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the medical costs were $25 or more. In several of the States the maximum limit is high enough to cover practically all except the more serious injuries, but it is in severe injury cases that the workman's needs are greatest.
It must be admitted, however, that in many cases employers and insurance companies furnish medical service in excess of the statu tory requirements, especially if by so doing the period of disability can be materially shortened. Furthermore, it is a common practica of many of the larger employers, who have an organized establishment medical service and hospital, to provide full medical treatment irrespective of the statutory provisions of the compensation acts.
SELECTION OF PHYSICIANS.
Should the employer or the employee have the right to select the physician in industrial accident cases? And should this right or privilege be exclusive or restricted? These mooted questions have in recent years received a great deal of attention in the workmen's compensation field. The subject is particularly important because it directly affects the employee, the physician, and the employer. The employee is interested in his own speedy recovery and in having a physician in whom he has confidence; the employer is interested in reducing his compensation and medical costs; and the physician is interested both financially and professionally. The interplay of these various and sometimes conflicting interests constantly causes friction and creates innumerable difficulties.
The statutory provisions and actual practices as regards selection of physicians are as follows:
Selection by employee at employer's expense.-In eight States 12 an injured employee is granted the right to select his own physician at the employer's expense. In Massachusetts, Nebraska, Rhode Island, and Washington this right is granted specifically in the act, although in Nebraska the right is limited to cases of dismemberment or major surgical operations. In Nevada, Ohio, Oregon, and Vermont the employee is granted this privilege by virtue of rules or interpretations of the administrative commission. In addition, the Texas act allows the employee to select the physician if the employer, having engaged a contract physician, fails or refuses to file the contract agreement with the industrial accident board; and in Colorado an "employee may, upon the proper showing to the commission, procure its permission at any time to have a physician of his own selection attend him."
Selection by employee at employee's expense. The laws in five States (California, Connecticut, Illinois, Missouri, and South Dakota) 12 Massachusetts, Nebraska (dismemberments and major surgical operations only), Nevada, Ohio, Oregon, Rhode Island, Vermont, and Washington.
grant the employee the right to select his own physician-at the employee's expense, however.
Selection by employee if employer neglects or refuses to provide adequate service. If the employer neglects or refuses to furnish competent medical service, or in case of an emergency, the employee is given the right to select the physician at the employer's expense in
Authority to order change of physicians.—If the physician furnished is incompetent or the medical service inimical to the injured employee, the laws of nine States 14 provide that a change of physicians shall be made if requested by the administrative commission or by the employee. In Washington, also, the State medical aid board, by rule, reserves the right to transfer the treatment of an injured workman to a surgeon whenever it becomes evident that the man is not receiving the service that he should at the hands of the physician of his choice.
Selection of physician by employer.-In all of the other States which provide for medical service in case of injury the employer or his representative, the insurance carrier, has the right to select the physician. Most of these laws, however, make no specific provisions as to the selection of physicians, but the courts and commissions generally hold that the obligation of the employer to "furnish" or 'provide" medical service carries with it the privilege of choosing the physician. This practice has been based on two theories: First, that the employer is more competent to judge of the efficiency of the doctor employed and to provide efficient medical and hospital treatment; and, second, that it is to the interest of the employer to furnish the very best medical and surgical treatment, so as to minimize the result of the injury and to secure as early a recovery as possible. As a matter of practice, however, in quite a large percentage of cases the employee is allowed to choose his own physician, but the extent of this practice depends upon the policy of the employers and insurance carriers. The large employers, especially those having an' organized medical service within their establishments, generally insist upon their legal right to select the physician.
Panel system. No State compensation law makes specific provision for a panel of physicians from which a choice is to be made. Cali-, fornia, however, has an incipient panel system, as shown in the following statutory provision: "If the employee so requests, the employer shall tender him one change of physicians and shall nominate at least three practicing physicians competent to treat the particular
13 Colorado, Connecticut, Hawaii, Idaho, Illinois, Indiana, Kansas, Kentucky, Maine, Maryland, Minnesota, Nevada, New York, Oklahoma, Pennsylvania, South Dakota, Tennessee, Texas, Virginia, and Wisconsin.
California, Connecticut, Indiana, Kentucky, Missouri, Nevada, Oklahoma, Texas, and Virginia.
case, or as many as may be available if three can not be reasonably named, from which the employee may choose; the employee shall also be entitled, in any serious case, upon request, to the services of a consulting physician to be provided by the employer; all of said treatment to be at the expense of the employer. If the employee so requests, the employer must secure certification by the commission or a commissioner of the competency for the particular case of the consulting or additional physicians." The foregoing provision does not apply, however, to employers' establishment hospital funds approved by the commission.
A majority of the medical profession thus far seem to be opposed or at least apathetic toward the panel system. Quite a number of State commissioners and members of the medical profession, especially those who have been in close touch with the administration of compensation laws, have come to the conclusion that some check upon free choice, exercised either by the employee or employer, is necessary.
In a paper prepared for the 1918 meeting of the International Association of Industrial Accident Boards and Commissions, Dr. Raphael Lewy, chief medical adviser of the New York Industrial Commission, stated that the ideal plan would be to leave the choice to the medical department of the industrial commission. At the same conference Dr. Charles H. Lemon, of Milwaukee, Wis., stated that no man is justified in doing major surgical work who has not been trained under a competent surgeon; while Dr. J. W. Mowell, chairman of the Washington Medical Aid Board, believed that there should be free choice in ordinary cases, but that in serious cases it would be better for the employee to take the advice of an expert. In a letter to the Bureau, Dr. F. W. Sears, chairman of the committee on legislation of the Vermont State Medical Society, stated that physicians should be selected by mutual agreement; the employer might allow the employee a choice from a list of physicians. One of the recommendations of Mr. J. F. Connor, commissioned by the governor of New York to investigate the management of the State industrial commission, provided that "a panel of physicians be designated by the commission, utilizing the advice of recognized medical societies, among whom injured workmen may have free choice, with power conferred on the commission to add to, or to remove from, such panel at their discretion."
The California Industrial Accident Commission found "by bitter experience that all physicians qualified by the laws of the State to practice surgery are not necessarily surgeons." The commission advocated a traveling medical inspector who will "be able greatly to diminish the abuse, now frequent, of overstay in hospitals, with the consequent overcharge against the State compensation insurance
fund."15 According to the commission unfit practitioners should be excluded either through the enforcement of the medical practice act or by the commission.
The Boston Medical and Surgical Journal of September 21, 1916, speaks editorially as follows: "It may be also that absolute free choice will eliminate competition between the present 27 insurance companies and bring about the concentration of all the compensation business under one insurance company, with whom all would be required to transact business under direct State supervision. There is a probability that the problem may be solved by the combination of free choice under a supervising consultant, agreeable to and appointed by the insurance companies."
Dr. William L. Estes, chairman of the committee on workmen's compensation of the Pennsylvania State Medical Society, in a paper read before a conference of industrial physicians in Pennsylvania," said:
Again, for injuries a surgeon should be called; few family practiioners have the requisite skill and experience to meet in the most modern way the emergencies of a serious surgical condition. The sufferings and disability of the injured man may be increased and greatly prolonged by the injudicious selection of a surgeon.
* * *
Most of the best modern hospitals have a definite organized staff of surgeons to carry on the work of the institutions, and the management of the hospital not only expects but requires them to treat the cases sent to the institution. Many injured men must go to hospitals. It would therefore result in serious confusion and disorganization were it permitted the injured workman to demand that his family physician shall treat him in the hospital. Besides, as stated above, it might result in placing an inexperienced man in charge of him instead of a man whose qualifications had been proved before he was given the place on the hospital staff.
Furthermore, under the present system of selection by the employer, it is not an uncommon practice in some States to allow employees to choose a physician from a panel nominated by the employer or insurance carrier.
REASONS WHY EMPLOYER SHOULD SELECT PHYSICIAN.
Inasmuch as the burden of paying the medical costs rests upon the employer, it seems reasonable that he should have a voice in the selection of the physician. He is naturally interested in reducing his compensation costs. This reduction depends to some extent upon the speedy restoration of the injured employee's earning capacity, which in turn is dependent largely upon the adequacy of the medical and surgical treatment furnished. Competent medical treatment, however, is not always possible if the selection of the
16 Report of California Industrial Accident Commission, 1914-15, pp. 25, 26.
16 Monthly Bulletin of Pennsylvania Department of Labor and Industry for February, 1917, pp. 51, 52.
physician is beyond the control of the employer, who is, as a rule, far more competent than the injured employee to judge of the efficiency of the physician. The foreign, non-English speaking, and not infrequently illiterate workman naturally chooses a physician of his own nationality, who is often incompetent and sometimes disreputable. Some physicians attempt to mulet the employers by prolonging treatment, making unnecessary calls, padding their bills, and overcharging generally, and because of their incompetency are an actual menace to the patients themselves. Numerous cases are on record in which injuries which should have had the attention of highly skilled surgeons were treated by physicians without surgical practice and wholly incompetent. Such treatment is always costly to the employer and frequently harmful to the injured workman. As stated by Dr. J. W. Mowell, of the Washington Medical Aid Board, before the meeting of the International Association of Industrial Accident Boards and Commissions previously mentioned: a
While this plan [selection by employee] seems quite equitable and it appears to be the natural thing to do, it has a good many shortcomings. For instance, to the isolated workman who is employed in a locality where there are only one or two physicians, free choice means little, and the injured workman has to accept the services of the first physician he can obtain. However, in the larger cities where there is a great number of physicians we find that some of the workmen make a wise choice, while quite a large per cent of them, for some reason or other, select a physician who is not very well equipped for the work at hand. We often find that a workman who has received a serious fracture will select a physician who knows very little about fractures; also a man who receives an injury to his eyes may go to an ordinary practitioner for treatment until the serious 'nature of the case makes it necessary to transfer him to an eye specialist, whom he should have consulted in the first instance. This occurs more or less with reference to all kinds of injuries. *
To my mind the principal thing that can be said in favor of free choice of physician by the injured workman is the effect it has on his mind that is, the feeling that he is getting what he wants.
Because of these conditions many employers and insurance carriers have insisted upon their legal right to select the physician. Most of the large manufacturing establishments, and even some of the insurance companies, have established hospitals in connection with their plants. It is maintained that more efficient medical service can thus be rendered at much less cost. Furthermore, it allows closer medical supervision. A common complaint made by employers is that workmen will not report minor injuries, many of which become septic and develop into serious cases. The prompt attention given to injuries and the close personal supervision made possible through
a See Bulletin 264 of the Bureau of Labor Statistics, pp. 197, 198.