Reprinted, with additions, from The Journal of the American Medical Association, May 10, 1952, Vol. 149, pp. 189-191 Copyright, 1952, by American Medical Association Part I of a Study by the COUNCIL ON MEDICAL SERVICE Indigent Medical Care in Erie This report will consider Erie County, New York, as the study unit. The population of Erie County is approximately 800,000, of which 575,000 persons are in the city of Buffalo. Erie County is chiefly an industrial area, with both light and heavy industry well represented. Farming is also a source of wealth for the county but comparatively few of the county's population are thus employed. ELIGIBLE POPULATION Approximately 16,770 persons in Erie County, or about 2% of the population, receive aid during the average month under one or more of the public assistance or general assistance programs. The number of persons in each program is as follows: General assistance and medically indigent..... ........ 5,300 Public assistance All of the above groups are eligible for the same medical care benefits. Certification as to eligibility for medical care is handled by the department of social welfare, with each case investigated to determine the program for which the person qualifies. Each case worker is assigned to a given geographical area and serves all programs. Once eligibility for care under one of the programs is determined, it is maintained as part of a continuing process under regular case worker supervision. ADMINISTRATION The board of supervisors of Erie County, an elected body, appoints a board of social welfare. This board, in turn, appoints a commissioner of welfare to head the department of social welfare, the agency responsible at the county level for all persons receiving aid under any program. This department determines eligibility and does the planning for all clients, subject to approval by the state department of social welfare. Within the county society welfare department is a medical division headed by a full-time physician and employing seven part-time physicians. It is the function of this division to check all bills and to review the diagnoses and therapy connected with the bills. The medical division also reviews each special procedure to ascertain its advisability. In addition to the review of bills and treatment, provision is made for remedying any abuses that may be found. In case of abuse, the physician or client is notified, depending on which of the two is at fault, and the matter is usually settled within the medical division. If a client is not satisfied with the decision, he has a right to appeal to the state board of welfare for a "fair hearing," as provided under federal law. The physician, in turn, may appeal to the medical director or to the county medical society. The department of social welfare also has a hospital division, which investigates and arranges hospitalization for nonrelief (medically indigent) cases, as well as a dental division, responsible for arranging for dental care. Hospitalization of active relief cases is under the direction of the individual relief units. SERVICES AVAILABLE All health services are potentially available to anyone on any of the programs. Each person is treated according to his needs, whether his is an aid to the blind case or a medical relief case. Furthermore, there is no time lag between the request and receipt of most services. Home and office calls by physicians are on a free choice basis; however, even though office calls are allowed, clients are urged to use the clinic services whenever possible. In emergencies a client calls a physician and identifies himself as an aid case. The physician is free to accept or refuse the case. If the client has difficulty in getting a physician or if he knows of no physician to call, he may contact his case worker, who will provide a list of four or five physicians. Although the county maintains its own hospital, all clients have a free choice of hospital and may have their own physician attend them during their hospital stay. The need for hospitalization in emergencies is determined by the attending physician, and the patient may go to the hospital immediately. In cases that do not constitute emergencies, application is made through the medical division. Outpatient care is available in the nine general hospital clinics to persons on any program. These clinics are partially supported by the county board of supervisors; therefore, when clients use them, the costs are not charged to the social welfare department's budget. Physiotherapy is available at any time in the outpatient clinics and with special permission may be obtained in a private physician's office. Nursing care in the home is available for all clients through the Visiting Nurses Association but must be authorized by the medical division. Drugs requiring prescriptions may be obtained at the pharmacy of choice, provided they do not exceed $5.00; if they cost over $5.00 the physician writing the prescription must receive prior authorization from the social welfare department. In emergencies, physicians are expected to provide such medicines as are necessary from their medicine bags. Diagnostic laboratory services are available in the Erie County Laboratory and may be used by any physician. The laboratory is located in the E. J. Meyer Memorial Hospital and does the clinical and pathological studies for the hospital. Convalescent care is provided in private nursing homes and in the County convalescent home. Eyeglasses are provided on prescription of a specialist. Special appliances are also supplied when prescribed by a physician and approved by the medical division. Ambulance service is maintained and provided by the various hospitals as a part of their regular services. Clients are entitled to a choice of dentists, or they may go to dental units in the outpatient departments of the hospitals. An official health education program is operated by the health department of Erie, and both preventive medicine and health education are emphasized by the case workers. Prior authorization, which means being enrolled on an aid program, is necessary for the benefits described. If a person who is not on one of the programs needs a physician and is given service, the physician must collect from the patient or assume the loss. There is no provision for reimbursing the physician who cares for a private patient who is unable to pay, even though that patient may be a relief client the next day. In other words, neither certification nor payment can be made retroactive. Special Program.-Erie County has a special county home and infirmary care program for individuals, except persons with mental disease, who need medical care and supervision on a long-term basis. It is available to persons on assistance programs as well as to those who do not qualify for a government program and yet are definitely in need of care. The home has a census of approximately 900 persons, with a special building set aside for persons under 50 years of age to aid them psychologically in their rehabilitation. The program is administered by the department of social welfare, and its costs are charged against the budget of the department. Financial status as well as need for care determines eligibility. This program costs Erie County approximately $75 a month for both medical and supervisory care, or $44 per month for supervisory care alone. PROVIDERS OF SERVICE All licensed physicians in the county are eligible to participate in the welfare program. No written agreement is necessary. The physician treats the welfare patient as he does a private patient. Approximately 600 of the 1,400 physicians in Erie County submit bills regularly; however, more than 600 participate, since prescriptions written by other physicians are presented for payment even though they do not submit a personal bill for services rendered. The nine general hospitals provide both hospitalization and outpatient clinic services to the welfare clients. The number of beds in each of these hospitals is given in the following tabulation. The E. J. Meyer Memorial (County)........ Deaconess Lafayette General Mercy Millard Fillmore St. Francis Our Lady of Victory. 858 722 277 63 325 473 53 229 448 Buffalo General The Buffalo General Hospital has a large pediatrics clinic, and the health department operates well-baby, prenatal, chest, venereal disease, and orthopedic clinics. All health department clinics are staffed by physicians on an hourly basis. Clients of all programs are eligible to attend any of these clinics. Fortyfive nursing homes participate in providing convalescent care. Patients may have their own physicians in these homes, but not if they go to the county convalescent home. PAYMENT FOR SERVICES Physicians are paid directly by the local department of social welfare at the rate of $2.00 for an office call and $3.00 per home call. There is also a general fee schedule agreed to by the department of social welfare and the Erie County Medical Society. The schedule covers obstetrics, minor surgery, x-ray, and fractures and dislocations. The fees are approximately 50% of the Workmen's Compensation Fee Schedule. A specialist on consultation in cases "not amenable to treatment by a general practitioner" receives $4.00 per office or home visit. He must be referred to the case by the attending physician or by the physicians in the medical division of the department of social welfare. Such referrals are usually made only in areas where clinics are not easily accessible. A flat rate of $11.75 per day is paid to the hospitals. This is an all-inclusive rate paid to all hospitals handling public assistance cases and comes from state and county funds. In the general assistance cases, the county alone pays for services. If a patient who is not on an assistance program is admitted to a hospital, the hospital social workers make a financial investigation. The person is asked to pay $2.50, $5.00, $7.50, or $11.75 (full rate), or may be declared eligible for free service as a staff case, depending on the result of this investigation. Public funds are not available for in-hospital medical and surgical care; therefore, physicians are not paid for staff cases and may not be paid for the part-pay cases mentioned above in any of the nine general hospitals. Nursing service provided by the Visiting Nurses Association is paid for at the rate of $2.15 per visit. Nursing homes are paid at the rate of $110 per month if they provide more than custodial care, while $90 a month is paid to those which provide only supervision. A person must have a medical recommendation to qualify for convalescent home care. COSTS AND FINANCIAL SUPPORT The medical services of Erie County indigent cases are financed by tax funds from federal, state, and county governments. The funds provided have generally been sufficient to carry out the program in its entirety. The total cost for medical Medical-Hospital Care, Erie County, April, 1951 This is the program for the indigent and medically indigent and also includes county infirmary cases described under Special Programs. care for all programs for an average month (April, 1951) was $168,072. The costs by program are shown in the table. The cost figures given in the table should be considered as samples or estimates, since the number of persons on the rolls of each program changes constantly. It is evident, however, that the cost of hospital services is considerably greater than the cost of physician services. Much of this cost difference is undoubtedly due to the fact that physicians are not paid for in-hospital medical care. Appropriations are made annually and are based on the previous year's experience. Since the funds for indigent medical care come within a departmental budget, an emergency grant may be procured should the appropriation prove inadequate. THE MEDICAL DIRECTOR OF ERIE COUNTY After World War II, the large population increase in townships adjacent to Buffalo brought about new problems in the welfare field. The Erie County board of supervisors saw that |