic Medical Center. The functions of the health cooperative and its relation to Civic Medical Center is described in the follow ing manner; The Center engages the Corporation (GHC); a. To carry out the personal health and hygiene education of present and future participants in center pre-payment plan. b. To foster the use by the public of all the medical facilities of the center. c. To educate the public to the medical and economic advantages of group health plans. d. To encourage and support sound local and national health programs. The foie of the Group Health Cooperative has been further described as; “ 79------ -- Ibid. 80 Group Health Journal, 1;4, April, 1941. 125 Extension of memoersiiip in CMC plan for medical, surgical and preventive care. Personal health and hygiene education of both organizations. A modern hospital, owned and operated by G.H.G. Support and advice to new cooperative medical units here and elsewhere. Support of sound local and national health programs. Reduction of the cost and increase in the benefits of co operative medicine.81 One of the largest groups which has become associated with Givic Medical Center is the Chicago Teachers Union. In September, 1938, a committee of this teachers* union made a study of the economic problem resulting from illness. Seven general conclusions or recommendations concerning periodic payment of medical services are as follows: 1. Medical costs for an individual or for a family can not be foretold and budgeted for as can rent, food, and d o thing. 2. Medical costs for a group can be predetermined quite ; accurately and be spread over periods of time and groups of people. 3. Medical service for a group, can, and must emphasize preventive care instead of mere relief for those who are ill. 4. Any group medical plan for our union must be a voluntary plan. 5. Medical service should be furnished through group medical practices. 6. Any medical plan must be controlled in part, at least. 126 by the members under the plan, but medical questions should be left to the doctors furnishing the service* 7V Any union contemplating the establishment of a group medical plan should familiarize itself with the essentials of modern medicine and, wherever possible, make use of existing medical resources*®^ An agreement has been worked out between the Chicago Teachers* Union and Civic Medical Center. A joint adminis trative committee has been organized consisting of three members of Chicago Teachers Union and one from Civic Medical Center. In general, the purpose of this committee is to extend membership, study the work of the group, recommend changes in the group arrangement when necessary, and deal with complaints. The medical committee has been coordinated with that of the other committees of the Teachers Union. One subscriber to the plan at each school has agreed to act as a local representative. At the present time about one thousand members and subscribers are eligible for medical service with 83 this health group. One of the unique features of this health group has been the sponsorship of a Cooperative Medical Institute. At this institute common problems are discussed and trends analyzed by national leaders of group medicine. In 1941 the third medi cal institute was conducted at Circle Pines, Middleville. ^^M.G. Grew and Elmer A. Daniels, "The Chicago Teachers Union Medical Center Plan," Medical Care, 15 162-63. 1941. 127 Michigan from August 17 to 23, The theme of this institute was "Better Access, to Better Health, Of special sociological interest is the cooperative manner and setting in which the institute is conducted. The importance of social recreation is not forgotten; "Institute sessions will open at 9:30 A,M, each day and continue through to noon leaving the entire afternoon and evening open for small group discussions, swimming, hiking, fishing, boating, folk dancing, crafts, music and the many other recreational activities that are regularly carried on by the Circle Pines Center staff of 25 leaders,The first day’s session of the institute was devoted to "The Need for Medical Care ;" the second day was given over to an examina tion of the various plans for low cost medical care that are now being used in this country; the subject of the third day was "The Doctor Looks at Cooperative Medicine" and experiences of the patients who receive medical care under some of these group plans; the fourth day was concerned with a study of the details of organizations of these groups and the fifth day was devoted to a general summing up of the entire institute o c and the discussions given. The caliber of speakers may be ascertained, at least partially, by the statements in the 84 Verna E. Siegrist, Circular of Information concerning the medical institute on cooperative health, July 23, 1941. 128 following quotation: Professor C.D. Giauque. President of Group Health Cooperative, Chicago, and Professor of Health and Physical Education, George Williams College; Doctor Lawrence Jacques, Head of Surgery Department, Civic Medical Center, Chicago; Mr. Harvey 0’Conner, author, editor of Group Health Journal; Mr. Gustave Postier, Consumer Education Specialist, Workers Service Project, W.P.A.; Doctor Elmer Rickman, Wage Earners Health Association, St. Louis ; Mrs. Esther Heinrich, Treasurer, and Dr. Elmer Daniels, Hermit Eby, Seymour Myserson, board members of Group Health Cooperative. Chicago; Doctor A.G. Palls; and Mr. Maurice Crew. The immeasurable value from a social psychological stand point to a group health association of having a representative number of its physicians and members meet in a quiet and congenial recreational area of retreat to discuss the emerging problems and difficulties of the health group can hardly be overestimated. Circle Pines cooperative camp permits both professional and lay members to forget the minutia and worries of the busy and fast moving processes of a metropolis and concentrate on an analysis of the whole project objectively and collectively. Lay members are likely to overlook the problems which physicians encounter and vice versa. A medical institute stimulates a wholesome interaction of ideas and personalities concerned with the group health association movement. By having members of various cooperative group health associations present it Ibid. 129 Q f 7 is possible to compare and contrast common problems# Group health associations by joint action may cooperate more efficiently with each other through these meetings. The social detachment and recreational activities found in a medical institute in a beautiful mountain resort are factors promoting attitudes of we-feeling and more optimistic and positive convictions among participants■than probably could be developed in a noisy urban center. In short, participants in this group medical institute, after hearing the discussions, think more in Gestalt terms of the nature of cooperative group medicine than formerly. The educational program of this health group has taken over the problem of publicity of Givic Medical Center. Through the following agencies and means the advantages of group health associations have become evident to thousands of people : Group Health Journal, speakers bureau, organized tours of Civic Medical Center, medical institute each year at Circle Pines, and the attendance of subscribers at the annual meeting of Group Health Federation. Such a balanced educational program as offered by Group Health Cooperative has been instrumental in broadcasting the nature of coop erative medicine to thousands who never might have heard 87 Among the nationally known leaders in cooperative medicine who also led discussion at the Institute are: Doctors Hugh Cabot, Kingsley Roberts, Michael Shadid. 130 of it. The Group Health Journal serves as an agency of inter communication between member and member. The following case was published in this periodical which sets forth the advantages of group medicine: T know Givic Medical Center...know the wonderful work they’re doing. My family— that’s my wife and I and three children. • .pay $4 a month for the prepayment plan* It:’ 8 the best investment I ever made. You remember the appendicitis operation my wife had to have last year? That was worth our membership for many a long year. And there was the examination that showed I had gall stones. I’m certainly glad the doctor found that one early. And then there’s a world of security in knowing the children are checked regularly.88 Mr. Petro Lewis Patras, Chairman of the Hospitalization Com mittee of Chicago Post Office Clerks’ Union, has related his experiences with Civic Medical Center as follows: I had opportunity to become personally familiar with the health service offered by the Civic Medical Center in Chicago, a private group clinic. Members and their families come in at least once a year for a thorough medical examination when well. If a member has any disease or illness such as a persistent stomachache, backache, headache, skin disease, rheumatism, or any of the thousands of different sicknesses, he comes in for diagnosis and treatment. He may see a general physician, specialist, have X-rays taken blood and urine tests, diathermy, in short he is entitled to the attention of every man and machine that modern medicine has developed for the protection of lives. All of this without cost beyond his membership dues. If he gets sick at home he does not have to worry about the doctor bill. If he needs to have an operation he goes to the hospital with a lighter heart he won’t have any surgeon’s fee.89 88 Cited in Group Health Journal, 1:4, May, 1941. 89petro Lewis Patras, "Search for Health Security," Medical Care, I: 161, April, 1941. 131 The steady Increase in members has made manifest the fact that the educational program of this group health association has awakened many people to the advantages of group medicine. Prom the standpoint of medical problems, one of the notable advances made by this health group has been in pre ventive or protective medicine. In an effort to diagnose pulmonary tuberculosis and arrest this condition in its earliest stages, every subscriber to Civic Medical Center is requested to have an X-ray examination of his chest. The examination is given without charge and probably was the first time an American group health association has undertaken so extensive a preventive health campaign. Doctor Lawrence Jacques, one of the physicians and surgeons for Civic Medical Center, has disclosed the importance of preventive medicine, especially in a group health association, as follows: What are the specific advantages of group practice in the field of prevention? We cannot in any direct sense ’prevent* gallstones, appendicitis, most types of cancer, heart disease, defects of visions or injuries received in automobile accidents. But we can, by early examination and persistent treatment, cure them when they can still be cured, and prevent many of their complications and end results. Early examination is another prevention. Unfortunately there have been two serious obstacles to early diagnosis and treatment: (1) the financial barrier, (2) lack of education, bn the part of both doctors and patients. And herein lies the twofold advantage of group medicine. For properly organized group practice should 132 dissolve the financial obstacle for a large segment of our population, and a proper relationship of groups of doctors to groups of patients should permit an adequate program of education#90 The Group Health Journal has called attention of members to the importance of X-raying each health group member. It is hoped by both subscribers and physicians that the corrosive opposition of the American Medical Association was stopped in Washington D.G. because of the verdict which designated that the medical society had been guilty of violating the United States %nti-trust" laws. Doctor Jacques comments on the testimony of Doctor Olin West, Secretary and General Manager of the American Medical Association, in the following way: Givic Medical Center, it should be noted, does not include all the physicians in this locality. This is ’not necessarily* unethical. The Civic Medical Center is a partnership. This is ’not necessarily’ unethical. Practice by a group of doctors and group prepayment is not in itself unethical. It would seem then that in the eyes of the secretary and general manager of the A.M.A. the Civic Medical Center is ’not necessarily’ unethical.91 The emphasis and place of an educational program have been given a prominent hearing in this group health, association. A high degree of social and medical organization characterizes Group Health Cooperative. 90 ''Preventive Medicine," Group Health Journal, 1:3, March, 1941. 91 Lawrence Jacques, "A.M.A. Trial," Group Health Journal, . 1:2, April, 1941. 133 GROUP HEALTH COOPERATIVE OF NEW YORK CITY This health organization was the first group to define, itself as a cooperative plan. It was organized a few years ago under the general directorship of the Bureau of Co operative Medicine, and the initial capital was contributed by individuals and agencies interested in furthering the principle of cooperation, especially as it applied to medical care. A subscriber to this health cooperative has the right to the services of a general physician, including an annual physical examination. Surgical and other technical services are offered by specialists practicing in this cooperative health group. Patients receive whatever laboratory and other services go are necessary for complete diagnosis of a case. About the same health conditions are excluded from service in this association as in the health groups previously analyzed and reviewed. Conditions existing at the time of enrollment, such as mental or nervous illnesses requiring treat ment by a specialist in psychiatry drug addiction, chronic alcoholism, routine eye refractions. Workmen’s and Veteran’s ^^How to Pay Your Doctcys’ Bills, (New York: Group Health Association Inc., £1940^ 134 Compensation cases, or cases requiring treatment in an asylum, sanatorium or isolation case in a public institution are not included in the service regime of this group health association. Maternity care by qualified obstetricians is available when the expected date of birth is at least months after both parents associate themselves with Group Health Cooperative*^^ No plan of group hospitalization has been developed as yet by this group health association. It is presumed that when the group has become large enough to support group hospitali zation, it will be incorporated in the plan. However members may now secure adequate hospitalization through the Associated Hospital Service of New York, a Blue Cross plan. Group Health Cooperative has no enrollment fee. Payment of the first quarterly premium includes a qualifying examina tion. If a subscriber is rejected because his state of health does not meet medical requirement for membership, he loses the first quarterly payment. Payments are made on a periodic basis. However, a saving of one dollar is made if prepayment of dues is made one year in advance. The following table on the next page sets forth the specific costs charged by this health group. An extra fee is charged in cases vfhere diagnostic X-rays are necessary if the charge does not exceed ten dollars. 136 94 TABLE V COMPARATIVE COST OP-MEDICAL SERVICES TO GROUP MEMBERS AND INDIVIDUAL MEMBERS '■TYPE OF MEMBER COST Group enrollment per month* . • , ...................... $1* 50 Non-group enrollment per month....................... $2.00 Each dependent per month......................... .... $1.50 136 For the first call made in the home, the physician’s fee is one dollar. A fee of twenty-five dollars is permitted in confinement cases. These charges are not excessively high in view of the lovf cost of monthly dues. Some nationally known leaders in the field of group health are on the medical advisory hoard of this organization, including Doctors Kingsley Roberts, and James P. Warbasse, who, for many years has been an outstanding leader and writer in the cooperative movement in this country. They are chairman and member respectively. Probably there is no other group health association which could boast of two such well rec ognized leaders in the field of cooperative medicine as Roberts and Warbasse. More physicians are connected with this cooperative health plan than with any other, as far as the writer could determine. At the present time, 1941, this group has about four hundred physicians who are in some way associated with the distribution of medical services. Because of the large number of physicians connected with this plan, the select ivity of physicians is probably not as accurate as in health plans that have a dialler medical staff. Any licensed physician is eligible to become associated with the organ isation. In this particular. Group Health Cooperative 137 resembles quasi group health associations for there is no attempt made to select the more competent physicians in a given community. In another regard this health group is similar to quasi group health associations inasmuch as there is no pooling of medical equipment, as yet. One of the distinct features of this particular group is that its members were recruited from the low income class. Eligibility depended upon incomes which do not exceed the following: two thousand dollars a year for a single person without dependents ; three thousand a year for a married couple or a person with one dependent; three thousand and three hundred dollars a year for a family of three persons ; thirty-six hundred dollars a year for a family of four persons. Subscribers are permitted to con tinue in the health group after reaching sixty years of age.^^ The most economical way to become a participating member in this health group is through a group membership consisting of at least seventy-five percent of fifty or more persons who have a common employer. This plan includes care for illnesses existing prior to membership with the group. Another plan which has been in operation permitted member- Ibid. 138 ship if at least twenty-five percent or ten persons (which ever was greater) with a common employer or organization. Because of the small fraction of members enrolled under this 96 arrangement pre-existing illnesses are not treated. Inasmuch as this health group has been in operation for such a short time, it is considered to be unjustifiable to recognize any problem as being solved at this early date. Note might be made, however, that the organizational frame work of this health group has been successfully and rather completely outlined. Economic problems have been the most perplexing difficulties with which this plan has had to contend. One of the officials of this health scheme says: Our principal difficulty thus far has been in raising sufficient capital to keep the plan going during the initial stage, before it has become self-supporting. We have been administering the plan through contributed capital, and will probably have to continue on this basis for at least another year. Other administrative difficulties have not loomed very large as yet, and we are prepared to handle a goodly increase in the volume of subscribers without complications. Of course, we will have to enlarge our staff as volume grows and eventually we. hope to arrive at the point where we can set up Group Health Centers in New York City.^" The community patterns of a large metropolis, such Ibid. 97 Personal correspondence with H.H., May 9, 1941. 139 as Hew York, may be factors inhibiting the development of health attitudes* A group health manager of one of the co operative group health associations observes something non- cooperative about the urbanites of Hew York as follows: I think the toughest problem Group Health Cooperative is facing is that Hew York City is an unusually poor place to organize a health group of any kind. Hew Yorkers are not cooperative minded enough. Social relationships between people which are circumscribed by secondary and tertiary group contacts impede the promotion of cooperative ideas. In ecological areas characterized by nigh- dwellers rather than neighbors the development of feelings of confidence is more difficult. The social distance between per sons residing in a large city is noticeably greater than for ruralites* Of course, once this group health association can tap a common "wishing well" for good health social relationships will probably be marked by a similar desire. 98personal interview with T.W* similar group health association as Group Health Cooperative of Hew York was founded in Boston in 1940 under the name of the White Cross Medical Service Plan of Massachusetts* A lay Administrative Board and Medical Board control respective policies and services of this association. One of America’s most famous writers in the field of social medicine serves as medical director. Doctor Hugh Cabot. The cost of fees is approximately the same as other group health associations analyzed* Annual dues of fifteen dollars per group member* Because of the nature of the health plan there is no pooling of medical equipment. One of the things that puts this health organization ahead of quasi group health associations sponsored by the American Medical Association is that a participating doctor on the panel must be a graduate f,^ of a Grade A Medical School and have courtesy privileges with a hospital approved by the American College of Surgeons* Preventive medicine is practiced in this group for White Cross members re ceive 4*7 physicians* services per capita per year; whereas the general public receives only 2*7 physicians’ service. 140 WAGE EARNERS ’ HEALTH- ASSOCIATION ST. LOUIS, MISSOURI In 1936 a group of individuals organized Wage Earners* Health Association for the primary purpose of distributing the costs of illness among many persons and to encourage the practice of preventive médical services. At the present stage in its growth there are approximately 450 member-participants in the health plan. This group health association is a member of the Group Health Federation of America, an organization which has set up ten dynamic prerequisites or criteria any health group must meet before it is accorded membership. At the present time members of this health organization are entitled to the following health services: annual health examination, medical service of a general practitioner and various specialists. Unusual illnesses necessitating special treatment outside the limits of services performed by the group doctors are referred to private specialists at the sug gestion of Wage Earners* Health Association physicians, most often by the medical director. Such specialists are paid for from health group funds. Among the special services offered by the health group are the following: internal medicine, general surgery, ear, nose, and throat, pediatrics, gynecology, allergy, maternity care (provided the member has been enrolled 141 for 18 months prior to delivery), genito-urinary {provided member has been enrolled for 12 months), venereal diseases (provided member has been enrolled for 12 months), office calls by staff members, home Cecils and hospital visits by the staff (subject to.certain charges), routine laboratory / examination, dental diagnosis each year. X-ray diagnosis, special laooratory examinations, and physiotherapy at ^ ^ 100 reduced rates# Excluded from treatment are the same general types of illnesses which other group health associations do not service, such as (1) pre-existing conditions which are disclosed at the initial medical examination, (2) drugs, (3) materials for special surgical dressings, (4) surgical and medical appliances, and (5) hospital charges and nursing. It is im portant to know that many of tne members of Wage Earners* Health Association provide themselves with adequate hospitali zation security through the Blue Gross Hospital Association, a national prepayment hospital plan. Also excluded from treatment are diseases of the mind and nervous system, tuber culosis, alcoholism, drug addiction, and conditions arising from illegal medical practice. Services involving litigation, services for accidents covered by insurance or the Workmen* s Compensation Act, or services paid for by a third person who ^Q^edical Care You Can Afford, Wage Earners* Health Association, St* Louis, pp. 8-9. 142 is not a group member are exempted from treatment. Lastly, dental care and services not authorized by the medical director are not rendered# Membership entrance examination fees in this health group are as followsI head of family $3.00, second family member $2,00, each additional member $1,00, A membership fee of $10.00 is required for each separate member, and two such fees are asked when an entire family participates in the group plan. The regular dues for the various classes of membership are well summarized as follows : (a) Group (individual); Any individual in an organized group of ten or more employed persons, $1,00 a month. (b) Group (family); Any individual in an organized group of ten or more employed persons with his wife and dependent children under 18 years of age, $1.00 per person with maximum dues of $3.00 per family per month* (c) Non-group (individual)£ Any individual not affiliated with any group, $1.25 per month. (d) Non-group (family): Any individual not in an organized group with his wife and dependent children under 18 years of age, $1,25 per person, with the maximum dues of $3.75 per family per month. (©) Persons 60 years of age or over pay double above rates. Home calls by physicians and hospital care for minor illnesses are subject to a one dollar fee; office calls are free. Medical. Ibid., p. 11, 143 services required as a result of special conditions are subject to the following charges ; In case of surgery, delivery, major illness, special examinations or special consultations, a lump sum will be charged in such a way that these amounts will not exceed $20.00 for seven days, $40.00 for eight to fourteen days, or $60.00 total for fifteen days or more in the hospital for each operation and the consequent physicians* care. Children under one year of age, 1- free office calls and $1.00 per visit thereafter. For children at home or in the hospital the same charge will be made as for adults. Children are eligible for membership at the age of one month. Injection (material supplied), physiotherapy, local anesthesia and issuance of health certificates, at minimum extra costs. Pluoroscope, X-ray, unusual laboratory studies or examinations,such as electrocardiogram, blood chemistry, serology, etc., at minimum extra c o s t .102 The professional personnel of Wage Earners* Health Association is composed of four medical doctors, one of whom serves as a medical director. Each of these four physicians emphasizes one of the following specializations : pediatrics, ear-nose-throat, gynecology and obstetrics, surgery, and internal medicine. When an outside specialist is consulted he is not pre-informed of the patient*s association with the health group, thus, the patient might be a private patient of the medical director. Patients are, as a result of this 102 Ibid., p.11. 144 ^privacy,” assured of receiving the best possible care the specialist is capable of rendering. This arrangement tends •to dispel the hearsay opinion advanced by non-group health association persons that private patients receive better medi cal care than do persons affiliated with a health group. Wage Earners* Health Association has solved similar problems as have been discussed previously in connection with other cooperative health groups. The major problem solved by this health group has been that of successfully applying a system of periodic payments to the cost of medical care. Members are enthusiastic in their recognition of the success of budget parents to health services and the importance of consumer control of the administrative policy. The follow ing statement by a member reveals a general attitude regard ing tEiese factors : You ask me what problems we have solved? First, I believe that our health group has provided medical care upon an actuarial basis. For a do 11^ a month per member a person is assured of excellent medical care by competent physicians. We have been responsible also, in helping to assure the doctors of a more permanent income and I think this makes the doctors appreciate our membership patronage. Another thing we have been able to do is work out a division of responsibility between consumers and doctors. We run the financial side of the health group and the doctors take care of the medical end of it.103 The provision of specialists for member-patients is an other problem solved by this group. The following cases are Interview with E.L. 145 indicative of the confidence attitude built up in the thinking of subscribers as a result of the care administered through the medium of medical specialists : Besides providing medical care at a cost which I can afford, in our health group, a person does not have to hunt around for a specialist when one is needed. How can I tell when I need a specialist? I don't really know what is wrong with me when I go to a doctor, and I think the same is true with a lot of other people# How in our group the medical director suggests when you need a specialist and also recommends one for you to go to. Our medical director has a staff of very well qualified specialists and he refers members when they need the services of these specialists. I have confidence in these specialists. They really know what they are about.104 In connection with this same point, several other members feel that they receive the same care as private patients do when they go to specialists. The following brief statements express the thought that there is no clinic" or "charity" attitude on the part of either patient or specialist when a member of this health group is receiving medical cares When our medical director recommends a patient for treatment by a specialist he does not tell the specialist that he is sending over a health group member. You see, our medical director also has private patients. As far as I can see our members are assured of as good medic^ care as any private patient going to the specialist.^^^ Interview with R.S. ^^^Interview with T.W. 146 One of the interviewees in this case suggested that the Wage Earners* Health Association was a factor not only in helping to stabilize family incomes through periodic payments, but he pointed out further that he thought the health group had been a factor in reducing morbidity rates also. He said; We have been instrumental in reducing the debts caused ' by illness through our pre-payment health plan* Probably the most important medical gain has been that our member ship notes a generally improved health which is reflected by reduced calls per member each year since the health organization got started. I think that this fact ought to be a very good selling point for members to recruit additional members to this health group*10^ Members interviewed evinced pride regarding the pre ventive program practiced by their health group, and were unanimous in expressing approval of it. Because of the nature of this health group the consensus of feeling among its members is one of non-restraint in the matter of visiting group physicians whenever they feel it is necessary to do so. Tradi tional attitudes of submission toward medical doctors, due in part probably to the high cost accompanying each visit to a doctor's office, have been reversed. As a member puts it: It is because I am paying for my medical needs when I am well that I feel a complete freedom to visit our medi cal director and his staff of wonderful physicians. I go to the doctor now when I even have a cold, whereas be fore I was a member of this health group I always put off Interview with J. 147 going to the doctor until I became seriously sick. Private doctors used to say to me. 'Why don't you come earlier, before your condition is bad?' But if the average person visited a private doctor everytime some little thing was wrong he would be 'broke ' nearly all the time. Now that I am a member of Wage Earners ' I do visit when necessary because^ it does't cost me anything extra. Besides, the doctors in the group want to check all health conditions in the early stages so a. pauient won't become seriously ill. This is a good thing for the patient and for his family and for all his friends as well.^07 Still another hurdle surmounted by this health group relates to the antagonistic attitude of the American Medical Association toward pre-payment health plans in general. A certain amount of tact and social discretion were used to good advantage in appeasing the prejudiced and competitive attitudes of members of organized medicine. The following case probably typifies how this health group met the problem: We have had a serious problem with some of the members of the medical profession v\rho did not understand our true purpose. Some of the A.M.A. doctors felt that we were going to instigate state medicine. You know as well as I that bur mission is not in the direction of state medicine. We had a salesman once who misrepresented the health organization and got us in hot water. He had made certain factual statements that were not true. However, the biggest thing that conservative medicine jumped on us for was that he had cited the name of one our doctors. They claimed naturally, as they always do, that this was a good case of 'personal advertising.' We had to explain the mistake and use some common sense to get out of this difficulty. We have hit upon a plan that is almost foolproof and as it now works has not generated any friction from organized medicine. We sell medical care through our group health association and make every effort not to mention the name 107 Interview with H.R. 148 of any medical doctor connected with the group. The general qualifications of our physicians are made.known, but not their names. We have found that it is better to use a little tact and judgment when dealing with the so-called ethics of medicine. I believe I can say that we have experienced very little criticism from organized medicine.108 It is interesting to find out in what ways members of this health group believe services could be improved. Many of the points suggested by interviewees merely are terse statements of immediate objectives. As is true of most health groups this one needs more members. It is necessary to have more equipment and a more complete coverage of medical services could be made possible. One of the interviewees gave a rather complete analysis of this problem of gaining new members: How should we gain members? Well, it can't be done by hiring professional salesmen. We tried that. Profession al salesmen cannot do a good job of preparing the member for cooperative living. Unfortunately, the salesman is likely to concentrate too much on making a 'sale* for the organization rather than in building up a sound attitude of appreciation for the concept of group medicine. We have found that 'high pressure methods' and cooperative principles do not mix very well. We are growing by having satisfied consumers telling their friends about the success of the group. Personal contact between our health group members and outsiders is perhaps the best way to gain new members. We are not interested in getting a bunch of 'joiners' who will be with us for only a short time and then drop out. Each member who drops out of our organization is a potential knocker and we don't want that caliber of member. , Most enduring things grow-rather slowly. There have been too many half-baked ventures in the cooperative movement.109 lOSfnterview with A.M. Interview with F.P. 149 The preceding case reveals that group medicine is not a commodity that can be sold, but rather an idea that must be accepted after an understanding of the principles of group health associations has been reached. This health group is growing- through contact between primary group methods. Inti macy of ' friends^ .affords a sense of confidence which is para mount to recommendation. Since health is not recognized by many of the agents of social communication as being an invaluable aspect of all phases of human life, this attitude of confidence cannot be overestimated. Confidence between friends who are receiving medical aid under diverse methods may become the first link in a chain to help break down the system of stratification so prevalent today regarding the methods of procuring medical service. Patients receiving care under private suspices will tend to look with favor on satisfactory care received by friends at group rates as group members. Diffusion of knowledge regarding health groups among friends may tend to create a new set of mores built up around the cooperative "our group" attitude rather than the proprietary "my doctor" attitude. An interesting social psychological attitude noted by several members of this health group represents the antithesis of that discussed in the foregoing paragraph. Inasmuch as 150 group medioine involves a saving because of grouping of medi cal personnel and equipment, some of the members have detected a doubt amounting to distrust in the minds of out-gi*oup persons contacted for- possible membership in the group, as the next case reveals: I have been somewhat surprised to notice that some of the folks 1 tried to interest in our group health plan have responded, after I told them that medical care was approximately a dollar per month per member, with the thought, 'You can't give good medical care for that price.' They think there is some catch in the plan. They want to know who the doctors are and how long the organization has been functioning. It has taken me some time to make clear how it is possible for us to offer such medical care at reduced costs. Some of the outsiders cannot grasp readily that we are mutually sharing the burden of illness. However, I believe that when the cooperative movement becomes more widespread we shall be able to talk, with greater ease on the subject of cooperative medic ine Another problem met by this health group, not uncommon to the other cooperative health groups studied, is that some members are in the organization for what they can get out of it. In other words, pecuniary values supersede social values, as the following case discloses : Most of our membership belong to the group because it is a good, cheap way to obtain medical benefits. There is little complete proof that our membership is interested in furthering ideas of cooperation. Although many of the members are also members of cooperative stores and activities, there are too many of them who just pay their dues and do not take an active part in the administrative control of ^^^InterVlew with A.Y. 151 our group. However, I guess that the human being is just that way. A few take an active part and the rest, who are too many, are apathetic about taking a vigorous interest, Extension of services is frequently observed by members as a way in which this health group could be improved. How ever, basic to an increase in services is increase in member ship. The extension of services deemed most important center upon the following: a medical center, specialists in more fields of medicine, dental services, inclusions of medicines with treatment at no additional cost, hospitalization, and a lower per capita cost. One member stated regarding extension of services: The choice of doctors must be made much greater. The ideal would be a plan under which a patient could choose any doctor he wanted pmpossible if centralization of medie cal equipment and personnel is applied^ The services must be made available anywhere in the United States, for at the present a person may pay fees for several years with out having an illness, and then have a serious illness when he is out of the St, Louis area. Then he is unable to enjoy the benefits at the time when they are needed simply because he is not in a particular city. Perhaps we can some day have an exchange system between various health groups novv operating in the United States, &his is provided in a limited way throught the groups now mem bers of the Group Health Federation^ Summing up the problems and ways in which services could be improved, one member says : "Personally, I feel that we are 111Interview with D,F, Interview with R.T.O, 152 doing a mighty fine job at present when .consideration is taken of the small size of our membership, The feature which most members mentioned as the one they like most about group health medicine is the budgeting of payments. Members mentioned several other implications besides the mere economy of such a plan. Some of the members pointed out that " a health group makes available medical care within my budget,A feeling of security and freedom was aptly expressed in the comment, " I know that X am protected against the unexpected costs of a serious illness. To me it is just like life insurance, only better. We take care of each other while we are still alive, Confidence in the physician is another significant attitude disclosed by a number of members. One case revealed this general attitude especially well as follows : When I go to one of our group health doctors 1 feel confident that he will give me only the service I 1 actually need and not keep us making trips to his office in order to increase his income. We go when something is wrong and feel that each visit to the doctor's office surely is one that will help me to get better as fast as possible. I know I used to regard some of the private physicians before the days of group medicine as 'robbers.' ^^^Interview with P.W, Interview with M,S, ^^^Interview with R.T, 153 Why in those days a patient would almost cringe at hearing that treatments would be necessary over an extended period of time. I never feel that way now.^^^ Some of the members were of the attitude that group medicine is a factor in spreading the benefits of democracy and cooperation in this country. There is in their minds the notion that cooperative medicine is something more comprehensive and significant than merely good medical care upon a periodic basis* The following case with an educator reveals this point quite wells I like our group health association because I am certain that it is a coming thing. I like the doctors which the health group has access to when a member needs medical attention. Besides, the medical benefits of a health group:.are not all it offers. 1 am thoroughly convinced that it is an effort to stop the onward rush toward dictatorship in the United States. I know enough about political science to know how Germany became subject to one of the worst dictatorships in all history. You see, if the middle class doesn't take a lead in helping to solve our social problems and adverse economic situations, the social forces of authoritarianism will gain the upper- hand in controlling the destiny of America. The co operative movement in every phase is an effort to forestall such attempts in the direction of dictatorship. Co opérât iveness will make democracy a social reality for all the people in this country. In fact, cooperatives are a form of social insurance against dictatorships. Our group health association is revealing to a number of people how the people may solve common problems by mere ly pooling their present resources. I suppose I am some what of an idealist, but I am convinced that the potentialities of group medicine extend beyond the limits of merely good medical care.H'^ llôfnterview with A.C# Interview with P.A/ 154 The professional manner of health physicians is apprec iated by members. They believe that many of the pleasant attentions which a private physician extends to his patients are not necessary. In other words, they don't mind the social farness between patient and physician as long as they feel that they are getting good medical care. The following case reveals this attitude in more detail; Of course, one of the reasons why I like my member ship in this health group is because of the sense of security which I have both economically and psychological ly* 1 go to any physician that I want to go to. Another thing I like about my membership is the fact that our health doctors don't give as much bed side manner to us. They are efficient and come right to the point. I have had too much experience waiting in the offices of physicians while they tell you a lot of silly trite things. Physicians are likely to have a very poor unders tending of philosophy anyway and when they try to harmonize illness and philosophy I can't stand it. Give me the efficient medical doctor and the impersonal relationship is mutually satisfactory. The prevention and education program of this health group is v/idely accepted as a favorable step. Summarizing the pre vention program one interviewee disclosed: I might say that I am very enthusiastic about our group health program. I consider it far superior to the group hospitalization program. After being in this organization for some time I am convinced that the average individual outside the organization receives a meager amount of medical service. In other words, under the present plan most people go to a pill peddler, or private doctor, only when they actually need a physician's services. The big 118 Personal interview with J.A. 155 field in mediain© as I see it is prevention and education. I really feel that I am paying this group a certain amount of money to try to keep me well, then, in ease any ailment develops, the staff tries to get me well and for this you might say they receive very little.119 Members of Wage Earners* Health Association have only cited a few things which they do not like about this health group. They are almost unanimous in their dislike for extra charges. Certain medicine^ and certain types of medical services are subject to additional charges, which is not unusual inas much as a fee of only $1.00 per month per person is charged. The typical reaction is represented by the following: I wish there could be some kind of arrangement made so that the extra charges for medicines, surgery, and other things would be removed. I realize that I am getting my medical care for reduced fees, but it makes the prepayment seem more like part-payment rather than a thorough going group health association. However, for me the charges are not quite so irritating, but some other members don't like it at all. For some of them it is not so easy to make it clear at the doctor's office that certain extra charges are collectable. Wow I am quite aware of the fact that both the agreement and our educational pamphlets present in a very clear and specific manner the details of the extra charges. A few of our members have remarked: 'I thought there was a catch in it somewhere and here it is--in extra charges I ' For myself I would prefer a higher monthly fee of about $2.00 per month in order to eliminate the bother of ' extra charges.' Still, X can see the point of some of our lower income members who are willing and probably can afford only part coverage. To theni partial medical coverage is like certain types of collision insurance that driver's have on their cars.^' 119Interview with J.C. Interview with W.S. X57 A few have criticized the medical doctors and the in convenience of having only one office: I don't like the fact that our membershjp lacks sufficient size to enable it to operate on an efficient and businesslike basis. The choice of our doctors is very limited and in some oases we are not entirely satisfied with the doctor and would like to go to others whom we like better. This is especially true when our illness is quite serious. While it doesn't make much difference to me, some of my friends in the health group resent the fact that a few of the doctors are not Americans.1^1 In connection with criticisms, of medical personnel, a minority of the members interviewed believe or at least subscribe to the thought, that group health doctors do not take as much interest in group members as they do in their private patients. "I am not convinced that the group health physician is as personally concerned with our health as a private or family practitioner would be.However, this may be a "carry-over" behavior pattern natural in individuals who have been the recipients of medical care under several methods. Individuals with this attitude probably have not adjusted to the cooperative principles operating in group health plans and look for Imitation of private practitioners in the method of service given by group health doctors. In support of the thesis that some members are hyper critical, and often universal critisizers of doctors in ISljnterview with M.G. IQO Interview with J. J. 158 general, the following case is submitted, which discloses unusual..insight into the patient-doctor relationship; As you no doubt have already observed, I am extremely enthusiastic about our health plan. My experience with the medical department has been.entirely satisfactory, I wonder if some of those who find fault with the service would not be the ones to have difficulty with doctors in private practice outside our organization# One in parti cular of our short time members, who was always finding fault with the association doctors, has had perhaps six private doctors, each one being cast aside as unsatis factory, Unfortunately, our growth has been slow. Why so many v/ill join Group Hospitalization Plans and not this one I do Hot understand. The most common complaint seems to be that they would not have their personal choice of doctor.123 Interviews with members of this health group indicate an unusual degree of interest regarding the nature of the health group and the problems it confronts. Discussion of the group usually proceeds upon a constructive basis. Criticism of the group was often less criticism than an attempt to analyze the group with a view to helping it surmount present obstacles. Thus, the attitude expressed by most of the members interviewed was a dynamic one, with much understanding of the early developmental stage of the health group at the present time, and a great willingness to accommodate themselves to whatever inconveniences may prevail now, since the outlook for the future success of the health plan is one of optimism ^^^Interview with A.H. 159 and confidence in thw workability of the cooperative principle as applied to medical services* Chapter summary. In light of the data disclosed in this part of the study the following observations might be made: 1. The social situation and community patterns are paramount in explaining the social nature of cooperative group health associations. These health plans were founded in order to cope with the great social need of providing adequate medical care for the low income class. There seems to be a transfer from the cooperative buying of material objects to the cooperative sharing of the costs of illness. Most of the cooperative group health associations were started in communities in which there was considerable cooperative activity antedating an organized interest in health groups. 2. Subscribers to cooperative health groups acknowledge attitudes of security from their membership in these associations. They do not worry about being confronted with a large physician's bill after an extended illness. Periodic payments remove the possibility of large post payments for illness. Members feel • that there is a certain mental peace and composure which results from health group membership. Members frequently cite the sense of security which is derived from membership in coopera- 160 tive health groups as the most important and vital by-product resulting* 3* Subscribers feel that the health group doctors are more motivated to be frank than fee-for-service physicians* The health group doctor has nothing to gain from prolonging an illness* 4* Cooperative group health associations are democratical ly controlled and administered. A division of control and management is characteristic of cooperative group health associations. The lay members, the consumers, control the important administrative policies and the professional members, the producers, regulate and administer medical service. A certain degree of mutual exclusiveness between these two areas of control seems imperative to the harmonious functioning of a cooperative health association* 5. Subscribers to a cooperative group health association have free choice of a selected group of physicians* Coopera tive group health associations insist that physicians employed must be practitioners with superior academic and experimental backgroun* Ô. Cooperative group health associations stress pre ventive medicine. Subscribers realize that it is more intelli gent and cheaper to take precautionary measures than to obviate the development of acute illness* The scientific skill of 161 maintaining good health is emphasized as much as the skill of treating and curing illness* 7# Group health associations have reached a national coordination stage with the organization of the following items; National Conference of Group Medicine, National Institute of Cooperative Medicine, and National Group Health Federation* 8* Cooperative group health associations are develop ing through primary group contacts and methods* The many opportunities for active participation in the growth of a health group are replete with face-to-face relationships* Co operative activity can he furthered by a more vigorous education al program* Perhaps more study classes in group medicine and related cooperatives would facilitate a better/ understanding of the purposes and methods of cooperative group health associations* These small study classes would afford more ways of learning how to cooperate by group learning situations* 9* The centralization of medical equipment in a medi cal center is an economic saving and avoids much of the duplication of scientific aids so common in the fee-for-service practitioner's office* 10* The centralization of medical personnel makes possible group consultation and intellectual interstimulation between physicians* Scientific knowledge is so vast in the field 162 of medicine that no one physician can master it all; hence group consultation on difficult cases is an important form of intellectual cooperation. Health group physicians are co- operators in both theory and practice of medicine* 11* These cooperative group health associations can be rightfully considered as important media for the reduction of the culture lag which has excited between medical science and its distribution of medical services. Group health associ ations have increase the availability of medical care to a large number of people in the low income group in the United States* CHAPTER IV PROPRIETARY GROUP HEALTH ASSOCIATIONS For more than a decade a number of group health associ ations have been in operation in the United States controlled by a group of physicians* Health groups under the director ship of proprietary physicians have developed in spite of attempts of local medical societies to exercise social authority in the field of group medicine. However, more recently, local medical societies have organized a variety of health plans utilizing a few of the principles of group medical practice which tend to act, in some instances, as barriers toward the more complete and extensive development of proprietary and cooperative group health associations* Organized medical societies have been so successful in this means of socio medical control that today there are probably more health plans under the indirect sponsorship of the American Medical Association than under the guidance of any other type of health group* A discussion of health groups sanctioned by the American Medical Association will follow in Chapter V, and will be termed as quasi group health associations* Ross-Loos Medical Group of Los Angeles, California, and Trinity Hospital of Little Rock, Arkansas, are analyzed as representing the two outstanding proprietary group health 164 associations functioning in the United States of America, at the present time. ROSS-LOOS MEDICAL GROUP Probably the Ross-Loos Medical Group isi representative of the best known type of proprietary group health plan. It was founded on April 1, 1929, in Los Angeles to render medical service to the employees of the Los Angeles Bureau of Water and Power. Since its origin it has grown prodigiously and today the employees of approximately one hundred and twenty organizations have subscribed to this medical group. The Police and Fire. Departments, school teachers, and many large industrial corporations have availed themselves of the facil ities provided by Ross-Loos Medical Group. The following types of medical services are offered by this health group; blood counts, hemoglobin determinations, blood typings, bleeding and coagulation tests, blood chemistry, icteric indices, Wassermann and Kahn tests, and a variety of sedimentation tests. Besides the foregoing a number of bacter iological and microscopic tests have been given, such as sputum examinations, spinal fluid tests, general cultures, animal inoculations for tubercle bacilli, examination of 165 smears, and dark examination.^ Facilities for X-ray examinations are numerous as may be noted by the following list; fluoroscopic, pyelographic, gastro-intestinal series, gall bladder visualizations, barium enemas, pelvimetry measurements, and flat plates for fractures. Principal physiotherapy treatments obtainable were; diathermy, short wave therapy, galvanic therapy, surgical sinusoidal wave, quartz light, ultra-violet light, infra-red light, manual massage, and manipulations. In addition, patients are supplied with prescribed drugs and dressings at no extra cost.^ Thus far no group health association has found it feasible to offer complete and unqualified medical treatment, and Ross- Loos Medical Group is not an exception to this general rule. The following statement particularizes the specific services excluded : Materials, procedures, or hospitalization ordered by an outside doctor, special nursing care, sick room furni ture, crutches, wheel chairs, orthopedic appliances, eye glasses, blood for transfusions, hypodermic injections, radium, deep X-ray therapy, vitamin therapy, medication and prophylaxis for venereal diseases, mental diseases, alcoholism, drug addictions or conditions arising from, and sanatorium or rest home treatment.3 ^From a pamphlet published by the Ross-Loos Medical Group titled. Information for Subscribers to the Ross-Loos Medical Group. ^Loo. pit. ®Loc. cit. 166 Injuries and accidents sustained as a result of employ ment conditions fall into a second classification exempted from medical aid under the Ross-Loos Medical Group* This regulation is applied to cases which receive remuneration under the California Workmen's Compensation Act* It is natural that the health group should not he held accountable for injuries occurring because of insufficient or inadequate pre cautions or negligence on the part of private industrial enterprises* As a matter of fact, for health groups to assume such responsibility might, in effect, encourage more care lessness and less stringent methods for accident control on the part of a few corporations* It is probable that some employers have instituted accident insurance largely because it is less expensive than lawsuits and full payment of work men's accidents* Such employers might utilize a health group as a means to avoid their own responsbilities toward employees. Then, too, the second exemption avoids duplication in payment. A patient who receives aid from the health group should not be recompensed at the same time under the legal stipulations of the Workmen's Compensation Act, and conversely, recipients of aid under the Workmen's Compensation Act should not receive payment or medication at the expense of the Ross-Loos Medical Group or any other medical organization 167 Since the Ross-Loos Medical Group does not maintain and operate a hospital of its own, patient-subscribers are permitted to make their own selection of a suitable hospital. The health group has made arrangements with a number of hospitals in the Los Angeles County area which make their facilities available to subscribers of the Ross-Loos Medical Group. It has been found more practicable and feasible, how ever, for the group health association to restrict hospitaliz ation as much as possible to the Queen of Angeles Hospital, where an average of about 100 beds are permanently occupied# The average monthly cost of hospitalization per subscriber to the health group is approximately 22 cents, or about two-thirds of a cent a day.^ During periods of illness a subscriber to this health organization is eligible to a ward bed or a private room for semi-contagious diseases for a period of not over ninety days in any period of twelve consecutive months# Some of the specific hospital services provided are the following: •••General nursing. X-ray examinations, laboratory tests, operating rooms, medical and surgical supplies, special diet, meals, anesthetics, electro-cardiograms, physio therapy treatments, hypodermic therapy, oxygen service, drugs, dressings, laboratory examinations and all other adjuncts customarily given in ordinary hospital procedure#^ %Ienry E# Sigerist, Newspaper P M, September 30,1940# ^Information for Subscribers to the Ross-Loos Medical Group# 168 Subaeribers who join with a group are charged a fee of$2.60 individually per month, or $30.00 a year.^ A person not belonging to a group, but eligible for membership is permitted to enroll on an individual basis at a rate of $3.00 a month. Dependents of subscribers pay considerably less in terms of fees than are customarily charged under fee-for- service medical care, i.e., office calls for dependents are 50 cents, home calls $1.00, minor operations not more than $12.50, major operations $25.00, confinement cases, including prenatal and postnatal care $20.00. It was found that the average cost per dependent family under the Ross-Loos Medical Group was 66 cents a month. Thus, in 1940, $37.92 a year paid the cost of medical care for a subscriber and his dependent 7 family members. Although dental care is not incorporated in the $2.50 monthly fee,» subscribers receive dental services at reduced rates by a group of competent dentists practicing in the Ross-Loos Medical Group building. Because these dentists have to pay only their office rent in the Ross-Loos Medical Group, they are able to offer dental services at lower rates. A carefully worked out schedule of dental fees is used in estimating the probable cost of dental services to the sub- ^Gorrespondence with H.C.L., February 4,1941, an official of Ross-Loos Medical Group. 7 Henry E. Sigerist, Newspaper jP M, October 4, 1940. 169 acriber before any dental work is undertaken. This health group permits the payment of dental bills by small monthly post installments. Unfortunately, there is no insurance against the "big dental bill." The scientific equipment and facilities of the Medical Group are owned by Doctors Donald E. Ross and Clifford Loos and sixteen senior physicians or co-partners. The remaining medical doctors are appointed on a salary basis ranging from o $3,600 to $10,000 annually. In addition to their regular salaries these physicians receive a bonus at the end of the fiscal year, and after a tenure of three years participate in a certain portion of the profits of the health organi- Q zation.^ It is, of course, manifest that physicians employed by this group health association are freed from the usual financial worries connected with traditional private medicine. Concerning the caliber of physician hired by Ross-Loos Medical Group, it might be said that "a high standard of train ing and experience is demanded by this group health plan. The Medical Group consists of ninety-six full, time physicians who represent the principal fields of medicine and surgery. In unusual cases, specialists from outside the group are called 9 Correspondence with H.C.L., August, 1941, an official of Ross-Loos Medical Group. 170 In for consultation and to give treatment. Doctor Henry Sigerist, Professor of the History of Medicine at Johns Hopkins Hniversity, has remarked: "Dr. Loos likes to appoint young doctors who may grow in the service. For general medicine the requirement is that a candidate has graduated R from a Gràde^medical school, that he has had at least two years of hospital experience as an interne and resident and that the time elapsed since his graduation does not exceed »10 seven years." Some of the conservative private physicians have suggested that the health group hires young physicians because they will work for less than older physicians. How ever, it would seem that the salaries paid by Ross-Loos Medical Group would tend to offset this criticism. On July 1, 1940, Ross-Loos Medical Group had approxi mately 24,500 subscribers of which 1300 were not members of occupational groups. The number of members and dependents served by this health group was about 75,000 potential patients. The main office is housed in an attractive four story building on 1135 Wilshire Boulevard, Los Angeles, California. As this health group developed, an ecological problem became evident, namely the scattering of members throughout the area of Los Angeles County. Branch health offices have been established in the following satellite ^%enry E. Sigerist, Newspaper P M, September 30,1940 171 communities of Los Angeles£ Alhambra, Belvedere, Inglewood, Long Beach, Pasadena, Pomona, San Pedro, Santa Monica, Van Nuys, Whittier# Associated offices of Ross-Loos Medical Group are located at the more distant communities of Lone Pine, Bishop, Independence, Victorville, and Mojave. Probably the most serious difficulty met by this health group has been forceful opposition expressed indirect ly by the American Medical Association and expressed directly by the Los Angeles County Medical Society. In 1934, Doctor Ross and Loos were expelled from the Los Angeles County Medical Society on the a.lleged charge of attempting to solicit patients, a practice the American Medical Association has decreed to be "unethical." Many of the subscribers to the health group became much irritated and the following remark of a professor in the University of Southern California some what generalizes the picture: "You asked me how the action of the Los Angeles County Medical Society in expelling Ross and Loos from membership has affected us. Not at all, thus far; but if the medical society should succeed in keeping Ross and Loos out of Los Angeles hospitals, then it means a fight.After a great deal of bitter debate and contro versy the American Medical Association reversed the decision --------- TT-------------- Cited by James Rorty, op. cit., p. 262. In this connection see also The Ross-Loos Clinic by H.U#M. Higgins, Pamphlet No. 2, March, 1936, Civil Service Assembly, pp. 15-20. 172 of the Los Angeles County Medical Society and thus re instated Doctors Ross and Loos to full membership with the Los Angeles County Medical Society. During the year 1934 the American Medical Association was not an ardent advocate of applying the insurance principle to matters of health. A second obstacle surmounted by the Ross-Loos Medical Group has been to extend the benefits of group medical practice and facilities to individuals who were not eligible to join formerly because they did not belong to a group which had subscribed. There were more than 1,300 individual sub scribers to this health group in 1941. An individual may join this group, but he is asked to pay a slightly higher monthly premium than a group member. The inclusion of dependents of subscribers to the benefits of the health group may be defined as a third difficulty successfully solved. During the initial develop mental stages of the health group an attempt was made to pro vide medical services to all the family members of a sub scriber for only $18.00 a year. It was soon discovered that it was impossible to offer health services at this fee be cause a number of the dependents were abusing the privileges 12 of dependent-subscriber. It has been found economically ^^A number of group health associations have realized that the cost per individual varies with the sex of the individual. Ross-Loos Medical Group is made up principally of male sub scribers and female dependents ; hence, the cost of medical care had to be increased. Goodyear Relief Association had same problem. 173 feasible to enroll all the members of a subscriber's family by raising the monthly fee to $2.50 or $30.00 a year, with an additional charge of fifty cents for each office call made by a dependent. By providing a sound economic basis for the health services available to dependents as well as sub scribers, more than 50,000 dependents have had the opportunity to have adequate medical service at a cost within the reach of the low-income middle class. Through the creation of a number of branch offices, the Ross-Loos Medical Group has solved an ecological and transportation problem which resulted from the great distances between community centers of population within Southern Calif ornia, especially within the area of Los Angeles County. A fifth problem has been solved through the annual expansion necessary due to the increasing number of sub scribers. Both the scientific equipment and professional personnel have been enlarged annually. In other words, the health group has been able to adjust to the steady increase of members. Let us turn to an analysis of attitudes and reactions of typical members to Ross-Loos Medical Group. These attitudes will disclose what members like and dislike about this ^proprietary gi^oup health association. In the following case with a faculty member of the 174 University of Southern California the reasons why he feels positively toward the health group are stated: I like the Ross-Loos Clinic because 1 can get any kind of service any time free. I repeat, any kind any time, and that is a lot. Two dollars a month payment is merely nominal when compared with what this regular medical service would cost me. My wife likes it so well that she has taken out a separate membership. The free part, the fact that you can go in any time, is one of the most valuable aspects. It means that you don*t wait until you are too ill. It, the plan, plays a big part in the prevention of illness. I like it because I can call on any of seventy or eighty physicians. Yes, I use the same ones and have three or four * family physicians* in as many different specialties, instead of just one jack-of-all practices type of family physician. I like it because they maintain a twenty-four hour service. You can go there day or night and get help. Or you can phone any time, and they always reply. They come to the house and don* t charge me a cent.^^ The above case reveals that the member’s favorable attitudes are partly due to the wide range of medical services offered and the subscriber’s choice of group physician. An employee subscriber of the Southern California Gas Corporation relates how his slightly favorable attitudes shifted to definitely favorable attitudes toward Ross-Aoos Medical Croup: I joined the Ross-Loos Group for the special purpose of getting my wife’s foot treated. My wife had been Interview with E*0> 175 bothered for a long time with her right foot and has been doctoring it for many years without any improve ment* Well, just about a year ago Ï took her to a private practitioner to have her foot examined, and the doctor suggested an X-Ray which, by the way, cost me $7*50* After examining the X-ray picture, the doctor said that a bone had to be removed from the right foot. I asked him what he would charge for the operation and how long my wife would have to remain in the hospital. The doctor said his fee would be at le as tf 150. and that my wife would have to remain in the hospital for at least five weeks and it would cost around $70. for hospitalization. At that time I could not stand that much expense so I put it off for a while and hoped totake care of it at a later date. A short time after that the boys at the Gas Works were forming a group to join Ross-Loos, and I joined to see if I could get my wife’s foot treated through this new medical group. I’ll admit that at first I was a little skeptical of the medical doctors employed by the plan. I took my wife to see Doctor H of the Ross-Loos Medical Group, after I had been a member for several months. He is the bone specialist for the group. He suggested an X-ray which cost only $3.50 and after examining the photo he said that there was nothing wrong with the bone in her foot, but that one of the ligaments in her foot near the small toe was shrunlc and was pulling the entire foot to one side and that was causing the pain and discomfort. Doctor H said that the ligament had to be cut before the foot could be of much use. I asked him how much such an operation would cost. Doctor H said it would cost around $12.50, and that there was no need for hospitalization. He performed the operation and placed a splint on her foot after wards. In less than ten days my wife was walking around again as if there never had been anything the matter with her foot. These non-group doctors cannot be trusted for they want to operate just to get your money. I now have complete confidence in both the # 176 skill and honesty of the physicians hired by Ross-Loos. Every time I have had to visit the Ross-Loos Clinic I have been satisfied. The foregoing ease suggests that perhaps a few people join this health group in order to have some pre-existing condition treated. Another observation may be that once members have become convinced of the value of health group physicians, they may find it very difficult to trust fee-for-service physicians. A few members of this group who have moved to another area in California not served by Ross-Loos Medical croup have remarked that they found it a problem to place confidence in the diagnosis of a private physician inasmuch as he charges a fee for his professional services. An employee of the Los Angeles School System explains that he joined this health group to have an operation taken care of because of the reduced fees : As I’ve told you, I joined this health plan mainly because of the operation which I needed. When the condition got so bad that I had to have the operation done, I didn’t have enough confidence in any of the group doctors. The medical doctors told me that it was a very serious operation for I had what they called ’tumors of the pancreas.’ DootorRoss volunteered to perform the technical operation himself, but I didn’t have sufficient confidence in his ability in this particular case. I insisted on a private physician. The thing that has amazed me is that the health group is going to share the expense of this operation. I ^ Interview with H.D. submitted by J.P.L. 177 know that Ross-Loos do not have to do this under terms of our agreement. This sort of thing makes for confid ence in the entire plan. What more could I askt They have a new convert in me and when I have ordinary ills 1 shall feel complotely free to have them treated there. It will be noted in a later part of this chapter that some group health members seem to lose confidence in the ability of Ross-Loos physicians in very serious cases. However, the Ross-Loos Medical Group is meeting this problem quite intel ligently. A health group member may select his physician and a certain percentage of the cost will be shared by the health group. Any lack of confidence in the specialists of Ross-Loos Medical Group is being checked, at least partially, by an overt willingness to cooperate with the health group member in the procurement of a physician who is able to inspire confidence in unusual cases. A teacher in the Los Angeles City Schools points out the confidence she has in the diagnosis of Ross-Loos Medical Group as follows ; One of the greatest satisfactions I have in beirg a member of the Ross-Loos Group is that I am not told I hai^e some serious illness which I do not have. X have had doctors, before I became a group member, tell me X had some very serious illness and needed a long and expensive course of medical treatment, when there was only a slight ailment. Our group doctors have nothing to gain financially by telling us falsehoods about our health. 15 Interview with M.B. 178 We teachers have been victims too frequently of the greed of private physicians. In the following interview with a police officer of Los Angeles it is noted that there are advantages in locating branch offices throughout the satellite communities of Los Angeles and the reasonable cost of services compared with fee-for-service medicine. Special attention is called to the fact that this interviewee feels that health group physicians have no ulterior motive in diagnosing a case. He says : I like the reasonable fees charged on a monthly basis for it is a cheap insurance against large doctor bills in the case of an expensive illness. I also like the fact that we have a local branch in my community. The fees charged dependents is certainly cheap enough. I am certain that I would keep my membership in this health clinic even if they raised the fees considerably. I guess some of my admiration for the group results from experiences which my wife and I have had. My wife has suffered from sinus trouble for the past fifteen years. I have bills in my possession that total a sum of $1,185 which I have paid to different doctors and with no satisfactory results. Since joining the Ross-Loos group I have paid $12.50 which included doctors* fees and medicine during the last year and I have noticed marked improvement in my wife’s condition. My wife is breathing through her nose now for the first in* fourteen years. However, she is not entirely cured and will need to continue treatment for a little while yet. I suffered from hemorrhoids for the past five years and paid out $285 to have them treated by se-called specialists. ^^prom expressionnaire of I.P. 179 The condition never was cured and would return after a lapse of six to eight months. I believe that these other private doctors intentionally prolong illness so that they can get more money out of you. Another thing I like about Ross-Loos is that the brands of drugs used are by nationnally known and recognized organizations such as Lily Brand and Upjohn Products. I haven’t changed doctors since belonging to the organi zation. It seems to me that the more friendly doctors are located in the branch offices, but the most skilled physicians are to be found in the central off ice. The satisfaction of the wish for security as it relates to the purchase of medical care is well stated in the following case of a college professors I have belonged continuously for about eight years to the Ross-Loos clinic. It costs me more than I get out of it in the way of services, but that is because we are a well family. No, it doesn’t cost me more than I receive, for I have had health protection, a sense of security and have been insured against sickness* And when we have been sick, I have had not big bills coming in, and that is a big boon. It is a big saving as a matter of fact. Before we joined, my wife had her tonsils out and her private physician gave us half rates because I am with the University or $30* Then I had mine out by a private physician and gave me half rate at $25. Then we joined Ross-Loos Medical Group and our son had his tonsils removed by Ross-Loos and it cost us $7. See the difference? As far as we could discover, our son had the best job done, too.18 It was the reasonable rate of fees and professional skill of Ross-Loos Medical Group physicians that were basic in fostering favorable attitudes toward the health plan. Interview with H.K* 1Ô Interview with R.B. 180 A dependent employee of the Southern California Bell Telephone company admits attitudes of appreciation which were, the result of the special attention she received as a patient. She notes: As you know the Telephone Company was one of the first groups to take advantage of the opportunities of group medical practices. It was necessary for me to undergo a operation. Doctor Donald Ross, one of the founders of the organization was my surgion in this case. He is perhaps one of the outstanding surgeons on the Pacific Coast. He was splendid to me. Even though he was busy, very busy, he never missed a day at the hospital but what he came in to say a few cheering words and to check on my condition. I had formerly thought that one was more or less just rushed through the mill, but my mind was changed on this completely. Most of the private doctors knock the Ross-Loos plan because they cannot or will not offer medical services for such nominal charges.19 The importance of overtures of friendliness which group physicians extend to patients tends to shorten social distance existing between physician-patient. It can hardly be overemphasized that gestures of friendliness between physician and patient promote confidence in the health group. A summary statement of features members like about Ross- Loos Medical Group may be observed in the following interview: Personally: my membership in the health group has been at all times satisfactory. I have been ill, and was cared for in the hospital. I have had a major operation and it was successful* I had an emergency operation for appendicitis for my young daughter and it was timely and successful. Interview with K.L# 181 The attitude of the nurses Is so kindly and at all times they make me feel that my health is a very personal consideration* As I have been in this health group a good many years, I have had contact with a large number of physicians. I have always found them fine, professional and considerate. I consider a membership in a health group one of the finest advantages we have. In fact, it has meant more to me and my family than I can adequately express#BO Not all the members interviewed expressed complete satisfaction with the Ross-Loos Medical Group. However, many of the criticisms were offered as suggestions for improvement of the services and facilities of the health group. One of the most serious criticisms raised seems to indicate that in acute cases subscribers may lose confidence in the group health doctors. This situation is well noted in the following case : When I hurt my finger they put a special apparatus on my arm and my finger started to turn black. X consulted a private physician when I got scared, and he too off the appartus and helped me out, but he charged me seventy dollars, No, I didn’t go to Ross-Loos when my finger turned black. If I had done so, they would have fixed me up for no thing In the following interview not only is a lack of con fidence in the health group uncovered,but also a criticism of the organizational set up of the Ross-Loos Medical Group: My first experience with Ross-Loos Medical Group was when I met Doctor G. I stated the nature of my illness and before he had given me a thorough physical examination he suggested a bladder irrigation. I was so dissatisfied with the inter view that I proceeded to look up a specialist in the group on nerves. It was the desk clerk who said that Doctor H ^^Interview with S.K. ^^Interview with E.O. 182 was the nerve specialist for the Ross-Loos Clinic# Doctor H did not examine me, hut merely listened to what I had to say, and then he prescribed some medicine# However, he did not examine me, as I.’>ve said, nor did he suggest at that time that I be examined by a doctor of the group* About a month later he suggested that I be examined by Doctor 0 when he learned that the medicine he had prescribed failed to help me# Doctor H made the appointment for the examination with Doctor 0 but was not present during the course of the examination# Whatever conversation they had was by telephone, and Doctor H told me to continue to take the same medicine that he had prescribed at the outset even though it did me no good# When my condition did not improve Doctor H again made an appointment for an examination with Doctor R and Doctor R made his report to Doctor H* Apparently Doctor R 861 id that there was nothing wrong with me because Doctor H told me to continue to take the same medicine. The failure to change medicine and treatment when the patient showed no sign of improvement appeared to me to be very unusual. I continued to take the medicine regularly for about seven months, and my condition was becoming worse all the time, and in the final analysis I stopped going to Doctor H for treatment and sought out a private practitioner for relief. I lost my faith and confidence in Ross-Loos doctors more because of their methods than their lack of professional skill. 1 found Doctor H of Ross-Loos to be a very friendly man who was quite attentive and interested in the case, at least at first. However, Doctor H did not seem very able as a physician. Doctor G and also Doctor 0 were very unfriendly and did not want to listen to what I had to say during the course of their respective examinations of me. I lost confidence when they seemed disinterested in my problem* How, I found Doctor R to be very domineering and irritable, although he seemed to be a very intelligent and efficient doctor* As a whole, for me, Ross-Loos Clinic is almost as expensive to a dependent for calls to the office, as are 183 calls to the office of a private practitioner. The fee charged at the Ross-Loos entitles the patient to an exam ination and nothingmore. Anything else that is done must De paid for extra, and usually the office call to a private practitioner includes all ailments treated for the one call. Let me give you an illustration. A call to Ross-Loos for an injection of vitamin B1 is fifty cents for admittance and $1.65 for the injection, or a total of $2.15. An office call to a private practitioner is $3.00 in most cases, and the charge includes the injection of vitamin Bl, and there are no general monthly fees. The method of operation of the organization could he improved by having a doctor or a group of doctors if necessary to give each patient a complete physical examination, and get a case history on record. It should then be the duty of the examining physician to assign the patient to the proper doctor for treatment, and the doctor to whom the case is assigned will have something to work on instead of going about in a hit or miss manner. There must be doctors in that organ ization that could help me if I only knew who they were and where to find them. I got tired going from one doctor to another for I thought that they were passing the buck, so to speak. The foregoing case discloses that the organizational set up of Ross-Loos Medical Group might be improved by forming a bureau to help direct subscribers to group physicians with specialized training and ability. Perhaps some type of 22 Interview with R.M. It should be remarked in all fairness to Ross-Loos Medical Group that a follow up study of this ease reveals that the patient is not completely satisfied with the treatment that she is receiving from her former family physician. She seems to have more confidence in him but claims that the expense is very great. There is some evidence that she may return to Ross-Loos and search for a physician that will instill confidence. A sympathetic physician with skill is the combination she hopes to find. 184 , generalized physical examination would facilitate the propér assignment of the patient. Lay members, especially new mem bers, need some person closely associated with the scientific resources and personnel to serve in the capacity as a health group g^ide. It is the utilization of the resources of a . ■ : modern health group that determines to a large extent its social and medical effectiveness. The proper assignment of subscriber to the medical resources of the health group would be an important factor in creating attitudes of satisfaction and lessening social distance between the subscriber and health group. In the following case the interviewee makes seme original suggestions for improvement that are worth noting: The old family doctor idea is lost. They need to assign every patient, yes, every member who comes in, to an adviser who will follow through with you from one specialist to another. I was sent from one doctor to another until I came to the orthopedist and he took personal interest in me, and continued to do so. They need to publish a list of their specialists so one could see who they were and what their training has been, just as colleges and universities do regarding their faculty members. Then they need to establish an Advisor system. They are all right if you know what is the matter yvith you, but if you do not, they are not helpful; hence advisors are needed badly. I understand that they send out to homes their lesser staff members. We have had two, and one didn’t act the part of a doctor at all. One did. One diagnosed my case all wrong, just jumped to conclusions which were very bad for me, but not correct as later events showed. 185 They do not treat you as a whole patient hut each sees you as a foot or an arm or a lung or a tooth or an earache. That personal touch and adviser and general consultant idea is missing. I insist that the theory is correct. If you have to have a thousand dollar operation the cost is dis tributed over many people and over many years of. your life. But the trouble is in the administration. The above case suggests that a list of the names of the physicians and their training and experience might facilitate the patient in selecting the right medical doctor. An advisory system of assignment in conjuncture with a roster of available physicians would serve to bring about a better social and medical Combination of patient-physician relationship. A good deal of social farness between subscriber and health group is due to the fact that some of the physicians do not seem very friendly and considerate of members. While thisppoint has been suggested in a few foregoing interviews, the following case focuses attention on this problem rather specifically: The ’professional attitude’ of the Ross-Loos doctors is definitely more formal and less friendly than that of private physicians. One feels that one is just a ’case’ whom the doctor does not even remember from time to time. There is an impersonal attitude and lack of interest on the part of the doctors unless one has a long illness or a very unusual one. 'Even then, the doctors make no overtures to the patients such as ’let me know how you are getting along’ or ’be sure to phone if you have any questions.’ In other P'Z Interview with C.D. 186 words, it’s up to the patient. It would really he difficult for the doctors to remember the facts about each patient or to spend unnecessary time in making the friendly over tures private physicians so often practice to gain the con fidence and cooperation of the patient. At first this attitude is disconcerting, but when one realizes these facts, ponders over the advantages of an organization such as Ross-Loos, and becomes willing to assume the initiative, the relationship becomes satisfactory.24 Perhaps gestures and deedsr of friendliness and interest by health group physicians Y/ould do much to promote socio-medical rapport between patient-physician relationships. It is un fortunate for this health group that a few of its physicians are not more aware of the importance of obtaining the patient’s confidence. These few thoughtless physicians of the health group make it appear as if all the Ross-Loos physicians are disinterested in their patients. The particularistic error is likely to interfere with rational attitudes toward the health group, on the part of lay members. A criticism is offered frequently by lay members of Ross-Loos Medical Group that the health plan is developing too fast. There are far too many members in Ross-Loos Clinic for the number of doctors. That is why a person has to wait so long before getting to see your doctor. Also they are rushed a lot because they seem to have so much to do for so many patients. If you ask me the clinic is having a bad case of ’growing pains.’ I think that the organization could also stand more equipment in the branch office imàiich make visits to the main office on Wilshire less necessary than is the ease at present. I hate to wait around in a ^^Interview with LJG 187 doctor’s office, What a waste of time, Hovfever, I must add that I’ve had to wait even for private physicians be fore I joined up with R o s s - L o o s,25 It is apparently not clear to all the health group members that there is an economic saving in pooling costly medical equipment in a centrally located office. As far as the health group is concerned, it will probably have to become considerably larger before each branch office can be fully equipped with certain expensive scientific apparatus* "Seems to me that the doctors at Ross-Loos want to do all the questioning about a member’s illness. The moment you ask questions about your illness the doctors get irritated and act as if to answer the question would only baffle the patient*Another subscriber interviewed pointed out the "annoyance reaction" in the following manner: I’ve noticed ’annoyance reaction’ on the part of physicians but not particularly toward cases of repeated visitations for very minor illnesses. We have a hypochon driac and he is always running to the doctors for the treatment of his imagined illness. The doctors treat him as a joke and practically all of them at the local branch office know him by his first name now* However, annoyance is caused by the questioning of symptoms of illness, after effects, and so on. Doctors are seldom rude, and will answer questions politely. But they are reluctant to volunteer Interview with T.L. It should be remembered that many othertinterviewee8 claimed that if a previous appointments were made they experienced little delay in seeing the doctor. PA Interview with A.M# 188 Information and at times do seem annoyed at too persistent questioning.27 The lack of consumer control is a conspicuous criticism against Ross-Loos. The group health association is administered and controlled by the producers, the medical doctors. In the following letter which was distributed to all Ross-Loos members it is not clear what the specific factors are that have made it necessary to raise the cost of membership dues. In order to influence subscribers into accepting the new premiums the alternative of a physical examination and an agreement with this health group on an individual basis. The notice is as follows: ROSS LOOS MEDICAL GROUP 1555 Wilshire Blvd. Los Angeles,California April 1, 1941 NOTICE TO ALL ROSS LOOS MEMBERS: In view of the fact that rising costs and various other factors have made it impossible for us to continue rendering the service to your group at the price of $2.00 per sub scriber per month, we regret to state that it is necessary to raise your prémium to $2.50 per subscriber per month. We feel sure that you and your subscribers will understand P7 Interview with R.D. Perhaps the irritation which Ross- Loos physicians expressed may be merely an occupational attitude common to most physicians. However, such an idea does not rule out the possibility of new occupational attitudes originating from group health association practice. 189 our reasons for having to make this adjustment. We are submitting three options for your consideration to accomplish this. 1. Providing 75^ of your subscribers are willing to accept this adjustment prior to the first day of May, 1941, the new rate will become effective On that date and n such subscribers as have expressed their willingness for the change may continue without physical examination and there will be no interruption whatsoever in their continuous subscription 2. Should less thean 76^ of your subscribers be willing to accept this adjustment, then, in accordance with the terms of our Agreement, the Agreement becomes null and void ninety(90) days thereafter, or will have the official starting time of April 1,1941, and which will terminate the Agreement ninety(90) days thereafter, or July 1,1941, and in order to renew the contract under such conditions at that time, July 1, 1941, it will be necessary to enter into a new agreement, at which time all subscribers must pass a satisfactory physical examination before acceptance and the rate at that time will be $2.50 per month. 3. If in the event a sufficient of your members do not qualify under the first two options aforementioned, then those of your subscribers who may qualify can continue as individual subscribers at the rate of $5.00 per month after passing a satisfactory physical examination, and in such an instance there is no agreement entered into between the group and ourselves. While we are leaving these proposed options entirely to your selection we suggest that Option Ho. 1 will probably be the more satisfactory to all concerned because if this is the option selected it will only be necessary to complete an addendum to your present Agreement and there will be no need for the more complicated procedures of signing new agreements and physical examinations for the subscribers, and there would be no interruption in the continuity of . service, which break might be a hardship for some Qf your 190 subscribers who are at present under treatment. ( SIGHED) H* Clifford Loos M.D. MEMBERS ; IT IS ABSOLUTELY NECESSARY THAT YOU CONTACT YOUR COLLECTOR BEFORE APRIL 15 REGARDING THIS MATTER. About the only power the health, group members had was in the selection of the three options set forth by the physicians of this health group. Salary members incomes have not been raised sufficiently to pay the fee increase. If the consumers had control of the administrative set up of the group health association, they could adjust the cost of service by mutual ly considering the needs and assets of producers(physicians) and consumers(subscribers). It would appear that the ad ministrative officers of this health group could terminate medical services for the 75,000 subscribers and dependents with only ninety days notice. 'Probably the greatest weakness in the proprietary group health association is that both medical and administrative control and policy are limited physicians. It might be suggested that this limited control by physicians is slightly undemocratic. The following case serves as a summary statement of the benefits of membership in the Ross-Loos Medical Group: The employées of the Southern California Gas Corporation are almost unanimously appreciative of the benefits of belonging to Ross-Loos. Many of them are laborers who, before joining Ross-Loos, had to neglect themselves and their families in health matters or go into debt to 191 receive proper care# To these men, the minor in conveniences of group medicine as practiced by Ross-Loos are not worthy of consideration. That they or their families sometimes are obliged to wait a while before receiving treatment, does not seem to concern them, nor do they seem to object to professional formality on the part of the Group doctors. These people are not wealthy enough to afford to be hypochondriacs, and medical care, even of a formalistic nature, is preferable to no care. Some of the men are a little more critical of the medical group, but not enough to drop membership! Pro bably some of them miss the ’my doctor’ attitude encouraged by the private practitioner, but I have heard no adverse criticisms of the quality of service administered by the Ross-Loos doctors. The feeling of security they have in health group may compensate for any lack which the health group may have. I have noticed an improved efficiency on the part of some of the ’chronic cold sufferers’ in our employ #10 are benefiting from the preventive type of medi care practiced by the Ross-Loos Medical G r o u p . 28 TRINITY HOSPITAL AT LITTLE ROCK, ARKANSAS A second example of proprietary group health association is represented by Trinity Hospital of Little*Rock, Arkansas. This health group was first organized in September, 1931, and offered medical and hospital services to employed groups and individuals on a voluntary health insurance plan. Subscribers to Trinity Hospital receive the following types of medical services at the hospital at no additional ex pense: diagnosis, treatment, laboratory and clinical tests. 28 Interview with J.L. 198 . X^ray examinations and treatments, radium treatments, surgical operations, professionul consultations, and immunization against smallpox, typhoid, diphtheria hy the medical personnel of the hospital# Patients confined in the hospital are given prescriptions and ordinary medicines at no additional cost.^^ Medical care and services are not given outside the hospital unless the member pays an additional fee. Physicians connected with Trinity Hospital are available for day calls within the corporate limits of the cities of Little Rock and North Little Rock and charge a two dollar fee. The fee for night calls is four dollars. Hospitalization and medical services have not been given to subscribers who had adverse physical conditions which existed at the time of enrollment, except in acute con ditions needing immediate attention. Hospitalization and medical care are not provided for subscribers who purposely self-inflicted an injury. Five medical services not provided are : visional, mental, dental, alcoholic, and venereal diseases. Dental care has been a problem in almost all health groups, and Trinity Hospital has been no exception. Maternity care is not given until ten months elapses since the date enrollment. Subscribers are given all necessary nursing care by ^^Gited in Agreement for Annual Medical Services with Trinity Hospital, Little Rock, Arkansas. 193 granate nurses, nursing supervision, use of operating room, anesthesia, surgical dressings, and routine laboratory tests* A subscriber is permitted to have an associate room, two- bed room, for a period of six weeks in any one year* Diets are provided for all hospitalized cases* The foregoing hospitalization is subject to a few limitations as follows: (1) cases which call for special or private nurses, (2) cases which the hospital is not equipped to take care of and which it does not under ordinary circumstances accept* Such cases as pulmonary tuberculosis, marked mental or nervous disorders, drug addictions, diseases quarantinable by the city, or state authorities are excluded from treatment in Trinity Hospital. It is clear that a relatively small hospital, fifty beds with ten physicians, cannot take care of rather infrequent and dangerous health services. Hospitalization is granted only to patients who are under medical care of physicians employed by Trinity Hospital. The necessity and termination of hospitalization services are determined by the physician in charge and his decision is final. Hence, it is not possible for a patient to determine the need for hospitalization and termination of his case. However, group health associations, whether laymen or physician controlled, have designated the physician as arbitrator of all medical questions. 194 If a patient desires special room accommodations other than an associated room, he is asked to pay weekly, in advance, the difference between the associate room rate, $3.00 per day, and the rate for such accommodations as he might select. A subscriber who joins on an individual basis is charged a monthly fee of $2.50 payable quarterly in advance. Individuals with dependents* including wife and all dependent minor children, are charged $6.00 per month in advance# Prepayments of medi cal dues six months in advance are given a 5^ discount ; while 10% discount' is made for a year * s prepayment of membership dues. A subscriber who joins Trinity Hospital as a member of a group is charged $2.00 per month and $4.50 for his family members. This health group has encouraged the prepayment of members* periodic dues. A lay manager is the clerical administrator of this proprietary health group. He is paid on a salary basis and receives in addition a percentage of the net earnings of the hospital from all sources. The ten physicians are part owners of the hospital -which is incorporated in the State of Delaware as a proprietary institution. Graduate nurses are employed this health association. No dental personnel is available to subscribers of this health plan, but this is not an exception to the general practice of group health associations. An official of this proprietary group believes that it 195 has met successfully the problem of coordination of medical facilities. He says: • .Professionally, we have been successful in coordinating a medical and surgical staff, and diagnostic and hospital facilities into a service unit, operating 30 ' with a minimum of waste of effort, time, and money.** From the standpoint of the subscriber he remarks: **We have made available to our subscribers complete medical, surgical and hospital services at prices that the low income groups can afford to pay, and at the same time have kept the plan actuarially sound and have given the physicians an adequate 31 income.** Several group health associations have almost failed because the economic structure of the institution was not sound. Almost since its inception Trinity Hospital has been under fire of the American Medical Association. The tactics or organized medicine have been instrumental in putting pressure upon the local county medical society of Little Hock, Arkansas. Because of the crystallized or conservative ethics of the American Medical Association and the **pressure tactics” it employs, all physicians connected with Trinity Hospital resigned as an organized protest. The recent decision in Judge Proctor*s ^^Correspondence with O.D.M, Trinity Hospital, Little Rock, Arkansas, January 31, 1941. 196 District Court of the District of Columbia, in which the American Medical Association was found guilty of violating the Sherman Anti-trust Laws, had the effect of lessening the organized opposition of the American Medical Association. Another contemporary problem which this health group has encountered is the education of its subscribers to the ad vantages of preventive medicine#^^ Probably a third problem, common to most group health associations, is the inability to secure dental services on a periodic basis under the health plan.^^ Review of chapter. In this summary statement attention is focused on the Ross-Loos Medical Group more than Trinity Hospital, for obvious reasons. 1. Proprietary group health associations exepipt from service about the same conditions cooperative group health associations do : care recommended by an outside doctor, treat ment of venereal diseases, mental conditions, alcoholism, drug addiction, and physical conditions which existed previous to the date of enrollment in the plan. 33Attention is called to two other proprietary group health associations functioning in the United States. (l)Franlc M. Close, M.D. and Staff of San Francisco, California has offered to its subscribers medical, surgical, and hospitalization services. Dependents receive medical and surgical care at industrial rates. (2) Milwaukee Medical Center of Milwaukee, Wisconsin was organixed in 1936. It offers rather complete medical and surgical services. 19^ 2* Proprietary group health associations have been the recipients of the organized opposition of the American Medical Association as have cooperative health groups. Local county medical societies have used the same tactics of social control and coercion, and have threatened hospitals that if they permitted any physician "not in good standing with his local medical society" to have hospital privileges the name of that hospital would not be included on its roster of approved hospitals, 3. The lack of cooperative or democratic control of proprietary group health associations is a conspicuous problem. Subscribers to these proprietary health groups are not given a voice in the control of policy. Pees and policies have been changed without the subscriber's approval. The only pressure the subscriber can exert is to drop out of the organization. However, subscribers have been willing to accept changes in policies and fees not because they agreed with them, but be cause health care under the traditional fee-for-service type of medical care though more costly was inferior than that offered by group health associations. In other words, in the minds of subscribers to proprietary health groups, the facilities of the average private physician, 4, The branch offices of Ross-Loos Medical Group have 198 solved in a marked manner the peculiar ecological setting of the Los Angeles community. There is some criticism that the physicians in the branch offices are not as competent as the doctors in the central office, however such criticism is far from conclusive. 5. Preventive medical care is a cardinal principle of both proprietary and cooperative group health associations. Members express the conviction that group health doctors do not prolong an illness as some private physicians are purported to have done. In these types of group health associations the medical staff has a stake in the good health of the group clientele rather than the illness of subscribers. Physicians are paid whether they treat illnesses or not; hence it is an advantage to prevent as much curative service as possible. 6. Subscribers express a sense of economic and health security which is derived from membership in a proprietary group health association. The big doctor bill is not a problem. The satisfaction of the wish for security is of capital importance to the maintenance of desirable attitudes toward social living. Medical doctors are assured of a guaranteed salary and tenure. Physicians can budget their expenditures because of certainty of income. Subscribers have a sense of "health protection" because of membership in a group health association. 7# Some subscribers evince a lack of confidence in the medical and surgical skill of Ross-Loos Medical Group physicians in very serious conditions* However, the health group is checking this lack of confidence by being willing to share the expense of procuring some other physician out side the group who will instill confidence* Members are thus compelled to place confidence in the entire health group* Recommendations* 1* A health guide is needed to help explain the nature of the health group and to see that the member is assigned to a physician that will be able to treat him* The health guide should follow through each case and find out from the member-patient weaknesses in the health group* Both proprietary and cooperative group health associ ations will become more useful by checking weaknesses in administration and medical care before they become firmly rooted in tradition and practice. 2. Study classes on various phases of group health medicine might instill more interest in keeping well and recruiting new members. 3. A local group health journal is needed to inform members of changes in policy and new trends in the group health movement in general. CHAPTER V QUASI GROUP HEALTH ASSOCIATIONS With, the approval of the American Medical Association a third type of group health plan has developed in the United States, which has been designated as a "producer type" of health organization* These producer types of health groups have been initiated in some instances in order to retard the further development of full-fledged group health associations, whether cooperative, proprietary, or state medicine variety. Because health groups sponsored by organized medicine lack some of the essential principles and characteristics of a group health association, they are considered as quasi group health associations. While theses health groups are not full- fledged, they foster, nevertheless, the principle of periodic payment of medical services.^ At the outset of this discussion it seems necessary to state the sociological purpose underly ing the endorsement of quasi group health associations by the American Medical Association. These quasi groups have imitated some of the more obvious and manifest principles of group health associations and have encouraged a feeling of social competition among persons de- ^An important item to be remembered about these quasi group health associations is that they represent a later development in group medicine. siring to enlist in the ranks of those securing medical care These are efforts to lower the cost of medical care while preserving, the essential.framework of private medi cal practice. They seek to preserve the freedoms of the individual physicians. They seek to preserve competition between individual physicians* They seek to preserve the hoary shibboleth of freedom of choice, and sometimes they seek to preserve the fee-for-service principle* Now obviously, such organizations do not even attempt to achieve the savings which have proved fundamental in efficient group practice. They do not effect savings in overhead. They do not effect savings in the substitution of techni cians for trained physicians. They do not effect the savings possible by purchase of materials in large quan tities. They cannot have the advantages inherent, in prop erly organized medical groups, in the skillful selection and careful supervision of their medical staff. They can not utilize the services of younger men since they continue to attempt to preserve a competitive basis. Moreover, they are inevitably burdened by the necessity of carrying what in economic jargon might be called "marginal and submarginal producers." The Medical Group can exclude the incompetent, the shiftless, the lazy, and the morally weak members of the profession. These by definition the medical society must carry and pay the price. In fact, practically the only saving which they can effect is at the expense of their members in lower fees though on a somewhat securer basis* In a word, this is not group medical practice at all. It does not take advantage of the basic principles which underlie efficient group practice.^ Others have pointed out that quasi health plans do not provide the economic savings and medical advantages of full-fledged group health associations. It is not a group of physicians practicing in a centralized medical center, but a collection of physicians treating individual members of occupational ^Hugh Cabot, The Patient* s Dilemma (New York: Reynal & Hitchcock, 1940), pp. 142-43. 202 groupa in private physician’s offices who comprise this type of health group * Thus, though the clientele of quasi group health associations is drawn from homogeneous occupational groups, the physicians are recruited by the hundreds, with individual offices scattered over eith^ county or state wide areas# In order to compare and contrast the type of medical services available, a number of health plans controlled by local medical societies are reviewed in this chapter. The health groups analyzed in this chapter stand in rather sharp contrast to the health plans previously reviewed in Chapters III and IV. CALIFORNIA PHYSICIANS’ SERVICE The California Physicians’ Service is the largest health plan of its kind in operation at the present time in the United States. It was founded on February 2, 1939, by the California Medical Society under the direction of Doctor Ray Lyman Wilbur, President of Stanford University, and former* ly President of the American Medical Association. He was one of the first representatives of organized medicine to realize the socio-economic implications of group health medicine to fee-for-service practice. It must not be overlooked that the 205 application of periodic payments to the purchase of medical care was somewhat of an innovation in the minds of the very conservative private physicians of California. When they realized that this innovation would not injure in any way their pri vate practices, their status quo attitudes gave way to the utilization of a system of prepayment of physicians’ fees. This quasi group health association represents a phase of social accommodation within the medical profession. Private medicine accommodates itself to merely one of the principles of group health and at the same time retains the matrix of traditionalism in medicine. An analysis of the literature published by this health group reveals a rather broad coverage of medical services offered to its subscribers. An appreication of the services available to subscribers may be gained from the following statement: (1) services, regardless of amount needed up to one year for each disease or injury, (2) treatment in the physician’s office, (3) treatment in the home for patients unable to go to the doctor’s office, (4) hospitalization when necessary, (5) surgical operations, (6) X-ray examinations and treatments, (7) laboratory tests, (8) services of physician- anaesthetist, (9) specialist if required, (10) annual physical examination, (11) California pre-marital examinations, (12) eye examination, refraction, and treatment, after one year. 204 (13) after one year operations for hernia, tonsil, adenoid, and nasal septum, (14) after two years of membership obstetri cal care was provided free,^ In this health group the following diseases and dis orders are excluded from treatment (1) mental conditions, (2) drug addiction, (3) alcoholism, (4) injuries received when committing felonies, (5) conditions which have manifested them selves before the date of membership#^ Dental services are not included, which is not an uncommon practice among group health associations. California Physicians* Service has developed a rather complete range of hospital services for its subscribers through the Associated Hospital Service of Southern California. Bed patients ag^e given the following hospital care: (1) twenty- one days of hospital care per year for each illness or accident arising from a separate and distinct cause. Ac commodations are provided in a room with three or more beds. However, if the patient desires a private room he is asked to pay the difference between the cost of his room and a private room. (2)All meals and dietary services are provided. (3) General nursing care, and (4) use of the operating room are ^Your Doctors and Hospitals Offer Health Service for You! Pamphlet published by California Physicians* Service, rÎ94:p , p. 5. p. 6. 205 available whenever necessary, (5) usual surgical and anaes thetic supplies, (6) splints, casts, dressings, and drugs 5 can be obtained at no additional expense. There are certain limitations and exclusions to the hospitalization services enumerated as follows : (1) con ditions existing at the time the patient-member joined, (2) conditions covered by the workmen’s compensation laws, (3) pregnancy or conditions resulting therefrom, mental disorders, rest cure, quarantinable diseases, pulmonary tuberculosis after diagnosis, or conditions paused by war.^ The sub scriber may select any Blue Cross Hospital v/hen hospital ization is necessary* The California Physicians’ Service offers five dif ferent payment plans for subscribers* Medical care is available to employees who have an annual income of less than $3,000, and who join as an occupational group. A registration fee of one dollar is charged as an initial fee. Plan No. 1 offers complete medical, surgical, and hospital services at a rate of two dollars and fifty cents a month. Plan No. 2 makes available complete medical, surgical, and hospital services at $2.00 per month. How ever, the patient is requested to pay the first two Iblh., p. 6. ^ Ibld«, p. 4. 206 physician’s visits in each separate sickness or injury. Plan Ho. 5 is designated to offer complete medical and surgical services for a fee of $1.70 per month# Under plan Ho. 4 complete medical and surgical service is pro vided if the patient pays the first two doctor’s visits in each separate sickness or injury at $1#20 per member. Hospital service can be obtained for ninety cents a month 7 per member under plan No. 5. At a cursory glance these plans seem very broad and inclusive. However, recognition of the social and democratic rights of tiae subscriber is conspicuously lacking when analysis of the various plans is made. All medical practitioners in California with a physician’s and surgeon’s certificate are eligible to professional membership in this health plan. Prom the standpoint of free choice of physician, this type of health group offers a very wide range of choice because of the inclusive character of the organization. One of the administrative officers in this health group has remarked regarding free choice of physician as follows: In the State of California there are approximately ten thousand four hundred Doctors of Medicine who are licensed to practice. Of this group approximately Ibid., p. 7. 207 four thousand are on Civil Service and not in private practice, or, they are employed by private industry and on a salary basis. Of the remaining six thousand four hundred four hundred in active practice we have five thousand four hundred and eight who are Profes sional Members of this organization, giving service to our Beneficiary Members# The member has a free choice of any Doctor on our list*8 Such a broad choice of physicians is similar to and in some cases identical with fee-for-service medicine. If the patient knows a good physician, he can have the services of that particular practitioner. A leading medical doctor in Los Angeles remarks : "Conservatively, 95% of my patients, when asked who referred them, reply that they have been recommended by another of my patients because, ’You have g had such good results with your patient, Mrs *" It is an unfortunate situation that the patient must select liis physician largely on the basis of hearsay information. Under this system there is no secondary selection of doctors on the basis of skill and ability as is the case in cooperative and proprietary group health associations* Regular group health associations select only physicians who have superior academic training and ability* An attempt is made to refine the patient’s choice of doctors from random choicetto free choice of a good physician and not just any medical doctor ^ Personal Correspondence with W.G.E. of California Physicians^ Service, February 13, 1941. ^ Personal Correspondence with F.W.O*, February 14, 1941* 208 with a medical license in cooperative and proprietary group health associations. A subscriber to California Physicians* Service comments: "How can I distinguish between a good physician and an incompetent one? There has been no effort to rate objectively these physicians. Being a lay person I lack the proper training necessary to evaluate various physicians and select the most competent one. A battery of tests might reveal the informational background of physicians. How if the patients knew the ratings of various physicians that would help a lot. "^^The method of selecting a physician on the basis of reputation is a practice which should have become outmoded many years ago. The scientific advances and social understanding regarding the nature of illness have been conducive to the establishment of more effective control of disease. Yet, the harbingers of the branch of science known as medicine contrive to perpetuate a system of random choice where objectivity is paramount to skilled medication. While quasi group health associations offer certain health services at nominal cost, they violate the principle of cooperation which is basic to a true estimate of the dynamic social implications of group medicine. Three types of professional memberships are provided as follows : administrative, professional, and beneficiary. ^^Interview with R.R. 209 All professional members must be doctors of medicine and hold such certificates in California. A fee of $5.00 is charged for the registration of each member. Employed groups are eligible for membership under this plan. Each physician is paid on the basis of a unit system, namely, in terms of how many units of medical service he renders. A unit is defined as "A method of computing the compensation due to the physician who has rendered medical and surgical service whereby a proportional valuation is set upon each kind of service by counting each such service as a determined number of units. The health scheme is advertised but not the physicians. The following answer to the question, is it ethical to advertise ; * Of course it is, when the advertisement is that of a physician or group of physicians seeking patients, but not when the advertisement, is that of an organization Inviting people to become members so that the organization may pay some doctor for taking care of some patient. In other words, California Physicians’ Service has no medical services to offer or to sell; being an organization it cc ..Icould not have patients and it does not propose to render medical or hospital care. All that the organ ization proposes to do is to pay for hospital and medical care when such care is given by a physician and hospital chosen by the patient from the funds of the beneficiary 11 California Physicians’ Service, Questions and Answers, (A pamphlet published by California Physicians’ Service), p. 26. 210 members which it holds in trust and administers for this purpose• In fact, the name of this organization, California Physicians’ Service, quite adequately describes the purpose and emphasis of this quasi group health association. The patlent-subscriber is somewhat secondary to the physician in matters of control of the organization. To practice preventive medicine on a wholesale scale is economically unsound for the physicians. It is the lack of emphasis on preventive medicine that reveals in another way that this type of health group is not complete and therefore a quasi group health association. Under this type of health group the more patient s a physician has the more his income is. The social importance and extensiveness of California Physicians’ Service can be gained by the following statement which appeared in one of the Los Angeles newspapers; San Francisco, March 6 A.P., The signing of a contract between the Farm Security Administration and the California Physicians’ Service, designed to provide low cost medical care to 5,000 California farm families, was announced here today# It was termed the first agreement between the government and the medical profession covering medical care for* rural rehabilitation borrowers on a state-wide basis. Several plans of county-wide scope are in operation, giving medical service to 68,000 P.S.A. families in 28 ^ Ibid., p. 16. 211 States. The P.S.A.-G.P.S. service provides for the furnishing of hospitalization and drugs as well as medical care. Families will pay for this on the basis of their financial ability and the P.S.A. will make up any sums which the clients cannot pay. Such an agreement between the government and a medical plan points in the direction of a functional adjustment between public medicine and privately controlled medicine. It appears that California Physicians* Service will serve as a shock absorber and thus cushion the trend toward state medicine by intercepting the distribution of medical services. Attorneys who have analyzed the articles and by-laws of this organization have pointed out that the California Physicians* Service has anticipated government aid for low income and medically indigent groups as follows : If there is further extension of government subsidized medical care, some vehicle for rendering such service is necessary. For this reason the articles and by-laws of California Physicians* Service provide that the corporation has power to contract * for the performance of medical services by its professional members or for the furnishing of hospital care or both...or for any other lawful object or purpose, with any public or municipal corporation, body politic, the State of California or any political sub division of said State,* or any administrative agency of the state or the United States of America, or * any corporation incorporated under the laws of the United States or any foreign state.* ' ' ' ' h ‘ A . Called to the attention of the writer by Doctor Emory S. Bogardus, cited in Los Angeles Times, March 6, 1941. 212 Under this power, California Physicians* Service is ready and able to undertake the same type of service that a number of non-profit corporations created by the Farm Security Administration render to needy farm groups and migrant workers. From the viewpoint of the texpayer and the public it would seem unanswerable that an organization representing the entire medical profession is more likely to use public funds in an economical and efficient manner, subject, of course, to normal supervision, than any government agency untrained in the problems of the profession. Evidently California Physicians* Service has been able to direct medical care through the aid of government allocations Thus, this organization has not been able to retard nor derail nor even sidetrack public medicine. It merely canalizes its distribution. One of the problems met by the California Physicians* Service has been the education of physicians to the point where they have accepted the plan as medically and economically sound. A second problem they have encountered has been to obtain the complete cooperation of hospitals in California, Probably the education of employees and employers to the point where they realized the advantages of prepayment medicine has been a third problem. A fourth difficulty surmounted by this organization is to accustom medical doctors to the point of -------XI------- Hartley F. Peart and Howard Hassard. The Organization of Califox*nia Physicians * Service, (Reprinted from the symposium on "Medical Care," published as the Autumn, 1939 issue of Law and Contemporary Problems, Duke University Law School, Durham, N.C.), p. 582. 215 acceptance of the insurance principle as applied to medical care. Medical doctors have maintained control of California Physicians* Service and thus a fifth problem has been over come. One of the member physicians of California Physicians* Service says : "Cooperative group medicine or health groups would allow a lay group to exert too much influence over the doctor. The panel system, as X understand, is the least objectionable of all. The California Physicians* Service plan is a form of the panel system and is for the low income 15 group only at the present time. " One of the outstanding problems this health group confronts is the necessity of broadening the base of membership eligibility. An official of the health plan points out : The problem now involved is attempting to set up a plan whereby the dependents of the subscriber may be entitled to medical and surgical care. Since California Physicians* Service was the first and only plan of its type organized there is no available data as to costs, etc., for medical and surgical care for dependents. Therefore, the Trustees are attempting to compile their own statistics on this before they can set up a monthly fee to be charged that will not prove too high for the people in the low income brackets# There has been some criticism of the plan because it seemed as though it might have been created for the express ■ I LT . Personal correspondence with F.W.O., February 14, 1941. Personal correspondence with W.G.E., February 13, 1941. 214 purpose of curbing the growth, of group health associations* A social worker in Los Angeles claimed that "O.P.S. has set up a plan for the purpose of purchase of medical services which competes with Ross-Loos Medical Group and psychologically acts as an inhibiting control in the organization of other 17 health groups in California." The conspicuous lack of dental services under this plan constitutes a third contemporary difficulty. Dental care has been omitted in several of the group health assoc iations that otherwise offered complete medical services. KING COUNTY MEDICAL SERVICE CORPORATION AT SEATTLE, WASHINGTON The King County Medical Service was organized in 1933 as a pioneer physician controlled quasi health group serving the area of Seattle. One of the interesting features of this health plan was that it represented the first effort of organized medicine to offer health services to groups of employees on a periodic payment basis. This health group had its beginning in probably the worst year of the "recent" depression. Surgical services are provided for any operation or ^Interview with R.R.S. for any acoidental bodily injury sustained by the subscriber, the duration of which is not to exceed twenty-six weeks. Medical services are rendered for the treatment of any disease or accidental bodily injury to the patient, for a period not to exceed twenty-six weeks. To prevent the spread of disease, prophylactic measures are obtainable to groups of employees likely to be infected. Dental examinations and X-rays are furnished when necessary for medical diagnosis. Upon the authorization of the Medical Director, X-rays are made in all cases of suspected fracture, and also to determine 18 other conditions. Conditions which necessitate the use of radium or deep X-ray therapy are not treated unless authorized by the Medical Director. Pregnancy and obstetrical cases are not included as health services under this plan, a somewhat unusual health limitation when compared with the other health plans. Pre-existing illnesses before acceptance of membership in King County Medical Service Corporation are not subject to treatment. Mental and venereal diseases are n> t included as conditions treated under this plan. Injuries received while riding in an airplane, or sickness sustained because of military or naval service in time of war are also --------- See King County Medical Service Corporation Contract 216 not eligible for treatment. Hospital and nursing services are provided for sub scribers to King County Medical Service Corporation by all standard hospitals and surgeries in Seattle, for a period not to exceed twenty-six weeks. A pamphlet published by this health group states the following concerning hospital ization : While there you are entitled to X-rays, laboratory, anesthetics, operating room, ward bed, general nurse, medicine, splints, braces, bandages, plaster casts, surgical belts, and crutchear, together with medical and surgical attention by the physician of your choice. If you prefer a private room you may have one by paying the additional cost. If, however, in the opinion of the Medical Director, a private room and special nurse are necessary they will be provided without cost to y o u . 80 Ambulance service is provided for all patients, to designated P1 hospitals in the Seattle area, by Shepard*s Ambulance Service. Subscribers are permitted hospitalization in any of thirteen designated hospitals. Rates for medical services in this health group plan vary within each occupational subscriber-group; hence it is not possible to obtain exact figures for the groups concerned. Ibid. 20 450 Physicians, Surgeons and Specialists, a pamphlet published by King County Medical Service Corporation. Ibid. 217 The average premiian fee paid per person per month is approx imately Fees charged range from $1.25 to $3.50 per person. Physicians and surgeons practicing in King County are eligible to become members of the panel. Four hundred and ninety practitioners out of a possible six hundred physicians, surgeons, and specialists have their names listed on the roster of this organization. -^n administrator of this health group has noted; "A great majority who are not participating in the plan are specialists in the care of conditions excluded 23 under the terms of our contract. " In this organization, as was true of all quasi group health associations, there was no effort made to present to the public a ”select” list of the most skilled and competent physicians and surgeons available to the subscriber-public. Business and administrative problems are handled by a business manager. Such an arrangement has freed physicians from the usual financial worries connected with the collection of fees from patients. * King County Medical Service Corporation is one of 22 Personal correspondence with A.J.J., an official of King County Medical Service Corporation, February 26, 1941. Ibid., approximately 19^ of the physicians of King County are not members of King County Medical Service Corporation, 218 several county quasi group health, associations sponsored by the State Medical Society of Washington. In Pierce Goynty and Yakima County similar health plans have been organized. One of the unique features of,King County*s organization relates to the restriction of health services to the ”bread- winner” of the family; hence, dependents and individuals not belonging to a group are excluded from the benefits of this plan. This health group is probably the pioneer organization offering medical services to groups of wage earners on a periodic payment basis. It has been able to enroll in the plan about 81^ of the physicians in King County. . The business administration of this health group has been taken out of the pnysicians* hands. The exclusion of dental services has constituted an acute problem, A second difficulty relates to the exclusion of dependents of members from participation in the quasi group health association benefits. The lack of provision for individual membership is a third difficulty characteristic of King County Medical Service Corporation* MEDICAL SERVICE BUREAU, AT ATLANTA, GEORGIA The Pulton County Medical Society launched its plan 219 in October, 1933, after two years of research and study as to the advisability of applying certain important aspects of the insurance principle to the payment of health service. The purpose of this quasi group health association was ”not financial gain but to promote the health and welfare of its members. t A subscriber to Medical Service Bureau was entitled to call on any physician whose name appeared on the roster of this organization for medical examination and treatment , surgical, obstetrical. X-ray, laboratory, eye, ear, nose, and throat, consultation, office calls, and home and hospital visits. Drug addicts and alcoholics were barred from membership and participation in the health benefits available through Medical Service Bureau. Health services were limited to white persons; hence Negroes in low income and relief groups were excluded from participation in the services of this plan. Race prejudice and discrimination are manifest in such a plan. The cultural setting of Georgia is conducive to the exclusion of Negroes from medical attention'no matter how great the need may be for their care. As might be expected, hospitalization, nursing care, and medicines are not included 24 A Plan for Medical Care (Atlanta; a leaflet published by Medical Service Bureau). 280 as part of the associate health services of this quasi health group. In general, tiie membership fee for an individual is $1.50 per month plus an enrollment charge of $1.00 to be paid at the time of application. The second member of the same family pays $1.00 for enrollment fee and $1.00 per month. The third member of the same family is charged an enrollment fee of fifty cents and seventy-five cents per month. Any additional members of the same family group each pays an enrollment fee of fifty cents and fifty cents per month. Inasmuch as eligibility is dependent upon income status, it is important to note the particular income levels admitted to membership, which are as follows: No dependents and an income not in excess of $75,00 per month. One dependent and an income not in excess of $125.00 per month. Two dependents and an income not in excess of $155,00 per month. Three dependents and an income not in excess of $145.00 per month. Pour or more dependents and an income not in excess of $150.00 per month. IMh. 26 Ibid. Maternity and tonsillectomy cases are not cared for by monthly payment but receive medical attention for an additional fee besides the monthly stipulation. Maternity patients are accepted on the payment of one year * s member ship in advance and a delivery charge of $20.00 Subscribers who required the removal of tonsils are accepted on payment of a full year* s membership and an operative charge of $15.00 With the exception of the foregoing limitations and special fees a subscriber is entitled to any other form of medical o»7 care without charge.^ Of the 500 members of the Pulton County Medical Society, 155 have signified a desire to have their names placed on 28 the roster of the bureau member-physicians. A lower per centage of eligible physicians is connected with this quasi group than with others previously reviewed in this study. The same problem is evident in connection with the intelli gent choice of a "good” physician that was observed in similar health groups operating in the United States. On May 1, 1941 there were 1,162 subscribers enrolled with Medical Service Bureau* These members were divided be tween 267 family groups ranging from two to nine members and 27 Correspondence with R.E.A., an official of Medical Service Bureau, May 9, 1941. the "balance of the members are individuals. It is reported that a number of members have been lost through the National Selective Service Act. A member is entitled to adequate medical care which in no\;way is limited by the nature of the disability. However, the Bureau had, at all times, the right with or without cause, to drop any member subscriber. This was done where "abuse^* of the service became apparent.The following statement revealed something of the administrative set up of this health group: Medical Service Bureau is a non-profit corporation governed by a President, Vice-President, Secretary and Treasurer and a Board of Five Directors all of whom are members in good standing of the Fulton County Medical Society. The Bureau is self governed under contract with the Society. There are no laymen on the Board of Directors. The lack of a provision for laymen on the Board of Directors of this quasi health group is not an uncommon practice. In fact, such a procedure is the rule among other heal th groups controlled indirectly by the American Medical Association. Even as a bargainer, the subscriber is not given an opportunity to express his reaction to the health services of such health groups. Lack of dental services is an important omission in the health services offered by Medical Service Bureau. The 30 lack of hospitalization is perhaps the most startling problem which confronts members of this health group. Something of the local situation and culture pattern is made manifest in the following comment by the Manager of this health organ ization: . . .We have a general hospital which gives free medical and hospital care. This service is available to the same income class that we are trying to attract to our plan and is in direct competition. People have received this care so long that they take it for granted and are not attracted by any payment plan. Perhaps the fact that only about 31^ of the eligible physicians in Pulton County have joined the group constitutes a third problem. In other words, the patient has "free choice” of physician within the range of member medical doctors con nected with the plan. Summary of chapter. The three examples of quasi group health associations analyzed in this chapter disclose something of the nature and methods of such health organi zations. 1. It seems that quasi group health associations were created and organized in a large number of instances for the express purpose of retarding the dual possibility of state medicine or group health associations whether 31 Personal correspondence with E.A.R., an official of Medical Service Bureau, February 8, 1941. 224 controlled by laymen or physicians. For this reason quasi group health associations might properly be considered as a form of social control over the direction of reforms in the distribution of medical services. Today, laymen who have not become associated with cooperative or proprietary group health associations are probably confused when a fee- for-service physician is able to state "Why we doctors have our own medical group. You need not organize another health group.” Physicians affiliated with quaai group health associations are factors in the social regulation of future medicine for at least two reasons: (1) laymen arc not democratically represented, (2) and in the event the government should enter the field of health, organized medicine has a plan through which the government might delegate full responsibility for the health needs of a certain portion of tne population, especially the poor. 2. The quasi group health associations reviewed in this chapter utilize the advantages of pt? riodic payments, which is an application of the insurance principle, to the purchase of medical and hospital services. 5. Economic savings which would have been derived from the pooling of medical and scientific equipment are not possible under this form of health group, nor is there such a facile opportunity for the pooling of medical 225 information and group consultation on difficult cases as is true in health groups which have a group of physicians working together within close physical proximity to each other. 4. It is clear that this type of health group has made no effort to prepare a "select" list of names of the mostcompetent physicians. Free choice of physicians almost implies any licensed physician belonging to the panel of a quasi group health association. 5. On the whole, the limitations of health services differ very little from full-fledged group health associations. Suc!^ conditions as drug addiction, mental disorders, alcohol ism, illnesses covered by workmen*s compensation laws, are generally exempt from service. b. Quasi group health associations which have been organized indirectly by the American Medical Association have limited their medical services, on the whole, to the low income class. The conservative physicians have thus maintained the sliding scale method of reckoning payment of professional services for the middle and wealthy classes. Y. Physicians are paid on the basis of some form of unit system. The more cases a physician treats the greater is his income. It would be uneconomical for the quasi group 226 health physician to practice preventive medicine on a large scale* The lack of preventive medicine as a cardinal principle stands in sharp relief to the practice of cooperative and proprietary group health associations. 8. The "basis of eligibility is narrower in quasi group health associations than in some of the other forms of group health associations. Dependents of subscribers are not always eligible for members nip. Provision for membership on an individual basis is also lacking in group he«.lth assoc iations controlled by the local county medical society. 9. The conspicuous lack of dental services constitutes a bottle neck in the health services of the group health associations analyzed in this chapter, lO. Quasi group health associations represent a social compromise within the American Medical Association, a compromise not only with the possibility of state medicine, out with full-fIndged group health associations. Such a compromise probably is another indication that group health associations have become a social movement with the inevitable controversies encountered in the emerging and organizational stages of any movement. As the movement progresses and gathers momentum probably a series of social adjustments and compromises will be effected as imitation and diffusion of methods make the various types of health groups appear. 227 at least, to be very similar. ■ 11. The culture complex of conservative medicine reveals the presence of culture lags within certain phases of it and modernism in others. The cluster of non-material culture traits concerned with the distribution of medical services through the channels of quasi group health assoc iations discloses that conservative medicine has incorporated modern methods of pecuniary payments (periodic fees), but has relegated to the background a refined choice of physician and a pooling of medical Equipment and scientific knowledge. CHAPTER VI CORRELATIVE DEVELOPMENTS ASSOCIATED WITH THE GROUP HEALTH ASSOCIATION MOVEMENT Several phases of the group health association move ment have been influenced or have had their origins in related health services. In this chapter an effort will be made to analyze the inter-association of group hospitalization plans and developments and the distribution of dental services organized around social situations defined by community pat terns with the group health association movement in this country. GROUP HOSPITALIZATION A number of social factors similar to those which helped to launch the group health association movement in the United States have been instrumental also, in inaugurating various plans of group hospitalization in this country. Prob ably the high cost of hospitalization has been one of the para mount determinants to precipitate efforts toward the establish ment of ghoup hospitalization plans utilizing periodic payments Not only are hospital fees often large, but the need for hospital care is generally unpredictable as to time and amount. 229 For the family breadwinner hospitalization necessitates absence from employment besides an additional out go of income for physicians’ and nurses’ services. It has been found that the average total cost of an illness requiring hospitalization is approximately one hundred and fifty dollars, sixty-five dollars of which is used for hospital care and eighty-five dollars for professional services in the home and hospital.^ Studies indicate that three-fourths of America’s families earn too little to pay for unexpected illnesses, which is not surprising when it is understood that the total cost of an average hospitalized illness is in excess of the monthly income 'of the average of this three-fourths of the population, verified on 1855-36 statistical data. Inasmuch as the socio economic hazard to the individual can be removed only by applying the distribution of risks principle, group hospital ization plans were created, organized, and developed in a 2 number of hospitals throughout this nation. Hospitals which accept the insurance principle note that since the inception of periodic payments for hospitalization, many patients who formerly would have been free or only partly paying patients, are becoming paying patients under prepayment Rufus Rorem, "Nonprofit Hospital Service Plans,” Medical Care, I: 137-38, April, 1941. ^ Ibid. plans. In short, a number of individuals in the low income group could not or have not been inclined to pay a large unexpected hospital bill which only served to augment their socio-economic instability. These reversals of attitude regarding payment of hospital bills represents a desirable shift of attitudes toward a social situation engendering feelings of dependence to one of social adjustment. The social situation, hospitalization payment, is being defined by cooperative action which makes for personal and financial indep endence. It was in 1933 that a system of periodic payments was accepted by the American Hospital Association as an "ethical" means of paying for hospitalization. A generous grant from a philanthropic foundation financed a program of annual approval of group hospitalization plans and methods. Doctor G. Rufus Rorem describes something of the professional nature of the hospital approval by the American Hospital Association as follows : The ’standards* cover.such points as nonprofit organization, emphasis on public welfare, representation ofpublic, hospital, and professional groups, hospital responsibility, free choice of hospital and physician, economic soundness, actuarial stability, dignified promotion and administration. Plans meeting these standards may identify their organization and their literature and promotion material by the use of the seal of the American Hospital Association superimposed upon a Blue Cross. Approval by the American Hospital 231 Association is regarded as a supplement to, not a substitute for, the requirements of state regularatory bodies, and it is not a legal guarantee of performance.^ The insurance principle as applied to the cost of hospitalization is accepted and approved by many national professional organizations and associations. In 1934 the American College of Surgeons endorsed the principle of periodic payments as applied to the unpredictable costs of hospitalization, and in 1937 the American Medical Association, at its annual meeting in Atlantic City, introduced principles which were quite similar in a number of ways to those established earlier by the American Hospital Association. It was claimed that the principles set forth by the American Medical Association were aimed to guide and characterize the application of the insurance principle as it applied specifically to the cost 4 of hospitalization. In a statement issued on June 18, 1939, the American Hospital Association recognized the social nature of recent trends.in the administration of hospital economics as follows; Present practices of hospital organization have been developed in response to public need, and for many years (wer^ fostered by the professional associations of this country, including the American College of Surgeons, the American Medical Association, and the American Hospital Association. ... The primary obligation of the hospital is ' Slbld. ^Clted by C. Ëufus Rorem, "Monprofit Hospital Service Plans," Medical Care, I: 142, April, 1941. 232 to provide and organize all the services necessary for the diagnosis, treatment and rehabilitation of the patient.5 Another evidence which pointed toward the acceptance of periodic payments for health care became noticeable when some of the more conservative medical and health organizations finally gave acqui escence to the practice of budgeting hospital bills on some form of prepayment basis. More than twenty State Legislatures have realized that "enabling acts” were necessary for the formation of a system of periodic payment for potential hospital bills. Many of these enabling acts substitute guarantees of service by a group of member hospitals for an investment of capital stock or the privilege of assessment upon policy holders. Doctor C. Rufus Rorem, Director of the Commission on Hospital Service of the American Hospital Association interprets hospital service plans concisely in the following statementss..."the hospital service plans tend to possess the economic characteristics of a program of social insurance rather than private insurance. It is necessary at this point to analyze some of the outstanding group hospitalization plans in operation in the United States to understand the possible parallel development in the application of insurance to the cost of another form of health care, namely, hospitalization. On the vfhole, it ^Ibld.. p. 14b. may be said that all plans of medical distribution, whether group or fee-for-service, endorse and utilize group hospital service. However, orthodox fee-for-service spokesmen purport that the economics of hospital and medical care must be kept separately. One of the outstanding full-fledged cooperative hospitalization plans is that of the Group Health Mutual Inc. of St. Paul, Minnesota, Comprehensive hospitalization and surgical coverage is available to its subscribers for approximately ninety cents a month per employed man. Slightly higher fees are charged for employed or dependent women. This health group presents one of the best evidences of the close relationship which may exist between a hospitalization plan and an emerging group health association. In fact, this hospitalization plan is a phase of a more inclusive program, as an officer of the plan points out: Our problem for the future is to extend our services into the field of complete medical and dental care for our members. Our hospitalization insurance is only the first step in this direction. At present_we are working on a plan to provide complete medical care for our members, and later will go into the field of dental care. We are now faced with the rather serious problem of the opposition of the organized medical profession to pre payment medical care plans controlled by laymen. How ever, we hope to overcome this obstacle in some way.^ ^ Personal correspondence with A.Â.L., Group Health Mutual Inc., April 5, 1941. 234 Probably the principle problem this health plan met and solved is that of providing hospitalization Insurance for its subscribers. Group Health Mutual, Inc. demonstrated that organization of a group health association could emerge from plans to offer either hospital or medical services. In general it has been true that most group health assoc iations are organized around a plan of periodic payments for medical services. However, group hospitalization plans, per se, were more widespread and common at an earlier date than were group health associations. In fact, in 1938 there were more than two and a quarter million persons enrolled in 8 hospital care insurance plans throughout this country. Of special significance to this study was the fact that Group Health:Mutua1, Inc. has been a pioneer in organizing a group health association around group hospitalization services, and has pointed the way for the development of more thorough and complete services of this kind in the immediate future. . On the West Coast, Associated Hospital Service of Southern California, with central offices located in Los Angeles, represents one of the most comprehensive periodic hospitalization payment plans in operation in the United "Public Health," Survey Midmonthly. LXXIV:391, December, 1938. 236 States endorsed by the Associated Hospital Service, California Physicians* Service, a quasi group health association, has worked hand in hand with this group hospitalization plan. These two organizations publish some of their literature jointly, which objectively reveals the close cooperation and division of labor between these two forms of health services, hospitalization and medical care. Hospitalization services available are considered broad when it is recalled that a hospitalized patient receives%%• twenty-one days of hospital services for only a pre-payment fee of^ninety cents a month. The patient is entitled to the following health services: care in a room of three or more beds, meals and services of a dietitian, general nursing care,"''*use of operating rooms, including surgical and anes thetic supplies, use of cystoscopic rooms and supplies, splints, casts, dressings, and drugs ordinarily furnished when hospitalized.^ The following letter by the President of Barker Brothers Department Store in Los Angeles, California, reveals something of the appreciation which his employees have felt concerning this group hospitalization plan: 9 Your Doctors and Hospitals Offer Health Service for You! A pamphlet published by California Physicians^ Service and Hospital Service of California, [1940^ 236 Associated Hospital Service was offered to our employees in August, 1938.... there has been ample opportunity to see the good that has been accomplished. Seven-hundred and twenty-four of our employees are subscribers, and including family groups there are 911 individuals covered. Two hundred and two of our employees or members of their, families have received benefits since the inception of this service, and the gratitude that has been expressed by them has been encouraging.^ There is no question but that Associated Hospital Service has been of great benefit to Employees of Barker Bros., and we are expecting that eventually almost all of our staff will be included in the membership... On May 7, 1935, a non-profit corporation was established under the supervision of the State Superin tendent of Insurance, under the name of the Associated Service of New York. On October 16, 1941, there were one million two hundred and fifty thousand subscribers enrolled and about four hundred subscribers are admitted daily for 11 hospital care and treatment. There are more than two hundred and fifty participating hospitals in Greater New York and Northern New Jersey. Originally the corporation was sponsored by the United Hospital Fund as a means of enabling persons of moderate income to budget their hospital Correspondence to Mr. Ralph G. Walker from Ivîr. Neil Petree, published in The Blue Gross, 1:1, May, 1941. 11 Personal correspondence with R.F.D. publicity department of Associated Hospital Service of New York, October 19, 1941. 237 bills. -Trustees of this corporation include representatives 12 of hospital societies of Greater New York. Dr. Paul Keller mentions the type of relations existing between Associated Hospital Service Plan dnd the medical profession as follows: The Board of Directors of the Associated Hospital Service of New York consists of eighteen members. Six of these are physicians appointed by the board of directors from a list submitted by each of the seven teen county medical societies in the metropolitan area including northern New Jersey. This one third representation of the medical profes sion creates a definite sense of responsibility on the part of the physician.... Nothing must be done that will alter the confidential relation between the doctor and the patient. An employed subscriber pays ten dollars per year ; a husband and wife pay;, eighteen dollars per year; a husoand, wife and unmarried children under nineteen years of age twenty-four dollars per year. The foregoing rates for dependent coverage applies only to groip s of ten enrolling through a common place of employment. Subscribers are en titled to hospital service benefits which include semi private rooms, operating or delivery room, laboratory. 12 Frank V. Dyk, "Associated Hospital Service of New York," reprint from April issue of Hospitals, 1937. Paul Keller, "Relation of the Associated Hospital Service Plan to the Medical Profession," Journal of the American Medical Association^ 114:1934, 1940. 238 X-ray filma and fluoroscopies, ordinary drugs and dressings, anesthesia if given by a hospital employee, basal metabolism tests, and serums. The foregoing hospital services are for twenty-one days, with one-fourth discount thereafter. Such conditions as pulmonary tuberculosis, venereal diseases. Workmen’s Compensation Laws cases, quarantinable diseases, and mental disorders are excluded from hospitalization 14 services. A problem this hospital association faces is put as follows : What happens when arrangements are made to provide medical and hospital services on an insurance basis without sufficient actuarial data is clearly told in a news release from the Associated Hospital Services of New York.... About 57,000 contracts with subscribers who en rolled through individual instead of organized applica tion are to be terminated. This was announced recently as a result of this study which indicated that under part enrollment procedures a proper distribution of risk was not provided. Another nationally known group hospitalization plan is the Glevelfctnd Hospital Service Association, established on September 1, 19o4. Approximately 521,284 employed sub scribers were members of this group hospital plan on October lb' 16, 1941. Subscription rates are sixty cents monthly for Frank V. Dyk, op. cit., p. 1. Jcurnal of the American Medical Association, 113: 682, August 19, 1939. Personal correspondence with J.A.M. of Cleveland Hospital Service Association, October 16, 1941. 239 semi-private rooms; dependents are enrolled at fifty per cent of the rate for employed subscribers and are entitlasd to fifty per cent discount on services which employed sub- scrioers receive free; payments are made through payroll IV deduction only. Members are eligible for the following hospital services: bed and board, general nursing. X-ray, operating room, anaesthesia, routine laboratory, drugs and dressings; payments made to non-participating hospitals in emergencies or while the subscriber is traveling; four and one-half dollars and six dollars respectively for ward and semi-private contract holders.The following statement reveals that the Director of this group hospitalization plan has a high regard for medical ethics ; "The Cleveland Plan is endorsed Dy the Cleveland Academy of Medicine. As a cardinal principle, the Cleveland Plan regards the ethics of the Medical Profession as a great safeguard for the health IQ of the community. ” Today this group hospitalization plan 17 John A. McNamara, vGleveland Hospital Service Association,” reprint from Hospitals, April, 1937. ■ 18 Ibid. 19 Ibid. 240 is one of the outstanding schemes of its kind. Voluntary Civic Plan of Missouri and Southern Illinois has more than 250,000 people in its plan. Employees of an organization under sixty-five years, in good health, are eligible for membership. A wife, or husband and all unmarj? ried and unemployed children between ninety days and eighteen, years of age can become associated with the benefits of group hospitalization. Each person is eligible for thirty days of care and in addition employed members and sponsored members receive thirty-three and one-third discount for semi-private accommodations up to six months. However, dependents are asked to pay a charge of one dollar per day; maternity care is given at the rate of two dollars per day. Some of the specific benefits of this group hospitalization plan are as follows : care in a two-bed room, meals and special diets, general nursing care, operating room as often as needed, all surgical dressings, all drugs and medicines except serum and glucose, routine laboratory service, ambulance service from hospital of first admission to member hospital to a distance of fifty miles. The following reveals the economics of the group hospitalization plan: individual employee seventy-five cents a month, first dependent fifty cents a month, all additional dependents twenty-five cents a month. Thus, one dollar and fifty cents provides complete 241 2 0 hospital coverage for an entire family. A considerable number of faculty members of Southern Illinois Normal University have accepted membership with this group hospitalization plan. Most of the younger faculty men are members. A young instructor remarks : You bet I am a supporter of the group hospitalization plan. I needed a serious operation last summer which was rendered at a very nominal charge because I was a member. Our baby was born under this plan at the Holden Hospital in Carbondale. We have saved about $100.00 because we were members of this semi-cooperative plan. The only thing I regret very seriously is that there isn’t any provision for group medical service and the hospital doesn’t seem to be much interested In trying to foster such an idea.^^ Some of the older faculty men interviewed claim that they are used to taking chances with the possibility of the need for hospitalization. As one remarked; "For young married people I think it is a good idea, especially if they plan to have a family. The saving on maternity cases and the hospitalization of their children will more than pay for their annual premium. A few important general features concerning hospital groups are that they tend to emphasize preventive medical care, early diagnosis, and early hospitalization of members. Periodic 20 From a circular leaflet published by Voluntary Civic Plan, July 1,1940. 21 Interview with J.T.W. Interview with W.I.A. 242 payments eliminate, at least partially, risk of financial insecurity not only for patients, but for hospitals as well, since hospitals with a periodic payment plan are assured of a predictable income# Blue Cross Hospitals are passing into the national coordination stage rapidly. The Interdependence and integration between various Blue Cross Hospitals are set forth as follows: A National Committee of Coordination was formed at New Orleans Conference of Blue Cross Plans, when Plan Directors and Officers met February 27th....The proposed program of activity for this year includes. A plan for complete reciprocity between all Blue Cross Plans. Creation and launching of a national program of Public Education, designed to acquaint the public with the benefits and values of group hospitalization*^^ More than 7,500,000 persons are enrolled with various hospitals associated with the national Blue Cross Hospital plan in the United States. Today there are sixty-seven approved plans of non-profit group hospitalization. GROUP DENTAL PLANS Within the last ten years a few no"§?orthy developments have been made in the distribution of dental services to the low income group in this country. Studies indicate clearly 2S The Blue Cross. 1:3, May, 1941, 243 the need for such dental reforms. The Report of the Committee on the Costs of Medical Care shows that "Among the mass of the population, only 21 per cent of individuals received any dental care during an average year....The proportion of the population who receive systematic and sufficient dental care must he 24 consideraoly less than 21 per cent. " For some time the Amer ican Dental Association has taken a similar attitude toward new group health plans as the American Medical Association. The following statement by a leading dentist testifies to the retarded developments and cultural lag manifested in dental plans; "No national or even community-wide plans of general dental service have been pubeinto Zoperation. Dental care for the indigent has been developed considerably in some cities as part of public relief. Children’s services have been extended in some places as part of a public health program. Many states have dental officers in their departments of health. One of the dental plans which somewhat altered the pre vailing system of dental economics is termed a dental service Oureau, organized for the purpose of providing dental care ^ Committee on the Costs of Medical Care, Medical Care for the American People (Chicago; The University of Chicago Press, 19o2), p. 11. À more recent study of dental needs by Rollo H. Britten, A Study of Dental Care in Detroit, Michigan (Washington: United States Government Printing Office, 1938). J.Â. Salzmann, "Program of Dental Care." Medical Care, I:2l3, Summer Issue, 1941. 244 for persons of modest income. Under this plan payments for dental services are made in small post installments. Bureaus are set up in the cities of St. Louis, Washington, Detroit, and Indianapolis to investigate the finances of each applicant, and devise a plan of payment in weekly or monthly install ments. The American Dental Association gave the Service Bureau plan its official sanction in the following resolution passed by its House of Delegates in 1935: Resolved, that the American Dental Association in annual session assembled approved of further study and experi mentation with plans to furnish such services as have been established in Washington, D.C. and St. Louis, Mo., as we believe that the outcome of such practical research might terminate in satisfactory solution of the vexing problems of providing adequate dental service to the low income group. Doctor J.A. Salzmann, a dentist, has summed up in a few words the progress of these Service Bureaus by stating: "The actual results.... were disappointing. The number of persons cared for even during the initial period was never considerable. In the Washington, D.C^ Bureau, the one most advertised, out of a population of half a million only about 10,000 persons used the agency in 1935 and by 1937 the number had dropped to 856."®’ ^ American Dental Association: Resolution passed by the house of delegates regarding dental service plans, November, 1935," Journal of the American Dental Association, 23:164, January, 1936. 27 J.A. salzmann, 0£. cit., p. 215. 245 A brief review of the official action of the American Dental Association will disclose how organized dentistry evaluates group dental plans and procedures. In 1935 the American Dental Association condemned the principle of compulsory health insurance as specifically applied to dental needs. However, in 1938 the, dental association took a more positive attitude toward probable changes in the payment of dental care as may be noted in the following eight resolutions, adopted by the House of Delegates of the American Dental Assoc iation, set forth before the National Health Conference which convened in the City of Washington as follows : 1. In all conferences that may lead to the formation of a plan relative to a national health program, there must be participation by authorized representatives of the American Dental Association. 2. The plan should give careful consideration to, first, the needs of the people ; second, the obligation to the taxpayers; third, the service, to be rendered; and, fourth, the interest of the profession. 3. The plan should be flexible so as to be adaptable to local conditions. 4. There must be complete exclusion of non-professional, profit-seeking agencies. 5. The dental phase of a national health program should be approached on a basis of prevention of dental diseases. 6. The plan should provide for an extensive program of dental health education for the control of dental diseases. 7. The plan should include provision for rendering the highest quality of dental service to those of the 246 population whose economic status, in the opinion of their local authorities, will not permit them to provide such service for themselves, to the extent of prenatal care, the detection and correction of dental defects in children and such other service as is necessary to health and the rehabilitation of both children and adults. 8. For the protection of the public, the plan shall provide that the dental profession assume respon sibility for determining the quality and method of any service to be rendered. The proposed "National Health Act," under the sponsor ship of Senator Robert F. Wagner, took some of its principles and ideas from the 1938 Health Conference. A number of hear ings were held during the year by a subcommittee of the Senate Committee on Education and Labor, at which a committee of the American Dental Association testified. Members of the dental association criticized the bill on several grounds, for, they said, it did not comply with the eight foregoing principles. They averred that dentistry was not even mentioned in the bill, and the measure was purported to have been worded vaguely. The American Dental Association proposed a three-point plan for meeting the problem of dental diseases in the United — - American Dental Association: Action of the house of delegates on the national health problem. Journal of the American Dental Association, Volume 25:2037, December^ T938. 29 J.A. Salzmann, op. cit., pp. 218-19. 247 States as follows : 1. Dental Research to discover the causes of dental diseases. 2, Dental Health Education to bring a knowledge of present methods of prevention and control to the public. 3* Dental care, particularly for children as the greatest amount of prevention can be accomplished in this Probably the next forward step in line with the recognition of the necessity for reform in methods of dental care is stated by Doctor Arthur H. Merritt of New York, President of the American Dental Association, in the follow ing manners Dentistry cannot be said to have discharged its duty to society when more than'\half of the people of this country receive little or no dental care. The next forward step is to bring such care within the reach of all...Education and research, however, are not enough. They offer only partial solutions to our problems. They do not make provision for the immediate care of those who are already suffering from the cumulative effects of long years of dental neglect...This is a situation which can be met only by treatment, which should be limited to the indigent, with especial at tention to the preschool child. This part of the program is clearly the responsibility of the state... it is no more the duty of the dental and medical . professions to care for those in this class than for ' any other group of citizens. They should, however, • take the lead and cooperate to the full extent of their resources. 30 U.S. Senate Committee on Education and Labor: Hearings before a subcommittee, Washington, D.O.; Government Printing Office, 1939, Part II; p. 557. 248 In this they have both shown willingness. In the spring of 1941 rather complete discussions of dental plans, proposals, ethics, and community resources were printed in a forty-eight page pamphlet published by the National Health Program Committee of the American Dental Association. It is in this pamphlet that description of four dental plans are set forth. A recent and comprehensive study of the dental needs of the adult population has been published by the American Dental Association in which it is revealed: A striking difference in need in persons on different economic levels is found to exist. In the case of almost every dental need, a marked inverse relationship is observed between different income levels and dental need. These differences are observed for both males and females. However, the range of difference between income level is much narrower for females than for males. It is signif icant that the level of dental need for the highest income level is almost identical for males and females, whereas the dental need for females in each of the three lower income groups is considerably lower than the need among males of the same groups. This would seem to indicate that on the upper income level, males and females exercise about the same daily dental hygiene. On the lower income levels, however, it appears that there exists a cultural lag in the dental education of males as compared with females.S2 The cost and need for dental services are set forth 31 Arthur H. Merritt, "The Centennial of American Dentistry," Journal of the American Dental Association, Volume 27:1974, November, 1940. 32 Raymond M. Walls, A Study of the Dental Needs of Adults in the United States. Published by the Economic Committee of the American Dental Association, 1941, pp. 111-12. 249 as follows : The average cost of dental care, based on the application of the fee schedule of the United States Veterans Administra tion to the average dental needs as revealed in the study, is found to be $48.96 for males 15 years of age and over and $45.43 for females in the same age range. The cost of dental care starts at about $40 for males and $45 for fe males in the lowest age group and rises to a maximum of $55 at the age of 50 years, beyond which age the average cost declines somewhat. Little difference is found in the cost of dental care for persons on different income levels. While .the dental need is greater among the lower income levels ; group, the difference in cost is offset by the fact that more expensive types of dental correctives are recom mended for the upper income groups. In conclusion, this study positively demonstrates that with adequate dental care, including both daily dental hygiene and regular visits to the dentist, the dental health of the nation can be raised to a much higher level. Improvement in dental health on a national scale can and must be brought about by a vigorous and continuous pro gram for dental care and dental education. It is surprising to realize that the average cost of dental treatment for adults is so great* This dental study like so many other health studies fails to recommend a particular method for raising the health status of the American people. Apparently the use of such terms as "vigorous and continuous SSibid.. pp. 112-13. 34 Of social psychological interest is the fact that American tooth pasëe and powder companies have singled out the teeth as b«ing a basic component of personality and good health. Many of the advertisements of leading dentifrices appeal to such personal qualities as physical appearance and halitosis! No wonder the American people are dental conscious. 250 prpgram" Implies that the dental services today do not reach enough of the people and that something must be done to ameliorate this condition. Usually post-payment plans function through "medi cal-dental service bureaus." As previously pointed out, these dental plans enable persons in low income groups to receive dental care at rates which are determined by their ability to pay, with payments arranged on an installment basis requiring no interest or carrying charges* Pre-pay ment plans constitute a second type of dental plan now in operation in the United States* The Unit service plan of prepayments for dental care has become widely known in the United States. The value of the unit was determined by dividing the amount of money available for dental bills by the number of units of service rendered. A third type of plan, credit and collection bureaus, have the primary purpose of establishing the credit rating and collection of service for professional members. Some of these bureaus arrange for some method of post payment of dental care. Group plans have been organized by industrial employers and employees for their children, for general residents of a community, or for union 35 or fraternal groups. ^^Program for Dental Health, The National Health Program Committee published by the American Dental Association, |l94^ pp. 24-25. 251 The Farm Security Administration has done some pioneer ing work in the field of group dentistry that demonstrates something of the nature of its possible trends. It is sur prising to realize that more than 100,000 low-income United States Farm families, or about 500,000 persons, have banded into groups to obtain adequate medical care at a cost they can afford. The health plan was started in a few rural counties five years ago, and now has extended into over 800 counties in thirty-five states. The Farm Security Administration has been granting small operating loans to help alleviate the conditions 37 of these farmers. It has been found that the dental care needs of borrower families are no less urgent than their medical care needs. Al though emergency dental care is limited to extractions, it has been provided in connection with a considerable number of medi cal care plans. However, recently there has been a steady in crease in the number of separate dental plans being organized to provide more complete dental service. In general, dental care activities which have resulted from the cooperation of ^^Special acknowledgement is extended to Doctor E.G. Williams, Chief Medical Officer, Farm Security Administration for making available certain materials concerning the experience of this division of the government in group dental plans. ^*^Medical Care Program for Farm Security Administration Borrowers, published by Farm Security Administration, p. 15,1941. 252 State and local dental societies and the Farm Security Ad ministration are considered as experimental. Many times, principles upon which dental care plans are based are similar to those of medical care programs, including free choice of dentist, basing the cost of the plan upon the average ability of borrower families to pay, and placing all dental aspects of a plan under the direct supervision of the dental pro fession. Dental care plans have organized separately from medical care plans in ten States. At present, such plans serve more than 20,000 families in over 150 counties. Other 38 plans are being organized. Generally, there are two types of dental care plans# One provides for elimination of infections and such minimum restorative dentistry as is necessary to place the month in a healthy condition. The other type provides certain minimum essential services of an emergency nature such as extractions^ the treatment of infections, simple fillings, and other pre- 39 ventive care. Plans of the first type are in effect in a number of States. The family dentist makes an estimate of the minimum amount of services, including restorative dentistry, required for a satisfactory mouth condition. These estimates are then ssibia.. p. 7. 3®Ibid. 253 reviewed by a committee of dentists. Individual family funds é L S to cover such essential services#vare within the ability of the family to pay are set up in a special bank account in the hands of a trustee, and, upon completion of the dental work, the dentist is paid out of this fund. Loans to cover this type of service are made often on the basis of repayment 40 over three years or more# The other general type of plan, found in a number of states, is typified best by a system operating in forty- four Arkansas counties. Some of the most urgent dental needs of a low income group of farm families who previously had practically no dental care are met by this plan. In Arkansas a family in a county area pays the basic sum of three dollars per family, plus fifty cents for each person in the family into a pooled fund on an annual basis. This fund is divided into twelve monthly allotments. Dentists submit bills for services and receive payment from the monthly allotments# When funds are insufficient to pay bills in full there is a pro rata distribution of the allotment# Reports indicate that the dentists are receiving an average of over seventy per cent on bills carrying their usual fees. The Farm Security Ad ministration comments: A dental care plan, which it is hoped may combine certain 254 of the heat features of the two plans described, has recently been approved by the State Dental Association in a Western State. In this plan the families pledge themselves to participate for a five-year period. The participation rates average $20 per family for each of the first two years. There is free choice of dentist and the services include an annual examination, cleaning and scaling, extractions, treatment of infections, fillings, and part of the cost of dentures or bridgework. This may prove a solution to the problem of families dropping out of a plan once a certain amount of corrective work has been performed. The National Youth Administration has established several programs for dental examination and care. In a good many Instances dentists are hired on a part-time basis. Not all of these programs have been established in consultation with district dental societies and it is claimed that dentists have been hired with little or no notification to the representa tives of organized dentistry in those areasThere are also several dental programs in New York and Chicago which are financed with the aid of funds from the W.P;A. It has been pointed out earlier that only a few group health associations in the United States have been able to offer their subscribers dental services as a part of health services at reduced rates, or for the cost of dental materials used. Ross-Loos Medical Group of Los Angeles, California, Greenbelt Health Association of Greenbelt, Maryland, and Farmers* ^^Ibid., pp. 7-8 42 Ibid., p. 8. 255 Union Community Hospital of Elk City, Oklahoma are three group health associations which provide some form of dentistry to subscribers. Farmers* Union Community Hospital is the only health group which has dentists as part of the health personnel and offers dental services, excluding the materials used, as part of the health services of the group. A majority of the group health associations analyzed have shared the common problem of inability to provide dental care for their subscribers on periodic payment basis. It is significant to recall that Ross-Loos Medical Croup and Farmers* Union Community Hospital have been in operation for more than twelve years. An official of the American Dental Association gives the follow ing reasons for the social retardation of group dental plans : In contrast to the rapid development of group medical plans there has been very little progress with respect to group dental plans. There have been a number of proposed plans which have never been put into operation, and the main difficulty seems to lie in the fact that much dental care is needed by such a large group of people that the cost is practically prohibitive.^^ A suggestion is offered by the writer that group health associations might surmount the problem that the average adult needs approximately fifty dollars in dental services a year by charging group members proportionate periodic payments based 43 Personal correspondence with S.R.L. of American Dental Association, July 29,1941. 256 on individual needs for a year period* Such a plan would effect the cure of existing dental disorders. An example will help make this plan clear. Mr. A needs forty-five dollars worth of dental treatment when he joins the group health association. His dental needs are met the first few weeks of his membership and he is asked to sign a contract stating that he agrees to pay three dollars and fifty cents for twelve months. At the end of this period he is eligible for periodic dental membership of one dollar per month.Dental and medi cal scientists have pointed out that the condition of the teeth has a vital affect upon other bodily processes. Ad equate dental services might be a factor in reducing the gen eral cost of health needs. Once curative treatment has been rendered preventive dental measures may be inauguarated by group health dentists. The above plan could be broadened to include dependents. The two essential points of this group dental program are: (1) meet the needs of existing dental conditions by individual installments, (2) place dental care on a periodic basis after the first year stressing earlier dental treatment and preventive dental service. The present state of affairs regarding dental payments Louis S. Reed, The Ability to Pay for Medical Care (Abstract of Publication Nol 25), Chicago: The University of Chicago Press, 1933), p. 8. It is pointed out that $10.70 per year per member would provide adequate dental service. 257 represents one of the principal bottlenecks in the group health association movement. Neither the science nor curative medicine measures of dentistry have advanced far enough to know what causes many dental disorders. However the most significant culture lag in dentistry relates to method 6f payment of dental treatment^ Not a single group health association in the United States offers complete dentistry on periodic payment basis. Three reasons may be advanced which at least partially explain the culture lag in adopting periodic payments for dentistry; (1) educationally, members do not realize the importance of dental health to the whole body, (2) social-psychologically, they have associated physical pain with dental treatment which Inhibit positive attitudes toward dentistry, (3) economically, members believe that twelve dollars per capita per year is too much to spend for health services for such a limited and restricted part of the body. Chapter abstract. 1. Group hospitalization attests objectively to the practicability of applying the insurance principle to another phases of health care and on a large scale. More than 7,500,000 subscribers, and 67 separate combinations of hospitals have organized themselves under the Blue Cross Plan. One reason which accounts partially for the widespread development of group hospitalization is that the American 258 Medical Association considers medical care as being separate from hospital care. The American Medical Association has thus reasoned that it is not "unethical" for hospitals to ^Pply the principle of insurance to the cost of hospitalization. Most group hospitalization plans have accepted the ethics of the organized medical profession in toto as being entirely satisfactory, hence have not felt the deliberate pressure of conservative medicine. Sociologically, group hospitalization plans represent a form of social conciliation with the ethics of American medicine. 2. Of course, there is evidence that hospitals per mitting physicians in poor standing with their local medical society to operate are running the risk of being omitted from the official list of approved hospitals published by the Amer ican Medical Association. Social and scientific status of the hospital are in danger by such omission. Group hospitalization plans, such as those of Group Mutual, Inc., have met with opposition from.the American Medical Association who fear the extension of group hospital care to general medical care. 8. Hospital administrators welcome group hospitalization because it is a means of supplying a predictable and dependable income. It is thus possible for hospital directors to plan, with a fair margin of assurance, the expenditure necessary for hospital maintenance, improvement, and expansion. 259 4# The application of the principle of health insurance through voluntary periodic payments for hospitalization makes manifesto:the social nature and implication of the group health movement in this country* Group hospitalization may he con sidered as a form of cultural thrust or lead. The accelerated growth which plans of group hospitalization have experienced is due in part to the lack of organized opposition from the medical profession. In fact, the medical profession has not opposed group hospitalization, hut has encouraged the develop ment of such plans. In fact, quasi group health associations have participated in diffusing factual information concerning the advantages of group hospitalization plans. 5. Another fact which may be considered as a contrib uting element explaining the culture thrust or advance of group hospitalization is the general passage of social legis lation permitting the application of the insurance principle to hospitalization costs. Almost one-half of the State Legis latures have passed new legislation for such purpose. Co operative and proprietary group health associations have not been very successful in obtaining suitable legislation for their respective health plans. In other words, group hospitali zation plans have experienced little difficulty in securing needed legislation, while, group health associations have encountered organized and stubborn social and legal opposition of certain groups within the medical profession* No doubt some of the accelerated growth of group hospitalization plans may be accounted for because of the differential action of State Legislatures toward these two forms of group health. In fact, in a few instances conservative medical groups were instrumental in encouraging the passage of legislation which limits health groups to quasi variety. 6. It is not simple to explain the apparent lag in the application of the insurance principle to the purchase of dental services. Several tentative explanations may be advanced : (1) dentistry does not constitute as great an economic burden upon the American people as does medical care, (2) dentistry has been, naturally, more limited in its area of need than general medicine, (3) probably the largest dental bills are confined generally to mature and older people, while medical care may become urgent at any age, (4) because of the nature of dentistry, dentists do not make such direct contact with the principle of insurance as applied to group hospitalization as have medical doctors; hence there is little opportunity for a transference of the insurance principle of group hospiti- zation to group dentistry, (5) also^tendency of American people to delay treatment of conditions that are not thought to be serious but cause considerable discomfort in the course of treatment. Group dentistry has been given its greatest stimulus 861 and aid from the indirect support of certain agencies partici pating in group medical care, particularly Farm Security Ad ministration and the National Youth Administration. 7. In this chapter were analyzed the most widespread forms of group health and most retarded. Group hospitalization plans are great culture thrusts compared with the culture lag of contemporary dentistry. CHAPTER VII A COMPARATIVE ANALYSIS OF THE ADMINISTRATIVE STRUCTURE, MANAGEMENT, AND CONTROL OF POLICY OF THE THREE TYPES OF GROUP HEALTH ASSOCIATIONS OPERATING IN THE UNITED STATES An effort has been made in this chapter to Illustrate graphically and to analyze the administrative set up of various group health associations. A number of charts have been constructed to present objectively something of the organizational framework of these health groups. A proposed model chart has been designed by the writer incorporating some of the best features various health groups have utilized. It is unfortunate that investigators in the field of social medicine usually fail to include as part of their studies relationships between managerial and professional personnel of health groups. This omission has been a serious one in view of the fact that the administrative control of group health associations is frequently the key to an appreciation and -understanding of the purpose and function of a variety of such groups. Often it has been the administrative structure and management which has been the chief distinguish ing element between the types of group health associations in this country. In the following section the administrative 263 structxire and management of group health associations are analyzed. STRUCTURE AND MANAGEMENT OF GROUP HEALTH ASSOCIATIONS The structure of a proprietary group health assoc iation, or producer type, is represented best probably by the Ross-Loos Medical Group of Los Angeles, California. A study of Chart I on the following page Indicates the organ izational framework of this health group. Inasmuch as most of the subscribers to Ross-Loos Medical Group have been recruited from a variety of occupational groups, the struc tural nucleus for the subscribers has been found in the organization committee of their particular occupation. In June, 1941, there were more than 187 separate organizational committees which were composed of representatives of respective occupations. The titles of these committees of employees varied, i.e., Los Angeles Teachers* Organization was known as "The Health Committee," Employees of the City of Los Angeles the "Medical Board of Control," and the Southern California Telephone Company the "Employees Medical Assoc iation. " The principal duties of these subscribers* committees are to arrange with their employers to make a monthly payroll CHART I ADMINISTRATIVE STRUCTURE OP THE ROSS-LOOS MEDICAL GROUP (Los Angeles, California) 264 Professional personnel (Medical doctors, nurses and technicians)_____ Clerical staff Hospitai- ization Individual members Dependents of subscribers Doctors Ross and Loos and 18 co-partners Member subscribers belonging to occupational groups Organizational committees of occupational group subscribers Prepared by Edward C. McDonagb. 265 deduction of their dues and to forward the total amount to the Hoss-Loos Medical Group* These committees have received complaints and have atten^ted to adjudicate such charges, generally In conference with an administrative represent ative of the health group# Another Important function of the lay committees has been to compile a report of the names of people who have terminated their subscriptions, names of new subscribers, and to present the health group with an official and accurate list of all dependents of subscribers#^ Organizational committees have functioned successfully as agencies augmenting membership enrollment# It has been a policy of the Ross-Loos Medical Group not to advertise nor to solicit business as an organization. Often when a group of employees sought membership with this group health association, a temporary organizational committee was formed. An administrator from the health group meets with this committee to explain types of services available, fees, and the nature of the association. Probably the next pro cedure If for the committee to circulate a bulletin among employees describing the nature of the health association# However, a careful review and analysis of the Information set forth In this bulletin Is made generally by a represent- ^ Robert J. Clarke, "How Subscribers to Group Health Plans Cooperate with Physicians," Medical Care, 1:223, July, 1941. 266 ative of Ross-Loos Medical Group. Robert J. Clarke, a former chairman of employees medical association of Southern California Telephone Company, has remarked that "the whole matter Is thus handlei on a voluntary basis. The committees are not allowed to publish anything about the medical service In any of the plant organs or other publications without the 2 permission of the doctor." An analysis of California Physicians’ Service, a quasi group health association, exhibits the structure of a producer health group which was authorized officially by the American Medical Association as a health group which conformed to the ethics of organized medicine. As previously pointed out this form of health group was organized almost for the express purpose of "heading off" the future develop ment of full-fledged group health associations, whether of layman or physician origin. The structure of this quasi health group reflects the control of administrative policy by members of the medical profession. Chart IÏ reveals the organizational set up of this, health group. It may be observed that this chart reveals the structure of the ad ministration of California Physicians’ Service as being organized around representatives of organized medicine. For Instance, of the nine trustees of this health group, 2 Ibid.. p. 225. CHART II ADMINISTRATIVE STRUCTURE OP CALIFORNIA PHYSICIANS* SERVICE 267 Hospital ization 1 Medical director Adminis trative members (limited to 75) 1 Assistant medical director 5,500 Professional members (M.D.*s) Board of Trustees (limited to 9 members) 19 District deputy medical directors Executive officers (President, vice- presidents, secre t- ary-treasurer) 27,000 member subscribers belonging to occupational groups (beneficiary members) Prepared by Edward G# McDonagh 268 eight are medical doctors# Monsignor Thomas J, 0'Dwyer, a leader in social service work, is the only layman on the Board of Trustees of California Physicians* Service* Of general interest is the fact that the President of the Board of Trustees of this quasi health group is a former President of the Ameri^ can Medical Association, Doctor Ray Lyman Wilbur* There is thus little doubt as to the conservativeness of this health group* The medical director and deputy medical directors are chosen by the Board of Trustees, but only after consultation with professional members in each district concerned*^ It was thought possible by such a procedure to select in each district a Deputy Medical Director in whom the medical profession therein had confidence* Administrative members are elected for a three year term. The State of California is divided into twenty-one ad ministrative districts and there are two administrative mem bers from each district elected by the vote of the profession al members practicing therein. - Terms are staggered so that all district representatives do not lose membership at any one time. In addition to the forty-two district members, the hartley P. Peart and Howard Hassard. The Organization of California Physicians * Service, pp. 576-77* 269 administrative members themselves have elected additional mem bers by a two-thirds vote to serve for a three year term*'^ A significant trend concerning a shift in the distribution of professional and lay members elected as administrative officers in California Physicians* Service is evident* In some of the earlier literature published by this health group seven of the thirty administrative members were non-medical doctors ; how ever, more recent leaflets published indicated that only nine of the sixty-eight administrative members are non-medical doctors* There has been a trend on the part of physicians to elect a larger percentage of physicians as administrative officers* Hence, management of this health group has been more and more under medical control*^ In short, the managerial structure of this health group has been largely under the direction and supervision of doctors of medicine, who represent organized and conservative medicine in California* Inasmuch as there are several important variations in the structure and management of cooperative group health associ ations, it is necessary to present the typical structure of several types* Farmers* Union Hospital, the oldest group health associa- ^Ibid.. p. 572. It is wortliy of comment that not a single sociologist or economist is an administrative officer of California Physicians* Service* 270 tlon operating in the United States, has a rather clearcut and easily perceived structure. Chart III discloses the essential framework of this health group controlled by con sumers. One delegate for every twenty members is chosen to represent the interest of the membership at an annual meeting which is held in Elk City, Oklahoma. During the interim the Board of Trustees, composed of seven members elected from the general membership, takes care of the official business of this health group. The Board of Trustees allocates an annual budget to the medical director which is spent as the medical personnel think best. A medical director manages and super vises the character and caliber of health facilities and services, while lay administrators manage and control the economic affairs, general policies, and methods of recruiting members. Additional insight into the structure and management of cooperative health groups is afforded by an analysis of Group Health Association of Washington D.C* At an annual election generally held in the last part of January the members elect three trustees. Members are represented on the board of trustees by nine delegates and the Federal Home Loan Bank Board selects two trustees from its organization. Elections are decided by a plurality of vote and the members receiving the highest number of votes are declared elected as trustees. 271 CHART III ADMINISTRATIVE STRUCTURE OP FARMERS* UNION COMMUNITY HOSPITAL Elk City, Oklahoma Secretary- President Vice Treasurer President Board of Trustees Clerical Staff Manager Business Medical Director Hospital ization Membership General Professional Personnel 1 delegate for every 20 members Prepared by Edward C. McDonagh 272 A regular meeting of the Board of Trustees.is held on the first Monday of each month.^ The Board of Trustees elect five members of the board to serve as an Executive Committee which manages the business affairs of this health group during the interim between monthly meetings of the Board of Trustees. Chart IV depicts the structural relationship between lay members and professional employees on page 273. The officers of this health group are as follows : pres ident, a vice-president, a secretary, and an associate or assistant secretary, a treasurer, and an assistant treasurer, all of whom serve for one year. The president presides at all trustee and membership meetings and ha<f general supervision over the affairs of health group. In case of absence of the president, the vice- president assumes all duties performed by the president. Be sides keeping an attendance record and minutes of each meeting, the secretary is the custodian of the corporate records and papers end of the seal of the health association. In this health association the treasurer has an Important series of duties to perform. He has custody of all monies, funds, securities, evidence of indebtedness, and other valuable documents of the organization. In addition, the treasurer signs all checks, notes, drafts or orders for the payment of money and performs ^By-Laws of Croup Health Incorporated, pp. 22-23, CHART IV 273 ADMINISTRATIVE STRUCTURE OF GROUP HEALTH ASSOCIATION, INC. (Washington, D.C.) President Secretary Treasurer Vice-president Executive Coimnittee (5 members) Medical director Membership 11 Trustees Clerical staff manager Bus ine s s Hospital ization Professional personnel general mem bership elected from 9 Trustees 2 trustees elected by Loan Bank the Board Home Prepared by Edward C. McDonagh 274 all such other duties as are incident to his office. The Board of Trustees makes contracts for and in behalf of the members of ®roup Health Association Inc. with physicians duly licensed to practice their profession in the District of Columbia. The Medical Director, with the approval of the Board of Trustees, engages the services of assistants, nurses, and other medical help. The Board of Trustees del egates to the Medical Director the responsibility of making medical services available to members without interference from lay sources ; hence, the confidential relationship existing between physician and patient is not destroyed. An advisory council consisting of 150 persons elected as representatives of the fifty Federal agencies, serves as a connecting link between the trustees and the whole member ship. As. Arthur G. Pe:terson, chairman of the advisory coun cil has pointed out; ^*The council keeps open and makes use of a two-way route for the transmission of ideas and Infor- 8 mat ion between the membership and the trustees.’ * Members who are dissatisfied with the medical care they receive are re ferred to the medical director. If the subscriber is not satisfied with the settlement, he is permitted then to appeal 7 Ibid., pp. 25-26. Q Arthur G. Peterson, "Washington, D.C.; Group Health Association," Medical Care, 1:226, July, 1941. the case to a oommittee on claims and adjustments. This com mittee settles small claims, and refers larger claims and grievances, with recommendations, to the Board of Trustees for final action. It is a significant fact that only fourteen Q complaints were presented to this grievance committee in 1940. The importance of a proper relationship between various committees is well set forth in the following statement; Recognizing that satisfied and grateful members are the best assets of a health association such as ours, every effort is made through the advisory council, through various committees of the Association, the medical director, and the business manager, to keep in contact with the mem bership and ascertain what gives satisfaction and parti cularly what arouses dissatisfaction. The machinery that we have set up seems to be accomplishing this purpose. Gov ernment employees in Washington tend to be concentrated in large buildings and often there are large groups in one office or organizational unit. News about our Association gete around pretty fast— both good and bad news* Nothing travels faster than adverse criticism from some dissatis fied member. Perhaps this is well, for the management is thus kept on its toes to correct any deficiency in service or any just cause for complaint. Group Health Cooperative Incorporated in Chicago typifies a new kind of mutual relationship between laymen and physicians of Civic Medical Center. The Group Health Cooperative has taken over the educational program for the physicians. Inasmuch as the educational program has been functioning only a short time, it is perhaps best not to draw any conclusions except to comment ^Tbld., p. 227. ^°Ibid., pp. 227-28. i -q f > g W W -P 5 h Cl < c m 0 H & M ftp C f t u j a . w 'd 04 a 3 > 0 ^ C c d © w > d q O 0 f4 p H A 0 0 X\ 5 f f l ^ C J Ar4 0 0 c d > c d C 0 c d ë u 0 277 that Chart V reveals that no other group health association has such a well planned, administrative framework. As pointed out in a previous chapter Civic Medical Center engages the the facilities of Group Health Cooperative, in addition to the foregoing, to educate and inform the public to the medi cal and economic advantage sc of group health plans. The ad ministrative framework of this health group is further desiqvicA to encourage and promote sound local and national health programs. Wage Earners* Health Association of St. Louis, Missouri, illustrates a nice division of administration be tween lay and professional members. The general membership elects a board of directors who in turn select a president, vice-president, and secretary-treasurer. The board of di rectors and the medical personnel engage an administrator who is equally responsible to both groups, the doctors and the lay organization, and is in charge of the business.^^All problems common to the two groups are settled through the administrator and committees. Chart VI on the following I page depicts the organizational framework of this consumer health group. A model organizational structure is proposed in Chart ^^Medical Care You dan Afford, p. 7. CHART VI WAGE EARNERS* HEALTH ASSOCIATION (St. Louis, Missouri) 278 Executive Administration Medical Business Director Manager President Educ ation Bureau Speakers President Vice- Directors Board of Membership Committee Treasurer Secretary Outside Specialists Membership General General Practitioners and Special ists Prepared by Edward C. McDonagh 279 VII, An analysis of tiie diagram will reveal that the member ship elects the usual administrative officers, A dichotomous division of administration is proposed between lay and medi cal membership. An executive director supervises such com mittees and divisions as the following: finance, education, research, speakers* bureau, collection of dues, payment of personnel, legal department, publicity and newsletter, study classes in group medicine, membership committee. One full time person ought to be employed to serve as a lay guide. He would explain the nature of the facilities of the health group to the new member, A close working - relationship between the physician guide and lay pilot would facilitate a more complete utilization of both preventive and curative health services by members, The medical director supervises such medical de partments as the following: radiology, internal surgery, plastic surgery, otolaryngology, obstetrics, ophthalmology, surgery, urology, anesthesiology, pathology, pediatrics, in ternal medicine, dermatology and syphilology, and psychiatry and neurology# Besides the foregoing the associate personnel and hospitalization service would be under the immediate di rection of the medical director. In order to afford lay mem bers a more intelligent use of the medical facilities and personnel of the group health association, it is suggested that a medical guide-physician should be employed. It would be his 280 0) 0] p L , pL , a E - i M t > > to t i U - P f t _ r a u ®H a ^ C D O Q m m C s X / A t > a ® Æi o ® ® 4h c d A cd o ''d •H «H > ÜÎ o u<\ o ” o ^ ^ ® M Oi c SI tr _c " D 281 duty to advise the lay member what area of medical specialty 12 the patient should seek. Many lay members are bewildered when it comes to the selection of medical resources. Perhaps a general practitioner might also, serve as tentative diag nostician of the patient's needs. It is the'writer's thought that the lay-guide and physicIan-guide would serve an important need, that of the intelligent utilization of the resources of a modern group health association by members. CONTROIi OP POLICY It has been found necessary in a number of instances to refer back to particular structural types of health groups in order to describe graphically the control of policy. An important distinguishing characteristic or differentiating trait has been the manner in which the membership participated in forming and controlling the general policy of health groups. The control of policy in a proprietary group health 12 A physician guide might view the patient's ills more in Gestalt terms than a specialist. Unfortunately, occupational attitudes and proclivities are likely to hinder clear perception of the patient's needs. Because areas of the body have a general effect on the entire body and personality, specialists are likely to relate a general illness to their particular specialty. The role of the physician-guide would be to aid the patient in his selection of a specialist, a proper area of spe cialty. '^This fact can hardly be overestimated. 282 association, such as Ross-Loos Medical Group, is solely in the hands of physicians* Members of a proprietary health association are not asked to participate in the formation of policy* If a member does not like a particular physician he is given the right to change to another Ross-Loos doctor* Complaints are heard in the various subscribers' organiza tional committees* The salient control of Ross-Loos Medical Group resides with the owners of the health association rather than with the membership, for example, on April 1, 1941, the administration of Ross-Loos decided that it was necessary to raise the periodic payment of fees* Members were given several alternatives; however, if a member did not select one of these alternatives his contract was cancelled at the end of ninety days* It is probably the lack of control of policy that is responsible for the notion among some members of this health group that Ross-Loos Medical Group has the "psychological atmosphere" of a clinic* Members realize and recognize clearly that they are neither owners nor directors of this type of health group. The control of policy in a quasi group health assoc iation is also in the hands of physicians. However, control in these quasi groups is lodged in the hands of an even more historically conservative group of medical doctors than is found in proprietary health groups. The American Medical 283 Association has maintained for a considerable time that physicians ought to control the general policy, medical services, and economics of health care. It is important to recall that quasi group health associations were organ ized to check the formation of health grotps which might have heralded the day of "state medicine," with its pur ported medical inefficiency and political corruption. Professional members, that is, medical doctors, htive complete control of this type of health group. Even ad ministrative members are elected by the professional mem bers. Only one layman is represented on the Board of Trustees of California Physicians* Service, representative of this type of health group, and this member is not an administrative officer. The lay person who desires medical care under this plan has to follow the prescribed rulings of the physicians. California Physicians* Service requires that its physicians r carry malpractice insurance which thus frees the doctors from responsibility for failure to render satisfactory med ical care. In fact, California Physicians* Service is "not responsible for negligence or other wrongful acts on the part of its professional members.**^^ The legal rights of 14 H.P. Peart and Howard Has sard, o£* cit., p. 581. 284 beneficiary members are clearly stated in the following com ments included in their contracts : "an arbitration clause in all medical service agreements under which all claims and disputes between professional and beneficiary members must be submitted by arbitration by an independent arbitrator 15 whose award is final and binding." Organized medicine has been successful in several states in prohibiting the formation of group health assoc iations which are jointly controlled by laymen and physicians# For instance, in Madison, Wisconsin, a bill to prevent dis crimination by medical societies or hospitals against doctors who participate in cooperative health projects or other pre paid medical plans was voted down by the assembly 63 to 22. Ohio has enacted a bill sponsored by the State Medical Society which provides the organization of professional 17 services on a prepayment basis. The essential points of the bill are as follows; 1. The plan must be approved at all times by a majority of the doctors in the area served. 2. The board of directors must have 15 members of whom nine must be doctors of medicine. cit. The Cooperative Builder, May 3, 1941, p. 12. In correspondence with Doctor Emory S. Bogardus. 285 5. . At least ten physicians must agree to serve the project. 4. Membership will be limited to individuals who earn #1,800 or less and families that earn not over #2,400. As in the New Jersey law, no plan can function in any county unless it is approved by the local medical society. The pas sage of the bill was opposed by one section of labor and by the Ohio Farm Bureau Federation on the ground that it restricted too much the scope and control of medical service organiza- 19 tions. The Massachusetts Legislature, faced with one bill promoted by the Massachusetts Medical Society and another by the already existing "White Cross" Medical Plan, passed both measures. The Medical Society Bill requires a majority of the governing body of any plan formed under the law to be approved by the Medical Society and places the control of such plans under the State Commissioner of Banking and In surance. The Bill sponsored by the "White Gross" assumes that both laymen and physicians shall be members of the governing body, but this body will be elected by the sub scribers without control by a medical society. It is shown Ibid. "Course of Events," Medical Care, liSVl, July, 1941. 286 that "Under the Medical Society’s Bill all licensed physicians in Massachusetts have the right to participate in a service plan, whereas under -the other law, participating physicians must not only be members of the,medical society but their professional qualifications must be approved by the medical 20 board of the plan." Organized medicine in the United States has anticipated government aid for the indigent group in society. For this reason it has built the administrative structure of a health plan which would place medical control under its auspices. Evidence that the Federal Government has recognized quasi health groups as medical distributing agencies was found in the collaboration of the government through the Farm Security Administration with California Physicians* Service. Cooperative group health associations are characterized by division of control between lay members and physicians. While laymen have supervised the general administration, especially in connection with the socio-economic functions of group health associations, there has been, nevertheless, a definite and clear division of labor existing between medical services and general administration. Medical dir ectors select, discipline, and control medical personnel. 20 "Course of Events," Medical Care, I; 271, July, 1941. 287 hence lay members are not permitted to interfere with medical services rendered by physicians and other medical personnel. ■ Farmers' Union Hospital Association, as indicated in Chart3IÇ is administered and supervised by a lay board of Trustees* While medical services are under the control of physicians, especially the medical director. Doctor M. Shadid, business matters including the collection and expenditure of money are under the direction of lay member representatives. Social psychologically the members of this health group feel that the organization belongs to them largely because they exercise control of its policies. Control of policy more than mere ownership seemed to have been a determining factor in fostering proprietary identification attitudes. Probably the development of a feeling of belonging is not possible to the same degree in a large group health association with thousands of members where opportunities for face-to-face relationships between lay members and professional personnel are somev/hat limited. The control of policy in Croup Health Cooperative of Washington, D.C. is quite similar to Farmers* Union Hospital Association. Generally, the Board of Trustees selects physicians on the basis of the recommendation of the medical director. Medical matters are controlled by the medical personnel, and the business manager supervises the 288.. expenditure of all pecuniary funds. The advisory committee serves not only as a connecting link between the Board of Trustees and geiieral membership, but as an interpreting agency of health group policy. In summary, medical policy is under the control of the medical director, economic and clerical policy under the business manager, general policy is directed by the Board of Trustees. Group Health Cooperative Incorporated and Civic Med ical Center of Chicago, Illinois, have somewhat similar divisions of control as have other laymen-physician group health associations. In this particular health group coop erative and lay members have taken control of the educational program; whereas the physicians at Civic Medical Center main tain control of all medical policies and services. As this health group develops there is the possibility of greater participation by the lay members in the economic administrative structure of the association. The educational program had just been launched when this study was made, thus it was impossible to draw accurate conclusions regarding its success or failure. Wage Earners* Health Association of St. Louis also provides for a division of control between lay members and professional members. The lay members control the socio economic phases of the health group while the medical doctors administer the health needs of the members. The executive director, a layman, functions as an arbitrator between the lay control and medical control* The medical director per mits no interference on the part of laymen with the dis tribution of medical services to members* In the model administrative structure proposed by the writer the lay members would serve as exclusive controllers of the education and economic affairs of the health group. The advantages of group health are best broadcast by laymen. The layman pays the costs of group health medicine, therefore, it is natural that he have a voice in the control of pecuniary affairs. On the other hand, the scientific distribution of medical services must be controlled by the agents of such services, the medical doctors. The medical director should be elected by the physicians, as a rule, since they are most familiar with the capabilities of their fellow workers. The Board of Trustees should represent three groups: the general membership, the lay administration, and the medical personnel. A certain intra-cooperation within each of these three groups is possible because of the external independence between the groups. The division of control between laymen and profes sional members makes for a democratic freedom. Inter-coop eration between executive director and medical director would tend to facilitate the development of better health services 290 to more group health members. Chap ter reoapitulatlon. Tentative summary statements of important points set forth in this chapter are enumerated as follows : 1. The administrative structure of group health associations is found to be an important criterion which distinguishes one type of health group from another. The administrative structure frequently discloses the organiz ational hierarchy behind a particular health group. 2. Group health associations which had their initial impetus in consumer health associations are well known for having structural and functional division of labor and author ity between lay representatives and employed medical doctors of the professional staff. Lay boards of trustees manage the socio-economic mabhinery supporting the group health assoc iation, while medical directors supervise health activities. This division of labor is made more pragmatic by a mutually exclusive relationship. Specialized services make for separate control of certain administrative areas of a coop erative group health association. 3. Subscribers to proprietary group health associations and quasi health groups are not as able to identify themselves with the health group as member-subscribers of cooperative health associations. Cooperative health groups encourage the 291 membership to take an active part in the general administration of the health group through participation on various committees* There is a strong likelihood that participation in the activities of a cooperative group health association augments health mind edness* Members of consumer health associations often elicit the comment, "This is our group health association," 4, The anticipatory pattern of California Physicians’ Service, a quasi health group, is almost a cultural thrust. Organized medicine, as represented by the American Medical Association, has been reluctant to accept any type of pre payment health plan, especially group health associations, as being expedient solutions to the problem of distributing medical care to the American people. The possibility of government medical aid to certain indigent groups has been a significant factor stimulating the medical profession to action. The administrative structure of medical care for the poor has already been blue printed by California Physicians* Service and similar medical associations in other states, notauly Michigan, Washington, and Florida. 5. There has been objective evidence that organized medicine has tried to check the further development of group health associations by two principal methods : first, through the formation of quasi group health associations which serve as competing health groups of both proprietary 392 and cooperative group health associations, and secondly, through an active and definite effort to have enacted social legislation in various states that would determine the administrative structure of health groups in such a way that organized medi cine would control their policies and management. Ü. It is recommended that in a model group health association a lay-guide should he employed to aid the members in the utilization of the health group facilities. Y# It is suggested that a physician-guide be employed to pilot the patient-member to the right physician and medical service. A better relationship between generalized and special ized medical care might be effected by telic advise of the physician-guide. CHAPTER VIII GOMPARISOH OP HEALTH PLANS IN FOREIGN COUNTRIES WITH HEALTH GROUPS IN THE UNITED STATES This chapter is developed around a comparative analysis and review of several attempts and plans in a selected number of foreign countries which have been instituted to meet the problem of distributing medical services to a large segment of the population, particularly the low income group. It is worthy of note that, on the whole, European countries have not been very reluctant to apply and adopt the principle of health insurance. Unfortunately, wars have interrupted the normal growth and internal maturation of health reforms and movements. The current World War is partially responsible for the disruption not only of health plans, but it has created also what amounts to a virtual smoke screen hindering clear and accurate per- ception of recent trends in the development 6r retrogression of health plans. Because of present world conditions it is possible to compare only pre-World War No. II tendencies with certain phases of the health movement in the United States. Chart VIII, on the following page, compares and previews the principles of group health associations in the United 294 g Is r a 5 Ai S la - «I P' II If 03 o p, 4 J <D p r i ra O #3: • il m Ç - o M <M G c - d ® aîlî § ” âi§ (H p ü « o *H PII r4 * —I Q> <D "H CO O > k O 5 o 2 H 5 +3 < 1 3 o o «M rH O < M 0 3 O T O < 0 O œ ( B t3 r j , •H > O O C S ^ k •H P< 03 0 3 P.S till O «H • k bÛ'P S3 ra o r 4 g ail ■d -H G Ë» X < d - d tH O G 60 G o . « - H 6 0 k ^ §J g SSM-g ^ s § r S r > - _a-:M3g S I c > d " N p -H "d -d ra o ^ “ Ts ■ «< -H -d -H Pj d o ^ -H -H <D . O ra -P ro-H ra k o ^SJ il ^ to r a r a kM 5-dpâ ■draps fn P c d ^ O c d S " 5 p r a p . < n r a "o o i f f p . § W ) si • g ' . _ r a d p p " d 4 - 1 f f a ■ ? > p d p r a ® f f é Û ra P îlil I -5 o <M p l Ü l i i œ f f o d ra ra P< r a ’ ® - ^ P - I P . P , d r a l!i ° ° A _â>g r a ^ k P O (»ra :1ln « S ê - 5 A r a p r a I Ils o 6 A à 1 -d p ra d p N ■d 0 >> G r a ra ^ p r a r a p «OA ra r4 03 p p 0 3p d C d d ra^ 0 d P 03 r a 0 3 0 P 0 •«■d p rH r a . 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It is the purpose of this chart to show the similarities and dissimi larities of various plans and schemes to solve the problem of providing low cost and preventive medical care to large sections of the working populations of selected countries# Five dif ferent plans have been compared on the basis of ten principles or criteria, including the following; cooperative consumer control, preventive medicine, group medical practice, periodic payment, recruitment of clientele, selection of physiciens, payment of physicians, specialists, cash benefits, and health insurance. The five types of health plans are: Group Health Association, Cooperative type. National Health Insurance(Great Britain), Quasi Group Health Association(California Physicians* Service), Proprietary Group Health Associations(Ross-Loos Medical Group), and State Medicine(U.S.S.R*) Attention of the reader is directed to the fact that this graphic presentation makes manifest not only basic internal differences between the three types of health groups operating in this country, but also points out that there is little striking similarity be tween group health associations in the United States and Na tional Health Insurance as practiced in Great Britain and State Medicine as operated in Soviet Russia# In order to obtain a deeper appreciation of the type 296 of health, organization operating in European countries a some what detailed analysis and comparison is made of representa tive plans in a selected number of countries# GREAT BRITAIN An outstanding health development in Great Britain has been the widespread adoption of compulsory health insurance legislation for the low income group# This important social legislation was an outgrowth of several salient factors# Health insurance has been provided for a considerable number of workers on a voluntary basis through what were known as Friendly Societies. Previous to 1911 David Lloyd George, during a visit to the Continent, was impressed with the degree and extent of health insurance legislation in Germany. Sociologically we might say that he was an important agent in the diffusion of a culture pattern of health insurance. In this same year he laid his proposal for a system of National Health Insurance before Parliament# Mr. George remarks ; **The medical profession, which at the outset viewed it with unconcealed distaste, now finds it a highly satisfactory source of an income consider ably in excess of that which they formerly secured from the section of the public vhich it covers.”^ Apparently the pecu- ^David Lloyd George, in his Foreword to Douglass W. Orr and Jean Orr, Health Insurance with Medical Care ; The British Experience, (New York: The Macmillan Company, 1938T, p. v. 297 niary advantages of health insurance were factors in reversing attitudes of antipathy and distrust to attitudes of confidence and acceptance on the part of British physicians. Mr. David Lloyd George summarizes the great social significance and im portance of health insurance as follows# "it has become the keystone of our social structure for the maintenance and im provement of the nation's health, and round it have clustered a host of ancillary schemes for extending and supplementing the services it renders. As previously noted, while the chief impetus behind National Health Insurance probably came from Germany, the form which this insurance has taken was determined largely by in ternal and regional conditions in Great Britain, particularly the tradition of the Friendly Society, which was instrumental in inaugurating the Approved Societies as carriers of health insurance. For instance, under the tradition of medieval Guilds the Friendly Societies were benevolent and fraternal orders of working men which offered not only sickness insur ance, but social activities, unemployment and death benefits, paid for on an insurance basis. It is important to realize that these Friendly Societies were providing medical care for Q Loc. cit. Douglass W. Orr and Jean Walker Orr, Health Insurance with Medical Care : The British Experience (New York: The Macmillan Company, 1938), p. 56. 298 5,000,000 British workers at the time Lloyd George proposed compulsory health insurance for the British nation. In the original, because Mr. Lloyd George had threatened the in dependence of these Societies, liberal groups rose to pro test Parliamentary action pertaining to health insurance# It was advised that the Friendly Societies be permitted to retain their autonomy and thus remain free to expand. Even Industrial insurance societies were asked to be included in the scheme* It was disillusioning perhaps to the leaders of Friendly Societies that many of the proposed advantages of Approved Societies failed to manifest themselves. Doctor and Mrs. Douglass Orr have made a first hand study of the operation of National Health Insurance in England, and pointed out the role of commercial insurance companies as carriers of health insurance as follows : The Friendly Societies with their social and fraternal traditions were soon overshadowed by more aggressive in dustrial companies which were quick to seize an opportunity to establish contact with so large a potential clientele. This was the "great scoop." Since 1912, some of the in dustrial societies have enrolled hundreds of thousands of insured persons, so that a majority of English workers, contrary to the theory of the original Acts, are in fact without effective control of their Societies.^ Such an unfortunate state of affairs brings home the thought ^ITald.. p. 57. 299 that one of the cardinal principles of cooperative medicine is that members maintain control over the administrative organi zation. In the United States lay control over the financial affairs of health groups serves as a protection against any thing similar to the "great scoop" occurring here. Several other benefits to the insured worker, who earns less than $1300 a year, are as follows : sickness benefit paid during an acute illness or for a maximum of twenty-six weeks, a disablement benefit paid during a prolonged illness, and a maternity benefit paid to an insured worker when his wife has a child. The social psychological benefits are disclosed as follows by an English worker; "In times of serious and pro longed illness, it prevents worry which the mounting of doctors* bills used to occasion and enables people to receive proper medical attention which otherwise they might be deprived. " It has been observed that there has been a duplication of administration machinery occasioned by the utilization of the Friendly Societies as insurance carriers. Doctor John L. Gillin critically sums up the Friendly Societies as agencies of health insurance in the following manner: The United States is very fortunate in not having built up, as had the countries of Europe[particularly Great Britai:^ voluntary health insurance schemes within private societies. This function is gradually giving way in the ^Cited in Op. Pit., p. 59. 300 cotmtries of Europe, since it is seen that they are pretty largely a useless piece of machinery.^ It is worthwhile to examine briefly the nature of health insurance as it is operated in Great Britain. The insured British worker has complete freedom of choice of physician. All licensed medical doctors may become mem bers of the health insurance panel. After a worker joins an Approved Society, he selects a physician. The physician is paid on a capitation plan or per capita basis rather 7 than upon a fee schedule of services. The British physi cian receives a certain income for every member of his plan whether ill or not. In this way the medical doctor is assured a definite income per year. Inasmuch as he is paid on a per capita basis, it is to the advantage of the physician to pay close attention to incipient illnesses in order to avoid the burden of medical care for the.^ seri- ou sly ill* Insured patients are not charged for medi^cines prescribed by physicians. Pharmaceutists are permitted a reasonable profit for the drugs used and; prescription fee. Quasi group health associations in the United States pay physicians for services rendered, hence it is not to ^ John L. Gillin, Poverty and Dependency (New York; D. Appleton-Gentury Company, 1937),p. 563. 7 ■ Barbara N. Armstrong, Imstrring the Essentials (New York; The Macmillan Company, 1.932), p. 329. 301 the economic advantage of the physician to practice preventive medicine. On the other hand, cooperative group health assoc iations and proprietary group health associations pay their physicians on an annual'salary basis, which is quite compara ble to a per capita basis, hence preventive medical practices are extensively utilized to cut down the number of critical cases. The panel physician under health insurance in Great Britain and the physician under either cooperative or pro prietary group health associations are paid the same rate whether members of the panel or health group are ill or well; it is thus obvious why preventive medicine is so extensively practiced in these health plans. In the United States the quasi group health association, which was organized by the leaders of conservative medicine, pays its doctors on the basis of how many patients they treat. Preventive medicine if widely practiced would decrease the income of physicians on the panels of quasi group health associations in this country. The ethics of the American Medical Association is perhaps responsible for this culture lag. Unfortunately, the treatment of persons suffering from poor health is an economic advantage to physicians on the panels of these quasi group health associations. In England the payment of cash benefits to the insured person during times of illness is connected indirectly with 302 medical services* Inasmuch as a cash benefit to a wage earner when ill is dependent upon a physician* s report, there is a slight possibility of "lax certification." There is the dan ger that if a physician had gained a reputation for writing - cash benefit certificates for some minor illness, he might "unethically" develop a large panel of members on false prem ises* .If the Approved Society has any reason to doubt the health eligibility of a member for cash benefits, it may appeal the case to the Insurance Committee* In such matters the Regional Medical Officer often serves as a referee. Some thing of the nature and extent of lax certification is shown in the following statement: A doctor who habitually issues unjustified certificates will be asked to explain to the local Panel Committee and may be fined by the Minister of Health. In 1933, at the behest of Approved Societies, the Regional Medical Staff examined some 300,000 cases. Of these 213,000 patients were found gunuinely incapable of work in line with the panel doctor * s findings ; in 80,000 cases, or roughly one out of four, benefits were stopped and the patient declared fit to work.8 An interesting similarity between the American group health association and health insurance in England may be observed in the case with which the patient may change physicians. A dissatisfied panel patient may complain to the Insurance Committee or he may switch physicians. In practice ^Douglass W. Orr and Jean Walker Orr, op. cit., p. 3. 503 "He may change at once by having his first doctor sign the Medical Card as a release and then get the signature of the new physician*...If, however, the disgruntled patient does not wish to face his first doctor, he has only to notify the Insurance Committee directly and the change will be made at the next quarter*^ Prom a sociological standpoint some of the interviews with British workmen which the Orrs obtained are particular ly revealing of basic attitudes toward health insurance# Doctor and Mrs. D.W. Orr say; Doctors and insured persons alike told us that N.H.I. brings working people to the doctor much earlier in sick ness than before, giving them the added protection of treatment when it is most effective. Wage-earners not only appreciate having a regular medical attendant who can treat their ills, but they are also learning the value of going early in order to prevent serious compli cations of minor ailments. At the Princess Club Settle ment we listened to a discussion of N.H.I. by members of a girls club, in which we saw the reflection of a wide spread attitude. One of the girls stressed the preventive value of health insurance. It used to be she said, that her family and friends would delay until the last minute before going to the doctor. Under N.H.I. they go right away when anything is wrong. She said she doesn't know)^ how her family would get along without health insurance. Her father has been sick a great deal and her mother has more than needed the maternity benefits. Another Englishman remarked; "My father was an invalid for p. 34. . p. 38. 304 about fifteen years, and received constant attention during the whole time. Could have had no better attention had he paid ordinarily.Still another pointed out; "My wife has had a stroke and has had continuous attention for two and half years# Doctor attends monthly now# Service very good. The following cases are cited by Doctor Orr as present ing typical attitudes of British health insurees toward National Health Insurance; Can call out or visit doctor any time. Very good service given by doctor. doctor is the family doctor and fortunately I do not need his services much. Find his services very satis factory when required. Last summer I had five weeks* continuous illness when he visited me at home. This summer I had two visits. Ser vices just the same as if I had been a private patient. I have not had reason to visit my doctor for some years. I hear he is one of the best--goes to a lot of trouble for his patients.... The doctors are not so particular as they would be if you wasn't on the panel.... Have only visited my doctor once since 1912. Service good! 13 One of the serious shortcomings noted by both physicians lllbld., p. 38. ^^Ibld., p.39. 13 Ibid., p. 40. 306 and patients has been the failure of National Health Insurance to include the dependents of workers in medical benefits offered. It is not an uncommon practice for a family doctor to care for a worker as a panel patient and his family as private patients. With the exception of quasi group health associations, group health plans in the United States have made provisions for dependents of subscribers. Perhaps an other weakness in the operation of health insurance has been created by unscrupulous physicians and business men who sell panel practices to young physicians at exorbitant prices. How ever, there is some evidence that the British Medical Associ ation is attempting to curb such practices. Physicians seem to be rather enthusiastic in their praise of National Health Insurance* The following cases reveal what some British medical doctors think of health insurance: Doctor H, a young woman physician,remarked> ^The differ ence between panel practice and private practice,* she says, * is that you give private patients a complete overhauling and medicine for a half-crown, whereas you give panel patients a complete overhauling and a pre scription for nothing. The panel patient gets the prescription filled free at his chemist's and you get your quarterly check from the Insurance Committee.' Another general practitioner claimed that an important ad vantage of the scheme was that the physicÊan had no book- Ibid. r~P. 149. 306 keeping to do for his panel patients; hence no accounts to keep, no bills to send. Such a scheme more than compensates for the "paper work" required in signing certificates and medical cards, and "putting the ticks" of visits and 15 surgery attendances. A somewhat analogous development to quasi group health associations in the United States has been applied to the dependents of health insured persons in England. The British physicians, through the Public Medical Service, have organ ized a plan whereby the dependents of insured workers may receive medical services by paying a voluntary contribution.^^ The contributor has free choice of physician. In adminis trative control the scheme is similar to California Physicians* Service inasmuch as control is vested rather completely with physicians. Apparently British medicine realized that it was ethically and financially sound practice to place the cost of medical care on a voluntary insurance plan through small budgeted payments for dependents of low income workers. British cooperative societies have been instrumental in furthering the principle of health insurance. One of the significant elements of genuine cooperativeness is democratic Ibicl.r~p. 149. 16 Ibid.. p. 155. 507 control of policy by members* The Co-operative Wholesale Society of Great Britain has established a special department for health insurance. Considerable controversy was generated in the cooperative movement by the proposed National Insuraaace Act of 1911. Before the act was passed, the commercial insur ance companies were successful in obtaining the passage of a section which permitted the insurance companies to vote separate sections to operate health insurance on a non-profit making basis. It was this concession which opened the way for the cooperative movement to do likewise. While the connection between an approved society which is a special section of profit making concerns is not, in strict law very close, yet in practice the connection is much closer, since the parent body also provides good will and special facilities 17 for operating. Professor Garr-Saunders specifically sets forth the detail of the health insurance section as follows : Control of the G.W.S. Health Insurance Section, therefore, vest formally in the insured members. The membership is divided into groups of not less than 750 members each group being attached either to a co-operative society or group of co-operative societies, or to a depot of theC.W.S. Each group of members is entitled to elect from its membership 17 Alexander M. Saunders, P. Sargant Florence, Robert Peers, Consumers * Co-operation in Great Britain (New York: Harper and Brothers, Publishers, 1938), p. 180. 308 one delegate for every 1,000 members to transact business at tiie annual general meeting of the section and at special general meetings.^8 It is worthy of note that the total number of insured contributors for England and Wales increased from 15,894,000 at the end of 1929 to 16,710,900 at the end of 1935, an increase of 5 per cent. During the same period the member ship of the Co-operative Wholesale Society Health Insurance Section increased by 132,000 or 49 per cent. It is thus clear that cooperative health insurance has grown rapidly in recent years and is now the seventh largest approved society in that country.In the United States, however, cooperative medicine effects a greater economic saving due to the pooling of scientific equipment than is true in Great Britain. SCANDINAVIAN COUNTRIES In 1891 Sweden adopted a system of voluntary health insurance which was subsidized by the government. Compulsory health insurance in Sweden has not been accepted largely because of the cost of such a welfare program. Cash ben efits have been more emphasized than medical care as a Ibid.. p. 180. Ibid., p. 182. 509 20 national program* Norway, in 1909 adopted compulsory health insurance legislation which offered medical care for wage earner and dependent. The official carriers of health insurance were either private or public sickness societies. At least one sickness society was required by law in each commune. Provision has been made so that private sickness societies could substitute for public societies. Doctor John E. Nordskog, Professor of Sociology at the University of Southern California, portrays well the nature and extent of health insurance legislation in Norway in the following manner: It is also worthy of stress that not only may the insured member who has been contributing to the sick ness fund receive compensation, but the spouse and children or adopted children under fifteen years of age who are dependent upon the member may receive compensation for medical and dental aid, and nursing. To a member * s spouse is to be given compensation of 75 crovms for burial expenses, and for children or adopted children who are dependent, a benefit of 50 crowns. A wife #io is not herself a member of the fund may receive compensation against confinement, and in addition, 30 crowns as aid for each child birth. For children and adopted children under seven years of age who are dependent upon the member, and who have been born with defects for which early med ical care might effect cure or relief, such medical aid is to be provided from the sickness fund.81 Barbara Armstrong, 0£. cit., p. 317. John E. Nordskog, Social Reform in Norway (Los Angeles : The University of Southern California Press, 1955), p. 131. 310 Norwegian health legislation contains a sliding scale of health cash benefits which is adjusted according to the number in the family. Where there was only one dependent a twenty per cent cash benefit, was given, and where there pp were two dependents a 35 per cent cash benefit. The ad ministrative details of Norwegian health insurance are as follows : ...the State pays two sixth of the average premium for each member ; the community where the work is done pays one sixth; the employer pays one sixth of the average premium for every compulsorily insured member in his employ...For each sickness insurance fund there is to be a governing body consisting of five members, three of whom shall be insured persons and one an employer liable to pay contributions, and also personal substitutes, elected by the communal council for three years at a time. Chairman and vice-chairman are selected by the governing body itself. Each fund has a business manager, auditor, or auditors, and the governing body may appoint nurses, masseurs, et cetera, such appointments to be approved by the National Insurance Institution. Eligi bility to the governing body of the fund is subject to certain limitations : every person who is entitled to vote under the Act respecting elections to the Storthing shall be eligible, provided that the business manager and auditor of the fund, other paid en^loyees of the fund, and medical practitioners and midwives who practice on behalf of the fund under a contract shall not be eligible. The Act also provides that every person who is eligible shall be bound to accept office if elected, unless he has attained the age of sixty years or is chief guardian or a member of the standing committee of the commune or has acted as a member of the governing body during one term of office. Management may be provided separately for each fund, or jointly when suitable and efficient. Barbara Armstrong, o£. cit., p. 313# John E. Nordskog, o£. cit., p. 145. 311 Denmark adopted in 1892 a more thorough.-going system of voluntary health insurance than that in Norway or Sweden. The government granted rather liberal subsidies to registered societies having at least fifty members. Both medical care and cash benefits were provided for the insured population. Barbara Armstrong sums up the Danish health insurance system as follows : Denmark fund had achieved a fine organization of medical care, often furnishing specialist’s services and convalescent treatment for both the insured per son and his dependent children, setting a standard that was not equalled under some of the compulsory systems. The success of voluntary health insurance in Denmark is heartening to struggling group health associations in the United States. Mr. Frederic G. Howe relates the extent of Danish health insurance as follows : "Sickness insurance is not designed exclusively for workmen. It is open to all men and women of similar economic standing, and includes small farmers, agricultural workers, civil servants, and the life. Two-thirds of the population are insured against sickness through their local agencies operating under general state supervision. It is significant that by 1925 almost every sickness Barbara Armstrong, o^. cit., p. 318. Ibid., p. 309. 312 fund made available to the insured person not only complete medical care by a general practitioner but also treatment by a specialist if necessary. Drug and nursing services have become quite generally accepted by the Danes as imper ative elements of health insurance. Until the advent of the second World War Denmark had become a leader in the fielf of complete medical services financed through voluntary health insurance under state supervision. GERIvlANY Germany inaugurated the first compulsory system of 26 health insurance on a national basis in 1883. Pour general types of benefits were provided by this health legislation: sickness, cash benefit, maternity benefit, funeral benefit. Local sick funds were the chief insurance carriers. A good example of local fund and organization may be gained from a brief review of the Leipgig plan. Free medical attendance and care was administered from the first day of illness. A cash benefit was given from the second day of disability not to exceed 55 per cent of the basic wage. Instead of the two foregoing benefits, a disabled insuree received medical treatment in a hospital or sanitarium. In addition to the 26 Emory S. Bogardus, Sociology (New Yorks The Mac millan Company, 1941), p. 450. 313 cash benefit, pecuniary provisions were made in the following cases ; maternity, death, and members of the family not 0 7 gainfully employed. More than four decades ago a panel was organized in Leipzig, Germany, made up of more than three hundred physicians, to offer medical services on a contract basis. The inclusive- ness of the physicians associated with the Leipzig panel resembles quasi group health associations in the United States. By having a majority of physicians practicing in the city on the panel list it was possible to allow for free choice of doctor. Medical doctors were paid on a per capita basis. Health resorts and medicine were available to members. In 1911 the German compulsory insurance law was extended to a larger number of workers, including teachers and homemakers. In 1932 more than three-fifths of the total population of Germany were covered by compulsory health insurance, ap proximately three-fourths of the medical profession were em ployed by insurance organization. The increase in family sick ness benefit was stated as follows: Whereas in 1911 about 37 per cent of the funds provided medical service for the family of the insured worker, thus reaching nearly five million people not required to be benefited by the act, in 1925 over 85 per cent of the local ^'^Ibld., p. 309. 314 and rural funds, comprising nearly 94 per cent of the insured workers, provided such service for more than fourteen million dependents. Nearly five million more (family members) were included under the rules of substitute funds and the miners funds, thus raising the nusiber of family dependents receiving medical care through the insurance system to nineteen million prior to the compulsory inclusion of family benefits.^^ Liberal hospitalization and dental service were obtainable by a large segment of the German workers. One of the most encouraging trends of the pre-Hitler period was toward the incorporation of preventive medicine methods as a part of the national health insurance plan. An effort has been made to utilize visual aids to dramatize the im portance of preventive and early curative steps as factors reducing the seriousness of illness. UNION OP SOVIET SOCIALIST REPUBLICS Medical services in the Union of Soviet Socialist Republics have been subjected to the most thoroughgoing changes. Imperial Russia had developed certain important aspects of health insurance. Writers on health insurance point out that the system of health Insurance in Soviet Russia is more inclusive than in any other country in the world. It would be difficult. In fact, to imagine now Russian health insurance could be more inclusive. All income groups are included under the system. The Soviet Ibid.. p. 312. 315 worker was eligible for medical services and cash benefits beginning the day be became disabled. All medical services including specialists, hospitalization, and medicine were provided free. Not only is the employed worker protected, but all his dependents as well. Maternity-grants are quite liberal when it is considered that the employed expectant mother is requested to take a leave of absence from twelve to sixteen weeks with full compensation. Nearly all pregnant women in the Ü.S.S.R. are not eligible also for these benefits, whether employed or not. Possibly one serious drawback of the Soviet medical program is the lack of freedom of choice of medical doctor, especially in view of organized private medicine in this country and Great Britain, which seems to meet with favor on the part of the patients. Soviet medicine is frequently described as State med icine inasmuch as the government supervises and financially Q9 supports medical care for the Russian people. Harry Elmer Barnes, a liberal writer,says. Whatever one may think of Soviet economics in general, no honest or Informed observer can well deny the remark able achievements which Russia has made with state med icine. In spite of severe, if not unique, handicaps, Russia provides better medical service for the mass of 29 It might be said that state medicine in Soviet Russia is merely a reflection of the social and economic organization of that country. 316 its citizens than any other country in the modern world. This has resulted wholly from the introduction of State medicine.30 Dootor Henry E. Sigerist spent considerable time and study in the last few years in the Soviet Union. He has become one of the most forceful physicians in this country demanding reforms in the payment and servicing of medical care. Doctor Sigerist remarks: Nobody can deny that Soviet medicine in the short period of twenty years and under the most trying cir cumstances, has stood the test and has created powerful measures for the protection of the people’s health. It has demonstrated that Socialism works in the medical field too, and that it works well, even now, in the early beginnings of the socialist state. It has a system that is full of promise for the future— for a very near future...^ State medicine differs from voluntary group health associations in several ways. Under state medicine, the lay person cannot feel that a particular clinic is "his health group." He does not select his own physician. The physician is assigned to him at his place of work. The growth of proprietary attitudes on the part of either lay members or physicians can not develop very firmly. Under a system of government or state medicine the worker pays his contribution into a common fund; hence there is little ^^Harry E. Barnes, 0£. cit., p. 477* ^^Henry E. Sigerist, Socialized Medicine in the Soviet Union (New York: Norton Book Company, 1937), p. 307. 317 specific nexus between pecuniary contribution and medical services# It is rather impersonal relationship, probably more so than exists under fee-for-service group health medi cine# Lay participation in the control and administration of medical services is a worthy educational activity of the American group health association^ for it makes for health consciousness. State medicine, as practiced in Russia, eliminates this personal Interest.and constitutes a serious shor t c oming . INDIA In Bengal, India, an interesting health movement has been under way. About 30,000 people were organized into twelve socities in 1939. These societies have stressed public health training and care. A common problem has been to devise methods for controlling malaria. The doctors are paid monthly by a group of contributors drawn from semi-rural areas. Members receive medical services upon the paynent of regular dues. In some cases the farmers have traded farm' products for medical care. Industrial and public health services are thus offered, A central laboratory for research for research is maintained by the cooperative health societies# Each week a health union 318 32 conference is held and the problems are analyzed. SOUTH AMERICA A tendency worthy of comment is the fact that in the Western Hemisphere, the relationship between individual and environmental services is close. When health insurance is instituted in South American countries, it begins with primary emphasis on health and medical services and with lesser em phasis on compensation of disability wage loss. A rather close bond has been established between insurance and public health objectives.The cooperation between these two agencies is certainly important and natural. A good example of health insurance legislation and procedure may be ascertained by an analysis of the situation in Chile* In this country a comprehensive and broad social insurance law and enactment was passed in 1924, covering the risks of old age, invalidty, sickness, and death. The health insurance measure was enacted as a community measure because the death rates were unnecessarily, high and because tuberculosis and other diseases, whose incidence is closely associated with socio-economic factors, were excessively 1 prevalent. In 1938 the law of 1924 was supplemented by a 32 Doctor Emory S* Bogardus, ^ ’Social Principles of the Co-operative Movement,*- a class lecture, December 4, 1959. 319 preventive medical act, which, stresses the necessity for early detection and treatment of tuberculosis, syphilis, rheumatism, afflictions of the heart and kidneys, and the 33 occupational diseases# In order to aid in the detection of these diseases all persons covered by social insurance are required to submit to a health examination once a year. The importance of medical care as compared with cash sickness benefits is well related as follows ; In the social insurance budget of Chile, provisions for medical and hospital services take the leading place. In 1937-38, expenditures for these services were seven times as large as disbursements for cash sickness benefits, and accounted for 77 percent of the total cost of benefits. In the development of its sickness insurance system, Chile lays particular emphasis on the construction of hospitals, the establishment of clinics, and the organization of medi cal centers in rural areas. In effect, where basic per sonnel and facilities are lacking or inadequate to pre serve health or prevent illness, the new social Insurance system attempts to meet these needs# It develops an in tegrated program, largely avoiding the traditional divi sion of effort among public health, private medical service, and social insurance protection of individuals*^^ The majority of group health associations in the United States, no matter what type, have ignored and excluded from treatment persons afflicted with syphilis# Such exclusion discloses a rather archaic attitude toward these so-called “social diseases.** Adequate preventive and early treatment of persons afflicted I.S. Falk, "Medical Services Under Health Insurance AbDoad," Social Security Bulletin, 3:1^, December, 1940;//-zo, I 34 Ibid., p. 13. 320 would be a wise step in the reduction of the prevalence of these diseases. American public health officials have been endeavoring to convince the public that elimination of social diseases is bacteriological rather than a purely moraliquestion Chapter review. Schemes of health insurance have been adopted more generally in Europe than in the United States. As a rule voluntary plans of insurance preceded compulsory health insurance. Numerous agencies which formerly administered voluntary health insurance have served also as carriers for compulsory health insurance, which has resulted in unnecessary but inevitable duplication of administrative machinery. There is evidence for viewing what seems to be a "culture lag" in this country regarding the adoption of health insurance as a possible advantage, since the possibility of adopting com pulsory health insurance, if considered socially desirable, may proceed without hindrance of “overlapping administrative machinery" which so much encumbered the development in European countries reviewed. It would be erroneous to com pare voluntary group health associations in the United States with the Friendly Societies offering voluntary health insurance prior to the adoption of compulsory health insurance in Great Britain, or with similar societies in other European countries, since the former comprise a complete, centralized, administra tive organization with medical information and scientific 321 equipment concentrated in focal areas easily accessible to member clientele; while the latter represents incomplete, decentralized, heterogeneous administrative organizations lacking the close interaction of medical personnel and uti lization of common medical equipment. Considered from a soci ological point of view, group health associations in the United States represent a further and more efficient social advance than even the most exemplory systems of compulsory health insurance in contemporary operation in Europe. It would be a comparatively simple process to effect a social fusion of the average group health association in the event that the government decided to set up numerous compulsory health groups throughout the nation, because of administrative centralization of clientele, personnel, and equipment. 2. Medical doctors in Europe were reticent at first to adopt health insurance as a means of financing the cost of medical care. A definite social psychological shift in attitude toward positive acceptance of health insurance is observable in European countries. Comparatively speaking, it is significant that American physicians have realized quite recently that it is now ethical to pay for medical care on a periodical basis. European medical doctors who have in surance panels probably have more economic security than do many fee-for-service physicians in the United States. Economic 322 security, thus offered, constitutes the satisfaction of a basic wish and makes for less emotional anxiety about pe cuniary matters on the part of the physician. 3. Usually under compulsory health insurance insurees do not control their local insurance carriers since commercial insurance companies have "stepped into the picture" and taken over control# As might be expected, democratic control is most manifest in cooperative carriers of health insurance in Europe. Gooperative health groups in the United States are well known for the democratic lay control of basic adminis trative policies. In fact, lay groups are important co owners of the health group in this country. 4# Even though, legally, group health associations in the United States are sometimes considered as failing to employ the principle of insurance, there are several factors v/hich reveal that, socio-economic ally, health groups, at least indirectly, use the insurance principle# For instance, both health groups and schemes of health insurance involve the budgeting of payments by a group of members or insurees# It is this group budgeting of payments of health services which makes it possible to share the cost of severe illness among a large number of people. The risk of illness is thus met by a great number co-members. Sir William Beverridge defines insurance as : "The collective bearing of risks is insurance. 323 It is Insurance, whether the individual contributes specific premiums to meet èach specific risk, or whether hr receives free insurance out of the general resources of the community or of industry. It is insurance whether the contributions are voluntary or compulsory* "35 short, insurance may be considered as an attempt to guarantee another against less by a contingent event. Illness may be thought of as the contingent event with medical care offered as compensation for the loss of health. 5. It seems quite doubtful whether either compulsory health insurance or state medicine as organized in European countries will be adopted soon in this country, inasmuch as the obvious lack of membership control of administrative policy is almost diametrically opposed to the prevailing democratic culture pattern in the United States, epitomized in the development of cooperative group health associations around a democratic ethos* 6. The relative free choice of physician and ease with which a member may switch physicians are common practices and elements of both health insurance and group health associ ations. Preventive medicine is practiced by the panel physician under compulsory health insurance because it reduces the num ber of services on his panel, and, since he is paid on a capitation basis, reduction of panel illness recurrences auto- 324 matieally frees him for additional time to devote to private patients from whom he receives a fee-for-service remuneration. Preventive medicine is practiced hy group health associations because it is advantageous to the economic security of the health group. Economically, it is unsound for physicians under quasi group health plans to practice preventive medicine, since their incomes depend upon the types and number of health services rendered. Therefore, preventive medicine must be left to the altruism of the individual physician under the quasi group health plan. Unfortunately preventive medicine has been advocated largely because of its economic soundness rather than as a means of practicing social telesis. 7. Probably it is true that quasi group health associ ations in the United States are more closely analogous to compulsory and voluntary health insurance plans as conducted in European countries than are other types of plans operating in this country because they lack coordinated pooling of equipment and have the same duplication and overlapping of apparatus and medical information as is found in Europe. Prom the standpoint of social organization and progress, European health insurance schemes and American quasi group health associations manifest unfortunate culture lags. CHAPTER IX MAJOR CONTEMPORARY PROBLEMS AND VALUES OP COOPERATIVE AND PROPRIETARY GROUP HEALTH ASSOCIATIONS Attention is focused in this chapter on the general problems confronting, and values emerging out of health groups in the United States. In preceding sections of this study unique problems of particular group health associations were analyzed in considerable detail, but this chapter contains analyses of a cross section of com mon and significant difficulties experiences by these health organizations. MAJOR PROBLEMS 1. Group health associations have been troubled with the problems of increasing their membership. The American people have not been so^d completely on the idea of group medicine. In fact, many people have never heard of the group health association. Besides the lack of awareness of the group health movement, quite a number of potential members fear health groups because they are seemingly contrary to our capitalist ethos 326 of the American culture pattern. Group health association administrators believe that a health group ought to have a minimum membership of between 3,000 and 5,000 in order to operate satisfactorily and effi ciently. It has been noted earlier that members in smaller group health associations pointed out that if they had more members many of their problems would be solved. In other words, there seems to be a law of increasing returns in operation. A membership of 3,000 compared with 500 would make available the following facilities and services to members: il) a greater range and variety of health services, (2) a'greater range of choice of medical doctors by individual members. This fact has been repeatedly made manifest by the expressions of members. It is very doubtful that two or three doctors in a small medical group can satisfy the eccentricities of enough members.to instill confidence in their ability. Members, like consumers, want to shop around a bit for their doctors, and a feeling of social rapport between doctor and patient must be established before treat ment can be effective. (3) A larger membership makes pos sible a reduction in the per capita cost of health services given, and (4) more medical equipment could be centrally located which would automatically help facilitate the utilization of such tools. 327 Group health associations in their initial stages of organization and function are in an unfortunate situation. One member of a Midwestern health association expressed quite well the plight which is true of a number of small health groups as follows : "Our problem is literally a vicious circle. If we only had more members we could give better service for less, which would in turn attract more members to our health plan. During the first period of growth we have to appeal to the farsightedness and cooperative spirit of people in order to convince them of the values of cooperative health. As our health plan becomes larger it will be possible to point out the pecuniary savings involved in our plan, besides the underlying spirit of cooperation. In short, if we had a larger membership most of our present problems would be solved. The addition of new members and the maintenance of old members is certainly a central problem of group health associations. Other insights into the problem of recruitment of members will be gained by an analysis of some typical attitudes expressed by non-members as to why they did not join a group health association. A college professor of the University of Southern California interviewed as to why he did not join a groip health clinic replied as ^ Personal interview with 0.J. 328 follows• No, I am not a member of the clinic. I have, investi gated them,, however, and perhaps they are all right if you live in"the city. But if you live in a suburb they have a branch office, and they do not appeal to me. In my case I live in a community where they have a Branch Office, but I was not favorably impressed. In charge is a doctor who does not appear any too compe tent. It would not do to trust my wife and children to his care. He has one nurse. The set up is too small, and there is no choice. Of course, you can come in to the city to the clinic, but that is too far away for us. It wouldn’t work in case of emergency. The Branch Office is quite impossible. We middle class people certainly get soaked when it comes to medical service. The wealthy can pay and the poor get service free, but we have to pay prices that we cannot afford. The group health idea is good. But still I don’t know whether a doctor on a salary will take as much interest in his patients as one on a personal fee basis. I’m afraid most of them would take an impersonal attitude and not be really interested. Why should they take a personal interest when you don’t pay them directly? Some of them are too young and inexperienced. But we are in dire need of something like the group health idea. No, I wouldn’t be interested to help run the clinic. I’d be satisfied with first class service and moderate rates and would let the doctors run it. It is up to them to make good as doctors.2 The ecological location of the central office seems to be a pro Diem in the mind of this interviewee. In the branch office there is probably little "grouping of medical personnel and medical equipment" which prevents the promotion of attitudes of confidence. The interviewee also thinks that attitudes ^ Interview with A,H. 329 of confidence are inhibited because he feels that doctors on a salary basis might not take as personal an interest in patients as doctors on a fee-for-service basis might. If the emotional definition of the non-member is that the physi cians in à group health association are impersonal, to all practical purposes the situation may be considered as real, even though there may be little of actual fact to support this feeling. On the other hand, if by demonstration, physicians employed by the group medical plans can show that they are interested in their patients, and that they can give service as good as under a system of individualistic medicine, then a reversal in attitude on the part of patients is pos sible. Another non-member of a group health clinic expressed his feelings as follows: I have thought of joining the clinic several times partly because several of my colleagues belong, and partly because I believe in the idea. I would like to try them out in minor ailments, but I’d rather keep my family physician for major illnesses. I wouldn’t want to trust them for really serious care. I understand that they are very busy there, and that they do not have enough doctors, and some of my friends who are members have had difficulty in getting one of their doctors out to the house when some one needed emergency care. This happened, in one case I know of, and after considerable delay a young doctor came out, but he did not engender confidence in the patient. I wish there was a real cooperative medical plan operating here, with competent doctors. I have 330 investigated one in Los Angeles but it is small and a high-strung doctor is in charge. It doesn’t give me confidence in the plan, although I believe in the idea and would like to help develop a strong health cooperative where the members control it and not the doctors. However, not all my friends would care to be bothered with voting. Some of them would rather play bridge or write books or do research. It is woeful the way intellectual people are not informed about cooperative undertakings. They are so individual istic that they don’t want even to be cooperative unless it will help them in their personal interests. So few people want to be cooperative for cooperation’s sake. I guess that it is the fault chiefly of education in homes and schools.^ Failure to recruit this member who believes in the principles of cooperation is due to the fact that he does not have confü ence in the quality of medical service dispensed by the grcup health association. In the grave and serious medical case the confidence of the patient is taxed. Members have repeatedly made mention of the fact that the physicians sent on home calls are not of a type to generate deep-seated feelings of confidence in the patient, Our mores have cultivated a physical stereotype into which the public feels medical doctors must fit. Thus, the unknown group doctor sent out on a home call must fit the preconceived social psychological stereotype of the patient or he is viewed with distrust even before he is able to demonstrate his ability. In this the private practitioner 3 Interview with T.W. 331 has the advantage, for he is usually called to a patient’s home after having had an opportunity to prove his worth in the traditional medical surroundings of his own office, which fits into the mental stereotype of the patient's notion of what the medical doctor in attendance upon him should be like. This case also gives insight into our individualistic ethos. Our culture pattern stresses individualism to the extent that it is becoming difficult for people to think in terms other than those prescribed by capitalism. As cooperation becomes more of an accepted pattern, group health associations will probably not meet with as much opposition from the citizens as they do at the present time. 2. Another major problem mentioned earlier which confronts nearly every member of a group health association operating in the United States relates to the physical distance which some members have to travel in order to obtain medical services. Efforts have been made by a good many group health associations to have district group health offices located in satellite communities surrounding larger cities. However, as in the case just cited, some of the members insist that they do not have a range of choice of physicians in these district offices. Two other problems become clear which have been touched upon, namely, the small group health association cannot support regional offices 332 because of a small membership, and, on the other hand, the large group health association which endeavors to provide regional clinics is criticized because it does not have enough physicians in each office. In the regional offices there are not enough members to warrant the additional ex pense of hiring more doctors. Perhaps some form of shifting doctors around until they are able to locate physicians who are acceptable to a majority of the local member-residents might help to alleviate this problem. A member of a group health association in the East expresses her feelings re garding the problem of location of the central office as follows : at It is a difficulty which I am confronted with each time I desire medical attention. I have to drive nearly ten miles to receive medical care. I have been for tunate enough to be in pretty fair health and thus have not had to experience the full import of such a condition. The ill ambulatory patient is put to a lot of inconven ience by having such a distance to go. If you feel quite ill it is a problem to know whether or not a person ought to attempt to visit the doctor. After a medical examination I often feel psychologically upset and . driving back home is somewhat dangerous. Yes, I know that it is possible to have a physician call at my home, but that involves an extra charge, and I feel like my periodic payments are partial when I do that. Of course, you know that we are working hard on a plan whereby a district office will be established.^ A somewhat similar attitude is revealed by a member 4 Interview with M.P. 333 of a cooperative group health association in the Midwest: I am used to doing all my shopping and taking care of nearly all my business with local stores and peopled I find it a bother to have to take the street car down to the doctor’s office. All the big stores are beginning to have branch stores in our community. I hope it will be possible for our health group to have a branch clinic near my home.^ Some of the group health members do not realize that it is a financial impossibility to provide a district clinic for only a few members. There is also the possibility that some members of health groups still feel that they are buying something and deserve “salesmanship" attention* Many group health members fail to remember that they sometimes had to travel some dis tance to reach the office of the private practitioner of their choice before they joined a health group. Not every kind of specialist is found in the neighborhood, and what general practitioners are handy do not invariably meet with the ap proval of all the residents of the area. In the case of group health members, perhaps there is realization and appreciation of the merits of cooperative medicine. The problem is prob ably not one of more deficiency of group methods as compared with private medicine, but rather one of hope for more of a good thing. 3. Organized opposition of the American Medical Associ- 5 Interview with P.P. 334 ation to plans of group health constitutes a serious problem for the majority of group health associations operating in the United States* The traditional interpretation of ethics of medicine has clashed rather directly with the recent social development and organization of new health plans aimed at alleviating and improving the health status of the low in come middle class in this country. Hospital administrators sense the prestige value of having the name of their hospitals listed as being among the approved hospitals in a bulletin- published annually by the American Medical Association, for it gives the hospital social status to be so listed. It is clear that group health physicians cannot function as effi ciently as general practitioners if they are denied the right to utilize the tools and equipment of modern hospitals* In certain types of illnesses necessitating hospitalization, such discrimination seriously endangers the member-patient’s health as well as the good will of the group health association* In a few instances group health doctors have been threatened with license revocation if they continued to be affiliated with group health medicine. It was pointed out earlier in this study that the Group Health Association of Washington, D.G* was instrumental in taking a number of leaders of the American Medical Association to trial on the ground that the medical body was guilty of 335 violating the Sherman anti-trust laws * ^ The twenty-one defendants were found not guilty, hut the American Medical Association was found guilty of the charge. Legally speaking the American Medical Association’s policy of direct suggestion and antag onism to health groups has been frustrated by this trial, yet the social-psychological effect of the campaign which they have waged for so many years still persists as may well be observed by the response of the following group health mem ber: Our problem is in trying to straighten out the mischief which the A.M.A. has been responsible for so many years. They have confused the issue rather completely. Both the medical doctors and the public are in a state of confusion regarding just what is group health medicine. I have talked with a number of fairly intelligent people as to why they did not become members of our health plan, and do you know what they generally reply? ’I asked my doctor what he thought of the plan and he said that it was a step in the direction of socialized or communistic medicine.’ Everyone has heard horror stories which circulate about as to how patients are treated under state medicine, so they do not want to become connected with anything that smacks of communism. It will take a long time to re- con vine e those people that our type of group health care is strictly American and not the idea of some crack-pot in Europe. The evil seeds sown by the A.M.A. are still growing weeds. For many years cliques within the American Medical Association have effectively indoctrinated physicians practicing in this ^Por an excellent and fair review of this trial see “The Medical ’Anti-Trust Trial.’ “ Medical Care, 1S272-76, July, 1941. Interview with Â.V. S36 country with the idea that health groups ultimately lead to socialism or socialized medicine, labels not acceptable to the American people# Physicians in turn have imbued their patients with the same distaste for group medical practice. Hence, many non-members, when interviewed as to why they did not affiliate with a health group, frequently responded in much the same vein as the following: Our private doctors are opposed to such new fangled ideaé and if they don’t like group medicine why should we I If group medicine was a good thing the doctors would be the first to become associated with it.^ The attitudes of many physicians in the United States have been conditioned, at least partially, by the determined effort of official literature, most manifest in the organi zational section of the Journal of the American Medical Association, to retard or completely frustrate the social growth of group health associations in this country. Since 1932 the first part of each issue has taken up in considerable detail a review of recent scientific achievements and studies of medical care. This section might have been termed the cultural thrust section. The latter part of almost any issue of this medical journal during the last few years has been a review and repetition of traditional fee-for-service medical service and its ethics. From the standpoint of modern group 8 Interview with M* J. 337 health associations this section epitomized the manifest cultural lag of modern medicine. It is a serious harrier to the group health movement to have the physicians in private practice false judgments of the values and purposes of health groups. Occupational ly the medical doctor occupies a very high status and the lay person is likely to subscribe to his opinions complete ly. There is undoubtedly a transfer of prestige from what the physician says about group health assbciations to the good will which group health associations are endeavoring to en courage. It is perhaps more important to realize that many of the accusations made against the principle and practice of group medicine are not only incorrect value judgments, but are plain erroneous judgments of facts* Again, the edu cational program of group health associations will have to be twofold: one, the education of the purposes and functions of group medicine to the lay person, and secondly, the spread ing of correct Information about the true nature of group health associations to medical doctors in private practice so that a reversal of attitude may be made possible. It is true that many physicians in private practice are not willing to become "boosters" for this movement, but a more neutral attitude may supplant the one of antagonism so conspicuous # today. 338 The following unfair criticisms are leveled against group health associations most often by physicians in private practice who were interviewed: group medicine is just an other name for state medicine, foreign doctors are the only ones initiating such medical plans, the confidential relation ship between patient and doctor is destroyed, patients do not have free choice of physicians, patients are regarded merely as cases rather than as personalities* Thus the need for an adequate educational program becomes obvious when opinions as subjective and erroneous as these are given, and believed by many patients who feel that the doctor is well informed in all matters pertaining to health care and its distribution. 4* The limitation of medical service which group health associations have found necessary to make constitutes another serious problem* Group health associations have found it difficult to include dental care as part of the periodic payment for health* When members are forced to go to a pri vate dentist’s office and pay for dental work on a fee-for- service basis it tends to split the learning process of developing consumer cooperative habits* Group hospitalization and medical care have been organized on a periodic basis, utilizing a distribution of risks principle. From the stand point of an advancing culture pattern toward the purchase of health care and services, the omission of dentistry upon a similar basis is a noticeable culture lag. 5* Another problem which confronts most group health associations analyzed in this study is that member-patients often fail to visit the health group medical center when the condition is ambulatory, but insist that the physician make a house call. A certain degree of shortsightedness and selfishness is probably responsible for this problem. Some of the specific difficulties arising from this problem are as follows : First: Requests for house calls are sometimes made when there is no medical reason to prevent the patient from coming to the health clinic. It is natural that calls made under such circumstances place an unjustified burden on the medical staff. Second; Requests for house calls are sometimes made when hospitalization is actually required, A physician can often determine from an ordinary telephone conversation that it will be best for the patient to go to the hospital.direct ly. It is suggested that while waiting for the doctor to appear valuable time may be lost for both patient and physician. Third: There is a slight tendency to wait too long before the doctor is called, and then to expect him to make the call at once. Perhaps this hesitancy to call the physician may be a carrÿ- over from the days of fee-for-service care. 340 especially when a considerable fee was charged for each visit to the doctor’s office. Fourth; The criticism is sometimes made that the doctor making the call is not the same one who had taken care of the patient in the office. Ecologically, it is physically im possible for one physician to make calls over a great urban area. Fifth; The complaint is made that physicians do not make calls promptly enough. It is obvious that the physician cahfct stop his work during an office emergency to see a patient 9 at his home. 6. The proper division of control between consumer- laymen and producer-physicians looms up as one of the most significant problems ini the group health association move ment. Cooperative group health associations have attempted to define the areas of control between subscribers and pro fessional members. It has not always been possible to draw a fine line of distinction between lay control of socio economic structure and physicians* control of socio-medical functions, of cooperative group health associations. In a few instances physicians have resigned because they were not accorded more control over the general administration of the See “Medical Care in the Home," Group Health Journal, I S3, November, 1941. 341 health, group. Proprietary group health associations have been con trolled completely hy the professional members, the physicians. Because lay members are not owners of this type of health group, they are extended very little, if any, control over administration. Lay control in a proprietary group health association extends only to the point of offering suggestions for "improvement," Thus lay members are not integral agents in deciding vital administrative policy, even regarding the cost of periodic fees. About the only real control lay mem bers can exert is non-cooperation with the health plan. Non cooperation may take the form of the lay person terminating his membership in the proprietary group health association. Yet, this is not a very satisfactory adjustment for the health consumer for he must rely only on fee-for-service physicians from then on, A form of internal control, in order to main tain good public relations, serves to regulate the proprietary health group. Lay members have been excluded from cooperative partici pation in the determination of policy in quasi group health associations. In fact, it has been pointed out earlier that this type of health group has been instrumental in having enacted in certain states(Ohio) legislation which makes it illegal for lay members to control the administrative policy 3#2 of liealth group* It is therefore the quasi group health associations that would prohibit free choice of the type of health group the patient would select* SOME MAJOR VALUES OP GROUP HEALTH ASSOCIATIONS In this part of the study attention is centered upon significant positive values growing out of the group health movement in the United States. 1. The promotion of attitudes of health-mindedness is one of the natural and inevitable by-products of associ ation in group health plans, as well as the focusing of at tention upon the important asset of good health* In other words, attention is directed not only to the positive values of good health itself, but to the social benefits of good health as well* It is a social advantage to each member to maintain good health, for it reduces the per capita costs of membership, and indirectly restricts the possibility of spreading contagious diseases in the community* Group health associations have, in particular, recognized the social nature and implications of both good health and poor health. Most of the group health associations circulate a newsletter among the membership which not only carries interesting local in formation about the health group, but short discussions by 343 group health physicians are included in order to more complete ly inform the membership concerning the nature of many of the commonest diseases so that treatment can be effective in the shortest possible time. This tends to encourage the recognition of symptoms which might be serious. Self-recognition of con ditions necessitating competent medical attention by physicians is another factor furthering health awareness* In this con nection Group Health Association of Chicago, Illinois, has been very progressive and alert. This group has promoted an annual group health institute so that members may hear discussed, by nationally known authorities and leaders, problems of group health associations and recent developments in medical science. The education programs of group health associations emphasize in every conceivable way the advantages of good health by general meetings of the membership, newsletters, group health institutes, and interstimulâtion between member and member. 2. An attitude of encouraging the spread of preventive medical practices is another value of association in a group health plan. Preventive medicine is practiced by group health associations because it is a more convenient and intelligent way of taking care of the illnesses of the human body. Socio economically it is cheaper to practice preventive medicine than to attempt extensive curative treatment. Members in each cooperative and proprietary ^roup health association studied 544 are urged to seek early treatment for the first symptom of any illness. Inasmuch as physicians are paid on a salary basis there is no pecuniary advantage or reward in treating patients for illness. In fact, extensive morbidity rates among the membership automatically increases the per capita cost of rendering medical care. Preventive medicine is in step with the emerging advances of tomorrow. Seemingly minor ailments are examined by physicians, who, in the final analysis, are the most competent to judge what is minor and major in health matters, and judgment is not left to the patient, unskilled in diagnosis* Several of the larger group health associations encourage extensive X-ray analysis besides periodic health examinations in order to determine the possible presence of any obscure organic condition, especially tuberculosis. Preventive medicine and early treatment of disease are cardinal virtues of group health associations. 3. Group health associations further cooperative attitudes. The development of group health associations, especially of the cooperative variety, serve as connecting links in the continually growing chain of social activities organized around the principle of mutual aid and help. Co operative consumer stores, cooperative wholesale branches, cooperative producer centers, together with cooperative credit 345 unions and insurance would not be complete without coopera tive health groups. The following case illustrates the transfer of cooperative attitudes from the purchase of food to medical care : I became interested in the cooperative health plan largely because a member of our food co-op was a member. I was told how the principles of cooperation apply to medical service. I was rather skeptical at first as to whether or not doctors could render as good medical serv ice if they were paid on any other than a sliding scale basis. We are now thoroughly convinced that cooperative medicine Is a social reality. We share the economic misfortunes of a costly illness much the same way as insurance. We are making cooperation work in another sphere of man's wants and you may be sure that the more places cooperative principles are applied, even on a small scale, the more people will come to realize co operation is a practical and efficient way to live a good life.^0 Group health associations represent another area in which human beings are learning to live and act not as indif ferent, isolated, individual factors in the social environ ment, but as socialized cooperators. 4. The use of the insurance principle in a cooperative group health association can be considered as a fourth value. Even though, legally, cooperative group health associations in the United States are sometimes considered as failing to employ the principle of insurance, from a socio-economic point ^^Interview with N.S. 346 of view these health groups utilize the insuranoe principle# One of the cardinal principles and features of cooperative medicine is the group budgeting of payments by health mem bers for medical services. It is the group budgeting of payments that makes it possible for the members to share collectively the cost of all medical services. The distri bution of risk or insurance principle permits a health group to predict with fair accuracy the amount of money necessary to operate the organization. Thus while it is impossible for the individual to predict whether or not he will be sub ject to an expensive illness,health group officials can pre dict the average costs of all members* illnesses at least one year in advance. Without the insurance principle or distribution of risk principle, group health associations could not function practically or efficiently. The sense of security which members report is partially due to the assurance that they need not worry about the cost of an expensive ill ness. For a nominal charge per member per month all health group cooperators are insured against a large doctor bill. 5. Members of health associations have expressed the feeling that membership in a group health organization furthers attitudes of security. A member of one of the first health cooperatives in the United States ably reveals the security attitude and its relation to other cooperative 347 enterprises : Last winter the cooperative hospital saved my life. While my wife was at the hospital with a new hahy I was stricken with a ruptured appendix and it was necessary for me to he at the hospital also. You can he sure that under ordinary circumstances the financial cost of having three members of the family at the hospital all at the same time would have been awful. Well, the combined bill for medical service and hospitalization was so reasonable that I was able to meet it without too much hardship. You know we have taken part in co-op activities for quite some time. If it was HD t for our hospital I don't know how I could have managed. I would have wor ried myself sick I guess. Group health associations are experiencing problems inevitable in a social movement evolving out of a social situation which has allowed a system of regimentation by medical doctors regarding the servicing of illness to become a part of the folkways of the American culture pattern. Nevertheless, the united efforts of cooperating units as represented by the various group health associations have been able to prick the traditional security of conventional medical practice, and are emerging successfully as demon strators of the workability in practice of the social theory of democracy. b. The social values arising out of the group health movement stress the dignity and importance of a functional 11 Interview with A.P. 348 and democratic »vay of improving the health of the American people. Collective action of members of health groups is focusing the goal of good medical care within the reach of a great many low-income group persons in this country. Group health associations make manifest that the patient- ■ member and doctor are co-partners in furthering a healthier America. The subjective social-psychological, values of good health have infinite social implications since good health tends to be a basic factor in'building positive and optimis tic attitudes toward life. Thus, sociologically, cooperative principles applied satisfactorily to medical practice may result in a more widespread understanding and diffusion of the underlying philosophy of the American democratic tra dition and culture. CHAPTER X SUMMARY OP FINDINGS, RECOMÎŒNDATIONS, SUGGESTIONS FOR FURTHER STUDIES, AND SOCIOLOGICAL IMPLICATIONS OF THIS STUDY In this chapter special attention is focused on the conclusions and generalizations derived from this investi gation of the group health association movement in the United States. In the latter part of this chapter a few recommenda tions and suggestions are offered which may prove worthwhile for future consideration and study. Several sociological implications are set forth as generalizations grov/ing out of this piece of research. I. ,FINDINGS Origins of the movement. 1. Private clinics have demonstrated the medico-economic advantages of pooling med ical personnel and equipment in a centrally located medical center. Group health associations have incorporated this aspect of clinical medicine in their organizations and today consider it a cardinal principle of group medicine. 2. Failure to adopt compulsory health insurance legislation in the United States as a form of social amelio ration made people conscious of the need for experimentation 350 in health insurance on a voluntary and small scale basis. 3* The first health group services were originated by progressive business corporations in this nation. The em ployees of these corporations have been the recipients of medi cal care on a periodic payment basis, have benefited from the economic saving of pooling medical personnel and equipment, and have enjoyed the great advantages prevalent in a system practicing preventive medicine. Undoubtedly, in many instances modern group health associations have imitated methods and principles practiced by corporation medicine. 4. The findings of the studies made by the Committee on the Costs of Medical Care in the United § ta tes demonstrated conclusively that members of the low income class do not receive adequate medical attention under fee-for-service medicine. Group health associations have used these scientific findings as effective arguments for their existence, formation, and development. Comparison of health groups. 5. There are three distinct types of group health associations operating in the United States. Cooperative group health associations are characterized by democratic and divisional control by laymen and physicians. Proprietary group health associations are typified by the concentration and centralization of control and ownership in the producers--the health group physicians. Quasi health 351 associations represent an effort of conservative medicine to thwart the group health movement through the formation of health groups which incorporate seemingly similar principles of genuine group health associations. 6. Chart ÎX on the following page objectively sum marizes the cardinal principles as they are applied in each of the three types of health groups. It is easily observed that cooperative group health associations offer the most complete and extensive range of health services, proprietary group health associations ir^ke available the next most complete ranger of medical services, and that quasi group health assoc iations give only a limited range of medical aid. These three types of health groip s exclude from medical treatment approx imately the same illnesses, among which are the following: illnesses covered by workmen's compensation acts, mental conditions, venereal diseases, tuberculosis, and certain types of brain surgery. Characteristics of cooperative group health associations. 7. The social situation and community patterns are vital factors explaining the origin of each cooperative group health association. On the whole, cooperative group health associations have been organized in communities where at least one cooperative enter prise antedated the health group. 8. In the cooperative group health association there 352 CHART X A SOCIO-MEDICAL COMPARISON AND SUMMARY OP THE HEALTH GROUPS ANALYZED Legend I-VI--Cooperative Group Health Associations VII-X— Proprietary Group Health Associations XI-XIII— Quasi Group Health Associations □ Principles Applied Principles not Applied Den tistry I si m +3 -p c d I I I : H r-j aS aS O ® •H W il o o CO Partial Dentistry Consumer control Preventive Medicine Selected Physicians Individual membership Guaranteed Sàlary for physicians Group con sultation Care for depend enta of members Pooling of med- ical equipment Hospital- ization________ Free choice of doctors_____ Group Membership_____ Periodic payments Group Health Associations Analyzed CO to o ® ® -p to O T i Ip Tt U3 to O P O M M eh K O to 353 is a funetional division of control between lay members and professional members. Lay members control the administrative structure and policy of the health group; whereas physicians exercise complete control over all medical decisions and services. The division of control between lay members and professional members in cooperative health plans is, on the whole, harmonious and offers opportunities rich in democratic participation and management. Thus, the cooperative health group is closely related to the prevailing democratic ethos of the American culture pattern. 9. Cooperative health associations utilize primary group methods of social control rather extensively by com mittee meetings of both lay and professional members in which face-to-face relationships and social interstimulation develop attitudes of we-feeling among the members. Cooperative group health associations emphasize the importance of the individual opinions and desires of the members. Characteristics of proprietary group health associa-tions. 10. Proprietary group health associations resemble cooperative health groups in almost every respect except in the method of administrative control. The physicians in the proprietary group health association serve as professional members and controllers of the administrative plan. From the standpoint of the consumer, the proprietary health group is not as democratic as cooperative 354 health group. Nevertheless, proprietary health groups rep resent an advance over quasi health associations. Characteristics of quasi group health associations. 11. Quasi group health associations are the result of an anticipatory pattern of judgment of organized medicine. Conservative groups within the American Medical Association are attempting to regulate and redirect the group health movement in this country by forming health groups which appear to be similar to genuine health groups, with administrative management completely under the direct control of the physicians. 12. Quasi group health associations and compulsory health insurance resemble each other in that neither practices pooling of medical personnel and equipiaent in a medical center. 13. The supporters of traditional medicine and quasi health groups have been instrumental in obtaining legislation which virtually makes it impossible in certain states to organize a cooperative or proprietary group health association. 14. The culture complex of conservative medicine reveals the presence of culture lags within certain of its phases and modernism in mothers. The cluster of non-material culture traits concerned with the distribution of medical services through the channels of quasi group health associations discloses that traditional medicine has incorporated modern methods of periodic payments by laymen but has relegated to the background a refined 355 choice of physician by the subscriber, a pooling of medical equipment in a centrally located medical center, and group medical consultation. Values and problems of cooperative and proprietary group health associations. 15. Attitudes of members of cooperative and proprietary group health associations indicate a sense of financial security. Subscribers feel that health group member ship eliminates worry about the cost of medical care. These mcmbox’s also believe that health association physicians are more likely to be frank in revealing diagnoses to patients than are fee-for-service physicians. Many health group members lack confidence in non-group doctors because they feel that such physicians needlessly prolong a patient's illness. 16. These two health association types employ only a select number of physicians. One thing is usually true of both proprietary and cooperative health groups, and that is that onvjthe whole, physicians employed by these groups must meet higher academic and professional standards than physicians who are members of quasi group health associations. These hdalth groups are also able to assure their professional members a predictable annual income which is a distinct advantage not found in the quasi group health plan. 17, Members of cooperative and proprietary group health associations recognize the socio-medical importance of 356 preventive medical care. It is economically advantageous for these two types of health group to practice preventive medicine efficiently. However, the principle of preventive medicine is not practiced by physicians associated with quasi group health associations because these doctors are paid in terms of the amount of curative treatment rendered to subscribers, 18. Both cooperative and proprietary group health assoc iations have been subject to the organized opposition of the American Medical Association. Cooperative and proprietary group health associations have threatened the values held paramount by fee-for-service practitioners; hence, traditional medicine reacted by attempting to frustrate the development of these types of health group. Qbrrelative developments of the group health movement. 19. Group hospitalization plans demonstrate the practicability of applying the insurance principle of distribution of risk and periodic payments to another phase of health care. Hospital administrators approve the principle of g roup periodic paymjents to another phase of health care. Hospital administrators ap prove the principle of group periodic payments because it assures the institution a predictable annual income. 20. Group hospitalization schemes present a form of compromise with the ethics and program of organized medicine ~ which has been less hostile to them than to other types of 357 health associations. Nevertheless, coercion and social ostracism have been used as means of controlling hospitals wnich dared to deviate from the ethics of traditional American medicine. 21. The extensive and rapid development of group hos pitalization plans in the United States resembles a cultural thrust, while the undeveloped nature of group dental plans represents a conspicuous culture lag in this group health movement. II, RECOMMENDATIONS 1. A greater effort should be made to make the average fee-for-service physician more aware of the democratic aims and low-cost achievements of group health associations. The group health association movement might develop at a faster rate and with less opposition if the average physician understood what group health associations stand for and how they are factors in building community health. 2. State legislatures should pass enabling acts that would make available to the lay person a free choice of type of group health association, i.e., cooperative, proprietary, and quasi group health associations. 3. The qualifications, training, and experience of health group physicians should be published in booklet form 350 so that lay members could make a more intelligent choice of phys icians. 4# The educational program of group health associations should be expanded so that more lay persons can become familiar with the purposes, advantages, and nature of such organizations. 5. A person acting as a lay guide should be associated with each health group in order to explain the facilities of the health group to new members and to aid them in becoming active participants in some phase of cooperative medicine. b# Inter-cooperation between consumer cooperatives should be encouraged with group health associations. The more ways in which cooperators can participate in cooperative activity the greater opportunity there is for developing more cooperative personalities. Lay participation in various activities ought to be encouraged. Study groups on group health medicine, recruitment of members, finance committees, publication and other committees offer invaluable opportunities for developing læ.dership abilities and traits by the participants. 7. A guide for selection of physicians should be employed by the larger group health associations to aid the subscribers in selecting needed medical specialists. In misunderstandings arising between subscriber and health group physicians the physician guide serves as an unofficial arbitra tor. 359 III. SUGGESTIONS FOR FURTHER STUDIES 1. The construction of model educational programs for cooperative, proprietary, and quasi group health associations* 2. The application of periodic payments, distribution of risks, to services in the fields of dentistry, pharmacy, and optometry. 3. How well informed is the average fee-for-service physician about the democratic nature and preventive practices of grorp health associations in this country? 4. In what specific ways could consumer cooperatives o- aid in promoting the group health association movement? 5. How large a range of hospital services and facilities is offered by the Blue Cross Hospitals? 5. How well informed is the average citizen about the group health movement. 7. Of the three types of group health associations, cooperative, proprietary, and quasi, which has the most popular appeal to the average lay person? (The nature of each type of group health association could be set forth in an expressionnaire and a representative number of lay persons could rank these group health associations accoadding to their personal first, second, or third choice.) 360 IV. SOCIOLOGICAL IMPLICATIONS 1. Social movements exhibit culture lags and thrusts. 2. The various parts of non-material culture, especial ly social organizational frameworks, are also subject to varying rates of acceleration and retardation. 3. Homogeneous occupational groups afford natural areas for the organization of parts and activities of associations which compose the structure of a social movement, particularly the group health association movement# 4. The social participation of members in the group health movement makes for greater consciousness of the purposes and values of a social movement# 5. Member participation in the activities of a group hv^alth association builds and promotes health mindedness. 6. Democracy through cooperative action and participation is becoming an emerging American way, 7. Cooperation may be considered the basic democractic social process# BIBLIOGRAPHY 361 A. BOOKS American Medicinet Expert Testimony out of Court. New York: The American Foundation]! [293^ 2 Volumes. Armstrong, Barbara, Insuring the Essentials. New York: The Macmillan Company, 1932, 717 pp. , The Health Insurance Doctor: His Role in Great Britain, Denmark and France. Princeton? Princeton University Press, 1939, 258 pp. Baker, Jacob, Cooperative Enterprise. New York: The Vanguard Press, 1937, 266 pp. Barnes, Harry Elmer, Society in Transition. New York: Prentice- Hall Inc., 1940, 999 pp. Bernheim, Betram. Medicine at the Crossroads. New York: William Morrow & Company, 1939, 256 pp. Britten, Rollo H«, A Study of Dental Care in Detroit. Washington D.G.: United States Government Printing Office, 1938, 69 pp. Bogardus, Emory S., The Development of Social Thought. New York: Longmans, Green and Company, 1940, 566 pp. Sociology. New York? The Macmillan Company, 1941, 564 pp. Brown, Leahmore, Group Purchase of Medical Care by Industrial Employees. Princeton University Press, 1938, 53 pp. Burley, Orin E., The Consumers * Cooperative as a Distributive Agency. New York: McGraw-Hill Book Company, 1939, 338 pp. Burns, Eveline, Toward Social Security. New York: l%iittlesey House, 1936, 269 pp. Cabot, Hugh, The Patient's Dilemma. New York : Reynal and HitehcocE7~1940, Childs, Marquis W., Sweden: IBhe Middle Way. New York: Con sumers Cooperative League, 1936. Christie., A.C., Economic Problems of Medicine. New York: The Macmillan Company, 1935, 242 pp. 362 Coffey, Diarmid, The Cooperative Movement in Jugoslavia, Rumania, and North Italy. New York; Oxford University Press, 1922, 99 pp. Committee on the Costs of Medical Care, Medical Care for the American Peoples the final report of the Committee on the Costs of Medical Care. Chicago: The University of Chicago Press, 1932, 213 pp. Cowling, Ellis, Co-operatives in America. New York: Coward- McCann, Inc., 1938, 206 pp. Daniels, John,Cooperation: An American Way, New York: Covici-Priede, 1938, 399 pp. Davis, Michael., Paying Sickness Bills. Chicago: University of Chicago Press, 1931, 276 pp. ___________ , Public Medical Services. Chicago: University of Chicago Press, 1937, 170 pp. Dodd, Paul Albert, Economic Aspects of Medical Services, with special reference to conditions in California. Washington D.C.: Graphic Arts Press, 1939, 499 pp. Downey, E.H., Workmen's Compensation. New York: The Century Company, 1924. Elliott, Sydney, The English Cooperatives. New Haven* Yale University Press, 1937], 212 pp. Epstein, Abraham, Insecurity; A Challenge to America. New York; Random House, 1936. Falk, Isidore S., A Community Medical Service Organized Under Industrial Auspices in Roanoke Rapids, North Carolina. Chicago: The University of Chicago Press, 1932, 109 pp. , Security Against Sickness ? A Study of Health Insurance. Garden City: Doubleday, Doran & Company, 1936,,423 pp. ___________, C. Rufus Rorem, and Matha D. 2ing, The economic Aspects of Medical Services. Chicago: The University of Chicago Press, 1933. Pishbein, Morris, Frontiers of Medicine. New York: The Century Company, 1933, 207 pp. 363 Ford, James, Social Deviation. Hew York: The Macmillan Company 1939, 602 pp. Fowler, Betram. Consumer Cooperation in America. Hew York: The Vanguard Press, 1936, 305 pp. ________, The Lord Helps Those. . . Hew York: The Vanguard Press, 1938, 180 pp. Gillin, John Lewis, Poverty and Dependency. Hew York: D. Appleton-Century Company, 1937, 755 pp. Guild, Cameron St. Clair, Surveys of the Medical Facilities in Three Representative Southern Counties. Chicago; The University of Chicago Press, 1932, 173 pp. Harris, Henry, California Medical story. San Francisco: Grabhorn Press, 1932, 397 pp. Harris, R.W., and Leonard Sack, Medical Insurance Practice. London: The British Medical Association, 1929. Higgins, H., The Ross-Loos.Clinic; A Pioneer Venture in Group Medical Service for Public Employes. Chicago: Civil Service Assembly of the U.S. & Canada, 1936, 29 pp. Hohman, Helen Fisher,‘The Development of Social Insurance and Minimum Wage Legislation in Great Britain. Boston: Houghton Mifflin Company, 1933. Howe, Frederic C., Denmark: The Cooperative Way. Hew York: Coward-McCann,Inc*, 1936, 227 pp. Laidler, Harry, Consujtners' Cooperation. Hew York: The League for Industrial Democracy, 1937, Ï64 pp. Lee, Roger I., The Fundamentals of Good Medical Care. Chicago: The University of Chicago Press, 1933, 302 pp. Leven, Maurice, The Income of Physicians. Washington D.C.: The Committee on the Cost of Medical Care, Abstract of Publication Ho. 24, 1932, 35 pp. McCleary, G.F., National Health Insurance. London: H.K. Lewis & Company, Ltd., 1932. 364 Minis, Harry I., Sickness and Insurance. Chicago: The ' University of Chicago Press, 1937, 166 pp. Moore, Harry H#, American Medicine and the Peoples * Health. New York; D. Appleton & Company, 1.9277 647 pp. Mumford, J.G., Narrative of Medicine in American. Philadelphia ; 1903, 508 pp. Neifeld, , Cooperative Consumer Credit. New York: Harper & Brothers Publishers, 1936, 223 pp. Newshohae, Sir Arthur, Red Medicine. Garden City: Doubleday, Doran and Company, 1933, 324 pp. Orr, Douglass W. and Jean Waler Orr, Health Insurance and Medical Care : The British Experience. New York: The Macmillan Company, 1938, 271 pp. Packard, Francis P., History of Medicine in the United States. New York: P.B. Hoeber, Inc., 1931, 1931, 489 pp. Paget, Sir J., Selected Essays and Addresses. London: Long mans, Green, and Company, 1902, 445 pp. Peeblies, Allon, A Survey/of Statistical Data on Medical Facilities in the United States. Washington D.C.: The Committee on the Cost of Medical Care, 1929, 119 pp. Podolsky, Medicine Marches on. New York: Harper and Brothers, 1934, 343 pp. Rainwater, Clarence E., The Play Movement. Chicago; The University of Chicago Press, 1922. Reed, Louis S., The Ability to Pay for Medical Care. Washington D.C.: Abstract of Publication No. 25 of the Committee on the Costs of..Medical Care, January, 1933, 15 pp. Riesman, David, Medicine in Modern Society. Princeton University Press, 1938, 226. Rorem, Clarence R., The"Municipal Doctor" System in Rural Sackatchewan. Chicago : The University of Chicago Press, 1931, 84 pp. 365 Rorty, James, American Medicine Mobilizes. New York: W.W* Norton and Company, 1939, 345 pp. Rubinow, I.M., Social Insurance with Special Reference to American Conditions, 1916, 490 pp. , The Quest for Security. New York: Henry Holt and Company, 1934, 634 pp. Sanders, A.M., Florence P. Sargant, and Robert Peers, Con sumer s* Cooperation in Great Britain. New York: Harper and Brothers Publishers, 1938, 558 pp. Seelig, M. Garbiel, Medicine. Baltimore: Williams Book Company, 1931, 205. Seidman, Joel I., Sickness Insurance and Group Hospitalization. Washington D.C.: Editorial Re search Reports, 1934, 50 pp. Shadid, Michael A., A Doctor for the People. New ^ork: Vanguard Press, 1939, 277 pp. ______ , Principles of Cooperative Medicine, 1939, 117 pp. Sigerist, Henry E., Socialized Medicine in the Soviet Union. New York: W.W. Norton & Company, 1937, 490 pp. Simons, A.M., and Nathan Sinai, The Way of Health Insurance. Chicago: The University of Chicago Tress, 1932. Stern, Bernhard F., Society and Medical Progress. Princeton: Princeton University Press, 1941, 249 pp. Turley, Louis Alvin, The History of the Philosophy of Medicine. Norman: The University of Oklahoma Press, 1935, 43 pp. The Medical Profession and the Public : Currents and Counter currents. Philadelphia: American Academyyof Political and Social Science, 1934, 112 pp. Vincent, Melvin James, The Accommodation Process in Industry. Los Angeles: The University of Southern California Press, 1930, 101 pp. Warbasse, James P., Cooperative Democracy. New York: Harpers and Brothers Publishers, T936, 2Ô5 pp. 366 Webbs, Sidney and Beatrice, The Consumers' Cooperative Move^ ment# London: Longmans, Green, and Company, 1921. Wilbur, Ray Lyman, The March of Medicine. Palo Alto; Stanford University Press, 1938, 280 pp# Williams, J.H. A Century of Public Health in Britain. London; A.G. Black Book Company, 1932. Williams, Pierce, The Purchase of Medical Care Through Fixed Periodic Payment. Hew York: National Bureau of Economic Research, Inc., 1932, 308 pp. B. PERIODICAL ARTICLES Agnew, H#, ”An Observer Looks at Group Hospitalization,” Hospitals, 12: 114-16, February, 1938. "American Dental Association: Action of the House of Delegates on the National Health Problem, ” Journal of the Ameri can Dental Association, 25: 2037-39, December, 193^0. "American Dental Association: Resolution passed by the House of Delegates Regarding Dental Service Plans, November, 1935," -Journal of the American Dental Association, 23: 163-68, 1936. "A.M.A. on Trial," Nation, 148: 4, December 31, 1938. "American Medical Association on Trial," The Journal of the American Medical Association, 116: 2058, May 6, 1941. "American Medical Association on Trial," The Journal of the American Medical Association. 116: 1538-40, April 5,1941. "American Medicine and the People's Health"Hygeia, 16: 299, April, 1938. Armstrong, D.B., L.I. Dublin, Eliz J. Steele, "What Medical Care Costs the Average Family," The Modern Hospital, 41: 1-5, November, 1933. Avnet, Helen Hershfield, "Costs of Physicians' Services under a Prepayment Plan, " Medical Care, 1:32-38, 1941. 367 "By Six-to-One in California; State Supreme Court's Action Upholds San Francisco Group Medical Group," Survey Graphic, 27; 547-9, November, 1938# Brown, P#K., "Industry's Answer," Survey Graphic, 16; 398, January, 1930# Bryne, T.J#, "Doctor Looks at Hospitalization," Illinois Medical Journal, 77: 71-75, January, 1940. Cahalene, R. P., "Group Hospitalization," New England Journal of Medicine, 220: 861-64, May 25, 1939. Carlson, A.D., "And Now, a Coop Hospital," Survey Graphic, 26: 470-73, 1937# Clarke, Robert, "How Subscribers to Group Health Plans Co operate with Physicians," Medical Care, 1:220-24, July,1941. Grew, M.C., and Elmer Daniels, "The Chicago Teachers Union Medical Center Plan," Medical Care, 1:162-63, April,1941. Davis, Michael, "Socialized Medicine; Arguemtns for and Against Compulsory Health Insurance," Good Housekeeping, 109; 22-23, August, 1939# Dawson, Marshall, "Medical Care Under Workmen’s Compensation," Medical Care, I: 1831, 1941. "Doctor Lawrence Jacques," Group Health Journal, 1:3, January, 1941. Duff us, R. L#, "The C^^isis in Medical Services," Harpers, 468-77, September, 1931# Ellsworth, Vont, " Health Program for California Farmers," Medical Care, 1:32-38, 1941# "Federal Health Program and the American Medical Association," Science, 88:275-76, September 23, 1938# Group Health Journal, 1:4, April, 1941. Group Health Journal, 1:4, May, 1941. Group Health Journal, 1:2, June, 1941# 568 Haigh, G*W*, "In Defense of State Medicine," New England Journal of Medicine, 202:1078, May 29, 1930. Hohn, M., "New Road to the Hospital," Parents Magazine, 12; 30-31, 1937. "Health Insurance for City Employees," (San Francisco) American Pity, 52: 15, July, 1937. "Health Insurance Plan for Public Employees," American City, 55:105, February, 1940. Jacques, Lawrence, "Preventive Medicine," Group Health Journal, 1:3-4, March, 1941. Journal of the American Medical Association, 113:682, August 19, 1939. Kelley, M.A., "Social Aspects of Hospital Service Plan," Hospitals, 14; 57-59, May, 1940. Kleeman, R.H., "For Three Gents a Day,” Good Housekeeping, 106: 36-37, October, 1937. Kleinschmidt, H.E., "Is there a place for the Voluntary Health Agency in View of the New Public Health Activities of the Federal Government, " American Journal of Public Health, 29: 49-54, January, 1939. Irving, P., "Socialization in Medicine Means Control by Politicians," Vital Speeches, 5: 203-5, January 15,1937. Lamping, T.J., "Significance in Group Hospitalization Plan," Illinois Medical Journal, 74: 269-74, September, 1938. Marguette, B., "Is the Private Health Agency on the Way Outf" American Journal of Public Health, 29: 46-48, January, 1939. Merritt, Arthur H., "The Centennial of American Dentistry," Journal of the American Dental Association, 27: 1974- *78 , Novemb e r, 1940, Patras, Petro, "Search for Health Security," Medical Care, I: 161-62, April, 1941. 369 Peterson, Arthur G., "Washington D.O* Group Health Association," Medical Care, 1:226-97, July, 1941. "Physicians’ fees and hospital bills," New England Journal of Medicine, 206: 781-86, April 14, 1932. Price, L., "Health Program of International Ladies Garment Workers Union," Monthly Labor Review, 49: 811-29, October, 1939. "Public Health," Survey Midmonthly, LXXIV: 386-90, December,1938. Pusey, W.A., "Some Tendencies in the Business of the Practice of Medicine," Journal of the American Medical Association, 90: 1897, June 9, 1928. Reed, L.S., "Hospital Care Insurance and social Security," Hospitals, 13; 25-29, February. Report of Special Committee to Study Hospital Insurance, Wisconsin Medical Journal, 37: 122-31, October, 1938. Rorem, Rufus, "Nonprofit Hospitals Service Plans," Medical Care, 1:111-17, 1941. , "Recent Developments in Hospital Service Plan," Hospitals 14: 36-39, March, 1940. Rubinow, I.M., "Do We Need Compulsory Public Health Insurance?" Annals of the American Academy of Political and Social Science. November, 1933, 1Ï2-120. Salzmann, J.A., "Program of Dental Care," Medical Care, 213- 22, 1941. Sand, R., "Social Insurance," Colorado Medical Journal, 27: 120, April, 1930. Schenenwerk, G.A., "Group Hospital Insurance," Hospitals, 14: 38-41, April, 1940. Strawn, T., "Hospitals’ Place in Hospital Care Insurance," Hospital Management, 46: 14, August, 1938. Sydenstricker, Edgar, "Group Medicine or Health Insurance Which Comes Firsts" American Labor Legislation Review, 79-87, June, 1934. Tischner, P.A., "Doctor ^ooks at the Voluntary Health Agency," American Journal of Public Health, 29: 536-37, March, 1939. 370 Van Steenwyk, E.A., "New Bine of March for Group Hospitalization," Modern Hospital, 49: 67-69, July, 1937. Vohs, O.P., "Group Hospitalization from Medical Man's Point of View," Hospitals^ 11: 52-55, November, 1937. Walch, J* Weston, "On the Witness Stand: The Pacts About Health Insurance." Winslow, G.E.A., "Sickness Insurance in Central Europe and Its Lessons for Us in the United States," Yale Journal of Biology and Medicine, New Haven, July 1, 1929, 391-40# Wynne, S.W., "Public ^ealth Vs Private Practice," Survey Graphic, 16: 394, January, 1936. C. BULLETINS AND PAMPHLETS A Primer of Cooperative Medicine. New York: Bureau of Cooperative Medicine, 1939, 15 pp. Amidon, Beulah, "Who Can Afford Health?" Public Affairs Pamphlets, No. 27, 1939, 31pp. Articles of Incorporation and By-Laws. Group Health Mutual Inc., St. Paul, Minnesota, 10 pp. By-Laws of Group Health Association Inc., Washington D.C., 1937, 29 pp. California Physicians' Service : Questions and Answers, j^94^ 27 pp. Cooperative Health Association. New York: The Bureau of Cooperative Medicine, 1937, 28 pp. Davis, Michael, Case Stories About the Costs of Medical Care and the Ability of People to Pay. Chicago : Julius Rosenwald Fund, 1935, 23 pp. __________, Security and the toerican Public. Chicago: The Julius Rosenwald Fund, 1936. 372 Eight Years' Work in Medical Economicsi 1929-1959, Recent Trends and Next Moves in Medical Care, Chicago: The Julius Rosenwald Fund, 1937, 45 pp. Poster, William F., Doctors and Disease. New York: Public Affairs Pamphlets, No. 10, 1940, 31 pp. Group Health Cooperative Inc., New York, 1940, 16 pp. Kruif, Paul de. Toward a Healthy America, Public Affairs Pamphlets, No. 31, 1939, 31 pp. Information for Subscribers to the Ross-Boos Medical Group, -------------------------------------------- K, Leland, R.G., The Health of Forty Million People, Chicago: The American Medical Association, 1939, 12 pp. Leven, Maurice, The Incomes of Physicians, Abstract of Publication No. 24, Washing ton D. C. : The Committee on the Costs of Medical Care, 1932, 11 pp. Medical Care in Selected Areas of the Appalachian Bituminous Goal Fields, New York: Bureau of Cooperative Medicine, 1939, 55 pp. New Plans of Medical Service. New York: Bureau of Co operative Medicine, 1940, 72 pp. Organization and Management of Consumers' Cooperative Associ ations and Clubs. Washington: United States Department Labor, 1934, 71 pp. Programs for Dental Health. The National Health Program Com mittee of the American Dental Association, 1941, 45 pp. Reed, Louis S., The Ability to pay for Medical.Care. Abstract of Publication No. 25, Washington, D.0.; The Committee on the Costs, of Medical Care, 1933, 15 pp. Report of the Connecticut Public Welfare Commission, 1919. 57 pp. Report of the Health Insurance Commission of Pennsylvania, 1919. 373 Report on Health Insurance by the New Jersey Commission on Old. Age, Insurance, and Pensions. 191*71 Report of the Illinois Health Insurance Commission, 1919. Report of the Ohio Health and Old Age Insurance Commission, February, 19Ï9. Report of the Social Insurance Commission of California, January, 1917. Report of the Wisconsin Special Committee on Social Insurance, 1919. Stewart, Maxwell, Cooperatives in the U.S.— A Balance Sheet. New York; Public Affairs Tamphlets, No. 32, 1939, 32 pp. Sickness, Insurance Catechism. Chicago; Bureau of Medical Economics, American Medical Association, 1938, 13 pp. Warbasse, James Peter, The Socialistic Trend as Affecting the Cooperative Movement. Chicago : The Cooperative League of the United States of America, 1940, 32 pp. D. REPRINTS Davis, Michael M., "The American Approach to Health Insurance," Milbank Memorial Fund Quarterly, July, 1934, Reprint Rosenwald Fund. Klein, Henry, Carrol E. Palmer, and John W. Knutson, "Studies on Dental Caries, " Reprint from Public Health Reports, No. 1932, 1938. Leland, G.G., "Group Hospitalization Contacts are Insurance Contacts," Reprinted from American Medical Association Bulletin, October, 1933. . ______ ,"Some Phases of Contract Practice," Bureau of Medicine and Economics, American Medical Association, Reprinted from American Medical Association Bulletin, October , 1932. 374 Leland, G.G., "Health Insurance In Er^land and Medical Society Plans in the United States," Reprint from American Medi cal Association Bulletin, October, 1934. Mountin, Joseph W., and Evelyn Plook, "Dental Programs Sponsored by Health Agencies in 94 Selected Counties," Reprint from Public Health Reports, No. 2096, 1939. Morris, Emory W., "Community Health Program," Reprint from The Journal of the American Dental Association, XXIIIs 495-*5üX. March, 1936. Peart, Hartley P., and Howard Hassard, "The Organization of California Physicians' Service," Reprint from the Symposium on Medical Care, published as of Autumn, 1939 issue of Law and Contemporary Problems, Duke University Law School, Durham, N.C. Roberts, Kingsley, "Health Programs Which Can Be Developed With out New Federal Legislation," Proceedings of the National Conference of Social Work, 1940. ____________, "Medical Cooperatives," Reprint from Health and Hygiene N.D. , "How Can We Get the Best Medical Care for All?" Reprint from The Ohio State Medical Journal, 36: February, 1940. "Prepayment Plans for Hospital Care," Reprint from Journal of the American Medical Association, 100: March 25, 1937. "Six Typical Hospital Service Associations," Reprint from Hospitals, April, 1937. Sigerist, Henry E., "Trends in Medical Education," Reprint from Bulletin of the History of Medicine, IX: February, 1941. "Some Defects in Insurance Propaganda," Reprint from American Medical Association Bulletin, March , 1935. E. PART OF SERIES 375 Abstracts of the Laws Pertaining to Cooperation in United States of America, Its Fosses sions and Territories. New York ; Works Projects Administrations, 1940, 350 pp. "Freedom and Interference in Medicine," Annals of the American Academy of Political Science, 200: 32-59, November, 1938. Leland, R.G., and A.M. Simons, "Do We îfeed Compulsory Public Health Insurance? No, " Annals of the Amer lean Academy of Political and Social Science, November, 1933. Sydenstricker, Edgar, "Health Insurance and the Public Health," Proceedings of the Academy of Political Science, June, 1935, 12-20. F. LEAFLETS ‘ A Plan for Medical Care. Atlanta. Medical Service Bureau 1940 Agreement for Annual Medical Services with Trinity Hospital. Little Rock, Arkansas, 1939. An Ounce of Prevention and a Pound of Cure Through Greenbelt. Greenbelt, Maryland, 1940. Gr>oup Health, Group Health Mutual Inc., St. Paul, Minnesota How to Pay Your Doctor* s Bills. New York : G^oup Heal th Association, 1940. The Answers About Group Health. Group Health Association of Washington D.C., September, 1940. Prepayment Plan, ChicagoS The Civic Medical Center, jl940^ Voluntary Givic Plan, Missouri and Southern Illinois, July,1940. Your Doctors and -hospitals Offer Health Service for YouI California Physicians* Service, 194TI 450 Physicians, Surgeons, and Specialists. King County Medi cal Service Corporation, Seattle, Washington. 376 G. NEWSLETTERS Chicago Teachers Union Medical Center Plan, Provided by Civic Medical Center, 1941. G.H.A» News, Annual Report Qf Group Health Association Inc., Washington D. C. : Jl941^ Contract Proposed by the Board of Directors. Greenbelt; Green belt Health Association, June 24, 1941. The Medical Care Program for Farms Security Administration. Farm Security Administration, 1941• Weitsman, Edward I., Newsletter, Wune 24, 1941, Greenbelt Health Association. H. NEWSPAPERS Los Angelas Times, March 6, 1941. Henry E. Sigerist, Newspaper _P M., October 4, 1940. The Ohio Co-Operator, April, 1941. The Cooperative Builder, May 3, 1941. APPENDIX 377 COPY OP ORIGINAL CONTRACT WITH LOS ANGELES COUNTY EMPLOYEES ASSOCIATION Dated July 25, 1929 AGREEMENT FOR MEDICAL AND HOSPITAL SERVICES THIS AGREEMENT made and entered into this 25th day of July, 1929, by and between the LOS ANGELES COUNTY EMPLOYEES' ASSOCIATION, hereinafter referred to as party of the first part, and the ROSS-LOOS CLINIC, a co-partnership composed to Doctors Donald E. Ross, and H. Clifford Loos, hereinafter referred to as party of the second part, WITNESSETH: That the ROSS-LOOS CLINIC will provide complete medical, surgical, and hospital services for members of the LOS ANGELES COUNTY EMPLOYEES' ASSOCIATION under the following terms and conditions : Every active member of the said association shall be eligible to receive benefits of this service upon the terms hereafter mentioned. The party of the second part hereby agrees that they will not enter into any arrangement or agreement for medical 378 or hospital services with any individual or group of individuals employed by LOS ANGELES COUNTY unless said individuals are members of the LOS ANGELES COUNTY EIÆPLOYEES* ASSOCIATION. If a member other than an active member desires to subscribe for the service mentioned herein, he may do so with the consent of the party of the second part. II The party of the first part will pay to the party of the second part on the last day of each and every month a sum equal to two dollars ($2.00) for each and every member of the LOS ANGELES COUNTY EMPLOYEES* ASSOCIATION who has subscribed for and is entitled to the service mentioned herein and who has been so certified by the party of the first part to the party of the second part. It is under stood that if an individual is so certified on a day prior to the 15th of the month that the full sum of two dollars ($2,00) is to be paid for said month, but if any individual is thus certified after the 15th of any month that no fee will be paid for such individual for said month. Any cost necessarily incurred in making collections from the persons mentioned herein is to be borne by the party of the second part. 379 III This contract may he terminated by either party hereto upon the giving of written notice to the other party of intention to terminate this agreement not less than 90 days from the date of said notice. IV It is agreed that the service to be rendered by the ROaS-LOOS CLINIC SHALL BE as follows: (A) To all members certified to the party of the second part as heretofore mentioned without further payment of any kind: 1. All medical and surgical attention intention including diagnosis, clinical or laboratory tests. X-ray examinations, treatments, operations, professional consultation, and visits. 2. All medicines and drugs with the exception of insulin, needed in the conduct of a case of sickness or of surgery which may be prescribed by the medical attendants. 3. All dressings, splints, etc., prescribed by the medi cal attendant, exclusive of orthopedic appliances, eye glasses, dentistry, crutches, wheel chairs, sicknoom furniture, etc. 4. Hospitalization of any subscriber where such treat ment is prescribed by the medical attendant for such period as 380 may be necessary in the treatment of any acute or chronic condition, providing the period of stay in the hospital of any one individual does not exceed three months in any one calen- year. Said hospitalization is to include ward bed in a first class hospital selected by the ROSS-LOQB CLINIC, such hospital selected by the ROSS-LOOS CLINIC, such hospital to be a privately operated institution. Should a subscriber desire other accommodations than those covered by the terms of this agreement, he will pay the difference between the ward bed rate of the private hospital selected by the ROSS-LOOS CLINIC and the cost of such accommodation as he may select. Hospitali zation shall be construed to mean bed, meals, general nursing. X-ray, laboratory tests, operating room, medical, and surgical supplies used, anesthesia, special diets, drugs, or any other adjuncts in ordinary usage in hospital procedure. 5. All cases of sickness and disease both medical and surgical are to be treated with the exception that cases of mental derangement and drug addictions are to be treated only up to such time as the patient may be legally committed to a state Hospital and provided further that the term "hospitali zation" should not. be construed to include treatment in a tubercular sanitarium. 6. The ROSS-LOOS CLINIC will maintain a complete and modern centralized office where all parties covered by this agreement residing in the metropolitan district of the city 381 or coimty of Los Angeles will report for service either by way of office or home calls ; the said metropolitan area is hereby designated as being that portion of the city or county of Lqs Angeles within a radius of ten miles from the Los Angeles County Court House. An office will be designated by the ROSS-LOOS CLINIC in the Los Angeles-Long Beach Harbor District: the San Fernando Valley; the Santa Monica Bay District;The San Gabriel Valley; and elsewhere as may be determined by both parties. All surgical operations will be performed by the surgeons of the central office and subscribers in all sections of the county will report to the central office for such work to be done, excepting in those cases where transportation would be to the detriment of the patient, or in emergency cases in which case the surgeon in the sub-office or the central office will render services required as may be requested by the patient. 7. Regular office hours will be maintained at both central office and sub-offices to meet the convenience of patients. 8. A 24-hour service by telephone will be maintained at both central and sub-offices with prompt response to meet demands for house calls, and it is further agreed that in emergency cases should the patient be unable to obtain the services of the physician at the sub-office, the ROSS-LOOS 382 CLINIC will respond to a call regardless whether the call is within or without the metropolitan district heretofore mentioned. 9# Except as above specified, the subscriber will not demand house calls to be made when he is in such physical condition that a visit to the office during regular office hours would not be detrimental to his well-being. 10. A subscriber residing outside the metropolitan district as heretofore defined may have residence calls made upon him upon the following conditions as to payments (a) If he resides within five miles of one of the designated suboffices, no extra charge. (b) In the event he resides more than five miles from the designated sub-office, the physician of the nearest sub-office will respond to the call, charging the subscriber mileage at the recognized rate as charged in the neighborhood where such call is made, providing, however, that such mileage charged shall not, in any event, exceed the sum of 50jé per mile both going and coming from the call, the mileage each way being computed on the basis of the difference between the dis tance from the sub-office to the call less the district of five miles. 11. Only regularly licensed physicians of high scientific 383 and professional standing, graduates of recognized, reputable medical colleges duly licensed to practice in the State of California, will be retained by the ROSS-LOOS CLINIC. In those cases where a specialist is required and provided that such specialist is not on the regular staff of the ROSS-LOOS CLINIC,the CLINIC will engage such a specialist, selecting one of recognized standing in the community. (B) Service to family dependents of subscribers : 1. Family dependents includes bona fide members of the subscribers* immediate family residing with him and wholly dependent upon him for support. 2. Family dependents will receive the same service and be entitled to the same privileges as the subscriber him self under the same rules as enumerated above and without pay ment of any fees for or on behalf of said dependent with the following exceptions to wit: The family dependents will pay the cost price for all medicines, drugs, dressings, splints. X-ray films, hospitalization and specialist as may necessarily be called in from outside the staff of the HOSS-LOOS CLINIC AND ITS SUB-OFFICES. ¥ IT IS FURTHER AGREED that in the event of a controversy 384 between the,ROSS-LOOS CLINIC or their representatives, and a subscriber, or should the said ROSS-LOOS CLINIC desire to drop from the list of subscribers any member of the LOS ANGELES COUNTY EMPLOYEES* ASSOCIATION, an arbiter shall be selected by the said Association, one by the said Clinic, and a third selected by these two and any decision arrived at by a majority of said arbiters shall be final and binding upon all parties concerned# IN WITNESS WHEREOF the representatives of the parties hereto caused the same to be signed, delivered this 25th day of July, 1929. (Signatures omitted here; see below-- Editor.) Amendment #1 IT IS FURTHER PROVIDED- AND AGREED AND TEÎE SAME is hereby incorporated in the foregoing agreement and made part thereof, that any member of the LOS ANGELES COUNTY EMPLOYEES* ASSOCIATION WHO has subscribed for the services herein referred to and who subsequently leaves the employ of LOS ANGELES COUNTY, may continue to subscribe to and receive the said services from the party of the second part upon the same terms and conditions as herein provided, upon the payment of $24.00 per year in advance, said payment to be made by 385 such subscriber directly to the party of the second part. Amendment #2 IT IS FURTHER UNDERSTOOD AND AGREED and the , same is hereby incorporated in and made a part of this agreement that on or after the first day of January, 1930, the part of the second part may declare the list of subscribers closed and may refuse to accept further subscribers to the service mentioned herein by giving thirty days notice to the party of the first part of intention to do so. Provided, however, that such notice shall not apply to or be binding upon any person who may hereafter join and be come a member of the LOS ANGELES COUNTY miPLOYEES * ASSOCIATION, until such person has been a member of said association for the period of thirty days. LOS ANGELES COUNTY EMPLOYEES* ASSOCIATION Signed; J. Roy MeClay, President Signed; Chas. S. Ryan, Secretary ROSS-LOOS CLINIC Signed; H. Clifford Loos 386 EXPRESSIONNAIRE The purpose of these questions is to lea m about the experiences and attitudes of group health association members. Sincere expression of what you think of your health group will be appreciated, ^our signature is not necessary inasmuch as it is more important to know what is thought than who thought it. 1. In what ways do you like your membership in a health association? 2. Since becoming a member have your attitudes toward health groups changed? Positively? Negatively? Why? 3. In what ways could the association services be . improved? 4. Do you take part in the activities and administrative control of your health group? 5. If you have any other comments, please use the other side of this page «r L « C CT D- f - 0 < x w^; { ï 5 O oo</p>

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Asset Metadata

Creator McDonagh, Edward C. (author)

Core Title Social phases of the group health association movement in the United States

School Department of Sociology

Degree Doctor of Philosophy

Degree Program Sociology

Degree Conferral Date 1942-05

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health and environmental sciences,OAI-PMH Harvest,social sciences

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c36-752295

Unique identifier UC11252992

Identifier DP31689.pdf (filename),usctheses-c36-752295 (legacy record id)

Legacy Identifier DP31689.pdf

Dmrecord 752295

Document Type Dissertation

Format application/pdf (imt)

Rights McDonagh, Edward C.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA