« ÎnapoiContinuă »
the medical societies and those adopted by the insurance companies, The former are generally minimum fee schedules, whereas the latter are maximum schedules. Moreover, the medical societies have difficulty in maintaining strict adherence to their schedules on the part of the members of the profession; on the other hand, relatively few of the experienced physicians and surgeons will sign the schedules of the insurance companies.
The rates contained in the fee schedules adopted by the several States enumerated above are somewhat lower than the regular rates of the profession. In many of the States the rates approved vary between different communities, depending upon the prevailing rates in the locality. In Massachusetts, for example, the guideposts by which the industrial accident board determined the reasonableness of fees were (1) the locality in which the doctor practices, (2) the nature of the complaint, (3) the ability of the man to pay, and (4) the standing of the practitioner in his profession.23 In Ohio, however, the amount of medical fees was determined with a view to impartiality and uniformity. Said the Ohio Industrial Commission in this connection:
We can not consider and maintain this impartiality and uniformity, of which we speak, if, as has been suggested by some physicians, we consider that the same services demand different fees from different localities, in industrial accident work. It is to be remembered that this act contemplates the considering of this whole subject on an industrial accident basis. This is an industrial accident law, based on industrial conditions, and the lack of appreciation of this very fact is the one great reason why there is difficulty regarding the medical aid feature. The medical aid compensation is charged to the employer on an industrial accident basis. The act contemplates the payment of reasonable compensation to the injured and reasonable compensation for medical attention.24
Because of the great variations in kind and amount of treatment required even for similar and apparently identical injuries, it is impossible to determine in advance what would be a reasonable fee for a particular injury. Consequently a medical fee schedule is commonly used merely as a guide or as a minimum fee table.
Because of the medical fee question, workmen's compensation laws have been the subject of considerable objection and adverse criticism by a part of the medical profession. Usually this criticism is of two kinds: (1) That directed against the law and its administration, and (2) that directed against the unfair and unreasonable practices of certain employers and insurance carriers. The first kind is heard most when a compensation law is first put into effect and is due
23 First annual report of Massachusetts Industrial Accident Board, 1912-13, p. 56.
primarily to the physicians' unfamiliarity with the law and with the duties and functions of the compensation commission. The loudest criticisms, too, generally come from those physicians who do not stand highest in the profession. The large majority of the profession have cheerfully cooperated with the commissions in the administration of the laws in the interest of the working classes for whose benefit such laws were enacted, and it is seldom, indeed, that a compensation commission has had difficulty with the higher class physician and surgeon. The second criticism is usually the result of certain practices on the part of employers and insurance carriers which are considered unfair to the medical profession and inimical to the best interest of the injured workmen.
The following extracts from a report made by the Massachusetts medical advisory committee to the physicians of the State probably epitomize the general experience under compensation laws in the United States:
A small proportion of these [insurance] companies have adjusters and other subordinates who are at times inclined to play cheaper games than proper. There has been a tendency on the part of some physicians, not many of them members of our societies, but still physicians ostensibly respectable, to pad their bills and raise their rates; in other words, to treat this law as an opportunity for medical graft. In many of these matters the medical advisory board has been able to help the industrial board toward a solution. * * *
It seems to us that the whole intent of the law is not charity, but rather to lift the injured workmen out of the pauper class and, at least for the fortnight following the injury, to furnish them with the best care, to give them the best possible chance for complete and early recovery and return to working power. Some of the insurance men regard the whole matter, seemingly, as a partially charitable service, and argue that as cut rates and charity were granted the sufferers by doctors and hospitals before this act went into effect, therefore this sort of thing should continue. * * *
Here and there insurance companies, usually the unimportant ones, have shown a desire to press the advantage given them by the phrase of the current law. In the main, however, the better companies * * * have shown themselves decent and reasonable, not inclined to overwork a technical advantage.25
Hospital fees.-The problem of determining the reasonableness of medical fees is further complicated when the injured man is sent to the hospital. The added difficulty arises from the fact that hospitals are in part charitable institutions and supported by donations of public-spirited citizens. Hospitals usually have three classes of service-public wards, semiprivate rooms, and private rooms. The public wards are maintained, at nominal prices, frequently less than actual cost, for patients who have limited means, among whom are included most of the industrial workers. Moreover, in case of public ward
25 Boston Medical and Surgical Journal, Sept. 18, 1913, p. 444.
patients, no charge is made for the attending physician or surgeon. For the other classes of service the rates are not only much higher, but fees for attending physicians and surgeons must be paid in addition. The question immediately arises, Should injured employees be placed in public wards, as they probably would have been before the enactment of compensation laws, or should they be placed in semiprivate or private rooms? if the former practice is followed the employers and insurance companies are benefited at the expense of the physicians and hospitals; whereas, if the latter plan is adopted, the remuneration received by the medical profession would not be in accord with the compensation acts, which provide that medical fees 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 such treatment is paid for by the injured persons"; and consequently employers and insurance carriers would be required to pay more than was intended by the law. The insurance companies maintain that were the injured workman to pay for his own medical and hospital bills he would in most cases be sent to a public ward, and physicians would graduate their charges according to the patient's income and ability to pay.
On the other hand, the hospitals maintain that they should not bə asked to treat compensation cases at a loss. The practice among hospitals varies. Some place compensation cases in public wards, some in semiprivate rooms, and others maintain a "compensation ward" at intermediate rates. The practice of doctors in sending patients to hospitals also varies. The majority, however, recommend that patients be placed in semiprivate wards, thus entitling them, according to the rules of the profession, to charge for their services in hospital cases.
EFFECT OF COMPENSATION LAWS UPON INCOME OF PHYSICIANS.
It is the consensus of compensation commissions and many physicians who have investigated the matter that workmen's compensation laws have increased rather than diminished the income of the medical profession, and this despite the fact that the rates in industrial accident cases have been somewhat reduced. Certainly the effect has not been detrimental in a pecuniary way. The lower schedule of fees has been counterbalanced by certainty of payments. "It is of great interest to physicians to remember," says the Ohio Industrial Commission, "that in the past, in from 50 to 75 per cent of the cases taken in aggregate, no pay was received for medical service rendered."26 Several investigations of the effect of compensation laws upon the income of physicians have been made by members of the profession. Dr. F. T. Rogers, former editor of the Providence
26 Bulletin of Ohio Industrial Commission, Oct. 1, 1914, p. 4.
Medical Journal, as a result of a questionnaire sent to the doctors of the State of Rhode Island, found that in about one-half of the cases in which replies were received there was no appreciable change in income; in about one-quarter there was an increase in the income; while in the other quarter there was a decrease in income. Summing up, Dr. Rogers said: "An act which affects but 13 per cent of the profession 27 unfavorably can not be a serious menace to our interests."28 Dr. William L. Estes, as a result of a questionnaire sent to the physicians of Pennsylvania, said: "It is evident, therefore, that a majority of the physicians of the State believe the law a good one, and is working efficiently for the good of the workingman, and not to the detriment of the physicians." Dr. Sears in a letter to the Bureau of Labor Statistics stated that in his judgment the Vermont compensation law has somewhat increased the remuneration of the medical profession. "It is probable," says the Wisconsin Industrial Commission," "that the compensation act has very greatly increased the income of the medical profession as a whole." The medical advisory committee of Massachusetts stated as its opinion that the compensation law "has worked out well so far-for a new law-and that on the whole the medical profession has lost nothing by it."
All except 1132 of the 45 workmen's compensation States have industrial accident boards or commissions to administer the compensation acts. The numerous technical medical questions involved and the constant need for medical advice have led to the appointment of medical advisers or directors in 13 States 33 and the Federal Government to assist the commissions in administering the medical provisions of the acts. The recent Missouri law also provides for the appointment of a medical adviser.
The duties and functions of these medical advisers generally include the following: (1) To examine claimants; (2) to be witness or give counsel at hearings; (3) to make medical reports on cases; (4) to be present at conferences of physicians examining claimants; (5) to make arrangements for specialists' examinations; (6) to select impartial physicians for examinations of claimants; (7) to pass upon the reasonableness of medical and hospital fees; and (8) to rate permanent disabilities.
"That is, 13 per cent of those to whom the questionnaire was sent.
Providence Medical Journal for March, 1915.
Monthly Bulletin of Pennsylvania Department of Labor and Industry for February, 1917, p. 48.
30 Fourth annual report of the Wisconsin Industrial Commission, 1914-15, p. 4.
"Boston Medical and Surgical Journal, Sept. 18, 1913, p. 444.
Alabama, Alaska, Arizona, Kansas, Louisiana, Minnesota, New Hampshire, New Mexico, Rhode Island, Tennessee, and Wyoming.
*California, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Nevada, New York, Ohio, Oklahoma, Oregon, Washington, and West Virginia.
ADMINISTRATION BY LOCAL BOARDS IN WASHINGTON.
A notable experiment in the field of medical administration was put into effect in the State of Washington in 1917. The Washington act provides for a State medical aid board composed of the medical adviser of the industrial commission and one representative each of the employers and employees. This board is authorized to divide the industries of the State into five classes, according to hazard. Employers subject to the act are assessed from 1 to 3 cents for each working day of each employee, to be paid to the State medical fund once a month. Deductions from the employees' wages of one-half of the assessments are authorized by law. The State board is also authorized to promulgate rules, issue a maximum medical fee bill, approve physicians' and hospital bills, and approve contracts between employers and employees as to hospital benefit funds.
The act also provides for the establishment of local medical aid boards for the actual administration of the medical service. Each of these boards, composed of one representative each of the employers and employees, must provide care and treatment for the injured, report the beginning and termination of disability and the cause of the injury, and also certify the medical bills. In case of disagreement the local boards shall appeal to the State medical board.
One of the most difficult problems the State board was called upon to solve concerned the appointment and functioning of the local medical aid boards.34 The framers of the law evidently intended that there should be a local board at each plant. Such local boards were workable in the larger plants but were utterly impracticable in the case of the smaller employers. The board, therefore, divided the State into districts and established a local board in each locality where a physician resides. The larger cities were divided on an industrial basis, six such districts being established in Seattle, and five each in Tacoma and Spokane. The State board experienced great difficulty in having the local boards appointed. The employers as a rule refused to serve on the board because they could not spare the time from their business and since the law allowed only $3 a day the workmen did not want to give up good-paying jobs to attend to local board work.
This situation was remedied by a 1919 amendment (ch. 130) to the workmen's compensation law. The act now provides for the creation of three local aid districts (one each in Seattle, Tacoma, and Spokane). In each district there shall be a local aid board to consist of two members who are to be appointed by the newly created State safety board. Each member of a local aid board shall receive a salary of $300 a month. Their duties are enlarged to include accident prevention work.
34 Report of Washington State Industrial Insurance Department for 1917, pp. 54-56.