"Revolt Against Costs"

That proud, introspective body, the American Medical Association, frankly calls it "the popular lay revolt against the costs of medical care.'' How to lay that "revolt" is the A. M. A.'s great current problem, as it is the problem of the Committee on the Cost of Medical Care. Last week neither the Committee (after four and one-half years' investigation) nor the A. M. A. had an effective campaign to offer. But a couple of hospitals, to save their heads, did something.

The solution must equate the doctor's cost of getting his prolonged education,* the cost of supporting himself and family, the cost of nursing, the cost of running hospitals and the patient's income. Everyone concerned overweighs his own factors in the calculus of these variables.

The American Nurses Association, for example, is striving to discourage girls from entering their vocation. Last week Dr. May Ayres Burgess of the A. N. A. complained: "Any nurse, to make a reasonable income in her field at the present time, must either be unusually competent, unusually lucky or more skillful in personal competition than are the rank and file." The usual fee for a private nurse has been $6 to $7 a day and found, for a 12-hr. day. But she worked on the average only three out of five days, getting $1,200 to $1,500 cash per year. Now nurses can be found to work for less money. But they prefer longer hours at the standard stipend.

Johns Hopkins Hospital's gestures at economy last week was to cut wages of everyone receiving $500 or more a year. Calculated as part of wages were the cost of full maintenance of employes. Nurses, dietitians and department heads cost $365 per year each to feed and house; orderlies and maids $250 per year.

Some hospitals in other cities are attacking the "lay revolt'' with fixed fees for all services. The doctor need not decide whether to charge his patient nothing to $25 for an office visit, nothing to $10,000 for an operation. When a patient gets into a "fixed fee" hospital he knows beforehand that he will pay about what Manhattan's Sydenham Hospital last week announced it would charge:

Surgical operations: difficult majors $100 to $150; ordinary majors $75 to $100; minors $10 to $50.

Medical fees: 1st week $25; 2nd week $20; 3rd week and after $15; but not more than $150 for the entire time in the hospital.

Consultation fees: $5.

Normal child births: $50, including one pre-natal examination; instrumental deliveries, including consultations, not more than $150 on any one case.

Operating room or delivery room and anesthesia: $15.

Nurse: $3 a 24-hr, day (she attends up to four patients).

Laboratory fees: $5 to $10.

Basal metabolism or cardiographs: $5. Xray: $5 to $35.

Parallel to those moderate charges are the fees of 60 years ago, when doctors lacked x-rays, cardiographs, basal metabolism machines, laboratories, when three years of study made a boy a physician, when there was no Johns Hopkins University School of Medicine. In A Doctor of the 1870's and 80's, recently published,/- Dr. William Allen Pusey, 1924-25 President of the A. M. A., reports that at Elizabethtown, Ky., his father, Dr. Robert Burns Pusey, used to charge:

Visits in town & office calls: $1.

Country trips: 1st mile $1; each subsequent mile 50-c-.

Consultation: $5 to $25; usually $10.

Child births: $10.

Operations: minor $5 to $25; major, chiefly amputations, $25 to $100.

Dislocations and fractures: $10 to $25.

Between 1870 and 1886 Father Pusey's income averaged $5,200 per year. That, estimates Son Pusey, was equivalent to about $13,000 in the same small town today "I never heard of a complaint at overcharge. Rather, his bill was usually paid with thanks. He did not make entries on his books of less than $1 and his accounts were settled on a cash basis. Hi would take in credit on a bill a calf, a young mule or horse that he could use and, if he wanted something, he would buy it by preference from one of his patients and credit it to his account."

The father, according to the son, "was a rather effective businessman who looked after his affairs in a quiet way that in the end got results. ... I surmise that only a few people in the community had a larger income; certainly his family lived as liberally as any other. He was indeed too generous with his expenditures, for like most doctors he did not make sufficient provision for an unproductive old age."

*"Are we undertaking, in the preparation of physicians, to produce a brand of professional attainment which we shall not be able to use because of the cost?" asked Dr. Rosco Genung Leland, director of the A. M. A. bureau of medical economics at last month's Congress on Medical Education, Medical Licensure & Hospitals.

*Thomas ($3)

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