this in spite of relatively little advance publicity. Mail and phone calls overwhelmed us. EMIC was not really in full swing for months to come, but anxious fathers and mothers were always with us. Because we had no additional staff at this time, clients often received little help and still they came. And what stories they told us-they were completely lost as to where to go, what to do. Many mothers had not been far from home before, mothers with hardly enough to keep themselves, and certainly no resources for paying or even planning for the coming baby. Many a serviceman came home for a brief furlough and spent hours coming to our office and getting the care for the baby arranged.

All groups in the community helped-the Red Cross, the Maternity Center Association, Army and Navy relief groups, our visiting nurse services, doctors and hospitals-and somehow we got the needs taken care of. But basic to all of this help on the part of community agencies was the fact that the doctor bills and the hospital bills could be paid. Soon after Korea calls began to come to the office again, and it was the old familiar story. Wives of servicemen who could no longer afford to pay for maternity care needed help.

The second point I would like to speak of is the case of administration. There were many administrative problems, of course, and we believe most of them could have been avoided had there been staff, experience, and some time to get the machinery set up before the program began. One of the best features of the old EMIC in my opinion was the fact that service was given without upsetting the usual pattern of medical and hospital care which operated in our community. Doctors, clinics, and hospitals gave service to EMIC patients as they were accustomed to serve any patient. There was completely free choice of physician; 81 percent of our maternity patients received care from private physicians.

Senator LEHMAN. May I interrupt you? I am glad to hear you say, because it coincides with statements that have been made to me, that "doctors, clinics, and hospitals gave service to EMIC patients as they were accustomed to serve any patient," and that there was completely free choice of physician, with 81 percent of maternity patients receiving care from a private physician. I am emphasizing that because so far as I can see from study of the bill there is no variation from that proposed in this legislation.

Dr. BAUMGARTNER. No, as I interpret the bill, there is not.

That in my opinion was one of the very good features of the old EMIC-that the usual pattern of community service was not upset. Senator LEHMAN. I think it is one of the good features of the bill. There will be no dislocation as far as I can see.

Dr. BAUMGARTNER. We did a special study of New York City cases closed in 1945 and 1946, when the program was really in full swing, and at that time it was estimated that 25 percent of the physicians in private practice in the city were caring for EMIC patients. It might be pointed out that there are specialists in many fields of medicine so that one could not expect that all physicians would be caring for maternity cases. But 25 percent of all physicians did care for EMIC patients. Of the some 3,500 doctors, 76 percent were in general practice, 12 percent were qualified obstetrical specialists, and another 12 percent were physicians who were specialists qualified in some other branch of medicine.

Further data concerning the medical care given maternity patients are found in another scientific report, copies of which I am also happy to leave with the committee.

(The document is as follows:)

MEDICAL CARE OF MATERNITY PATIENTS UNDER THE EMERGENCY MATERNITY AND INFANT CARE PROGRAM IN NEW YORK CITY1

(Vivian Pessin, Helen M. Wallace, M. D., F. A. P. H. A., and Leona Baumgartner, M. D., F. A. P. H. A.,2 New York City Department of Health)

It is difficult to analyze the patterns of medical care of patients or certain types of patients in a community, because the necessary data are usually lacking. For example, what proportion of maternity care in a community is given by obstetricians, by physicians in general practice, and by other physicians, or what proportion of maternity patients are seen by a consultant, is commonly not known. It is likewise not usually possible to ascertain on a community-wide basis whether patients with serious complications actually receive the benefit of skilled consultation service when necessary. With the advent of the Emergency Maternity and Infant Care Program (EMIC) it has been possible to study certain patterns of medical practice rendered to maternity patients who were eligible for care under the program. This program, which was in operation in New York City from July 1, 1943, until July 1, 1949, paid for medical, hospital, nursing, and other types of care for pregnant wives and infants of men in the four lowest pay grades of the Armed Forces.

This paper analyzes certain factors in relation to the use of the medical resources in the community. Another communication deals with the costs."

It is recognized that analysis of a wartime program may lead to conclusions that may be invalid under other conditions. Nevertheless, studies of the EMIC Program are significant, for this program allowed for the fullest use of all the community's resources, in accord with existing patterns of practice. No new resources were developed, no new physicians hired or recruited to do the job. Because no critical shortage of either physicians or hospital beds developed in New York City, the maternity practice was probably relatively little changed during the years this study covers, except as the hospital stay of maternity patients was shortened from prewar times.

METHOD OF CHOICE OF PHYSICIAN

Any physician licensed to practise medicine in New York State was eligible to care for EMIC maternity patients. The selection of the physician or of clinic care was made by the maternity patient herself. Thus, there was free choice of physician by the patient, with one limitation: The physician had the privilege of accepting or refusing to care for a maternity patient under the program. The fact that the fee paid for the care of the maternity patient was less than that received by most physicians in New York City probably influenced this free choice, for some physicians undoubtedly referred EMIC patients elsewhere for care. Figures are not available to indicate what the average medical fee for maternity care was in New York City, but certainly the obstetric specialist averaged considerably more than the $50 or $75 allowed under EMIC for the private patients he usually cared for. The splendid cooperative spirit of the physicians in general led them to receive EMIC patients by the hundreds and to accept the relatively small payment with only an occasional protest.

The decision regarding the use and choice of a consultant for an individual maternity patient was made by the attending physician caring for the patient. It was widely publicized to the medical profession that consultation service by a qualified consultant was paid for by the program, and such consultation service

1 American Academy of Pediatrics. Child Health Services and Pediatric Education. New York: The Commonwealth Fund, 1949.

* Credit is also due Frieda Greenstein and Molly Park for their assistance in compiling the data, and to the EMIC office staff, especially Ann Eisenstadt and Beatrice F. Mandell, without whose devoted services these studies could not have been maintained.

* Pessin, V., Baumgartner, L., and Wallace, H. Distribution of Costs under the Emergency Maternity and Infant Care Program with Special Reference to Costs of Maternity Care in New York City. A. J. P. H. 41, 4: 410-416 (Apr.) 1951.

Neither midwives nor osteopaths were included. The former were excluded by the State plan which allowed only licensed physicians to be paid. No case requesting payment to an osteopath came to our attention.

was urged by the administrative agency, the New York City Department of Health, for maternity patients with incipient or serious obstetric or medical complications. Indications for consultation were drawn up and approved by the EMIC Obstetric Advisory Committee to the Commissioner of Health. The criteria of a qualified obstetrician were likewise drawn up and approved by this committee and were as follows:

1. Physicians who were diplomates of the American Board of Obstetrics and Gynecology.

2. Physicians who presented evidence that their training and experience were the equivalent of training and experience required for admission to the examination of such specialty board, as determined by the EMIC Obstetric Advisory Committee to the Commissioner of Health.

Similar definitions of a qualified consultant were applied in the various other medical specialties.

The consultant called was usually one of the attending physician's choice, although a list of qualified consultants was available in the EMIC office and was used on request from either physician or patient.

METHOD AND TYPE OF PAYMENT TO THE PHYSICIAN

The inclusive rate method of payment was used. Thus, a physician in general practice was paid a flat fee of $50 for complete maternity care, including at least five antepartum visits, care during labor, delivery, and postpartum period, and also including final postpartum examination at approximately the sixth week after delivery. A qualified obstetrician was paid a 50 percent higher fee ($75) after December 15, 1944. Physicians who were qualified in specialties other than obstetrics received the same fee as a physician in general practice when they gave maternity care to EMIC patients.

Qualified consultants in the various medical specialties, when called in by an attending physician, were paid by either one of two methods, depending on the type of care rendered: (1) A flat fee for certain types of services, i. e., Caesarean section, including preoperative and postoperative care, or (2) on a per visit basis where the consultant was called merely to see a patient. Since the total cost of the consultation service was borne by the EMIC program, cost should not have been a factor in the attending physician's use of a consultant, and the decision to call in a consultant should have been based only upon the need of the individual patient. The use of a qualified consultant was no financial deterrent to the attending physician, since the attending physician received the total fee for maternity care, even though the consultant may have performed the actual delivery. Thus, there was every advantage and no disadvantage in the use of a qualified consultant when indicated.

The EMIC program paid for the total medical care of the patient including concurrent illnesses during pregnancy. Thus, it was not legally possible for the physician to charge, nor the patient to pay, any additional amount for medical care when a physician agreed to accept a maternity patient under the program.

SAMPLE STUDIED

In the first year and a half of operation in New York City, the program was organized, most of the policies developed, and more than 12,000 maternity cases were closed, i. e., care was completed and paid for. During the next 2 years 1945 and 1946, the program was in full swing, and the bulk of the cases, 31,378, were cared for. By the end of 1946, the number of cases was declining, and in 1947 only 6,925 cases were closed. The years 1945 and 1946 were therefore chosen for study because they were considered typical of the program and because they provided a sufficient number of cases for adequate study. Payment was made after the postpartum examination and the cases studied were closed approximately 2 months after delivery. It follows that the bulk of the cases analyzed in this report were delivered from approximately November 1, 1944, through October 31, 1946.

Of the 31.378 maternity cases closed in 1945 and 1946, 19 percent sought and received care as clinic and ward patients. Another 6 percent had an attending physician, but did not receive complete care. The remaining 75 percent were attended by private physicians and received complete care; the latter group, consisting of 23,388 patients, composes the series studied in this paper. They

The 23,388 cases studied consist of 22,948 who had hospital and medical care and whose costs were analyzed in another paper; and an additional 440 whose hospitalization was not paid for by EMIC or who were not hospitalized.

constitute approximately 8 percent of all infants delivered in the city during that period. There were only 12 maternal deaths among these 23,388 patients.

NUMBER OF PARTICIPATING PHYSICIANS

There were 3,476 practising physicians who gave care to the 23,388 maternity patients in New York City during the 2-year period studied. This figure, which is exclusive of physicians who cared for patients on hospital general services, represents about 25 percent of the physicians in private practice in New York City at the time of study. Of the 3,476 physicians, 76 percent were in general practice, 12 percent were qualified obstetricians, and 12 percent were physicians who were qualified specialists in other branches of medicine; all other specialties are represented (as attending physicians caring for maternity patients) except plastic surgery (Table 1).

TABLE 1.-Emergency maternity and infant-care program; maternity cases attended by private physicians and given complete care; cases closed in 1945 and 1946-New York Ctiy

DOCTORS; NUMBER AND PERCENTAGES; DOCTOR-CASES; NUMBER AND AVERAGE PER DOCTOR, AS ATTENDING DOCTOR OR CONSULTANT; BY TYPE OF PRACTICE OF DOCTOR

A doctor-case is one doctor on one case. For example, when a case was seen by three doctors, it is counted as three doctor-cases. For this reason, the sum of doctor-cases is usually greater than the total number of cases.

These 75 doctor-cases tabulated as general practitioners acting as consultants consist of cases in which the status of the doctor changed, and cases where general practitioners acted for qualified consultants, gave anesthesia, assisted at delivery, etc.

Less than 0.05.

There were 402 qualified obstetricians who participated in the care of this group of patients; the number of qualified obstetricians known to be actively engaged in practice at this time was 550. Thus, almost three-fourths of the obstetric profession participated in the program during this 2-year period. Obstetricians participated as attending physicians, on the average, in about four-fifths of their cases, and as consultants in the remainder.

There were 6,323 patients attended by obstetricians, and an additional 1,537 who were seen by consultant obstetricians. In other words, of the 23,388 maternity patients in the series, 34 percent were seen by at least one obstetrician, including 27 percent who were attended by obstetricians. About twothirds of the cases with obstetricians were cared for by physicians who were diplomates of the American Board of Obstetrics and Gynecology.

There were 13.323 such physicians between June 1946, and July 1947. according to Child Health Services in New York State, by George M. Wheatley. M. D., Director of the New York Study for the American Academy of Pediatrics, February 1949.

NUMBER OF CASES PER DOCTOR

Since some patients were seen by more than one physician, a doctor-case unit was used in some of the tabulation. A doctor-case is defined to be one doctor on one case, so that a patient with three physicians was tabulated as three doctor-cases. Using this unit, there were 25,978 doctor-cases, or 7.5 cases per physician over the 2-year period. Although most patients were seen by general practitioners, the average number of patients per physician was by far the greatest for obstetricians (20.0).

Most physicians saw fewer than 10 cases each. On the other hand, 14 physicians saw 100 or more patients. Thirteen of these physicians were qualified obstetricians according to EMIC standards; the fourteenth limited his practice to obstetrics and gynecology, but was not a fully qualified specialist according to the EMIC definition.

While most of the physicians cared for fewer than 10 cases each, most of the women were seen by physicians who took substantial numbers of EMIC cases. As would be expected, the figures varied with the type of practice of the physician. In general, an obstetrician cared for more patients than a general practitioner, who in turn saw more patients than other types of physicians.

NUMBER OF PHYSICIANS PER CASE

There was little or no tendency for the patients to change their physicians after the original selection; fewer than 1 percent had more than one attending physician. It is noteworthy that more than 99 percent of the patients remained with the attending physician whom they had originally selected, although, under the program there would have been no financial problem in changing physicians (table 2).

TABLE 2.—Emergency maternity and infant-care program; maternity cases attended by private physicians and given complete care; cases closed in 1945 and 1946-New York City

NUMBER OF CASES BY NUMBER OF ATTENDING AND CONSULTANT DOCTORS PER CASE

Ninety percent of the cases were seen by only one physician. On the other hand, there were 5 cases with 5 physicians each. The reason for the large number of physicians in these 5 cases, as illustrated below, was the need for different types of consultants because of complications. In all 5 cases, mother and child survived.

No. 32974-This patient was under the care of a general practitioner and 14 antepartum visits were made. Patient first presented herself for antepartum care at about the fifth month of pregnancy, with clinical evidence of hypertension, massive albuminuria, severe edema of lower extremities, history of rheumatic cardiac disease, and the presence of a compensated valvular lesion. Patient was hospitalized in eighth month, for treatment of these complications. Patient was seen on several occasions by an obstetric consultant for treatment of her toxemia; was seen by a hematologist for blood studies (sugar, urea nitrogen, NPN, total protein, albumin and globulin); was seen by an ophthalmologist because of headaches and papilledema; also seen by an internist because of her cardiac condition. Patient was treated conservatively, and delivered a living child. Both mother and baby survived.