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A study of the Los Angeles medical agencies providing care for certain classes of low income groups

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A study of the Los Angeles medical agencies providing care for certain classes of low income groups

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Content A SIUDY OF ÎEHE LOS ASGELBS MSLIOAL AGEHOIBS PROVIDING GARB FOR OBRÎAIU GIASSBS OF LOW IRG0MB GROUPS A Thesis Presented, to The Graduate School of Social Work The University of Southern California In Partial Fulfillment of the Requirements for the Degree Master of Soience in Social Work ty Miriam Hosenhouse June 19S9 UMI Number: EP66130 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. Diss©naïi©n PM blisM ng UMI EP66130 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 T his thesisy w ritte n under the direction of the candidate’s F a c u lty C om m ittee and approved by a ll its members, has been presented to and ac cepted by the F a c u lty o f the School of S ocial W o r k in p a r tia l fu lfilm e n t o f the requirements f o r the degree of MASTER OF SCIENCE IN SOCIAL WORK D e an Faculty Committee Chairm an ÎABLB OF COOTBMS OH&PTBR PAGB I. æHB PROBJiEM ATO DBFIHIÎIOH OF ÎEBBÎS USED . • . . 1 The prohlem. 1 Definitions of tems used. . . . . . . . . 9 Medical facilities 9 Olinio............. 10 Medical care ......... . . . 10 Cost of medical care ......... 10 Income .......................... 11 Dow income group .. .. ...... IB Medical social problem . . . . . . . . . IB Organization of remainder of the thesis. . , . IB II. SOOIAD DYUAMIOS OF MEDICAL CARE.............. 15 Relationship between low income and higher illness rates. 15 Income trends in California. ........ 16 Change of economic status and incidence of illness ...... ..... 17 Employment status and incidence of illness • 18 Medical care and economic status, and change of economic status....................... 19 Medical charges and economic status » change in economic level............... B7 ii CHAPTER PAGE Uneven distribution of medical charges . . . . 29 Conclusions from Statistical evidence....... 33 III. REVIEW OF NEW PLANS FOR MEDICAL SERVICE....... 35 New England............................. . 37 Mid'-Atlantic.................... 42 South-Atlantic ............... 46 Middle West . .............. 50 Pacific. ....•« 51 Canada .............................. 55 IV. LOS ANGELES MEDICAL AGENCIES. ......... 61 , Part-pay Clinic............................ 65 White Memorial Clinic......... 65 All Nations Foundation Clinic. ........... 69 Good Hope Hospita 1 Association............. 74 Graves Memorial Dispensary .......... 77 California Babies Hospital ... ........... 79 Eye and Ear Hospital Clinic........... 8E Children»s Hospital Society - Outpatient Department . 84 Group plans........................ 88 Boonsha ft Medical Group................. 91 Ross-Loos Medical Group.............. 92 Associated Hospital Service. . ........... 98 CHAPTER PAGE V. SUMMARY AND CONCLUSION........................ 108 BIBLIOGRAPHY ..................................... 120 APPENDIX........................................... 126 CHAPTER I STAMIEM OF FROBLEM AND DEFINITION OF TERMS It was the purpose of this study to survey the agencies in Los Angeles which serve the medical needs of the individual whose income approximates $75 per month and of the family with an income of #1E0 per month. This group of persons was ineli# gible for admission to the Los Angeles General Hospital and other strictly charitable institutions and yet did not have sufficient income with which to purchase the necessary medical services for the number of illnesses which assail the group yearly. What is the relationship existing between the agencies which serve this group and the actual medical needs of the group? Are these agencies adequately meeting the prohiba of medical care? What is the ability of these individuals to pay for the costs of medical care? To ^at extent is the incidence of illness rates of this selected portion of Los Angeles* pop ulation related to economic level, to employment status, and to change in economic level of the group? Are the lack of medical care and inability to pay for such care duo^causal agents in the extent of illness among this group? These questions only lead the way to the wider and more exhaustive question: what is the relationship between the ill ness rates of a group and the economic level of the group? It has long been recognized that there is a connection between poverty and ill-health, and poverty and dependency, always putting the emphasis upon ill-health as the primary causal agent in the relationship. Miss Ida M. Cannon aptly para phrased the ideology of the earlier part of the twentieth century: As a cause, and also as result of social distress, disease is a large factor in the plight of those who become dependent on public and private charity. Mr. Devine says that inquiry into the physical condition Of members of the families that ask for aid — with out for the moment taking any other complications in to account — clearly indicates that either as a chief cause or as a complication due to the effect of other causes, physical disability is . # # a very serious disabling condition at the time of application in three^fourths « . « of all the families that come un der the care of the New York Charity Organization Socidby. Thus the lessening of disease is of impor tance not only for health and comfort, but for economic welfare and social progress. In 1919 at the National Conference of Social work, the equiva lent concept was propounded: Overwhelmingly it is sickness that is responsible for the death in the prime of life of men vdxose widows despite state and municipal aid to mothers, still de mand the largest percentage of relief provided by fam ily social work agencies. It is sickness that causes hospitals, dispensaries, and physicians to be the form of community service most frequently used by social workers in helping families. Sickness preventable sickness — brands the children of the poor even in infancy. It seizes them for its own again and again, in their youth and in their prime, until those who ^ Ida M. Cannon, Social work in Hospitals, (Russell Sage Foundation, New York, lÔTs), p.TST. succeed lu surviving to old age are covered with the scars of the destroyer.® The consequences were again mistaken for the cause. The older conceit concerning the dynamics of illness and poverty has had to he revised in the light of newer theories substantiated by research and scientific investigation. Systematic inquir ies were made into the causes of the disease of the low inocmie group. The incidence of illness rates in the various economic groups of the population was examined. The reasons for the lack of medical care were discovered. A real relationship be tween the poverty and the illness of the low income group was clearly discernible. Illness was disclosed as being a con comitant variable of poor living conditions, of inferior diet, and of the other detrimental circumstances of belonging to the low income group. Illness is not the primary cause of poverty; it is the effect of poverty, of the housing, sanitary, and quarantine conditions of the low income group, of the over fatigue and occupational poisoning of this group. Pasteur*s gexm theory has grown a corollary: that certain social con ditions are favorable or unfavorable to the growth of germs in the human organiem and that these social conditions may devitalize the body and lessen its resistance to the disease ^ Earl de Schweinitz, Sickness as a Factor in Poverty, Proceedings, National Conferenoe of lâocTaT work, 1919. p. 159 4 germ. The harmful effects of the depression were not visi ble in the ordinary barometers of health -?• death rates and reports of oommonicable diseases. The death rate from all causes reached the lowest figure on record in the first half Of 193S, but during the winter of 1933-254, mortality was on a slightly higher level than in corresponding months of im mediately preceding years, except for periods of influenza epidemic. Hence, the comfortable conclusion has been drawn that the physical well-being of the American people has not suffered, and in view of the continued low death rate, may have been benefited by the economic catastrophe. Recent mor tality and morbidity studies have shown that "mortality*^ in the general population is not an accurate index of **siokness** in the families of the unemployed and that the important causes of death are not the most frequent causes of illness. In a survey of ten c(»nmanities in 1935 by the United States Public Health Service, the disabling illness rate of families having no employed workers in 193B was found to be consistex£Ly higher than that of families haviz^ part-time or full-time workers. The conclusion of this modem study was that: A correlation between sickness and low income is not confined to periods of depression# A high ill ness rate, high death rate, and high birth rate have always gone hand in hand with poverty # # . Tremen dous shifts in economic status and standard of living took place during the repression # # # &nd, this study foundlthat illness is associated with sudden 5 change in standard of living.^ The findings of recent studies have indicated that there is a close correlation between low eooncmio status and high illness rates, inadequate medical care, and inability to meet the costs of medical care.^ Nqmerous studies show that illness is both more cmmion and more severe among the lowest income group. Thus, families of low economic level know higher illness rates than do those with more adequate incomes. In 19B1 the United States Public Health Service conducted a survey of white people in Hagerstown, Maryland, which revealed that among the ”well-to-do and comfortable** house holds visited, 10.3 per cent had cases of sickness; among ^moderate** households, IB.3 per cent had cases of sickness; and among **poor and very poor** households, 16.9 per cent had 5 cases of sickness. Inquiring into the prevalence and causes of orthopedic impaizment, the National Health Survey, directed by the United States Public Health Service, disclosed. ^ 0. St. Perrott and Selwyn D. Collins, Relation of Sickness to Income and Income Change in Ten Surveyed ôomman- m ' es, ' ï h i mTgeaïtETvôIT'M , " &TI##:"up:" 17=18 , ^ Publications of the Committee on the Costs of Medi cal Oaro; of the United States Public Health Service, and Margaret 0. Medical Care and Costs in California E%mi- lies in Relation to]^o^^^''^]^^g7"'3Wte^eIIeFTREErhIsTra- tibh of California, Èan !gtranoisoo, 1935. j S The three economic groups quoted above were fixed by a sliding scale based upon annual income, size of the family, and the purchasing power of the dollar at the time the study was made. Selwyn D. Collins, gconomic Status and Health, United States Public Health Bulletin, ko. lèS, , p. 5. That orthopedic Impairments were found more often in the lower income groups than in the higher, üfhefeas one person to a hundred who was part of a family with an an nual income of $3000 and over had an orthopedic impair ment, three persons of every hundred on relief were so handicapped.* The reciprocal relation of low income and illness was more vividly exhibited by the incapacity rates from orthopedic in jury. Incapacity from these conditions among persons on re lief was almost four times as great as among persons in the $3,000 and over income group. Thus, the heavy cost of ortho pedic cases due to the length and intensity of treatment,and in the case of the wage-eamer due to the loss of wages over a long period of time, placed an excessive burden on those least able to carry it. In an earlier Bulletin, the National Health Survey disclosed that illnesses requiring the individ ual to remain absent from work or bedridden for one week or longer in a twelve month period occurred among families on relief at a rate of 57 per cent higher than among families with annual incomes of $3,000 and over. Families of relief and low economic status experienced more frequent illness during each year than those of the upper income groups, and their illnesses were of longer duration. Thus, the average case of disabling chronic illness among relief families was 63 per cent longer in duration than the average case in the ^ United state Public Health Service, preliminary Re port, the National Health Survey, Bulletin No. 4, Washingfon, B. 0., 1938, pp. 7—8. group with incomes of $3,000 and over. It is evident from these investigations that the modem corollary to the germ theory is firmly established on fact. With the confirmation of social circumstances as a prime factor in the health of the nation, the importance of research into the medical facilities serving the low income group in Los Angeles was pertinent and appropriate. Los Angeles was a city of 1,393,430 population, almost EE per cent of Califomia’s total population, (according to the 1936 census figures). Of this approximate one and two-fifths millions persons residing within Los Angeles city limits, 80.8 per cent had incomes under #8,000 per year, and 39.8 per cent had less than #1,000 per year.^ It has been this group of individuals that experienced higher illness rates, higher disabling rates, and higher death rates than the other income groups. Apart from its stable population, Los Angeles has been used seasonally as the winter camping grounds for thousands of migratory workers who bring their health prob lems into the city. Supplying the medical facilities that ^ These statistics were inferred from the percentage distribution of income classes for the entire United States in 1989 as prepared by Maurice Leven, The Income Structure of United States, The Brookings Institukioh. Washington, i).0. s were within the means of the low income group in Los Angeles, were six clinics, five hospitals, two group insurance organ izations for medical care, and one group hospitalization plan. It would be of interest to contrast the few institutions that provided medical eare for this large group with the number of physicians, dentists, hospitals, sanitariums, and clinics available in the city. There was approximately one doctor to every 180 persons in Los Angeles, while for the state as a 8 whole there was one doctor to every 685 persons. Of the "under #1,800" income class in Californian cities of one million and over population, 18.9 per cent of these persons required medical attention and only 43 per cent of the indi viduals of this group requiring medical attention received medical treatment. ^ Yet all the hospitals in California 10 operated at about 79 per cent capacity. The income for 31 per cent of California doctors of medicine was under $8, u per year. Apparently there is for the state as a whole. ® California Medical-Economic Survey, Preliminary Report. 1935, pp.U, 88. ^ Ibid., pp. 45 , 50. Ibid,, p. 11. Ibid.. p. 31. 9 and for its largest oommunlty, Los Angeles, a serious malad justment of the distribution of its medical service and the ability to purchase medical care. The present study, inas much as its object is to study the Los Angeles agencies min istering to the medical needs of this low income group, will relate very generally the problem of Los Angeles* medical needs to those of the state and the nation. The correlation of economic status and illness in Los Angeles will be deduced from the number and type of medical facilities available to that group. II. DEFINITIONS OF TERMS USED Medical Facilities. Since this study is dealing with the available agencies that promote the health of the low in come group, and not the sum total of medical agencies within Los Angeles, the term, medical facilities, has been inter preted to signify those clinics and hospitals which serve this group at reduced fees and the group insurance organizations for hospitalization and medical care. The clinics and hos pitals were designated as part-pay agencies by the Los Angeles Council of Social Agencies and the administrative heads of the said institutions. The group insurance plans for medical care and hospitalization have long been appreciated as in struments in the service of the lower economic groups. 10 QlialQ. It is an institution receiving ambulatory pa tients for diagnosis, therapeutic or preventive medical ser vice. There are many variations of the clinic-type of insti tution; however, the part-pay, full-pay, private group clinic, and group insurance clinic are within the meaning of medical facilities as previously interpreted. Medical Pare. Medical care includes all the methods, techniques, and services necessary for the prevention and cure of disease and the restoration of the body and mind to a normal state of health. However, it must be remembered that mental diseases, social diseases, and drug and alcoholic ad diction, have crept away from the fold of private medicine and have become the concern of public health. Hence, the three group insurance organizations will not treat mental cases, al coholic or drug addiction oases, provide hospitalization of tuberculous patients or give care to those cases compensable under the Workman*s Compensation Act of California, with the exception of treatment prior to commitments to the proper in stitution. All treatment for social diseases by these groups was special and extra fees were charged. The clinics and hos pitals providing care at reduced rates had no such general ex ceptions to their services. Costs of Medical Care. In this study the costs of medical care has been construed to mean the cost of "good" medical care, not the costs of "ideal medical care." It 11 would Include payments for the cure and care of diseases and defects and for preventive services. Actual expenditure in the United States for health services was #3,666,000,000 per 12 year, according to the Oommittee on the Costs of Medical Care. The Committee on the Costs of Medical Care estimated that $36 per person per year would represent the cost of "adequate med ical care." This figure, however, did not include public health and the cost of hospital care for mental and tuberculous pa tients, but it did include #10.70 per person yearly for dental care. Deducting this last figure for dental care, the cost of "adequate medical care" became $26.30 per individual per annum. The costs of "good medical care," #75.75 per person yearly, as computed by Samuel Bradbury, was the figure arrived at by an estimation of the cost of medical care. If adequate services are bought at minimum fees on a fee-for-servioe basis. On the other hand the Com mittee on the Cost of Medical Care's figure (#25.30) is the estimated cost of actual services bought from physicisns and others at a total cost equal to the average annual rate of remuneration earned by the several types of practitioners . 3 - 2 5 Income. Income has been defined as all funds received by the family whether through earnings, savings used, money borrowed, returns from investments, or gifts received. Falk, Rorem, and Ring, The Costs of Medical Ogre. Committee on the Costs of Medical Care, University of Chicago Press, Publication No. 27, 1933. p. 517 Samuel Bradbury, The Cost of Adequate Medical Care, p. 53. 12 Low Income Group. The low income group in this study was considered that group whoso income was above that of re cipients of relief and whose maximum income was #1,500 per year per family or #900 per year per individual. Medical Social Problem. Modern medical care has realized that there are certain social conditions which so act as to cause a maladjustment between the individual and other individua.ls, and his social environment. These social conditions lower the resistance of the human body to disease. Medical social problmms are those maladjustments that occasion the growth of disease, that are inter-active with disease or those that require the aid of a social worker to re-adjust the individual to other individuals and to his social en vironment. The realization that sickness is a sign of poor or morbid conditions and must be treated socially as well as medically is the basis of medical social work and of medical social problems. III. STATEMENT OF THE ORGANIZATION OF THE STUDY The study of the Los Angeles Agencies was accomplished by means of personal interviews with the officials of these agencies. Each interview followed the course set by a schedule or questionnaire, so that all information obtained might be systematized. The material was organized so as to present the clear est formation of the problem and purpose of the study. IS Chapter two had as its object the presentation of the sociolo gical dynamics of medical careL^as found in the related studies of medical care in California. Two such surveys have been con- 14 ducted: the California Medical-Economic Survey in 1936 and the Margaret C. XImn study under the California State Relief Administration in 1935.^^ Both studies are analyses of the incidence of illness, the extent and volume of medical care, and the costs of medical care in California. This chapter sought to identify the correlation of low economic status and inability to meet the costs of medical care — in the state of California. Chapter three will present the various plans of medical service for the low income group in the United States and Canada. Bach agency was considered from the following points: scope of service, social coverage, quality of care, financial basis of the organization, costs to the patient, professional status and administration. There was a sampling of agencies in the New England states. Mid-Atlantic states. Mid-west states. South Atlantic states. South Central states, the Pacific states, and a brief outline of the "Saskatchewan Plan" of medical care in Canada. Chapter four will contain a California Medical-Economic Survey, Preliminary Report, 1936. --------- Margaret 0. %em, ^dical Care and Costs in Califor nia Families in Relation to Boonomlo status, T55BT pp. 1Ï6. 14 statement of the method of procédure of the present Investi gation, the sources of data, and the findings from those in vestigations of the medical facilities in Los Angeles which serve the low income group. Bach agency will he summarized on the basis of the following points: scope of service, sta tus, administration, financial organization, staff, and func tions of the organization. In addition, each administrative head of the various institutions was asked to give his or her opinion relative to the problem of medical care and its fu ture. Chapter four will have included within its content a chart analysis of the various plans for medical service in Los Angeles that are within the means of the low income group. The last Chapter (Y) will contain the conclusions of the fore going chapters, the needs revealed by this study, and the es sentials for a satisfactory medical program in Los Angeles. GHAPTBR II SOCIAL DYmmiGS OF MEDICAL CARE That there exists a causai relationship between low in come status and higher illness rates has been the basic conten tion of this study. Two California surveys, confirming this fundamental, were conducted in 1936: the California Medical- Economic Survey and the California State Relief Administra- p tion Study under the directorship of Margaret C. Elem. It was the intent of this chapter to demonstrate clearly and un equivocally the dynamic relationship between income level and the incidence of illness, medical care, and the ability to meet the costs of medical care. The analysis of the incidence of illness, the extent and volume of medical care, and the costs of medical care was directed from three different bases Of analysis: income level, employment status, and change in economic level subsequent to the onset of the depression. Containing as it did in 1936, 28 per cent of California's to tal population, Los Angeles was vitally concerned with these California Medical-Economic Survey, Preliminary Re port to Committee of Five For the Study of Melicaj Care tke CaTifomïa Medical Association. üaliŸoi^^a Meâical- T5?6": --------- p Margaret C. Xlem, Medical Care and Costs in Califor nia. Families in Relation to Economic status, GSbA, 19M6. . 16 Inquiries of medical care in the State of California. Each study was conducted from distinct points of anal ysis. A random sampling was taken of California households, constituting the low-income and wage-earning families of two or more persons, living in urban and rural communities, and dependent upon the industries and trades for their livelihood. The sample of California families was so selected that its distribution approximated that of the white population of the state as a whole. These families were then classified accord ing to 1933 income status# The XIem study reported that in 44 per cent of the surveyed families, incomes were found to be 3 under $1,800 per year, while 56#8 per cent of the families studied by the California Medical^Eoonomio Survey reported 4 similar income status. The finding of the United States Pub lic Health Survey of eight Eastern cities in 1938 supported this percentage distribution, reporting that 66#1 per cent of the selected families had incomes under #1,800 per year.^ In order that the relation of illness rates and of ^ See Appendix Table I. ^ See Appendix Table II# ^ G. St. J. Perrott and Selwyn D* Collins, Relation of Sickness to Income and Income Change in ten Surveyed l^bm- munities .keprint No. Ï6# from the Public^eaïth Reports, vol. So, Hb. 18, may 1936. p. 602. 17 medical care to diminished income might be studied, urban fam ilies were classified according to change in economic level from 1989 to 1933. There was a great increase in the number of families with incomes under $1,800 per year and a marked decrease in the number of families with higher incomes. ". . the number of families with incomes under $600 increased three fold from 1989 to 1933, while the proportion with incomes of $8,000 or over diminished from more than 37 per cent in 1989 6 to 16 per cent in 1933”. Whereas in 1989, 86.6 per cent of Oalifomia households were under $1,800 per year, that per centage was almost doubled in 1933, reaching 66.4 per cent of 7 the selected families. Miss Xlem said: A more detailed analysis ... revealed that 79 per cent of the families with incomes under $600 in 1989 were still in this class in 1933. Nearly half of the households with incomes of $600 to $1,199 in 1989 had dropped by 1933 to incomes under $600 ... A decrease in annual income, however, does not neces sarily entail a change in standard of living, since the size of the family and the purchasing power of the dollar in both periods under comparison are also determining factors. These factors were therefore taken into consideration in classifying families into three economic levels; namely, relief, moderate and comfortable.^ 6 See Appendix Table III. Margaret 0. Hem, op. cit., p. 6. 7 8 " ’ Margaret C. Hem, op. oit.. pp. 6-7. 18 Thirdly the analysis was concluded from the basis of employ ment status of urban families. What were the effects of un employment upon health, not only due to decreased income, but also to strain and interruption of normal living habits? A close correlation was found to exist between low economic level and high illness rates, whether the analysis was based on income level or employment sta tus in 1933, or on change in economic conditions sub sequent to onset of the depression.^ The surveyed families reported illnesses experienced during the three-month period preceeding the date of interview; those reporting sickness were classified according to severity (either disabling or none-disabling) and according to time of onset ( either prior to or within the period covered by the study) # A disabling illness was interpreted as one of such character as to interrupt the patient’s normal routine of daily living. The highest rate of disabling illness among the urban and rural families classified according to 1933 income was reported by families receiving relief (180 per 1,000 persons), and the lowest rate (115 per 1,000 persons) by the highest in come class; the rates of disabling illness of the intervening income groups tended to graduate progressively between these 10 two limits. Adjustments to the age factor, eliminating the ^ Margaret 0. Hem, og. cit., p. 9. Ibd^., p. 11. Based on the reported illnesses of 16,460 during a three-month period in 1934. 19 variable age differences between the income classes, made no appreciable difference in the illness rates. Though not at tempting to classify the illnesses of its sample of Califor nia population according to disabling or non-disabling, the California Medioal-Bconomio Survey found a notable difference between the medical needs of the various income groups. The California Medical-Economic Survey reported that 17.3 per cent of persons with incomes under $1800 per year required medical attention, as compared with 8.6 per cent individuals with in comes of $6,000 and over who reported the need of medical oare.^^ The analysis of illness rates among families classified according to change in economic level from 1989 to 1933 showed that decrease in family income is closely correlated with an increase in the incidence of illness. Miss Hem continued fur ther to state that families who were "comfortable” in 1989, but were recipients of relief in 1933 had a disabling rate of 886 per 1,000 persons, the highest rate reported. Families, "comfortable” in both 1989 and 1933, had a disabling rate of only 186 per 1,000 persons. The rate of those who dropped from "moderate” to "relief” in the four year period was 174 per 1,000 persons, contrasting sharply with a rate of 136 per California Medical-Economic Survey, oj>. cit., p. 11. 20 1,000 persona for the group designated as "moderate" hoth 12 years. Corroborating these findings, Parrott and Collins stated: It is seen that individuals in families on relief have a higher inpideneo of disabling illness than any of the other groups of the surveyed population, what ever their economic history during the depression • • • Among relief families the income change between 1929 and 1952 is associated with illness in the same manner as families not on relief; that is, the families that suffered that greatest change in economic status ex hibit the highest illness rate.^® Bearing out the close correlation between income and illness, families suffering from unemployment reported higher illness rates than families with full-time wage-earners in 1933. The tendency for an increasing disabling illness rate to occur among the unemployed was exemplified by families with no employed members in 1953, who reported the rate of disabling illnesses as 198 per 1,000 persons; the rate dropped to 146 per 1,000 persons in families having part- time workers ; and the decrease of the rate to 125 per 1,000 among those families having full-time workers showed clearly the influence of income status over illness rates.Compar ing these figures with those obtained by the United States 12 Margaret C. Elem, 0£. cit.. pp# 12*15. Based on reported illnesses of 12,091 persons during a three-month period in 1954. 15 Perrott and Collins, 0£. oit., p. 22. JKlem, op. cit., p. 16. Based on reported illnesses of 13,270 persons "during a three-month period in 1934. 21 Public Health Service Study conducted in 1932 in three Bast- xs em cities. Miss Blem indicated that the latter study found a disabling rate of 177 per 1,000 among the unemployed, 138 per 1,000 among those whose workers were on part-time employ ment,^ and 130 per 1,000 in families reporting full*time work ers. fhus it was seen that the disabling illness rate of families having no employment was consistently higher than that of families having part-time or full-time workers. In their study of ten communities in 1935, Perrot and Collins concisely summed up the relationship between disabling ill* ness rates and the employment status of the group: Inasmuch as most of the families having no employed workers in 1932 had one or more employed workers in 1929, these data are striking evidence of the associa tion between a relatively high rate of disabling sick ness and loss of employment during the depression, with accompanying loss of income and reduced standard of living. Certainly the concurrence of the statistical evidence of both studies evince the close association of illness to economic level, employment status, and change of economic level. Perrott, Sydenstrieker, and Collins, Sickness and the Depression. Milbank Memorial Fund Quarterly, vol. Xl, lo7 7rTi^7T9S4. pp. 281*: See Appendix Table IT. Perrott and Collins, op. cit.. p. 13. 22 Medical care has always been in direct relation to eoonomio statue. It was pointed out by the Oommittee on the Costs of Medical Care that the two extremes of the economic scale, the poorest and the richest, receive the best medical care, the former through the charitable clinics and the latter, through the purchasing power of its income. However, Miss Klem stated that , Families of low econcanic level, although experiencing higher illness rates than those with more adequate in comes, do not have medical care for as great a propor tion of their illnesses as do families with larger in comes, notwithstanding the availability of free medical servicel^ ---------- -- --------------------------- It was noted that the highest rate of serious illness oc curred in households of the unemployed and in families in the lowest income groups, especially those which had had the most extreme change in economic status. These same families received medical care for a smaller proportion of their ill nesses than did those with employed members and higher in come: the financial circumstances of a family have a direct bearing upon the extent to which medical care is received. The amount of medical attention obtained was influenced also by the previous economic level of the family; "relief” families who had formerly been in the "moderate” or Margaret 0. Hem, op. oit., P. 43. Underscoring by the writer of this study. 23 "comfortable” group obtained medical care for a greater pro portion of their illnesses than did those households classi fied as "relief" in both 1929 and 1935. The lowest percent age of disabling illnesses receiving the attention of a phy sician was found in the group whose economic status was "re lief” in both 1929 and 1933, but the proportion receiving medical care progressed steadily with each higher income lev el. A greater proportion of hospitalization was secured by the low income group for their illnesses than was by those in the'higher income families, but nearly all of it was free care provided in public institutions. A critical neglect of dental service was found in families with diminished incomes, 19 and a marked need of dentistry was revealed in all groups. "That economic factors are serious barriers to the re ceipt of medical service is apparent when the extent of such 20 care is considered in relation to family income." The Klem study noted that 68.4 per cent of all reported illnesses in the "relief" group received any type of medical care; of fam ilies whose income was from #600 to #1,199 only 70.2 per cent received medical care; while 78.1 per cent in the highest in- 21 come group were receiving medical attention. 19 Margaret 0. Klem, op. oit., p. 17. ^ ma., pp. 18-19, 21 See Appendix Table V. 24 The Oaliforala MecliGal-Bconomio Survey published in the same year reported that of the families whose inoomes were under $1,200 per year only 49.8 per cent of these persons requiring medical service were receiving such attention; as compared with persons whose inoomes were $5,000 and over, of whom 91.9 22 per cent were receiving treatment. Both the Klem and the California Medioal-Bconomic studies disclosed the volume of medical care received by those of the $5,000 and over income category was almost double the care received by those whose annual income was under #1^00. The State Relief Administration survey indicated that the extent to which medical care was obtained was influenced by the previous economic status of the family and the employ ment status of its wage-earner. ... families who received relief in both 1929 and 1933 secured medical attention for only 60.9 per cent of their disabling illnesses, but 1933 "relief” fam- ' ilies whose eoonomio level had been "moderate” in 1929 reported medical care received for 71.3 per cent of disabling illness<cases, and those who had been in "comfortable" circumstances in 1929 reported care for 78.4 per cent . . . . . . . . . . . . . . . The proportion of illnesses receiving care was found to in crease slightly with ascending degree of employment, from 70.6 per cent in unemployed families to 74.2 per cent in See Appendix Table 71 25 23 families with full-time workers. That low economic status has been intimately related to the lack of sufficient medical care and inability to meet medical costs has been considered a truism, yet these studies #ade evident the close associa tion with almost visual clarity by the statistical method. Families of low economic status suffered higher illness rates than did those with more adequate incomes, but because of their inability to meet the costs, they could not purchase medical attention for a greater proportion of illnesses. The findings of the Klem study revealed a definite correlation between the amount of illnesses receiving medi cal attention and the ability of the recipients to meet the charges. Half of the households of the unemployed and a greater proportion of those in "relief" families were treat ed without charge. There was a tendency among "relief" fam ilies which had been economically independent before the on set of the depression to assume charges for a considerably higher proportion of their illnesses than did families whose status was "relief" in both 1929 and 1933. Miss Klem, re ferring to this trend, stated: When "relief" families are considered in light of their previous economic level, striking variations ap pear in the proportion of free care which they received Margaret 0. Klem, op. cit.. p. 21. 26 . # families who were classified as "relief" in hoth 1929 and 1933 received free care for 61 #7 per cent of all their illnesses, while "relief" fami lies who had been in "moderate" circumstances in 1929 received free care for only 38.9 per cent, and those who had been "comfortable", for 36 per cent The costs of medical attention in cases of serious and long-time illness were disclosed to be above the financial capacity of most low-income and wage-earning families. About 30 to 40 per cent of all surveyed families in the various in come categories were owing for medical service and the bills were long-out standing. "However", asserted Miss Klem conclu sively, "average charges incurred during the three-month per iod of the survey indicated that medical costs, if evenly dis tributed, would not be a burden incommensurate with ability OR Of mcBfc families to pay". When the surveyed families were classified according to 1933 income, the average three-month charges per family receiving medical care graduated regularly according to the economic status of the family, from $8.06 in "relief" families to $51.61 in the $3,000 and over income group.The variation in these averages were affected by the differences in the volume of medical care received and by the proportion of free and partial-pay care provided for 24 Margaret 0. Klem, 0£. cit.. pp. 46-46. m a . , pp. 43-44. See Appendix 3able VII. 27 illnesses in the various income groups. She dangers in the use of the concept of average expenditures for medical care were realized by Miss Klem. It has not been the average charge that was the problem of the low income group, but the uneven distribution of medical charges among families in the same income class. Mr. Davis remarked that "because the blunderbuss of sickness strikes so unevenly, no average an- 27 nual expenditure means much for the individual.” During the three-month period of the California state Relief Admin istration survey, one "relief" family incurred medical charges of #291, and another family, with an annual income between #2,000 and #3,000 per year reported a medical bill of $721. Yet in these same income groups, 67.7 per cent and 30.6 per cent of the families, respectively, did not incur medical charges, either because no care was needed or obtained, or 28 because no charges were made for services received. The variations and averages in medical charges among urban families classified as to change in economic level re vealed even more emphatically the association of the amount of medical charges with income status. Those whose average charges were the lowest (#1.77) during the three-month period Michael M. Davis, Paying Your Sickness Bills, The ity of Chicago Press, Chicago, 111., iàSl. p. 4Ü. 28 Margaret C. Klem, op. cit., pp. 48-49 28 Of the survey in 1934 were the families which had received relief in hoth 1929 and 1933, and the highest average charges ($27.62) were incurred by families which had been in "com fortable" circumstances in both years. Emphasizing the role of the decreased income in relation to medical charges during the three-month period were the average charges of two "re lief" groups in 1934; the first which had been "moderate" in 1929 incurred average charges of $5.21, while the other which had been "comfortable" in 1929 incurred average charges of $9.80. These variations in the average medical charges in the three-month survey period indicated the great er degree of free care obtained by the "relief-relief" fam ilies and the greater extent to which families that had been in better circumstances sought medical attention for their illnesses. Hence the importance of the uneven distribution of medical costs has not been exaggerated, large costs have fallen upon small purses. High-cost sicknesses have not been respectful of the economic circumstances of the family. In the "relief" group of the Klem study, for œample, half of the families had no medical charges whatsoever either because care was not required, or received, or because such service was obtained gratis. More than 15 per cent of the total charges of the "relief" group during the three-month period was in amounts of less than $10, the proportion of families 29 among which these charges were distributed was nearly 85 per cent of the total "relief" group# However, amounts from $10 to #60 constituted 52.7 per cent of the total charges and this proportion was borne by only 13.2 per cent of the "re lief" families surveyed. The heaviest medical charges for the three-month period were incurred by only 1.9 per cent of the total "relief" group; this small portion of the group incurred 31.7 per cent of the total charges of the "relief" group. Thus, it was seen that the incidence of costs and that of illness were two variables upon which no calculations could be made. To further complicate the burden of ill- health, sickness has never been distributed evenly among the total population, regardless of the economic factor. The Oommittee on the Costs of Medical Care in their study has pointed out that of the individuals studied, 47.1 per cent had no ailments 32.2 per cent had one ailment 13.6 per cent had two ailments 6.4 per cent had three or four ailments .7 per cent had five or more ailments Therefore, the burden of medical charges was found to be un even and uncertain, as sickness can not be budgeted in ad vance by the individual. Thus sickness has been a non-budget* able emergency, so long as the individual family must deal 29 Publication of the Committee on Costs, Ho. 27 p. 43. (Falk, Rorem, and Ring, Costs of Medical Care, Univer sity of Chicago, Press, Chicago, 111.TlL^33) 6S3 pp. so with it out of its own resources* In Miss Klem'8 survey, the incidence of illness, ex tent and volume of medical care, and the costs of medical care were studied from three viewpoints: first, 1933 income level; second, change in economic level from 1929 to 1933; and third, the 1933 employment status of the wage-eamer of the family. The close correlation between low economic lev el and higher illness rates, lack of medical care, and in ability to meet the costs of medical care was consistently revealed by the above points of analysis. In both the Klem and the California Medical-Economic studies the volume of medical care was not compared with a standard of adequate medical service, for even the volume of care received by the highest income group was inadequate when compared with certain standards of adequacy such as the hee-Jones study developed. The findings analyzed made clear that the customary fee-for- service system did not provide sufficient means for accommo dating the costs of medical care to the financial capacity of the families requiring attention. The undesirable result of this situation was indicated by the California State Roger I. Less and lewis Webster Jones, The Fundamen- tals of Good Medical Care, University of Chicago SressV dhicago, ÏIT 7 m F T T p T T s rr — 31 Relief Administration survey's findings to be three-fold: (1) insufficient medical care for low-income families;. (2) free and partial-pay care for a large proportion of the ill nesses attended; and (3) unpaid bills covering a considerable 31 portion of the fees charged. The highest disabling illness rates were found in families in the lowest income levels; that is, among relief recipients and families with annual income of less than $1,200; among the depression poor — those who were in moderate or comfortable circumstances in 1929, but who were forced by poverty to seek public relief in 1933, and among households with no employed members. “ It was these same families that, in spite of their higher illness rates, obtained medical care for a smaller percent age of their illnesses than did families of higher economic status. A sharp reduction of dental care was noted in fami lies of diminished incomes. The findings of these studies showed a real association between the extent and volume of medical care and the ability of recipients to meet the charges. It appeared consequently that there exists a direct as sociation between illness rates and income status. The high est disabling illness rates were found among the lowest income group, i.e. relief, among the unemployed, and among those whose economic level dropped sharply during the depression. Miss Klem Margaret 0. Klem, op. cit.. p. 69. Ibid., p. 69. 32 was unable to conclude definitely that the "higher illness rates are the results of the drop of income# This may be," she said. One of the factors which is responsible for the higher illness rate, but there are many other factors which this study was not able to measure. For example, it may be that the families had a drop in income suffered these financial reverses because of poor health . . . The one fact which is clearly shown is that the families who had a decreased earning power and consequently were those families who could least afford the expenses of serious illness, were the group that suffered the highest illness rate."®^ However, this statement of Miss Klem's was contradicted and invalidated by her statement in reference to the relation of disabling illness rates to the 1933 employment status: The same tendency Encrease of disabling illness rates among the part-time workers and unemployed workerêl was apparent when the analysis was restricted to families whose unemployment did not result from sickness. ^4 Therefore, although Miss Klem has not ruled out the factor of predisposition to ill health, which might cause the lower ing or loss of earning power, for all the findings, she has shown in this one very vital relationship that the factor of ill health, did not disturb the correlation between disabling Margaret 0. Klem, op. cit.. p. 16. 3^ Ibia.. p. 16. 33 Illness and employment status as previously found. It was impossible to draw any other conclusion from the material presented by the two California studies, and the substantiating evidence of the United States Public Health Service surveys. That the random sampling of low income groups could represent any sort of selection of those pre disposed to ill health was irrational and opposed to the principle of random sampling. If this large group of low in come level were to represent the shifting downward, economi cally speaking, of those with a diathesis to all forms of disease, this might explain the position of those individuals who had been on relief in both 1929 and 1933. But how can one account for the shift of those individuals of "comfort able" circumstances to "relief" status and their illness rates which were the highest reported? ^5 Margaret 0. Klem, 0£. cit., p. 16. Families with no employed members during part of 1933 reported a disabling illness rate of 198 per 1,000; families with part-time workers, a rate of 146, and households with full-time workers, a rate of only 126. After eliminating those whose unemployment resulted from sickness, the disabling illness rates in these households were 179 per 1,000 persons in families with no wage-eamers, and 143 and 126, respectively, in those with part-time and full-time employment. 34 Collins and Perrot ooncluded that: While concentration of the less fit in the ranks of the unemployed may have played a part in bringing about the situation observed in 1933 Çhe close correlation of illness and economic level7] it does not seem probable that selection is the whole story. Particularly signi ficant are the facts that the highest, illness rates were observed among those who had suffered the greatest 'change in standard of living and that the excess in illness existed among children as well as adults. ^6 The dynmnic relationship between economic status and incidence of illness must be primary to any study of medical care. Bo onomic status, causative, and incidence of illness, result ant are basic to the understanding of any particular problem of medical care. Perrott and Collins, op. cit., p. 28. OHâPTSB III RS7IEW OF HEW PIAHS FOB MEMGAIi SBRYIOE It was of interest to study the various plans of med ical service being utilized throughout the United States in meeting the needs of the low income group. The reports and studies of these agencies were reviewed and summarized. From the Hew England states, the Mid-Atlantic states, the South Atlantic states, the Middle West, the Pacific states, and also Canada, were selected representative medical agencies, each considered from a variety of points.^ Bach agency was o analyzed on the basis of the following points: (1) Scope of service:- Did the agency give general or specific medical service? What did it in clude or exclude? Was care given by general practitioner and/or specialist in home, office, clinic, and/or hospitals? was hospital, dental, and nursing care obtainable by the patients? Were medicines, eye glasses, and appliances given by the agency? (2) Social coverage ;- What groups of persons class ified by age, sex, race, employment, and ^ Julius Rosenwald Fund Publication, Hew Plans for Medical Service. Chicago, 1936. p. 74. ^ Ibid., pp.76*7. 36 économie status came within the scope of the agency? What proportion of the population of the area covered did these persons include? What proportion of the population who may need the service offered by this plan and who might be served by this plan were actually served by it? (3) Quality of care : - Were there any tests applicable in judging the quality of service? Was the ideal medical service the standard of comparison or the service usually secured by persons of simi lar circumstances? How was the quality of care supervised? Were there any attempts to appraise the quality of care? (4) Financial basis ; Did the beneficiaries contri bute to the plan by regular fixed periodic pay ments, so that service was received as a right? Was the plan a philanthropic service supported by the physicians, so that service was received as a charity or privilege? Were the payments arranged according to the needs of the individ ual case through a credit bureau or installment payments; or according to systematic periodic payments by or in behalf of beneficiaries? Did general taxation from local, state or national m governments contribute to the support of the plan? (6) Posts of service;- What relation to the incomes of the group served did the payments bear? In comparison with the usual cost of similar service to persons in like conditions, what were the costs of service? (6) Professional status :- What was the status of those who furnished medical service under the plan? Were there any systematic arrangements made to insure the maintenance of the profession al management of professional affairs? (7) Administration;- Was the directorship of each agency so constituted as to be fairly represen tative of the major groups of people or inter ests concerned in the service? Was the adminis tration competently directed by responsible per sonnel? What proportion of the total expendi tures were the costs of management? I wm mamm) states Brattleboro Memorial Hospital Benefit Association. This was a voluntary sickness insurance providing hospital care and surgical care after payment of a stated initial charge by the patient and was under the auspices of a local 38 non-profit organization. It was in 1929 that the Thomas Thompson Trust Fund was established in Brattleboro, Vermont, to build a plan whereby the large and unusual expenses of hospitalized illness were to be budgeted by regular payments to some agency, now the Brattleboro Memorial Hospital Benefit Association. The fees charged to the subscriber ranged from $5,00 to $10.99 annually. Provisions for protection might include the entire family and for the entire expense of the hospital, surgical, and nursing service rendered. Those who have taken advantage of the plan were in sured against the following contingencies: (1) In case of operations, cost of surgeon's fees, charges for room, food, and staff nursing at the Brattleboro Memorial Hospital up to a certain maximum amount, which in practice is usually $300 after the first $80 of expense has been paid by the patient, (which is in addition to yearly payments). (2) In the case of illness not requiring surgery, the best of hospital ac commodation including staff nursing, after the first $30 has been paid. Only half the maximum amount allowed in case of surgery was allowed for non-surgical cases. Ho medical fees were paid other than for surgery. The patient was permitted to chose his own surgeon. The costs of service were tested during the first years of operation, with a limited membership. By 1932 ap proximately 1000 persons were covered by this plan. In the 39 summer of 1936 about 3000 persons,(or one-third of the town's population) had joined this organization, in addition to the 1000 students who had been carried under a special ar rangement • From 1927 to 1934 there were approximately 200 hospi tal admissions, one for each 22 member-years of protection. For the fiscal year ending September, 1933, approximately $7,900 was paid for memberships and for that same period some #6,800 was paid for benefit payments. It was found that the service rendered members cost an approximate average of sixty cents per member-month, ex clusive of overhead. This figure was arrived at by dividing the amount paid out in benefits since 1927 (#30,850) by the total months of membership since that time (#52,180). Three types of maximum benefit protection are offered: $150, #200 and #300, with annual subscription rates of $6.00, $6#66 and #10 respectively for each single person. Married couples were offered memberships at #7.80, #10.40 and #15.50 respectively. Adult dependents were served for $3.90, $5.80 and #7.80 respectively. Child dependents up to fifteen years of age had an annual fee of $2.00 and, children from fifteen to twenty-one years were served for $5.00 per year. Surgical work and other hospital bills were paid for, only if furnished at and under the rules of the Brattleboro Memorial Hospital and by surgeons approved by the directors 40 of the hospital. Benefits were not applicable to sickness or injuries arising from illegal violence, alcoholism, or venereal disease. Likewise, the benefit association pay ments were not made for maternity service, conditions due to pregnancy, chronio conditions, or for throat operations on persons under fifteen years of age. Other services included infirmary service and special nursing in the hospital and these may be included in the benefits by an increase in the premium rate paid. Middle-Hate Plan of the Baker Memorial Unit of the Massaohusetts General Hospital, Boston. Mass. In this plan hospital care and professional services were provided for persons of moderate means for fees limited by an arrangeiyent between the professional staff and the hospital administra tion. The Middle-Rate plan for hospital patients was started by the medical staff and the administration of the Baker Memorial Unit of the General Hospital, Boston, in 1930. It was an attempt to reduce the total cost to the patient for the care of hospitalized sickness, without changing the profession al relations between the doctor and the patient. A unique arrangement, or rather set of arrangements, have been made between the doctor and the patient. The staff of the Baker Memorial Unit agreed to render professional ser vices at moderate fees, with a maximum of $150 regardless of the type of case. On the other hand the patient must agree 41 to restrict Ms expenditures for hospital and special nursing services to those required by medical necessity and reoonmen- ded by the staff. The hospital had agreed to provide service at prices not exceeding the cost to the hospital. For each patient admitted to the hospital a conference between the three parties concerned with the agreement is held and the admitting office determines through personal interview whether the patient is eligible for care in the institution. The business office of the Plan has been the collector of fees for the physicians and special nurses and has kept all financial records. Since the Baker Memorial Unit Plan was opened in 1930 the occupancy of the institution has increased gradually, from 2,376 yearly admissions in 1930 to 3,326 ad missions in 1931. In 1934 the Baker Memorial Unit contained a bed capacity of 226, and also 30 bassinets for new bom in fants. During 1934 the admissions exceeded 4,400 patients. The average charge for all oases admitted to the Baker Memorial Unit during 1934 was $169.67, including physician's fees, special nursing, and hospital care. The average length of stay was thirteen days. It is the opinion of the hospital administration at Baker Memorial that the unit could not have been con ducted as successfully from 1930 to 1934 except on the MiddleRate Plan. Such a plan might be arranged in an existing hospital unit without the construction of new facilities. It is stated that the hospital!s medical staff as well as the administration believe the plan to be advantageous from the point of view of the patient of moderate means since it enables such a patient to 42 consider the costs of a hospitalized illness as one total and make arrangements for payments through one agency, assures the doctor of a reasonable fee for his professional services, and guarantees that other expenditures for the same illness will be limited to those required by medical necessity.^ II MLD-ATmmiO STATES Dental Health Service, Inc., Hew York Pity. This clinic has provided dental care for persons tUlo have not been able to pay the usual fee for dental services. The clinic has been self-supporting. Its purpose has been to supply as complete dental services as possible to persons of moderate means. Four chairs, operating approximately eleven hours daily, have served the low-income workers in industry as well as clients of social agencies. During the depression years the clinic has served about 2,600 persons annually. The management of the Dental Health Service was vested in the newly organized Committee on Community Dental Service of the Hew York Tuberculosis and Health Association on April 1, 1926. This directorship was to continue until such time as the service should be entirely self-supporting. The den tists, employed by the clinic, have conducted private offices elsewhere in the city and have been remunerated for their time in the clinic. The dental hygienists and administrative S Julius Rosenwald Fund Publication, op. cit., p. 14. 43 personnel were employed full-time* The olientele, for the most part, has consisted of persons of low income who are referred by their employers or otherwise endorsed as to eligibility* The patient must make and sign a document as to earnings, other income, and depen dents; in addition, he must state that he is unable to af ford the services of a private dentist* Ho social workers have been employed by the agency, as it has been thought that this would be an unnecessary expense and that the recom mendation of a dependable organization or person known to the clinic, is satisfactory. The dental services supplied by this agency have been all the various services found in general practice; gas ex tractions, root canal therapy, periodontia, and orthodontia, as well as minor oral surgery, have been referred to special ists in private practice who serve the patient at reduced fees. The fees charged by the clinic have been established by a cost accounting system which includes every item of over head, service (every member of the clinic staff is paid), and supplies. After the clinic became self-supporting, the board authorized a fund for replacement of equipment. All excess income has been used for the benefit of the patient. Thus, when a small surplus was realized in 1933, it was inmiediately applied to the reduction of the charge of simple fillings. Bach new patient, with the exception of an emergency 44 cas© for the relief of pain, has been required to have a thorough prophylaxis, followed by an Z-ray series. After the patient's needs have been discussed and the cost of ser vice at the prevailing clinic rates have been estimated, the client's needs are treated in the order of their importance. The dentist, who first treats the case, has usually contin ued in charge. Consultation service for patients of moderate means at Mount Sinai Hospital, Hew York City. This clinic for a diagnostic service was established under the auspices of a large hospital providing service at reduced fees for patients who are referred by private doctors. The consultation ser vice was established in 1932, as an experiment in placing its professional and physical facilities, at the disposal of the practicing physicians of the city for the study of complica ted diagnostic problems among their low-income patients. The clinic has operated as an independent unit of the hospital and not a part of the out-patient department. Batients have been accepted if referred by their physician and if they have an income less than $2,400 per year for unmarried individuals and #4,000 per year for a total family income. Diagnostic service alone has been rendered the.patients; no therapy has been done. Upon the completion of the clinical investigation, the patient is returned to the referring phy sician with a diagnostic opinion and detailed advice concern- 45 iûg appropriate therapy# !The internist, surgeons, and specialists have composed the memhers of the visiting staff of the hospital proper. Fifty per cent of the gross income has been used to remunerate the medical staff. A flat fee of $35 has been charged for every patient regardless of the nature of his illness or the number of consultations or laboratory examin ations required. The hospital has derived no profit, direct? ly or indirectly, from the operation of the consultation ser vice. The medical society of the State of Few York has of fered no criticism of this experiment. During the years of its operation more than 1,800 physicians have referred more than 4,400 patients for invest igation. The volume of referred patients during 1935 was 35 per cent greater than during the previous year. During the first year of operation the deficit of the Consultation Service amounted to #6,142.63; the second year showed a de ficit of #5,517.87; but the third year’s deficit decreased to $2,866.80. The first nine months of 1935 have shown a small surplus which will be applied to a fund for replace ments. It was stated: By furnishing a diagnostic service of unlimited thoroughness at low cost to persons of limited means, the institution has given these patients a type of complete service which they could not otherwise have secured or it has enabled them to conserve their slen der resources for the subsequent treatment of their disease. In this manner it has undoubtedly enabled 46 a number of physicians to retain private patients ^ whom they might have lost to public wards and clinics. Ill SOUTH ATmUTIG STATES The Medical Bconomio Security Project, Washington, D.G, This project has operated as a central investigative and ad mitting bureau for hospital and clinic care for those unable to pay and for the determination and collection of medical, dental and hospital fees from those able to pay; it has been conducted under the auspices of the Community Chest and the County Medical Society. In June, 1934, the Medical Society of the District of Columbia, adopted a set of principles in dicating policies to be pursued in any plan for providing medical care for the indigent sick. A half-year later the Medical Economic Security Project of Washington, D.O., was put into operation by the cooperation of the hospitals, the Community Chest, the medical and dental societies, and var ious public health organizations. The Project has consisted of a three-fold organizations: the Central Admitting Bureau for Hospitals, the Medical-Dental Service Bureau, and the Permit Office of the Board of Public Welfare. The Central Admitting Bureau was given the task of handling all those who applied for Community Chest aid in sickness. The Julius Hosenwald Fund Publication, op. cit., p. 19. 47 Comimmity Chest has allocated a fund of #300,000 to nine hos pitals* The function, therefore,of the Central Admitting Bureau has been to administer that sum* After approval by the Central Admitting Bureau, ap- plcanta for Hospital care, whether in the wards or out-patient department, are presented with cards which guarantee the hos pital full-payment for services to be rendered. Thus, the hospitals have been relieved from the attempt to collect bad debts and from the need for investigation of clients for free or part-paid care. Each case is handled by the Central Ad mitting Committee on a personal basis, and there are no hard and fast rules for eligibility to service. If the Central Admitting Bureau has found a patient unable to pay anything for his hospital care, this case is referred for a permit from the board of Public Welfare for complete free service in the municipal hospital. The Medical and Dental Society of the District of Columbia have established a third division of the Medical Economic Security Project, known as the Medical-Dental Ser vice Bureau* This bureau has served as a cooperative, non profit enterprise to adjust payments for previous, present or contemplated medical, hospital or dental care. Its fac ilities have been available to any person who encounter a financial disability. A budget plan is worked out so that the client may pay old debts, or contract to pay for 48 necessary future services» with the total fees adjusted to the individual*s personal circumstances and income. Fulton County Medical Service Bureau, Atlanta, Georgia, The Medical Service Bureau has operated as a voluntary health insurance plan for persons of limited means, sponsored and ad ministered by the local Medical Society, The plan was insti tuted in April, 1934 and in 1936 it had approximately E62 doctors affiliated with the Bureau. Any individual idiose in come is under #1,800 per year per family has been eligible to subscribe for the services of the Assooiation. There has been an enrollment fee of #1.00 and a monthly fee of #1.60; other members of the family may be enrolled for medical ser vices for the additional charge of #1.00 per second member and per third member or more. This payment entitled the subscriber to a complete medical and surgical service, both diagnostic and treatment, but not to hospitalization. A subscriber in need of care has had only to call at the offices of the Association for authorization to see a physician of his choice. The services offered cover all medical and surgical specialties, and the patients have been entitled to services for all types of chronic and acute illnesses known to exist at the time of joining the organization. In August, 1936, there were 800 subscribers. The physicians were remunerated according to a fee schedule for different types of professional services. 49 However, the receipts from the subscribers were inadequate to pay the costs of maintaining the office of the Bureau and during the first nine months nothing was paid to the physi cians who served under the plan. The deficit for the first nine months was made up by an assessment on members of the Medical Society. Individuals may enroll regardless of whether they are employed with other people in groups and there is no arrangement made for payroll deduction for large numbers. Holston Talley Qommunity Hospital, Kingston, Tennessee. This hospital was established in 1935 by George W. Eutsler. It has operated as a non-profit association, sponsored by civic leaders, with a guarantee from a philanthropic foundation. There was only one hospital in this community of 1,600 per sons. Under the present plan the subscription rates are 76p^ per month for employed groups, and a #1.00 per month for in dividuals who pass a medical examination. For an additional 26^ per month a subscriber’s dependents may receive a 26 per cent discount on hospital bills. By December 1, 1936, the enrollment included approximately 2,000 subscribers and 3,000 dependents. Hospital Service Association of Hew Orleans, Hew Or leans , Douisiana. This assooiation operated as a non-profit organization, trustees serving without pay. The initial working capital of this association was provided by the four participating hospitals. All employees of the association 60 are paid. It was established in 1934 and by 1936 the en rollment was 10,606 employed subscribers and 31,815 depen dents « The subscription rates are 76/ monthly for ward ac commodations, and $1.00 monthly for semi-private rooms. Sub scriber’s dependents have been entitled to one-third discount on all hospital services in participating hospitals. The sub scriber has been eligible to receive without extra charge, twenty-one days room and board at the hospital, nursing, operating room, laboratory tests, ordinary drugs and dress ings, and one-third discount on all other special services such as X?-ray, basal metabolism tests, and serums; after twenty-one days of free hospitalization the subscriber has been entitled to receive one-third discount on all bills.Ho benefits are rendered except in the four participating hos pitals. IV m m m tost Qommunity Doctor, Washington Island, Wisconsin. The Community Doctor has been engaged to provide medical care for this isolated area. Washington Island, a farming and fishing community, is about sixty miles north of the southern shore of lake Michigan and several miles from shore. The community has no town settlement, the school, churches, and stores are out in the open country. The community consists of fifty-five farms. 61 independently owned and operated. The inhabitants are mostly Scandinavian in origin. Because of the isolation of the community it was felt that the 800 inhabitants must keep a doctor on the Island to take care of them whenever necessary. In 1933 the plan was adopted which guaranteed the doctor a salary of $3,000 per year. The doctor has been entitled to charge regular fees of $3,00 for a home call and $1.00 for an office call. If these collections do not total $3,000 annually the guarantors make the difference equally. To make sure that every family will be a guarantor the doctor is obligated to charge non- subscribers $16.00 instead of $3.00 for the first call. Ho matter how large or small a family’s annual doctor bill, it pays its pro-rated share of the guaranty, usually nine to twelve dollars a year for families and half that Amount for single persons. Y PAOmO STATES King County Medical Service Bureau (and others) Seattle « Washington (and elsewhere X These medical service bureaus have operated as voluntary sickness insurance groups under the auspices of Medical Societies, and have provided professional services and hospital care to employed persons. Several large groups of physicians in Washington and Oregon have offered during the last few years their services to 62 employed persons for an agreed annual payment. Free choice of doctors from among participating groups of from thirty to three hundred physicians has "been provided. An extensive service has been offered, covering medical, hospital, and nursing care, both for injuries covered by workmen’s compen sation acts and for ordinary sickness not connected with em ployment. In Washington the State Medical Society has spon sored the movement which has been administered through special bureaus established by the local County Medical Societies. Each Medical Service Bureau was authorized to make arrange ments to provide medical care for groups of employed persons. Bach Bureau has served as a non-profit corporation, directed by a board of trustees, designated (in Washington) by the County Medical Society. All administrative problems were turned over to a group of directors selected by the trustees. Bach Bureau has a professional medical director to supervise the medical service rendered. A sales director was chosen to run the office and establish agreements with em ployed groups. The original working capital has come from the initial membership fee of the physician, which represents the purchase price of one share of stock in the Bureau. These membership fees have ranged from $6 to $100 dependent upon other sources of funds which may be available in the commun ity. The corporation in Seattle has not operated as a joint- stock company; the working capital came from the initial 53 membership donations, #10 each. In Portland, Oregon the shares of stock were sold to participating medical practi tioners at #100 each. Each participating physician entered into an arrangement with the corporation by which he author ized the organization to utilize his services agreeing to accept payment for services on the basis of a given fee schedule. At Tacoma, the Pierce County Industrial Medical Bur eau, organized several years ago, was operated by the Pierce County Medical Society. During the latter part of 1933, it had 2,600 subscribers, with approximately 100 participating physicians out of the 169 physicians residing in Tacoma. The Yakima County Medical Bureau has offered the services of 60 members of the County Medical Society to its over two thou sand subscribers. In 1933 the Multonomah Industrial Health Assooiation of Portland was organized. In November, 1936, this organization served 6,000 subscribers through the ser vices of 236 participating physicians. The King County Med ical Service Bureau in Seattle was established late in the summer of 1933 and had enrolled, by October 1, 1936, 26,000 employed persons to whom it offered free choice from among 380 practitioners. Although these agencies are similar to each other basically, each plan has its individual features. Portland, for example, has limited its membership to those whose incomes 54 cLo not exceed $1,800 per year. The Seattle Plan has speci fied that employees may enroll in minimum groups of six. The rate of monthly or annual payments varied with the individual plan and with the scope of the benefits offered. The usual charge to the subscriber was from one to two dollars per month. Services offered varied from full coverage to the care of acute conditions only. At the time of sickness the patient may choose any physician on the list of participating practitioners. The physician whom he first consulted will continue the case. However, in emergency any physician on the list may be called for temporary service. The bureau itself has the responsibility of the de termination of the identity of the patient applying for ser vice. The practitioner, however, must report to the bureau when a subscriber applies for treatment, and when treatment has been completed. Bach physician must report the cost of the medical services rendered for each individual case, sum marizing them in a monthly statement to the bureau. These statements, then, are given to the medical audit committee to determine the suitability of the treatment given. With the approval of the general practitioner, the services of a specialist may be obtained. In Washington and Oregon medical service agreements may be drawn between the employer and the medical bureau. Under the workman’s Compensation haws, agreements were made 65 BO that either the employer pays the sum to the state, which then pays the physicians and hospitals according to an estab lished fee schedule, or the employer may make contracts with the hospital and physician directly. Both Washington and Oregon have permitted employers to require payroll deductions for general medical services to employees, if a certain pro portion of the employees agree to the plan. VI OAHAM Saskatohewan Plan’ * of Medical Gare in Rural Canada. This unique plan has rendered medical care to the entire pop ulation of certain rural municipalities by the employment of salaried physicians, paid by general taxation. These rural communities which offer little inducement to the development of private medical practice have found this method to ÿe suc cessful in securing adequate medical service. A number of rural municipalities, since 1922, have employed or subsidized doctors who were then known as the municipal doctors. The rural municipality in Canada eroompasses approximately 18 square miles and corresponds to the county political division in the United States. Saskatchewan, Manitoba, and Alberta have used the plan since 1922; however, its use is most ex tensive in Saskatchewan. There are about 300 rural municipal ities in the province of Saskatchewan and more than 60 of them employed full-time municipal doctors during the year of 66 1966. These full-time physicians were paid a regular salary, ranging from #3,000 to #6,000 per year. Other municipalities subsidized the physician with grants of $1,600 or less as in-r duoement to practice in the community. The Municipal Act of Saskatchewan has included special provisions concerning the engaging of physicians for service to the community. Every contract between the community and the doctor is subject to the approval of the Health Service Board, the chairman of which is the Minister of Public Health, The Provincial Medical Society has officially approved the municipal doctor system. The Saskatchewan Department of Pub lic Health drafted a model agreement between municipalities and the municipal doctor. The agreement binds the physician to give medical service without cost to all residents of the area. The physician renders general medical services and makes no charge for the care of fractures, minor operation, or maternity cases if they are within the competence of a general practitioner. The municipal doctor must immunize all children and others who request such service against small pox, diphtheria, and other communicable diseases. The pro tective and preventive services include inspection of school children once a year. The doctor must have his own means of transportation. A written report by the doctor must be pre sented to the municipal commissioners. The municipality has agreed to pay the physician a 57 specific salary and to provide telephone service. The phy sician may take three weeks’ leave of absence each year if he furnishes the substitute at his own expense. This leave does not include the time necessary to at tent the local med ical meeting, the annual meeting of the provincial associa tion, or any meeting of Saskatchewan Health officers. The physician is entitled to two weeks vacation with pay for the purpose of graduate study, at least once every two years. The physician may charge two dollars plus reason able mileage fees for every home call that is judged by the physician to be unnecessary. The financial support of the municipal doctor system has been in most instances a property tax uniformly levied on the value or land acreage of the respective farms. The benefits are available to all residents of the municipality, whether citizens of the municipality or not, and whether or not they own property. The municipal doctor is usually the official health officer for the municipality. There has been an increase in the number of immunizations against communicable diseases in the municipal doctor areas. Very little abuse of the privi lege of free medical services has been reported. In the autumn of 1935, the Deputy Commissioner of Health predicted that another decade would find municipal doctors in nearly every community that could support a medical practitioner. 68 To present each of the above plans for medical service more vividly and concisely, each agency has been outlined in an alphabetical skeleton. This skeletal representation was made possible by the construction of a scale of classifica tion which used the letters "A" through to enumerate the pertinent facts of the institution. The scale ® made possible the comparison of the various agencies on the basis of four major points, namely, the social group involved, the payment for service, the agency in charge, and the services availa ble. The following is the scale used to classify and com pare the agencies: I. SOGIAh GROUPS IHVOEVED A. General population B. [^ployed group or groups 0* Persons of moderate means D. "Poor" persons B. Students II. PAYMBHT FOR SBR7I0B F. General taxation G. Fixed periodic payments from the beneficiaries, voluntary insurance H. Fees from individuals served I. Community Chest I. Private funds (gifts, endowments) K. Fees on installment or commuted basis ^ A like scale for graphic presentation was used in the Julius Hosenwald Fund Publication, Hew PlanS, for Medi cal Service, Chicago, 111., 1936, p. 8. 69 III. AGBHGY IH CHARGE L. Government (oity, county, or state) M. Voluntary non-profit association H. Private medical group 0* Hospital P. County Medical group IV. SERVICES AVAIIABLB Q. Physician R. Hospital S. Dentist It was felt that this scale for measuring the medical organ ization, as presented in this chapter, was both adequate, in that it brought to sight the fundamental machinery of each agency, and graphic, as one can see at a glance the agency and its workings. The alphabetical skeleton made distinct the trends in the newer plans for medical service. The typical agency was found to be one that served the general population, was fi nanced by fixed periodic payments by the beneficiaries, was administered as a voluntary non-profit association, and gave both hospitalization and physician’s services. The eleven agencies were selected as representative of the current ten dencies in medical service. It was of interest to examine the graphic portrayal of the nation-wide plans for medical service and to relate and compare these with the agencies of Dos Angeles, the primary concern of this study. That subject will be described in the following chapter. 60 TABDl I fltle ' ' " ^ of Agency édclài Croup Involved rayaehts for Services Agency in Charge Services Available BRATTDIBOHO MEMORIAD HOSPITAD A G m Q,R BAKER MmORIAD UHIT OF BOSTOH ammAii HOSPITAL A H 0 Q,R DÉHTAL HEALTH SERVICE HEW YORK C H M S MOÜHT SIHAI OOHSULTA- TIOH SERVICE, H.Y.C. c H 0 Q MEDICAL ECOHOMIC SECUR ITY PROJECT, WASHIHGTOH, B.C. * C,D K L,M,P Q,R,S FHLTOH GOUHTY MEDICAL SERVICE BUREAU C,D G P Q HOLSTOH valley OCMMUE- ITY HOSPITAL A G M R HOSPITAL SERVICE ASSO- GIATIOH OF HEW ORLEAHS A G M R COMMUHITY DOCTOR, WASH- IHSTOH.ISLAHD, WIS. A G M Q KIHG COUHTY MEDICAL SERVICE B G P Q,R "SASKATCHEWAH PLAH** A F L Q Also indigents. GHAPTBR IT LOS AHGELES MBPIOAL AGSHOIBS PROTILIHG CARE OH A PART-PAY OR FEE BASIS Los Angeles, the fifth largest city in the United State, had in the spring of 1938 a total of ten part-pay medical agencies which served the individual whose income approximated $75 per month and the family with an income of $120 per month. There were in the city many other medical institutions which did their share to alleviate the burden that sickness placed upon individuals, but these were strict ly charitable agencies and did not accept individuals whose economic status was as high as that of those persons included within this study. The agencies were designated as part-pay medical organizations by the medical division of the Los Angeles Oouncil of Social Agencies and by the administrative heads of the various agencies. Included within the group of ten agencies were the three group plans for medical care in operation in Los Angeles; two of these agencies offered com plete medical care for group and individual enrollees and the other operated as a group hospitalization plan. Seven clinics and out-patient departments made up the group, six of which included hospitalization with some connected hospital. Each institution was visited and the administrative head was inter viewed. In order that the uniformity of information might be 62 insured, a schedule was devised which was used as an inter view guide.^ The information requested closely approached the schedule or criteria developed in the Julius Hosenwald Q Fund Publication on Medical Services , although the present schedule was constructed without knowledge of the earlier study. Each agency was studied on the basis of the follow- points: 1. Description of the organization: What was the medical scope of the agency? General or specific? Children or adult? Hospitalization? What were the physical facilities of the agency and its location in the city of Los Angeles? What was the status of the agency? Charitable or profit- making, public or private? 2. Administrât ion of the institution: What was the source of operating power? State license? Who were the officials, their duties, and functions? 3# Financial organization of the agency: What was the source of the funds? Private and/or public funds? Were Community Chest allocations received? 4# Staff of the agency: What was the personnel of the medical staff? Doctors, nurses, laboratory 1 See Appendix Table 71II ^ Julius Hosenwald Fund Publication, Hew Plans for Medical Service, Chicago, 1936. pp. 6-7. 65 teelmioians, and pharmacists? What were the numbers of the employed and those of the vol te ers? Was there a social service division? Who composed its staff? Humbers of those paid and those volunteering their services? 5. Functions of the organization: a - What groups of persons were eligible to the agency according to finances and residency?^ What services were available to the people served? Were there any special conditions to be met for certain services? b - What was the range of fees? How was it de termined?^ All private medical agencies in Los Angeles have an agreement that three years State and one year County residence are prerequisite to service. ^ For those agencies of semi-charitable status who belong to the Los Angeles Council of Social Agencies a special code of fee schedules has been devised. The patient is classified according to an alphabetical code from "A to S" by the financial worker or admitting clerk. The individual classed as "A" pays 60/ per visit registration fee and full clinic charges; the "B" client pays 36/ registration fee and threer-fourths clinic charges; the "C" patient pays 26/ regis tration fee and one-half clinic charges; the patient pays 10/ registration fee and one-fourth clinic charges; and the individual coded as "E" is a no-pay patient. Though many of the clinics do not use the full range of classification yet the coding is retained for those fee schedules prevalent with in the particular clinic. Hence, there may be a fee range from 60/ to 26/ and the code used will be the "A to G", re taining the essentials of the "A to B" code. 64 0 - What was the procedure with the patient preliminary to the receipt of medical care? ' d- Were social case work techniques' employed such as referrals to other agencies for further services, placements for convalescent care, and follow-ups? e - What was the number of indiv iduals cared for during a given period? How did these persons classify according to new patients, old patients, race and nationality, age, sex, prevalent type of illness? f - What was the relationship of the agency to other agencies in reference to services and referrals? g - Was the agency a member of the Los Angeles Social Service Exchange; this made the service given charitable status regardless of the part- pay of the patient? Lid the agency belong to c the Council of Social Agencies? 6# What did the administrative head of the agency know of the efforts made in Los Angeles and elsewhere to meet the medical needs of the low income group? ^ All the organizations belonging to the Council of Social Agencies and/or the Community Chest submit a financial and service report to the medical division of the Council of Social Agencies yearly. 66 7. What were the forms used by the agencies for keeping patients’ histories? Were there any g reports or surveys of the agency available? I. PARTs^PAY OLIHIC White Memorial Clinic♦ a private charitable organiza tion on 204 H. Boyle Avenue has served the low income group of the north-eastern section of Los Angeles for many years. Both adults and children have been eared for by this agency which has provided general medical services to the middle class population of both its immediate vicinity and the lar ger area of Los Angeles proper. Hospitalization and labor atory facilities have been secured from the White Memorial Hospital. The clinic is owned and operated by the College of Medical Evangelists as an educational and non-profit corpor ation. The clinic itself is licensed by the State of Cali fornia. The Board of the College of Medical Evangelists ^ The Los Angeles Social Service Exchange is the clearing house for all social service cases throughout Los Angeles County. All cases are registered at the exchange and record is kept of the registration. The Exchange is maintained by the Community Chest. 66 has complete control of the services given, the conditions for eligibility to services, and the various heads of the clinic; the medical head of the clinic and the people in charge of the social service. The White Memorial Clinic has two sources of funds; the fees paid by the clients of the organization and the funds of the Medical College. The deficit which accumulates yearly by the clinic is met by an allocation from the Medi cal College. Ho funds have even been obtained from the Com munity Chest. The medical staff of the clinic is composed chiefly of volunteers from the physicians and surgeons connected with the College of Medical Evangelists. There were, in 1938, eighty-four volunteer medical men in attendance at the clinic, and twelve who were paid by the College as resident doctors. Twelve full-time nurses are employed by the College for duty in the clinic. The technical facilities of the White Memor ial Hospital are used so that the clinic has had no need to employ a separate staff of laboratory technicians. The social service staff of the clinic is composed of three full?-time so cial workers and three full-time clerical workers, both of whom are paid personnel. The conditions for eligibility to the services have been determined for the most part by the medical division of the Los Angeles Council of Social Agencies, though the 67 principles of case work are employed in order to make each case an individual one. A family with an income of #110 per month is considered to have the maximum income allowable for services rendered at the clinic. The following services are among those offered: general medicine, surgery, pediatrics, allergy, skin clinic, orthopedics, venereal disease clinic, hospitalization. X-ray facilities and laboratory services. A patient eligible to any services at the clinic is eligible to all services. Certain cases involving long and continuous treatment and/or hospitalization may be accepted on a case work basis regardless of income level. Certain allergy, venereal, or orthopedic cases are such. Each patient is classified according to the fee suitable to his income and is interviewed yearly to re-determine eligibility. Three codified groups are in usage: A ^ these individuals pay 25/ per visit and are seen once a year to establish their eligi bility; B - these persons are above the budget limitations insofar as income is concerned but need expensive treatment and service and thus are accepted on a temporary basis, pay ing 26/ per visit and extra for other services; C - these patients receive free care. The persons classification is determined at the first interview. The patient makes direct application to the clinic for services. At the time of registration eligibility of the in dividual to service is determined and the questionnaire and 68 faoe sheet are filled with the personal data of the patient. Where the individual presents a medical social problem or in those cases whose budget is above the prescribed amount, the social worker is called and she determines eligibility. After eligibility has been established, the patient is given an ap pointment to the proper department of the clinic. Social case work techniques, such as referrals, fol low-ups, and placements for convalescent care were utilized by this agency. Referrals to the Cedars of Lebanon eind the Los Angeles County Hospital were made for special cases of cancer and to the City Health Department for tuberculosis. Ho placements for convalescent care are made by this agency, but each case is referred to the proper family agency for social service. A routine follow-up system is employed with all surgery, pediatric, chest, and heart cases and other fol low-ups are made at the request of the doctor in charge of the case. During the fiscal year of 1936-37 there were 14,916 new patients, and a total of 129,602 visits. There were no figures on the number of old patients or the total number of patients. Predominant nationalities were, in the order given, Mexican, American and Jew. There were no particular age groups among the patients. The proportion of sex distribution was slightly in favor of females. The types of illnesses prev alent among the patients, as shown by the size of the 69 department within the clinic, were general medicine cases, special medicine (luetic), skin clinic, orthopedic, and sur gery. Ho written reports of the activities of the clinic were available. The Clinic has contracted for regular service with the White Memorial Hospital for laboratory. X-ray, and hos pitalization facilities. The White Memorial Clinic is a member of the Los Angeles Council of Social Agencies and of the Social Service Exchange. The officials in charge of the clinic are not trained social workers and therefore had little theoretical back ground in reference to the problem of medical care. However, there was the feeling among these officials that the needs of this class of people are not being met in Los Angeles. For the most part the officials have little knowledge of any at tempts made elsewhere to meet the needs of the situation and they have not formulated any plan of action themselves. All Hâtions Foundation Clinic, at 603 Gladys Avenue, is a private charitable organization licensed by the State of California as a clinic and dispensary. The clinic is lo cated near the transportât ion center of the city in the midst of the rooming-house and apartment house neighborhood, pop ulated by migratory workers, transients, and "poor whites." The medical scope of the organization is general and provides hospitalization at the Methodist Hospital, where it maintains 70 four beds a day which are paid for by funds from the Ommuni- ty Chest. îThe source of operating power of the All nations Clinic is the All nations Foundation of los Angeles. The All nations Foundation, which consists of a family welfare bureau, a set tlement, and the clinic, is legally controlled by the Methodist Missionary Board, a national organization. Its local organic zation is a special board which sets the policies and directs the management of the entire local foundation, including that of the medical clinic. The All nations Clinic is not a self-supporting clinic, since one-third of its patients are free service cases. The Clinic is maintained by contributions from three sources: the Community Chest, the Mathodist Missionary Board, and fees from the patients. Since the All nations Clinic is not connected with any hospital close by, it has a more complete medical staff than do other clinics in the city. There are forty volunteer doctors and dentists who give from two to six hours weekly to the clinic; in addition, there is one staff physician who is at the clinic full-time, and for which service he is remuner ated by the clinic. There are five fullestime and part-time registered nurses who are paid for their services. The other paid members of the medical staff are: one pharmacist, two dental assistants, and one laboratory technician. One 71 volunteer optometrist completes the medical staff of the clinic. The social service staff of the clinic is headed "by the Director of the clinic and includes one medical social worker, and admitting clerk, and a registrar; all of whom are paid. Volunteers intermittently serve in a social service and clerical capacity. The conditions of eligibility to services of the All îîations Clinic have been for the most part determined by the Council of Social Agencies in Dos Angeles. There is a basic intake policy of acceptance of a family of four with an income of #110 per month; however, cases are accepted on a case work basis. There are certain conditions to be met besides that of income, namely, residence in the State of California, and the typé of treatment required, go clients of the State Relief Administration or from the Los Angeles County Welfare Department are accepted. WPA workers are accepted if they are technical non-residents or non-residents. Transients are accepted only for emergency treatment such as dressings, toothaches, boils; but no longtime services are available for this problem group. The services available are those found in the following departments of the clinic: general medicine, dentistry, B.g.T., endocrinology, eye, gynecology, surgery, orthopedics, refraction, urology, vener eal diseases, laboratory tests, go cases requiring treatment for cancer or tuberculosis are accepted and there is no de- 72 partment of pediatrlos within the clinic. The fees paid by the patients are determined by the code ranking assigned to each individual by the admitting clerk. Bach clinic patient is rated according to the "A-B* scale determined by the Council of Social Agencies. The top fee, that is, classification A, is and the other fee schedules follow the ”A-E" code, of payments. The same scale is used for the determination of prescription, laboratory, and hospitalization fees. If possible, those individuals who are unable to pay for medical services rendered by the clinic are given work to do for the organization in return for those services. In order that the client might receive medical care, it is necessary that he make direct application to the re ceptionist at the clinic. The client is then interviewed by the admitting clerk who determines eligibility and takes the social case history. The registrar gives the patient an ap pointment for a general medical examination prior to any special treatment and also makes appointments for emergency aid. The medical social worker sees the patient only if there is a medical social problem. Referrals to other social agencies are very infrequent ly made as many of the cases are referred to this agency by any of the Protestant agencies in this city; the other 60 per cent of the patients are unattached men and women of over 73 middle-age and there is not muoh need for case work. There is an occasional placement for the convalescent care of un attached men and women, following hospitalization. Some follow-ups are made with venereal disease cases where there is a social problem. During the year, January to December, 1937, there was a total of 4,592 new and old cases. There were 23,690 pa tient visits. One hundred and ninety-seven patients were admitted to the hospital and there were 1033 days of free hospital care. Some forty^two different nationalities were represented among the patients of the All gâtions Olinic, but the majority of the patients are Americans. Especially since the depression, these patients are sent here by their own private physicians. All age ranges are served by the . clinic. The clinics most often called upon for service are the dental, general medicine, and the venereal disease clin ics. The clinic has a contract for hospitalization at the Methodist Hospital and does make referrals to various city, county, or Council of Social Agencies* organizations. The All gâtions Clinic is a member of the Dos Angeles Council of Social Agencies and the Social Service Exchange. Each year a brief statistical report of the clinic is made and sent to the Council. The Director of the clinic is very much interested in the problem of medical care for the low-income group and 74 feels that the olinio is doing its share in alleviating some of the need for medical care. However, the problem of the future of medical care or the meeting of the present problem on a city?"Wide basis is one for which the Director of the clinic has no solution. Good Hope Hospital Association, at 1241 Shatto Street, is a self-endowed association, operating under the State Con stitution as a no stop-no profit corporation. The organiza tion renders complete medical treatment and diagnostic ser vices for adults of thirteen years and over. The clinic is located in the apartment house district near the main busi ness section of Dos Angeles and occupies about one-quarter of a city block. The clinic is managed by a board of trustees composed of laymen and is self@*perpetuating. The function of this board is to determine the policies of the organization and to control its finances. The board of medical tiustees is composed of members elected by the vote of the medical staff, and its functions are to set the requisites of the medical assistance given and to determine the eligibility to the medical staff. 2he financial organization of this association is dif ferent from that of other clinics in the city. There is a self-endowed fund which is used to make up the deficit year ly between the costs of operation and the payments received 76 from the patients. The medical staff of the Association consists of one hundred and eighteen doctors who volunteer their services. Four paid externes will be employed shortly by the Hospital Association. There are also one Z-ray operator, one refrac- tionist, and four nurses, all of whom are paid employees of the Association. The social service staff consists of the Director of social service who is also the Director of the olinic and four medical social case workers. The entire so cial service staff is paid. The Good Hope Hospital Association has the most liber al intake policy of all the clinics in the city. A family of four with an income of #130 per month is used as the basic income level. If a patient is at all eligible to services he is eligible to all services offered. Ho person is eligible for diagnostic services alone. The following services are available: general medicine, Z-ray, deep therapy, laboratory, radium treatment, and hospitalization at the Good Samaritan Hospital. The procedure preliminary to the receipt of medical care at this agency differs from that of any other clinic in the city. Any private physician may refer a patient to the clinic. Ho direct applications are accepted. The client is seen by the intake medical social worker who determines the eligibility of the person to services. An appointment is 76 then made to the specific medical department. There is a very low percentage of the intake cases that are referred to other organizations. Placement in pri vate convalescent homes is used extensively and much use is made of WPA housekeepers. Follow-ups are made on all cases in which there is an indication of a medical social problem. During the year of 1937 there was a total of 9,676 patients: 1,469 of whom were new patients, 8,206 were old patients. There were no special nationalities served by the clinic. Female patients were twice as prevalent as male pa tients. The general medicine and the allergy clinics are the most frequently used of the Hospital Association. Ho workmen’s compensation cases are taken. All referrals by this agency are made at intake except where a social problem presents itself later. The Hospital Association has an agree ment with the Good Samaritan Hospital for the hospitalization of its patients. The Good Hope Hospital Association is a mem ber of the Council of Social Agencies and of the Social Ser vice Exchange. There were no printed reports available. The Director of Social Service knows of the various efforts made in other parts of this nation to meet the needs of the low income group in Dallas, Alameda and the various Group Hospitalization plans of Los Angeles. The Director thinks that the future is hot in the privately organized medical groups, but in the compulsory health-insurance which 77 would leave private agencies free to do research and expérimentât ion. Graves Memorial Dispensary, at 737 gorth Broadway, is the Dos Angeles Medical Department of the University of Oalifomia. It is thus a publicly?owned clinic supported from general taxation funds, plus endowment, and is a non prof itahle organization. The clinic is located near the railway terminal section of the city which is populated hy Mexicans and the poorer white population. The medical scope of the organization is general; however, no hospitalization or surgery, other than minor, isiavailable. The University of Oalifomia is the administrative head of the clinic. The Superintendent of the clinic, a registered nurse, is appointed by the Board of Regents of the University and has full charge of the clinic. The clin ic is self-supporting and receives no allocations from the Gommunity Chest. The various officials, however, are paid by the University. The medical staff of the clinic consists of sixty- five volunteer doctors, ten part-time paid nurses, one paid technician, and one paid phaimacist. There is no social ser vice department. All persons are eligible to the clinic who are able to pay a twentyr*five cent admission fee. go inquiry is made in to the financial status of the patient. If the individual is 78 unable to pay the nominal fee he is referred to the Los Angeles Oonnty Hospital. The following services are avail able: children’s clinic; eye, ear, nose and throat clinic; general medicine, nervous diseases, orthopedic clinic, skin and venereal diseases, surgical diseases and injuries; wom en’s diseases, and rectal clinic. There are no conditions for services offered other than the ability to pay the ad mission fee and the extra charges for dressings and medicines. The preliminary steps to the recept of treatment In this par ticular agency are much less complicated than those of other clinics. The patient merely makes direct application to the clinic and, upon the payment of the registration fee, is sent to the doctor in charge of the clinic which cares for the special complaint of the patient. Few social case work techniques are employed by this agency, go placements in convalescent homes, rest homes or boarding homes are made; nor are there any follow-ups on the cases. Some referrals are made to the White Memorial Olinic or to the Good Hope Olinic if the patient seems able to pay more than the small fees of this particular agency. The ”A-B” range of payments is not followed by this clinic. Luring the year, 1937, there was a total of approx imately 60,000 patients served. These were for the most part white Americans. The proportion of the sexes was ap?- proximately equal. There was no outstanding type of illness 79 aided during the year. All Workman’s Compensation oases were sent to the Los Angeles County Hospital. This clinic has no contracts for services outside the clinic and makes no referrals to family case work agencies. The Graces Mem orial Clinic is a member of the Los Angeles Council of Social Agencies, but not of the Social Service Exchange, go reports or studies have been made of the clinic. The superintendent of the clinic has no knowledge of the various efforts being made elsewhere to meet the problem of medical care for the low income group, other than the part of the Good Hope Hospital Association in Los Angeles. California Babies Hospital, 1401 South Grand Avenue, is a charitable medical institution, incorporated under State law. The medical scope of the hospital is limited to mater nity cases, and children up to fourteen years of age. The Hospital is located in the old residential section of down town Los Angeles, and occupies approximately one-'tenth of a city block. The California Babies Hospital is legally controlled by the California Babies Hospital Corporation which was or ganized in 1919 with an endowment fund of #60,000. A board of directors consisting of seven members serving for three years is selected from the corporation members. The board has full powers over finances and the policies of this organ ization. The financial organization is built around the 80 endowment fund of #50,000^ fees from the patients, and a yearly allowance from the Community Chest. The medical staff consists of thirty-six doctors, twenty of whom are volunteers, and sixteen of whom comprise the volunteer consulting staff of the hospital. There are three full-time and three part?-time nurses who are on a sal aried basis. There is one paid clerical worker and three vol unteer clerks. One resident physician is paid for out of the endowment fund. Internes from the California Hospital receive training in pediatrics in the Babies Hospital. The social service staff consists of the Superintendent from the clinic and a medical social service worker, both of whom are paid. Individuals with a family of four and an income rang ing from $100 to #126 per month are eligible to the services of the hospital. Special cases are accepted on a case work basis. Long-time hospitalization and intensive care cases such as orthopedics and asthma are admitted from higher in come groups. The following services are available : general medi cine, surgery, pre-natal department, eye, ear, nose and throat, luetic, physio-therapy, infant feeding, allergy, wet-nursing bureau, i^armacy department, Z-ray department, laboratory de partment, and dental department, hospitalization at the Cal ifornia Lutheran Hospital. Bo contagious diseases are treat ed with the exception of whooping cough which is treated in 81 a special clinic. One of the rare wet-nursing bureaus is maintained by the Hospital and it is the center for such ser vice in Los Angeles. The clinic patients are rated according to the ”A-B" classification of clinic charges determined by the Gommunity Ohest and the Gouncil of Social Agencies. All patients who meet the financial and resident re quirements upon direct application are eligible. The pre liminary eligibility is deteimined by a clerical application interviewer. There is a social service worker who takes the history and determines final el%ibility. Each patient is required to bring a written release from his doctor if treat ment has been received within the last three years. The pa tient is then referred back to the clerk who makes an ap pointment to the proper department of the clinic and registers the patient to the clinic. Referrals to other agencies are made either at time of intake when eligibility is denied or when the conditions in the case warrant the attention of other social agencies. A snail percentage of case placement is made at Junior League Gonvalescent Home for further rest and care, payment for which is based on the ”A-B” classification of the patient. Follow-ups are made on all cases in regard to finances and on those in which a medical social problem is indicated or upon the doctor’s request. 82 There was a total of 6,427 patients cared for during January to December, 1937, of whom 2,068 were new patients* There was a total of 13,193 visits during that year. Thirty- three different nationalities were represented of which the American, Mexican and Jewish populations predominated* The sex distribution was even. The Hospital has a contract with the California Lutheran Hospital for hospitalization services. It is a member of the Los Angeles Council of Social Agencies and Los Angeles Social Service Exchange. The Superintendent of the Oalifomia Babies Hospital has no knowledge of efforts made elsewhere in meeting the needs of the middle class except those found in the Gommun ity Ghest organization. Eye and Ear Hospital Clinic, at 600 Lucas Street, is a semi-charitable organization, operating under a clinic and dispensary permit, from the State Department of Health. The medical scope of the olinic is limited to the treatment of eye, ear, nose and throat ailments, and allergies. Hospital ization is provided for those cases requiring such treatment in the Eye and Ear Hospital. The clinic is located near the heart of the business section of Los Angeles, and occupies a ninety by one hundred and fifty foot lot. The Clinic is administered as part of the Hospital itself, which is a corporation owned by Drs. Jesberg and Brigham, who hold the controlling shares. The head of the 83 Hospital is Dr. Jesberg and the chief of staff is Dr. Brig ham. There is a business manager who is a paid official. It is these officials who decide the policies of the clinic. Through the fees of the clients, the clinic manages to pay for itself, that is, the salaries of the staff of the clinic and the running expenses. However, the overhead of the rent is not met by the income from the clinic. Private funds from the Hospital itself are used to make up the de ficit yearly. The clinic receives no support from the Com- munity Ohest. The medical staff of the Hospital Clinic is composed Of two paid house physicians, and four volunteer physicians. In addition, there are two nurses, one laboratory technician, one refractionist, and one clerk, all of whom are on a sal aried basis. The head of the social service is also the refractionist and is paid in that capacity. There is one ad mitting clerk and one social worker both of whom are paid. The conditions of eligibility to this clinic are very liberal as compared with others in the city. The basic in come per individual per month is $80 to $100. Their ser vices available are all those connected with the care and treatment of the eye, ear, nose, throat, and allergy, and such hospitalization as may be necessary. There is a 50^ charge per visit which is increased if medicine is required. All city schools have special rates for the services of the 84 olinio. There is a reduced fee for hospitalization. In order to receive service the patient makes a direct application to the admitting clerk who determines the eligi bility of the patient. All medical social problem cases are interviewed by the social service worker. Very few referrals are made to other social agencies in the city. Follow-ups, by letter or visit, are used when occasion demands such tech niques. There was, during the fiscal year of January to Decem ber, 1937, a total of 15,567 patients served by the clinic. There was no outstanding characteristic of the group served insofar as nationality, age, or sex. The clinic has a reg ular agreement with the Los Angeles County School system, through Dr. Blanche Brown, to provide clinic care for school children. The Bye and Bar Hospital Clinic is not a member of the Los Angeles Council of Social Agencies nor of the Social Service Exchange. The Children’s Hospital Society — Outpatient Depart ment, at 4614 Sunset Boulevard, is a private charitable in stitution. The care of this Out-patient Department is lim ited to children under fourteen years of age, and to the care of all children’s diseases except contagious diseases. Hos pitalization is provided at reduced rates at the Children’s Hospital. The Hospital is located in the center of a resi dential Hollywood district and occupies approximately a 85 quarter of a oity block* The Outpatient Department operates under a clinic and dispensary license from the State Department of Health. The clinic has also a permit from the College of Surgeons for the intemeship of doctors. There is a Board of Directors of the Children’s Hospital composed of lay people. The members of this board are chosen from the larger group of the Board of Managers, all of whom are life members. The Board of Direc tors has as its functions the control of the policies and finances, equipment of the Hospital, general probl^s, and public complaints to the Hospital and Outpatient Department. There is an Executive Staff of Physicians who chose the res ident and house doctors. All changes in regards to the sup ervision and care of patients are under the management of this staff. The heads of the departments and of this staff are chosen yearly. The Outpatient Department is supported by funds from the Community Chest, fees from the patients, property given as gifts, monies from various charitable societies connected with the hospital, and fees from the sale of serum. Fifty- four per cent of the budget is appropriated to the institu tion by the Community Chest. The medical staff consists of one paid resident phy sician, two paid house physicians, and forty-two volunteer physicians who donate time to the Outpatient Department. 66 There are seven paid, full-time nurses, and three part-time paid nurses, and four student nurses who receive no remuner ation for their services. There are twelve volunteer den tists who serve the Outpatient Department. There are also six physio-therapy workers, one technician, and four order lies, all of whom are paid. The clinic is headed hy a di rector who is paid for her services and in addition there is a director of social service who is also a paid member of the staff. The social service staff is completed by three full time paid workers, and one part-time paid worker, eighty vol unteer workers, and the necessary clerks and stenographers. The conditions of eligibility to the Outpatient De partment of the Ohildren’s Hospital are set by the Council of Social Agencies. A family of four with an income of $110 per month is the basic income level. Public welfare cases needing treatment for allergy are taken if they are unable to get into the County Hospital. The services available are the following : general medicine, infants clinic, eye, ear, nose and throat, skin clinic, luetic clinic, orthopedic, al lergy, cardiac clinic, psychological clinic, spastic clinic, posture clinic, epileptic clinic, nutrition and endocrine clinic, diabetes, proctology, and hematology. Hospitaliza tion at the Children’s Hospital and the use of its laboratory facilities are also part of the services available. The con ditions for services are determined by case work procedure. 87 the length of the services required, and the debt of the fam ily. The range of payments for services has been set by the Council of Social Agencies and follows the "A-E” fee schedule. Each patient is classified at the time of the^first interview and his eligibility is re-established yearly. The patient wishing to be treated at the Outpatient’s Department of the Children’s Hospital makes direct applica tion at the Information Desk, at which time the individual gives preliminary information as to the ailment, what doctors, have been called in on the case, and whether the patient has the one year resident requirement. The individual is then given a number and sent to a volunteer worker who takes the case history and determines eligibility. Medical social problem cases are sent to the Director of the Social Service staff and to the medical social worker. If the patient is eligible to the Outpatient’s Department, he is registered and given a card to the department for general medical examination and is later referred to the special department that treats his ailment. Some referrals are made to private doctors and non-residents are referred to the #iite Memorial Olinic. Fol low-ups are routine on the doctor’s recommendation. An ap pointment is made for the patient to visit the clinic and where a patient has failed to attend the clinic two cards are sent to the patient. If the patient does not reply to the two cards, it is up to the doctor to decide if a home 88 follow-up is to be made. During the year of 1937, there were 6,351 new patients treated (there were no figures as to the total amount of pa tients eared for during the year). The total visits of pa tients to the olinio were 84,908. The predominant races and nationalities were white, Mexican, Negroes, Japanese, and Chinese, in the order named. The clinics most frequently at tended were the general medicine, the allergy, and orthopedic. The Hospital has a regular agreement with the clinic to pro vide hospitalization at reduced rates. The clinic is a mem ber of the Community Ohest and the Council of Social Agencies. However, only those cases in which intensive social service is rendered are registered or those cases in which other so cial agencies are concerned. A yearly pamphlet is issued by the Hospital which summarizes the work of the preceding year. II. GHOUP PLANS FOR MEDICAL SERVICE Boonshaft Medical Group, at 947 West 8th Street, is a private, profit-making organization under Dr. Boonshaft, who has complete control and final decision in all matters concerning the operation of the Medical Group. The Medical Group is not organized as a corporation. The medical scope of this plan includes all medical and surgical attention, hospitalization and clinical or laboratory tests for chil dren and adults enrolled as individuals or employee groups. 89 The offices of the Medical Group are located in one of the medical-dental buildings in central downtown and occupy the whole of one floor. The offices are equipped with the new est and most modem apparatus. The Group Medical Plan operates as a private practice scheme under the direction of Dr. Boonshaft as an individual. It will be, eventually, on a cooperative basis at which time there will be heads of various departments who will form a committee to decide the policy and direction of the Medical Group. Dr. Boonshaft is the director of the Medical Group and his associates are employed by him. The Medical Group is a private, self-supporting agency, maintained entirely by the fees of its clients. It receives no funds from pub lic or private charities and is not a member of the Gommun ity Chest. The medical staff of the Group consists of twelve physicians who are paid for their services. Each of these is a specialist in his field and has not less than five years actual medical experience. There are three registered nurses, two technicians, and a dentist and a dental technician; the entire staff is paid for its services. The dentist and den tal technician are employed by the Medical Group for the sole purpose of consultation and recommendation. There is no so cial service department as this is not a charitable instil* tution. 90 Any individual, family, or employee group may secure medical and surgical care for themselves and their families (children up to the age of nineteen) at a specified monthly fee with the exception that mental diseases, alcoholic or drug addiction cases, cases of attempted suicide, and injur ies arising out of and in the course of employment and com pensable under the workman’s Compensation Act of the State of California are not treated. As stated above, all medical and surgical attentions, clinical or laboratory tests. X-rays, treatments, operations, professional consultations and visits are available. In ad dition, the Medical Group furnishes medicines and drugs needed in cases of sickness and prescribed by the Medical attendant, ^t also furnishes dressings, splints, etc., as prescribed by Medical attendant. Ambulance service, to the extent of ten miles traveled by the patient per one trip, is furnished when it is ordered by the Medical attendant. There are the following exceptions to the definition of medical and surgical attention: the patient will pay cash for all ortho pedic appliances, eyeglasses, crutches, Wieel chairs, sickroom furniture, special nursing, hypodermic medication, radium treatments, deep X-ray therapy, and treatments for social dis eases pits cost of medication; the Medical Group will not pay for a donor in blood transfusions; nor will it assume respon sibility, financially or otherwise, for any outside doctor 91 called in on a case, nor for any medication ordered by that doctor. The range of payments for service at the Medical Group are as follows: $2,50 per month for a family including de pendent children under nineteen years of age occupying the same residence; $1.25 per month for an individual: unmarried members, unmarried employees of members, or those who wish to secure medical service for themselves alone; special fee per month for the dependents of those who participate at the $1.25 monthly rate; and $1.75 per month for individuals who enroll apart from any employee group. Upon termination of services, employees may continue to receive the medical care by remit ting fees in advance, quarterly, semi -annually, or annually, direct to Louis Boonshaft, M.D., and Associates. In the event of a surgical operation twelve monthly payments in advance must be made, and no monthly fees will be required for the following twelve months. Services will be discontinued if fees are not paid in advance. Reinstatement will necessitate a physical examination at fees of: individual, $2.00, family $5.00, and acceptance for medical and surgical services thereafter will be at the option of the Medical Group. The members of this Medical Group are enrolled from certain large employment groups such as the various depart ments of the County Administration or large corporations at which time whole groups join to receive medical attention. 93 It is possible, however, as the above paragraph describes, for other persons to receive medical care by other arrange ments with the Medical Group. The service is personalized and individualized and each person makes an appointment for the services of the individual doctor at a particular time. At the time this study was conducted, no figures were avail able concerning the number of clients cared for during a given period. This agency is entirely independent of any other a- gency in the city and does all its own work at the central office. Special arrangements are made with hospitals when hospitalization is necessary. The Medical Group is not a member of the Gouncil of Social Agencies nor of the Social Service Exchange. There have been no printed reports made of the workings of this plan for medical care. Doctor Boonshaft is fully acquainted with the vari ous plans throughout the United States to provide adequate medical care, at a low cost per individual, and believes that this is the future of the medical profession. Ross-Loos Medical Group, at 1366 Wilshire Boulevard, is a private, profit-making institution. It was founded by Dr. Donald E. Ross and Dr. H. Clifford Loos and began oper ation on April 1, 1929. The ideals back of this movement were to so equitably distribute the costs of medical care that even the low est wage earner would be enabled to receive everything that the present science of medicine has to offer. Since 93 its inception only carefully selected groups of em ployees have been accepted. The procedure from the start has been to consider each patient as a paid private patient, and the atmosphere of a public clinic has been carefully avoided. At the present time a majority of the staff have become active par ticipants in the institution and share with the founders the benefits and responsibilities of the organisât ion." The Medical Group furnishes all medical and surgical atten tion necessary for all children and adults. It also pro vides hospitalization for those ailments where such treat ment is necessary. Its main office is located close to the business section of Los Angeles. There are branch offices in Alhambra, Belvedere Gardens, Glendale, Inglewood, Pasa dena, Santa Monica, Van Nuys, and Whittier. Bach of these offices is fully equipped with facilities for minor surgery, laboratories, physiotherapy departments and drug dispen saries, as well as the regular doctors* offices and recep tion rooms. The Ross-Loos Medical Group is a private organization, consisting of eighteen co-partners. Dr. Donald B. Ross is Chief Surgeon. Dr. H. Clifford Loos is the Executive Di rector. There is a Board of Managers consisting of the Chief Surgeon, the Executive Director and five of the co partners. The work of the Board is divided into sections ^ Pamphlet published by the Ross-Loos Medical Group, Infoimation for Subscribers, 1938, p. 1. 94 and each of the members of the Board heads a department. One member supervises the professional personnel, interviews and engages doctors, and fixes their duties. Another member ar ranges the operation of the pharmacy, and has the responsibi lity of the standardizing of drugs used throughout the entire institution. Another is in charge of hospitalization and acts as a contact between the hospital and the group. Another mem ber has the responsibility of the technical personnel of the organization and has the supervision of the engagement of laboratory technicians and nurses. The fifth member of the staff has charge of the maintenance of the equipment used in the building and advises the board in matters of repair or replacement. The business manager supervises the non-tech- nical employees, has charge of the accounting, purchasing and stores department of the institution, and in general, serves as assistant to the executive director. The sources of income of the Medical Group are fees from subscribers, fees of dependents, and private practice. In 1956 the main headquarters represented an investment of more than $75,000, combined with a capital investment in the branch offices of some $14,000, making a grand total of $89,000, exclusive of automobiles. The partners of the Medical Group are not paid a stated salary, but receive a percentage of the net profits, according to their interest in the group. The remaining doctors are on a salaried basis 95 the mininrunt of which is $3,600 per amrmE and honuses are given twice annnally on the hasis of tenure. îhe medical staff consists of fifty-seven full-time physicians and seven who are reimbursed on the basis of a per capita payment made by the group on the basis of the num ber of subscribers living within their districts, irrespec tive of the number of calls made by the subscribers. The Medical Group also employs its own nurses, technicians and pharmacists. There is no social service division of the Medical Group as the Group is a non-charitable organization. The Ross-I*oos Medical Group receives subscribers from groups of employees at the rates of $2.00 and $2.50 per month for complete health service and places the dependents of these subscribers on a fee schedule basis. There are no conditions as to the income level or the residence of the subscriber. The Medical Group furnishes the following medical and surgical attentions : diagnosis, any clinical or laboratory tests. X-ray examinations, treatments, operations, profess ional consultations and visits, excepting that the subscriber will pay for all orthopedic appliances, eye glasses, crutches, wheel chairs, sickroom furniture, treatments for social dis eases plus cost of medication, special nursing, hypodermic medication, radium treatments, and deep X-ray therapy treat ments; all medicines and drugs needed in the conduct of a case of sickness which may be prescribed by the medical 96 attendant; hospitalization to any suhecriher without fur ther cost, where such treatment is prescribed by the medi cal attendant, for such period of time as may be necessary in the treatment of any acute or chronic condition, provi ding the period of stay in the hospital for any one indivi dual does not exceed ninety days duration in any twelve month period, excepting that the Medical Group will not furnish hospitalization for obstetrical, abortion or mis carriage cases, mental diseases, contagious diseases, any cases not admissible to ordinary hospitals, and will not furnish sanitarium treatment for tuberculosis, or any con ditions, requiring rest home or sanitarium accomodations; ambulance service to the extent of a total of fifteen riding miles, (distance traveled by patient) per ore trip when or dered by the medical attendant; and treat all diseases, both medical and surgical, with the exception of mental diseases, alcoholic or drug addiction cases, and cases of attempted suicide. The Medical Group shall mantain a twenty-four hour service by telephone and shall give response to demands for home calls as well as for office consultations and treatments The Medical Group does not furnish dental work, donors in blood transfusions, nor will it asstmie responsibility, finan cial or otherwise, for doctors called outside of the Medical Group. Family dependents include bona fide members of the 97 subscribers* immediate family residing with him and wholly dependent upon him for support. Family dependents will re ceive the same service and be entitled to the same privileges as the subscriber himself under the same rules as enumerated above and without any payment of fee for, or on the behalf of, said dependent with the following exceptions: the family de pendents will pay the cost price for all medicines, drugs, dressings, splints. X-ray films, hospitalization and special ist as may necessarily be called in from outside the staff of the Hoss-Loos 01inio and its sub-offices. The charges at present are as follows: office consultation or treatment, 50/; residence call $1.00; ordinary laboratory tests, 50/; rabbit test for pregnancy, $3.00; pathological tissue ex amination, $5.00; blood chemistry examination, $2.50; gas tric analysis, #1.00; stool examination, 75/; physiotherapy treatment, 50/; electro-cardiogram, in office, $7.50; in home or hospital, #10.00; basal metabolism test, $5.00; minor operation including operating room, anesthetic and re covery bed, not over $12.50; major operation, $25 (no charge for any calls made in hospital); confinement case, including prenatal and postnatal care, $20; deep X-ray therapy treat ment $1.50. All X-ray examinations at rates as specified by the Industrial Accident Oonmiission of the State of Oalifomia. In order to make the service available to the subscri ber at all times, the simplest methods possible have been 98 inaugerated. All unnecessary red tape has been eliminated. An appointment service is maintained at all offices for the convenience of the subscriber. In order to render home calls more efficacious the subscriber is asked to give full parti culars concerning the ailment so that the doctor may be able to treat it. The Medical Group now has approximately 19,000 sub scribers who, with their families, make up a population of some 60,800 persons being oared for by the Ross-hoos Medi cal Group. There were no statistics available concerning the age, sex, and type of ailment distribution of the group served. The Medical Group has no regular contracts for ser vices with hospitals, arrangements being made by one of the Board members as the situation arises. Eo referrals or placements are made by this agency. The Ross-Loos Medi cal Group is not a member of the Council of Social Agencies or the Social Service Exchange. The Ross-Loos Medical Group, as a whole, is vitally interested in the progress of the medical group plans for service. Since its inception, the Group has acted as the van-guard in the fight for medical service which would be available to the low-income group. Associated Hospital Service of Califomia, at 1161 South Broadway, is a non-profit organization for the bene fit of the community and is approved by the Bos Angeles 99 Gounty Medical Association and the California Medical Asso ciation* The Hospital Service consists of twenty-nine af filiated hospitals located within the territorial boundaries of Southern California. The Service provides hospitalization for any illness or injury except tuberculosis, quarantinable diseases, mental disorders, alcoholism, and those injuries compensable under the workmen's Compensation Act* The Service is a non-profit corporation organized un der the provisions of a special act of the California State Legislature, receiving its permit to operate on this basis from the California Insurance Commission. There is a board of twelve directors, representing the hospitals affiliated and the medical profession and also the general public. In addition, there is an executive director who has full charge of the financial organization, the issuance of subscription agreements, and who follows in general the policies outlined by the board of directors. The financial organization is a simple one. A fund is created from the regular subscription charges, and is used for the sole purpose of meeting the hospital charges. The only staff that might be included is the staff of nurses at each hospital which renders general nursing care. There are no physicians or social workers connected with this Service. Applications for this Service are accepted in groups only. The applicants must be in good health, not more than 100 sixty-five years old, and must be residents of the area served by the member hospital. The applicant must sign a statement that he or she understands that the benefits of this plan do not apply if a definite need for hospital care is known at the time. Size of the organization forming a group should be not less than five employees and not more than twenty employees with one hundred per cent of employees enrollment. In an or ganization of twenty or more employees forty to sixty per cent must enroll depending upon the total number of employees and the percentage of women in the employed group. Families may join when husband or wife is employed by the organization. The service is limited to the husband and wife and all un married children under nineteen. Other members of a family or household may enroll provided that their applications are submitted at the same time by another member of the family or household who is an ©nployed subscriber. Every subscriber, including family members accepted by the plan, is entitled to any or all of these services when his own doctor says he must go to a hospital; hospital care for twenty-one days in one or more admissions each contract year; semi?-private accommodations (a bed in two, three, or four-bed room); general nursing care; meals and services of dietitian; routine medications and dressings; casts, splints, intravenous medications; surgery supplies and med ications; use of operating rooms; use of oystoscopio rooms 101 use of labor and birth rooms and care of mother and baby for twelve days (after waiting period and other provisions of subscriber's contract); private room upon the payment of the difference between $5 and the daily rate of the room selected. Subscribers selecting a private room are entitled to the above services. Services rendered by a private physician or surgeon not belonging to the group, and his consultants or medical specialists and special private nurses are excluded. The plan does not include services for conditions resulting from preg nancy during the first year of enrollment. Outpatient ser vices are not included. Rates have been so established that the plan will op erate on a self-sustaining basis. The plan does not depend on new enrollments to provide financial soundness. Individ ual subscription, where 60 per cent of the employees in a group are men is, monthly, 76/; quarterly, $2.60; semi annually, $6.00; and annually, $9.00. Individual subscrip tion for other groups than the above is, montl^y, 85/; quarterly, $2.76; semi-annually, $6.30; and annually, $10. The subscription for a husband and wife is monthly, $1.50; quarterly, #4.70; semi-annually, $9.20; and annually, $18. A husband and wife and all unmarried children under nineteen years of age may have a subscription at the following rates: monthly, $2.00; quarterly, #6.20; semi-annually, $12.20; and annually, $24.00. Monthly payaents are accepted only 102 through payroll deduction. Payments of the individual sub scription rates except monthly may be made direct to the Asso ciated Hospital Service of Southern Oalifomia by each sub scriber upon written notice. An initial payment must accom pany each application unless the payroll deduction method is used. As this Service is not a charitable one, none of the social work techniques were employed. At the time this study was conducted, the Hospital Service was in its begin ning and there were no figures available concerning the num ber or type of patients served by this organization. The Hospital Service has a regular contract with each of the affiliated hospitals for the provision of hospital care for its subscribers. In order that the subscriber might receive the benefits of this Service, it is only necessary to give the Hospital admitting officer the Associated Hospital Ser vice identification card. This Service is not a member of the Council of Social Agencies nor of the Social Service Exchange. What were the significant features of the medical agencies studied in Los Angeles? Each agency was examined on the basis of the social group served by the institution, the financial support of the agency, the administrative con trol, the services available to the individuals, and the sta tus of the service, whether charitable or non-charitable. Of 103 the ten agenoies, seven accepted only persons of moderate or low economic status. Two agencies gave their services entire ly to employee groups and rendered medical service on the med ical group plan. Only one agency accepted individuals from the general population, regardless of residence and finances, other than the ability of the individual to pay the fixed periodic payments for services; the agency also enrolled subscribers from large employee groups. Hence, the low in come group in Los Angeles had seven part-pay medical agencies which aided in their physical welfare. The majority of the Los Angeles agencies meet the problem of finances through the payment of fees by the pa tients, funds from the Community Chest, and monies from pri vate funds, such as gifts and endowments. Only three agencies had a fixed payment for medical servfjes on a monthly or year ly basis. The fees paid by the individuals at the various clinics operating at reduced rates often approximated the monthly fee paid by the subscriber to the medical group, and the service at these agencies (the medical groups) was re ceived as a right guaranteed by their voluntary insurance plan of payment for medical service. For the most part, the medical agencies were controlled by voluntary non-profit agencies. However, two of the institu tions were under the direction of hospitals. Only one agency was directed as part of the function of the government : the 104 Graves Memorial Dispensary under the University of Oalifomia which is a State University. Two agencies were operated as private profit-making institutions, giving services to the people of Los Angeles on a fixed payment plan at reduced rates. The most notable fact concerning the services available at the agenoies was the lack of dental care for this low in come group, a fact which was noted in the various national Q surveys and in the two California studies. There were two agenoies which offered physician, dental, and hospital care. Six medical organizations gave physician and hospital care. One plan was a group plan for voluntary insurance of hospi tal costs and the other agency rendered only physician's care. Of the ten agencies, five organizations were members of the Council of Social Agencies and of the Social Service Exchange. These five agencies registered each patient with the Exchange and this step then forever brands the individ ual as having received charity; . in fact it might even act to disbar the individual from receiving public relief in Committee on the Costs of Medical Care, Final Re port , The University of Chicago Press, Chicago, ill., 1W2 pp. 226. California Medical-Economic Survey, Preliminary Report to Committee of Five for the study of Medical dare of the Gal if ornia^l^edl cal Association, Cal i f ornia Medi caï- Economio Survey, 1925, pp. 11-61. E. Klem, Medical Care and Costs in California Families in Relation to kc^ornlc^ status, California State Relief Administration, 19ë5, pp. 74. 105 times of unemploymentTwo of the agencies. Graves Memor ial Dispensary and the Eye and Ear Hospital 01 inic, although giving medical care on a part-pay basis, have not registered patients with the Exchange. Only three of the ten agenoies operated as private institutions, putting no stigma on the patient for the receipt of medical care at special rates. 10 Using the alphabetical skeleton described in Chapter III 9 The California Welfare and Institutions Code Section 2555, defines legal residence for eligibility for relief to be three years continuous residence during which time no public or private relief or support from friends, charitable organi zations or relatives other than legally responsible relatives has been received. Social Group Involved A. General population B. Employed group or groups C. Persons of moderate means D. ”Poor" persons E. Students Payments for Services P. General Taxation G. Fixed periodic payments from the beneficiaries, voluntary insurance H. Fees from the individuals served I. Community Chest Funds J. Private funds (gifts, endowments) Km Fees on installment or commuted basis Agency in Charge Itm Government (city, county or state) M. Voluntary non-profit association H. Private medical group 0# Hospital P. County medical group Services Available Q. Physician R. Hospital S. Dentist 106 the Los Angeles agenoies arranged themselves in a pattern different from the agenoies representative of the newer trends of medical service. Whereas, the latter agencies ex pressed the tendency to involve the general population, the Los Angeles agencies served only the group of lower economic status. The majority of Los Angeles agencies received finan? cial support from the fees of the patients, the Oommunity Chest, and private funds; in the survey presented in Chap ter III, it was seen that most of the agencies were financed by fixed periodic payments from the beneficiaries. Both the review of the various plans for medical service and the Los Angeles agencies showed the current trend of relying upon voluntary non-profit associations for the receipt of medical care, and the current lack of dental care among the services available to the individual. Thus, it was seen that the Los Angeles plans for medical services differed somewhat from those of other parts of the nation, but contained with in them the seeds for future growth and development with the growing needs of the population of Los Angeles. 107 TABLE II Title Of Agency Social Group Payment for Services Agency in Charge Services Available WHITE MEMORIAL CLIHIC G,D H,J M Q.R ALL HATIORS OLIHIO C,D H.I,J M Q,H,S GOOD HOPE HOSPITAL ASSOCIATION G E,J M Q$R GRAVES MEMORIAL DISPENSARY D H,F,J L Q. CALIFORNIA BABIES HOSPITAL G,D H,I.J M Q #R, S EYE AND EAR HOSPITAL CLINIC G.D,B H,U 0 Q,R OUTPATIENTS* DEPARTMENT HOSPITAL C,D H,I,J 0 Q.R BOONSHAFT MEDICAL GROUP A.B G N Q,H ROSS-LOOS MEDICAL GROUP B G N Q,R ASSOCIATED HOSPITAL SERVICE B G M R CHAPTBR V SXMMâHY AND GONGDÜSION The purpose of this study was to examine the part-pay medical facilities available to the low income group in Dos Angeles. The study of these agencies was, of necessity, re lated to the more fundamental problem of medical care. The Los Angeles medical agencies were but one part of the Los Angeles problem of medical care, and to be pertinent must be studied in proper relationship to the total picture of the economics of medical care. It was with this intent in mind that the statistical evidence of the Oalifomia medical surveys, in particular, and the national surveys in general, was presented. The study of the Los Angeles part-pay medical facilities was of importance in view of the findings of the various studies. That there were, in Los Angeles at the time of the study, ten medical agencies which served the medical needs of the low-income group, and that these agencies ex tended medical care upon the fulfillment of certain prerequi sites, was of little importance unless these agencies were studied against the background of the peculiar health problems of the low-inoome group. The dynamic relationship between income level and the incidence of illness, medical care, and the ability to meet the costs of medical care was demonstrated clearly and 109 forcefully by the statistical method. The analysis of the incidence of illness, of the extent and volume of medical care, and of the costs of medical care was based upon a three-fold examination of these points in relation to: in come level, employment status, and change in economic level subsequent to the onset of the depression. A close correl ation was found to exist between low income status and high illness rates, whether the analysis was based on income level or employment status in 1933, or on change in economic situation following the onset of the depression. It was noted that the highest rate of serious illness occurred in households of the unemployed and in families of the lowest income groups. The highest incidence of disabling illness existed among "relief" families and lowest among the high est income group. It was among the "relief" families of 1933, which were of "comfortable" status in 1929, that the highest rates of illness were experienced, while families whose economic condition improved from "moderate" to "com fortable" experienced the least sickness. Furthermore it was found that the disabling illness rate of families hav ing no employment was consistently higher than that of fam ilies having part-time or full-time workers. The receipt of medical treatment was intimately re lated to the income level of the family, to the previous economic status, and to employment status. Though the 110 highest rates of serious illness occurred inithe households of the unemployed and in families of the lowest income groups, a smaller proportion of their illnesses were receiving medi cal attention than were the illnesses in families with em ployed members and higher incomes. The volume of medical care received was affected also by the previous economic lev el of the family. "Belief" families which had formerly been in the "moderate" or "comfortable" group obtained medical at tention for a greater proportion of their illnesses than did those households classified as "relief" in 1929 and 1933. A critical neglect of dental bervice was found in families with diminished incomes. Families of low income level had greater Incidence of illness than those with more adequate incomes, but because of their inability to meet medical charges, they could not purchase medical attention for a greater proportion of their illnesses. The costs of medical care in oases of serious illness and illnesses of long duration were disclosed to be beyond the financial ability of most low-inoome groups. Most families had bills for medical services long-outstanding, yet the average charge for medical care, if evenly distributed, would not be a burden incommensurate with the ability of most families to pay. The variations and averages in medical charges among urban families classified according to change in economic level revealed clearly the association of the amount of medical charges with income status. Those whose average medical charges Ill were the lowest were the families which had received relief in both 1929 and 1933. A distinct increase in the amount of medical charges was discovered in families of 1933 "relief” status which had been "comfortable " in 1929. In both the idem and the Oalifomia Medical-Economic surveys the close correlation between income status and the incidence of ill ness and the receipt of medical care was indicated. It was seen that marked differences existed in the extent to which different classes in the community required and secured med ical and dental services. These differences represented gaps in our present system for providing medical attention which must be bridged by some means of spreading the risk of medi cal costs. With full realization of the importance of the findings of both national and state surveys, it was of import to leam of the actual part-pay medical facilities in Los Angeles that were available to the low income group. The group, then, which was the subject of this study was the very group which suffered most severely from higher illness rates, both serious and disabling, which was in receipt of the least amount of medical attention, and which was the least able to meet the costs of medical care. The old fallacy that the poor and the rich receive the most adequate medical attention has been run to the ground. That the need for medical services varies in versely with the family income, that the relationship between 112 those who receive treatment needed and those who need treat ment varies inversely with family income, and that the free services dedicated to the poor were not a fraction of the amount necessary under any civilized definition of adequate medical care has shown that the old adage is no longer true. What, then, were the types of agencies in Los Angeles seek ing to ameliorate the maladjustments of the medical service to the needs of the low-income group? At the time this study was conducted there were ten medical agencies which served the individual whose income ap proximated #76 per month and the family whose income was $120 per month. There were other wholly charitable agencies, but these, however, were not available to the individuals and families whose economic status was as high as $76 to $120 per month. Seven of the ten agencies were part-pay, semi-charit able institutions belonging to the Los Angeles Oouncil of Social Agencies whose policies of eTgibility were governed by the medical division of the Oouncil of social Agencies.^ The three other agenoies were group plans for medical ser- 2 vice, operating as a form of voluntary health insurance. White Memorial 01 inic, All Nations Clinic, Good Hope Hospital Association, Graves Memorial Dispensary, Oalifomia Babies Hospital, Bye and Bar Hospital Clinic, and the Outpa tients* Department of the Children’s Hospital. ^ Boonshaft Medical Group, Roo-Loos Medical Group and Associated Hospital Service. 113 Bach of the ten medical institutions were examined on the ba sis of the social group served by the agency, the financial support of the agency, the administrative control, the ser vices available to its clients, and the status of the service, whether charitable or non-charitable. Seven agenoies (the part-pay medical institutions) accepted only persons of mod erate or low income level. Two of the group plans, the Ross- Loos and Associated Hospital Service served only employee groups. Only the Boonshaft Medical Group accepted individuals from the general population, regardless of residence and fi nances, other than the ability of the individual to pay the fixed monthly fees for service; this agency included among its subscribers both employee groups and individuals enrolled 88 a single or family unit. The seven part-pay medical agencies in Los Angeles were financed through the payment of fees by the patients, funds from the Oommunity Chest, and money from private funds such as gifts and endowments. It was the three group medical plans which had a fixed periodic payment for services rendered which acted to spread the risk of illness for the group served. The average annual fee paid by the individuals at the various part-pay clinics often approximated the annual fees paid by the subscriber to the medical group, and the service at the group medical agencies was guaranteed by the voluntary insur ance plan for payment of medical service in commensurate return 114 for such payment. Most of the medical agencies were con trolled by a voluntary, non-profit organization. Two of the institutions, the Eye and Ear Hospital Clinic, and the Out patients* Department of the Children’s Hospital were under the direction of their respective hospitals. The Graves Mem orial Dispensary was directed by the University of California which is a State Institution. Two agencies, the Boonshaft and the Hoss-Doos Medical Groups, operated as private, profit- making institutions, serving the people of Dos Angeles on a fixed, periodic payment plan, at reduced rates. Bearing out the findings of the statistical survey, it was noted that there was a distinct lack of dental care in the services available at the medical agencies providing treatment for the low in come group. There were only two medical agencies which of fered physician, hospital, and dental care; these were the All Nations Clinic, and the California Babies Hospital. Six medical agenoies provided both physician and hospital care; included within this group were both part-pay agencies and medical group plans.^ Only one agency, the Graves Memorial Dispensary, provided physicians care and minor surgery but no hospitalization. One group plan. Associated Hospital ^ White Memorial Clinic, Good Hope Hospital Associa tion, Eye and Ear Hospital Clinic, Children’s Hospital, Boonshaft Medical Group, Ross-Loos Medical Group. 115 Service was a foim of voluntary insurance for hospital costs. Of the ten agencies, five institutions were members of the Los Angeles Oouncil of Social Agencies and of the Social Service Exchange, maintained and directed by the Oommunity Chest: White Memorial Clinic, All Nations Clinic, Good Hope Hospital Association, California Babies Hospital, and the Outpatients Department of the Children’s Hospital. Each of these five agencies registered its patients with the Exchange. The Graves Memorial Dispensary and the Bye and Ear Hospital Clinic, operating as part-pay medical agenoies, have not registered patients with the Exchange. Only the three group plans for medical service belonged to neither the Los Angeles Council of Social Agencies nor the Social Service Exchange and received no allocation from the Community Chest. Their clients received medical attention and hospitalization at a low, annual fee, thus avoiding the stigma of semi-charit- able service. The higher incidence of illness of the low income group and the inability of this group to pay the costs of medical care have led inadvertently to the development of two general plans in Los Angeles for providing medical at tention for individuals of #76 to #120 income per month: one, the semi-charitable institutions and two, the medical group plans of voluntary health insurance. The seven part- pay medical agencies have operated at full capacity. 116 Two of the three medical group plans were conceived and de veloped in 1938; the Ross-Loos Medical Group developed in 1929 has had to expand its facilities each year to admit those seeking services. This study indicated generally the maladjustments of the present medical plan for services in the light of the evidence presented. Since no attempt was made to evalimte the Los Angeles medical agencies and the services provided for the low income group by these agencies, this study was limited in its scope. It appeared that there was a need for a medical survey that would accurately interpret the Los Angeles medical problem. Specific statistics pertaining to Los Angeles would be of great value in meeting the maladjust ment of medical facilities and health conditions. A statis tical survey based upon city-wide participation would def initely picture the medical needs of each income group sur veyed. The variations of Los Angeles Health problems from those of the State and the Nation would be discovered. The facilities, both charitable and private, serving each income level, incidence of illness, receipt of medical care, distri bution of medical charges for each group, would be necessary for the development of an adequate plan for medical service. From the statistical material presented in Ohapter II it was evident that, in spite of the free and part-pay medical care extended by medical agencies and humanitarian doctors, a 117 large proportion of the low income group in California did not receive medical attention. That this was true in Los Angeles was to he deduced from the facts. There was, no doubt, a considerable portion of the low income group in Los Angeles not receiving medical attention, notwithstanding the seven part-pay medical institutions and the three medical group plans. A certain proportion of those needing medical attention failed to secure it because of the semi-charitable status of the medic6tl agencies providing attention. The high percentage of families and individuals in the low income group who require medical care and do not re ceive it, the extent of part-pay care provided by institutions to those unable to pay, the uneven distribution of illness and thus of medical charges led to the conclusion that the present system of fee-for-service has been inadequate and wasteful. Hospitals, equipped with all the latest scien tific facilities and trained personnel; physicians and den tists unable to practice medicine because of lack of paying patients; and the individual whose efficiency and usefulness have been rendered ineffective by inability to purchase med ical attention: these were serious gaps which evinced the discontinuity of the present system of medical care. The concept of medical care must be re-interpreted on the basis of the realization that it is for the benefit of the nation, as well as of the individual, that public 118 health be maintained at the highest degree possible. OiYilized oommunities have arrived at two conclu sions from which there will be no retreat, though their full realization in experience has nowhere been completely achieved ... The Health of Every Individual is a social concern and responsibility ... Medical Oare in its widest sense for every individual is an essential condition of maximum efficiency and happiness in a civilized community ... no responsible person denies or doubts the necessity of providing adequate medical care ir respective of the ability of the individual to pay for it.4 4 Sir Arthur Hewsholme, Medicine and the State. G. A. Allen and Unwin, Ltd., London, p. %. BIBLIOGRAPHY 180 BIBLIOGRAPHY Adams, James K., Bxpertoent in Group Medioal Care (Louisiana) American Maniement Asso^ationV Sew ŸorkVTS'SB. 8 pp. Aly, Bower (Editor), goeialized Medicine. Lucas Brothers, Missouri, 1935« 688 pp. American Medical Association, Bibliography on State Medicine, ïhe Association, Chicago, dotbber Si, l’ üS’ O" 5? pp. Armstrong, Donald B., Dublin, Louis I., Steile, Elizabeth, The Cost of Medical Gare. Metropolitan Life Insurance ïïbmpany. pp. Armstrong, Donald B*, Community Health: How to Obtain and Preserve it. Funk and! wagnalls, Sew ŸorkT^'^^• 6F pp• Boonshaft, Louis D., M.D., Health Instance. (unpublished) Paper read before the EStli Annual keetïng of the Califor nia Conference of Social Work, April, 1936, Los Angeles, California♦ 18 pp. Bradbury, Samuel, The Cost of Adequate Medical Care. The University of dhioago Press, Chicago, 1937. B'è' pp. Buehler, E. 0. (Compiler and Editor) , Free Medical Care. Hoble and Noble, New York, 1935. 980 pp. Cabot, Richard G., M.D., Social Service and the Art of Heal ing. Dodd, Mead and Company, New York, 1969. Sl^Tpp. California Medical-Economic Survey, Preliminary Report to the Committee of Five for the Study of Medical Gare of We Gal i f ornTaTfelR cal As s ooiat ion. Gal if ozmia, 19^5791 ' pp 1 Supple ment, 3d pp. California Medical-Economic Survey, 1934-1936, Fomal Report on Factual Data. California Medical Association, Caii- fomia, 10S¥. l74 pp. Cannon, Ida M., Social Work in Hospitals. Russell Sage Foundation, Survey Associates, Inc., New York, 1915. 857 pp. Carpenter, Niles, Medical Care for 15,000 Workers and Their Families. WasEfï^Tôtt.nSTff.rTeSD. SÏÏ ------------- 181 Gatlin, Luey Cornelia, The Hospital as a Social Agent in the Community. W. S. Satuaders Company, tHilaaeTpbïa and London,1918. 113 pp. Clark, Evans, How to Budget Health. Harper Brothers, New York and London, 1993.’ S6ë pp. Collins, Selwyn D., Economic Status and Health. IT. S. Pub lic Health Bulletin, K. 188, 19ST. 8 pp7 Committee on the Costs of Medical Care, Medical Care for the American People. The University of Chicago Press, Chicago, 1938. 838 pp. Davis, Eleanor, Company Sickness Benefit Plans for Wage Earners. Princeton trniversity Department "ofTTconomics and Social Institutions — Industrial Relations Section, New York, 1936. 78 pp. Davis, Michael M., "Change Comes to the Doctor." Survey Graphic, April, 1934. 856^9 pp. _____ , Clinics, Hospitals and Health Centers. Harper and Brothers, New York and tônïon, 1967“ 848 pp. ______ , Paying Your Sickness Bills. The University of ' Chicago I^ss, Chicago, 1931. 873 pp. , Public Medioal Services. The University of Chicago " WessV’ Chicago ,1937” l9t) pp. de Schweinits, Earl, "Sickness as a Factor in Poverty." Proceedings, National Conference of Social Work, 1919. m ' J p p . -------------------------------------------- Division of Research and Surveys, Gregory Silvermaster, Director, Economic Trends in California. California Emergency Sell of ^dm ini st rafi oh, S'ah Francisco, February 1935. 86 pp. Dodd, Paul A., Ph. D., Penrose, E. F., Ph. D., Economic As pects of Medical Services. Graphic Arts Press, Inc., Washington, B.C., 1939# %99 pp. Dublin, Louis I., Lotka, Alfred J., The Money Value of a Man. The Rouald Press, New York, 1930 . 400 pp. Duffus, R. L., Shall Medicine Be Socialized? New York Times, December 4, New York, 1998. lEE Epstein, Abrahsm, Insecurity: A Challenge to America. Random House, i^ew Ÿorlc, 1935’ . 861 pp. Falk, I. S., Security Against Sickness. Douhleday, Doran and Company, Inc. Gar den dity, îfew York, 1936. 483 pp. , Present and Future Organization of Medicine. Milhank Memorial Istihd 'Quarterly. Bulletin l2 : April, 1934. 116- 86 pp. Falk, I. S., Elem, Margaret C. and Sinai, Nathan, The Inci dence of Illness and the Receipt and Costs of Medical Care ^ong Sipresentative Families. Pablioaiion^^o. 28 of the Committee oh the Oosts oï Medical Care, Chicago, 1933. 387 pp. Falk, I. S., Rorem, C. Rufus, Ring, Martha D., The Costs of Medioal Care. Committee on the Cost of Medical' hare, Wo. sV, The University of Chicago Press, Chicago, 1933. 683 pp. Fishhein, Morris, M.D., Frontiers of Medicine. The Century Company, New York and Dondon,’ T9391 6'OT"pp. Frankel, Dee E., Cost of Medical Care. Metropolitan Life Insurance Company,TT969, Wew York. 11 pp. Higgins, H.U.M., The Ross-Doos Clinic. Published by the Civ il Service Assembly of the ïïnit'ël! States and Canada. March, 1936. 89 pp. Johnson, Julia, Socialization of Medicine. H. W. Wilson Com pany, New York, l9&8. 396 pp. Elem, Margaret 0., "Medical Care Among Families of Dow and Moderate Income." Western Hospital Review, vol. XEIII. No. 1, March 11, 19957 Medical Care and Costs in California Families in Relation to"Bconomlc ' Status. State Relief Administrât ion of California, Frank Ÿ. Mclaughlin, Administrator, San Francisco, 1936. 74 pp. App. 30 pp. Dee, Roger I., Jones, Lewis Webster, ^e Fundamentals of Good Medical Care. The University of Cihicago Press, bhTcago, 15937— 83T^. Deven, Maurice, The Income Structure of United States. The Brookings Institution, Washington, D.C., 1998. X73 pp. 123 Moore, Harry H*, Amerioan Medioine and the People's Health. D. Appleton and Company, Wew York and London, l92l. 957 pp. The National Health Survey Sickness and Medical Care Series, Bulletin No. 1, ^ Estimate of the Amount of Disabling Illness in the Country as a lEble. Division of Public Wealth "Methods, Natibnaï^Institute of Health, U. 8. Pub lic Health Survey. Washington, 1938. 8 pp. National Industrial Conference Board, Inc., Recent Deyelop- ments in Industrial Group Insurance. New York. 1934. i9?R',"%o;:9rpp:------- ---------- Newsholme, Sir Arthur, Evolution of Preventive Medicine. Williams and Wilkins Company,“ISaltimore, l96Y. 219 pp. . Medioine and the State. Williams and Wilkins Com pany, “ "BaTFEore. SOD" pp. Newsholme, Sir Arthur, Eingsbury, John Adams, Red Medicine. Doubleday, Doran and Company, Inc., GardenCity, New York, 1934. 324 pp. Perrott, G. St., Collins, Selwyn D., Relation of Sickness to Income and Income Change in 10 Surveyed dommuhities. lepriht ¥o. IMd froin ïlie"TuETib’ Wealth Reports, vol. 50 No. 18, May 3, 1936. 696^-622 pp. Perrott, Sydenstricker, and Collins, "Sickness and the De pression, A Preliminary Report Upon a Survey of Wage- Earning Families in Ten Cities." U.S. P.H.S. Study, Milbank Memorial Fund Quarterly, vol. ZI, No. 4, July, 1934. 28Ï-29B ppl . "Medioal Care During the Depression, A Preliminary Report upon a Survey of WagS'^Eaming Families in Seven large Cities." U.S. P.H.S. Study in Milbank Memorial Fund Quarterly, vol. No. 2, April, 19347 114" pp. Phelps, R. M. (Compiler) , The Socialization of Medicine. H. w. Wilson Company, New York, 1930. I W pp. Preliminary Reports, the National Health Survey Sickness and Medical Care Series, Bulletin, No. 2. Illness and Med ical Care in Relation to Economic Status. Division of Public healRi Methods, "National Institute of Health, U.S. Public Health Survey, Washington, 1938. 8 pp. 124 Preliminary Report, the National Health Survey, Sickness and Medical Care Series, Bulletin, No. 4, The Prevalence and Causes of Orthopedic Impairments. Division of PubYie Health Methods, National Institute of Health, U.S. Public Health Survey, Washington, 1938. 20 pp. Proceedings, National Conference of Social Work, "Sickness as a Factor in Poverty" byT&rl He Ebhwelnitz, 1919. 159 pp. Record of the Eighth National Conference on Social Security, Social Security in the United States. American Association for S0 o ial Se curTFy, Ini., ¥ew^ork', " April 21 and 27, 1935, 42-102 pp. Record of the Ninth National Conference on Social Security, Social Security in the United States, American Association for Social SecurTFy, inc., ¥ew York, " April 24 and 25, 1936. 108s*144 pp. Record of the Tenth National Conference on Social Security, Social Security in the United States, American Association for social SeourTFy, Tnc., l!few York, April 9 and 10, 1937 79-178 pp. Reed, Louis S., The Ability to Pay for Medioal Care. The University of Chicago Press, Chicago, 19S8. 107 pp. Report of Senate Committee to Investigate the Advisability of a health Insurance Acb To Reduce the' High "dost of Sickness, 'Üalif omia Legislature,^p^l ,"1936. Report of the Social Insurance Commission of the State of — ^%lTFor3[al— January, im,"lafcE; 15197----------- Rosenwald, Fund, Julius, New ig.ans of Medical Service, (M. Davis, Director for Medical Ser^ces). îhe Julius Rosen wald Fund, Chicago, 1936. 74 pp. Shuman, John W., California Medicine (A Review). A. R. Elliott Publishing Company, 19307 1Ô4 pp* Simons, A.M., and Sinai, Nathan, The Way of Health Insurance. Publication No. 6 of the Committee on the Study of hental Practice of the American Dental Association, The Univer sity of Chicago Press, Chicago, 1932. 215 pp. 125 Sinai, Nathan, Elen, Margaret 0., The Qosts of Medical Pare to 4500 Famllieg — Preliminary Report. “UommîssTon on tEe Costs of Medical bare, wasningîoh, B.C., 1930. Warbasse, James Peter, Medical Sociology. D. Appleton and Company, New York and London, 19lO. 338 pp. Webb, Sidney and Beatrice, The State and the Doctor. Longmans, Green and Company, London and rfew York, 19ÏÔ. 276 pp. Williams, Pierce, The Purchase of Medioal Care Through Fixed Periodic Payment. Rational Bureau of Scbh omi o Re se arch, The., "hew York,' 1932. 308 pp. APPENDIX APPENDIX TABLE I NUMERICAL AND PERCENTAGE DISTRIBUTION OF THE SURVEYED FAMILIES* IN FAMILIES CLASSIFIED ACCORDING TO 1935 INCOME Annual Family Income. 1933 Number of Families Per cent of Total Total 4,541 100 Relief 641 14 $ 0 - 1 599 820 18 •:60G - 1,199 1,303 29 1,200 - 1,999 1,201 26 2,000 - 2,999 397 9 3,000 - and over 179 4 * Margaret C* Klem., Medical Care and Costs in Califor nia Families in Relation to Economic Status, p. 4. TABLE II DISTRIBUTION OF FAMILIES BY SIZE OF COMMUNITY AND 1933: INCOME* BASED ON RECORDS FOR 4,882: FAMILIES INTERVIEWED BETWEEN OCTOBER 1 AND DECEMBER 31, 1934 Size of Community Family Income All Incomes Under $1,200-f2,000-$3,000-f5,000 $1200 1,999 2,999 4,999 and ove; Percentage All Communities 4, 100 882 55,2 2,693 26.2 1,281 11.1 545 4.9 238 2.6 125 Under - 5,000 16.7 10.7 4.1 1.3 0.5 0.1 5,000- 99,999 35.9 19.3 9.3 4.0 2.1 1.1 100,000-999,999 24.9 12.5 7.1 3.2 1.2 0.9 1,000,000 and over 22.6 12.7 5.7 2.6 1.1 0.5 * California Medical Economic Survey - etc.(in biblio graphy). p. 43. 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Asset Metadata

Creator Rosenhouse, Miriam (author)

Core Title A study of the Los Angeles medical agencies providing care for certain classes of low income groups

School Graduate School of Social Work

Degree Master of Science

Degree Program Social Work

Degree Conferral Date 1939-06

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

Tag health and environmental sciences,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Advisor McClenahan, Bessie A. (committee chair), Greenleigh, Arthur D. (committee member), Nordskog, John E. (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c39-459705

Unique identifier UC11314636

Identifier EP66130.pdf (filename),usctheses-c39-459705 (legacy record id)

Legacy Identifier EP66130.pdf

Dmrecord 459705

Document Type Thesis

Format application/pdf (imt)

Rights Rosenhouse, Miriam

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