Consumer-sponsored plans are organized and directed by subscribers. They resemble somewhat industrial plans organized and financed by employees.

Government plans have been established by a Federal, county, or city goversmental unit for its employees. Membership in organizations of this type a usually compulsory.

NURSES IN PREPAYMENT PLANS

In 1945, nearly half of the 229 organizations furnishing information reported that they employed registered professional nurses as full-time members of their staff. The total number of nurses employed by these 109 organizations was 2,092. A comparison with similar data received in 1943 (table 1) shows la' there has been little change in either the number of nurses employed or in their distribution by type of organization. In each year from 65 to 70 percent were employed by industrial organizations, approximately 15 percent were associated with private group clinics; consumer-sponsored plans and Government plats sponsored by the War Food Administration employed from 5 to 10 percent each while 2 percent or less were associated with medical society plans.

The majority of nurses employed by prepayment medical care organizations either perform duties corresponding to those of nurses employed by physics in private practice or are associated with hospitals owned or controlled by the organization. A smaller number serve as visiting nurses.

A striking difference among plans appears in the extent to which nurses are members of the staff. Almost all private group clinics and industrial financed entirely by the employer have staff nurses. Medical society plans, which in most instances provide medical services through physicians in individual præ-tice, reported very few nurses on their staffs in 1945. The outstanding exception is in California where the medical society plan furnishes care for residen's of war-housing projects and provides the services of general practitioners and nurses though clinics established in the projects.

TABLE 1.-Number of prepayment medical care organizations employing nurses. number of nurses associated with each type of organization, 1945 and 19431

[Data furnished by 229 organizations in 1945 and by 214 organizations in 1943]

1 Data for 1945 relates to January-May; that for 1943 is largely for the spring of that year.

Other..

105

TABLE 2.-Number of persons eligible for care under prepayment medical care organizations and number of nurses associated with such organizations, by census region 1945 and 19431

[Data furnished by 229 organizations in 1945 and by 214 organizations in 1943]

1 Data for 1945 relates to January-May; that for 1943 is largely for the spring of that year.

The 177 nurses employed by Government organizations were associated with plans sponsored by the War Food Administration for seasonal farm workers recruited, transported, or placed by that agency. This figure represents the average number of nurses employed during a year, for the number varies greatly with the seasons. An annual average of 97,300 persons are eligible for medical care through these organizations. Services are provided at Government expense and all members are entitled to the services of visiting nurses. Nurses associated with these War Food Administration-sponsored organizations covering 6 areas of the country perform such duties as giving health education, organizing health clubs, making periodic sanitary inspections, holding nursing conferences, advising on nutrition, assisting at clinics held by physicians, arranging for hospitalizations when necessary, making contacts with physicians, maintaining clinics, and acting as a liaison with the local health departments and local voluntary agencies. Many of the persons eligible for services call on the nurses for treatment of minor ailments which do not need to be brought to the attention of the physician; in 1943, on the average, two visits to nurses for services of this type were made for each clinic visit to physicians.

Number of persons eligible for services and nursing staff.-Approximately 5,000,000 people were eligible for medical care in the 229 organizations furnishing information in 1945, an increase of more than 1,500,000 over the number eligible for services through the 214 organizations reporting in 1943. During the interval between the two studies several new medical society plans were organized; the number providing information increased from 35 in 1943 to 53 in 1945, and the increase in membership in plans of this type was almost 1,500,000. Changes since 1943 in membership in other types of organizations are relatively insignificant when compared to this increase.

Since medical society plans rarely employ nurses, their increase in membership and the present nursing shortage probably account for the fact that nursing staffs have not grown in proportion to membership. Persons eligible for care in industrial plans decreased by 13,000 and the number of their staff nurses decreased by 152. Private group clinics increased their membehship by 16.000 and the number of staff nurses by 52. Consumer-sponsored plans, excluding those financed partly by the Department of Agriculture, more than doubled their membership but employed only 19 more nurses than in 1943. Governmental plans sponsored by the War Food Administration averaged 97 300 members, a decrease of 138,000 persons, but they increased their nursing staff by 69 nurses.

Regional distribution.-A comparison of the number and percent of nurses employed throughout the various sections of the United States shows that there

has been practically no change during the past 2 years (table 2). In 1945, as in 1943, 50 percent of the nurses employed by prepayment medical care organizations were associated with plans in the Pacific coast region; 12 percent were employed by organizations in the east north central States; other regions en ployed less than 9 percent each, while the New England States reported only 3

nurses.

The region in which the largest number of nurses were employed (the Pacifie also had the largest membership in prepayment medical care organizations. It this region the ratio of nurses to persons eligible for medical care was 1 to 1,700 The east north central States, with the second largest membership as well as the second largest number of nurses, had a ratio of only 1 nurse to every 430 persons eligible for medical care. In most regions the ratio averaged 1 nurse to 2,000 persons.

PERSONS ELIGIBLE FOR NURSING SERVICES

In 1945 about 2,200,000 persons, or 44 percent of the 5,000 000 eligible for medical care, were entitled to receive either special duty nursing or services of visiting nurses or both-an increase of 500,000 over the number eligible for the services in 1943. Approximately 1,100,000 or 50 percent of the persons eligib'e 'o receive these services in 1945 were associated with industrial organizations: more than 800,000, or 37 percent, were eligible through medical society plans in Washington and Oregon; 7 percent through private group clinics; 5 percent through Government plans sponsored by the War Food Administration; and percent through consumer-sponsored plans.

A comparison of data furnished in 1945 and 1943 shows that the percentage of persons eligible for special duty nursing or services of visiting nurses or both varied to some extent when considered by type of plan (table 3). The noticeable increase was in medical society plans in Washington and Oregon where 85 percent of all persons eligible for care could receive one or both of these services in 1945 as compared with 75 percent in 1943. A decline occurred for Government plans except for War Food Administration sponsored (which in 1913 agreed to provide nursing service to 16 percent of those eligible for medical care) due to the fact that in 1943 the largest number eligible for nursing service were in organizations operating in the national park areas. These plans have been discontinued temporarily because of the war. Industrial plans financed by employees provided special duty nursing or services of visiting nurses or both to 77 percent of their subscribers and dependents in 1945 and increased the number eligible for services from 516,000 in 1943 to 577,000 in 1945.

Special duty nursing.-In 1945 and in 1943 more than one-third of all persons eligible for medical care were entitled to receive special duty nursing. Whe medical society plans in Washington and Oregon agreed to provide such services to 85 percent of their membership, those plans in other States furnished nei ber special nor visiting nurse's care. Industrial plans financed by employees included special duty nursing among the services available to 73 percent of those eligible for medical care; jointly financed plans made such services available to 45 percent of their membership, and employer-financed plans to 28 percent. In private group clinics, 40 percent of the membership was eligible for this service Governmental plans reported no special duty nursing. The largest increase in proportion of membership eligible for special duty nursing services was in the medical society plans in Washington and Oregon; such services were available for 75 percent of the membership in 1943 and for 85 percent in 1945. The greatest decrease was in the jointly financed industrial plans; the proportion of men bers eligible for special duty nursing services dropped from 68 percent in 186 to 45 percent in 1945.

TABLE 3.-Number of persons eligible for medical care and percent eligible for special duty and visiting nurse service in prepayment medical care organizations, by type of organization, 1945 and 19431

[Data furnished by 229 organizations in 1945 and by 214 organizations in 1943]

I Data for 1945 relates to January-May; that for 1943 is largely for the spring of that year.

Although some organizations provide special duty nursing in the home, in most cases this care is given only in the hospital. Contracts usually set no special limit to the length of time such services can be furnished. Recommendations of the physician are, of course, a standard requirement for furnishing this form of service.

Services of visiting nurses.-The major change in the proportion of members eligible for one or both types of nursing service occurred in the group eligible to receive the services of a visiting nurse. In 1945, 557,000 or 11 percent of the persons eligible for medical care in prepayment organizations, were entitled to receive services by visiting nurses; in 1943, 619,000 persons or 18 percent of those eligible for medical care were entitled to this service. With the exception of consumer-sponsored plans, which made this service available to 10 percent of their membership, and medical society plans in Washington and Oregon where 4 percent may receive the service, all persons eligible for this type of care were associated with either industrial or government-sponsored plans. The War Food Administration in both 1943 and 1945 included care by visiting nurses among the services available to all those eligible for medical service through its plan. Several industrial plans furnishing this care in 1943 reported that in 1945 the service had been temporarily discontinued.

VOLUME OF NURSING SERVICES AND COSTS

In a few instances, organizations which gave information on nursing services also reported on the volume of care provided. One organization with 85,000 subscribers in 1945 reported that 24-hour special duty nursing was provided up to a maximum of 30 days in any one case. This service was paid for at the pre

vailing rate of a dollar an hour. For the fiscal year ended June 30, 1944, the cust of providing this service averaged a little more than 1 percent of the organization's expenses. The annual cost of the service amounted to $22,389 or approximately 26 cents per subscriber per year.

Another organization gave the following figures on costs of special duty nursing:

A third organization with approximately 48,000 subscribers reported an aut expenditure of $7,344 for special duty nursing, or an average cost of 16 ceris per subscriber per year.

In 1943, one organization serving 8,000 persons, both subscribers and dep-t-lents, employed two full-time visiting nurses. During that year these res made about 3,200 visits to the homes of subscribers, an average of 40 visits per year per 100 persons eligible for care. In a second plan with about 14,270 b scribers, an average of 44 visits per year per 100 subscribers were made. In ti a plan the average cost per visit was $1.23.

A third organization, with approximately 10,000 subscribers, reported a yearly cost of $5,000 for services of visiting nurses or about 50 cents per person elgti for care. Approximately 40 visits per 100 persons eligible for care were d over a year at an average cost of $1.45 per visit. These visits were made to ap proximately one-third of the members eligible for this service. In addition to the visits reported above, members also received a total of 2,254 visits from te metropolitan visiting nurses association in the city where the plan operates Through both organizations, a total of 6,335 visits were made, or an average of 63 visits per 100 persons eligible for care.

In the fourth organization, services of visiting nurses were available to 15 proximately 9,000 employees in a war industry as part of a medical-care prostan financed entirely by the employers. During 1944, the company paid $400K 17 salaries to the three regularly employed visiting nurses; other costs incurre! providing the services were not reported. During the year, visits averaged ab 63 per 100 persons eligible for care.

Since each organization providing information on costs of nursing serv`<« used its own accounting method, there is little if any comparability among in ganizations, though it is clear that nursing services can be provided at reasın Ye cost. The directors of plans that give nursing services are enthusiastic about the benefits derived by the patients and the organizations. When the nursing sh age is relieved many organizations will doubtless increase their nursing s Other organizations which have not employed nurses in the past have ip Bened their intention to do so when nurses are available. Salaries have inpad greatly during the war years; the beginning salary in one organization for esample has risen from $1,200 to $2.000. A few organizations providing ir format ce on salaries paid in 1945 indicated a range from an entrance salary of $1,800 to a high of $2,500-$3,000 a year.

[Reprinted from the American Journal of Nursing, vol. 42, No. 7, July 1942) REGISTERED NURSES IN THE UNITED STATES OF AMERICA

By Pearl McIver, R. N., Senior Public Health Nursing Consultant,

States Relations Division, United States Public Health Service

The 1940 Census of the United States reported 369.287 trained nurses in the United States. However, that figure includes students who were in training at the time the census was taken as well as those nurses who may have bad training as nurses but who are not registered. Therefore, it is to be expected