If, at the end of each fiscal year, the reserve fund is not exhausted, this money is prorated to physicians as based on the total units credited each of them during that year. In 1951, this additional payment was at the rate of $.20 per unit.

The rationale behind this rather involved method of payment is its provision for an equitable distribution of available funds in spite of fluctuating demands for medical assistance. With the value of the unit totalling $.75 in 1951 ($.55 plus $.20), physicians were paid for services to welfare clients at approximately 75% of private rates.

Regardless of the accommodations used, the Deaconess and Columbus hospitals are remunerated at the minimum bed rate, currently $9.00 per patient day, for ward care provided assistance clients. The payment for other hospital services, including use of x-rays, physiotherapy, laboratory services, etc., is assessed at full private patient rates. Old age assistance, aid to the blind, and aid to the permanently and totally disabled clients are not automatically eligible for hospitalization at public expense. Rather, they are reinvestigated at the time of commitment and are required to exhaust all available cash on hand before the Department of Public Welfare will subsidize any portion of their hospitalization.

In spite of the provision in the 1949 amendment to the Social Security Act for direct payment to vendors of medical services, the laws of the State of Montana still require that in order to achieve federal and state matching, the monies paid for pharmaceuticals must pass through the hands of the individual welfare client. Thus, the monthly stipends of Cascade County's public assistance clients may be increased by a maximum of $5.00 for this purpose. If this stipendiary increase is insufficient to cover the cost of all necessary pharmaceuticals, the balance is paid directly by the DPW. Each case must be handled individually; the welfare board disbursing order stipulates what portion of each bill must be paid by the client and what portion will be underwritten by the DPW. Pharmacists are paid for welfare prescriptions at their standard retail prices.

COSTS AND FINANCIAL SUPPORT

In table 3 are given the costs of medical services provided to the indigent and medically indigent during July, 1952. The costs per eligible person were computed by dividing the total costs by the total eligibility as brought forward in table 1, viz., 1,400 persons. The cost of the entire program is, of course, lower than that of a typical winter month, during which the total eligibility, i. e., the welfare case load, is increased. On cursory inspection, it may appear that the costs of hospitalization are disproportionately high. The total cost of hospitalization, however, is a function of the utilization of medical aid benefits, whereas the total

cost of physicians' services is a function of eligibility alone. Thus, these data may bespeak an abnormally high utilization.

The total cost of drugs and appliances as presented here includes both that fraction paid directly by the DPW and that fraction paid to pharmacists by way of increasing the monthly stipends to individual welfare clients. An estimated 30% of the $707.21 was paid through stipendiary advances.

Approximately 10% of the total cost for hospitalization was met by old age assistance, aid to the blind, and aid to the permanently and totally disabled clients without welfare assistance from either state or county. Thus, the total cost of the medical assistance program as given in table 3 is some $650 in excess of the actual cost to the welfare department.

The financial responsibility involved in the provision of physicians' services to the indigent and medically indigent in Montana

TABLE 3.-Total Costs and Costs per Person Eligible for Medical Assistance During July, 1952

This figure represents the costs of convalescent home care, which were in excess of subsistence stipends.

has been delegated by the state legislature to the individual counties. In Cascade County, the costs of hospitalization must also be met principally through local funds, since public assistance stipendiary grants alone approximate the maximums imposed by the federal and state legislatures. Therefore, excepting some small amount of matching of the costs of pharmaceuticals, the Cascade County medical assistance program is supported entirely by local funds.

The legislature of the State of Montana allows county commissioners to assess a maximum property tax of 10 mills for the support of the entire welfare program. Should this maximum tax be imposed and the monies so obtained be exhausted before the end of the fiscal year, the state will grant to the commissioners those funds that may be necessary to continue the program. Should a tax less than the maximum be imposed, supplementary state funds are provided as a loan. In Cascade County, the current welfare tax is 9.6 mills.

SUMMARY

The several agencies and individuals most intimately concerned with medical care benefits are bound by written contract to their various roles in the Cascade County medical assistance program. The program is centered about three such contracts, viz., a contract between the Cascade County Commissioners and the county medical society, a contract between the medical society and the Montana Physicians' Service, and a contract between the society and the individual physician.

In compliance with the terms of the current medical societycounty commissioner contract, the society receives prepayment in the amount of $2.00 per eligible person in return for the provision of physicians' services to all certified welfare clientele. The statistical facilities of the Montana Physicians' Service are utilized by the medical society for the administration of this contract. Within the society, committees are set up for regulation of the program's activities. The major portion of those monies awarded to the society under the contract are prorated among participating physicians.

All certified welfare clients are equally eligible for benefits provided by the program. In that both free choice of physician and free choice among all local vendors of medical services is offered, the welfare client is extended medical care which is not only quantitatively but also qualitatively equal to that available to the private patient.

The authorization procedures required by the program might appear cumbersome for the physician as well as the welfare client. In truth, regulations have been made very elastic. The physician's application for authorization to continue therapy beyond a single home or office call involves merely phoning the local M. P. S. office. The M. P. S. later contacts a member of the claims committee. Then, unless the attending physician is informed to the contrary within some 48 hours, he simply assumes that authorization has been granted.

The statutes of the Montana state legislature have notably affected both the operation and the economy of Cascade County's medical assistance program. One of the primary objectives of prepayment programs founded in other parts of the country has been the achievement of greater federal and state matching as effected through distribution of the costs of medical assistance among all those eligible, such that federally imposed maximum grants were not exceeded. However, the law of the State of Montana specifies that the costs of maintaining a "county physician" must be met entirely by county funds. In Cascade County, the medical society acts as county physician; thus, this edict precludes any state or federal matching in its payment. Furthermore, state ordinances complicate the picture as concerns payment for pharmaceuticals. Prior to the 1949 amend

ment of the Social Security Act, the administrative problem involved in the payment of all assistance monies to individual clients was by no means peculiar to the state of Montana. But, with the endorsement of direct payment to vendors of services, this source of complexity has been eliminated in many states.

Notwithstanding these legal limitations, the Cascade County Department of Public Welfare, the medical society, the M. P. S., and other local providers of medical services have cooperated in both the creation and the effectual implementation of a medical aid program of which any community might well be proud. The unfaltering interest apparent among those persons even remotely connected with the program, now in operation over three years, supports the contention that the citizens of Cascade County will through the years continue to provide to their indigent the very highest quality of medical care.

Reprinted, with additions, from The Journal of the American Medical Association, January 24, 1953, Vol. 151, pp. 320-323

Copyright, 1953, by American Medical Association

Part VIII of a Study
by the

COUNCIL ON MEDICAL SERVICE

Medical Care of the Indigent in Polk County, Iowa

This study considers the medical care available for indigent and medically indigent residents in Polk County, Iowa. The county has approximately 226,000 residents, of whom 178,000, or 79%, live in Des Moines, the state capital. It is both an agricultural and an industrial area, with the growing importance of industry indicated by a 30% population increase in the last 10 years.

TABLE 1.-Persons Eligible for Aid Under General and
Public Assistance Programs

In 1951, approximately 5,732 residents of Polk County, or 2.5% of the county's population, were eligible for aid under general and public assistance programs. The number eligible for aid from each program are shown in table 1.

The total number of individuals eligible for aid to dependent children was not available, and, at the time the survey was made, Polk County had no aid to the permanently and totally disabled program.

General assistance clients must be legal residents of the county. Reciprocal agreements have been made with other counties, however, to provide aid for nonresidents who cannot safely be moved to their home counties for treatment. The public assistance programs do not require legal residence in the county for medical care.

ADMINISTRATION

Both general and public assistance medical care are administered on a county-wide basis. Home care and hospitalization, however, are administered by two different agencies. The Polk