medical benefits offered by that program. In table 1 are enumerated those eligible for and those actually receiving medical assistance during January, 1952. The 9,337 persons eligible for medical assistance represent 2.5% of the total county population. ADMINISTRATION In conference with the executive council of the county medical society and with local organizations representing other vendors of medical services, the Lake County Department of Public Welfare founded and authorized benefits for its medical assistance program. Under DPW guidance, each of these organizations has set up a reviewing committee that is charged with the negotiation of fee schedules and the policing of its own members who participate in the program. When medical de TABLE 1.-Eligible Population and Recipients of Medical Assistance During January, 1952 * These totals were estimated by expanding the case load of North Township, the population of which is 40% of the total county population. cisions are concerned, the program provides that "The final authority is the representative of the various professional groups" and that all decisions relative to need for medical care or hospitalization rest with the attending physician. The 11 medical aid programs administered by the township trustees are in essence similar to that of the DPW. Exceptions to this generality will be discussed later. Although North Township only was studied, the 11 township trustee programs are believed to be sufficiently alike to be considered together here. SERVICES AVAILABLE The Indiana State Department of Public Welfare delineates 12 medical services that may be awarded to certified assistance clients. All of the following services are extended to clients of the Lake County DPW: Physicians' services in the home, office, and hospital are available to Lake County DPW clients on a free choice basis. No prior authorization is necessary; neither is a client required to present any credentials upon soliciting the services of a physician. Physicians may confirm the prospective patient's eligibility by telephoning the DPW offices, however. In emergencies, physicians practicing in other counties may be consulted; indeed, DPW cases are often referred to Chicago physicians. The in-patient facilities of Lake County's five general hospitals are available to the DPW client on the recommendation of the physician attending him. No separate authorization by the offices of the DPW is prerequisite to admission. Within these hospitals, the welfare patient is in no way segregated; the discretion of his physician places the sole limit on services extended him. For purposes of curtailing unnecessarily prolonged hospitalization, the services of licensed nursing homes are solicited by the DPW. Prerequisite to commitment here are the written recommendation of the family physician and authorization by a DPW home visitor. The Northwestern Indiana State Nursing Association maintains a registry in the offices of the Lake County Medical Society. Through this agency, the attending physician may place registered nurses in the homes of convalescing DPW clients. The services of qualified practical nurses may also be authorized by the DPW on receipt of the attending physician's written petition. Prescriptions for all drugs, save those considered experimental, may be issued to DPW clients. The physician is requested not to dispense but to "script" pharmaceuticals. Then, prescriptions may be filled by any private pharmacy participating in the program. Before special appliances may be issued to DPW clients, the pharmacist must request special authorization from the welfare offices. Only those appliances necessary to the client's rehabilitation are granted. The services of optometrists and opticians are limited to fitting and supplying eyeglasses. Dental services are also limited. "Transportation costs necessary to secure medical care" generally refers to ambulance services. With the exception of the services of registered and practical nurses in the home, benefits extended to clients of township trustees are similar to those listed above; however, each service, i. e., each office call, home call, pharmaceutical, etc., must be individually authorized by the offices of the trustee. Furthermore, the attending physician is not permitted to hospitalize the township trustee client unless a second so-called referral physician is consulted. This referral physician may be any licensed physician appointed by the trustee for this purpose. PROVIDERS OF SERVICES In accordance with a working agreement between the DPW and the Lake County Medical Society, all licensed physicians. may provide treatment to welfare clients and expect payment per the established fee schedule. The physician expresses his willingness to participate through a written agreement. This agreement is not subject to periodic renewal; rather its tenure is halted only by a written request for release from the program. Of 320 physicians actively practicing in Lake County, all but two have agreed to accept DPW clients as patients. No written agreement is required of purveyors of medical services wishing to participate in the township trustee programs, but the additional bookkeeping, authorization procedures, etc., required by these programs apparently prevents their achievement of the popular acceptance enjoyed by the DPW plan. However, an estimated 70% of Lake County physicians have at some time participated in the programs. Of primary importance to the smooth running of the DPW medical aid program is the reviewing committee of the medical society. This group is composed of eight physicians representing various sections of the county. The executive secretary of the medical society and the DPW director attend as technical advisors. It is their function to review all medical treatment, to check adherence to the fee schedule, and to amend and interpret that schedule to meet changing situations. This committee does not consider township trustee cases; instead, the trustee follows the course of medical treatment through the aforementioned authorization procedures and through bills submitted by the vendors of medical services. Here, again, referral physicians are consulted when questions of a technical nature arise. The five general hospitals providing services to Lake County DPW and township trustee clients are: Hospitalization of DPW clients for a period greater than 10 days requires special authorization by a member of the medical society's reviewing committee. All licensed nurses, dentists, osteopaths, ambulance concerns, pharmacists, optometrists, and opticians are eligible for participation in the DPW medical aid program provided they individually agree to accept the negotiated fee schedules. PAYMENT FOR SERVICES For physicians' services to DPW clients, the current fee schedule provides that reimbursement be made at the rate of $2.00 per office call, $3.00 for home calls during the day, and $4.00 for home calls during the night. For hospital calls on postoperative and fracture cases, the physician receives $1.00 per call; for calls on medical cases, $2.50 per call. The surgical and medical fee schedule covers 1,300 other procedures from allergy tests to roentgenograms. On completion of a course of therapy, the physician submits an itemized bill to the offices of the DPW. Except under special circumstances, the charges listed should be in compliance with the above-mentioned fee schedule. One copy of the bill is filed beneath the name of the client receiving treatment; here the DPW cross-checks against duplication of services. A second copy is forwarded to a physician member of the reviewing committee. The individual committeeman reviews all physicians' bills, considering the diagnosis, quality of treatment, and adherence to fee schedules. Questionable bills are set aside for presentation to the committee as a whole at their regular monthly meetings. Here final judgment is rendered. Payment is awarded or refused by the DPW in accordance with the decisions of the committee. Each of the five participating hospitals has its own individual fee schedule. Room rates range from $7.00 a day for ward accommodations to a maximum of $13.50 day for private rooms. A procedure similar to that described above is used for the reviewing and payment of hospital bills. Here, the reviewing committee is composed of the five hospital supervisors. The fee schedule for pharmaceuticals provides that the DPW be billed at the invoice cost of the drug, plus the cost of the container plus 50%, plus $3.00 per hour professional fee. Appliances are billed at cost plus 50%. The Lake County Pharmaceutical Society reviewing committee approves payment for the services of participating pharmacists. For benefits given DPW clients, other vendors of medical services are similarly reimbursed in accordance with their individual fee schedules. The township trustees follow these same fee schedules in paying for services rendered to general assistance clients. COSTS AND FINANCIAL SUPPORT The costs of medical care for old age assistance and aid to dependent children clients are shared by federal, state, and local governments; 85% of the funds are county and 15% are state and federal. Medical care for aid to the blind clients is supported entirely by state funds. The DPW hospital commitment program and medical assistance to wards of the juvenile courts are made possible exclusively through county funds. Table 2 presents the costs of medical assistance during January, 1952; the total monthly cost of medical assistance as administered by the DPW was $38,272.45. In accordance with totals brought forward from table 1, the cost of medical assistance per eligible DPW client was $5.03, and the cost per DPW patient treated, $20.88. 46293 0-54-pt. 310 The township trustee medical aid programs are supported entirely by township funds. With a total monthly cost of $32,535.12, the computed cost per person eligible under the trustee program is $18.83; the cost per patient treated is $55.14. A portion of this higher per patient cost is allegedly due to more prolonged rehabilitation follow-up on the part of the trustee. Should the cost of the trustee's medical assistance program exceed the yearly budgetary estimate, additional funds may be solicited from the County Council. The council is obliged by law to provide such funds; however, the funds available to DPW trustees for medical assistance are limited and the programs must be curtailed in the event of heavy medical case loads. This has never happened. TABLE 2.-Costs of Medical Assistance in Lake County, Indiana, During January, 1952 Physicians' Services $ 4,986.00 $ 7,949.00 $93.00 $250.00 $231.00 $ 5,206.75 Hospitalization..... 7,995.00 Administration and others....... 3,374.00 96.00 535.00 20,460.18 4,978.77 4,633.00 1,866.00 279.00 18.00 121.00 1,889.42 Totals.......... $20,282.00 $16,230.00 $552.00 $816.00 $392.00 $32,535.12 These are estimates derived by multiplying North Township cost statistics by 2.5. SUMMARY Programs administered by 12 separate and distinct agencies provide medical assistance for the indigent and medically indigent of Lake County, Indiana. Although all of these provide essentially the same medical benefits, the 11 programs administered by township trustees require authorization prior to the receipt of each individual medical service. These authorization procedures and the stipulations relevant to referral physicians have discouraged as wide a professional participation here as that enjoyed by the DPW program. All indigent groups are given free choice of physician and, as well, free choice among purveyors of other medical services. In general, services equal in scope and quality to those available to nonindigent residents of Lake County are provided for the indigent and medically indigent. All programs provide for medical supervision of all medical aspects. The DPW program establishes reviewing committees from within the organizations representing the vendors of medical services. These committees are responsible for overseeing the participation of members of their respective professional groups. |