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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 elass, 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 a minor voice, in the selection of medical treatment will its opportunity and endeavor in the direction of prevention be seriously hampered ?
How much danger is there of the formation of a medical monopoly in allowing the selection of doctors by the insurance company?
Is it possible to arrange a workable fee schedule for treatment to injured employees?
What practical regulation can be made regarding the free choice of medical service by the injured workman?
When free choice of service is allowed, how are padded bills to be prevented ?
You can help the Board by selecting a committee who will voluntarily render their services in order that we may come to what, in our mind, is a satisfactory as well as a just conclusion about these things. We do not desire to be left in the air without any assistance on your part. You all know there is only one place in the world where no errors are made, and that place is in the grand stand.
I would suggest that you form a committee representing your various societies a committee of three, five or seven - to confer with us and see if we can't map out some plan of campaign so that you will be satisfied, the Industrial Accident Board be satisfied and all concerned be satisfied.
When the doctor for the injured employee holds that disability or incapacity for work as the result of the employment still remains, and the doctor for the insurance company claims that he is able to go to work, a matter which must be decided by expert decision, — how can this expert, impartial examination best be obtained? How should it be remunerated? We select a doctor. How should that doctor be selected Shall you give us a list of ten, fifteen or twenty names that we can select from? So far, what assistance we have received we have received from doctors who are friends of the Board. I must say that the leaders in the profession have generously given to the Industrial Accident Board of their time and knowledge in order that they might assist us in working out the very much involved task of putting on its feet an entirely new piece of legislation.
How can the law be best worked out to see whether there is malingering or not?
Should medical practitioners be allowed higher fees for services to employees under the Workmen's Compensation Act than the existing standard fee for the care of workmen? The guideposts by which we determine the amount of fee that a doctor is entitled to are: first, the locality in which he practices; the doctor in the mountains of western Massachusetts does not receive nor expect to receive what the metropolitan doctor does; second, what is the nature of the complaint ? third, the ability of the man to pay; fourth, the standing of the practitioner in his profession.
Under the Workmen's Compensation Act what should be the standard? Here is a man making $10, $15 or $20 a week who is brought into your office. Should the compensation for the doctor, under these conditions, be the same under the Workmen's Compensation Act as if there were no act or insurance? The charge should be identically the same as if the man was not insured under the Workmen's Compensation Act. In addition, should there be a distinction drawn between the remuneration for medical services from persons who may be included under the act? You all know that a man injured under the Workmen's Compensation Act receives half his weekly wages as compensation. Should the medical fee be measured by the fact that the injured man makes $20 a week and his compensation under the act is $10, or that he makes $8 or less a week and his compensation under the act is $4?
In the matter of disputed bills, both as to number of calls and the charge per call, what would be a fair way to arbitrate these claims? Of course, the responsibility is with the Industrial Accident Board. The insurance
company sends the bills to the Board, we look them over and we decide that the bill is reasonable or otherwise. In the case of disputed bills should you have a committee of one, two or three from the Massachusetts Medical Society to work with us? We will do this: the doctor whose bill is contested may select a doctor, the insurance company select a doctor, and a member of the Board will give his time in order that a fair and just conclusion may be arrived at. This board of arbitration decides. Another thing: you notice that under the act reasonable medical and hospital service is provided for. How far can that be legitimately extended to include supplies for false limbs, eyes, teeth and things of that kind? We are getting practically 100,000 accidents a year reported to us, and we are having many cases of broken teeth, lost eyes, limbs, etc. Should the act be extended by authorizing the purchase of artificial limbs, false teeth or eyes?
Many hospitals throughout the Commonwealth have jumped their rates owing to the act, and to-day discriminate against the employer insured under the act and in favor of the man who does not insure. The man who insures under the act finds out that the hospital is charging him $14, and his next-door neighbor, not insured, is paying to that hospital but $7 a week. We have had cases where good hospitals charge $10.50 for service. Are we going to approve a bill for one hospital for $10 and another for $21, both performing the same service ?
A man is brought into a hospital and is attended by a man on the staff of that hospital. Should the doctor on the staff of that hospital receive compensation during the two weeks that man is in the hospital ? In many cases it is done. It all comes back to the question of cost. If the cost of the doctors and the hospitals is too much, the insurance companies will hire their own doctors and build their own hospitals. In fact, one insurance company is building its own hospital, and we are probably going to have more of such hospitals.
As a result of this meeting, a medical advisory committee of seven, consisting of Dr. Frederic J. Cotton of Boston, chairman, Dr. Francis W. Anthony of Haverhill, Dr. Samuel Fletcher of Chicopee, Dr. Samuel H. Calderwood of Boston, secretary, Dr. Francis D. Donoghue, Dr. Frank E. Allard and Dr. William H. Ruddick, all of Boston, chosen from the various medical societies of Massachusetts, was appointed. After many meetings and most careful consideration of all the problems involved, this medical advisory committee united in the following recommendations to the Industrial Accident Board :
First. That a permanent advisory medical committee is necessary.
Second. That we consider it inexpedient to have a medical man as a member of the Industrial Accident Board.
Third. That the Industrial Accident Board should have a consulting surgeon upon whom should fall the duty of detail work in preparation of matters to be laid before the advisory committee. Matters in dispute regarding services and fees of physicians should be referred to this committee for recommendation.
Fourth. — That insurance companies be requested to provide suitable blanks for notifications as well as specifications of services rendered by physicians.
Fifth. - That industrial insurance companies be encouraged to allow all reputable physicians to render services in industrial accidents, provided they are willing to render such services upon reasonable basis.
Sixth. - That the Accident Board should make arrangements with which the insurance companies should co-operate; that any physician whose bill is in dispute may appear before a representative of the Accident Board within a reasonable distance of his home.
Seventh. That the Accident Board shall provide for medical referees by districts.
Eighth. - That fees paid by the companies should not be less than the average minimum fee in the locality in which the service is rendered.
Ninth. -- That charges up to $50 for major operations are not excessive.
Tenth. That physicians other than impartial physicians named by the Board, appearing at hearings before the Board, shall receive the compensation as provided for under section 8, part III. of the act.
Eleventh. - That services rendered by lodge physicians be paid for, provided it is not inconsistent with the rules of the order.
Twelfth. - That specialists, established and recognized by the profession as such, may receive special rates for their work, provided the case requires special skill.
Thirteenth. That the ruling previously made by the Accident Board that “ fees should not be charged an injured party whose employer was insured larger than the injured party would be charged were he not insured,” should be interpreted to mean that in a given accident the fee paid by the insurance companies for services should not be less than the