cost of physicians' services is a function of eligibility alone. Thus, these data may bespeak an abnormally high utilization.

The total cost of drugs and appliances as presented here includes both that fraction paid directly by the DPW and that fraction paid to pharmacists by way of increasing the monthly stipends to individual welfare clients. An estimated 30% of the $707.21 was paid through stipendiary advances.

Approximately 10% of the total cost for hospitalization was met by old age assistance, aid to the blind, and aid to the permanently and totally disabled clients without welfare assistance from either state or county. Thus, the total cost of the medical assistance program as given in table 3 is some $650 in excess of the actual cost to the welfare department.

The financial responsibility involved in the provision of physicians' services to the indigent and medically indigent in Montana

TABLE 3.—Total Costs and Costs per Person Eligible for Medical Assistance During July, 1952

* This figure represents the costs of convalescent home care, which were in excess of subsistence stipends.

has been delegated by the state legislature to the individual counties. In Cascade County, the costs of hospitalization must also be met principally through local funds, since public assistance stipendiary grants alone approximate the maximums imposed by the federal and state legislatures. Therefore, excepting some small amount of matching of the costs of pharmaceuticals, the Cascade County medical assistance program is supported entirely by local funds.

The legislature of the State of Montana allows county commissioners to assess a maximum property tax of 10 mills for the support of the entire welfare program. Should this maximum tax be imposed and the monies so obtained be exhausted before the end of the fiscal year, the state will grant to the commissioners those funds that may be necessary to continue the program. Should a tax less than the maximum be imposed, supplementary state funds are provided as a loan. In Cascade County, the current welfare tax is 9.6 mills.

SUMMARY

The several agencies and individuals most intimately concerned with medical care benefits are bound by written contract to their various roles in the Cascade County medical assistance program. The program is centered about three such contracts, viz., a contract between the Cascade County Commissioners and the county medical society, a contract between the medical society and the Montana Physicians' Service, and a contract between the society and the individual physician.

In compliance with the terms of the current medical societycounty commissioner contract, the society receives prepayment in the amount of $2.00 per eligible person in return for the provision of physicians' services to all certified welfare clientele. The statistical facilities of the Montana Physicians' Service are utilized by the medical society for the administration of this contract. Within the society, committees are set up for regulation of the program's activities. The major portion of those monies awarded to the society under the contract are prorated among participating physicians.

All certified welfare clients are equally eligible for benefits provided by the program. In that both free choice of physician and free choice among all local vendors of medical services is offered, the welfare client is extended medical care which is not only quantitatively but also qualitatively equal to that available to the private patient.

The authorization procedures required by the program might appear cumbersome for the physician as well as the welfare client. In truth, regulations have been made very elastic. The physician's application for authorization to continue therapy beyond a single home or office call involves merely phoning the local M. P. S. office. The M. P. S. later contacts a member of the claims committee. Then, unless the attending physician is informed to the contrary within some 48 hours, he simply assumes that authorization has been granted.

The statutes of the Montana state legislature have notably affected both the operation and the economy of Cascade County's medical assistance program. One of the primary objectives of prepayment programs founded in other parts of the country has been the achievement of greater federal and state matching as effected through distribution of the costs of medical assistance among all those eligible, such that federally imposed maximum grants were not exceeded. However, the law of the State of Montana specifies that the costs of maintaining a "county physician" must be met entirely by county funds. In Cascade County, the medical society acts as county physician; thus, this edict precludes any state or federal matching in its payment.

Furthermore, state ordinances complicate the picture as concerns payment for pharmaceuticals. Prior to the 1949 amend

ment of the Social Security Act, the administrative problem involved in the payment of all assistance monies to individual clients was by no means peculiar to the state of Montana. But, with the endorsement of direct payment to vendors of services, this source of complexity has been eliminated in many states.

Notwithstanding these legal limitations, the Cascade County Department of Public Welfare, the medical society, the M. P. S., and other local providers of medical services have cooperated in both the creation and the effectual implementation of a medical aid program of which any community might well be proud. The unfaltering interest apparent among those persons even remotely connected with the program, now in operation over three years, supports the contention that the citizens of Cascade County will through the years continue to provide to their indigent the very highest quality of medical care.

Reprinted, with additions, from The Journal of the American Medical Association, January 24, 1953, Vol. 151, pp. 320-323

Copyright, 1953, by American Medical Association

Part VIII of a Study
by the

COUNCIL ON MEDICAL SERVICE

Medical Care of the Indigent in Polk County, Iowa

This study considers the medical care available for indigent and medically indigent residents in Polk County, Iowa. The county has approximately 226,000 residents, of whom 178,000, or 79%, live in Des Moines, the state capital. It is both an agricultural and an industrial area, with the growing importance of industry indicated by a 30% population increase in the last 10 years.

TABLE 1.-Persons Eligible for Aid Under General and
Public Assistance Programs

In 1951, approximately 5,732 residents of Polk County, or 2.5% of the county's population, were eligible for aid under general and public assistance programs. The number eligible for aid from each program are shown in table 1.

The total number of individuals eligible for aid to dependent children was not available, and, at the time the survey was made, Polk County had no aid to the permanently and totally disabled program.

General assistance clients must be legal residents of the county. Reciprocal agreements have been made with other counties, however, to provide aid for nonresidents who cannot safely be moved to their home counties for treatment. The public assistance programs do not require legal residence in the county for medical care.

ADMINISTRATION

Both general and public assistance medical care are administered on a county-wide basis. Home care and hospitalization, however, are administered by two different agencies. The Polk

County Welfare Department, which is in charge of all assistance programs, certifies the client's eligibility for welfare aid on an individual casework basis. Those certified are automatically eligible for physician's care in the home or office, which is provided through the welfare department. Every patient who uses the Broadlawns Polk County Hospital or its clinics as a public assistance patient must be certified as eligible by the hospital, even if he has already been certified for welfare aid by the welfare department.

The outpatient department of the hospital is responsible for its social service and records. Medical social service workers interview the patients, determine their eligibility for free care, and arrange the transfer to private hospitals of patients who are ineligible. The department also makes arrangements for nursing home care or such follow-up treatment for discharged patients as the physician advises. Nonresident and transient patients are also interviewed by this department and directed to the proper agencies from which to obtain aid.

The hospital is governed by the Broadlawns Board of Hospital Trustees, an elective body that serves without compensation. The board determines the appropriations needed to maintain hospital services and is responsible for the administration of welfare hospitalization and clinic care. Medical counsel for the board is provided by an advisory committee of the Polk County Medical Society, composed of nonstaff physicians, and by the executive committee of the attending medical staff. This executive committee, composed of the chiefs of the various departments, makes all professional and medical decisions concerning hospital policy, subject to board approval.

Some informal coordination of home care and hospitalization programs is provided by the Council of Social Agencies, through its Social Service Exchange, to which authorizing agencies report all assistance clients. In this way, each welfare agency can determine the total aid given any individual.

The Polk County Medical Society takes an active part in the welfare program. The society's consultant committee meets once a month to review bills for physicians' services to welfare patients. The committee determines whether charges conform to the established fee schedule and whether the services rendered are in accordance with program regulations. The county welfare director and the committee act together to control abuses of assistance programs by physicians and by the public. The society. also makes every effort to assist those patients who are not eligible for care at Broadlawns Hospital.

Dissatisfied patients may appeal to the state administrative boards, and old age assistance clients may, in addition, appeal to the courts. The medical society's grievance committee reviews complaints against participating physicians or, if necessary, can refer complaints to the grievance committee of the Iowa State Medical Society.