organization are organized with lateral communications in such fields as purchasing, personnel, payroll, and planning. The new organization seems to have eliminated some of the difficulties of the previous arrangement in which there was a medical director and an administrative director jointly reporting to the board. Internal communication has been improved, and many of the internal operations have been streamlined and simplified.

Group Health faces the future with more assurance each year as we achieve greater stability and feel that there must be an end to the number of mistakes that can be made. From the actuarial point of view as well as the organizational, many of our basic problem are behind us, and we are in a far better position now to develop the type of medical program which has already been nearest to the heart of the idea of the Group Health program.

'Submitted by W. A. MacColl, M. D., executive director, Group Health Cooperative of Puget Sound.

HEALTH INSURANCE PLAN OF GREATER NEW YORK

1. Membership education.—Education of HIP members is conceived of as encompassing the areas of health information and knowledge of the physician at work, the nature of group medical practice on an insurance basis, understanding of administrative functioning, how to use services efficiently, and what to do to help the program improve.

All 30 medical groups sponsor quarterly bulletins which include materials concerned with the areas just mention.

Last year 10 medical groups held meetings with their own subscribers, some on a monthly basis. Members of the medical staff attend also. Here, as in the bulletins, information and discussion is concerned with all the same areas. Five of these medical groups are working with subscriber-physician committees― planning and conducting the educational program. Definitely scheduled for the coming season are an additional 10 medical group meeting programs and about 75 meetings are anticipated. There will be a marked increase in subscriber committees also.

Meetings with the medical staffs of three groups have been held to discuss patient relations. Work with the medical and administrative staffs of groups is intended to help realize the potential they have as educators of subscribers. Four boroughwide meetings have been arranged with the general physicians of all groups where membership education was discussed.

Educational columns are provided on a regular basis to about 10 contractorgroup news organs.

2. Growth.-HIP ended its sixth year of operation on March 1, 1953, with an enrollment of approximately 400,000, about 5 percent of the population of the city.

In addition to its enrollment of city employees and their families, HIP has contracts with 438 business and industrial firms, labor unions, and social welfare agencies.

The 30 medical groups now operating under the plan in various parts of the city and in Nassau County include about 1,000 physicians and specialists, about 6 percent of the practicing medical profession in this community.

Twenty-seven of the groups have their own group centers, many of which have been built within the last year, or have centers under construction. The remaining 3 groups of small enrollment size plan to acquire their centers within the next 6 months.

3. Utilization and research.-During the year more than 1,700,000 professional services were rendered by physicians of the 30 medical groups. These figures do not include the laboratory, X-ray, physical therapy, or nursing services.

The following observations were derived from the continuous reporting made by the 30 medical groups to the division of research and statistics of every contact of an insured person with an HIP physician: HIP enrollees average 5.3 physician services per year. About 48.1 percent of these professional services are rendered by family physicians and 51.9 percent by specialists. Of these services, 78.5 percent are rendered in medical group centers and doctors' offices, 11.2 percent are home visits, and 10.3 percent are professional services rendered to patients in hospitals.

For every 1,000 person-years of coverage, 16 major operations are reported, as are 21 minor operations in hospitals and 92 minor surgical procedures in medical centers, doctors' offices, and in patients' homes. For every 1,000 women of

childbearing age in the enrollment, 57 deliveries are attended annually by HIP obstetricians.

Each year since 1949 an increasing proportion of HIP enrollees have availed themselves of the services of their medical groups. Three-quarters of all covered persons now see their doctors at least once within a given year. Although this is a surprisingly large ratio, HIP hopes that this proportion can be brought up to 100 percent within the near future when everyone will report for annual health examinations, even though he feels no need for any other medical service. Newly enrolled employed groups are apt to make heavy demands for care of hitherto neglected conditions. A 19-percent sample of a recently enrolled laborunion group received services during its first year of enrollment at an annual rate of 7.5 per person. Its annual rate of minor operations was 187 per 1,000 persons covered. Its annual rate of radiological services came to one service for

each person enrolled.

In addition, the division of research and statistics is carrying forward a carefully planned research project intended to compare scientifically established samples of the HIP enrollment and of the general population in regard to their comparative sickness experience and medical care, with attention to such characteristics as age, sex, educational status, and family income.

4. Financial status.-At December 31, 1952, the admitted assets of HIP, as reported to the New York State Insurance Department amounted to $3,588,315, compared with $2,966,623 at the end of 1951. Surplus and legal reserves at the end of 1952 amounted to $2,405,858, of which $555,500 represented non-interestbearing loans. In 1952, 79 cents out of every premium dollar was used for medical services in the interest of our insured population. After a year's study of rising medical costs, the board of directors of HIP authorized an increase in the base premium rates, effective October 1, 1953, of about 20 percent. All of the increase goes to the medical groups. Out of the new capitation of $29.40, $1.20 is for the pension fund for doctors, and 54 cents is for the special-services fund.

5. Community relations.-The only opposition we are aware of is from organized medicine. Relations with all other elements and organizations in the community are good. During recent months we have noted a marked increase in the interest of numerous labor unions in HIP.

6. Plans for 1953-54.-In the coming year we expect to make more detailed studies of the medical groups with the aim of increasing service to them. Consultation is now offered in 11 areas. (1) Quality of medical care and service of physicians. (2) Professional and administrative organization and operation of medical groups. (3) Application and interpretation of standards, contracts, etc. (4) Medical center planning. (5) Nursing. (6) Health education and preventive medical programs. (7) Subscriber relations. (8) Community resources. (9) Business management and accounting. (10) Statistics. (11) Legal.

Most recent consultants added to the staff have been one in medical practice, to work with doctors individually, to evaluate and help improve practice and the relations between general practitioners and specialists, to visit offices, study records, and consult with the group medical directors; and a consultant on community resources, to help the medical groups to utilize available resources. Another consultant to be appointed soon, is one to study the quality of laboratory services, and to advise the groups in methods of improving these services. Presented by Irving Shapiro, HIP health educator.

HOSPITAL BENEFIT ASSOCIATION, PHOENIX, ARIZ.

During the past year, this organization has enjoyed a healthy membership growth, a sound financial position and the establishment of new, attractive home-office quarters in Phoenix, plus the enlarging of its Tucson branch office. 1. Membership growth.-Despite the fact that the Phoenix and Tucson areas, due to their marked increase in population growth, have become the proverbial hunting grounds for numerous out-of-State insurance companies in addition to the hospitalization plans already established in Arizona, Hospital Benefit Association membership increased 29.24 percent over the previous year. At the present time our membership roster totals over 35,000.

2. Membership education.-The most important factor in maintaining any increase of this kind is, of course, the retention of membership. We find that our HBA Bulletin has helped to a great extent in keeping our members well informed as to the need for adequate coverage, the value of their membership,

as well as keeping them abreast of current activities of the association and its plans for the future.

Published bimonthly, the bulletin includes such information as a report of the annual meeting of the association; information about its growth and financial position; articles on health care; questions and answers on coverage, benefits, how the plan operates, etc.; plans for moving into new quarters, resulting in increased efficiency and greater economy; items on the value of retention. how they can earn additional benefits; items about members receiving coverage in various parts of the world; letters from members expressing appreciation for the manner in which their claims were handled; information to returning veterans about reenrollment; various reminders about premium payments, vacation coverage, and many other valuable pieces of information.

3. Financial status.-At the annual meeting of the association, held May 13, the report showed that the assets of the association as of April 1953 totaled $235,380.46, representing a gain of 23.9 percent since the end of last year.

4. Utilization.-Statistical figures on utilization we believe are unimportant at this point. Our records show that during the past year, utilization, as compared to increased membership, has been normal. At the present time, we are sending out an average of 25 checks a day.

The point which we would like to stress here is the fact that the hospitals throughout the State, the country, in fact the world have been exceedingly cooperative in admitting HBA members without any unnecessary delay or redtape.

Since many of our members are located throughout the United States, Alaska, Hawaii, and other parts of the world, payment of claims in many of these places has become more or less commonplace, including Germany, Hong Kong, and more recently Peru. In every instance, however, the hospitals, no matter where located, have admitted HBA members requiring hospitalization by simply recognizing their membership cards.

5. Community relations. In addition to the bulletin, which in itself we have found to be an excellent means of maintaining good community relations-particularly among the thousands of members, their friends and neighbors-we also maintain an extensive advertising program which keeps the name of the association constantly in the minds of the public through the following media:

Newspaper: Display ads are run once each week in the Phoenix and Tucson daily newspapers.

Radio: 4 stations in the Phoenix area and 2 in Tucson run 5-minute programs Monday through Friday.

TV: An afternoon participating show which runs 3 days a week in Tucson, A full half-hour newsreel (world news) show has been contracted to run once a week in the Phoenix area.

Car cards: We are presently to have a 100-percent showing in all Tucson buses. These cards have a pocket containing a self-mailer “take one” inquiry card.

Arizona Medicine: A full-page message appears every other month in this magazine of the Arizona Medical Association. This not only gives us the opportunity to reach the medical profession throughout Arizona but many of the hospitals as well.

Special program for hospitals.-A half-hour transcribed radio program of Christmas music and commentary honoring the Arizona hospitals was presented over the Arizona Broadcasting System on Christmas Day last year.

The program A Christmas Salute to Your Hospitals traced the origin, growth, and development of today's modern hospitals and their highly complex services. Choirs from the University of Arizona and the Arizona State College participated in the musical portion of the program.

A broadcast was donated as a public service by this organization and presented under the supervision of the Arizona Hospital Association.

Submitted by George E. Richardson, director, Hospital Benefit Association.

The health program

LABOR HEALTH INSTITUTE, ST. LOUIS, MO.

A record number of individuals receiving a record number of health services are the events that highlight this report on LHI activities for the fiscal year July 1951-June 1952. Nine thousand different people took advantage of the facilities available to them as LHI members for a total of 103,000 visits. For the first time

since 1950, the majority of the patients treated were not new patients, but had received services from the institute in prior years. Thus, an effective preventivehealth program is coming into being. For as people get into the habit of seeing their doctors regularly, diseases will be found early when they are easiest to

cure.

Another byproduct of the high proportion of returned patients is the decrease in the average number of patient visits from 13 per patient in 1950 to 12 in the past fiscal year. As the backlog of neglected medical needs of the new patients is taken care of, the number of visits required to maintain their health need not be as great. This trend should continue into the future, assuming that the membership remains stabilized. Since 1951, the average LHI membership has remained at the 14,000 mark.

The "typical" 1951-52 LHI family consisted of 3 people with a weekly income of $51. Two of the family members had been down to the LHI before, one member was a patient new to the institute.

AS LHI members, this family's health bill came to $37 for the year. As non-LHI members their bill would have been $337. The family thus appears to have saved $300. But actually its savings were much greater. For it is reasonable to conclude that many of these visits would not have been made if the family had to pay for them out of its own income. Fifty-one dollars a weeks does not go very far when the essentials for life-food, clothing, and shelter-are so costly in this inflationary period. How then to price LHI's greatest saving to its members, the saving of their health that might otherwise be seriously damaged from the neglect that lack of money created. It can't be done. For health is a priceless commodity.

Because Labor Health Institute realizes that the health of its members is often dependent on the level of health in the community, it has taken an active part in the health and hospital division of the Social Planning Council of St. Louis. LHI also participated in the St. Louis hearings of the President's Commission on the Health Needs of the Nation.

LHI's service to its members and its contribution to the labor and group health movements is possible because of the existence of a negotiated clause in the contracts of nearly 200 local 688 shops which required a percentage of gross payroll to be paid to the Labor Health Institute for the medical care of their workers: 31⁄2 percent if only the worker is covered, 5 percent if the worker and his family are covered. By June of 1952, only 11 shops were left under the 31⁄2-percent p'an. All others had the 5-percent plan in effect.

This clause produced an income of $874,500, another recordmaking event in LHI's history, exceeding the previous fiscal year's income by 8 percent. Thus, LHI was able to afford what the individual worker could not, the health care he and his family needed.

The major part of the hospitalization costs incurred by the LHI members during the fiscal year were also paid by LHI. The average hospital bill of the 1,530 cases requiring hospital attention, either as inpatients or outpatients, came to $110. LHI paid 82 percent of this bill on the patient's behalf. It is interesting to note that the trend is toward greater use of LHI doctors for cases of hospitalization. Whereas in the 1950-51 fiscal year period 60 percent. of the inpatient cases were under the care of LHI doctors, in the last fiscal year, 72 percent of the inpatient cases were under the care of LHI doctors. There were about 25 percent more inpatient cases this year than last, with hospital days increasing in the same proportion from 9,300 of 2 years ago, to 11,550 of the past year. Average days per inpatient cases remained the same over the 2-year period-82 days per inpatient case.

The job ahead

1. Education.-Though we are proud of the fact that in this period 9,000 of our members, plus their families, benefited from the services of LHI, there is still the fact that 5,000 of our members did not use the LHI. Furthermore many that do participate do not use LHI most effectively. Broken appointments remained an administrative problem throughout the year. Some patients dropped in without an appointment for emergency care when according to medical standards an emergency did not exist. House calls were asked for in some cases where it would have been better for the patient to come down to the medical center or go directly to a hospital because of the better facilities existing there for treatment than existed in the patient's home. Some patients came in to see the doctor at the center when it really wasn't necessary, while some patients did not come in when the patient's symptoms would indicate

39087-54-pt. 6- -30

doctor care was needed. These problems of nonparticipation and of poor utilization were analyzed as problems of membership miseducation. Thus, an LHI membership education committee was set up to find some answers to these problems. Though in existence for just a few months, they have made some progress. An attractive, easy-to-read LHI membership information booklet has been prepared and will be distributed to all LIII members in the near future. A series of health posters is being prepared for monthly posting on shop-bulletin boards.

All union new member meetings now have an LHI person assigned to explain what are the benefits of LHI membership and to encourage these new members to come in for a complete physical checkup.

How to get greater participation at the annual meetings is being given serious consideration by the LHI membership education committee because of its interest in seeing that a basic principle of LHI, democratic control by the membership, is a living reality.

2. Blood bank.-Supplying the pints of blood needed by LHI members and their families during the course of illness was a problem that reached emergency proportions during the past year. A special blood-bank committee worked out a proposed plan consisting of the following basic principles: (1) Establishment of a unionwide donor-registration plan, to include eligible donors and eligible family members of the local. (2) Adoption of the principle of giving when needed by registered donors.

3. Hospital xrvice plan.-Before 1949, hospital insurance coverage was given to LHI members through the Blue Cross. After careful study, it was felt that our members would receive more extensive benefits under a plan of our own. With this thought in mind, the LHI Hospital Service Plan was brought into being on February 6, 1949. Now, 4 years later, the adequacy of the benefits provided by the LHI Hospital Service Plan is being questioned. For hospital charges have steadily mounted during the plan's existence while the schedule of benefits, drawn up in terms of 1949 hospital prices, has remained constant. Thus, the gap between the amount LHI pays to hospitals, on the patient's behalf, and the total hospital bill means, for the hospitalized patient, a deeper reach into his own pocket than has hitherto been necessary.

What can be done to lessen the amount the patient is paying is a problem currently confronting the Labor Health Institute. To help in its solution, a special extension of benefits study is in the process of being made. As soon as the results of the study have been analyzed by the LHI rules and regulations committee, recommendations will be forthcoming which should do much to answer this problem of the membership.

(NOTE.

were used.)

Benefits were increased; LHI's costs remain lower than if Blue Cross

4. Doctor negotiations.-The problem of doctor-fee determination confronted the LHI administration most of the year and is still not completely settled. The difficulty arises because of the lack of established precedent for this payment of part-time doctors connected with a prepayment medical care plan. An attempt has been made to tie in LHI doctor fees with going rates for doctors in private practice in St. Louis. The principle of seniority increment has also been introduced in order to discourage turnover among the medical center staff, and to show some form of appreciation for doctors' years of service to our membership.

It is our hope in the coming years to consolidate the gains pointed up in this report and to extend the services. We hope by a broad program in which the membership participate actively to learn how to obtain greater cooperation he tween the members and the medical center, hospitals, and auxiliary facilities. We hope by this type of health education program to more wisely utilize the services available, to teach our membership the symptoms of disease that they should be alerted to watch for, and finally, to render the best medical care program available anywhere. It is by mutual understanding and a spirit of cooperation that comprehensive medical care reaches its ultimate fruition within the framework of presently known medical knowledge.

Submitted by John O. McNeel, M. D., medical director of LHI.