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an establishment hospital minimize the danger of blood poisoning and result in earlier recoveries. It is also maintained that malingering can be better controlled and prevented when the employer has supervision over the medical service furnished.
REASONS WHY EMPLOYEE SHOULD SELECT PHYSICIAN.
On the other hand, during the last two or three years, there has been a widespread reaction against the present system of selection by employers, and it may well be asked, Why this reaction if the system is as beneficial as is maintained by its advocates? Three reasons are generally advanced in favor of free choice of physicians by employees.
In the first place, the free and unhampered choice of one's own physician has generally been considered as one of the inalienable rights of mankind. The relationship existing between a patient and his physician is private and personal. Furthermore, the therapeutic value of confidence and faith in one's physician is well recognized by the medical profession, and this confidence naturally is assured when the injured workman selects his own physician. Moreover, the injured man has most at stake. It is he, and not the employer or physician, who suffers; it is his life which hangs in the balance. A man desires a doctor whom he knows, with whom he can freely and unreservedly discuss his ailment, and in whom he has confidence.
Another factor which has influenced the movement for free choice has been the dissatisfaction with the kind of medical service frequently furnished by employers and insurance carriers. While it is true that many employers maintain excellent hospitals with highly skilled surgeons and trained nurses in charge and provide medical treatment even in excess of statutory requirements, this is by no means the general practice. The kind of service furnished by many employers, and particularly by insurance companies, is entirely inadequate. There has been a tendency to employ contract doctors (and this tendency is increasing), many of whom have not been especially competent. Furthermore, physicians employed on a contract basis frequently have more cases than they can take care of properly and in addition are not inclined to give them the same personal attention as would be given by physicians engaged directly by the employee. The evils and abuses of this contract system have been repeatedly pointed out and condemned by compensation commissions and the medical profession.
Another important problem is to determine when the injured workman has sufficiently recovered to be able to return to work. Obviously it is to the employer's interest to reduce the disability period as much as possible, and frequently this fact influences unduly the
decision of the employer's physician, especially if employed on a contract basis.
The third factor in the movement for free choice has been the opposition of the medical profession to the medical practices of the employers, and particularly of the insurance companies, which have developed under the compensation laws. Physicians have demanded their regular rates those which they had charged before the advent of workmen's compensation laws. Insurance companies, on the other hand, have insisted that the increased security of payments under compensation and the economic and financial status of the injured employee should be taken into consideration in determining the reasonableness of fees for medical and hospital services. There has also been a tendency on the part of some physicians to pad their bills and to raise their rates. As might be expected, such a condition immediately resulted in numerous and acrimonious disputes, between the medical profession on the one hand and the employers and insurance carriers on the other, as to medical fees. The compensation commissioners were usually able to effect a working compromise, but such compromises have on the whole been unsatisfactory. Insurance companies have refused to pay medical bills unless they were satisfactory, and physicians in retaliation have threatened to refuse to treat industrial cases unless guaranteed their regular rates. As a counter measure employers and insurance carriers have begun to furnish their own medical service, establishing dispensaries and hospitals and engaging surgeons and trained nurses. Obviously a continued extension of the system of establishment hospitals and contract doctors would ultimately exclude a large majority of the medical profession from the field of industrial surgery. It is the evident extension of this practice that causes apprehension in the ranks of the profession and is the motive power behind their movement for free choice of physicians.
CONTRACT DOCTORS AND ESTABLISHMENT HOSPITALS.
When State compensation laws were first enacted many of the larger employers had in operation benefit schemes for the protection of their employees in case of accident or sickness. The compensation laws in about one-half of the States permitted these substitute schemes to continue, provided the benefits furnished equaled those provided in the compensation acts. Thus, many, if not most, of the larger employers in the United States at present, have their own organized medical service and establishment hospitals with surgeons and nurses in charge.
This is especially true of the far western States where the contract hospital system predominates. In fact, the compensation laws of
seven western States 17 specifically authorize employers to make contracts with their employees for medical and hospital service.
One criticism against the contract system is that the cost of the medical benefits under the compensation law-a burden it was intended for the employer to assume-is shifted to the employees. Another criticism is the commercialization of the medical service by nonmedical men. In Washington, for example, the contract plan has given the State medical aid board considerable trouble because of such commercialization. These nonmedical men form a hospital association and then secure the services of a surgeon, pay a small part of the proceeds to him for the work and keep the remainder. This has brought about a lot of dissatisfaction among the workmen and physicians of the State, causing some agitation toward State hospitals for the care of workmen under the compensation act.
The most potent criticism against contract practice is that through it injured employees receive inferior service. As already stated, many employers furnish medical and surgical treatment of the highest character, but that is not the general custom and is especially not true in case of many insurance companies. The California Industrial Accident Commission in its 1916-17 annual report made the following observation regarding the contract system:18
Many poorly equipped medical men are not above accepting industrial cases which they can not handle. The commission feels keenly its responsibility in this matter, and, of course, desires that the very best services shall be accorded the injured workingman.
There has been noted in the last fiscal year an ever-increasing tendency toward "contract practice" among the insurance companies. This is a most deplorable condition, since the contracts are frequently made with men of poor judgment and some whose only equipment appears to be a willingness to work for little money. One great failing in this contract work is that treatment and results of treatment are seldom subject to comparison or supervision. There is a tendency toward surgical "inbreeding," in that a man, secure in his exclusive care of the cases for an insurance company, may do pretty much as he pleases as long as he is acceptable to the company. The result is poor work.
Very often has contract practice brought to this office cases for inspection by our medical department. These injured men present themselves for the purpose of satisfying their doubts as to the results or character of treatment which they have received.
These examinations frequently result in change of doctors or exactions of satisfactory treatment by the insurance companies. * * Whether the control of the medical practice and the exclusion from the industrial accident field of the unfit practitioners shall come through an enforcement of the medical practice act, or whether through regulations of the industrial accident board specifying the character of physicians eligible for industrial work is not yet known.
17 Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Washington.
The situation constitutes a distinct menace at the present time, an suggests possible failure of the good effects of a most excellent law.
"There are a great many good men," said Dr. B. P. Magnuson, medical director of the Illinois Industrial Commission, before the fifth I. A. I. A. B. C. conference,19 "who have started as contract surgeons, simply as a stepping stone to work up, but those men leave it, because they can't get adequate compensation for their work from the corporation. The contract surgeon, therefore, has fallen into disre pute, because, on the average, he doesn't measure up to men in civil practice who are doing the best kind of surgery. * * * The contract surgeon is often careless; he gets a biased view. The claim agent bothers the life out of him to get a man back to work."
MEDICAL AND HOSPITAL FEES.
Probably no one phase of workmen's compensation has caused more vexation to commissions or created more ill feeling among the medical profession than the question of medical and hospital fees. Basis for medical fees.-Prior to the enactment of workmen's compensation laws there had been little distinction in the treatment of injuries which arose out of the employment and those which arose outside of the employment. In either case the person sustaining the injury was financially responsible for the medical and hospital treatment furnished, but since a large proportion of such persons were unable to pay for the treatment received the hospitals and physicians accepted them as charity patients, usually charging low rates and collecting fees only in cases where the patient could afford to pay. The compensation laws, however, definitely placed upon the employer the burden of furnishing medical services in industrial accident cases; but no provision was made as to medical fees, except that they should be reasonable, and, in 18 States, 20 that they should be limited to such charges as prevail in the same community for similar treatment of injured persons of a like standard of living when treatment is paid for by the injured persons. In view of these facts the medical profession as a whole maintained that medical services in industrial cases should be remunerated at full value and that such cut rates and charity as had been granted the sufferers by hospitals and doctors should be discontinued. They also believed it to be an injustice to expect the medical profession to adopt a sliding scale of fees, governed by their clients' ability to pay, when other institutions and businesses, including the very same employers and insurance companies, are not subjected to the same principles and practices.
19 Bulletin No. 264, Proceedings of the fifth annual meeting of the International Association of Industrial Accident Boards and Commissions, held at Madison, Wis., Sept. 24-27, 1918, pp. 142, 143.
20 Alabama, Connecticut, Hawaii, Idaho, Indiana, Kentucky, Louisiana, Maryland, Minnesota, Missouri, Nevada, New York, Oklahoma, Pennsylvania, Tennessee, Texas, Vermont, and Virginia.
Obviously, the medical profession, in common with other professions and vocations, should receive a just and adequate remuneration for its services. The ordinary fee rates of physicians are probably determined in a general way with reference to the paying ability of the moderately well-to-do classes of society. Undoubtedly they are also influenced by the fact that much of the medical services rendered the poorer classes will never be paid for. In view of these facts what would be a just basis for determining reasonable and equitable fees for medical services? As already stated, 18 laws provide that the standards prevailing in the community for treatment of persons having the same standard of living should be taken into consideration. Three States (Idaho, Kentucky, and Texas) further provide that the increased security of payment guaranteed by a workmen's compensation law should also be taken into account. Practically all of the State commissions do consider these factors in determining the reasonableness of medical fees.
Fee schedules.-The ultimate determination of the reasonableness of medical fees in workmen's compensation cases lies with the administrative commissions and courts.
In 28 States 21 the compensation commissions or courts are specifically authorized to approve, regulate, or fix the amount of medical and hospital fees. The laws of two States (Colorado and Washington) authorize the commission to issue a table or schedule of fees which shall serve as a basis for compensating medical services rendered. Moreover, medical fee schedules have been put into effect, under general authority to regulate or approve medical fees, by the compensation commissions of the following States: California, Maryland, Nevada, Ohio, Oregon, Washington, and West Virginia. In passing, it may be noted that all of these States have either exclusive or competitive State insurance funds. Also, the Massachusetts and New York compensation commissions, in approving medical fees, have been governed by a medical and a hospital fee schedule formulated in cooperation with the medical profession, hospitals, and insurance companies of the State. In New York, however, the State medical society later repudiated the fee bill because the insurance companies interpreted it as "a maximum fee bill, not as a minimum fee bill."
In addition to the foregoing official schedules promulgated by the State compensation commissions, medical fee schedules have been adopted quite extensively by insurance companies, by many county medical societies, and by a few State medical societies. There is a fundamental difference, however, between the schedules adopted by
21 California, Colorado, Connecticut, Delaware, Hawaii, Kansas, Idaho, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New York, Ohio, Oklahoma, Rhode Island, South Dakota, Tennessee, Texas, Utah, Virginia, and Wisconsin.
22 Quoted from American Medical Association Bulletin of May 15, 1915, p. 388, by Dr. I. M. Rubinow in July, 1917, issue of the Journal of Political Economy, p. 717.