STATEMENT OF DR. LEONA BAUMGARTNER, ASSISTANT COMMISSIONER OF HEALTH, NEW YORK CITY HEALTH DEPARTMENT

Dr. BAUMGARTNER. I am Dr. Leona Baumgartner, Assistant Commissioner of Health, New York City. I am happy to be here, Senator, in my own behalf, so to speak, and happy to be here wearing three hats, which, I think, is quite a privilege for a woman, in 20 minutes, for I am going to speak as an administrator of the EMIC program in the last war, and I am going to speak for the American Public Health Association, and I am also authorized to speak for the Child Welfare League of America.

I would like to speak first as an administrator, one who handled the EMIC program in New York City for a period of 6 years from 1943 to 1949, when over 66,500 mothers and infants were cared for at a total cost of roughly $72 million. This number included 412 percent of the women who were cared for in the total national program. So, it gives you at least that much of a sample.

In New York City the average cost per mother was $114.48 and, per infant, $95.53. The latter was used almost exclusively for the care of sick babies.

We have made extensive studies of the distribution of costs in these cases, and these have been published in a scientific journal, reprints of which I am happy to leave for the study of the committee, if they so wish.

(The reprint is as follows:)

DISTRIBUTION OF COSTS UNDER THE EMERGENCY MATERNITY AND INFANT-CARE PROGRAM WITH SPECIAL REFERENCE TO COSTS OF MATERNITY CARE IN NEW YORK CITY

(Vivian Pessin, Leona Baumgartner, M. D., FAPHA, and Helen M. Wallace, M. D., FAPHA,' New York City Department of Health)

Providing adequate medical and hospital care for all who need it is one of the major problems of the American scene at the present time. During World War II an opportunity arose to experiment through the Federal Emergency Maternity and Infant-Care Program (hereafter called EMIC) with a program that attempted to give complete service for a small segment of the population requiring certain types of care. The program provided payment for medical, hospital, nursing, and other necessary related services for pregnant wives and infants of men in the four lowest pay grades of the Armed Forces. The restriction to these pay grades of eligibility for care involved little administrative difficulty. Payment was made by the administrative agent (the state or municipal health department) directly to the individual or agency performing the service. No special service units were set up, but the services usually available in the community were used-i. e., private physicians, hospitals, and others rendering service were paid directly for the care given to the patient. The method of payment was essentially a "fee for service" one, although, because of the possibility of defining care around pregnancies as a unit and because of the limitation of service for the infant to the first year of life, an inclusive fee was set with the possibility of extra payment in unusual cases.

The importance of studying critically such a program seems self-evident. The conclusions one may draw from a wartime experience may not, to be sure, be applicable at other times, but this program, using as it did the usual medical and hospital facilities available in all communities in the United States and its territories, is worthy of special study. In fact, one of the serious criticisms that might be leveled at this venture was that, apparently because of the wartime pressures, it was impossible concurrently to plan for and carry out widespread studies. At the inception of the EMIC program, in New York City, plans were made to collect certain data that might subsequently be analyzed. Previous

communications have thrown light on the completeness of reporting of fetal deaths, the average length of time for which prematurely born infants were hospitalized, and the costs of caring for premature infants. The present paper deals chiefly with the cost of maternity care, throwing light indirectly on the kinds of service that the maternity patient received, a subject which is more adequately dealt with elsewhere."

The New York City EMIC program was operated by the City Health Department from the program's inception on July 1, 1943, until June 30, 1949. During this 6 year period, $6,151,010.62 was expended for the case of 53,728 maternity patients and $1,226,345.96 for the care of 12,837 infants, or a combined total of $7,377,356.58. The average cost per maternity case was $114.48, and per infant case $95.53, in this 6 year period.

ADMINISTRATIVE COSTS

Of interest and importance to administrators is the administrative cost of operation of any program. The administrative costs of the program charged to federal EMIC funds amounted to $319,879, during the period from July 1, 1944, to June 30, 1949, covering 5 of the 6 years of the program's operation. During the first year (July 1, 1943, to July 1, 1944), no funds were allocated for the administration of the program, and the staff of the City Health Department carried the load. Of this sum of $319,879, $269,849 (84 percent) was expended for salaries of personnel (medical director, medical social worker, public health nurse, accountant, statistician, tabulating machine operators, clerks, typists, stenographers), and $50,030 (16 percent) for office supplies, equipment, record forms, rental of statistical machines, etc. The amount spent in New York City for administrative purposes from federal funds constituted 4 percent of the total federal EMIC funds expended. This amount is slightly larger than the national average of 2.5 percent," possibly because of the greater number of calls for direct services from the administrative agency which had to be met in a locally administered program.

AMOUNT OF PAYMENT FOR MATERNITY SERVICE

1. Hospital Service

Inpatient Care.-Inpatient hospital service was paid for on a cost basis' and a per diem rate was established for each hospital. The ceiling per diem rates which increased from $8.25 to $13.00 were established by selection of the rate under which 90 percent of the individual hospital's per diem costs fell. Either the day of admission or the day of discharge of the patient was paid for, but not both days. The length of stay in the hospital for each patient was determined solely by the individual patient's condition and need, as determined by the attending physician.

Outpatient Care.-Outpatient visits were paid for on a cost basis' and a per visit rate was established for each hospital. The ceiling per visit rate was $2.50, 2. Medical Service

A physician in general practice was paid a flat fee of $50 for complete maternity care, including at least 5 antepartum visits; care during labor, delivery, and the hospital post-partum period; and a final postpartum examination at approximately the 6 week postpartum. Additional payment was made to the physician on a visit basis for the home and hospital care of non-obstetric intercurrent illness during the ante-, intra-, or postpartum periods. After December 15, 1944, all physicians who were qualified obstetricians' received fees 50 percent higher than those stated above for general practitioners.

3. Consultation Service

Consultation service by qualified specialists was paid for on a visit basis or, when specific service such as an operative procedure was performed, on a flat fee basis with fees varying from $37.50 to $75.00. Payments for consultants' visits were as follows:

The amount of consultation service given was determined by the attending physician and consultant, and was based upon the patient's condition.

4. Nursing Service

Bedside nursing service was paid for at rates in accordance with those established by the local districts of the New York State Nurses Association and increased from $6 and $8 in 1943 to $10 and $12 after 1945, for 8-hour and 12-hour duty. The amount necessary was determined by the attending physician based upon the patient's needs.

Home nursing visits by members of the visiting nurse associations were paid for on a cost basis at $1.50 per visit.

5. Miscellaneous Services

Other services such as blood, plasma, ambulance, oxygen, unusually expensive drugs, were paid for at the prevailing market rates with ceilings established.

SAMPLE AND MATERIAL STUDIED

10

The sample selected for this report consists of 22,948 maternity patients receiving complete care under the New York City EMIC program including medical care by a private attending physician and hospitalization, and whose cases were closed-i. e., all bills were paid-in 1945 and 1946. Some aspects

of the medical care of this group of maternity patients are reported elsewhere." This sample represents 43 percent of all pregnant women who received maternity care under the EMIC program during its 6-year period of operation.

The materials used for analysis were the payments made to doctors, hospitals, etc. These, for the most part, reflect directly the services which the patient received. There is one important exception. "Operations" and "visits" were paid for separately only when performed by a qualified consultant called in by the patient's own physician. Obviously the same services were performed in many cases by the qualified obstetricians who were caring for their own patients. But for administrative purposes it is important to know what provision needs to be made for payments for special services. Therefore, the analysis of cost and not service figures is valuable.

UTILIZATION OF SERVICES

All cases were under the care of private physicians and were hospitalized, since the series studied was limited to such cases. In over 5 percent of cases operations were performed by consultants called in by the attending physician. Four percent were patients seen by an outside consultant; 3 percent had benefit of services such as the provision of drugs, ambulance service, etc.; 1 percent had supplementary medical care for intercurrent illness; and 1 percent were given transfusions or plasma. Each of the remaining services (out-patient

1 Credit is also due to Frieda Greenstein and Molly Park for their assistance in compiling the data, and to the EMIC office staff, especially Ann Eisenstadt and Beatrice F. Mandell, without whose devoted services these studies could not have been maintained.

2 Baumgartner, L., Wallace, H. M., Landsberg, E., and Pessiu, V. The Inadequacy of Routine Reporting of Fetal Deaths. A. J. P. H. 39: 1549-1552 (Dec.) 1949. 'Wallace, H. M., Baumgartner, L. and Park, M. L. The Average Length of Stay In the Hospital of Infants Born Prematurely. Pediatrics 1: 66-68, 1948.

Wallace, H. M., and Baumgartner, L. The Care of Premature Infants In New York City. A. J. P. H. 39: 845-853 (July) 1949.

Pessin, V., Wallace, H. M., and Baumgartner, L. Medical Care of Maternity Patients Under the Emergency Maternity and Infant Care Program (EMIC) in New York City. A. J. P. H. 41, 4: 402-409 (Apr.) 1951.

Eliot, M. M., and Friedman, L. R. Four Years of The EMIC Program. Yale J. Biol. & Med. 19: 621-635. 1947.

New York State Department of Health. Information on Purchase of Hospital Care, The Federal Emergency Maternity and Infant Care Program, The New York State Plan. Revised Jan. 1, 1946, 11 pp.

A qualified obstetrician was defined as follows: (a) Physicians who were diplomates of the American Board of Obstetrics and Gynecology; or (b) Physicians who presented evidence that their training and experience were the equivalent of training and experience required for admission to the examination of such specialty board, as determined by the EMIC Obstetric Advisory Committee to the Commissioner of Health.

New York City Department of Health, Bureau of Child Hygiene. Information Guide for Physicians-Emergency Maternity and Infant Care Program. July 1, 1945. pp. 1-15 Of the 31,378 maternity cases closed in 1945 and 1946, 19 percent received care as elinic and ward patients. Another 6 percent had an attending physician, but did not receive complete care. The remaining 75 percent were attended by private physicians and received complete care. The latter group, consisting of 23,388 cases, is composed of 22.948 who had hospital and medical care and whose costs are herein analyzed and an additional 440 whose hospitalization was not paid for by EMIC or who were not hospitalized.

hospital care, bedside nursing, and nursing home visits) was received by less than 1 percent of the cases.

The percentage of women who had these ancillary services increased sharply with the cost of the case; that is, the expensive cases not only had more of the same kinds of service as the inexpensive cases, but also more kinds of services. The omission of the auxiliary services from the program would have affected the patients who needed help most (i. e., those whose bills were high) proportionately more than those whose bills were low. For example, in the most expensive group ($200 and over), 52 percent had operations; 28 percent consultations; 26 percent drugs, ambulance, etc.; and more than 10 percent each had transfuions, bedside nursing, and care for intercurrent illness. This contrasts with the less expensive cases (under $120), of whom less than 1 percent had any of the listed auxiliary services.

TABLE 1.-Emergency maternity and infant-care program cost analysis of maternity cases receiving complete care1 cases closed in 1945 and 1946, New York City

PER CENT OF COST PER CASE FOR STATED SERVICES, BY TOTAL COST PER CASE Total cost per case (in dollars)

1 Including hospitalization and services of private attending physician.

TABLE 2.-Emergency maternity and infant-care program cost analysis of maternity cases receiving complete care' cases closed in 1945 and 1946, New York City

AVERAGE COST PER CASE FOR STATED SERVICES, BY TOTAL COST PER CASE

1 Including hospitalization and services of private attending physician.

ANALYSIS OF COST PER CASE

A total of $3,057,077.64 was expended for the care of this group of 22,948 maternity patients, or $133.22 per patient. Payment for in-patient hospital care and obstetric care by the attending physician constituted the great bulk of the cost, 55 percent and 41 percent respectively, with very little spent for out-patient hospital care and medical care of nonobstetric intercurrent illness. Medical consultation service accounted for approximately 2.7 percent, nursing 0.4 percent, and miscellaneous services 0.6 percent (see Table 1).

The costs and percentages of the total cost of the services show a definite relationship to the average cost per patient. Proceeding from the least to the most expensive group, the average cost of hospital care rose steadily from $42 to $139; the percentage of total cost remained between 52 and 58 except for the lowest group, which consisted mainly of municipal hospital ward cases. Thus, as the cost per case increased, there was a large absolute increase in the cost of hospital care, but little or no relative increase (see Table 2).

Payments to the attending physician averaged close to $50 for cases costing under $130, and fluctuated between $55 and $62 for more expensive cases. This stability reflects the "fixed fee" policy for medical maternity care, under which the complexity of the case had only a minor effect on the size of the attending physician's fee. That the average cost of the attending physician's fee was close to $50 in most groups is a reflection of the fact that the majority of the maternity patients were cared for by attending physicians who were general practitioners.3 The percentage of funds expended for the attending physician's services (exclusive of additional payments for nonobstetric intercurrent illness) decreased from 54 percent of the total for the least expensive cases (less than $100) to 21 percent for the most expensive group ($200 or more).

The cost for other services was very low, absolutely and relatively, for cases costing less than $150. For more expensive cases, however, the cost for other services became substantial, accounting for 27 percent of the total cost of the most expensive group ($200 or more).

DISTRIBUTION OF CASES BY COST PER CASE

The modal cost group of cases, $120 to $130, comprised 21 percent of all cases. Three-fourths of the cases cost between $100 and $150. Seven percent cost less than $100 and only 4 percent cost more than $200. The cost per case ranged from $39.76 to $1,148.82.

The least expensive case, costing $39.76, was for a patient who aborted early in pregnancy.

The most expensive case ($1,148.82) was a patient who had a Caesarean section with postoperative pelvic phlebitis, pulmonary embolism, pleurisy, and pneumonia. This patient was critically ill, but subsequently recovered. Every service offered by the program was used in the care of this woman, with the exception of out-patient visits; these services included care by a private physician ($50), hospitalization for 43 days ($311.32), consultation visits and operation by a consultant ($50), and ancillary services (at a cost of $737.50) including ambulance, oxygen, penicillin, and bedside nursing in the hospital by a private nurse and in the home by a public nurse.

The next most expensive case ($1,145) was a woman who developed a postpartum toxemia and who received continuous bedside nursing care for 23 days. Another patient ($1,105) had a Caesarean section, followed by pelvic peritonitis; she was operated on subsequently for an appendiceal abscess; this patient required 28 days of hospitalization, including 25 days of continuous bedside nursing.

LENGTH OF IN-PATIENT HOSPITAL STAY

The average length of hospital stay of this group of maternity patients was 9.4 days. This figure represents the actual number of days hospitalized since, as previously mentioned, either the day of admission or the day of discharge was counted and paid for, not both. Approximately 50 percent of the women stayed in the hospital 9 or 10 days, and 21 percent stayed 8 days. Fourteen percent of the women stayed less than 8 days and another 15 percent more than 10 days. The longest period of hospitalization in this group was 118 days.

Wallace, H. M., Baumgartner, L., and Park, M. L. The Average Length of Stay In the Hospital of Infants Born Prematurely. Pediatrics 1: 66-69, 1948.

98358-52-4