raising the level of medical care and providing complete service The purpose of the reorganization was to create an office that could coordinate Erie County's various medical activities, avoid duplication and overlapping of services and provide professional guidance to the total medical care program. This is done by the medical director and his staff. He is the liaison officer between the department and all agencies or agents providing medical care. He attends meetings of the medical society, the board of social welfare, the board of managers or laboratory, and the Meyer Hospital's board of managers. The seven part-time physicians working under the medical director are given the title "medical investigators." These men act as medical advisors to the social work staff and interview all clients with medical problems. In addition, they call at the various hospitals to review the medical histories and charts of hospitalized clients and thus prepare themselves to discuss the cases with the social work staff. The success of the Erie County plan is due in no small degree to the capable administrator who is now Erie County medical director. MEDICAL SOCIETY RELATIONSHIP The medical society of the county of Erie plays an important though unofficial part in the indigent medical care program. The medical director is a member of the medical economics committee of the society, and the society has a spokesman, who is a physician, on the Erie County board of social welfare to represent the medical viewpoint. The society works closely with the medical division not only in urging physicians to participate but in formulating medical policies and in developing rules, procedures, and the fee schedule; for example, by agreement between the Erie County welfare department and the Erie County medical society, all medical service by physicians in hospitals is rendered without charge. This agreement is based on the fact that the University of Buffalo has a medical school that uses the various hospitals as teaching units and, therefore, needs staff cases for teaching purposes. Another interesting example is the limitation of free choice of physician agreed to by the medical society and the social welfare department. Free choice is restricted only to the extent that (1) if the medical division questions the adequacy of care by the individual physician, the division may direct the client to go to a hospital clinic for complete medical examination, and (2) patients in hospitals are to be cared for without pay or are placed under the care of the physician or surgeon on service at the time. Every member of the medical society is provided with an outline showing clearly how he can participate and the services that are available to him and to the welfare patient. These outlines of procedure and policy have the approval of the medical society and simplify physician cooperation. SUMMARY Medical care for welfare recipients in Erie County is provided through a well-coordinated and complete service program. While it depends to some degree on the liberality of New York State laws for its organization, its successful operation is the result of a close and continued cooperation between all of the agencies and groups involved. Administration is entirely local and provides for adequate medical supervision and direction. The Erie County department of social welfare administers all health care services as a unified program. All persons who qualify as welfare recipients are permitted the same services and the same facilities. Overlapping services and duplication of effort, two bugaboos of good administration, are practically nonexistent. Certification is handled by qualified case workers, each of whom has responsibility for all welfare recipients in a given area. Since all recipients may have the same privileges, there is no scrambling from one group to another in order to obtain special medical services. Further, a relief client has potentially available to him every medical service that can be provided in the county of Erie. The medical division of the department of social welfare occupies a unique position in medical care administration. In reviewing and approving all bills for medical service, it serves as a protection against abuses by either physicians or recipients. Its authority to decide what, if any, special services a person needs makes it possible for every case to be considered on an individual basis. Direction of the division by a physician and an adequate staff of physicians assures the program of medical supervision and of the professional viewpoint so necessary to sound planning and administration. The attitude of the medical society toward the county welfare program and the relationship between the society and the medical division assures the recipients of high quality medical care. The interests of those who are ill, of the general public, and of the physicians whose services are used in the program are all considered in relation to each other so that each gains as a result. Control measures are necessary to prevent abuse of the program and are accepted in a spirit of cooperation and good will. One goal of this comprehensive program is rehabilitation, and any service will be authorized that the medical division believes will aid in returning the client to a normal life, whether it be as a worker or as a housewife. It is obvious that one-time costs that will return a man to work are much more economical than longterm care. While this is not a new concept, it is usually found on paper and rarely, as here, in operation. The Erie County indigent medical care plan accomplishes the primary objective of any such plan. It makes available to the indigent sick all of the medical, hospital, and related services available to other citizens of the community and does this with a minimum of disturbance in the normal physician-patient relationship. Further, it has succeeded in partially compensating private physicians on a fee basis and in utilizing all available facilities, private and public, at a minimum of cost to the taxpayer. 46293 0-54-pt. 3- 8 Reprinted, with additions, from The Journal of the American Medical Association, July 26, 1952, Vol. 149, pp. 1247-1249 Copyright, 1952, by American Medical Association Part II of a Study by the COUNCIL ON MEDICAL SERVICE Indigent Medical Care in This report is a study of medical care available for indigent and medically indigent residents of the city of Madison in Dane County, Wisconsin. Dane County has a population of approximately 165,000 and is primarily a farming and dairying county, with some small industries. Including the 14,000 students at the University of Wisconsin, 100,000 persons, 61% of the county's population, reside in Madison, the state capitol and county seat and the main business center of the county. Public assistance is provided on a county-wide basis, but each of Dane County's 60 political subdivisions is responsible for general assistance to its own indigent residents. For this reason, a study of welfare medical care in Madison is considered more practical than a survey of the entire county's programs. ELIGIBLE POPULATION Residents of Madison are eligible for general assistance medical care when admitted to the welfare department's relief rolls or deemed medically indigent by the department. An average of 230 residents received such aid monthly in 1951. An estimated 3,651 persons in Dane County received aid monthly from public assistance programs in 1951. In table 1 are given figures on the various types of assistance, with the proportion of the population aided by each program assumed as the same in city and county. According to the estimate in table 1, approximately 2,457 Madison residents per month, about 2.5% of the city's popula tion, received general or public assistance and were therefore eligible for medical care at public expense in 1951. ADMINISTRATION The general assistance program is administered in Madison by the city welfare department, which determines eligibility of both indigent and medically indigent clients. Each client's eligibility is certified monthly. The welfare department is also in charge of planning and authorization of benefits, subject to the approval of the city council, to which the department makes monthly and annual reports. Any appeals by clients are made to Madison's director of welfare. The public assistance program for all of Dane County is supervised by the Dane County pension department. Eligibility for aid to the blind and aid to the permanently and totally disabled is determined by the state department of public welfare. The county agency determines eligibility for old age assistance and aid to dependent children and is responsible for the planning, authorization, and approval of bills for all public assistance programs. Certification of clients lasts at least a year before a recheck is necessary. The county pension department reports to the county board of supervisors and to the state department of public welfare. Clients may appeal county decisions to the state authorities, who must, by law, provide a "fair hearing." Both programs provide for control of abuses by patients; for example, a patient who changes physicians too frequently can be required to choose a single physician to treat him for the duration of his illness. TABLE 1.-Estimated Average Monthly Coverage, 60 37* Old Age Assistance... Aid to the Blind.... Aid to Dependent Children.... Aid to Permanently and Totally Disabled.... Estimate, based on percentage of county's population resident in Madison. Complaints against physicians are referred to the Dane County Medical Society. The society's medical coordinator reviews complaints concerning fees or refusal to accept welfare cases and can, if necessary, refer the complaint to the society's board of censors for further consideration as to disciplinary action. SERVICES AVAILABLE Benefits provided by the general and public assistance programs are sufficiently alike to be discussed jointly in this report. All health services are potentially available to anyone on any of the programs and are generally provided on a "free choice" basis. Each person is treated according to his needs, and the extent and course of treatment is usually decided on by the client's physician. Home and office calls are provided by physicians on a free choice basis. Specialists' care, in or out of the hospital, is provided on referral by the attending physician. The patient may be referred to a specialist or to a group clinic of his choice. |