United States Department of Agriculture Farm Security Administration ACTIVITIES OF AH. EXPERIMENTAL RURAL HEALTH PROGRAM IN SIX COUNTIES DURING ITS FIRST FISCAL YEAR, 1942-43 Program Sponsored by the Department’s Interbureau Committee on Post-War Programs By Jesse E. Yaukey, Statistician UoSo Public Health Service assigned to the Farm Security Administration Washington, Do C. March, 1S45 A cknowledgments Grateful acknowledgment is made of the assistance of the business managers and office assistants of the six health associations whose activities are the subject of this study. Detailed and accurate reports of services, charges, and payments submitted monthly by these offices have provided the main sources of data used. Material assistance was also rendered by Miss Ruth Bunker, Miss Leah Resnick and Miss Doris Carroll in the preparation of the tables and graphs incorporated in the study.- Valuable contributions were also made by Dr. F. D. Mott, Chief Medical Officer of the Farm Security Administration, and members of his staff. Dr. R. C.., Williams and Dr. S. D. Collins of the U. S« Public Health Service, who read the manuscript and made helpful suggestions for its improvement. CONTENTS - Chapter Page I Summary Statement- .......................... g Plan of Operation 2 Volume of Service 3 Charges and Payments 6 II ■ Organization and Membership Q Organization o o og o,, o 3 Services Offered and Provision for Payment 9 Enrollment of Members ...................... *.... 10 Income Grouping of Members ....................... , 0 0 0 12 Percentage of Eligible Families Holding Membership 13 III Volume of Service _v Comparison mth Service to General Rural Population .... 15 Physicians ' Services 16 Received by Each Association 16 Monthly Variations ., 20 Surgical Services ...................................... 24 Received by Each Association ......................... 24 Monthly Variations 26 Hospital Services ...................................... 27 Received by Each Association ......................... 27 Monthly Variations ................................... 29 Drug Service ........................................... 30 Dental Service ......................................... 38 Received by Each Association ......................... 38 Monthly Va riations ................................... 42 Nursing Service ........................................ 45 IV Charges and Payments for Service ......................... 49 Totals Charged and Percentage Paid Per Family 49 Distribution of Charges by Type of Service .............. 50 Disbursements ..... ..................................... 53 Appendix tables .......................................... 60 ACTIVITIES an experimental rural health program IN sii* COUNTIES DURING ITS FIRST FISCAL YEAR, 1942-43 i sutory statement Plan of Operation During the latter half of 1942 the Department of Agriculture, act- ing through1 its Interbureau Committee on Post-war Programs,sponsored health servi°e associations among the farm population of six dif- ferent ruf’3-! counties. These associations were set up with the assistano-'6 of Farm Security Administration personnel, which also provided a certain amount of supervision and advice on their operation. The urinary purple of the undertaking was to assist local rural groups in wording out clans for meeting their health problems, and to add to t>ne fund of experience in the field of health service to rural peo/ple. The associations were formally incorporated with boards of di-rectors in active charge of their operation. Membership was ooen ito all residents in the counties, in which the associations were located, who secured most of their income from agricultural pursuits. Members paid annual dues amounting to six per cent of their net cash income during 1941 and these payments were supplemented where neces- sary from Farm Security Administration funds in sufficient amount to bring the total payments per member to a sum ranging from 950 to 957 for the different associations. This membership fee was then dis- tributed in definite amounts to funds designated for the different types of service to be provided. The fund for each service was then divided into twelve equal marts and one of these parts was used to pay the cost of that service each month. For all services, except physicians and drug service in one county, payments were made on the basis of bills sdbmitted for services rendered (the fee-for-service plan). In one county the physicians dispensed their own drugs and each one was paid for service and drugs on ih e basis of the number of families for whom he was recognized to be the family physician during the month, regardless of the amount of ser- vice rendered (the capitation plan). The services offered were general practitioners' care, surgeons' and specialists' care, hospitalization, drug service, dental care and, in four associations, community nursing service. Due to the shortage of nurses, only three, of the four associations were able to actually provide nursing service and they succeeded in doing it for only part of the year. The membership of the different associations ranged from 4.61 families of 2,015 persons to 2,379 families of 10,337 persons* Membership of the six associations together totaled 8,141 families of .35*827 persons. The percentage which the membership in these associations constituted of the total rural-farm population of the counties, in -which they were located ranged from 31 to 69 per cent for the different associations and averaged 45 per cent for all associations. The average annual net cash income per member-family in 1941 is available for three, of the associations. It was $383, $180 and $114 per family respectively. Volume of Service The amount of medical care received by members of these associations was well above that found to have been received by the general rural population, according to the survey of the Committee on the Costs of Medical Care. Almost three times as many cases received physicians' care as received this service in the general rural population and a similar increase was noted in the number of cases hospitalized. The number of physicians’ office and home calls was also considerably more than that for the general rural population, though the increase was less marked, than the increase in the number of cases. This is to be expected since the additional cases receiving physicians’ care would naturally be less severe cases requiring a proportionately smaller amount of care. It is significant that the increase in the number of calls was entirely in the field of office calls, the number of home calls being actually reduced by half a natural effect of illness receiving earlier care. In spite of the number of hospital admissions being quite above that for the general rural population, the number of days of hospitalization received is slightly less. This is the only one of the rates, showing volume of physicians', surgeons', hospital, and dental service, which was higher for the general rural population than it was for the health associations. , The number of health associa- tion members receiving surgical care was one and one-half times as high as that-for the general rural population and the number of tonsillectomies was almost three times as high. Dental service rates also ranged from one and one-half to two times the rates for the general rural population. The rates indicating the volume of the different kinds of service received by the members of each of the six associations varied considerably. For physicians’ service, the association rates ranged from 1964 to 1022 cases and from 549$ to 1778 ca'!ls per thousand persons per year. The averages for all associations mere 1408 cases and 2917 calls per thou- sand oersons oer year. A close correlation mas noted between the rates indicating the number of cases served and the number of calls per case. The associations serving the smaller number of cases also rendered the smaller number of service that would be left. As the number of calls were reduced the proportion of home and hospital calls was found in general to increase, supporting the theory, proposed above, that for associations rendering a smaller volume of service.the proportion of more severe cases is relatively high. The monthly call rates for the different associations sh owed some unnatural fluctuation during the first month or two of operation, and for three associations they were affected by the collapse of the drug service. The average month-to-month rate for all six associaticns is, however, quite with a slight increase in volume apparent through the months from November,1942 forward. This increase in the number of physicians’ calls is accompanied by a slight decrease in the number of cases served, resulting in a rise in the number of calls per case for all six associations from 1.85 in September, 1942 to 2.49 in August, 1943* This trend characterized the experience of each of the six associations. The proportion of the total volume of calls which were home calls was found to reach its highest point during January, February, and March for four of the six associations. On durgical cases the record is not complete, since some minor surgery was reported as general physicians'-service. This incomplete record, however, gives a high case rate, averaging 70 cases per thousand persons and ranging from 196 to 36 cases for the different associations. Com- plete records have been secured on tonsillectomies, appendectomies, and surgical operations on gynecological cases. Rates for these services for all associations were 34 cases per thousand persons per year for tonsillectomies and 8,4 and 9.0 cases respectively for the other two services. This is two and a half times the tonsillectomy.rate for the general rural population and a fifty per cent increase over the prevail- ing rates for the other two types of service, fhe monthly surgical case rates for all associations, if tonsillectomies are omitted, remain rela- tively constant through the year. The monthly variation in the, tonsil- lectomy rates conforms closely to the corresponding variation f6r the general population!. Hospital admissions for all associations averaged, 110 per thousand persons per year with the rates of the different associations ranging from 177 to 59. These admissions constituted from 5.3 to 8*7 por cent of the total cases receiving physicians1 and surgeons' care. The number of days of hospitalization per thousand persons per year averaged 4 24 for all associations and ranged from 727 to 266. This rate showed a tendency to decline slightly through the year with a rise during the winter months and a pronounced rise at the end of the year possibly associated with a corresponding rise in the number of surgical cases. This same pattern, noted in the monthly variation in the number of days of hospitalization used, is also evident in the monthly rates showing number of days pf hospitalization per case. Drag service gave the associations more difficulty than any other service offered. For two of the associations this service collapsed once during the year, and these two associations and also a third one had to reouire part payment of the cost of prescriptions by members in order to carry the service through the year. The effect of this requirement was evident in the reduced number of orcscriotions used and it may also have reduced the volume of physicians’ service, though evidence on that point is not conclusive. The reductions in the number of prescriptions used for these three associations brought them to the point where thejr compared closely with the monthly rates for the other associations. This rate mas between two and two and a half prescriptions per person per year. The charges per prescrip- tion ranged from 69 cents to $1.19 for the different associations mith 83 cents the average for all associations. The two associations which succeeded in carrying their drug programs through the year, without adjustment showed the lowest average charges. They ran 69 and 71 cents per prescription. Examination of the monthly average charges per prescription for the different associations shows a slightly declining trend in the averages for these two associations, while for the other associations the rate tended to rise after the patient began to pay part of the charge. The dental services offered under the program mere limited. Emergency dental '"vice provided for all members and beyond this, prophylaxis, extractions and fillings mere provided particularly for children and young people to the extent that the allowance of funds and the time of the cooperating dentists mould permit*-It mas found that emergency ser- vice, as contrasted mith service mhich might be postponed to some later date, pas a much less dominant part' of the dental service than it mas of the. other services offered by these associations. One of the associa- tions provided no fillings but centered its attention on extractions and examinations including a large number of diagnostic x-rays, and this mas the only association for mhich the charges submitted during the year exceeded the funds provided for their payment. The extraction rate for this association mas 745 teeth per thousand persons per year. Extraction rates for the different associations ranged from this 745 dornn to 404 mith an average of 571 for all associations. The rates for fillings in the different associations ranged from 528 to 282 per thou- sand persons per year mith 368 the average for all associations. Total dental services including prophylaxis, examinations, treatments and other similar services in addition to extractions and fillings averaged 1,056 per thousand persons per year for all associations. Of the total number of cases receiving extractions 25 Per cent mere children under 15 years of age, and 43 per cent of the cases receiving fillings belonged in this age group. The trend in the monthly rates for both fillings and extractions mas domnmard for all associations mith a tendency tomard a rise at the end of the year for several of then. The number of extractions mas rather consistently in excess of fillings all through the year for all except one association mhich came to the end of the year mith a ratio of 1.3 fillings per extraction. The ratio for the five associations providing fillings mas seven-tenths of a filling per extraction. Community nursing service mas planned by four of the six associations as a part of their program. Only three of the four -mere, however, able to secure nurses and they for only part of the year. Reports on nursing -service were received from only one of the three. In this association the nurses collaborated with the nurses of the local county health unit and rendered a very satisfactory volume of the usual health unit services. Charge sand Payments In all except one of the associations payment was made for all services rendered, except nursing, on the fee-for-service basis. Payment for nursing was made on the salary basis, and in one of the associations the physicians dispensed all drugs prescribed and received payment for their services and drugs on the capitation basis. For the services for which charges were submitted, the average charge per family was found to vary widely for the different associations. For physicians’ service for which the variation was the broadest, it ranged from. $56.47 to $20.66 per family. Variation in volume of service was a major factor in producing this variation in charge though the associations rendering the largest volume of service disc had comparatively high fee rates. Payments averaging 55.9 per cent and ranging from 96 to 32.7 per cent •were made on physicians' charges. Surgeons' and specialists*' charges came next after physicians’ in point of variation from the average. They averaged $9.01 per family with a range from $15,00 to $7.03 Payments ranged from 96 to 43,5 per cent and averaged 67 per cent. Hospital charges averaged $11.20 per family, drug charges $10,10 and dentists' charges $6,62, These charges were relatively uniform for all associations and payments on them averaged.88.1, 87.6 and 97.9 per cent respectively. It was found that the association which had a high average charge per family for one service was likely to have high averages for other services also with the- result that the cumulative charge per family for all services in the different associations shows a wider variation than is found in the charges per family for any individual service. On the basis of this cumulative charge per family the five associations for. wl ich charges for all services were submitted fall into distinct groups, one having charges per family totaling over $90 and the other having charges totaling only between $50 and $55, Percentage distribution of charges by type of service for all associa- tions shows 47.4 of the charges for physicians' service, approximately equal amounts around 13 or 14 per cent each for the three categories, surgical and specialists’ services, hospitalization,. and drugs, and ten per cent.for dental service. Similar distributions shown in the reports of the Committee on the Costs of Medical Care and the Consumer Purchases Study are only roughly comparable to these for the five associations but tend to indicate that the five associations' charges for physicians' and surgeons' services may constitute a-slightly larger proportion of their total than these charges constitute for the other two groups. This is consistent with the increased volume of physicians' and surgeons' service which the members of these associations are shown to have received. Disbursements of the six associations totaled §4-16,367.57. The cost of administration averaged 6.6 per cent of this total for all associations, Tith the nercentages for the-different associations ranging from 5.5 to 10,7 per cent. II ORGANIZATION AND MEMBERSHIP Organization The counties in which the Experimental Rural Health Program was to be carried on were chosen with the approval of the Interbureau Committee on Post-War Programs according to carefully developed criteria. The following are seven major points on which the counties wrere tested: 1. Active County Agricultural (see below) Planning Committee 2. local interest in medical care needs 3. Typical rural county 4. Farm income approximately the same as in the State as a whole 5. Medical, dental and hospital facilities reasonably adequate and reasonably accessible to all farm families in county or area 6. Receptive attitude on part of professional groups 7. Desirable; Full-time local public health unit On the basis of these criteria six counties were chosen in which health associations were set up. The names of these associations, the states in which they are located and the dates on which they began operation are shown below. Activities Association State started Cass County Rural Health Service Texas Sept. 1, 1942 Hamilton County Medical Aid Association Nebraska Sept. 1, 1942 Nevada County Rural Health Services Association, Inc, Arkansas Sept. 15 , 1942 Newton County Rural Health Services Association, Inc, Mississippi Aug. 1, 1942 Walton County Agricultural Health Assn. Georgia Nov. 1, 1942 Wheeler County Rural Health Service Texas July 1, 1942 This report briefly describes the basis on which the associations operated and the amount of services of different types which were received by the members from month to month, through the year. It is based on information found in monthly reports of the different associations and is limited to an analysis of the gross volume of the different types of service received, A more detailed study, involving age, income and race of the members and illness diagnosis, is in progress. (a) Experimental Rural Health Program, Interbureau Coordinating Committee on Post-War Programs, U. S. Department of Agriculture, March, 194-2. Local initiative in forming these associations was provided by the County Agricultural Planning Committees. They brought together repre- sentative farmer groups who heard the proposal of the Interbureau Com- mittee on Programs and finding it acceptable, formed associa- tions, drew up their constitutions and by-laws, elected boards of directors and were formally incorporated according to the laws of their various states. The boards of directors then assumed active charge of the programs and carried them through the year. Membership was open to all families and persons who secured most of their livelihood from agricultural pursuits. Each family was required to pay a fee equal to six per cent of its net cash income during 1941, rrith a minimum fee of five dollars' for the Newton and Nevada County associations, six dollars for the Cass, walton and ‘'"heeler County associations and ten dollars for the Hamilton County association, and with a maximum fee equivalent to the over-all per family cost of the program as agreed upon in advance. These fees were s upnlemented from Farm Security Admini- stration funds through grants to the associations in sufficient amounts to bring the total up the the full amount per member required to cover the cost of service. According to this plan only those members unable to pay the full cost benefited from the Farm Security Administration grant funds made available to the associations. The estimates on cost of* service per family were made by the boards of directors after due consultation with the local professional groups to whom they would look for provision of the health services to be secured for their members. The amounts settled upon were $50 for the Cass and v'alton County associa- tions, $54 for the Nevada, Newton and TVheeler County associations and $57 for the Hamilton County association. Services Offered and Provision for Payment The services offered by all associations were physicians’ care, surgeons' and specialists' care, hospitalization, prescribed drugs, and limited dental service. Community nursing service was also included in the program of three associations. Specific limitations on the ser- vices varied for different associations but the tendency was to provide medical care .for virtually all types of cases except definitely chronic conditions such as tuberculosis and cases which were either eligible for service through local health departments or covered by some form of insurance. Hospitalization was limited in most associations to 14 days per caee. The trend with reference to dental care was to provide for all members prophylaxis and extractions necessary for removal of threat to health, and in addition amalgam and synthetic porcelain fillings for children. The distribution of membership fees to cover the cost of these various types of service in the different associations is shown in Table 1. Table 1. Allocation of membership fee•to■different types of service 0*0' SJ tJ 33 CO 0" 02 a o o 3 3 O 3 3* CD B 3 3 3 CO 4 3 H- C+ C*" CO TO d TO CO 3 h*• p H- H* CD H* H* H- rd 3 r+ O o O co to TO p 3 H* CD c+* CD i-* CO P •-3 3 3 — 3 O p c+ 1 CO c+ c+ in — P Hr xi H o CD f 3 O H* P H- CO r+ CO -£0= On H H O O 30 H <3 U) on O O O P • • ■ • • • • • • • co O O O o O o o O O CO ° Q o o O o o 0-0 — 33 =S* P on 0 30 |3 <3 OJ 133.33 - •183.32' 247 : 17.2 | 200 - 299 85 1 i 17.8 170 i 19.3 •183.33 - 233.32* 115 8.0 300 - 399 83 ! 17.4 | •73 8.3 1233.33 - 283.32; 60 | 4.2 400 - 499 59 .1 12.3 . 27 .4 . 3.0 1283.33 - 333.32l 19 1.3 500 - 649 60 1 12.6 1 i 1333.33 - 383.32 15 1.0 650 - 799 i7 : 3.5 v | 31 3.6 1383.33 & over 20 ; 1.4 : 800 & over 60 , 12.6; ? i Total 478 •100.0 ' 881 j 100.0 Kin • •- ■ ■ • I * 1437 1 100.0 i The information supplied by these counties, giving details for the higher income groups, beyond that shown above, indicates an average net cash income of $383' for the Hamilton County association, $180 for the Walton County association and $114 for the Nevada County association. While definite information of this sort has not been received from the other three associations, some indication of the average income of their members is ■ provided in their average payment per family on member- ship fees, 'These payments represented six per cent of the net cash income of the members during the. 194-1 crop year with a minimum set by each association representing the smallest amount to be- accepted from any family regardless of income. This provision had the effect of producing an average oayment oer family slightly above six per cent of the average annual income. The average payments by families on membership fees for.the different associations are listed below in order of size of payment. The minimum fee accepted.'from any family by each association is also shown• Association Payment per member Minimum fee Association Payment or r member Minimum fee Hamilton $25 .in $10 Cass $9.50 $6 21.63 6 Nevada 7.88 5 Walton 11.77 6 Nerdson 6.06 5 Percentage of Eligible Families Holding 'Membership It is of interest to note the percentage which the membership of these associations constituted of the total rural-farm population of the counties in which they were located, (Table 5) • Members hie in these associations is available to a slightly broader group than that included in the rural-farm classification of the Bureau of the Census. The usual qualification for membership was that the family earn more than half of its income from agricultural pursuits whereas therural - farm population is limited to families living on farms, However, the alternative population figure available is that for the entire mral population and, of the two, the rural-farm population more nearly defines the group from, which the membership of these associations was drawn • Table 5. Percentage which members of each association represented of the total rural-farm population of the county in which it was located 0,-4' Membership Rural-farm i Per cent ! Association End of fiscal year population I Holding Famili es Persons (1940 census) I ’ lembership All Assns. 8141 . 35,827 79,552 45.0' Cass 2379 10,337 22,701 45.5 Hamilton * 478 2,079 6,060 34.3 Nevada 1437 6,350 13,796 46.0 - Newton 1985 8,958 17,910 50.0 Walton 881 4,031 13,146 30.7 Wheeler 981 4,072 5,939 68.6 It is to be remembered in this connection that the percentage of the farm population covered by membership in these associations cannot in every case be considered a measure of the acceptance of the urogram by the farm groups in the various counties. In three of the associa- tions - Cass, Wheeler and -Merton Counties - the funds available for supplementing membership fee payments by members were exhausted and when that point was reached they were able to add only such new members as were able to pay the entire membership fee themselves. Among the six associations the lowest percentage of the rural-farm population holding membership was 31 per cent in Dalton County, Georgia and the highest was 69 per cent in County, Texas. The average for the six associations was A5 per cent. III VOLUME OF SERVICE Comparison with Service to General Rural Population The volume of each of the different types of service received during the year, charges, payments, and certain significant rates for each association and for all associations taken together are shown in Table 25. Rates shown indicate that the volume of ser- vice is. consistently high for all types of service. Comparison of the more significant rates with corresponding rates for the general rural population are shown in Table 6. The rates shown for the general rural population are based on the findings of the Committee on the Costs of Medical Care in its survey made in 1928- 31. It seems evident after the points of difference have been taken into account, that the health association members received from 60 to 75 per cent more physicians' calls than the general rural population. Health association rates are also higher for all other types of service except hospitalization. Here the number of hospital admissions is higher than that for the general rural pop- ulation but the number of dags of'hospitalization is slightly lower. The higher admission rate may'be taken to be reasonably satisfactory evidence that cases needing hospital care'at least secure admission to the hospital more readily than they did with- out' the help of these associations and this is significant. Hos- i- wm pital care has been made available to them. If the total number of days of hospitalization wised is less than among the general rural population it is due to earlier discharge from the hospital and it is a safe assumption that, having secured admission to a hospital, a case will not be dismissed until at least it is past its more critical sta,ge. It will be noted that the high hospital admission rate shown in Table 6 for the health associations is matched by a correspondingly high rate for cases receiving physicians1, care. Both of these rates are almost three tines the rates for the rural population and this is the widest contrast to be found among the two groups of rates shown in Table 6. The corresponding rates for days of hospitaliza- tion and physicians' calls among health association members differ much less widely from those-for the general rural population. This is taken to indicate that under the health association program there has been a tendency to call on the doctor or seek admission to the hospital for much less severe illnesses or complaints. The result has been a marked increase in the number of cases for w/hich physicians’ care or hospitalization or both havo been requested but a marked decrease in the amount of service each core re- quired. The significant averages indicated for health associa- tion cases are 2,0 office and home calls per physicians’ case and 3.9 days of hospitalization per admission as compared with 5.0 office and home calls per physicians’ case and 11 days of hospitalization per admission for the general rural population (a). Further support of the theory that higher casd rates for phy- sicians’ and hospital service arc due to less severe cases re- questing service is found in the marked reduction in the number of physicians’ home calls. The number of home calls received by health members is 208 per thousand persons 'as compared with 530 among the general rural population. The increase in volume of physicians’ service has been entirely in the field of office calls. The percentage of office and home calls which were home calls was seven per cent for the health associations as compared with 34 per cent for the general rural population. The major significance of this trend in the health associations' program lies in its bringing less severe cases of illness under physi- cians’ care — with hospitalization where necessary -- and thus averting more severe illness. In addition to this there is also the conservation of the physicians' time indicated in this re- duction in the number of home calls. This decrease in the home call rate over that for the general rural population should also allay the fear? sometimes expressed that there will be a tendency on the part of the patients to call physicians to their homes unnecessarily if they do not have to pay an extra fee for such service. Physicians1 Services Received by Each Association The rates shown in Table 6 represent the average of the experience (a) Collins, Selwyn D. ; Variation in Hospitalization v.dth Size of City, Family Income and Other Environmental Factors. Public Health Reports 57; 1535-1659 (October 30, 1942), This is the rate indicated by crude totals of admissions and- days of hospitalization. Ago - adjusted rates for admissions and days of hospitalization shown in Table 6 indicate an average of 12 days of hospitalization per case. Table 6, Selected rates per thousand persons per year for services rendered by all associations and corres- ponding rates for the general rural population 1 Service Health associations General rural population Physi c ians' service • ‘ ' ' ' ‘ 1 Cases 1409 526(a) Calls, office and hone 2821 1570(b) u ■, office 2613 1040(b) H , home 200 530(b) Surgical cases • 1 i Cases 70.4 47.7 (o) Tonsillect onie s 34.3 13.5 (c) j Append e c tomie s 5.4 5,2 (c) Gynecological 9,0 5o 5 (c) (Hospital service ! \ 1 Admissions no ; 42 (d) Days hospitalized 424 505 (d) Dental services ! Cases pcj c1 ) 159 (e) Extractions 571 275 (e) Fillings 368 249 (e) (a) Collins, Selwyn D,: .Frequency and Volume of Doctor’s Calls Among Males and Females in 9,000 Families, Based on Hation-Wide Periodic Canvasses, 1928-31, Public Health Reports 55: 1977-2020, P, 1985, Table 1. The rate shown is the rate for the general population, urban and rural and so is probably somev/hat hi her than the corres- ponding rate for the rural population only. (b) Hollingsworth, Helen; Klem,NMargaret C,; Medical Care and Costs in Relation to Family Income* Social Security Board, Bureau Memorandum No. 51, March; 1943* Table IOC. These rates are not entirely com." parable to the corresponding health association rates, since they include calls of surgeons and specialists while the health association rates cower the services of general practitioners and only a limited amount of surgery. Correction for this factor would tend to decrease the general rural population rates and so increase the difference between them and the health association rates. On the other hand, the general rural population rates are limited to services to cases of illness while the health association rates include physical exam- inations, immunizations and other services not related to illness. Unpublished data of the Committee on the Costs of Medical Care, how- ever, indicate that such services constitute only from five to nine per cent of the total volume of physicians’ calls. They are, there- fore, only a minor factor in accounting for the difference betvreen these rates for the general rural population and the health associations of all six health associations. Examination of the records of each of these associations shows considerable variation among them in the volume of different types of service received. ig fAys'sc//)y*s/cy#/?s'' co//s os~ is shown in Table 11 to be 70.4 as compared with a rate of 47,7 (Table t) for the general rural population. The rates for the different associa- tions range widely from 196 cases per thousand persons per year for the Hamilton County association to 35.9 cases for the Nevada County associa- tion. This rate of the Nevada County association is, however, the only Table 11. Number of surgeons' and specialists’ cases per thousand uersons per year in each association Service All assns o i Cass ! Hamiltont Nevada Newton> 1 “““ I T'u alt on ! Wheeler; Number o£ cases per thousand persons per year J All surgery 70,4 j 78.1 1 I 196,0 35,9 ! 57.2 ! 55.7 i 80,1 i Tonsillectomies 34.3 i 42,7 78,4 11.4 1 V/i ’ r. , ■ o o' 20.7 ; 36.4 App ende c torai e s n A O o *3? 13.1 5.0 4,4 i 5.5; 9.2 i 9* (5 Gynecological 9,0 , 7,6 8,4 7,1 6,9 4.7 1 22.2 Other 18 o 7 14,7 104,2 1 13,0 10.2 21.1 1 11.9 Non~ surgical ! 1 ! i i i Specialists 11.5 1,7 33,7 ' 6,6 30,3 | 2.1 .9 J one which falls below the rate of 48 cases for the general rural popula- tion. While it is felt, as has already been stated, that the records of surgical cases generally are not altogether complete, this criticism does not apply for the totals of tonsillectomies and appendectomies since these services are definitely considered surgical services and are cer- tain to be consistently reported as such. Half of the surgical cases reported for all associations were tonsillectomies. The ratios for the different associations range from 50 per cent in the Newton County asso- ciation to 32 per cent in the Nevada County association. The tonsillec- tomy rate for all associations was 34.3 per thousand persons per year which is more than two and a half times the rate of 14 for the general rural population (Table 6). The rates for the individual associations range from 78,4 for the Hamilton County association to 11,4 for the Nevada County association. It is natural that there should bo an extra- ordinarily high rate for tonsillectomies due to the backlog of elective surgeryr of this type which exists especially among, rural people. The wide variation in rates for the different associations is probably due quite as much to the varying limitations on service such as scarcity of surgeons, etc., as it is the variation in need for this service in the different associations. The- appendectomy rate for all associations taken together was 8.4 cases per thousand persons per year which is 50 per cent above the rate of 5.2 cases for the general rural population (Table C). The rates for the different associations range from 13.1 cases for the Cass County associa- tion to 4.4 cases for the Nevada County association. Surgery for gynecological conditions among women averaged 9.0 cases per thousand persons per year.for all associations with the range for the different associations running from,an extremely high rate of 22.2 cases for the “Wheelor County association to 4.7 cases for the Walton County association. The comparable rate for the general rural population is 5.5' cases (Table 6). The high rate for the Wheeler County association is accounted for at least in part by a tendency on the part of this asso- ciation to count cases for whom service at the time of obstetrical de- livery included surgical repair of lesions sustained or other, like servic* Information on other typos of surgical operation is not available at this time but will bo provided in a more detailed study now under way. Monthly Variations in Surgical Services The .rat.es per thousand persons per year indicated by the surgical oper- ations performed each month are shown in Table 12 to drop markedly dur- ing, the...winter and spring months. However, exclusion of tonsillectomies from .the..total rates indicates that they are almost entirely responsible for this variation, the rate for other operations remaining relatively constant through the year. The marked rise in August in the rate for Table 12. Rates per thousand persons per year indicated by the number of tonsillectomies and other surgical opera- tions performed each month during the year i , Month All surgery Tonsil- lectomies All surgery !i except ton- sillectomies | September i 113.2 85.0 28.2 * October 78.3 45.9 32.4 1 November 66.5 35.0 31.5 ! December 44.9 19.7 25.2 j January 50.3 15.2 35.1 j February ‘ ■ 52.4 18.9 33.5 i March 47.5 17.0 30.5 I April 65.2 23.0 42.2 ! May 50.2 20.5 29.7 j Juno 71.2 39.2 32.0 i July 82.2 32.6 49.6 August 127.2 60,0 67.2 other, surgery as well as for tonsillectomies is possibly due to an effort prior to the end of the fiscal year to take care of various surgical cases which had not received earlier attention. Examination of the-rates of the various associations on surgical cases for August shows that they arc all well above the average rates of the same associations for the year, indicating that they all contribute toward elevating this August rate. The variation in the monthly tonsillectomy rates for the different health associations is shown in Figure 3. For all associations except the one in Hamilton County the rate reached its lowest point during the winter months with considerably higher rates prevailing for the warmer months at the beginning and end of the fiscal year. In Table 13, a percentage dis- tribution of all tonsillectomies performed in different months of the year in the six associations is compared with a similar distribution of tonsillectomies in the surgery of the general population, found in un- published data of the Committee on the Costs of Medical Care. The exceed- ingly close similiarity in the percentages shown for the different months Table 15. Percentage of tonsillectomies done in each month of the year in Experimental Health Program, and among the general population j Month 1 i Six ;as sns, i General ! population i Month Six assns, i General i population i i Monthly percentage ;January 1 . 4.6 3.3 July 14.6 12.2 ; February 4.1 5.5 August 20.6 20.3 iMarch j 5,6 5.6 September j 11.1 ! 10,8 ■Ap ri 1 j 5.0 4.8 October 8.5 1 7.5 ’May | 9.5 ! 6.9 November 4.8 ! 7.2 i Juno s 7.9 10.3 December 3.7 ) 5.7 indicates that the variation in the association rates from month to month can be accounted for largely by seasonal influences and that there is, therefore, no appreciable evidence of a tendency toward a reduction in their rates as the year has progressed. There was some expectation of such a reduction as the backlog of accumulated need for tonsillectomies was reduced, but apparently the work of this first year has not made sufficient headway in meeting this need to bring about such a reduction. Hospital Services Received by Each Association Significant rates covering hospital service for the various associations are shown in Table 14, Tabic 14c Number of admissions and days of hospitalization per thousand persons per year, number of days of hospitaliza- tion per case, and percentage of physicians’ and surgeons'1 cases hospitalized for each association j Association 1 Admission rates Rates for days of hospitalization Days per ease Per cent of attended cases hospitalized All assnso 110 424 3.9 7.4 Cass 130 503 3.9 7.4 Hamilton i 99 580 5.8 5.3 Nevada 59 266 :4c 5 5.6 Newton 102 297 2.9 8 c 5 17a It on 76 305 4.0 : 6.5 Wheeler 177 727 4.1 8.7 S. /JonJhJy r~e?/e~s yor~ <7*s&o c/ &~/~/ or? There is evidence that the admission totals reported for particularly the Cass, Newton, and YTheeler County associations include a limited number of cases which received X-ray, laboratory,' operating room, or other hospital service without actually being admitted to hospital residence. This would account in part for the low number of days per case and also for the higher percentage of physicians’ and'surgeons’ cases receiving hospitalization, which is shown for these associations. The high rates covering days of hospitalization for especially the Cass and Wheeler County associations, however, indicate that they rendered a large volume of service to in-patients and that removal of these out- patient cases from their records would probably not materially.affect their- rates. The rates shown for all the associations including those which did not-feature this out-patient service indicate a high rate of hospital admissions with apparently a preponderance of less severe cases, which - resulted in a very short average period of hospitalization per case. The admission rates ranged from 177 to 69 which compares favor- ably with the rates of 42, shown in Table 6,'for the general rural popu- lation, and the average number of days hospitalized per case ranged from 2.9 to 5,8 as compared with the corresponding’fate of 11 days for the general rural population (a). Charges per case and per day are shown in Table 25. The average charge per case for all associations was $23.70 and for the different associa- tions it ranged from $20,86 for the Newton County association to $37,28 for the Nevada County association. The charge per day for all services averaged $6.04 for all associations and ranged from $4.94 for the Hamilton County association to $8,26 for the Nevada County association. These rates covered ward care, operating room, delivery room, routine laboratory, drug, and related services. They are somewhat affected by having included in them the charges for service to out-patients, already mentioned. These out-patient charges are, however, not included in the rate for room or ward service only, also shown in Table 25. ..This rate ranged from $3,82 for the Newton County association to $5.00 for the Cass and Wheeler County associations, with an average of $4,53 for all associations. Monthly Variations in Hospital Services Figure 4 shows a slight decrease through the year in the number of days of hospitalization used by the various associations with a small seasonal rise during the winter months, and a rather pronounced rise at the close of the year. This latter rise is likely due in part at least ,to the unusually large amount of surgery done at the end of the year, to which reference has already been made. The average number of days of hospitalization per case for each associa- tion during each month of the year under review is shown in Table 15. (a) Same as Footnote (a). Page 16. Table .15. Monthly averages of number of days of hospital- ization per case for each association i Month } 1 All , assns. Cass Hamilton • 1 Nevada I 1 Newton Walton’ Wheeler Number of days of hospitalization per case ! ■ July '42 1 Tl ! .... .... . ■ i .... | • • e o < I • • • • ! 2.99 ; August 1 1 • • • • • • o • • • o O .... 2.36 o • « • 3.38 I September ! 2.80 2. 97 4.77 3,42 2.30 0 0 0 9 \ 2.87 . October j 3.40 3.03 4.12 3.96 3,04 I 9 9 9 9 j 4.72 ■ November | 3.96 | 3.94 6.86 i 5.03 1.90 1.22 5.00 j ! December 4.10 3.79 7.57 3.25 5.38 4.50 j 3.23 | January '43 4.80 j 4.09 8.70 4.11 4,73 1.15 | 5.59 I | February i 4.69 j 4,64 6.69 4.69 2.72 4.15 i 5.19 | March t 4.34 3.80 7.37 4.87 4.78 2.81 4.46 | April I 4.31 j 3.90 6.78 4.15 3.61 4,12 | 5.67 ! 1 May I 4.12 ! 4.13 7.37 : 5.20 2.89 4.79 3.98 | ; June 3.70 4.43 3.68 4.96 2.66 4.16 3.44 j July I 4,13 | 4.13 5.78 j 4.91 3.20 4.13 5,28 s : AugUSt i 4.64 ! 4.13 3,87 ! 8,00 O O 0 o 3.90 5.3S September * .... ! 1 . . O O | .... j 2.21 • 0 • o 3.70 J • • o o ■■ October 1 i. ■ • • O • I I • o o « ! .... • o « • 4.59 .... The trend indicated'by the rates for all the associations taken together is toward a longer period of hospitalization per case during the winter months followed by a shorter period during the spring and early summer and then a more lengthy period again at the end of the year. The rates for the different associations, shown in Table 15 all adhere closely to this general trend. There are scattered high rates for other than the winter months and the final months of the year under review but in general higher rates tend to prevail during these periods. This also describes the trend of the line showing monthly rates for days of hospitalization in Figure 4. These variations in the rates shown in Figure 4 were attributed to seasonal factors for the rise during the winter months and to an increase in surgical cases for the rise during the final months, and these same factors are likely responsible in some measure for the variation in the number of days of hospitalization per case. Drug Service Information on drug service is available for only five of the six asso- ciations, In the sixth association - in Yfheeler County - the physicians dispensed their own drugs and were paid for them on the capitation basis just as they were paid for their professional services. No record of the number of prescriptions dispensed has been provided by this associa- tion, Of the remaining five associations, the Newton, Nevada, and Cass County associations found it necessary, due to the low percentages paid /or- a#ys <*y Ao&y>//&//?a/ron /or eercA &*xsrac/ e?//on on drug charges, to make adjustments in their drug program, during the year. The Newton County association was the first to adjust. As is indicated in Figure.5, an exceedingly large number of drug prescriptions were filled for this association during its first month of operation. The rate indicated by this first month's service was 5726 prescriptions per thousand persons per year which was 20 per cent above the average rate for all associations for the year and more than twice the rate finally established by this association for the year. Only 45 per cent was paid on drug charges for this month. The number of prescriptions issued during the second month was less than during the first month, but still quite high. In the third month the druggists reached the conclusion that the basis on which the service was being operated was untenable for them, and during the fourth month no prescriptions were issued. In the fifth month the service was resumed with the patient paying half the cost of each prescription at the time he received it, and the association paying the other half at the end of the month. This arrangement began in December and continued through/April.• In May the part of the charge paid by the patient was reduced to one-fourth with the association pdying three-fourths. This arrangement continued through May, June, and July. It is of interest to note in Figure 5, that this reduction in the patient's payment on each prescription did not apparent- ly increase the number of proscriptions issued, thou h there was for some reason a marked increase in the number of proscriptions issued in July. The Nevada County association was the next to develop difficulty with its drug service; After getting under way in September its prescription rate mounted to 5515 per thousand persons per year in October with 64 per cent payment oh druggists' bills for that month. This situation continued practically unchanged through November, and in December there was a reduction in the number of prescriptions issued but the average charge per prescription (Table 17) rose, keeping the percentage payment on druggists' bills still at 64 per cent. Very few proscriptions were issued during January; on February 11, an arrangement whereby the patient paid half of the cost of the prescription was put into effect, and the service was operated on this basis through the rest of the year. The other association to make adjustments in its drug servie was the Cass County association. It started in September with an exceedingly high rate of 4084 prescriptions per thousand persons per year and a payment of 44 per cent on its druggists' bills. Through educational methods among its physicians and members it gradually reduced the number of prescriptions issued through October, November and December, but in January the record (Figure 5) shows a return to the September situation with a reversion to the December rate in February, In lurch the plan of requiring the patient to pay half of the cost of his proscription was introduced and the service was continued to the end of the year on this basis. Figure 5 shows the rate at which prescriptions were issued through the rest of the year. A marked decrease is shown for May and June but it is doubtful whether this can be attributed to the requirement that the patient pay half of the cost of his prescrip- tion since the higher rates for March, April, July and August were established under this arrangement. In addition to the records of the three associations which found it necessary to make adjustments in their drug service during the year, there is included in Figure 5, the record of the Walton County associa- tion, one of the two associations which was able to avoid making such adjustments. After a period of adjustment at the beginning of the year its rates for physicians' calls and drug prescriptions follow each other closely through the year with the number of prescriptions slightly under the number of physicians’ calls. Lines showing the monthly rates for physicians' calls and cases have been included in Figure 5 to show something of the relationship which exists between physicians' and drug service. In all throe associations which made adjustments in their drug service, the rate for physicians' calls reached its lowest point of the year at the time when the drug service was more or loss in suspense and the adjustment was in the process of being made. Following this adjustment period, however, the number of physicians' calls and the number of drug prescriptions gradually in- creased, and it is difficult to say to what extent, if any, patients wore deterred from calling on their physician through the requirement that they pay part of the cost of their prescriptions. It is noted, however, that in both the Cass and Newton County associations the number of drug prescriptions issued under the association program dropped below the number of physicians* calls made in the same month during the period of adjustment and, while recovering somewhat as the part-payment arrange- ment got into operation, continued to be less than the related total of physicians' calls through the rest of the year. The fact that the totals of drug prescriptions were less than the related totals of physicians' calls throughout the year for the Walton County association, in which the association continued to pay the full cost of all prescriptions through the year, suggests that this may be a normal relationship for these services. But in the Nevada County association the totals of prescriptions rose above the related total of physicians' calls after the patient began paying half of the prescription charge and maintained this relationship through the rest of the year. The number of prescriptions per thousand persons per year and related charges per prescription for each association and for all associations taken together are shown in Table 16. rjonMJy rvZ&sS' /or- yy~*^C'r'/y>i/os y?Ays-/c/ os»a/ r/ ub/-/o*n County trsr^oc'jn'J/arts' Table .16. Number of prescriptions per thousand persons per year and average charge per prescription for each association under various plans of operation Assns, Period covered • ft' . No. of prescriptions per thousand— •• j persons :i?Qr year Charges per prclscription All assnso Full payment 2976 $0.83 t - . Part payment 2158 1.02 Cass Sept. ’42 - Jan. ’43 3866 .38 Feb. - Aug. '43 • ■ 2599 .92 : Hamilton Sept. ’42 - Aug. ’43 2559 .69 Nevada Sept. - Dec. '42 2875 1 .92 ; Mar. - Sept. ’43 2360 .99 Newton Aug. - Septo' '42 3265 .90 Jan, - July ’43 * 1518 1.15 Walton Nov. «42 - Oct. 43 2112 : .71 :.. — — For the associations which paid only part of the c-o-st of prescriptions during part of the year, separate rates are shown for the periods during which these arrangements were in effect, and for the Newton and Nevada County associations the records for the months during which their drug programs more or less ceased operating were omitted in calculating these rates. Both this table and Figure 6, showing the monthly prescription rates for each association, emphasize the fact, which has already been noted, that the prescription rates for the associations which found it necessary to make adjustments in their arrangements for their drug service during the year were abnormally high during their first months of operation. They ranged from 2875 to 3866 per thousand persons per year as compared with 2559 and 2112 respectively for Hamilton and Walton County associations. Another factor which doubtless played a largo part in making necessary the adjustment in the drug services of the Cass, Nevada, and Newton County associations was their higher average charge per proscription. Table 16 shows the average charge per prescription for the Hamilton and Walton County associations to be 69 and 71 cents respectively, while for the Cass, Nevada, and Newton County associations this charge ranged from 88 to 92 cents while the associations were paying the full cost of the prescriptions and from 92 cents to $1.19 when part was being paid by the patient. Table 17 shows the monthly variation in the average charge per prescription for each association. The Hamilton and Walton County associations began their year with averages of about 80 cents per Table 17. Average monthly charge per drug prescription (including charge to patient, if any) for ! ■ each association Month 1 . All assns. Cass Hamilton | Nevada Newton. Walton Cha rgc per prescription . 1 | August ’42 j • • • »•* t „ ! i $0,89 | © • • September $0.90 $0.90 $0.79 ; $0.87 1 .92 | o • • October .87 .82 .82 .87 j .87 O 0 • [ November .86 .88 • .74 .87 ; . . . $0.82 j December o 94 .90 .69 1.03 ; .97 1 .80 January '43 .91 .91 .63 i 1,09 j 1.18 .80 February .93 .90 .62 1.11 | i.ii s .70 Ma rch .91 .90 .73 .93 * 1.13 1 .70 April .91 .93 .62 1.00 1 1.10 j .69 May ! .96 .96 .67 , ' 1.03 i 1.18 j .65 j June | .96 .96 .69 1.05 j 1.23 • 66 ' July 1 .98 .88 .71 1.04 : 1.12 .69 | August | .91 .93 ! .67 1.06 ' 0 0 0 .69 i September i ... 1 o o • • • o 1.08 o o • .71 ; October o o • | • • • • • • j • • • ... .71 Indicates point at which arrangement, requiring patient to pay part of cost of prescription, was introduced. prescription, which were considerably lower than those for the other three associations, and during the year they were able to reduce these averages so that the average for the entire year was 69 cents for the Hamilton County association and 71 cents for the Walton County association. The lowest monthly average shown during the year for the Hamilton County association was 62 cents and for the Halton County association, 65 cents. The monthly averages for the other three associations shown in Table 17 show a definite tendency to increase following the adoption of the plan requiring the patient to pay part of the cost of his prescription. The tendency is not great for the Cass County association; more marked, and also beginning a few months before the new arrangement became effective, for the Nevada County association; and quite pronounced for the Newton County association. The point at which the new arrangement became effec- tive for each of the three associations is indicated by a line drawn across the column of averages in Table 17, Reference has already been made to Figure 6, showing the number of pre- scriptions per person per year indicated by the number of prescriptions issued each month in the different associations. Possibly the most significant fact to be noted in this graph is the manner in which the various associations, after adjusting their difficulties by various r 6>. SJon+A/y on for* cacf 4*3'so c/af/on sn Yearns of sH/mA€t~ yponjron y>**~ yeor~ methods during-the first months their programs were in operation, finally settled to prescription rates which were strikingly uniform for all asso- ciations. From March on to the end of the year the lines for all the different associations, except possibly the Newton County association, adhered very closely to the average for the five associations, and the Newton County association rate approached this average in July. This is possibly the nearest approach to uniformity to be found in the widely varied experience with drug service of the five associations. Dental Services Received by Each Association Dental services differ from the other services offered by these associa- tions in that the emergency factor is much more dominant .in determining what medical care shall be rendered a case than it is in determining what dental care the case shall receive. Dental emergencies created by severe toothache, or other like situations which would be considered emergencies in the estimation of the members of those associations, constitute a relatively small percentage of the cases normally receiving dental care. A large proportion of the dental care rendered has therefore been elective, and the cooperating dentists have on this account been able to delimit the program so as to make the most efficient use of the six or seven dollars per family allotcd to them for dental services. The rule followed has generally been to give first consideration to severe tooth- ache or other emergency situations for any member of the association, and then to go as far as their time and funds would permit in providing fillings, extractions, prophylaxis, and other indicated service (exclusive of replacements) for children and young people under 15 or 18 years of age On this basis the associations developed programs which provided services, the charges for which adhered reasonably closely to the funds designated for dental care. The allotment for dental service during the fiscal year 1942-43 was per family in all associations, except the Wheeler County association, in which it was $6. Table 18 shows the allocation of funds in the different associations on the basis of this allotment, the charges submitted for dental services, and the amount these charges exceeded or fell short of the total allocated. Tabic 18. Allocation of funds and charges for dental service in each association and surplus or deficit at the end of the year ' Assn. Allocation Charges Surplus or deficit (-indicates deficit) All assns. &56,001 $54,070 $1,931 Cass 16,653 16,625 28 Hamilton 3,541 4,507 -1,166 Nevada 10,059 9,067 992 Newton 13,895 13,342 553 Walton 6,167 5,168 999 Wheeler 5,886 5,361 525 It should be pointed out that these fund allocations in Table 18, while they represent the total's theoretically due the dental programs out of the different associations’ budgets, do not in all cases reflect the actual totals of funds made available for this service. For members joining the associations after the first month of the fiscal year, the full year’s fee was charged, but out of this in some cases, only one- twelfth of the six or seven dollar dental allotment for each of the re- maining months of the fiscal year was actually drawn for dental service, and that part of the dental allotment which belonged to months prior to the time the membership became effective was put in a general fund with similar contributions from the fund allocations for other services, and this general fund was used to equalize in some measure the percentage payment on bills for different types of service. The only association shown in Table 18 to have charges for dental service in excess of the funds allocated ia the Hamilton'County association and, rather strangely, this is the only one of the six. associations which did not Ipclude fillings in its program. Its extraction -program was somewhat heavier than that of the other associations, its rate, being 745 teeth ex- tracted per thousand persons during the year, as compared with a rate of 571 extractions for all six associations, but the distinctive feature of its program was its emphasis on examinations, including X-ray films. In all the other associations, except the Wheeler County association, the charges for dental service closely approximate the funds actually made available for this service. In the Wheeler County association only one dentist was available, and the volume of dental service rendered was limited by the amount of time he was able to give association members. The rates for dental cases, extractions, fillings, and all services for the various associations during the fiscal year 1942-43 are shown in Table 19. The terra "dental case", as used in this connection, refers to a visit or series of visits in the course of which the dentist completed the service desired by the patient at that time. The term "all services" includes prophylaxis, treatments, examinations,•and other similar services covered by the program, in addition to extractions andillings. Table 19o Number of dental cases, extractions, fillings, and all services per thousand persons per year for each association Assn. Cases Extractions Fillings ■■ All services 1 Hates per thousand persons per year ! t All assns. 294 571 368 1056 j Cass 247 712 282 j 1049 i Hamilton 371 745 ... 1329 j Nevada 27 5 624 329 1072 | Newton 338 432 517 1004 | Walton 303 539 308 974 1 Wheeler 300 404 528 1106 c?ry • the Consumer Purchases Study ; Type of service Five assns. ' CCMC CPS ’ Physicians Surgeons - 47.4 i • i i s \ 42,9 34. 9,0^°) (d) 15.?(®) Specialists 14.6 k ! J ; Hospitals 14.6 i ' 13.6 16.9\e' 1 Druggists 1 13,5 Dentists 9.9 14.5 11.9 | Other services \ i 12.1 29.2 services for the CCMC and CPS groups include glasses, private nursing, health and accident insurance, and service by non-medical practitioners, which are not offered by the five associations. It also includes X-ray, laboratory tests, immunizations and, for the CPS, hospital services, which are included under other headings for the five associations. The CPS survey covered non-relief farm families only, and the total charges per family averaged $.47 per year. The CCMC survey covered all white residents in rural areas and the percentages shown are for the $1200 - $1999 income groups for which the average charges were $53.70 per family per year. The chief difference between the figures shown for the five associations and those for the other two groups is in the field of physi- cians’ and surgeons’ services. Charges for physicians’ and surgeons’ services for the five associations represented 62 per cent of the total charges, whereas for the other two groups they were only 42.9 and 43.2 per cent respectively of the total. This proportionate increase in charges for these services in the five associations over that found for other groups is consistent with the increased volume of physicians’ and surgeons' services which members of these associations are receiving (Table 6). (c) Obstetrical service is included under specialists’ service in the CP distribution and under physicians' service for the five associations (d) Included under other services. (e) Include all drugs while for the five associations the charges are for prescribed drugs only. Disbursements Total, disbursements of the six associations, distributed by type of service, and percentage of these totals, are shown in Table 24, The disbursements shown in this table do not include payments Ifor drugs by association members. They do, however, cover all expenditures made by the associations. The payments for different types of service were made in accordance wi-th? budgetary allocation of- funds- at the beginning of the fiscal year (Table d). Consequently they do not reflect the .demands of the different types of service on the resources >of- the associations as satisfactorily as the distribution of charges shown in Table' 22. The distribution does not conform exactly to the budgetary distribution shown in Table 1 since contingency funds and balances!from the funds of any service, for* which charges had been paid in -full, j have been distri- buted among the different types of service in proportion to their need. » The cost of administration averaged 6,6 per cent of the total expenditures of all associations. It ranged from 5.5 per cent for the'Nevada County association to 10,7 for the Walton County association. The higher per- centages (10.7 and 8.6 per cent) for the Walton and Hamilton County asso- ciations £re accounted for largely by their smaller membership - 881 and 478 families respectively. Expenditures for administration and travel covered t|ie salary of a managpr, the salaries of his clerical staff, the rental and maintenance of his1 office, and the provision of forms and records required for the operation of the association. Type of Service i assns. Cass Hamilton Nevada Newton Walton Wheeler $1*16,367.57 Expend!ture s To tal $118,021.80 -9.27,h06.95 $72,3^.65 $102,971.09 $1*3,71+7.53 $51,875-55 Physic ians 114.8,176,1|8 38,06i|.00 11,329.71+ 28,182.62 38.581.1*1 11*, 389.21 17,629.50 Surgeons - ll+,27U.OO Specialists 53,839.81* 2,91+1.80 9,1+88.30 15,398.09 5,110.95 6,626.70 Hospitals 79,266.89 23,790.00 1+.798.71+ 12,936.08 17,61*1.97 6,858.90 13,2Ul.20 Druggists 50,1*73.30 16,653.00 2,526.07 8,102.39 12.181.57 U,82U.66 6,185.61 Dentists 52,1*20.19 16,625.01 3,1+55.87 9,066.50 13,335.32 5,072.1*9 14,867.00 Nurses 1*, 71*2.38 1,359.65 582.73 2,800.00 • Administration 27,1*1*8.1*9 7,256.11* 2,351+.73 3,986.03 5,631*. 73 u.691.52 3,325.51+ Percentage distribution Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Physi cians 35.7 32.2 1+1.3 39.0 37.5 32.9 31+.0 Surgeons - Specialists 12.9 12,1 10.8 13.1 15.0 11.7 12,8 Hospitals 19.0 20.2 17.5 17.9 17.1 15.7 25.5 Druggists 12.1 li+.l 9.2 11.2 11.8 11.0 11.9 Dentists 12.6 il+a 12.6 12.5 12.9 - 11.6 9.1+ Nurses 1.1 1.2 .8 6,14 Administration 6.6 6.1 8.6 5.5 5.7 10.7 -6,14 ’■ ■ . Table 21;. Disbursements by type of service and their percentage distribution for each association All Assns. Cass , Hamilton Nevada Newton Walton Wheeler (ll* Mo .) Average membership Families 7,996 2,379 l*6l 1,395 1,980 839 9U2 Persons 3U,9Ul 10,337 2,015 5,880 8,960 3,822 3,927 Physicians* service Cases 50,155 17,199 3,331 6,011 10,200 U,392 9,022 Total 105,860 33,856 8,229 11,718 15.93U 8,881 25,21*2 Calls, office 93,055 29,756 7,695 10,050 1U.038 6,898 21*, 618 n , home, day 6,51*3 1,780 576 1,230 1.15U 1,721 282 u , home,'night 85I Uho 5k 128 11*0 U9 Uo ,T , hospital 3,1*11 1,880 ioU 310 602 213 302 Obstetrical cases . 195 59 • 135 •489-/JV 4U6-//V 137 Charges $233,780.00 (a ) £.116,1*00.75 $26,01*8.98 $31,550.97 $1*0,197,1*0 $19,581.90 (a) Payments (a ) $ 38,061*.00 sn.329.7u $28,182.62 $38,581.1*1 £ll*,389.21 ($19,77U*50) Surgeons*-Specialists* service Surgical cases 2,507 807 395 211 513 213 368 Tonsillectomies 1,221 UUl 158 67 309 79 167 Appendectomies 299 135 10 26 h9 35 uu Gynecological 320 792 17 h2 62 18 102 Other 667 152 210 76 93 81 55 Non-surgical cases 1*09 18 68 39 272 8 1+ Charges $ 81,325.78 $52,831.00 SU.7UU.50 $9,991*. 00 $16,027.03 ■* 8,373.25 £ 9,356.00 Payments $ 5U,598*51 $ll*,27l*.00 $2,91*1.80 .■59.U88.30 $15,398.09 $ 5.110.95 8-7,385.37 Table 25 • Membership, amount of each type of service received and related charges, payments and rates for each association Ail wheeler assns. Cass Hamilton Nevada Newton Walton (14 Mo.) Hospital service 3.906; t 9 — . * . . Admissions i.34o 200 347 V 912 292 815 Obstetrical cases hospitaliz ed 3Sf 98 0S~/ 19 y! At 137 Total davs hospi tali zed 15,101 5,200 1.169 15,665 26,605 1,165 3,3)40 Charges &91,l6l4.. 8 5 #28,912.50 #5,766.140 #12,936.08 $17,641.97 #6,858.90 $19,049.00 Payments •180,875.614 $23,700. ,00 *4,798.74 .#12,936.08 $17,641.97 $6,858;.90 $14,849-95 Drug service No. of prescriptions 72 .,088 32,368 5,157 12,334 14,140 8,069 • Charges 166,,66l.. l6( a) $29,106.80 *3,375-74 312,351.31 #15,898.61 15,728.70 (a) Payments $58,4l0.23(a,b) #22,809. 58(b) #2,526.07 $12,351 • 31(b)$15 ,898.6l(b) #4,8214.66 (•# 6,185.61) Dental service Cases 10,1482. .2,554 748 1,618 5,028 1,157 1,377 Extractions Cases - under • 15 years 1,776(0) 325 111 . 190 627 - 212 311(c) 15 years and over 5,476(c) 1,829 312 921 1,234 571 600(c) Teeth - deciduous ho. 317 345 154 228 )3,872 313 451 permanent 7,014 . 1,347 3,41+2 1,748 1.403 Fillings . Cases - under 15 years 2,327(c) 223 (c) 139 l,iU46 215 304(0) 15 years and over 3,092(c) 890 (c) 598 679 216 709(0) Teeth - deciduous '} 13,084 36 (c) 105 jU,636 59 288 permanent 2 fill (c) 1,828 J 1,118 2,137 Table 23« Membership, amount each tvpe of service received and related charges, payments and rates for each association (continued) All assns. Cass Hamilton Nevada Newton ’"/heeler (ll; No . ) Dental service (continued) Other service ■ Cases - under 15 years 956 81 291 78 183 143 180 15 years and over 3,238 472 880 622 300 343 621 Total services 37,612 10,8U2 2,672 6,303 8,991 3,724 5,080 Charges $5)4,069.50 $16,625.01 $U,507.00 $9,066.50 $5,168.00 $5,361.00 Pavments $52,9114.19 $16,625.01 $3,455.87 $9,066.50 $13,333.32 $5,072.49 $5,361.00 Charges, all services $223,876.06 , 61+2,62 $75,898.86 $103,107.00$l45,710.75 Pates per thousand persons per year Physicians’ services - Cases II4O8.5 1663.8 1653.1 1022.3 1158.14 III49.I I96J4.O Total 2916.7 3275.3 U083.9 1992.9 1778.u 2323.7 5494.8 Calls, office 2615.3 2878.6 3818.8 1709.2 1566.7 I8OI4.O 5359.0 " , home 207.7 21I4.8 213.4 231.0 Il4i4.l1 I463.I 70.1 " , hospital 95.8 181.9 51.6 52.7 67.2 55.7 65.7 Obstetrical cases 2ij. 2 I8.9 29.3 25.0 -3^2- 29.8 31/ Surgery - Cases 70. 4 78.1 196.0 35-9 57.2 55.7 80.1 - Tonsillectomies 34.3 42.7 7B.4 11.14 34.5 20.7 36.4 Appendectomies 8.1; 13.1 5.0 14.U 5.5 9.2 9-6 — Gvnecological . 9.0 7.6 8.14 7.1 6.9 li.7 22.2 Hospital service Admi ssions 109.7 129.6 99.3 ... .59.0 101.7 76.4 177.14 Davs hospitalized l+2i4.1 503.0 580.1 , ■266.1+ 296.9 30I4.8 727.1 Table Membership, amount of each type of service received and related charges, payments and rates for each association (continued) All assns. Cass Hamilton Nevada Newton na 1 to n Wheeler (ll+ Mo.) Pates per thousand persons per year ' Drug service No. of prescriptions 251+6.8(d) 3133.2 2559.3 2516.2(d) 1907.9(d) 2111.2 Dental service Cases 29k-h 21+7.1 371.2 275.2 337.9 302.7 300.0 Extractions 570.6 711.9 7U+-9 62U.1 1+32.1 539.2 1+03.6 Fillings 367.5 281.9 (c) 328.7 517.1+ 308.0 527.8 Total services 1056.3 IOI+8.9 1329-1+ 1071.9 1003.5 971+.1+ L106.0 Physicians* services No. of calls per case 2.1 2.0 2.5 1.9 1.6 2.0 2.8 No. of office calls per home and hospital call 8.6 7.3 ll+.U 6.0 7-h 3.5 39.1+ Charges per case #5»68(a) $6.77 $ 1+.81 $5.25 $5-91+ $1+. I4.6 (a) Amount paid per case .^3.00 $2.21 * 3.35 41+.69 $3.78 $3.28 $ 2.19 Hospital service No. of days per case, all cases 3.9 3.9 5.8 h-3 2.9 i+.o i+.l Per cent of physicians* and surgeons’ cases hospitalized 7 'h 7.U 5.3 5.6 8.5 6.3 8.7 Per cent of hospital cases admitted for delivery 7.3 pass 5.5 16.8 Per cent of deliveries hospital- ized ■9^9-**/ 50.3 1I+.1 a**.? 100.0 Charges per case ■ 521 263 322 121+2 275 357 August 306 302 361+ ... 275 I4.65 September - 3 kk ' • 0 • 1+63 . . . 251 ... October 231+ • • • • • • * » * 231+ ... - ■ ~ . .. . .... ' Appendix Table JO. Monthly rates (annual basis) for dental fillings for each association Month ; An | assnso 1 Cass Number of " * * “i j Hamilton dental extract Nevada ions per j Newton ! 1,ralton thousand persons per - 1 v,Theeler vear July 'Ij.2 / I 1 ••• j 000 , 0 0 e I ... 371 | August S-6S 0 0 0 . = . j 778 388 -September | '669 1075 U50 353 ! 395 0 0 0 l+6S October i 730 120l 791 729 173 . V . 583 I November ! 768 1265 701+ ] 953 371 \ I li(.8 1+35 ■ December U}P i 537 971 ! 667 197 322 217 j January 'U3 1 510 607 1121 558 231+ 569 h S3 ' February 519 631+ 1056 518 320 ; 1+30 1+77 . March 55)4 522 III4O 581 U60 567 1+91 | Apr^l , 623 , 670 3Q9 825 561 720 359 I May . 1+9S i i+I+8 2PU 597 608 1 1+38 1+19 June 6)46 . | 392 1071 5ll|. i 793 357 311 : July 1+3 s 550 221 5l+0 29i+ 532 268 - August i Sl+6 I * 582 725 605 ; .,0 1 596 379 ; September i 85o I 0 0 i 888 0 0 0 1 830 i 000 j October : j | 60S i i ••• 1 i i f « • 0 s ... r i 1 605 i i ■ Appendix Table J>1 . Monthly rates (annual basis) for dental extraction- for each association