1437

PANEL AND CONTRACT PRACTICE

AN AMERICAN VIEW OF HEALTH

INSURANCE

IT is unfortunately true that many Americanwritings designed to impart instruction on Europeanhealth insurance systems contain errors of fact, andto this must be attributed the misconceptions ofhealth insurance that are so prevalent in America.Such, for instance, as the belief that the Englishsystem is on the verge of bankruptcy ; that it isdetested by the insurance doctors, who would gladlybe rid of it ; and some other delusions strange enoughto appeal to the sense of humour which, in spite ofa widespread American belief to the contrary, is animportant part of the English character. Suchcriticisms cannot, however, be brought against thelatest American book on health insurance, Dr. 1. S.Falk’s " Security against Sickness."1 Dr. Falk had

exceptional qualifications for his task. He was in

charge of the field work carried out by the Committeeon the Costs of Medical Care during their five years’study of the conditions under which medical care isgiven, or not given, in the United States-the mostcomplete study of the economics of medical practiceever undertaken-and he has made a special studyof European health insurance both by an intensivescrutiny of documents and by personal visits to

eight European countries. The result is a valuablebook : informative, eminently readable, and markedby a critical acumen that inspires confidence in theauthor’s judgment.

Dr. Falk approaches health insurance from the

point of view from which it is generally regarded bystudents in America and other countries where ithas not yet been introduced. In Europe healthinsurance began as something in the nature of a

savings bank. Its aim was to provide money fordisabled wage-earners. Medical care came later and

long held a secondary position. With the advanceof medical science, which not only increases the

efficiency of medical treatment but makes it moreexpensive, it has become of primary importance,even from an economic point of view. The inquiriesof the Committee on the Costs of Medical Care showthat the cost of securing adequate medical treatmentby private arrangements imposes an economic burdenheavier than loss of earnings due to incapacity forwork. Hence in the new countries health insuranceis regarded chiefly as a means of providing medicalcare, and the payment of cash benefits during periodsof incapacity as a function to be discharged by aseparate authority or by the authority administeringunemployment insurance. The health insurancesystem adopted last March by the legislature ofBritish Columbia, the first British dominion tointroduce compulsory health insurance, gives no

cash benefits but is limited to the provision of medicalcare.

The changes in the German health insurance systemmade by the National Socialist government are dulyset out in this book. The insurance societies (Kran-kenkassen) have been integrated as elements of a

single system, and by an equalisation fund the seriousinequalities in the benefits given by the varioussocieties have been lessened if not removed. Theadministration of the societies has been transferredfrom the old management committee to a

" leader,"one for each society, appointed by the government,

1 New York : Doubleday, Doran and Co. 1936. $4.

who is assisted by an advisory board containing adoctor nominated by the local medical organisation.Thus, for the first time, the medical profession hassecured representation on the bodies administeringsickness insurance in Germany. The State contri-bution to the cost of the system has been discon-tinued, and the employer’s contribution raised fromone-third to one-half of the joint contribution of

employer and employee. The sanatoria and otherinstitutions and the preventive services of the Kran-kenkassen have been transferred to the invalidityinsurance administration, and the Hartmannbundand other medical organisations have been dissolvedand exclusive legal status has been given to a newmedical body, the Kranken7cassendrztliche VereinigungDeutschlands (K.V.D.), which is under the supervisionof the Ministry of Labour. Insurance practice canbe undertaken only by members of the K.V.D., and"

non-Aryans " are excluded from membership.Contracts for medical service are no longer madebetween the societies and individual doctors but arenegotiated centrally between the insurance authori-ties and the K.V.D., wliich by its local branchesdistributes among the doctors of the various areasthe sums available for medical remuneration.

Of special interest is the account given by Dr. Falkof the French method of medical remuneration, theentente directe, by which the doctor’s fee for each" medical act" is paid by the patient, who is reim-bursed part of the cost by his insurance society. Thechief object of this method is to prevent undue callsupon the doctors’ services, and it exercises an attrac-tion on the medical profession in countries in whichthe adoption of compulsory health insurance seemson the way to become a matter of practical politics-in New Zealand, for instance, where the introductionof a health insurance scheme appears to be imminent.Dr. Falk’s account of the method is not likely toencourage its adherents. In practice it requires avast amount of official checks and safeguards, andit has not tended to enhance the prestige of themedical profession in the community. This is largelyowing to the wide discrepancy between the fee scheduleof the insurance societies and the fees charged bythe doctors, which are based on the scale fixed bythe local medical association. The patient is reim-bursed by his society 80 per cent., not of the doctor’sfee, but of the fee allowed for the service in the

society’s schedule, which is usually much lower.The schedule fee of the Paris societies for a day visitis 17 francs, but the minimum fee of the medicalassociation is 30 francs, so that the patient’s reim-bursement (fr.13.60) forms only 45’3 per cent. ofthe fee actually paid. In French insurance practicethere is still the barrier of a substantial fee interposedbetween doctor and patient. The method wasadopted at the insistence of the doctors who, nowthat they have secured it, are not sure that it iswhat they really want. As Dr. Falk observes :

"

By the victory of dictating the system of remunerationand of assuring all patients completely free choice ofdoctor the French doctors achieved stringent limitationof fees, a complex and cumbersome fee schedule, necessityfor close administrative supervision, conflicts with theinsurance authorities, and a considerable loss in publicesteem. The confusion which has followed upon the

Pyrrhic victory seems to have exceeded what occurredin Germany with salaries, per-capita payments andfee schedules, and is vastly in excess of what hasbeen customary in Great Britain under per-capitapayments."

1438 PUBLIC HEALTH

It must be admitted that in some respects theBritish scheme emerges in an unfavourable lightfrom Dr. Falk’s comparative analysis, After 23 yearsit is still mainly concerned with the provision of cashbenefits. Of the total expenditure only 38 per cent.is devoted to providing medical care, as against60 per cent. in France, 69 per cent. in Germany,and no less than 80 per cent. in Denmark. Unlikemost continental systems it provides small specialistor institutional treatment, no nursing, or laboratoryaids to diagnosis ; it does nothing for the dependantsof the insured, and its maternity provisions are

limited to a cash payment on confinement. But

against these inadequacies must be set the inestimable

advantage that the system has from near the begin-ning been worked with the cordial cooperation of themedical profession, and in this respect it stands almostalone. Moreover, though it is true that as regardsthe range of medical benefit the system is where itwas at its inception, great advances have been madein the health work of the local authorities-e.g., inproviding treatment for tuberculosis and venereal

diseases, and maternity and child welfare services ;and the Local Government Act, 1929, has led tofurther important advances. All this is recognisedin Dr. Falk’s book, which may be studied with profitby all who, whether as doctors or administrators, areengaged in the working of national health insurance.

PUBLIC HEALTH

ISOLATION OF SCARLET FEVER IN

THE HOME

BY DUNCAN FORBES, M.B.E., M.D., D.P.H.MEDICAL OFFICER OF HEALTH FOR BRIGHTON

IN Brighton, since October, 1931, scarlet fever

patients have been isolated at home if they couldbe nursed in a room by themselves or in a room withtheir mother in a separate bed. After a period offour years I think it worth while recording the results,although even now the numbers are small.

TABLE I

A Contrast in the Numbers of Secondary and Return Casesfollowing Home and Hospital Isolation

TABLE II

Non-immune School Contacts with Onsets 6 days or moreafter Notification

As shown in Table I. the result of home isolation,particularly in the first fortnight, compares verybadly with that obtained by the removal of thepatient to hospital. On the other hand, under thehospital conditions stated later in the paper, it wouldseem that the greater infectivity of patients dischargedfrom hospital, as shown by the number of returncases, outweighs the excess of infections from home-nursed cases during the period of isolation.A better appreciation of the position as to infectivity ’

is gained from Table II., which shows a greater numberof school-children at risk per family in the hospital- :nursed group and an equal percentage of family reinfec- :

tions in each group. From this Table it appearsthat in the age-group 5-14 the chances of infectionare about equal, whether or not the patient is removedto hospital. An analysis of Table I. shows thatequal percentages of mothers are infected whether ornot the child is removed to hospital, which is remark-able seeing that the mother is usually the nurse of thechild isolated at home. The figures are too small,however, to justify any definite conclusion.To make home isolation more efficient is difficult

as the health officer cannot control family life ; on

the other hand, it is possible to avoid cross-infectionin hospital by such methods as cubicle isolation,open-air nursing, and a strict isolation of the individualpatient by a highly trained nursing staff. Whetheror not this is worth while to save a 5 per cent.reinfection-rate in a mild disease such as scarletfever is worthy of consideration.

Saving obtained by home nursing.-In Brightonin the years 1922-25 the removal-rate was 74 percent., whilst in the years 1932-35 the removal-ratewas 45 per cent. This meant an actual reductionof the number of patients removed to hospital in thelatter period of 472. The average stay in hospitalbeing five weeks, this meant a saving of 2360 weeksof hospital treatment. As the diminution in thenumber of hospital-nursed cases allowed us to nurseour tuberculous joint and other orthopaedic cases

in a vacated ward I estimate the saving at some1000 a year. It may be objected that I have nottaken into account the loss of school attendance

by the prolonged exclusion of the contacts of home-nursed cases. In Brighton there is no such loss asthe rules for exclusion of contacts is the same-

namely, until the Monday week following isolationeither at home or in hospital. I can trace no schoolor other infections from this short exclusion ofcontacts with home-nursed cases.

TABLE III

Intervals between the Discharge of Hospital-nursed Casesand the Onset of Return Cases

I

Infectivity of the hospital-nursed cases.-The nursingof patients in Brighton is in large wards of 14 bedswhere uncomplicated cases after three weeks in bed ’mix freely with each other. The absence of cubicle

nursing and the free contact of the patients who are