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mental disease, tuberculosis, guarantinable diseases, venereal diseases, alcoholism, drug addiction, self-inflicted injuries, and congenital defects. Now, with few exceptions, plans have abandoned one or more of these restrictions. Most plans will not provide care for the sole purpose of obtaining a diagnosis, and all deny service for cases in which care is available through workmen's compensation or governmental facilities.
When a subscriber changes his job, he may continue his membership by making payment direct to the plan at a slight increase in rate, or he may transfer to an existing Blue Cross group at his new place of employment with no lapse of coverage. If the subscriber moves to another community he may enroll in the Blue Cross plan there without a waiting period. He may continue his membership after retirement and after he reaches the age of 65, although he cannot enroll after the age of 65, except in large Blue Cross groups where the age limit is waived.
In Blue Shield medical-society plans the amount of protection depends on family income. There is usually no income limit for enrollment purposes, but if the income exceeds a specified amount, the benefits are applied as a credit to the total charges made by the physician. The usual annual income limits are $2,500 for a single subscriber and $4,000 for a family. Participating physicians agree not to charge patients whose income is below these amounts a fee higher than that specified in the contract.
Most Blue Shield medical-society plans exclude plastic or cosmetic surgery for a condition existing at the time of enrollment; alcoholic or drug addiction; congenital anomalies; drugs, appliances, and eyeglasses; functional disorders of the mind or nervous system; rest cures; preexisting conditions during the first 11 months of enrollment, unless waived in the group contract because of a large percentage enrollment.
A recent study indicates that slightly more than a fourth of the civilian noninstitutional population aged 65 and over had some hospitalization insurance in March 1952. Proportionately more men than women had insurance. Proportionately the white population had nearly three times as many with insurance as the nonwhite. Insurance held by those 65 and over was heavily concentrated in the age group 65-69 and was most common among urban residents and persons in the labor force especially in nonagricultural employment."
Major or excess medical expense contracts. This type of insurance, usually referred to as "catastrophic," was first offered for sale about 2 years ago by a few of the insurance companies. Such policies would be of more benefit to patients with cancer and other long-term cases than the older type contracts of Blue Cross and Blue Shield and insurance-company group coverage.
This type of insurance is designed to meet the costs that normally exceed the protection of the usual group-insurance plan. It is anticipated that the usual group hospital and medical-care plans will pay the deductible amount, or the employee can pay that amount without undue financial strain.
The insurance company pays 75 percent of the medical expense for any one illness, in excess of the deductible amount, up to the maximum stated in the policy, usually $2,000 to $5,000. Each new illness or injury is entitled to its own maximum. Medical expense is defined as any expense incurred by the insured for the diagnosis, treatment, or care of a nonoccupational, accidental bodily injury, or disease. This includes physicians', surgeons', and nurses' fees, hospital and clinic charges, X-ray examinations and treatments, laboratory tests, anesthesia, drugs and medicines, and all other therapeutic services and supplies.
The coverage under this type of insurance is very broad. Only accidents and illnesses covered by workmen's-compensation insurance are excluded. Preexisting conditions are covered, provided the employee is at work when the policy is written. Even psychiatric treatment is covered, and also dentistry, if directed by the insured's physician.
This type of insurance is usually written for employees with annual earnings of $5,000 or more. At the end of 1952 about 700,000 persons were protected by insurance of this type.
An example of this type of insurance is the General Motors' plan for salaried employees earning $5,000 or more a year and for their dependents. After deduction of the amounts paid or the services provided under its basic Blue Cross-Blue
5 Falk, I. S., and Brewster, Agnes W., Hospital Insurance for the Aged, Social Security Bulletin, November 1952.
Editorial staff of Prentice Hall, Inc.: Successful Employee Benefit Plans. New York, Prentice Hall, Inc., 1952, pp. 63–66.
Shield hospital and surgical expense program, an additional amount is deducted from the total expenses depending upon the income of the employee-$100 for employees with salaries up to $12,000 a year, with a graded additional deductible amount up to $300 for those earning more. After the deductions are made, the supplementary plan pays 80 percent of the remaining expenses up to $10,000 incurred during a single medical expense period by an employee and up to $5,000 incurred for a dependent.'
The interest of organized medicine in obtaining more protection for cancer patients through voluntary health insurance was indicated recently. Dr. Louis H. Bauer, president of the American Medical Association, issued a year-end statement setting forth the association's 1953 program which included as one of the association's 9 objectives for 1953 the extension of voluntary health insurance not only to cover more people but also to embrace those over 65 years of age and those suffering from illness of long duration.
The CHAIRMAN. I realize it is not an easy figure to advance. We are seeking all of the information that it would be possible for you to give us on that question of cost.
In concluding my questioning I was impressed with the statement that was made by Dr. Farber in which he said that there were maybe 2,000 in this Nation who were capable of making an accurate biopsy.
Two thousand is a large number from some standpoints, but as you look at this Nation as a whole and its great expanse, 2,000 in that particular classification does not seem to me to be a very great number to meet the problem that we have facing us in cancer.
Dr. FARBER. May I answer that point? I am very glad that you give me another opportunity to continue the remarks that I should have continued a while ago. I cannot give you the exact number of pathologists. I can give you the exact numbers certified by the American Board of Pathology as having had sufficient training, who passed the examinations, the number given to me who are permitted to call themselves certified pathologists. No matter how large the number is, it is certainly far from enough to meet the needs of the surgeons of the country who require the help of the pathologists at the time of an operation. May I make that point?
The CHAIRMAN. Yes; I am glad you emphasize that. That is what struck me, and that was the purpose in asking the question, so that you could emphasize the point you have just made.
Are there any further questions?
The CHAIRMAN. Mr. Williams.
Mr. WILLIAMS. To what extent is the X-ray used as a means of detecting cancer, or are there practical means of detecting cancer through X-rays, blood tests, and other similar tests which could be carried out on a universal basis?
Dr. CAMERON. There are cancers which occur in various parts of the body, some of which are not exhibited by this type of procedure, but the presence of cancer in many sites can be determined with high accuracy by X-ray examination.
In the case of malignant tumors of the bone this is a relatively simple procedure, because the bone density differs from the surrounding tissues. However, when you are trying to determine the presence of a tumor arising in the stomach, in which the density of the tumor does not differ from the density of the surrounding structures, it is necessary to apply different techniques. In brief, diagnosis of
Major Medical Expense Plans Are Adopted by Three Large Firms-Employee Benefit Plan Review, fall, 1952. 8 New York Times, January 2, 1953.
stomach cancer requires us to exercise knowledge of the digestive system. As another example by injecting air into certain potential spaces in the brain it is possible to identify with reasonable accuracy certain tumors of the brain and spinal cord.
I cannot give you a figure on it without some further study, but I would say that X-rays are certainly one of the most valuable means we have in arriving at a diagnosis of cancer.
Dr. Farber has pointed out that final diagnosis is determined by a laboratory study, by a biopsy.
Mr. WILLIAMS. Chest X-rays have been made over a period of the last 5 or 6 years by these mobile units which go around to different parts of the country. When this drive was put on I believe that was a tuberculosis drive, if I am not mistaken, but I was wondering if cancer has been detected in cases like that to any extent.
Dr. CAMERON. Yes; in this procedure you certainly discover cancers of the lung, which certainly cannot be found by any other screening device. In the studies which have been made the tuberculosis patients have been generally younger. The age group that we are concerned with in cancer patients is somewhat older. I think the tuberculosis people would agree with that statement. We feel, for instance, that X-rays of the chest in men over the age of 45 will result in earlier diagnosis of lung cancer, and that is very important.
Mr. WILLIAMS. That might be an opportunity for the Government to assist in cancer detection through these mobile units. Do you think such a program would be worthwhile?
Dr. CAMERON. I think that as a program of mass screening, the X-raying of large numbers of men for cancer of the lung is entirely feasible, and I feel that it is necessary if we are to achieve any substantial measure of control over this form of the disease.
Mr. WILLIAMS. Would not the same thing be true of blood tests? Dr. CAMERON. No; there are no practical blood tests for cancer. There is helpful information which can be obtained from blood tests and from other body secretions in specific forms of cancer, but they are not applicable as screening methods.
For example, a particular substance which works in the blood, known as acid phosphatase, is found in the blood in increased quantities in patients with cancer of the prostate. This is one of a series of diagnostic procedures employed in the absence of more definitive information, and I think cannot be considered a blood test.
Mr. WILLIAMS. At the moment, cancer control, as I understand it, depends primarily on early detection; does it not?
Dr. CAMERON. At the present moment?
Mr. WILLIAMS. Yes.
Dr. CAMERON. I think that is fair; yes, sir.
Mr. WILLIAMS. Do you know anything that the Government might be able to do to assist in bringing about earlier detection of these cases throughout the country, any kind of a program that might be instituted along those lines?
Dr. CAMERSON. Yes, I do; and I think it is being done.
Now, the degree to which it is being done is, perhaps, something which would involve us here for a long time. My feeling is that the mechanism for discovering the kind of effective case-finding activities which you point out that are so badly needed exist now. I think that there is opportunity for very fertile discussion as to the extent
to which they can be augmented and made to turn at a faster rate. If you were asking for my thought I would say again that I would like to consider that further and I would like to talk with our colleagues about it because it is obviously an enormously important direction to take.
The CHAIRMAN. Having in mind what Mr. Williams has just brought out, and your answer that early detection is very helpful in the treatment of the disease, would not a system of clinics of a large character be helpful in getting those results?
Dr. CAMERON. That has been considered, and I mentioned the fact that there are about 240 detection centers in the country.
The CHAIRMAN. That does not seem many to me for 48 States.
Dr. CAMERON. No; but you see what they have done. I ask you to turn to a chart which will summarize our experience in there. It is chart No. 16.
We have studied the results of the examinations for cancer in about 90 of these detection centers, and we found that the rate of cancer was about 8 per 1,000 patients examined. They are presumably well people. You see that in the younger people very little cancer was found. The rate is of practical interest in people from 50 to 59, and over the age of 60 the number of cases found is of real interest in regard to control measures. It suggests, among other things, that we might concentrate the search for cancer in those age groups in which it is profitable to look for it.
The CHAIRMAN. I had particularly in mind, Doctor, general clinics. Would not they be helpful in the case of cancer as well as heart and all of the other diseases that mankind experiences? I have in mind, even in these X-ray-detection centers that you speak of, that very frequently they examine a man maybe for cancer, and it may not be detected, but maybe some other deficiency may be found. That would be a helpful thing which would be taken advantage of as a Government program.
Dr. CAMERON. In this series of examinations 65 percent of the patients were found to have had noncancerous disease or other abnormality.
It depends on the degree of thoroughness of the examination. It has been said that a normal patient is one who has been incompletely studied, so I think that if you want to intensify the examination and extend its coverage you can turn up a great deal of abnormal findings, which would tend, in the aggregate, to prolong life.
The CHAIRMAN. We are all aware of these drives that are put on for the purpose of detection, for instance, of tuberculosis, heart disease, and what not. They are directed to that particular one phase that that particular organization is interested in. I have in mind what could be obtained from a general inquiry that would examine for all purposes, and in that connection I was very much inmpressed with the explanation that was made of the so-called Kaiser system in California. I do not know too much about it, and we will know before the hearing is over, I hope, but the thing that impressed me about what was being done was this general examination by which those who were members of the organization were put through general tests and any of these deficiencies that existed were expected to be brought to light. It may have been cancer, it may have been heart disease, it may have been tuberculosis, or it may have been any one of these many
diseases, but the study of the individual was made along all lines, and not just one line. I am wondering whether there is not something that might be done by a Government agency, either Federal, State, or local, that would bring about this general examination and that would make it possible for people to be advised early of the conditions that exist and thereby get a better opportunity of cure of the disease.
Dr. CAMERON. I think it is important to bring out here, Mr. Chairman, that most of these examinations which have been done in the name of cancer case finding are general and complete physical examinations. That is why they have been able to turn up these other things, but I think this must be recognized, that the idea of a routine physical examination has been advocated for many years by responsible medical organizations, and by insurance groups, and the medical association went on record as favoring this type of medical practice. There was a program instituted some years ago to give this type of examination to the policyholders of the insurance companies, but when the examination in the name of health maintenance, general health maintenance, was offered it really did not take hold.
When this examination was offered in the name of finding a way conceivably of being delivered from an alarming, fearsome disease people had stimulation, and it was cancer which made the physical examination idea take hold. Of course, it is not really universal, but it is practiced today much more widely than it ever has been. Í think that the complete physical examination leaves much to be desired. Unfortunately I do not know the answer. I think it is examination; we are preparing to continue these general physical surveys in the name of cancer case finding.
There is one more point, and that is that doctors recognize their individual responsibilities now in this kind of medicine, and there has been a generally spreading sentiment on the part of the profession to incorporate this kind of prophylactic medicine within the framework of office practice. So I could not be sure to what extent a system of clinics is necessary.
The CHAIRMAN. I have in mind that when it comes to a physical examination, complete in character, it is just outside of possibility that a family can pay for a father and mother and four or five children, on the basis of the charges that are made at the present time. Of course, that in itself is a deterrent.
On the other hand, when you do it from a public standpoint it unfortunately is too true that the individual does not see the importance of it and is not willing to take advantage of it.
However, I am pursuing all lines of thought with respect to these matters and the emphasis that you have placed on early detection was what brought this to my mind to ask the questions.
Mr. CARLYLE. Mr. Chairman?
The CHAIRMAN. Mr. Carlyle.
Mr. CARLYLE. Dr. Cameron, I note on chart 17 the location of cancer clinics throughout the country. What particular service is rendered by these clinics?
Dr. CAMERON. The cancer clinics are usually operated within a hospital. They form part of the physical structure of the outpatient departments in such hospitals. These clinics are staffed by representatives of the various medical specialties serving that hospital. Characteristically they consist of the pathologist who has been mentioned