HEALTH INSURANCE

Manawatu Standard, Volume LVII, Issue 196, 20 July 1937, Page 2

HEALTH INSURANCE

A NATIONAL PLAN, SUBMITTED BY B.M.A. MEETING OF DIFFICULTIES. In response to a request by the Government Investigation Committee on National Health Insurance, the New Zealand branch of the British Medical Association has submitted a plan for a national health insurance scheme. It points out, however, that it is not to bo taken that in submitting the plan the association is urging the'immediate introduction of its full scope. In view of the defects which experience of national health insurance has shown in other countries, and of the wide provisions already existing in our own health system, the committee urges the exercise of the utmost caution in adapting national health insurance to New Zealand conditions.

The plan, the association states, is based on what are judged to be the needs apparent at the present time which may be met by a modified adoption of the insurance principle for incorporation in our system on a limited scale. In the formation of the plan it has been necessary to deal with the needs of the community sectionally. We wish to emphasise that in doing this there is no thought in the mind of the profession of any social or class distinction other than the differences with which we have actually to deal jn medical work, whereby the endowment of health, the. circumstances affecting health, and accessibility to health service vary amongst individuals from innumerable causes. In the suggestions offered the association wishes further to emphasise that it does not seek the institution of a “poor man’s service” or a system of “poor relief.” but desires to meet special difficulties whore they arise, sij that complete health service may lie equally attainable, though not necessarily “free,” to the whole community. POPULATION GROUPS.

We have grouped the population into four sections, following the above principle. thus:— Section • I.—Old age pensioners, unemployed and unemployable, part-time and casual workers, others of small earnings or income who are not dependants of other persons, and the dependants of all those wiiere their earnings or total income (in the case of married people, their combined income) does not exceed old age pension, unemployed or sustenance rates. For those we suggest that complete service might be provided, as hereinafter outlined, in order that they may be as advantageously placed as the rest of the community in respect of necessary health service. Tills section of the population receives at present hospital services and other services attached to hospitals, though not always on an understood free basis. Not being able to afford domiciliary medical attention, they tend to occupy hospital accommodation for conditions for which hospital treatment is not required. They require more adequate service, especially in tlic direction of ordinary domiciliary medical and nursing service, the provision of which should give some relief in the matter of hospital accommodation. This, in our opinion, is the only section of the community which requires complete service solely at the expense of the public funds. The rest of the community can and should, either in who'e or in part, provide for their own health services.

Jn regard to probable costs, we are unable on account of insufficient data to give any accurate indication; but as amongst those affected there a relatively high incidence of sickness and special disability, a higher rate of remuneration would be required than obtains in existing contract practice winch embraces a selected body ol people. CONTRIBUTIONS IN PART.

Section ll.—Wage and salary earner's whose total income docs not exceed: (a) 60s per week, gross, single; (b) 80s per week, gross, married, without children (combined in come), 10s per week higher income for each child under 10 years being allowed to entitle inclusion. For this section we propose that they should be contributors for themselves and their dependants to a scheme whereby they would be provided with complete health service as in Section I. In the light of past experience, we think their contribution could be made on such- a scale as would defray the cost of general practitioner service, and some of the cost of hospital service; but to furni.ii complete service. public funds would.be required to bear part of the costs. Superficially, it may seem anomalous not to include in this section those who arc working on their own account, but of sometimes no greater income than the above. But such people do not as a rule suffer entire loss of income when laid aside by sickness. Arrangements are generally made whereby their trade or business is carried on. so that their need is not usually as great as in the case of those whose temporary inability to work means cessation of income. Further, in all assessments of income from wages and salary it will be necessary to include allowances in kind of every description, and, as has been found in every country, the correspondiu(r assessment of equities in the case workers presents a very complicated problem. But in the next section we hope to show that something can be done to guard the main risk of this deserving body. Section 111.— All having income not exceeding £SOO per annum, and not included in Section If. The sickness risk which presses on such people is not ordinary domiciliary and consulting room medical attendance. It is the more serious illness involving hospitalisation, specialists’ service, and costly diagnostic procedures. We suggest, therefore, that this section should make their own arrangements for themselves and their dependants for ordinary medical attendance, but should contribute to an insurance fund for hospital, specialist and consultant services, this fund to provide a cash benefit for those purposes. This should be on a compulsory and self-supporting basis. It has been demonstrated that, spread over such a group, a scheme can be run on a sound basis, e.g., “Oxford and District Provident Association” in England. We believe that this would give considerable relief to the problem of hospital accommodation and finance. Section IV.—Those with income exceeding £SOO per annum. This section are capable of providing all services for themselves. There are opportunities for insurance against sickness risks open to them, if they like to avail themselves of them, -and they could he admitted, if they choose, to the scheme suggested for Section 111.

The underlying idea of these suggestions is that the insurance principle should be brought in to assist people to meet their needs where those press most heavily, and that they should rely more and more on that principle as their circumstances permit them to use it.

COMPLETE HEALTH SERVICE. The term “Complete Health Service” has been used in the foregoing, and

it is necessary to explain wliat is understood in that term. The health system as a whole embraces a wide variety of activities which fall, broadly, under two headings, preventive medicine and curative medicine. What we wish to show is how an insurance scheme can be dove-tailed into the existing system of curative medicine.

The elements of a complete service have the family doctor as the essential pivotal point, and are here set out in the order in which they are commonly related to his 'work. Norma.ly, these various elements should be employed through reference by the general practitioner who is the family doctor. (a) General practitioner service, (b) nursing service (home); (c> anaesthetics ; (d) pharmaceutical services; (e) consultant and specialist services; (f) laboratory and radiology services. (g) hospital services and ambulance, (h) maternity services ; (i) physiotherapy and massage services ; (j) dental service We are not including here certain items which appear to come more conveniently under direct departmental control, such as mental hospitals, spas, ami provision lor certain special diseases. We next propose to discuss a little more fully the various items of a com plete service. General Practitioner Service,—Where employed under an insurance system, the general character of ordinary private practice should be preserved us it exists at present; but surgery (excepting certain minor surgery), maternity work, and the administration ol anaesthetics—local and general—must be excluded. General practitioner service should he linked with the otliei services in order that full and consecu tive knowledge of the health condition of patients can he maintained, The association has formulated certain pnn ciples which arc in conformity with those adopted elsewhere in the relation ship of this branch of service to health insurance systems. These principles provide:—That the confidential basis between the family doctor and his patients be maintained, and that satisfactory relationships between him and all other agencies concerned in .serving the health interests of the people should be fostered. That there be statutory right of every registered medical practitioner to undertake national health insuran That r to Ce ’ensure the best quality of service, remuneration be adequate. That there be free choice as between doctor and patient. That income limit be fixed for those eligible. .

Nursing Service. —Home nursing service to undertake the proper nursing of the sick in their own homes in suitable cases under medical supervision would he a great assistance, and would tend to relieve the costs of hospitalisation. Pharmaceutical Service. —-Supply of drugs, dressings and medical and surgical appliances should be made only under medical prescription. Under insurance conditions there is a tendency to rising costs due to increased consumption of drugs, not actually necessary but difficult to avoid. To control this undesirable development we flunk it advisable that the patient should bear some part of the cost of medicines. or at least of repeat prescriptions. Anaesthetics. —In modern medicine the variety an 1 choice of anaesthetics suitable in different conditions have become very wide. They are more costly than commonly supposed. At the present time the selection of _ suitable types of anaesthesia is- an important part of every surgical procedure. The administration in particular cases is a matter of special skill and costly apparatus and material. Consequent'}', anaesthetics must be considered as a separate service, and allowance made for special types of anaesthesia where required.

Consultant ami Specialist Service. — In the best interests of the people thc=e should he available as called for hv the family doctor. The general practitioner should feel free to refer questions of difficulty to consultants and specialists. Laboratory and Radiology Service. —in modern machine diagnosis has come to depend more and more upon investigations of this kind, and effective treatment in many conditions depends upon the laboratory and radiology department. These types of service entail exceptionally costly equipment. and specialised technical and professional personnel, but are quite essential to complete service. HOSPITAL SERVICE.

This is, naturally, a most important factor in complete service, and, in order to he most effective, must he closely related to treatment by the family medical attendant, and available in both public and private hospitals. The linking up of hospital service with domiciliary and convalescent treatment would he facilitated by the employment of hospital almoners. Experience has shown that better service to the patient and economy to hos pit.als are obtainable by convalescent arrangements made by these officers, and the.employment of trained persons for this work should he encouraged. Out-patients departments should be retained purely for casualty and emergency work. In the plan submitted we content plate Section T being given hospital benefit in public hospitals, when recommended by the practitioner, at no cost to themselves, in the case of Section If so.mo fraction of hospital cost would he defrayed by their insurance contributions As regards Section HI (and Section IV, if electing to join) the lienefit is a cash one, and normally sufficient for hospital, consultant and specialist costs, thus relieving rates and taxes. In the case of all sections, persons preferring to he treated in private hospitals should have maintenance costs paid on the same scale ns allowed in public hospital, and an allowance toward specialist treatment for Sections I and 11. It can he demonstrated that stay in private hospital tends to he shorter than in public hospital for several reasons, so that there is no need for differentiation. fn order to provide more efficient service for special types of disease, better linking up of hospitals is required. This can only he achieved by a redistribution of hospital districts so as to provide larger districts, permitting proper classification of hospitals according to their ability to deal with special varieties of work. Patients would thus bo easily transferred from one hospital to another according to their medical and surgical requirements rnthei than according to their geographical domicile. . . To facilitate the treatment of special classes of cases requiring facilities which can he provided only in PJiblic hospitals, it will lie necessary to institute a system of community hospitals, involving reorganisation of the system of hospital administration. We visualise these changes coming about, not l>v iinmedXs radical overthrow, hut by gradual development, until health districts, hospital districts and health insurance 'districts are the same, with all health activities in a district relationship. Maternity Service.—Provision for this elemental human need -by complete maternity services, both domiciliary and hospital, including ante-hiatal and post-natal attendance by a medical practitioner, should he made for those unable to meet their own requirements, even if no other part of this plan be adopted. In view of the

enquiry now proceeding we do not propose to comment iurther on this except to point out that of recent years ante-natal supervision has assumed great importance, and entails much additional attention by practitioners, and further, that allowance has to be made for the more common reliance on specialists in difficult cases. Physiotherapy and Massage .Service.—This is a necessary modern adjunct to treatment required through reference by practitioners. Dental Service. —This is a matter for discussion with the Dental Association, and we merely mention it as we frequently, as a part of medical treatment. have to refer patients to this allied profession. Medical Service for the Maoris. — This association has come to the conclusion. after discussion with members who have had experience, and with the department, that this is at present a separate problem which cannot l>e d n alt with as an insurance question. We think the matter has lwen taken up on correct lines by the Health Department. Mileage —The question of mileage has proved, in all overseas Dominions, one of the knotty problems in the discussion of n. n t'on o l health insurance, and we have Imp-.l of no full solution. To meet special difficulties, we suggest that it may In? possible in addition to transport allowances for ordinary circumstances. to make allocation for places specially difficult of access. Med : oel Research.—Tim profession appreciates (he interest the committee has shown in this matter There are manv questions srmcifienllv affecting the health "of the New Zealand people, not only on the fie'd of diseases but also as regards nutrition, which require invest ig"+"on, as well as points related to medical research elsewhere. We urge the strongest possible support for this need. V It is felt that the first stop should lm the institution of a Council of Medical Research to instigate and supervise med-eal research and control expenditure. W» suggest that a suitable body for the purpose might be fepnd in the m<-<-],'cal members of the Roan] of Health ; for winch lrndy we are later proposing reconstitution. THE COST. The association regrets having to disappoint the committee in regard to a submission of terms and costs. The plain fact, is that there i s not sufficient information available to make this possible. We are not in a posit'on to make or accept an offer. For tlie same reason we venture to suggest that the committee is similarly placed. We were asked to submit a scheme sectionallv arranged, so that one part nr another could be adopted. This we have done, and we trust it will demonstrate the magnitude of a complete scheme. Tf. and when, the people, knowing the implications, decide that such a plan, or part of it. should be adopted, and when full d'h are available. then costs and definitions can be discussed.

Sn?'h matters as administration of tin service are also dealt with in the B.M.A. plan.

3.45 P.M. EDITION