California (section 15) provides for such medical, surgical and hospital treatment, including nursing, medicine, medical and surgical supplies, crutches and apparatus, as may be reasonably required at the time of injury and within ninety days thereafter, to cure and relieve from the effects of the injury, the same to be provided by the employer, and in case of his neglect seasonably to do so, the employer shall be liable for the reasonable expense incurred thereby in behalf of the employee in providing the same.

Ohio (section 42), in addition to the compensation provided, disburses and pays from the State Insurance Fund such amounts for medical nursing and hospital services and medicines as it may deem proper, not to exceed in any instance the sum of $200.

Oregon (section 23) provides that the man may provide medical, surgical and hospital care not to cost more than $250 in any one case.

The Industrial Accident Board requests that the Legislature give the Board the power to require the payment of bills for medical and surgical treatment, medicine, medical and surgical supplies, crutches and apparatus when necessary, beyond the first two weeks after the injury, in unusual cases where the injury is so serious as to require and warrant such additional medical treatment.

THE MEDICAL PROBLEMS OF THE ACT.

While the Massachusetts law has seriously curtailed the incomes of many lawyers, the legal profession has accepted the act with a spirit of fairness. Some of the best lawyers in the Commonwealth have prosecuted appeals to the Supreme Court, without charge to injured employees, to help the Board to get the act judicially interpreted by our highest tribunal.

In Massachusetts, as elsewhere, the most embarrassing question that the Board has had to settle has been the charge for medical relief.

Section 13, Part II. of the act, says that fees of attorneys and physicians for services under this act shall be subject to the approval of the Industrial Accident Board. This law does not provide that all bills shall be thus approved. The liability insurance companies, through a long series of years, had practically driven the doctors into an attitude of antagonism towards the insurance companies in general. Insurance companies had medical examiners, investigators and friendly doctors to whom liberal fees were paid, but the insurance attitude towards the medical profession seemed to be that when treating industrial injuries physicians were dishonest and needed watching; an attitude which on the part of the doctors as a class was reciprocated in kind.

Under the act insurance companies dispute certain doctors' bills and submit them to the Board for action, but the Board has no knowledge whether even larger amounts for similar services to injured employees have not been paid to doctors favored by the insurance companies. Doctors, like every other class of human beings, have their minimum of black sheep. Some doctors have presented bills for services under the act which were many times as large for insurance cases as were charged for similar cases which were not insured. Doctors without special knowledge were sending specialists' bills for specific treatment. These bills were properly disputed by the insurance companies, but, taken as a whole the medical situation was one of extreme embarrassment for the Industrial Accident Board.

After several months of endeavor to meet this situation the Industrial Accident Board found it necessary to call together the medical societies of Massachusetts in conference, and a meeting of these societies was held at the State House on March 26, 1913. At this meeting the medical problems of the act were presented to the doctors by James B. Carroll, the chairman of the Board, as follows: -

The Industrial Accident Board has asked you to come here to-day because we know that among the medical profession there is misunderstanding as to the operation of the Workmen's Compensation Act and the relation of the medical profession thereto. We are here to-day to correct any false impressions about the act, and to suggest that we get together in a spirit of justice and hearty co-operation.

In the first place, the Workmen's Compensation Act is a broad, humanitarian measure, and, as its name implies, it is primarily a workmen's compensation act, and for the benefit of no other class, calling or profession. It is provided in the act that when we hire an expert to examine an injured employee the maximum fee we can pay, under the statute, is $5, no matter how long or how difficult the examination. When we sit in judgment on these cases and arbitrators are called in, their fees are limited to $5. We must remember that every dollar paid under the Workmen's Compensation Act comes, fundamentally, out of the employers of Massachusetts, and any great expense placed on the administration of the act by hospitals or doctors means so much of an increase on the part of the obligations of the employers, and a corresponding decrease in the benefit which the toilers and the workers of the Commonwealth are to receive under it.

This act is designed to place personal injury cases upon something like a scientific and a humane basis of settlement, and the doctors, if the ratio of the past few months continues, will receive five times as much under the Workmen's Compensation Act as they did under the old Employers' Liability Act. Dealing with a statute, we have no election, except to construe that law as written. We are dealing with a condition and not a theory, an act as it passed the Legislature, under which the right to supply reasonable medical and hospital attention is exclusively and entirely with the insurance companies. In other words, under this act neither the injured man nor the employer has any right whatever to select his own physician. That is the exclusive duty and right of the insurance company.

If the insurance company furnishes the hospital or makes a reasonable attempt to supply the medical and hospital attention, you, gentlemen, have no claim whatever against the insurance company. Your claim is

exclusively and entirely against the employee, but by the co-operation of the Industrial Accident Board, and the various insurance companies insuring employers throughout the Commonwealth, we have a working agreement with them that has not the force nor the operation of the law. By reason of our efforts and fair co-operation by the insurance companies, they have allowed injured employees to select their own physicians, and, so far as I know, in the great majority of cases that working agreement is being carried out in good faith. There may be exceptions. The insurance companies, exhibiting a spirit of fair play, have said, "Let the injured man, although we are permitted by law to furnish the physician, select his own physician." Whether that working agreement is to be effective or not, whether it is to continue or not, depends entirely upon your good judgment and sense of fair play.

If I understand the law correctly in these matters you have no right whatever to charge, simply because there is an insurance company in the case, any more than you would charge the injured man if he came to your office for your personal treatment and assistance. Remember that, because the continuance of this working agreement depends, as I said, entirely upon you. This is all a question of cost. The insurance companies at first objected strenuously to this agreement. They said they could not do business if they could not select their own doctors, but the Industrial Accident Board asked them to try it, and so far it is working satisfactorily.

It has been asked, if this is a good working rule on the part of the doctors of the Commonwealth and the insurance companies, why can it not be incorporated into law? As you know, the Senate rejected last week a similar proposition, giving to the injured man the right to select his own physician, so that the law stands exactly as it was written, and it is only by virtue of a working agreement that this change has been brought about.

It must be kept in mind that under the law fees of physicians for services are subject to the approval of the Industrial Accident Board. As a matter of fact, the only bills that come before the Industrial Accident Board are those where payment is contested by the insurance companies. The Board is not in a position to know whether the insurance company that refuses to pay Dr. A's bill has not paid a bill to Dr. B. We only pass on contested bills. Doctors' bills refused payment by the insurance companies are sent to the Industrial Accident Board. The Industrial Accident Board has felt compelled to say to the insurance companies that if a bill is disapproved by them there should be some reason given for such disapproval. If it is claimed that a doctor's bill has been padded in any way some evidence to substantiate this claim should be given to the Board.

Some bills that have been refused payment by insurance companies have been fair, but others are exactly the contrary. When a young

doctor, living and seeking practice in a neighborhood of working poor, asks $5 a visit, sometimes making two visits a day, the answer is obvious. When doctors visit patients with a crush of the nerve of the thumb, or a lacerated wound, and claim they make three visits a day because of the necessity of administering opiates, what is the answer? These, however, are only the common, every-day troubles of the medical features of the Workmen's Compensation Act.

Workmen's compensation laws which aim to compensate injured employees have a very much more far-reaching object in view, and that is the prevention of industrial accidents.

The Board is anxious that the medical profession should be properly compensated and not be deprived of any professional privileges, and especially that this great movement may be put on a firm and just foundation, and for these purposes calls this meeting and seeks your co-operation. We come to you not as partisans but as fellow workers. The physicians of Massachusetts will receive at least five times as much in fees from the Industrial Accident Board through the insurance companies as was received by them under the Employers' Liability Act. We ask the medical profession to help us to a proper answer to all questions in which it is concerned, so that we will be in a position to have the well-considered judgment of the medical profession to guide us.

If the injured workman is treated by the insurance company's doctor, the insurance company pays his bill. If a nurse is required, it will pay the nurse's bill and for the necessary food, but for the injured workman's board and his care by his wife there can be no charge. If the injured employee goes to the hospital as a private patient, the board which was received at home free is paid for, plus the services of the physician. If he goes to a hospital in a public ward, he receives board, nursing, care and medical attention for less than the cost of the board alone. Was it the intent of the Legislature to make a specific industrial class, and, by allowing doctors' bills but not compensation during the first two weeks after the accident, to indicate the desirability of a better kind of medical service than that offered by the free dispensary?

When an injury occurs in industry, the first and most important thing to do is to restore the family breadwinner to health and earning power. Will results be more satisfactory if the injured employee can select his own doctor, or if a capable doctor and efficient service be selected by the insurance company for him?

The attempt to solve the question of the cost of medical aid, by allowing the injured employee the privilege of seeking the best service satisfactory to himself, has been shown in foreign countries to be subject to great abuses. The insurance association and the government, if farsighted, will not content itself simply with the cure of the ills which are found to exist, but will aim at preventing them and getting the injured person back to work. If the insurance company has not a voice, or only