Medical Service Plans Under Collective Bargaining' UNIONS, IN NEGOTIATING HEALTH PROGRAMS for inclusion in agreements, have adopted two general approaches. One is the cash benefit plan, under which visits to doctors, hospitalization, maternity, and surgical costs are provided through employer pay-roll contributions (premium payments) to a commercial or union-owned insurance carrier.2 The other is the medical service plan, under which medical care is provided through a health center supported by employer pay-roll contributions at little or no cost to the workers. Although the medical service plan covers relatively few workers compared with the cash benefit type, the comprehensive medical care sought for low income groups through such voluntary, private organizations merits particular attention. In the early part of 1947, representatives of the Bureau of Labor Statistics and the United States Public Health Service studied two comparable medical service plans established through collective bargaining: The Labor Health Institute in St. Louis and the Union Health Center in Philadelphia. Origins of the Plans Both medical service plans were started in the war years. Favorable business conditions, part of operating expenditures offset through tax deductions, and wage stabilization regulations, which made direct wage increases difficult to obtain, stimulated the establishment of the health centers. The Philadelphia Union Health Center was established in March 1943, under the terms of an agreement between the Philadelphia Waist and Dress Manufacturers' Association and the International Ladies' Garment Workers Union (AFL) acting through the Philadelphia Joint Board Waist and Dressmakers' Union. This was the first ILGWU plan to be established under collective bargaining, the earlier centers having been maintained by the union through dues and assessments. Funds to 1 Prepared by Jonas Silver formerly of the Bureau's Industrial Relations Branch and Dr. Lee Janis, U. S. Public Health Service, under the direction of Abraham Weiss. 2 Some plans provide for contributions to a union administered fund. The ILGWU founded the first union health center in New York in 1911. For a description of this plan, see Monthly Labor Review, February 1947 (p. 201). operate the new venture were obtained fr employers' contributions of 31⁄2 percent, beginni in June 1942, and raised to 6 percent in 19 including unemployment benefits. A sick ben and vacation fund was also financed from th contributions." Unlike the ILGWU in Philadelphia, the Louis Board of the United Retail and Wholes Union (CIO) had no model health center previo ly set up by the union. The local union offici had been members of a consumer group heal association, organized by a physician who la became the medical director of the Labor Heal Institute, and they were convinced that no "ins ance package" could meet the health needs of t workers. The employers were not so easily co vinced, however. Although conferences on t proposed medical service plan were held in 194 agreements covering the projected Labor Heal Institute were not obtained until the summ and fall of 1945. For the first few months of i existence, the new health center was conduct from the office of its medical director, largely wi the aid of a loan later repaid to the union. E November 1945, sufficient funds were accumulat from the employer pay-roll contributions of 3 percent to enable the Labor Health Institu to move into its own quarters in a downtown offi building. 6 Membership and Eligibility The Philadelphia program serves about 15,00 workers, of whom 10,000 are in dressmaking an 5,000 in knit goods, cloaks, raincoats, departme stores, and south New Jersey dress firms. Th nondressmakers' locals have their own agreemen providing for health insurance funds. Under e isting arrangements they are not direct partic pants in the Union Health Center, but reimburs the health insurance fund of the Waist and Dres makers' Joint Board on a fee-for-service basis fo those members who avail themselves of the center facilities." In 1945, average earnings in the Philadelphia ladies' garment industi were reported at $32 per week. The break-down is 2 percent for health center, hospitalization, surgic and sickness, 2 percent for vacations, and 2 percent for unemployme insurance and administrative costs. In 1946, average earnings in the companies covered by the St. Louis Lab Health Institute were reported to be about $33 per week. 7 Members of nondressmaker locals report to their own locals first and the are referred to the Union Health Center. In St. Louis the several locals of the Retail and Wholesale Union bargain separately with individual employers, most of whom have agreed to the standard health benefits clause. In March 1947, 23 employers in wholesale establishmentsdry goods, hardware, food, candy-and 15 small shoe-repair shops were parties to agreements covering somewhat less than 3,000 workers (since increased to 5,000). In addition, about 2,000 dependents of these workers were participating in hospitalization benefits obtained through the St. Louis Labor Health Institute for which they themselves paid. A small number of special members were drawn from the staffs of the union and the institute; additional members were drawn from a group health association, a cooperative organization in existence for 10 years and now contracting with the Labor Health Institute for services. In Philadelphia, a worker becomes eligible after 6 months' membership in the union, provided he is not more than 13 weeks in arrears in dues, regardless of the length of time his employer has been contributing to the fund. No provision is made for participation of outsiders. 8 In St. Louis, employees of a company agreeing to contribute to the health fund must wait 30 days before becoming eligible. Workers newly hired by companies already under the medical service plan must wait 60 days. Membership under the St. Louis plan is open to all workers in the bargaining unit, whether union members or not.9 Policy-Making Bodies The St. Louis Labor Health Institute was organized under the laws of the State of Missouri as & nonprofit corporation. Under the bylaws of the institute, control and management are functions of the board of trustees, composed of 27 members, of whom 18 are members of the union, 8 are employers, and 1 is a public member (currently a university professor). As a practical matter, a much smaller number of union and employer Dependents may obtain technical services (X-ray, metabolism tests, ete at reduced cost upon referral by a private physician. Most of the agreements with contributing firms provide for a modified zion shop. representatives serve on the board. The union members of the board are elected at the annual meeting by the regular members of the institute from candidates nominated by a committee of the board of trustees. Employer representatives are nominated and elected by the board of trustees as a whole. Between the quarterly meetings of the board, the executive committee of 9, of whom twothirds are union members elected by the board of trustees from among its own number, supervises the activities and carries out the policies of the St. Louis Labor Health Institute. The board of trustees is authorized to "approve and enforce all plans, projects and policies of the institute, hear reports of semiannual audits of the financial records of the institute, and have general supervision of the St. Louis Labor Health Institute." The health insurance fund of the Philadelphia Waist and Dressmakers Joint Board is controlled by a Health Insurance Fund Committee consisting of two representatives (designated by the joint board) from each of seven of the eight locals 10 comprising the joint board. Three additional members of the committee hold office by virtue of official positions on the joint board. The committee is divided into health center, sick benefit, vacation fund, and appeals subcommittees. Since the Philadelphia Health Insurance Fund Committee is an offspring of the Dress and Waistmakers' Joint Board, no important decisions are made without the concurrence of the parent body. All funds are deposited in a bank account, maintained in the name of the Health Insurance Fund Committee, from which all payments are made. The committee decides on the amount to be appropriated "to any one or more" of its purposes. The committee elects three officers from among its members including the director of the Union Health Center. An affirmative vote of a majority of the committee may alter or amend the rules and regulations of the fund. Only dress and waistmakers' locals are represented on the Philadelphia Health Insurance Fund Committee, although, as previously indicated, outside locals participate in the health center. Employers are not represented on the administrative board nor is there a separate advisory employer body. 10 The agreements of one of the locals do not provide for contributions to the Health Insurance Fund. Day-to-Day Administration The organization of the St. Louis Labor Health Institute for day-to-day operations places key authority in the hands of the president of the board of trustees and the medical director. The former is also director of the joint board of the union and has general supervision of the activities of the institute. The president makes "regular reports and recommendations to the board of trustees on plans, finances, and projects." Between meetings of the board, the president is responsible to the executive committee. The bylaws empower the president to recommend to the board of trustees a medical director and a business administrator. The medical director is authorized to select professional personnel and supervise the functioning of the medical program. He also has "final authority on the extent of medical services to be rendered any individual," and reports regularly to the board of trustees. The business administrator engages all nonprofessional personnel with the approval of the president and reports directly to the president. Although there are no physicians on the board of trustees, two representatives of the medical staff attend board meetings. A union and an employer representative (members of the board) attend the business conferences of the medical staff. In this manner an exchange of views is obtained between medical and lay persons. At the Philadelphia Union Health Center, the administrative director reports monthly to the health center and sick benefit committees, inasmuch as he is responsible for the day-to-day operations of these programs. (The vacation and fair-income funds are handled in the office of the joint board.) One step removed in authority from him is the medical director who is selected by the Health Insurance Fund Committee; he has immediate responsibility for administration of the medical service plan. On matters of appointments to the professional staff, adding medical departments or equipment, the medical director makes his recommendations to the lay director, who in turn goes before the Health Insurance Fund Committee for final authorization. Unlike the St. Louis organization, in which the medical director reports directly to the board of trustees, under the Philadelphia plan greater authority is placed with the lay director. Whatever the for mal division of responsibility, effective day-to-da administration of these two plans results fro teamwork between lay and medical administrator Medical Staff The medical staff of the St. Louis Labor Healt Institute is an autonomous unit under the supe vision of the medical director, assisted by a associate medical director. Staff appointmen are initiated by the medical director, subject t the approval of the 23 physicians and surgeon employed by the institute. The medical me select their own chief of staff, and committees o facilities, equipment, and make recommends tions on salaries. Most of the staff physicians ar specialists in their fields, as evidenced by the fac that all, except the general practitioners an dentists, are diplomates of specialty boards. A staff physicians are employed on a part-time basi at the minimum rate of $5 an hour, this employ ment supplementing their private practices. Th caliber of the institute's medical staff is admit tedly of high quality, as attested to by the sta members' standing in the medical profession i St. Louis. In Philadelphia, the health center's medica staff is selected by the medical director, subjec to the formal approval of the lay director an the Health Insurance Fund Committee. A staf of 22 part-time physicians and 3 consultants serv the Philadelphia garment workers. Staff mem bers average 6 hours a week and are paid at th minimum rate of $6 an hour. Although there ar no staff committees, it is planned to form a med ical committee on scientific matters to confer or problems affecting the center. The medical di rector also intends to have the professional staf choose its own members in the future. Group Practice Both centers endeavor to conduct group practice under which the associated specialists and general practitioners get the benefit of each other's opinions through staff consultations. It is pointed out that under a prepayment group practice plan a patient may be given tests, X-rays, or further examinations that may be required, without delay or additional costs. Such pooling of knowledge and skills, as well as equipment, it is claimed, makes possible complete utilization of all advances in medical science at a greatly reduced cost. In practice, it has not always been possible to realize fully the theoretical advantages of group medicine at these health centers. A number of the St. Louis physicians interviewed expressed the opinion that when the staff is composed of specialists with few general practitioners, there is a tendency to withhold criticism of one another's work because of the aura of infallibility which surrounds specialization. In Philadelphia the extent of group practice is limited by the scope of the plan which confines medical care to diagnosis and therapy of ambulatory cases on referral by private physicians. Most of the doctors interviewed joined the health center for reasons other than their interest in the labor movement. A reason frequently given for joining the staffs of these organizations was the opportunity afforded thereby to supplement private practice. In the absence of medical service plans, the same doctors would be treating some of the same patients at a clinic or hospital without remuneration. From a professional standpoint, all are interested in the ready availability of technical services and of consulation with fellow physicians under group practice. Medical Services Provided The two health centers differ in extent of medical services provided the membership. The St. Louis Labor Health Institute offers the workers complete medical care described by its medical director as "portal to portal medicine." The Philadelphia Union Health Center restricts its services to treatment of ambulatory cases, i. e., patients who can be treated at the center. Doctors' visits to the home are not included, while hospitalization and surgical fees are extended only on a limited cash benefit basis. The difference in approach is explained largely by the fact that no established pattern was set by the Retail and Wholesale Union, whereas the Philadelphia Dress Joint Board followed in the footsteps of its predecessorthe Union Health Center in New York. However, in Philadelphia the worker receives complete ambulatory care, while in New York medical attention is limited to an amount equivalent to $25 a year per member. In part, too, the difference in approach between the two plans is attri butable to the St. Louis union leaders' experience in a consumer group health association. Union officials and the medical director of the St. Louis Institute were determined from the start to obtain for the members the best and most complete medical care available, even though it meant a large initial investment for facilities, equipment, and staff. In their view, it was extremely important to leave no gaps in the development of a complete medical care program that might defeat the fundamental aim of safeguarding the workers' health. A general physical check-up alone was inadequate, if not followed up by the necessary treatments, however elaborate they might be. It was also considered essential to the success of the program that the members understand the importance of preventive as well as curative measures and the need for visiting the Labor Health Institute at regular intervals. The fact that medical care problems are often linked with sociological conditions was recognized by adding a psychiatrist and a medical social worker to the professional staff. Under the St. Louis plan, a worker is entitled to the following medical care without cost to himself: Diagnosis and treatment by general practitioner and specialist (such as eye, ear, nose and throat, skin, internal medicine, gynecology, obstetrics, and pediatrics); home and hospital calls by staff physicians; technical services (such as X-ray, fluoroscope, physiotherapy, and laboratory tests); regular physical examinations and routine dental care; and major and minor surgery. Hospitalization costs are covered by Labor Health Institute participation in the local Blue Cross Plan. (In general, provisions are 60 days per contract year in member hospital at no cost for room and specified extras; additional days at discount.) Extra charges, not covered by Blue Cross, are paid by the institute. Pharmaceutical and surgical appliances are provided at reduced costs. The institute has purchased an apartment house to be converted to a hospital as an addition to the medical center. The Philadelphia Union Health Center operates its limited medical service plan with modern medical facilities and equipment. In addition to the standard departments, orthopedics, minor surgery, dermatology, and endocrinology are included. Technical departments cover X-ray, electrocardiogram, basal metabolism, physiotherapy, and clinical laboratory. Ambulatory care is furnished the worker without cost, except for pharmaceuticals and appliances provided at reduced prices. Dependents of members are not treated at the center, but for a reduced fee they may obtain services of the technical departments on referral by private physicians. If the required medical specialty is not available at the center, the patient is referred to a qualified doctor whose fees are paid by the Union Health Center. Membership in the St. Louis Labor Health Institute is open to families of regular members on a dues-paying basis ($3 a year for adults, $1 a year for each child). Families may obtain medical services on a reduced fee-for-service basis. In October 1947, a new family plan was introduced under which an employee, a spouse, and children under 18 become eligible for full medical services and hospitalization, provided the employer agrees to remit 5 percent of the employees' gross pay. The policy under the Philadelphia plan is to encourage members to obtain an annual physical examination at the center but to consult their own doctor on other occasions if they can afford to do so. When treatment or special diagnosis are required, the private doctor usually refers the member to the center which uses its facilities as long as the patient can be treated as an ambulatory case. The record of diagnosis and treatment is made available to the referring physician. This procedure is followed to maintain the traditional relationship between the referring physician and a diagnostic center. Should the worker require surgery, the Philadelphia Health Insurance Fund allows $25 toward defraying the cost of a major operation-as defined by the medical director. Hospitalization benefits are $2 a day up to and including 12 days of hospitalization in any benefit year." In addition, sick benefits are payable at the rate of $10 a week for a maximum of 10 weeks in any one benefit year after a 9-day waiting period, whether or not hospitalization is required.12 Before a worker may 11 It is proposed to increase the surgery allowance to $50, and the hospitalization benefits to $3 a day up to 31 days. 12 Although the St. Louis Medical Service Plan does not provide for cash sick benefit allowances, most of the agreements of the Retail and Wholesale Union with member companies of the Labor Health Institute cover sick leave to the extent of 10, 20, 30, or 7, 14, 21 days a year at the regular rate of pay for continuous service ranging from 1 to 10 years. Workers may, if they wish, utilize services of an LHI physician to certify disabling illness. receive hospitalization or sick benefits, a physician must certify the existence of a disability. If the doctors engaged in this work are not on the regular staff of the Union Health Center, they are com pensated for each visit. In general, these medical service plans exclude care of injuries or diseases incurred in the course of employment which are provided for under compensation laws, 13 and treatment in a sanitarium or public institution. Tuberculosis and alcoholism are not treated after diagnosis has been made.1 Under the St. Louis plan, newly hired workers who become members subsequent to the company's date of entry in the institute are excluded for treatment of pre-existing chronic conditions. However, no exception is made in the initial group which represents 90 percent of the members. Worker Utilization of Services Both health centers faced a serious problem at the start in obtaining adequate participation in the medical service plans. Workers' failure to utilize the services was attributed to the inertia of accustomed ways of obtaining medical care, i. e., calling upon the family doctor only when absolutely necessary. It took time for workers to understand what was available to them free of charge. Fear that disabling conditions might somehow be revealed to employers or affect their jobs also was a factor in retarding utilization. In St. Louis, the Retail and Wholesale Union attempts to bring the advantages of the Labor Health Institute to the attention of its members through health education pamphlets, a health column in the union newspaper, and forums under the auspices of health and safety shop councils at work places. To a limited extent, the institute has provided in-plant medical services, such as mass inoculation against influenza. In some instances, employers use the institute for pre-hiring physical examinations. It is planned eventually to widen this phase of medical service so that the Labor Health Institute will staff the medical departments of contributing employers. In an effort to expand its activities, the Retail and Wholesale Union has interested a number of AFL and CIC unions in St. Louis in the possible use of the insti 13 However, the Philadelphia ILG plan includes care of industrial injurie and illnesses. 14 The ILG has long made provision for tuberculosis care in the form o cash benefits ($250) or sanitarium care. |