RICH PAY FOR POOR

Evening Post, Volume CVI, Issue 126, 24 November 1923, Page 13

RICH PAY FOR POOR

IN STATES HOSPITALS

IN NEW ZEALAND NEITHER PAY

UNLESS THE HONEST PAY FOR

THE DISHONEST.

(By "M.N.")

Recent publication of the Medical Superintendent's report, and of the enormous amount of : uncollected patients' fees at the Wellington Hospital, provides food for thought. . . FEE-LESS STATE HOSPITALS. From Dr. D. Macdonald Wilson's references to the complex hospital system cf the .United States, with its simple types and composite types, certain impressions arise. One is that the limit of simplicity is attained in a hospital that invites none but the non-paying patient, excludes all others, and collects no fees. :

That ■ typo of hospital, municipally controlled, escapes the cost of booking fees and of trying to collect .them. It escapes all that worry. But it is still put to the' cost and worry of maintaining an intelligence department (or, as some people would say, an espionage department) to assure that no person able to pay obtains admittance.'

The problem would-'seem to be how to provide the cost of treating the poor and of excluding the not poor. It seems that in the United States thay provide the cost out of taxation or rates; but as there is no special hospital rate, and as other municipal enterprises are competing with the hospital for a share in rates and taxes, the money asked for apnually by the hospital superintendent may be cut down by the municipal authorities. The hospital superintendent and his staff handle no money; they have to cut their coat.according to the cloth they are allowed. It is therefore- not surprising to learn from Dr. Macdpnald Wilson that these rate-supportod" hospitals for non-paying patients "are usually maintained at less cost than the other hospitals." They ha-ve to' be. PARTLY- FEE AND PARTLY FREE.

: In various grades above this simple type of rate-supp6rted' "charity" or municipal hospital come other types of hospital. These latter charge fees. It is not desirable here to complicate the subject by going too closely, into the particulars of each type as described by Dr. Macdonald Wilson, but it may be pointed put that there are certain hospitals that may be described as partly fee and partly free—hospitals that have a certain number of free beds or wards. In most cases these hospitals, unlike the municipal or "charity hospitals, are not supported from rates or taxes, and therefore the cost of the non-paying patients must be found out of the fees of the paying patients or out of the endowments provided by the wealthy philanthropist who is so big a figure in America and so small a figure in New Zealand.

; The contrast presented by the ratesupported, fee-less, municipally-controll-ed, charity hospital, and the rate-less, fee : charging, mixed hospital, under private or semi-private control, helps to focus the issue.

It' is extremely doubtful whether . a publicly-elected hospital board in New Zealand is fitted to hold the balance nicely between- itg' rich" and its rpoor patients, with justice to the former and mercy to the latter. •..■■'

: From Dr. Macdonald Wilson's 1 report it seems to be plain, that elective control is not asked' to : carry out, in the United' States, such discriminating work. ■ Elective control.iii the United States is asked to treat the poor—or thoseof them who do not find a. place. in the mixed hospitals—arid to investigate -and guard against the entry of non-poor. And no doubt in the latter branch of its responsibility it meets with' difficulty enough in the way of influence and '.'pulls." : ..BIG-MESHED' NETS CATCH FEW FISH.

But a big publicly-owned general hospital in New Zealand is.asked to collect fees from those who can pay, and the melancholy failure of - the attempt is shown in the enormous amount of-out-standing fees at ,the Wellington Hospital. , The mesh of the net is so big i that .large fish as well as small escape. Apparently only the honest are caught, and they catch themselves. The attempt of public control in New Zealand to. discriminate between- ability and inability to pay. has become a joke,. In America the hospital people at least' know what they want-and'how to get it. If they don't want .fees, they don't, try to get.them.' If they do want fees, they get them. In ;New Zealand public hospitals fall between, the two. stools. They offer a penalty to honesty, a prize to dishonesty, the effect of which is to discourage the former.

The idea of making those people pay who are able to pay,, and of letting off those people who are unable to pay, has been popular ever since the days of Robin Hood. There is .no record that Robin Hood possessed an intelligence department designed to find out who had money and who had not. But probably Robin Hood and his men were* themselves . sufficiently .of the people to need no intelligence department and no system of inspection. DISCRIMINATING' DESPOTS. It is possible to imagine some kind of individual despot—even a highway robber—possessed of. a fine and just sense of discrimination in levying his charges. . A highly skilled and chivalrous modern doctor—of which there are, fortunately, not a few—is capable of becoming a benevolent despot of this kind. That is to say, he is capable of commanding so niany patients, in all stations of life, as to be able to make the rich pay for the poor. v He can collect tribute, and he can decline it.

To the big private practitioner must bo added, in these latter days, the big private hospital, or clinic. A story comes to New Zealand concerning an American institution;>o. highly modernised,-and possessed of so many resources of diagnosis and treatment, that its cost per patient must be far in'excess of that of New Zealand hospitals. A ;New Zealand visitor to the institution saw, there two patients—a. Woman who had been sent by her native township, which had subscribed about -250 dollars foi her treatment; and an. old man. It was conveyed to the visitor that both patients would receive, the best treatment; that the' clinic would take none of the woman's money;- but that' it would require some thousands of dollars from the old man, who was almost if not' quite, a millionaire: . ' • It is possible that a big ■'modern hospital, with its. intelligence, department and comprehensive recording system, and privately controlled, may be able to use an unfettered judgment in such cases, a judgment .rivalling Solomon's; but—is such a : thing possible in any public-controlled institution, where the prize often goes to the wire-puller? . POPULATION AND WEALTH It is; perhaps, fair to add that the American population is big enough to allow specialisation and classification of hospitals, under which classification the

public hospital's job is to give free treatment to the poor; while the le£s poor resort, according to their resources, to an ascending scale of privateor semipnyate- institutions. There are in the United States hospitals of moderate fee, made possible by philanthropic endowments. And this is where New Zealand is lacking. The lack in this country, of private or semi-private hospitals giving genera! service for a middle scale of fees may explain the situation. Had •6L e? lsted ' the Publ;c general hospital might _have pass 2 d over to them patients of moderate capacity to pay, whose capacity then would have been reasonably tested. Instead, the public general hospital has tried to treat all classes, and has quite failed to recover the proportion of fees to which it is fairly entitled. Ihe discrimination is too fine for a public body of the kind that exists to-day. And scarcity of population and wealth makes it hard to get away from the present system. ...

A PREMIUM TO DISHONESTY. „Th,e,,s itu. ation is fairly summed up.in the following passage in Dr. Macdonald Wilsons report: "As will readily be Been, such a system (the United States system) depends for its success upon philanthropy and a population able to pay large fees for treatment. Without wealthy philanthropic individuals, the Present system in the States could hardly exist, and the Government or municipality would be called upon to meet greater obligations. Again, without a large population able to pay heavy fees, and thus cover cost of free patienta, many of these hospitals would be constantly in debt. Already some of them not well endowed have difficulty in meeting expenseß." "■■'■'-. •Under.hospital managements that are honest, capable, and not responsible to electors, the attempt to make the rich pay for- the poor has. some chance of success.

Under the average New, Zealand Hospital Board, which . generally wants to please eyerybody and follow the line of least resistance, the rich do not pay for the-.poor; but the honest pay for the dishonest. . . ■

Still, .allowing for this inherent weakness of the system, uncollected fees should not be allowed'to reach their present scandalous ■ proportions: ;