Reprinted, with additions, from The Journal of the American Medical Association, January 2, 1954, Vol. 154, pp. 83-84 Copyright, 1953, by American Medical Association MEDICAL CARE FOR THE INDIGENT Part XI of a Study by the COUNCIL ON MEDICAL SERVICE Medical Care for the Indigent in Vanderburgh This is a study of medical services available to the indigent and medically indigent population of Vanderburgh County, Indiana. Of the county's 160,000 residents, 130,000 live in Evansville, an industrial center with manufacturing plants producing automobiles, refrigerators, construction machinery, and various steel, plastic, and tobacco products. ELIGIBLE POPULATION Table 1 shows the number of clients eligible and those actually receiving medical care during an average month under the general and public assistance programs. All those eligible for assistance under these programs are automatically eligible for medical care at public expense. ADMINISTRATION For years the medical care of the indigent and medically indigent of Vanderburgh County was provided on a charity basis by individual physicians. In 1947, a survey of public opinion indicated that (1) the people of the county did not know that physicians received no pay for these services and that (2) the public favored a program whereby a token payment would be made for these services. A program was subsequently devised based on a contract between the county medical society and the Department of Public Welfare and the township trustees. The society members agreed to provide medical care for all properly certified indigent and medically indigent patients in the three local hospitals in return for a monthly token payment to the society. Individual physicians may also treat public assistance clients outside the hospital, and such care, to properly certified patients, is reimbursed by the Department of Public Welfare. The attending physician determines what medical care will be provided to public assistance patients. The committee on indigent care of the medical society supervises the medical aspects of the program. This committee establishes fee sched ules and drug lists; it meets with the Department of Public Welfare monthly to review unusual or expensive cases and the methods of therapy used in such cases. Subcommittees of this group at each of the three hospitals attempt to keep hospital costs down and supervise care of the indigent in the hospital. The case workers of the welfare department certify those clients eligible under Indiana law to receive grants for old age assistance, blind assistance, and aid to dependent children. This department also administers the assistance grants for the Indiana child welfare and crippled children programs. The general assistance programs are administered at the township level by the township trustees, elected officials who are, according to Indiana law, "the overseers of the poor." The investigators of the trustees' offices certify eligibility of the clients. There are eight townships in the county; however, since Pigeon Township includes most of Evansville and provides almost all the township assistance in the county, it is the only one whose medical program will be discussed. The TABLE 1.-Average Number Eligible and Receiving Medical Assistance, March, 1952 (Estimated) Pigeon Township trustee engages one white and two Negro physicians to take care of home and office calls of general assistance clients; no payments are made to private physicians for general assistance cases treated outside the hospital. For hospital care, the township trustees have the same arrangement with the medical society as has the welfare department. SERVICES AVAILABLE In general, all clients of the welfare department are eligible for the same medical services. Freedom of choice of physician is provided for home and office care; hospitalized cases are under the care of the staff physicians at the hospital selected by the patient. Frequently the Department of Public Welfare learns the names of physicians on staff service at the selected hospital and sends the patient to one of these physicians for a "work-up" before hospital admittance. The attending physician may prescribe such drugs and special appliances as he feels are necessary; however, physicians are urged to use drugs on the approved list. If a drug not on this list is prescribed and exceeds by 10% or more the cost of the comparable drug on the list or is not comparable with any 46293 0-54-pt. 3-13 drug on the list, the prescription must be signed by two physicians. Prescriptions for cortisone and other expensive drugs must have the signatures of two physicians and must also be approved by the society's indigent medical care committee. Complete dental care is available for all public assistance clients, except that old age assistance clients are not provided with dentures. Eye treatment is provided for all welfare department clients. The aid to the blind program includes remedial measures; old age assistance clients may also receive eye treatment when medically necessary. Nursing services in the patient's home are provided by the Public Health Nurses Association. Nurses are paid according to a fee schedule for such services to old age assistance and aid to the blind patients; no charge is made for aid to dependent children patients. In emergencies, the Physicians and Nurses Exchange can approve medical care for public assistance clients, since the welfare department provides this organization with up-to-date lists of all welfare recipients. The public assistance patient has freedom of choice of pharmacies, but the pharmacy must be certain of authorization before it fills a prescription. In the hospitals, no distinction is made between assistance patients and other patients; however, assistance clients are hospitalized in the least expensive rooms that medical conditions permit. All hospital facilities may be utilized for the assistance patient, including x-ray, laboratory, physiotherapy, and, at Protestant Deaconess Hospital, radioisotopic services. No restrictions are placed on the use of these services; the attending physician is the judge of the program of therapy. St. Mary's Hospital maintains a prenatal clinic that serves the indigent and also provides some postnatal services. During 1952, the clinic gave care to 58 patients on 360 visits. Protestant Deaconess Hospital maintains a crippled children's clinic for the indigent, employing the services of an orthopedist, a pediatrician, and a nurse. In addition to the officially provided services, the hospitals also care for many patients who do not qualify under one of the assistance programs but who are unable to pay for all their medical care. Patients under general and public assistance programs are cared for in nursing homes, rather than hospitals, whenever possible. Both physicians and hospitals cooperate in transferring patients to these homes as soon as medically appropriate, in order to decrease the cost of the programs. General assistance clients receive approximately the same services as public assistance clients, except for physicians' home and office calls, which are provided by the three township physicians, without freedom of choice. PROVIDERS OF SERVICES There are 174 physicians active in the county medical society, all of whom may provide home and office care to welfare department clients. Ninety per cent of the physicians participate in the program to some extent, although much of the work for the indigent is done by a few men. Most of the doctors in the medical society are on the staff of at least one of the three hospitals in the county, and these staff physicians provide all in-hospital care for the indigent. Township assistance clients receive home and office care from the three contract doctors of the township. All three hospitals participate in the program. Welborn Memorial Baptist Hospital has 116 beds; St. Mary's, 178 beds; Protestant Deaconess, 245 beds. St. Mary's and Protestant Deaconess provide some specialized clinic services, but none of the hospitals maintains an outpatient department. Convalescent care is provided through 17 state-approved nursing homes in the area. The Public Health Nursing Association provides home nursing to old age assistance and aid to the blind patients at a reduced rate. All pharmacies in the area are eligible to fill assistance prescriptions. For the in-hospital care rendered by physicians, the Department of Public Welfare and six of the eight township trustees make monthly token payments to the Vanderburgh County Medical Society; the two townships that make no payment are too small and too poor to afford such payment. Table 2 shows the various monthly contributions; since Pigeon Township is the county's largest and contains most of the county indigent, it contributes more to the society than all the other townships together. Private physicians who provide medical care to certified public assistance patients on home or office calls are paid by the welfare department according to a fee schedule agreed upon by the society's committee on indigent medical care and the welfare department. In January, 1954, the welfare department will begin limiting calls, whether home or office, to three per month unless prior authorization is obtained. The township trustee engages the services of one white and two Negro physicians to provide home and office care for gen eral assistance clients. The white physician receives a salary of $225 per month, while the Negro physicians are paid $3.00 for each office call and $4.00 for a home call. Hospitals give no discounts for assistance patients but charge the Department of Public Welfare and the township trustees the full hospital rates for care rendered to indigent patients. Pharmacies also receive the full retail price for prescriptions; bills are presented monthly. COSTS AND FINANCIAL SUPPORT The expenditures of the Department of Public Welfare for the public assistance medical programs are given in table 3. TABLE 3.-Average Cost of Public Assistance Medical Care TABLE 4.-General Assistance Medical Costs Including Hospital Care, Pigeon Township, 1952 In addition to these expenditures, the department also supervises 72 children in foster homes; medical care for these children totaled $593.51 during the month of March, 1952. Pigeon Township provides approximately 80% of the general assistance care of the county; during 1952, 126 major operations and 38 minor ones were performed for indigent residents of the township under this program. The estimated value of medical services given by physicians to the indigent of all townships in the county during 1952 amounted to $45,000. The annual cost for medical care for assistance patients is shown in table 4. The costs of the public assistance program are met by the state, with matching federal grants up to a monthly maxi |