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Sixth Session

TUESDAY AFTERNOON, MAY 14, 1918

MR. WINSLOW was called to the chair and introduced Dr. Warner to speak on the organization of medical work as affecting health insurance.

Medical Work and Health Insurance

DR. WARNER opened by stating that the subject had interested him deeply for some time, and particularly since he had been on the Ohio commission. One point was clear to him personally, that in providing medical service in large amounts it was entirely reasonable to apply to it the same business principles that were applied to the production of any other commodity. Manufacturing was done on a cooperative, organized basis. People no longer manufactured things in their own homes, one by one. We had gotten beyond that in most things, but we had not yet gotten beyond it in medicine. "Why," was a long story, but the fact remained.

There was no prospect of a satisfactory solution to the medical question, either under present methods or under health insurance, as long as individualistic practice of medicine prevailed. That must go. It was going, and health insurance would do much to bring the day when we would have something better.

Hospitals and dispensaries had always had more or less organized practice of medicine. However, as the work had been done in these institutions it had certain defects which a consideration of the question, and some experimental work as well, had recently convinced him were entirely correctable. The fundamental defect of the hospital as an organized producer of medical care was that many at one time most of them, but he was glad that he could now say no more than many of them"-were not organized institutions for the practice of medicine but hotels for the sick, where any individual doctor took an individual patient and cared for him in an individual way. The fact that another doctor had another patient in the next room did not change the situation. There was a common kitchen, and certain other things in common-just as there were in hotels. But the hospital as an organized unit for bringing

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to bear upon each patient all the knowledge, all the skill, and all the equipment of each of its constituent parts was a comparatively recent development. At present many hospitals were of this type, but the public did not know the fundamental difference between the two types where they existed. The people did not know, did not realize it, or they did not care. If hospitals were to do what they could and should do to contribute to the welfare of the workingman, that condition must be changed; and fortunately it was entirely correctable.

Dispensaries were, in theory, perhaps ideally organized for contributing to this work. In dispensaries there was always cooperative practice of medicine. The assumption of the staff was that they did not know all there was to know about medicine. Individualistic practice of medicine, on the other hand, always assumed that every doctor knew all there was to know about medicine, and therefore one took his choice and would get the same thing in all cases. That was not true. The development of specialties had made it absolutely impossible for any one man to master all of them, and if he did not know that, it meant that he had not mastered any of them.

Dispensaries had always been cooperative. They had always had on the staff various men who gave special attention to special lines and therefore the sum total of medical skill was greater than could be obtained by seeking any one physician, no matter how eminent he might be.

The principle of organized cooperative medicine had gone through several grades. The top grade, of course, was the model clinic. That was for the man of means. He went there and paid a good round sum and he got service. These clinics had specialists in all branches, and no matter where the consideration of any particular case might lead, the requisite treatment was given by men of skill. That was cooperatve practice of medicine at its best.

The next grade was the so-called "pay" clinic, where men of ordinary means could go. The number of people who appreciated the value of cooperative medicine was becoming greater. The workingman had learned it from the still lower grade of clinic, that is, the ordinary free dispensary. Wage-earners who went to these dispensaries learned that they received attention there and received service, they got along pretty well, and they were enabled to see a type of man whose time they could not buy.

There were, therefore, these three types of cooperative medicine. They were making their way into every bit of medical practice in this country except in districts so outlying as to make it physically impossible, but there was no longer any prospect for individualistic practice of medicine in any community which could develop the other kind. It still existed, but it had no future. It was dead professionally.

The defect of dispensaries had been that they were organized not for the benefit of the people they served but for the convenience and partly for the benefit of the medical men who worked in them. To be on a hospital or dispensary staff was a valuable asset to any doctor. It was an asset to him as an advertising medium, about the best that there was open to him. It was an asset to him because he usually learned something that he could not learn anywhere else. Therefore it had been very easy to get men to serve on dispensary staffs, but they served gratis, therefore dispensaries were organized and run largely at their convenience and open at the time of day which was most convenient for them. And the poor patient, if he happened to select the proper time, got very good service; if he happened to land in at just the wrong time he could come back the next day. That was correctable, and was being corrected. In many dispensaries now the point was especially brought out that the staff must be a paid staff. The old voluntary staff was out of date, and as fast as the hospitals could they were going on this new basis. It was hard to do it just yet, because the need of it was not appreciated by the public or by the sort of patients which the dispensary must have in order to make the change, but it would be done.

Individualistic practice of medicine could not be claimed to yield the doctors as net income more than 50 per cent of their gross receipts. The other 50 per cent of their receipts went to pay for medicines, office rent, automobiles, and other necessaries. But there was no occasion for maintaining outfits in thousands of different places in one city for the practice of medicine. Just as there was no longer occasion to manufacture goods in workmen's homes, and it was found convenient to concentrate production in factories, so it would be found convenient to put the modern practice of medicine into institutions and make it available for the use of the people, with a tremendous gain in efficiency.

As to the cost, at the pay clinic at the Lakeside Hospital, as he

had said in a previous session, the physician's pay was set at the minimum rate of $5 for two hours' service. That did not seem very much, but if a doctor worked seven hours a day-and at that rate even a doctor ought to work seven hours a day-he would in the course of a year draw $5,250; and if half of the physician's income was now taken up by expenses of his practice, what such men would draw would be equivalent to $10,500 on the basis of individualistic practice. How many doctors drew $10,500 out of their practice, not in bills, but in money? Any doctor working under organized medicine at the rate named would be so much better off than now that there would be no comparison.

What would cooperative medicine mean to the patient? The Lakeside night clinic had been going a little over a year, and was piling up a surplus on a 50-cent fee. The patients paid 50 cents for consultation or treatment, and paid extra for their medicine, which averaged probably 25 or 30 cents more. A great many did not get medicines. It was not necessary for physicians under this system to give rhubarb and soda. If patients did not need medicine, they did not get it, and they were pleased because they did not have to pay for it. The average total expense to a patient for one visit was 75 cents. A charge of $5 was made for certain special injections, but these were expensive operations which must be antiseptically done and required attendant nurses and extra doctors. From those fees the institution was now making money, and in order to come out even it was necessary to enlarge the scope of the clinic. That was what could be done by the organized practice of medicine. If the process of cooperation and organization were carried further there would be a corresponding decrease in cost as there would be in large-scale production.

As to the attitude of the medical profession toward health insurance, there was, of course, no crystalized attitude. Many physicians were seeing clearly the fact that organized practice of medicine was coming, with or without health insurance. Health insurance would bring it quicker, but it was coming anyway. It existed now. Pay clinics were increasing, more hospitals were putting them in, and in a couple of years they would probably number thousands. Anybody could organize one. It required practically no funds, the equipment was already there.

The physician who saw clearly that organized practice of medi

cine was coming was convinced that the sooner it came the better. A great many physicians saw the possibility of state organization of medical practice. They might not take this quite so kindly as they would organized practice of medicine, but many recognized that organized practice of medicine was coming-in fact, had come— and the sooner that all got on that basis the better off they all would be. It was for the interest of the medical profession to operate on the organized basis. When it did, the problem of getting medical care of the right type for a large number of persons would be as simple as it was to-day to buy a large number of stove handles or any other commodity.

Although there would probably be some opposition to the development of social health insurance, it would come from those who were defending the individualistic practice of medicine, and from those who did not see their way clear to get into the organized practice of medicine on the ground floor. It was always those who were pinched who howled. As to why they did not see their way clear to get in, there was only one reason. The good men would. get in, the others, some of them, might be left out. Whether that would be a damage to the public who received medical care from those men, he would not say. On the other hand, the upper stratum of medical men, those who were interested in the advancement of the profession and in producing the greatest amount of service for the welfare of all the people, would welcome the new development and would help it.

CHAIRMAN WINSLOW thought that all were sure that the care of the sick was in process of evolution, and that all believed nobody should go without medical or surgical care because he could not afford it.

Ten-Cent Fee Covers Prescription Cost

MR. RANSON said that three groups came to the dispensary of which he was superintendent in Chicago. Some came because the dispensary was connected with Rush Medical College. They came not because they were poor, not because they expected treatment, but to learn what doctor to go to for their particular illness. If a person came in with a serious stomach disorder and wanted to know where to go, he was referred to a prominent specialist, and it was certain he would get good service.

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