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A comparative review of the medical services programme for public assistance recipients in British Columbia Mann, Aileen Elizabeth 1955

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A COMPARATIVE REVIEW' OF THE MEDICAL SERVICES PROGRAMME FOR PUBLIC ASSISTANCE RECIPIENTS IN BRITISH COLUMBIA  by AILEEN ELIZABETH MANN  Thesis Submitted i n Partial Fulfilment of the Requirements f o r the Degree of MASTER OF SOCIAL WORK i n the School of Social Work  Accepted as conforming to the standard required for the degree of Master of Social Work  School of Social Work  1955 The University of B r i t i s h Columbia  ABSTRACT  This thesis has reviewed the medical care programme for public assistance recipients i n B r i t i s h Columbia. I t has been concerned with e l i g i b i l i t y qualifications, the extent of services provided, and the administration and financing of these services. As background material, recent developments i n social assistance medical care i n Canada were summarized. Particular attention was given to an analysis of the Saskatchewan programme, as i t s philosophy of public assistance i s similar to that of B r i t i s h Columbia. E l i g i b i l i t y for medical services i s not a complex subject i n B r i t i s h Columbia because i t simply extends to a l l categories of public assistance. The same may be said of the actual provision of services. B r i t i s h Columbia does not have the usual administrative tangles usually surrounding the kinds of services offered because of the fact that i t has chosen to provide comprehensive care. The admi n i s t r a t i on and financing of the programme offers plenty of material for discussion by the student of public administration. I t i s evident that the provincial role i s predominant, as i s true of many aspects of provincial-municipal relations i n B r i t i s h Columbia. The contribution of the municipalities i s largely confined to a share i n the financing of the scheme, and this i s not large. The Director of the Medical Services Division carries administrative responsibility for the programme, but the Canadian Medical Association (B.C. Division) through i t s Social Assistance Medical Service i s responsible for remuneration to the individual physician from a pooled fund provided by the provincial government. The administration of public funds by a private body i s a much-discussed issue i n the extension of public medical care, but i t suffices here to state that the plan seems to be working s a t i s f a c t o r i l y i n B r i t i s h Columbia. Probably the distinctive contribution of the programme i s the integration of the physician and the social worker i n the planning of the physical and social rehabilitation of the individual. The relatively comprehensive nature of services, both medical and of a social work nature, contribute to the integration. The extension of medical care i s now a l i v e l y issue i n Canada, and has become a focal point i n federal-provincial relations. B r i t i s h Columbia has prepared i t s e l f for an inclusive programme through the i n troduction of hospital insurance, but i t s pioneering i n medical care for the needy may also be of aid i n the planning of the larger programme which must inevitably come.  ACKNOWLEDGMENTS  The writer wishes to acknowledge the assistance received from Professor W.G. Dixon of the School of Social Work i n regard to the organization of material and i n the reading of draft chapters. Particular thanks are due to Mr. E.W. G r i f f i t h , former Deputy Minister of Welfare,for his cooperation and help, to the General Administration and personnel of the Social Welfare Branch for their guidance, stimulation, and encouragement.  TABLE OF CONTENTS Page Chapter 1:  The Problem of Medical Care i n Public Assistance Programmes  Chapter 2:  Development of Public Medical Care i n B r i t i s h Columbia  Chapter 3:  E l i g i b i l i t y and Services i n Medical Care i n  1 22  B r i t i s h Columbia  23  Chapter 4:  Administration and Financing of Medical Services  46  Chapter 5:  Conclusions  59  Appendices: Appendix A - Administrative Structure of Social Welfare Branch, Department Health and Welfare, Victoria Appendix B - Social Welfare Branch Regional Map, Department Health and Welfare, Victoria Appendix C - Social Assistance Medical Service Quarterly Report Appendix D - Bibliography  65  66 67 68  LIST OF TABLES Page Table I :  1940 Schedule of Payments by the City of Vancouver to the Vancouver Medical Association  29  Table 2:  1942 Schedule of Payments by the City of Vancouver to the Vancouver Medical Association  30  Table 3:  Categorical Distribution of Recipients of Medical Services as of May 1, 1955  36  Table 4:  Percentage of Accounts Paid to Physicians Participating i n Social Assistance Medical Service  52  Table 5: Medical Services, Drugs, Optical, Etc. Expenditures  56  A COMPARATIVE REVIEW OP THE  MEDICAL SERVICES PROGRAMME FOR PUBLIC  ASSISTANCE RECIPIENTS IN BRITISH COLUMBIA  CHAPTER I THE PROBLEM OF MEDICAL CARE IN PUBLIC ASSISTANCE PROGRAMMES  The term "public assistance" denotes the various forms of f i n a n c i a l aid granted from public funds to those who, f o r one or more of many reasons, prove they are unable themselves t o provide the necessities to maintain l i f e . The purpose of public assistance i s two-fold.  F i r s t , i t i s provided to meet  the immediate needs of people threatened by destitution.  Second, i t i s so  administered as to assist them to gain or regain a status of self-dependence. Hence public assistance may be regarded as an attempt to remedy rather than merely relieve the problem of destitution. Among the chief causes of destitution are i l l health and physical incapacitation.  Illness, malnutrition, and the lowering of physical stamina  may be among the effects of destitution.  Obviously the provision of adequate  medical care should be an integral part of any public assistance programme. Medical care for persons receiving public assistance should be the same as that available to anyone i n the community at large.  This means the  provision of curative services which are adequate and appropriate to i n d i v idual need, which are given a t the proper time and carried on f o r the period required to be effective, and which are administered i n accordance with the highest standards of medical knowledge and practice.  The objective i s  the restoration of sicit or disabled children, men and women to a state of health which permits them to occupy a useful, satisfying, and when possible self-dependent place i n the community.  Humanitarian concepts underly this  - 2 programme, and are the basis for providing treatment to alleviate pain for those suffering from chronic diseases, and for whom rehabilitation may  not  be possible* Besides these curative services, the public health or preventive services provided by government departments play a large part i n inducing and maintaining good health.  They should include pre-natal and post-natal  c l i n i c s , school health services, dental care for childrenj immunization programmes, the control of communicable diseases, sanitation, food and water inspection, consultation on nutrition and public health education. Health and welfare are inseparable concepts and must be considered so i n public assistance programme planning.  To be of maximum effective-  ness these programmes should be closely coordinated i n their administration and financing.  Constitutionally health and welfare services are the respon-  s i b i l i t y of the provinces i n Canada and, through provincial l e g i s l a t i o n r e lating to municipalities, of the local areas.  The federal government has,  however, shared the financial burden of most categories of destitution and public health within recent years. The social security measures introduced i n the past twenty years by the Government of Canada provide against destitution caused by unemployment, old age, blindness, physical and mental d i s a b i l i t i e s and the effect of war services. Remaining as the responsibility of provincial governments are the programmes of financial support and remedial services for those who  may  become destitute by reason of individual breakdown. Workmen's compensation provides for those who are temporarily rendered unemployable by industrial  accident.  Mothers' Allowances provides f o r dependent women with children.  Foster home care i s provided under provincial child welfare l e g i s l a t i o n f o r children i n need of support. Besides these categorical statutes, some provinces have enacted social assistance legislation of one kind or another to meet the needs of those who do not qualify f o r any of the above benefits.  This l e g i s l a t i o n  usually makes i t possible for the provincial government to share the costs with the municipalities. the whole cost. administers  Otherwise, the local area i s required to assume  'Whether costs are shared or not, the municipality usually  the social assistance programme. At the present time agreements  are being worked out by which the federal government w i l l assume a share of the financing of social assistance. In none of the above social security and public assistance programmes does the federal government share the costs of medical services. Both the preventive and curative health programmes are the responsibility of the provinces and municipalities. However, since 1948, the federal government has made substantial amounts of money available on a matching-grant basis f o r the purpose of laying the foundation f o r a nation-wide health service.  The grants made have been used to bring hospital, c l i n i c a l , technical,  administrative, research and professional f a c i l i t i e s and services up to minimum standards i n those provinces with serious deficiencies i n their total health planning, and to broaden and strengthen existing services generally. The federal government i s constitutionally responsible f o r health services to Indians, Eskimos, and to sick mariners.  Since the creation of  the Department of Veterans  1  Affairs i n 1944, certain health services are  provided f o r ex-servicemen and women of any war since the Boer War. Previously only veterans who saw action i n a theatre of war i n World War I were given such treatment.  On a shared basis with the province, federal money i s  available for assistance to indigent immigrants and their families who have been i n Canada less than one year and for remedial care to persons i n receipt of blind allowances. Characteristics of Medical Care i n Canadian Social Assistance General problems of medical care i n social assistance programmes i n Canada have recently been reviewed by Dr. Malcolm G. Taylor.  1  He examined i n  considerable detail organized programmes i n five Canadian provinces to meet the medical care needs of welfare groups. Dr. Taylor states that Ontario and Nova Scotia offer the limited benefits of physicians i n office or home, certain laboratory procedures and emergency drugs.  The three comprehensive public medical care programmes are  those of the westernmost provinces - Saskatchewan, Alberta and B r i t i s h Columbia.  These are the provinces that have established government-sponsored  hospital care programmes f o r the general population.  Their a l l - i n c l u s i v e  schemes are practically identical i n range of benefits which include medical, surgical and obstetrical services, i n office, home, or hospital; dental care i n Alberta and Saskatchewan; a l l necessary drugs i n Saskatchewan and B r i t i s h Columbia; and ancillary services of optometrists, physiotherapists, and p r i vate duty nurses. In each of the f i v e provinces Dr. Taylor describes the beneficiaries  ^Taylor, Malcom G., "Social Assistance Medical Care Programs i n Canada", American Journal of Public Health, Vol. 44, No. 6, pp. 750-759, June, 1954.  - 5 as t y p i c a l l y the following: means test, Pensions,  (2) (4)  (l)  recipients of Old Age Security who pass a  recipients of Old Age Assistance,  (3)  recipients of Mothers' Allowances, and (5)  public assistance to unemployables.  recipients of Blind recipients of  In Nova Scotia the programme o r i g i n a l l y  (1950) included those i n receipt of Old Age Pensions, but i n 1952 when the federal government introduced the universal pension for this group, the prov i n c i a l government withdrew the benefits from i t , leaving i n the programme only those receiving Mothers' Allowances and Blind Pensions.  Mileage pay-  ments f o r physicians' home c a l l s to rural patients has been a consideration i n four of the provinces.  One of the main reasons for the discontinuance of  services to Old Age Security recipients appears to be due to the high mileage accounts associated chiefly with home c a l l s to the aged. Administrative Agency Dr. Taylor states that the pattern established i n 1935 by the  Ontario  government for the administration of physicians' services has been followed by other provinces excepting Saskatchewan.  The Ontario government entered into a  contract with the provincial medical association for the provision of medical care to qualified beneficiaries for a stipulated sum of money, to be administered by the association or i t s agent.  In Alberta the medical association  office administers the medical benefits as a side line to i t s other a c t i v i t i e s . In Ontario and B r i t i s h Columbia, the associations have set up separate admini s t r a t i v e agencies with boards composed solely of representatives of the profession.  In Nova Scotia the programme i s administered by the physician-spon-  sored medical care plan. In Alberta the government entered into a similar contract with the  - 6 dental association for the provision and the administration of limited dent a l benefits, a consistent extension of the principle.  I f the principle of  delegating the administration to the association of the profession providing services were to be extended to i t s logical conclusion, drug benefits would be administered by the pharmaceutical association, nursing benefits by the nurses association, physiotherapy benefits by the physiotherapists, and so on. The high cost of such repetitive administration would be a colossal one. In Saskatchewan the attitude i s that this i s a programme to be  ad-  ministered by the health department as part of i t s total programme. However, aware of the important role of the profession i n i t s successful administration, i t r e l i e s for policy guidance and assessment of accounts on a three-member Central Medical Assessment Board nominated by the Association, and appointed and paid by the government. The practice of permitting a private agency to distribute government funds among i t s own members without direct government participation i n or supervision of administration i s a departure from accepted government procedure.  Dr. Taylor states he discussed this question i n each of the four  provinces following this practice, and they maintain the profession can administer the programme better because the association has the power to d i s cipline i t s members more effectively than a government agency.  The asso-  ciations have added that they administer the programmes inexpensively and their costs have proved t h i s . The soundness of administration by the medical profession has been further backed by the fact that complaints from the receivers of the service  are practically non-existent. However, i t must be remembered that benef i c i a r i e s of these programmes are probably the most inarticulate group of the population and, as the services they receive are free they perhaps do not consider they are i n the same position to complain as persons who are paying for the services.  The professional bodies have apparently merited  the confidence governments have placed i n them. In three provinces - Ontario, B r i t i s h Columbia and Nova Scotia i t i s the welfare department that negotiates the contract with the medical association; i n Alberta, the health department makes these arrangements, and i n Saskatchewan, the health department administers the programme.  Opin-  ion i s therefore f a i r l y evenly divided as to whether administration of the programme i s one for health or welfare. Method of Payment According to Dr. Taylor, there i s uniformity i n the payment for physicians' services.  Each government agrees to pay a fixed annual per capita  sum f o r a l l i t s e l i g i b l e beneficiaries.  Each medical association agrees to  accept this amount as payment i n f u l l for a l l accounts submitted i n accordance with the o f f i c i a l fee schedule.  Since this amount i s , with one ex-  ception (Nova Scotia since 1952), inadequate to pay a l l accounts at 100 per cent of the fee schedule, prorating i s used.  Per capita payments have been  increased from time to time i n keeping with the steady increases i n demand for service and increases i n fee schedules, which have tended to reduce the percentage payment of physicians fees. In Alberta this method of negotiating a fixed per capita amount for the payment of an indeterminate number of services i s u t i l i z e d i n the  - 8provision of dental care. Ontario has added the formula of assessing each physician's accounts i n accordance with the patterns of practice established by his confreres with due allowance for individual difference. In the programmes of the western provinces i n a l l other professional services - for example, dental services, physiotherapy - payment i s made i n accordance with professional fee schedules negotiated specifically for these programmes. U t i l i z a t i o n and Costs Dr. Taylor points out that the recipients of these programmes are characterized by either low income or old age, or both, and since the programmes remove the economic barrier, and do not require a recurring means test high rates of u t i l i z a t i o n are to be expected. With respect to hospital services Dr. Taylor has found that the u t i l i z a t i o n of these i s high.  The combination of high admission rates and  prolonged stay may be explained by the presence of a f a i r l y adequate supply of hospital beds, a shortage of doctors i n rural areas, a probable lack of nursing and boarding home f a c i l i t i e s f o r alternative suitable care. Pharmaceutical Services Dr. Taylor's findings indicated that the u t i l i z a t i o n of drugs i n the B r i t i s h Columbia and Saskatchewan programmes follows the pattern of drug programmes everywhere - a persistent increase i n the annual number of prescriptions, and a higher increase i n drug expenditures.  - 9 In 1952 the total per capita costs of a l l services were given as follows:^ Nova Scotia Ontario Saskatchewan Alberta B r i t i s h Columbia  -  S  9.96 10.84 77.44 53.76 76.89  While medical care programmes are expensive their provision i s an acceptance by society that medical services are today another of the basic needs along with food, clothing and shelter.  Established medical care pro-  grammes for social assistance recipients are of an exceptionally high standard.  One criticism may be that they are available too late.  If people had  such medical resources available earlier, they might not have been obliged to seek public assistance. While the above presents a general picture of social assistance medical care i n Canada, i t i s appropriate before describing B r i t i s h Columbia's programme to provide a background of information on Saskatchewan. I t i s a province of somewhat comparable size and social welfare philosphy. 2 & 3 The Saskatchewan Plan On January 1, 1945, Saskatchewan inaugurated a tax-supported programme of v i r t u a l l y complete medical services for persons receiving public assistance.  To keep administration and expenditures manageable, certain  groups - constituting 85 per cent of the t o t a l - were defined as provincial Taylor, Malcolm G., "Social Assistance Medical Care Programs i n Canada", American Journal of Public Health. Vol. 44, No. 6, pp. 758, June, 1954. 2 ' Province of Saskatchewan. "Medical Services Division". Public Health Annual Report. Report of the Department of Public Health f o r the f i s c a l year April 1, 1953 to March 31, 1954. pp.114-136. 3 Roemer, Milton I.; Feader, Carman P.; and Acker, Murray S. "Medical Care for the Indigent i n Saskatchewan". Presented before the F i r s t Canadian Medi c a l Care Conference i n Association with the Forty-second Annual Meeting of the Canadian Public Health Association, Quebec City, May 31st to June 2nd, 1954.  - 10 responsibilities, with the remainder continuing to secure t h e i r health services from local governments.  The purpose was to ensure that the aged, the  handicapped and, others i n need would reeeive comprehensive health services on a uniform basis, the programme being but one part of the general welfare programme.  In addition, the municipalities of responsibility were relieved  of considerable portion of health costs. '  The medical care programme i s administered by the Medical Services  Division under authority of the Health Services Act.  Through administrative  necessity, the benefits are provided under two sub-programmes.  The  first  provides benefits to persons receiving regular and long-term public a s s i s tance i n the form of pensions or mothers' allowances.  A health service card,  issued to the head of the family, entitles the holder and his dependents to health care as required. The second programme provides benefits mainly to recipients of social aid who  are c e r t i f i e d by either the department of Social Welfare or  Municipal Affairs (Local Improvement D i s t r i c t Branch) as being i n need of health services. Most of these are short-term cases.  Health service cards  are issued only when benefits are provided over an extended period. The two certifying departments determine who w i l l receive pensions, allowances, or social aid.  The health department arranges for the  provision of essential health services for these beneficiaries and determines the manner i n which the services w i l l be  provided.  Health Services for Long-Term Beneficiaries (Programme l ) The beneficiaries of this programme include the following group:  - 11 recipients of old age security who qualify for the provincial supplemental allowance on a means test basis, together with their spouses and dependents; recipients of blind persons' allowance, their spouses and dependents; recipients of mothers' allowance including incapacitated husbands and dependents, child welfare cases and certain children assigned to guardians. The annual report of the Medical Services Division of the Department of Public Health for the f i s c a l year A p r i l 1, 1953 to March 31, 1954 states that since 1945 there has been a gradual, though somewhat irregular, increase i n the number of beneficiaries under this programme.  The noticeable decline  i n the last two years appears to be associated with the upward swing i n economic conditions and the national universal benefit for those reaching 70 years. There i s no doubt, however, that the long time trend i n numbers of e l i g i b l e persons i s upward. Excluding local government beneficiaries, both programmes served approximately 4 per cent of the 1953 population of 861,000 i n Saskatchewan. Of a l l persons 65 years and over, 27 per cent were public assistance beneficiaries. A l l beneficiaries are eligible for a wide range of services. Medical care includes the services of physicians and surgeons i n home, off i c e , or hospital.  Comprehensive hospital care includes a l l benefits of the  Hospital Services Plan together with certain additional benefits excluded under this Plan such as out-patient services and extra drugs.  In addition,  dental services, drugs and appliances, optical services, nursing, physiotherapy, and chiropody may be obtained when required. Health services are not available outside Saskatchewan except i n  emergencies, unless prior approval i s granted.  Reciprocal agreements exist  with the governments of Alberta and B r i t i s h Columbia whereby health services are provided to those pensioners who transferred between provinces on or prior to December 31, 1952.  Pensioners moving after that date must esta-  b l i s h residence i n the province i n which they are residing before qualifying for medical services. Medical and Surgical Services Under an agreement with the College of Physicians and Surgeons of Saskatchewan, the per capita payment of $15.00 was applicable for f i s c a l years 1952-1955. As of April 1, 1955 the per capita was increased to S16.50. The physicians' rate of payment for those e l i g i b l e i n Programme 1 i n 1953-1954 amounted to 52.61  per cent of the schedule of fees.  Transportation costs are  paid physicians on a mileage basis for any rural home v i s i t s .  Saskatchewan  reports that with time and experience, there tends to be a gradually i n creased u t i l i z a t i o n of physicians* services. A central medical assessment board, nominated by the College of Physicians and Surgeons and appointed by the Minister of Public Health, assisted i n the authorization and assessment of medical accounts and functioned as an advisory board concerning the operation and administration of the medical care portion of the programme. Drug Services Recipients are responsible for 20 per cent of the cost of most drugs.  However, the entire cost of : insulin, parenteral l i v e r extract,  vitamin B12 concentrate, and appliances are covered.  On the recommendation  of a physician, the entire cost of drugs i s paid where a real hardship i s  - 13 shown to exist. ance group.  Drugs represent a major expenditure for the public a s s i s t -  According to the report of the f i s c a l year April 1, 1953 to  March 31, 1954, the average prescription price across Canada was 13.7  per  cent higher i n 1953 than i n 1952 and a similar situation prevailed i n the United States. Dental Services Recipients are permitted to select the dentist of their choice but are not allowed to change dentists during the course of any one t r e a t ment.  The regulations are designed to encourage preventive work.  Research,  has shown that this service i s under-utilized for the children under the age of 14 years, due possibly to the lack of knowledge and conviction regarding the need for dental care for children, who are not suffering pain; poor d i s tribution and shortage of dentists i n the province; and d i f f i c u l t i e s around travel to areas where dental services are available. F i l l i n g s and extractions present few administrative problems but prosthetic dental service i n Saskatchewan as elsewhere, requires certain l i m i tations.  Since 1951 the government pays $50.00 towards the cost of a l l com-  plete upper and lower dentures, leaving the recipient responsible to negotiate the balance with the dentist. Second sets of dentures are provided, i f necessary, five years after the f i r s t set.  Prior approval by the dental director  of the Department of Public Health i s required for complete dental X-rays, oral surgery, gold inlays, dentures, complete or p a r t i a l , and denture relines. Hospital Services Each beneficiary i s entitled to coverage of the Saskatchewan  Hospital Services Plan, which provides hospitalization i n any Saskatchewan hospital as long as medically necessary.  The Plan simply estimates the  funds required to cover the long-term beneficiaries and obtains i t from the general revenues of the provincial government.  Out-patient services,  a portion of emergency hospitalized i l l n e s s outside the province, and cert a i n drugs excluded from the benefits of the Hospital Services Plan are also provided.  The increased out-of-province payment by the Saskatchewan  Hospital Services Plan of $7.50 per day beginning i n 1954 had the effect of reducing the share of the payments f o r these beneficiaries paid by the Medical Services Division.  In 1953, Saskatchewan Hospital Services Plan  expenditures for the group of long-term beneficiaries amounted to Sl,817,224.76**or approximately $62.58 per capita. Nursing Services Special private duty nurses are provided, on the request of the attending physician. Home nursing care through the Victorian Order of Nurses i s also financed, when prior approval i s obtained.  The per capita  cost for this service increased from 33 cents i n 1952-53 to 48 cents i n 1953-54. Optical Services Eye glasses are obtained d i r e c t l y on prescription from a physician or an optometrist. Prior approval i s required only i f a second pair of eye glasses i s sought within two years.  Saskatchewan reports that the  wholesale cost of optical supplies increased during the f i s c a l year although the refraction fee remained constant.  'Based on discharges for the calendar year  1953.  - 15 Other Services Services by physiotherapists i n private offices or i n hospital out-patient departments are provided, when prescribed by a physician and approved by the Medical Services Division.  Chiropody services and appliances  for foot ailments are provided d i r e c t l y on application by the patient and without prior authorization.  Expenditures for physiotherapy services provided by  other than physicians increased from 4 cents per capita i n 1952-53 to 6 cents i n 1953-54. Per capita expenditures for chiropody increased from 15 to 17 cents. Health Services f o r Short-Term Beneficiaries (Programme Two) The Department of Social Welfare c e r t i f i e s those individuals or groups of persons who are entitled to health services under this programme. In general, they are persons receiving social aid on a short-term basis J single homeless, and transient persons; transient families; Metis; c i v i l i a n rehabilitation cases; wards; gaol inmates; juvenile delinquents; indigent immigrants and indigent poliomyelitis cases.  Persons receiving social aid  and medical indigents residing i n local improvement d i s t r i c t s are c e r t i f i e d by the Local Improvement D i s t r i c t s Branch of the Department of Municipal Af;!  fairs.  Paraplegic cases may receive benefits i n regard to special care given  at certain centres outside the province by the Department of Veterans' A f f a i r s . Excluding immigrants, medical indigents i n local improvement d i s t r i c t s and indigent polio cases, there was an average increase of 46 social aid cases i n 1953-54 over the previous year. , With certain exceptions, the health services for this group are similar to those provided f o r long-term beneficiaries (Programme One).  They  include medical, dental, hospital, optical and nursing services, drugs, physiotherapy, and chiropody.  Indigent immigrants have been provided  health services under a separate agreement with the federal government which contributes 50 per cent of the cost. This agreement provides health services f o r a period of one year for a l l indigent immigrants who enter Canada with the intention of requiring Canadian domicile. Under a reciprocal agreement with the B r i t i s h Columbia government each province provides health services f o r wards l i v i n g i n the other province. Transportation The Saskatchewan government has operated an A i r Ambulance Service for approximately nine years and i s giving consideration to expanding this service.  Patients with emergency conditions are flown to outside hospitals  through the service of the Saskatchewan Government Airways, which makes emergency f l i g h t s throughout the entire northern area when required. ients, however, are brought i n and returned on scheduled f l i g h t s .  Most patThe nor-  thern outpost area i s served by a two-way radio service operated by the Department of Natural Resources so that no d i s t r i c t i s completely isolated as far as communications are concerned. Administration The entire programme i s administered by a staff of thirty-four persons constituting the Medical Services Division of the Provincial Department of Public Health. provincial capital.  A l l a c t i v i t i e s are centralized i n one office i n the  The Regional Health Offices established throughout the  province f o r public health services do not at present carry any direct respons i b i l i t i e s i n this programme.  The Division i s composed of a Medical Director  = 17 and Assistant Director, a Technical Advisory Section, E l i g i b i l i t y  Checking  Section, Assessing and Coding Section, Accounting Section, and Office Management Section. The Medical Services Division works closely with the Saskatchewan Department of Social Welfare.  F i e l d workers of this Department  stationed throughout the province interpret benefits available to the needy persons.  In addition, a l l the long-term and some of the social aid bene-  f i c i a r i e s are mailed a descriptive pamphlet on the whole programme. Municipal Medical Care Programmes Saskatchewan's municipal medical care programmes, commonly known as municipal doctor plans, play an important role i n the rural l i f e of the province.  They originated about 40 years ago and, while not as significant  as i n the early years i n the total organization of medical care, they s t i l l provide an important measure of protection f o r about 170,000 persons.  The  plans are financed and controlled by the municipalities under contract with physician or group of physicians. Their purposes are primarily to attract and hold doctors i n rural areas and to ease the burden of medical b i l l s by spreading medical costs over many families and over a period of time. They are financed through taxation on land or a combination of land and personal taxes.  The programmes receive some support through pro-  v i n c i a l government grants which are made available on an equalization f o r mula designed to provide the maximum amount of aid to the municipalities with the lowest assessment  1  Receipt of grant aid i s contingent upon the  ^Municipalities operating prepaid medical care programmes and f u l f i l l i n g the requirements of medical care grant regulations receive a f l a t grant of 25 cents per capita plus an equalization grant i f the per capita land assessment i s under §900. The equalization grant ranged from 20 cents per capita per year, where the per capita assessment was $800. to $2. where the assessment f e l l below $299.  contract between the participating parties being i n accordance with a "model contract" designed to protect the interests both of physicians and of the persons paying for and receiving the services.  In addition, the health de-  partment provides a f u l l time consultative service available to any municipal unit operating or intending to operate a programme. Not a l l programmes are "approved". A few operate without health department supervision and, of course, without provincial grant assistance. The department encourages municipalities, i n their negotiations with physicians, to enter into agreements which w i l l ensure complete coverage of a l l residents, a wide range of benefits, an equitable taxation load, and a volume of service f a i r both to the practitioner and to the beneficiaries. Beneficiaries should expect to have prior claim over private patients to the services of the physicians, and the physician i s expected (where health regions have not yet been organized) to undertake a certain amount of public health work. Issues i n Medical Care i n the United States That there i s a good deal of similarity i n the problems of medical care confronting public assistance agencies i n the United States i s shown i n a recent a r t i c l e by Pearl Bierman i n the Social Service Review.  1  Increase i n Medical Requirements and Costs In discussing this subject Miss Bierman points out thattwenty  ^Bierman, Pearl. "Medical Assistance Programs". The Social Service Review, June 1954, Volume XKVTII, number two. The University of Chicago Press, Chicago, I l l i n o i s , U.S.A.  - 19 years ago persons i n receipt of public assistance were employable.  Today,  persons benefiting from such financial aid are l i k e l y to be unemployable and to have heavy medical needs.  The need for public assistance i t s e l f  often arises from i l l n e s s . Miss Bierman states that information available for one threeyear period indicates that about one-fourth of a l l new a i d to dependent children families were i n need because of the i l l n e s s or d i s a b i l i t y of the father, and that about one-fourth of a l l Aid to Dependent Children families during one year of this period were i n need because of the premature death of the father.  At times during this period as many as one-third of the gen-  eral assistance recipients were destitute because of the i l l n e s s or d i s a b i l i t y of the family head. Large numbers of old age assistance recipients are unable to work because of chronic i l l n e s s or impairment.  By d e f i n i t i o n a l l recipients of  aid to the blind and aid to the permanently and t o t a l l y disabled are dependent because of d i s a b i l i t y .  When there i s provision to assist for the medi-  c a l l y indigent - those who are otherwise self-supporting but cannot meet medical needs - such help i s generally limited to the "catastrophic i l l n e s s " i n which costs are high. According to Miss Bierman, differences i n the family unit and i n housing have made i t necessary for agencies to meet many of the service needs of public assistance recipients. Also, the gradual aging of the population, and changes i n standards and advances i n practice of medical care have increased costs.  A change i n philosophy, on the part of both the providers  - 20 of medical care and public assistance agencies, has further added to the costs.  More and more agencies are expected to pay the usual rates or the  f u l l cost of care. Status of Medical Assistance Programmes i n 1953 I t i s Miss Bierman's opinion that, while much progress has been made with respect to medical care programmes, much more can be achieved.  Re-  ports submitted to the American Public Welfare Association i n March, 1953, by the forty-eight states, plus D i s t r i c t of Columbia, Alaska, Hawaii, Virgin Islands, and Puerto Rico, indicated a wide variation i n adequacy and scope. Sixteen states reported that no state public assistance funds were available for general medical care; two indicated a complete medical programme for public assistance recipients administered and financed by the state departments of public health and fourteen states reported their source of f i n ances to be local funds but only six of these were considered adequate. A number of states reported health departments administering state-^wide programmes, which appeared to be the only states permitting a l l public assistance recipients the means of obtaining the same scope of services. According to Miss Bierman the lack of state financial participation i n medical care does not necessarily mean that l o c a l i t i e s do not sometimes provide sufficient care.  Without the leadership of the state agency, however,  local administration of medical assistance programmes may not provide f o r the same scope of services and for equitable treatment of recipients throughout the state.  Miss Bierman considers that limited and inadequate medical assistance programmes, and lack of provision for the medically indigent, a l l keep public assistance agencies from accomplishing  their major job; that  of restoring people to the highest degree of self-sufficiency.  Facilities  for the medically indigent are generally inadequate and outside the large c i t i e s provision for treating them i s generally lacking. Miss Bierman stresses the need for f u l l cooperation on u t i l i z a t i o n of health and welfare services. State Agency Responsibilities In this thesis, which reviews the programmes of medical services, the question of State Agency responsibility i s of particular interest.  In  Miss Bierman s opinion local units, i n the main, cannot afford the kind of 1  professional health personnel necessary to administer medical assistance programmes properly.  State agency consultation and supervision i s essential.  As the American Public Welfare Association stated i n 1939,  "the function of  the Federal authority should be to assist with financial aid and with the maintenance of standards rather than to administer the service.  The state  authority should either be responsible for enough assistance to and supervision of local administration to insure sufficient service and good standards, or for administration on a state-wide b a s i s " .  1  The state public assistance agency also should be responsible for guiding the l o c a l i t i e s i n establishing effective and e f f i c i e n t methods and i n controlling the cost of medical assistance.  American Public Welfare Association. "Organization and Administration of Tax-Supported Medical Care" (unpublished policy statement, 1939) p. 5.  CHAPTER 2 DEVELOPMENT OF PUBLIC MEDICAL CARE IN BRITISH COLUMBIA  B r i t i s h Columbia, unlike Nova Scotia and New Brunswick and nearly a l l the American states, has never had a poor law.  However, there  has been the equivalent of this i n a simple provision of the "Municipal Act" which was one of the f i r s t Acts to be passed after the entry of B r i t i s h Columbia into Canadian Confederation  i n 1871.  This Act set out the areas of jurisdiction over which the municipal governments would have autonomy. poor".  One of these was  "the r e l i e f to the  Amended many times since then, the "Municipal Act" has  continuously  placed the responsibility for health and welfare of the indigent upon the local organized areas.  The section referred to i n the present Act states  that " i t shall be the duty of every c i t y and d i s t r i c t municipality... to make suitable provision for i t s poor and destitute".  1  This duty did not make heavy demands i n the early days of municipal history, because requests for aid were small and there was no machinery to see that the municipalities took the legislation seriously.  The  population was often too sparse to make local organization possible.  The  province on account of i t s administrative jurisdiction over unorganized territory, was compelled to assist i t s own destitute, particularly the aged and the sick, and to provide for burial of indigents.  To aid the occasional  case that came to the attention of the local representative i n the  R.S.B.C. 1936. Chap. 109, Sec.  501  - 23 i n the Provincial Legislature, a Destitute Poor and Sick Fund was set up i n the Provincial Treasury i n 1880. The Provincial Home at Kamloops which offers institutional care to older men was opened i n 1893.  The Marpole Infirmary (formerly known as  Home for Incurables) was established i n 1922.  Grants to resident physicians  i n outlying d i s t r i c t s , to compensate them i n some measure for service to the poor and to encourage them to remain i n remote communities, began before 1886. The municipal costs of destitution grew due to population increase and change of social and economic conditions.  Not u n t i l the onset of the de-  pression of the 1930's did the problem become a grave one to the municipali t i e s and the provincial government. At this time an Unemployment Relief Branch under the Provincial Department of Labour was created.  I t was  charged with the duty of administering successive Federal Acts passed to relieve the distress of the thousands of unemployed. i  It created policies and regulations to provide needed r e l i e f on an impartial basis according to funds at i t s disposal. I t attempted to bring a measure of uniformity i n municipal practice, and extended assistance to the l o c a l governments through a sharing of costs.  Through cooperation of the  federal government, and other provincial departments, work projects were instigated.  I t maintained a staff of investigators who served throughout  the province, and insofar as numbers would allow, made an attempt to include positive rehabilitation services.  - 24 With the depression, families and individuals moved their place of residence.  These movements created problems which resulted i n the passing  i n 1935 of the "Residence and Responsibility Act".  This Act stated legal res-  idence could be established i n a local area after one year's continuous  resi-  dence on a self-supporting basis, or three years' residence i f i n receipt of relief.  Thus the responsible area was now obligated to pay the cost of r e -  l i e f given u n t i l the recipient had established residence elsewhere. With this programme for financial assistance, many municipalities were forced into bankruptcy and the treasuries of both provincial and municipal governments were depleted.  Although i t had no direct responsibility  to do so, the federal government was forced to enter the situation with a grant-in-aid programme to the province. In 1935, a l l existing social welfare administration was placed under a Director of Social Welfare, within the Provincial Secretary's Department. Under this new administration, the f i e l d service was expanded i n the rural parts of the province and social workers were assigned to various areas. This staff gave a generalized service which included mothers' pension, the destitute, poor and sick r e l i e f , child welfare, tuberculosis control, mental hospital, and industrial schools services, and took care of inquiries from collector of institutional revenue and other agencies.  Because of problems  created by long stay patients i n acute general hospitals, hospital clearance was instituted i n January, 1938. In 1941 the provincial government assumed 80 per cent of the cost  - 25 of direct r e l i e f to unemployable persons residing i n organized areas, paying 100 per cent of this cost i n the large unorganized t e r r i t o r y of the province. The policy established toward the end of the depression of granting such f i n ancial a i d on a basis of need yet within a set maximum scale was continued. Individual consideration was given to individual situations, with the focus of rehabilitation. In October, 1942 was seen the beginning of amalgamation of the separately administered services.  To begin with, the Unemployment Relief  Branch, the Mothers* Allowance administration, and the Child Welfare Branch were brought together under the Department of the Provincial Secretary. The new office was named the Social Assistance Branch.  The f i e l d staff of the  Unemployment Relief Branch and of the Welfare F i e l d Service were brought under i t .  The chief executive of the Branch was given the t i t l e of Assis-  tant Deputy Provincial Secretary. Early History of Medical Care  1  The Unemployment Relief Branch appointed a medical doctor i n the early 1930's to give p a r t i a l service to the work project camps.  This con-  sisted of supervising the medical care i n the camps given by the local doctors i n the area where the camps were situated.  These doctors were paid a  small monthly retaining fee of §50.00 to $75.00 a month. This was a categorical service designed to be a precautionary measure to guard against epidemics i n the camps.  No service was given to  the municipalities or to the public generally. A treatment c l i n i c f o r  Interview with Mr. E.W. G r i f f i t h , former Deputy Minister of Welfare f o r B r i t i s h Columbia, July, 1955.  - 26 single men, mainly transients, was established i n Vancouver and the chief function of the Branch doctor became supervision of this C l i n i c . About this time, the provincial government decided to pay f o r medical services i n unorganized t e r r i t o r y on a tax fee basis ($1.00 a v i s i t ) . From 1934-1936 the government contributed to the municipal medical care on the basis of 25 cents per capita of the r e l i e f population monthly and the municipality had to put up the equivalent amount.  Some municipalities d i d  not take advantage of t h i s arrangement because they had d i f f i c u l t i e s i n reaching agreements with the local doctors. During the depression years, the efforts of the general administration were steered toward finance; that i s , of obtaining money to maintain the men i n work camps.  In the peak per-  iod of the depression there were 11,000 i n about 200 road camps.  At the  same time there were also 133,000 i n receipt of financial a i d and this would be about 20 per cent of the population. There was always consciousness of the need for medical services and this was bom out by provision of medical services for the indigent whenever finances were available.  In the 1930*s  those i n receipt of financial aid were i n normal health, but due to the work situation were unable to provide f o r themselves.  Therefore, a health problem  was not a pressing one. The d i f f i c u l t i e s encountered i n negotiating any type of medical care programme with some municipalities stemmed mainly from the interpretation placed on the "Municipal Act" dealing with the provision f o r medical care. Many municipalities contended that provision f o r the poor and destitute  - 27 covered food, clothing, shelter but not medical services.  The Administrator  who later became Deputy Minister of Welfare contended that suitable provision for the care of these people should cover a l l the needs of the individual i n cluding hospital and medical care.  Grants were not made to hospitals refusing  to care f o r patients who were indigent. The Attorney General's Department supported the interpretation of the Clause i n the Municipal Act that medical services were to be provided. Until the Medical Services Branch of the Provincial Secretary's Department was organized i n 1935, the provision of medical r e l i e f continued to be a municipal responsibility.  When the Branch was f i r s t organized, i t  was contemplated that responsibility f o r medical services f o r the indigent would be assumed completely by the Provincial Secretary's Department, but i n practice this did not take place, and funds for the Medical Services Branch were provided by the Unemployment Relief Branch of the Department of Labour.  In effect, therefore, the Medical Services Branch was simply one  section of the Unemployment Relief Branch. This Branch arranged medical services (general practitioner service, necessary drugs and a few extras) for recipients of unemployment r e l i e f i n unorganized territory and made grants (essentially on a 50-50 basis) to municipalities which desired to provide organized services (general p r a c t i tioner and drugs) to those on unemployment r e l i e f within their boundaries. The f i r s t medical director was appointed i n December 1934. By 1935 agreements were i n effect with most of the municipalities including a l l the larger  - 28 ones.  The municipalities i n turn made their own arrangements for remun-  eration of physicians, agreements with the medical profession for lump sum payments being most common. In Vancouver, a f u l l time doctor, nurses, and a n u t r i t i o n i s t were members of the City r e l i e f s t a f f .  A plan to provide maternity services f o r  unemployed families was started i n August, 1933, with wider provision, i n cluding a l l basic medical services, following i n January, 1934.  The general  principle was accepted of a monthly grant to the local medical association which was disbursed pro rata to the doctors submitting accounts.  F i f t y per  cent of the total grant ($5,000.00 a month) was paid by the City, the remainder by the Province. The contract with the Vancouver Medical Association provided f o r both general practitioner and specialist service.  A l l essential operations  were covered, and hospital charges were met j o i n t l y by City and Province. Dental treatment was limited to extractions and glasses were supplied free i f recommended on grounds of health. While the r e l i e f office had a standard pharmacopeia, i t arranged d i r e c t l y f o r the supply of medicines and met this particular cost as a 100 per cent c i t y charge.  The fees of a doctor and  nurse at agreed standard rates were paid for home confinements, while one inclusive charge was made for hospital  confinements.  Recent Administration of Medical Care In 1940 the situation regarding medical services and drugs was as follows:  The provincial government paid for medical services to social allowance  - 29 cases i n provincial areas on a tax fee basis.  I t should be noted that medical  services were granted only to the Social Allowance Group and not to Old Age Pensioners or Mothers' Allowance cases.  I t can be said, however, that limited  services were extended to Old Age Pension and Mothers' Allowance cases where extreme urgency was shown. Drugs were supplied free and the Government was granted a 10 per cent discount by druggists.  Hospitalization was available  and the Government paid to the hospital a specified daily rate i n addition to the daily per capita grant. The granting of medical services and drugs to municipal social a l lowance cases was entirely the responsibility of the municipality.  Here again  no ancillary service was granted to Old Age Pensioners or Mothers' Allowance cases except under extreme conditions of urgency. In the f a l l of 1940 the c i t y of Vancouver concluded an arrangement with the Vancouver Medical Association on the following basis.  The City was  to pay a per capita rate to the Medical Association, v i z ; TABLE I 1940 SCHEDULE OF PAYMENTS BY THE CITY OF VANCOUVER TO THE VANCOUVER MEDICAL ASSOCIATION No. of Persons i n Receipt of Allowance  Source:  Payment per Month to Vancouver Medical Assoc.  20,000 and over  .30  17,500 to 20,000  .31  15,000 to 17,500  .32  15,000 and less  .33  Departmental Comptroller, Department Health and Welfare, V i c t o r i a .  - 30 This was the f i r s t agreement based on a per capita payment established by a municipality and a Medical Association for the provision of medical services to Social Allowance cases. Effective November 1st, 1942, a new agreement relating to medical services for Social Allowance cases only was drawn up between the c i t y of Vancouver, the Vancouver Medical Association and the Province. The Province agreed to pay 50 per cent of the cost.  The following i s the  schedule of payments: TABLE 2 1942 SCHEDULE OF PATMENTS BT THE CITY OF VANCOUVER TO THE VANCOUVER MEDICAL ASSOCIATION No. of Persons i n Receipt of Allowance  Payment per Month to Vancouver Medical Assoc.  12,500 to 15,000  .34  10,000 to 12,500  .35  7,500 to 10,000  .36  5,000 to 7,500  .37  2,500 to 5,000  .38  2,500 and under  .39  Source: Victoria.  Departmental Comptroller, Department of Health and Welfare  In addition to the above payments i t was also agreed that where the number covered by the agreement was 10,000 or less the per capita payment would be supplemented by a f l a t $100.00 per month.  - 31 In a circular l e t t e r dated January 21st, 1943 the Provincial Government offered to share with any municipality on a 50-50 basis the cost of medical services up to a maximum of 33 cents per person per month.. A municipality could make arrangements with the local medical association to this effect. The agreement was to include recipients of Social A l lowance, Old Age Pension and Mothers' Allowance.  The provincial government  would also pay 50 per cent of the cost of drugs to these cases.  The agree-  ment, however, did not cover optical or dental services which were a 100 per cent municipal charge.  The same service was extended to a l l social as-  sistance cases i n unorganized t e r r i t o r y where the provincial government was 100 per cent responsible for the cost. Por some years the Unemployment Belief Branch had supplied medical services to destitute persons from unorganized t e r r i t o r y and, when i t was necessary for them to be hospitalized, the Medical Services Branch had paid a specified daily rate varying from Si.00 to $2.00, to the hospitals i n add i t i o n to the daily per capita statutory grant.  On March 31st, 1953 such  additional payments were terminated. In March, 1943 the government decided to increase the maximum per capita rate previously set at 33 cents to 40 cents; thus a municipality could enter into an agreement with a medical association offering a maximum per capita payment of 40 cents.  Payments for medical services i n unorganized  t e r r i t o r y were s t i l l on a tax fee basis and drugs were free to social assistance recipients, the government receiving a 10 per cent discount from  druggists.  The medical services offered to both organized and unorganized  cases included operations and specialists services.  About the same time  i t was further agreed by the provincial government, that because of the small number of cases i n municipalities with a population of 1,000 or less, these cases would be regarded as being i n unorganized t e r r i t o r y for the purpose of granting medical services and drugs. In September, 1944, services were arranged whereby a recipient of social assistance who, although a municipal responsibility, was residing i n unorganized territory would receive medical services from the Provincial Government.  However, i f the municipality responsible for the case was  one  which had accepted the general medical and drug scheme the municipality would be b i l l e d for 50 per cent of the cost.  I f the municipality was  one  which had not accepted the scheme the municipality would be b i l l e d 100 per cent of cost.  At this time the c i t y of Vancouver provided a certain limited  dental and optical service.  Regulations pertaining to medical services and  drugs were extended to provide these services to a spouse of an Old Age Pensioner, Blind Pensioner or Social Assistance recipient. On A p r i l 1st, 1947 the province agreed to share costs on a 80-20 basis with municipalities, making the necessary arrangements with local physicians for the provision of medical services.  The province would also  share on an 80-20 basis the cost of prescribed drugs, based on the B.C. Formulary.  At the same time the Social Welfare Branch agreed to pay $3.00  per day to any hospital receiving statutory grants under the Hospital Act  - 33 i n respect of every genuine in-patient who was i n receipt of social assistance. An administrative review of the medical programme by the Director of Medical Services Division i n July, 1947 indicated the necessity for a uniform scheme of medical care.  The services being rendered throughout the  municipalities showed alarming variations.  Emergency medical care was being  given payment or no payment. Lack of uniformity led to considerable inconvenience and embarrassment and perhaps emotional disturbance on the part of the client, and financial embarrassment to those rendering the service. There was no provision for remedial work and no means for an individual to obtain service outside his local area.  In unorganized areas coverage was  given by the doctors on a fee for service basis. In organized areas there were almost as many schemes as there were municipalities.  As an example of  the discrepancies which existed i t was noted that the per capita rate varied from 40 cents to 66 cents. As a result of this review, the problem of medical care received much attention and the ensuing negotiations culminated i n the agreement of March 1st, 1949 with the medical professional.  This provided complete medi-  cal, surgical and obstetrical care to a l l clients regardless of their place of residency.  This subject w i l l be expanded i n Chapter 4.  In the interim, January 1st, 1949 with the introduction of the Hospital Insurance Service a l l social assistance cases were covered for hospitalization premiums, being paid 100 per cent by the provincial government.  - 34 On January 1st, 1950 Drug and Optical services came under the equalization plan as Medical Services.  Glasses were supplied to recipients  of social assistance at no cost to them individually.  However, i n the case  of breakage, or loss, the patient would be expected to replace them i f i t could be done without too great a financial burden. The provision of dental services remain under the supervision of the municipalities although maximum rates of payment are set by the Medical Services Division. On April 1st, 1952 hospitalization of Social Assistance cases was charged at cost by the Hospital Insurance Service, whereas previously premiums were paid by the Welfare Branch.  CHAPTER 3  ELIGIBILITY AND SERVICES IN--MEDICAL CARE IN BRITISH COLUMBIA  Eligibility.. E l i g i b i l i t y for medical care i n public assistance i n B r i t i s h Columbia has a good deal of simplicity about i t .  In the main, a l l people i n  receipt of public assistance and their dependents are e l i g i b l e .  Specifi-  cally, care i s provided f o r recipients of Old Age Security who qualify f o r the bonus provided by B r i t i s h Columbia on a means' test basis, recipients of Old Age Assistance, Social Allowance to unemployables, Mothers  1  Allow-  ance, Blind Persons' Allowance, and Disabled Persons' Allowance who qualify for the provincial bonus.  In a l l the above categories dependents who are  the sole responsibility of the head of the family also receive f u l l medical coverage.  A l l these beneficiaries receive a "Medical Identity Card", i s -  sued to the head of the family and on vrhich dependents and those entitled to medical services are indicated.  In addition, services are given to the  children i n the care of the Superintendent of Child Welfare.  Those who re-  ceive temporary financial assistance from time to time are not granted coverage for medical services. Persons i n low income groups are not e l i g i b l e for medical services as provided by the Department of Health and Welfare.  However, some  hospitals have out-patients departments for the medically indigent, the Vancouver General Hospital providing particularly comprehensive  service.  - 36 Referrals are made by doctors or social workers. Table 3 indicates the relative numbers i n each of the e l i g i b l e categories and their percentage to the whole. TABLE 3 CATEGORICAL DISTRIBUTION OF RECIPIENTS OF MEDICAL SERVICES AS OF MAY 1. 1955  No.  Recipient  1.  Recipients of Old Age Security, who qualify for bonus  2.  Recipients of Old Age Assistance  3.  Recipients of Blind Persons' Allowance  4.  Recipients of Mothers' Allowance  5.  Recipients of social allowance to unemployables  6.  Recipients of Disabled Persons' Allowance  7.  Child Welfare Responsibilities Total  Source: Victoria.  Number  Present  36,417  52.7  8,621  12.5  591  .9  1,338  1.9  18,792  27.2  127  .2  3,167  4.6  69,053  (100.070  Departmental Comptroller, Department of Health and Welfare,  The total number of public assistance recipients as of May 1st, 1955 totalled 69,053, or approximately 5 per cent of the 1954 population of 1,266,000. (Figures for B r i t i s h Columbia issued by the Bureau of S t a t i s t i c s . ) It w i l l be noted that a large proportion of the recipients, 66.1 per cent are i n the age group of 65 and over.  - 37 Many administrative problems associated with public assistance are related to a mass of regulations and rules both for e l i g i b i l i t y and services provided.  The virtue of the B r i t i s h Columbia scheme i s that i t  minimizes these problems i n i t s relatively simple rules for e l i g i b i l i t y and i t s inclusive programme of medical care. Services Medical and Surgical An agreement reached by the Canadian Medical Association  (B.C.  Division), the Union of B.C. Municipalities and the Government of B r i t i s h Columbia has made available to every recipient of public assistance complete medical, surgical and obstetrical care i n home, hospital and doctor's o f f i c e . The administration and financing of this agreement w i l l be explained i n some detail i n Chapter 4. There i s free choice of doctors, including specialists.  Consul-  tations i n a centre where specialists are available can be arranged by the attending doctor, either by communicating d i r e c t l y with the desired special i s t or by contacting the local social worker.  In the latter case the worker  forwards the request, together with a social summary, to the Medical Services Division.  The Medical Director reviews the problem i n i t s entirety and d i s -  cusses i t with the appropriate specialist.  When arrangements are completed  the Division contacts the social worker giving instructions regarding the time and place of the appointment and authorizing return transportation i f required.  r- 38 The services of the physicians are the foundation of medical benefits.  According to recent s t a t i s t i c s , there are 1,368  doctors i n  private medical practice i n B r i t i s h Columbia, which means that there i s one doctor for every 925 persons.  The average reported for Canada i s one  for every 970 people, so B r i t i s h Columbians i n general are s l i g h t l y more fortunate i n this respect than the rest of Canada, although there figures do not reflect the distribution of doctors throughout the Province. Pharmaceutical Drugs and medicines are provided on prescription without cost to the c l i e n t .  The second edition (1953) of the B.C. Formulary, i s the guide  to be used i n prescribing. drugs. gist.  I t contains a comprehensive l i s t of allowable  The commonly prescribed drugs are supplied through the local drugNew and unproven drugs may be obtained by the prescribing physician  for his patient by obtaining the authorization of the special committee appointed by the Canadian Medical Association (B.C. Division) i n 1954.  Re-  quests for such drugs are made through the Medical Director of the Division who  refers them to the committee. Transportati on Transportation i s provided for clients i n need of surgery, special  treatment or consultation.  Services are arranged at the closest centre at  which they are available. The type of transportation most suited to the client's condition i s u t i l i z e d , whether i t be by t r a i n , bus, aeroplane, taxi, private car, ambulance or boat. indicated.  An escort i s provided i f medically  The Medical Director's authority i s required i f transportation  - 39 costs are i n excess of a certain specified minimum. Dental The dental services which are supplied include extractions, dentures and prophylaxis. These services may be obtained from any qualified dentist who i s w i l l i n g to provide them at allowable rates.  Authority f o r  the provision of dentures may be granted by a d i s t r i c t supervisor of the Social Welfare Branch when the recipient, or dependent, has been without teeth for four months or less, or when they are to replace dentures which are no longer serviceable. When dentures are required for a recipient, or dependent, who has been without teeth for more than four months, the request for dentures must be forwarded to the Director of Medical Services Division through the Regional Administrator, and must be accompanied by a complete medical c e r t i ficate outlining the medical reasons for the request and an estimate by the dentist.  Requests for prophylactic dentistry, f i l l i n g s and partial plates  are submitted to the Director of Medical Services through the Regional Administrator,  i  A l l cases are dealt with on an individual basis and f u l l i n f o r mation including an itemized estimate from the local dentist accompany a l l such requests. An arrangement with the B.C. Dental Association provides dental treatment for dependents of less than eleven years of age of persons i n receipt of public assistance.  Dental services for children i n care of  the Superintendent of Child Welfare are arranged l o c a l l y .  - 40 Optical Eye examinations for recipients of public assistance and their dependents can be obtained from an eye specialist or an optometrist according to the doctor's instructions.  Optical services not covered under  the terms of the agreement with the Canadian Medical Association (B.C. Division); namely, optometric services and glasses, may be authorized by the l o c a l welfare office provided the client has not received similar services for a period of two yearso Ancillary Appliances such as a r t i f i c i a l limbs, trusses and elastic stockings may be authorized by a d i s t r i c t supervisor on a physician's prescription unless the cost exceeds a specified minimum. More expensive appliances may be provided on the authority of the Director of Medical Services. Hospitalization Hospital benefits are available to a l l persons who have resided one year i n the Province and include a l l services provided by acute general hosp i t a l s on the public ward l e v e l . pected to pay co-insurance  Recipients of public assistance are not ex-  charges.  B r i t i s h Columbia has seven hospital beds per thousand population, including beds for treatment of acute or chronic i l l n e s s .  In 1953 the total  beds i n public and private hospitals across Canada provided five beds per thousand population.  1  The services of out patient departments are available to the re- . cipient of public assistance and great use i s made of the various c l i n i c s  B r i t i s h Columbia Hospital Insurance Service. Does not include available beds i n Mental, Tuberculosis or Federal Institutions such as D.V.A., Department of National Defence or Indian Health Services and does not indicate d i s tribution throughout the Province. 1  - 41 of the Vancouver General Hospital's Out-Patients Department i n providing medical care f o r recipients from a l l parts of the province. Miscellaneous Treatments by physiotherapists are approved only when prescribed by a physician to relieve an acute condition.  Services of special private  duty nurses, chiropractors and chiropodists are not provided by the Department. A l l services are expected to be obtained within the Province of B r i t i s h Columbia.  However, the Social Assistance Medical Service has a re-  ciprocal agreement with the Province of Alberta.  This permits use of f a c i l -  i t i e s i n that Province when they are more readily available than those i n B r i t i s h Columbia. Because of the increasing use of specialized resources i n Vancouver, such as the Western Society for Rehabilitation, the Canadian Arthr i t i s and Rheumatism Society, the Health Centre for Children, and the B r i t i s h Columbia Cancer Institute, i t i s imperative that the Social Welfare Branch has adequate personnel to see that the multiplicity of services are made available to the people who  require them.  The ideal i s to have professional  workers who have had sound basic training. The only programme u t i l i z e d where a comprehensive rehabilitation service i s offered i s at the Western Society f o r Rehabilitation where the Branch sponsors a limited number of a r t h r i t i c s , paraplegics and other orthopedically disabled. i l l u s t r a t e d by:  Many of those persons sponsored are success stories as  ,- 42 Mr. A,  R  , a single man born i n March, 1929 was driving  a truck i n September, 1950.  I t overturned, fracturing and dislocating his  back at the eleventh and twelfth vertebrae. His injury resulted i n paralysis of the lower part of his body. p i t a l on September 4th, 1950.  He was admitted to the Vancouver General HosHe received considerable treatment there u n t i l  April 26th, 1951 when he was admitted to the Western Society for Rehabilitation under the sponsorship of the Social Welfare Branch. Prior to Mr. R his  's accident, he had completed Grade 10 and during  stay at the Centre, he was tested through the Youth Counselling Service  which indicated a f a i r amount of interest and a b i l i t y i n office work, and suggested that the best p o s s i b i l i t y for his future was i n this line of endeavour. While at the Centre he undertook a correspondence course i n accounting which he completed i n June, 1952 with f a i r l y high marks.  In the meantime he con-  tinued to improve, and was supplied with a wheelchair and f u l l length paraplegic braces. He was discharged from the Centre December 6th, 1951, but continued as an out-patient for a time.  He t r i e d several jobs after leaving the Re-  habilitation Centre, one as a radio dispatcher with a taxi company, another pay r o i l work with a cartage company, but neither of these worked out.  In  January, 1954 he was placed on the Social Welfare Branch staff on a temporary basis as checker i n the Provincial Pharmacy. He has proven to be a s a t i s factory employee and i s now on the permanent s t a f f . Another i l l u s t r a t i o n i s Mr. D  of Osoyoos, a single man aged  67 who had been receiving treatment for rheumatoid a r t h r i t i s at the Oliver  - 43 Hospital* for  He was transferred to Vancouver General Hospital i n July, 1953  screening prior to transfer to the Provincial Infirmary. On July 30th,  1953 he was seen i n consultation at the Vancouver General Hospital by the Medical Director of the Canadian A r t h r i t i s and Rheumatism Society, who stated, "I think there i s a very reasonable hope that this man w i l l respond to active measures and thereby avoid long-term institutional care.  In fact he may be  able to return to his original employment as a janitor i n a hotel.  For this  reason we are requesting authority to admit him to the Rehabilitation Centre for a period of two months following hospital care". During the five weeks Mr. D  was i n the Vancouver General  Hospital he was treated with rest, physiotherapy and drugs with an excellent response.  He became a resident trainee i n the Western Society for Rehabili-  tation on August 27th, 1953, his maintenance being paid by the Social Welfare Branch.  At the time of transfer a l l signs of rheumatoid a r t h r i t i s had sub-  sided and the effusions had cleared from his knees. of movement, and his l e f t hip was again normal.  They both had f u l l range  He was walking normally and  required no analgesics. The Centre's pre-discharge medical report dated October 16th stated:  "On admission to the Centre his only d i s a b i l i t y was a subsiding  shoulder-hand syndrome on the right.  The right shoulder had a range of  movement approximately 50 per cent of normal with pain (i.e. i t was p a r t i a l l y frozen).  The right elbow had a slight flexion deformity and his  right hand was diffusely swollen. right.  still  He was unable to make a f u l l f i s t on the  Neck movements were s l i g h t l y restricted.  During his stay here he  has been treated with rest, physiotherapy and cortisone and improvement  has continued.  His shoulder i s less painful and i t s range of movement has  increased considerably. The swelling of his hand i s subsiding and while he s t i l l cannot make a f u l l f i s t i t i s stronger.  I t i s f e l t that with con-  tinued use, his shoulder-hand syndrome w i l l subside completely over the next six months or so.  I t does not constitute a very great d i s a b i l i t y at present.  His general health otherwise i s good for a 68 year old. Certainly he does not now appear to be a candidate f o r the Marpole Infirmary.  I f e e l that i f  he could be provided with assistance for a few months he could look after himself at home." The medical social worker of the Canadian A r t h r i t i s and Rheumatism Society stated that Mr. D  cooperated f u l l y i n the treatment programme  and made excellent use of the available arts and crafts f a c i l i t i e s . Mr. D  Before  l e f t the Centre he was able to walk forty blocks without fatigue  or other effects.  The Social Welfare Branch i n the area was notified of his  return i n order that they might help i n work plans and ensure financial assistance i f necessary. This case i s the story of an amazing transition of an almost completely helpless individual i n May, 1953 to a physical and mental state of a normal individual i n his 60's by the end of October that year.  He was d i s -  charged October 27th, 1953 and returned to Osoyoos. At that time he was w i l l i n g and able to accept a job as caretaker of the local community h a l l . A residue of Rheumatoid A r t h r i t i s i n his right shoulder and hand, which had greatly subsided, was a l l that was l e f t to remind him of his former extremely helpless and apparently hopeless condition.  - 45 Mr. D  had been i n receipt of Social Assistance intermit-  tently since March, 1947 previous to his treatment. and Rheumatism Society has advised us that Mr. D  The Canadian A r t h r i t i s i s at present s e l f -  supporting. Mr.. D  's remarkable response to treatment has f u l l y j u s t i f i e d  the efforts of the Department to assist i n the efforts of rehabilitation of a selected number of patients i n the Rehabilitation Centre. tunity not been available, Mr. D-  Had this oppor-  would probably have been i n the  Marpole Infirmary and supported by public funds.  As i t i s , i t seems more  than l i k e l y he w i l l be able to do productive work for another two or three years at least.  I t i s expected too, that he w i l l be able to improve h i s  farm s u f f i c i e n t l y to enable him to l i v e i n relative comfort when he r e t i r e s .  CHAPTER 4 ADMINISTRATION AND FINANCING OF MEDICAL SERVICES  Organization of Social Welfare Branch Before dealing with the administration and financing of medical services, i t i s advisable to outline the organization of public welfare i n the province. The General Administration, headed by the Deputy Minister of Welfare responsible to the Minister of Health and Welfare, has j u r i s d i c t i o n over the operation and promotion of a l l social welfare services set up by the provincial government.  The Deputy Minister delegates authority  to the Director of Welfare and the Assistant Director of Welfare to assist him with the detail involved i n this unified administration. Within the Social Welfare Branch the separate statutes that make up the Province's social l e g i s l a t i o n are administered by separate specialized divisions responsible through the General Administration to the Deputy Minister.  These Divisions are as follows:  See Appendix A.  The Family Division i s the office administering the Social Assistance and Mothers' Allowance Acts.  The Old Age Assistance Board ad-  ministers the Old Age Security Act, Old Age Assistance Act, Blind Persons' Allowance Act and Disabled Persons' Allowance Act. Division administers medical services.  The Medical Services  The Child Welfare Division ad-  ministers the Protection of Children Act, Adoption Act, and Children of Unmarried Parents Act.  In addition, this Division i s responsible for the  development and direction of the placement of children becoming wards of the government i n foster homes.  The G i r l s ' Industrial School provides  for treatment to g i r l s committed, principally under the Juvenile Delinquents Act.  Brannan Lake School for Boys provides treatment to boys com-  mitted under the Juvenile Delinquents Act. Kamloops offers institutional care for older  The Provincial Home located at men.  The Welfare Institutions' Licensing Board administers the Act which protects through, licensing and inspection, boarding homes, camps, nurseries and kindergartens.  The Training Division i s responsible for  staff development and training of in-service personnel.  Tuberculosis and  venereal disease services provide case work services within the Health Branch and the social workers are i n the employ of the Social Welfare Branch. Psychiatric Social Services provide case work services on behalf of patients at the Provincial Mental Hospital, Crease C l i n i c , Woodlands School and Child Guidance C l i n i c s .  These various establishments are under the jurisdiction  of the [Provincial Secretary's Department, but the social workers are i n the employ of the Social Welfare Branch. The Field Service Staff i s the operational arm of the service, and i s located i n d i s t r i c t offices i n every part of the Province, bringing the benefits of the Social Statutes and various programmes d i r e c t l y to the people i n need of them. For administration purposes the Province i s divided into six regions each headed by a regional administrator whose duty i t i s to administer the policies of the Branch i n his particular region as formulated by the General Administration i n V i c t o r i a .  See Appendix B.  In addition the  - 48 regional administrator interprets this policy to the municipal offices and acts as the l i a i s o n person between the municipalities and the Province. The supervision of the work done by the provincial social workers, that i s , the planning essential to adequate professional treatment of problems encountered and recommendations with respect to the expenditure of public funds, i s provided by d i s t r i c t supervisors, of whom there are twenty. These supervisors serve both provincial and municipal staffs and are located i n strategic positions throughout the Province. A chief f i e l d consultant for Regions two and six acts as a l i a i s o n between the Field and the Divisions, and gives direction on casework handling as i t effects specific cases brought to his attention. When i n the opinion of the chief consultant a change i n policy i s warranted, i t i s his duty to bring this matter to the attention of the regional administrator and general administration.  He i s available at a l l times on a consultative basis to the  d i s t r i c t and divisional supervisors. The provincial social worker i s the key person i n this organization, as i n the f i n a l analysis i t i s he who serves the people d i r e c t l y .  There are  forty-six social workers i n divisional office and one hundred and forty-three i n the f i e l d service.  1  Each social worker's service i s that of family casework  i n which he used the l e g i s l a t i o n or programme of government most appropriate to the needs of the family or individual.  The use of these resources demands an  intimate knowledge of each, and s k i l l and integrity are demanded i n establishing need or meeting e l i g i b i l i t y requirements, i n using public money wisely  Office of Assistant Director of Welfare, Social Welfare Branch, Department of Health and Welfare, V i c t o r i a . Memo, dated September 13th, 1955.  - 49 and economically, and i n working toward the saving of the family l i f e and the building of s e l f - r e l i a n t citizens for the future. Medical Services Division The Medical Services Division, Social Welfare Branch, Department of Health and Welfare, i s responsible for carrying out the programme formulated by the provincial government to give general medical and special medical, dental and optical services to persons i n receipt of public assistance. The entire programme i s administered by a staff of f i f t e e n persons comprising the Medical Services Division.  The staff includes a medical  director, who serves on a part time basis, a medical social work consultant, pharmacists, checkers, clerks, stenographers and clerk typists.  The medical  director i s responsible to the Director of Welfare. In his administrative capacity he works with the local doctors and social workers throughout the province to prevent i l l n e s s , maintain good health, and foster the highest degree of rehabilitation of which the person i s capable.  The medical social work consultant of the Branch functions as  the l i a i s o n between the social workers through the province and the medical director and i s responsible f o r bringing out the medical-social aspects of the case problems. Decisions and arrangements for transportation of assisted persons to and from special treatment centres, and to doctors for consultation, d i a gnosis and treatment come within the scope of the medical director. A l l accounts for transportation, drugs, optical, dental and ancillary services  - 50 are forwarded to the Division, checked, approved and passed to the Accounting Division of the Branch for payment. A pharmacy i s operated by the Branch and i s located i n Vancouver. Drugs required on a chronic basis are supplied through this dispensary which employs three qualified pharmacists. In 1954 the Canadian Medical Association (British Columbia Division) appointed a special committee of medical men to advise the medical director on the advisability of providing new and unproven drugs on the prescription of the private physician.  During the past year these prescriptions, when ap-  proved, have been f i l l e d at the provincial pharmacy. Nursing and boarding homes i n the province having public assistance patients submit a monthly requisition f o r drugs which are supplied by the pharmacy, and the Protestant and Catholic Children's Aid Societies also secure supplies f o r their receiving homes. Approximately 1,240 individual prescriptions are dispensed monthly. Administrative Relationship with the Medical Association The physicians services programme was i n i t i a t e d after due study disclosed the variation i n existing medical arrangements. Discussions throughout the Province culminated i n a plan inaugurated March 1st, 1949 when the medical treatment agreement between the Government of the Province of B r i t i s h Columbia and the College of Physicians and Surgeons of B r i t i s h Columbia, now called the Canadian Medical Association - B.C. Division, came into effect to provide f u l l medical, surgical and obstetrical care i n home, office or hospital i n accordance with recognized medical practice f o r each beneficiary of public  assistance. In consideration of the services rendered by the Association, the Government agreed to pay to the Association at the end of each month a sum equal to one-twelfth of an annual all-inclusive capitation fee of fourteen dollars and f i f t y cents ($14.50) for each person i n receipt of public a s s i s t ance and for each dependent, the amount to be paid to be based on the number of persons entitled to such service as shown on a master l i s t supplied by the Social Welfare Branch of the Department of Health and Welfare. capita rate i s subject to annual review.  The per  The municipalities were to share  on a per capita population basis and were to refund to the Province 20 per cent of the per capita cost.  The formula used to determine the municipal  share i s as follows: Total cost of medical services m x •, TT2 Total population of province , _ ,. *\ (less Indians) :  r  n  x  20 7n?7 100  .. „ . . population of mumci• • r. p a l i t y = municipal share, n  x  The administration of the fund paid to the Association and the rendering of the service was placed i n the hands of the medical profession. The Social Assistance Medical Service was set up to execute the details of the plan. The government agreed to provide to the Association at the end of each month a l i s t of a l l persons and the number of their dependents who have been granted assistance subsequent to the submission of the master l i s t . Also, the government agreed to provide each head of family or single person with an identity card, showing the registration number and the names of the dependents of each such person.  - 52 The Association i n turn agreed to furnish to the government any information which i t might require as often as practicable and, i n any event, an annual report was to be submitted not later than the 31st of January of each year.  The Association now  submits a quarterly report.  See Appendix C.  It was mutually agreed that the Association w i l l not be required to provide treatment for diseases or conditions for which care i s provided without cost by public authorities (for example; pulmonary tuberculosis, venereal  diseases  and mental illnesses, established preventive care, service-connected  dis-  a b i l i t i e s or any care by a tax supported agency).  Occupational  accidents,  or diseases for which the patient i s entitled to benefits under any Workmen's Compensation or similar law were also excluded. Experience showed as time went on that there was an increase u t i l i z a t i o n of the services and thus prorated payments to the doctors creased.  in de-  After study and negotiation the per capita rate was revised to  $18.50 effective A p r i l 1st, 1952. effective A p r i l 1st, 1954.  Another upward revision to $20.00 was  Under the most recent agreement, April 1st,  /iliQlusive 1955, the annual a l l capitation fee was raised to $22.50. TABLE 4 PERCENTAGE OF ACCOUNTS PAID TO PHYSICIANS PARTICIPATING IN SOCIAL ASSISTANCE MEDICAL SERVICE 1st Year  67.1$  March 1, 1949  -  February 28,  1950  2nd Year  56.9$  March 1, 1950  -  February 28,  1951  3rd Year  52.0$  March 1, 1951  -  March 31,  1952  4th Year  60.0$  March 1, 1952  -  March 31,  1953  5th Year  53.5$  March 1, 1953  -  March 31,  1954  Source:  Social Assistance Medical Service.  - 53 Since the i n i t i a l agreement i n 1949, changes.  there have been some minor  An agreement entered into May 5th, 1954 reads i n part as follows: "WHEREAS the Government and the College of Physicians and Surgeons of B r i t i s h Columbia negotiated an Agreement made the 7th day of February, A.D. 1949, to come into force on the 1st day of March, 1949, to provide a complete medical service to be operated on a uniform basis throughout the province, AND WHEREAS, i t i s desirable to continue the provisions of a complete medical service to be available to persons resident i n the province who are i n receipt of allowances under the provisions of the following Provincial Acts, that i s to say: Old-age Assistance Act, Blind Persons' Allowances Act, Mothers' Allowance Act, Social Assistance Act, Disabled Persons' Allowances Act and Protection of Children Act and the following Act of Canada, that i s to say: Old Age Security Act, who are otherwise e l i g i b l e under the Regulations of the Social Welfare Branch. AND WHEREAS i t i s agreed that the Agreement made the 4th day of June, A.D. 1952, between the Government and the Association be cancelled as of the 31st day of March, 1954. AND WHEREAS the Government and the Association have negotiated an Agreement for the provision of the said services by the Association through i t s members on the terms and conditions hereinafter set out: NOW THEREFORE the parties hereto, for the consideration hereinafter set out, agree as follows: 1. (a) i . The Association agrees with the Government that i t w i l l through i t s practising members and as hereinafter provided, provide during the term of this Agreement, without charge to the patients, f u l l medical, surgical and obstetrical care i n home, hospital and office, and when referred by the physician, out-patient diagnostic services provided i n any hospital defined i n the "Hospital Insurance Act", as a hospital required to furnish general hospital services provided under the said Act, i n accordance with recognized medical practice to a l l persons resident i n the Province who are entitled to and i n receipt of Old Age Security, Pensions, Old Age Assistance, Blind Persons' Allowances, Mothers' Allowances, Disabled Persons' Allowances or social allowances under any of the said Acts, and to their dependents, and to such additional persons as may from time to time be agreed between the parties, and who, when requesting such service, produce an authorization or Health Service identity card provided by the Government".  Agreement signed May 4, 1954 between Canadian Medical Association (B.C. Division) and Government of B r i t i s h Columbia.  - 54 Agreements with Optometric and Pharmaceutical Associations Arrangements have been entered into with the Optometric and Pharmaceutical Associations for fixed rates for glasses and optical examinations and for drugs at reduced costs. Financing In B r i t i s h Columbia, social assistance costs are shared largely by the municipalities with the provincial government on a 20-80 basis.  For  example, the municipalities pay 20 per cent of social allowance costs f o r those recipients resident i n the municipality or local area under the provisions of the "Residence and Responsibility Act".  The municipal share of  medical services i s on a somewhat different basis.  I t may be explained as  follows: The gross payment to the Social Assistance Medical Service i s r e duced by the ratio of population i n unorganized t e r r i t o r y to the t o t a l population of the Province. After this deduction i s made, the balance indicates the payment to be made for social assistance cases residing i n municipalities and i s further reduced by 80 per cent, being the provincial share.  The r e -  maining 20 per cent (municipal share) i s assessed on a per capita of population basis, dividing by the t o t a l population i n municipalities according to their individual populations. A l l population figures are based on the latest federal census returns. Accounts covering the municipal share of the cost of medical care are rendered on a quarterly basis by the prov i n c i a l government to the individual municipalities.  - 55 The method of determining individual municipalities' share of the cost of Drug and Optical Services i s fundamentally the same as that used i n computing the municipalities' share of medical costs with the following exception.  As the total cost of such service cannot be determined u n t i l the  books of the provincial government are closed each f i s c a l year, the amount b i l l e d to municipalities i s based on the estimated cost of the services f o r the year.  At the end of the f i s c a l year an adjustment account i s rendered  i n accordance with actual costs.  As i n the case of medical costs, b i l l i n g  of municipalities i s on a quarterly basis. Costs Adequate medical services are expensive and the overall costs of such care are mounting.  The total expenditure rose from $185,973.68 i n the  1946-1947 year to $2,038,096.40 i n the 1953-1954 f i s c a l year. of these costs i s shown i n Table 5.  A breakdown  TABLE 5 MEDICAL SERVICES. DRUGS. OPTICAL. ETC. EXPENDITURES  Medical  Year  Drugs  Dental  Optical  Trans.  Other  Total  $ 2,876.33 S  185,973.68  6,319.58  3,602.90  335,073.61  3,817.73  10,484.90  10,317.53  466,469.70  24,764.96  13,425.22  14,156.08  3,990.96  948,724.10  387,242.73  30,915.12  23,543.17  13,612.38  1,839.60 1,145,982.34  723,524.87  448,886.21  50,044.06  28,972.01  14,860.51  3,170.24 1,269,457.90  1952/53  1,012,555.82  500,373.41  71,392.69  42,387.62  16,377.71  5,878.82 1,648,966.07  1953/54  1,219,968.63  658,599.63  86,717.17  44,330.50  17,380.03  11,100.36 2,038,096.40  1946/47  $ 104,375.86  $ 65,690.53  $ 6,457.75  $ 1,821.06  S 4,752.15  1947/48  185,613.57  123,913.10  13,008.82  2,615.64  1948/49  250,004.18  172,554.46  19,290.90  1949/50  592,908.17  299,478.71  1950/51  688,829.34  1951/52  Source:  Departmental Comptroller, Department of Health and Welfare, Victoria.  - 57 These r i s i n g costs may be attributed i n part to the increase i n numbers of recipients. This increase i n turn i s due to several factors of which perhaps the most important i s the increase i n proportions of older people.  A study being made by Dr. James Tyhurst, of the Allan Memorial In-  stitute of the Royal Victoria Hospital, Montreal, shows Canada as a country which i s "aging" rapidly. Since 1881 Canada's population has increased by three times, while the percentage of those over 65 has jumped by s i x times. "Taken by Provinces, Quebec i s the "youngest" with 5.7 per cent over 65. The others: Newfoundland 6.5; Prince Edward Island, 9.9; Nova Scotia, 8.5; New Brunswick, 7.6; Ontario, 8.7; Manitoba, 8.4; Saskatchewan, 811; Alberta, 7.1; and B r i t i s h Columbia, 10.8. When i t comes to distribution, about 60 per cent of aged l i v e i n Quebec and Ontario, but i n trends the Western Provinces are getting "older" much faster than the east. The percentage of increase i n the rate of aged i n Quebec since 1881, for instance, i s 398, compared with 6,546 i n Manitoba and 10,146 i n B r i t i s h Columbia". I t i s a well known fact that older people require relatively greater services.  This situation has been brought about i n part by medical  science's success i n increasing our l i f e span and part by the numbers of aged people attracted to this province due to geographical factors *nf\ gressive welfare policies and health resources.  New  pro-  legislation has also  increased the numbers of e l i g i b l e recipients. Public awareness of available services has added to the numbers u t i l i z i n g them and the changes i n family patterns result i n more people requiring public support rather than depending on their families.  B.C. Government News "Aging Population" Volume 3, August, 1955 Number 7, page 5.  - 58 A second reason for r i s i n g costs i s increased dependence on public programmes rather than on private agencies.  A t h i r d i s the general acceptance •  of the philosophy that the provider of service should receive remuneration commensurate with prevailing standards i n the community. A general rise i n costs has been a fourth factor.  A f i n a l element i s medical advances r e -  quiring more costly drugs, equipment and f a c i l i t i e s . Relationships with Municipalities There i s some evidence that the municipalities accept the per capita formula for medical services.  This acceptance has come about with  years of experience which have proven to municipal councils that the programme i s operated e f f i c i e n t l y .  They approve of having requests for trans-  portation, ancillary services, dental attention and other special needs channelled through the Medical Services Division.  In addition, they have come to  realize the advantage i n having agreements on a provincial basis with the medical, optometric, and pharmaceutical associations which provide the services at reduced costs. The wealthier municipalities with the lower numbers of public assistance recipients are paying more i n proportion for the medical services than the poorer municipalities with the higher numbers of beneficiaries. In effect, tax payers i n wealthier municipalities are subsidizing the tax payers i n poorer municipalities.  CHAPTER 5  CONCLUSIONS  With the foregoing background of information, i t i s now possible to make some assessment of the Medical Services Programme i n B r i t i s h Columbia. The B r i t i s h Columbia government has gone a long way, probably further than any other i n Canada, i n the provision of medical care.  Cer-  tainly, from the point of view of the recipient the programme has been most satisfactory and i s available with a minimum of r e s t r i c t i v e regulations. The assisted person may have the services of physicians i n home, office or hospital.  He has free choice of doctor and his relationship with his pro-  fessional person i s the same as that of an insured person i n any prepaid medical care programme. When a consultation i s needed, this can be arranged by the doctor.  I f hospital care i s required, the doctor i s able to admit  his patient. Boarding home or nursing home care i s provided dependent on the person's needs and the resources available.  When special treatment i s neces-  sary the closest centre to the person's home i t u t i l i z e d .  Necessary trans-  portation by means of bus, ambulance, t a x i , t r a i n , boat or aeroplane i s provided.  The doctor can issue a prescription for most medicines needed i n  s c i e n t i f i c practice of his profession. Eye attention can be secured through an ophthalmologist or an optometrist, according to the doctor's instructions, and glasses when prescribed, are provided.  In dental care, extraction of  -  60  -  teeth and provision of dentures are permitted, and prophylactic work i s allowed on a limited scale. In the furnishing of these various services, the object has been to meet the needs of the individual by alleviating pain and by assisting him to reach his maximum capability, thereby becoming, i f possible, a s e l f - r e specting and self-dependent member of the community. An outstanding feature of the B r i t i s h Columbia programme i s the fusion of health and welfare i n the medical planning f o r the c l i e n t .  While  specific direction of the programme and provision for treatment comes under the medical personnel, the social worker has an important role i n f a c i l i t ating the provision of service.  Moreover, the social worker can contribute  an understanding and knowledge of the client i n his social situation to the attending physician, and the Medical Services Division which w i l l assist i n dealing with the emotional aspects of i l l n e s s which serve as barriers to r e covery.  In working with the sick and the handicapped, the same basic case-  work concepts are observed as i n working with other groups of people who need the worker's help. On the other hand, the physicians who render the service have had occasion to complain.  They have stated that as more and more people u t i l i z e  their services and use them more frequently, the government's contribution to the doctors has not increased proportionately.  They also point out that  other prepaid medical schemes such as Medical Service Association provide only limited medical care f o r limited periods, whereas under Social Assistance Medical Service, recipients receive complete medical care as long as they l i v e .  - 61 Further, under the Medical Service Association Plan, beneficiaries are aware that their contributions have some relationship to u t i l i z a t i o n of the service.  Public assistance recipients do not contribute to the cost of  the programme, and i t i s claimed that they have no interest i n minimizing these costs.  Accordingly, the Canadian Medical Association, B.C. Division,  has asked that an effort be made to educate the persons i n receipt of medical services so that there w i l l be l i t t l e or no abuse of privileges afforded them under this programme.  I t i s the writer's opinion that the major r e -  sponsibility for this interpretation l i e s with the medical profession i t s e l f . In assessing the B r i t i s h Columbia Medical programme, reference  was  made to others on this Continent and the one most comparable was found to be the Saskatchewan scheme.  A number of similarities were discovered.  Gen-  erally speaking the groups covered and services available are similar. Both have province-wide agreements with the medical profession based on per capita payments.  Another similarity i s their universal hospital plan which ob-  viates the necessity of special programmes for public assistance patients. Both provinces provide comprehensive drug services but maintain some degree of control over mounting costs through the u t i l i z a t i o n of professional medical advisory committees. However, certain differences do exist; the principal one being i n the f i e l d of administration.  Saskatchewan delegates this responsibility to  i t s Public Health Department and B r i t i s h Columbia to i t s Social Welfare Branch.  A further administrative variation occurs i n the control of the  fund providing professional medical care.  Saskatchewan has retained gov-  ernment control of the fund while B r i t i s h Columbia entrusts the responsibility  to the medical association. The per capita payment to the medical men at the present time i s substantially higher i n B r i t i s h Columbia.  However, this may be offset  to a. certain extent by the transportation allowance made i n Saskatchewan for rural home c a l l s .  Saskatchewan's drug policy entails payment of 20 per  cent of the cost of each prescription by the recipient while B r i t i s h Columbia exacts no payment,  B r i t i s h Columbia maintains some degree of regulation  through the use of a formulary which l i s t s the allowable drugs.  In contrast,  Saskatchewan (through i t s advisory committee) specifies the drugs which are not allowable.  Saskatchewan expects the client to bear 50 per cent of the  cost of dentures and to negotiate with the dentist the terms of payment. In B r i t i s h Columbia the securing of a contribution depends on the resources of the client and his family. Emergency transportation f o r medical treatment i s undertaken by Saskatchewan's A i r Ambulance Service. No comparable f a c i l i t y exists i n B r i t i s h Columbia, although transportation i s provided when necessary by normal f a c i l i t i e s .  Saskatchewan finds i t necessary to bear the cost of  transporting paraplegics to other provinces for rehabilitation*training, while B r i t i s h Columbia does not incur this expense because there excellent f a c i l i t i e s exist within the province. The question of the medical profession administering i t s own programme i s always an issue with many people. philosophy of the observer.  Any opinion i s dependent on the  While there are dangers inherent i n a profes-  sional group administering government funds, the dangers are minimized i f  - 63 the parties to the agreement have a sense of purpose and a s p i r i t of cooperation.  I t i s this writer's opinion that this has been the case i n  B r i t i s h Columbia with the result that the scheme i s working out s a t i s f a c t o r i l y to persons receiving the service, the medical profession who provide the service, and the government which i s responsible for the spending of tax funds. B r i t i s h Columbia's programme, being under provincial control, ensures province-wide uniformity of services and uniformity of means t e s t . This results i n generally higher standards of medical care and an equitable distribution of available funds. Medical care may be the responsibility of public health or welfare departments.  Those who believe that public health administration i s superior  maintain that certain advantages result from closer relationship with health personnel, that competitive demands on available funds are avoided, and that integration with preventive health programmes i s desirable.  In the writer's  opinion, health services under welfare administration are considered as part of the total needs of the c l i e n t and not as separate entities.  This concern  for the person as a whole results i n the preservation of his sense of personal worth through the relationship with the social worker. I t i s d i f f i c u l t to arrive at an objective assessment of the cost of the programme to B r i t i s h Columbia as i t i s so comprehensive.  Saskatch-  ewan's programme i s not s t r i c t l y comparable since provision of service depends to a considerable degree on local i n i t i a t i v e . This thesis has shown amongst other things that public assistance  recipients are really beneficiaries of a comprehensive health insurance programme. At the time of writing health insurance for a l l Canadians i s becoming both a medical and p o l i t i c a l issue. At least three provinces have now taken a definite stand i n urging the federal government to i n i t i a t e some form of health insurance.  While costs of the public assistance medical care  programme may loom large i n the provincial economy, the prospects are that they soon may be shared by the federal government. B r i t i s h Columbia can take some satisfaction i n the pioneer efforts i t has made i n bringing comprehensive medical care to the most needy portion of i t s population, and i t s experience with the programme w i l l undoubtedly offer guidance i n the comprehensive programme of health insurance yet to come i n Canada.  - 65 APPENDIX A ADMINISTRATIVE STRUCTURE OP SOCIAL WELFARE BRANCH, DEPARTMENT HEALTH AND WELFARE, VICTORIA D E P A R T M E N T H E A L T H  &  OF  W E L F A R E  SOCIAL WELFARE  BRANCH  ACCOUNTING Estimates, Accounting and Statistics  DEPUTY MINISTER OF WELFARE  RESEARCH  MEDICAL SERVICES Direction of Medical Service for Social Welfare Branch  DIRECTOR OF WELFARE  Social Surveys & Research  PERSONNEL ASSISTANT DIRECTOR OF WELFARE TRAINING In-Training Library  DIRECTOR INDUSTRIAL SCHOOLS  FIELD CONSULTANTS  T . B . and V . D . SOCIAL.SERVICES  'ARE INSTITUTIONS LICENSING Licensing and Inspection of:  Services to Patients in Hospitals and Clinics  larding Homes •phanages iternity Homes >stels irserles .ndergartens, etc.  PROVINCIAL HOME  PSYCHIATRIC SOCIAL SERVICES  Care lor Dependent Aged Men  Services to Patients in Crease Clinic, Mental Hospitals, Homes for Aged, Woodlands School  Provincial Home Act  Provision of Maintenance for the Aged Old Age Assistance Act Old Age Security Act The Blind Pensions Act (Federal) The Blind Persons Allowance Act Old Ape Assistance Act (Provincial)  REGION 2  REGION 1  CHILD WELFARE  OLD AGE ASSISTANCE BOARD  FIELD SERVICE Provision of Social Service to a l l Categories Serving! Child Welfare Mothers' Allowances Social Allowances Old-Age Assistance Tuberculosis Division Venereal Disease Division Mental Hospitals Child Guidance Clinic Boys' Industrial School Girls' Industrial School Hospital Inspection Branch Welfare Institutions Provincial Home Collections Service Law Courts Family Allowances (Federal) Veterans Affairs (Federal) Indian Affairs (Federal)  REGION 3  FAMILY SERVICES  Protection of Neglected and Dependent Children  Safeguarding the Family Unit - Service; to Single Persons Counselling  Adoption Act Children of Unmarried  Mothers' Allowance Act Social Assistance Act Deserted Wives and Childrens Maintenance Act Parents Maintenance Act  ParentB Act  Protection of Children Act Juvenile Delinquents Act  REGION 4  BOYS' INDUSTRIAL SCHOOL Rehabilitation of the Co mini tted Delinquent Coy Industrial School for Boys Act  GIRLS' INDUSTRIAL SCHOOL  MISCELLANEOUS  Rehabilitation of the Committed Delinquent Girl Industrial School for Girls Act  REGION 5  REGION 6 = ]  REGIONAL ADMINISTRATOR  Provincial Offices Albemi Courtenay Duncan Nanaimo Victoria  Municipal Offices Amalgamated Saanich Victoria  Municipal Offices Served Provincially Alberni Campbell River Central Saanich Courtenay Cumberland Duncan Esquimalt Ladysmith Lake Cowichan Nanaimo North Cowichan Oak Bay Port Alberni Qualicum Beach FIELD CONSULTANT  REGIONAL ADMINISTRATOR  Provincial Offices New Westminster Vancouver  We8tview  Municipal Offices Amalgamated Burnaby Coquitlam New Westminster, City North Vancouver, City North Vancouver District Richmond Vancouver, City West Vancouver  Municipal Offices Served Provincially Delta Fraser Mills Port Coquitlam Port Moody Westvlew  FIELD CONSULTANT  REGIONAL ADMINISTRATOR Provincial Offices  Municipal Offices Amalgamated  Kamloops Kelowna Penticton Saljnon Arm Vernon  Kamloops, City Kelowna, City Penticton, City Vernon, City  Municipal. Offices Served Provincially Armstrong Coldstream Enderby Glenmore Merritt North Kamloops Oliver Peachland Princeton Revelstoke Salmon Arm, City Salmon Arm, District Spallumcheen Summerland  FIELD CONSULTANT  REGIONAL ADMINISTRATOR  REGIONAL ADMINISTRATOR  Provincial Offices Cranbrook Creston Femie Grand Forks Trail Nelson New Denver  Provincial Offices  Municipal Offices Served Provincially Cranbrook Creston Fernie Grand Forks Greenwood Kaslo Kimberley Nelson Rossland Trail Warfield  FIELD CONSULTANT  Pouce Coupe Prince George Qucsnel Williams Lake Prince Rupert Smithers Municipal Offices Served Provincially Dawson Creek Prince George Prince Rupert Quesnel  FIELD CONSULTANT  REGIONAL ADMINISTRATOR  Provincial Offices  Municipal Offices Amalgamated  Abbotsford Haney Chllliwack  Chilliwhack Township Langley Surrey  Municipal Offices Served Provincially Chilliwack Hope Kent Maple Ridge Matsqui Mission, District Mission, Village Pitt Meadows Sumas  FIELD CONSULTANT  <-• 66 ** APPENDIX B SOCIAL WELFARE BRANCH REGIONAL MAP, DEPARTMENT HEALTH AND WELFARE, VICTORIA  139° 60j3 1  138°  137°  136°  135°  134°  133°  132°  131°  130°  129"  126°  128  125°  124  123  119°  120  121°  122°  118  c  S O C I A L  W E L F A R E  R E G I O N A L  ii  R  ! J<o'"i c,  E  G  I  O  HO"  112  113°  114°  115°  116°  117  B R A N C H M A P  O F F I C E :  N  VICTORIA VANCOUVER  XCANAL  57  VERNON  -V  NELSON LTELE6RAPH  CWE EEK<  PRINCE GEORGE ~  6  /  :  V  0  X  O  /  \  CHILLIWACK  56  •i  57 Y  z  ,  \ .  V•n, U V  ratiatuiu  D Graham1 t'l \,  11. \  -  A; 1  56  i  ^  — ForU» 1  TAKi-AN  55 'Trembled  "iTelkwa DIXON  STUART^ ,1 "  ENTRANCE  PRINCE R U P E R T ^  541  B  u  r  n  #  53  s  e> r~  ^ franco's  i>WNCEGEO||GE  TV Brides EN ~ILOTTE  53!  52  H2-  0 Vft  52*  IliianceviH^I  'ff  QUEEN  J*  »-lW!l>'  511  i  KcmlKo\ 1  \0^o'  .'  CHARLOTTE 51  SOUND DMA'  tarK  1  501  BRITISH  1  QUO  COLUMBIA  49 (Ceepeece  S O C I A L W E L F A R E REGIONAL M A P Scale  I49I  1  OFFICES  SHOWN  THUS  O  REGIONAL.  BDY'S  SHOWN  THUS  f  135°  134°  J  JSaW>° I'OftRTE  •  REGIONAL-  136°  0\l  133  c  132°  S'' 1  131  130  129  128  126  125  124  123  1 ** 2  121  120  119  117°  116  c  115°  SOCIAL ASSISTANCE MEDICAL SERVICE QUARTERLY REPORT JANUARY 1/5U  Income & E x p e n d i t u r e  TO MARCH 31/5U  Q u a r t e r Under Review  Y e a r t o Date Per P e r s o n T o t a l Per Quarter  Income Amount R e c e i v e d f r o m Government B a l a n c e from P r e v i o u s Y e a r : Reserve Contingent L i a b i l i t y Previous Quarter: Reserve Contingent L i a b i l i t y  $310,057.66  $1,218,1.86.76  $U.573  6,607.06 1,691.25  .025 .006  21,198.73 1,899.20  $333,155.59  $1,226,785.07  $ii.6oU  Doctors i n General Reserve V.G.H. M e d i c a l B o a r d Out-Patient Hospital Services Contingent L i a b i l i t y  $291,797.oU li02.1|2  $1,093,050.62 1,775.61  $U.102  T o t a l M e d i c a l Expense E x p e n d i t u r e : Other  $312,023.U9  11,813.30  $l,l69,08ii.25 1.8,382.02  $U.388  Total Expenditure $323,836.79 Amount T r a n s f e r r e d t o Reserve 7,233.20 Amount T r a n s f e r r e d t o Cont. L i a b i l i t y 2,085.60  $1,217,1.66.27 7,233.20 2,085-60  u569 .027 .008  $333,155.59  $1,226,785.07  $U.6oi+  Expenditure: Medical  12,000.00 6,729.67 1,899-20  i|2,000.00  2U,685.oU 7,572.95  .007 .158 .093 . .028  .181  SOCIAL ASSISTANCE MEDICAL SERVICE STATEMENT OF INCOME & EXPENDITURE JANUARY 1/5U TO MARCH 31/5U Y e a r t o Date  Q u a r t e r Under Review  Amount R e c e i v e d from Government B a l a n c e from P r e v i o u s Y e a r : Reserve Contingent L i a b i l i t y Previous Quarter: Reserve Contingent L i a b i l i t y  Deduct M e d i c a l Accounts  Amount  Amount  $310,057.66  $1,218,U86.76  I  6,607.06 1,691.25 21,198.73 1,899.20 100.00 95.30  $333,155.59  $1,226,785-07 1,169,0814.25  $ 21,132.10  $  57,700.82  8,211.35 25.00 675.00 77.18 150,29 162.15 835-00 536.5U 22)4.69 150.00 20.00 180.00  $  33,201.85 125.00 2,700.00 259.38 608.31 351.89 U, 561.149 1,136.27 853.10 600.00 20.00 796.55 198.80 580.05 U50.00 206.8U 198.9k 525.92  $  U7,37U-39 1,053.52 31c 72 114.17  $ 11,813.30 7,233.20 2,085.60  $  U8,382.02 7,233.20 2,085.60  3.9U .59 .17  $ 21,132.10  $  57,700.82  U.70  312,023.U9  U.70  Breakdown o f A d m i n i s t r a t i o n and Other Expenses Salaries Honoraria Rent Light Telephone Fuel I . B. M. Office Supplies Postage Expenses: E. L. D. Expenses: D r s . Janitor's Services & Supplies Unemployment I n s u r a n c e L e g a l Fees A u d i t o r ' s Fees Miscellaneous M.S.A. Health Insurance 1  Furniture & Fixtures Unemployment I n s u r a n c e Health Insurance E x c e s s o f Income o v e r E x p e n d i t u r e Amount T r a n s f e r r e d t o O o n t i n g e n t L i a b .  $  U9.56 U5.83  1*6.10  130.81.  $ 11,519.53 315.18 21.  la  SOCIAL ASSISTANCE MEDICAL SERVICE PROGRESS REPORT JANUARY l / g i t TO MARCH 31/5U Accounts R e c e i v a b l e  Category M. S. C. 0. 0-  Q u a r t e r Under Review  Year to Date  No. Covered I,hk7 16,587 3,060 37,501 8,877  A. A. w. D. A. S. & B l i n d A. A.  .  Monthly Average 67,1*75 Quarterly Total 202,1*26 a t f?1.5Ul6 Amount T r a n s f e r r e d from B a l a n c e : Reserve Contingent L i a b i l i t y  $310,057.66  $1,218,1*86.76  $21,601.15 1,899.20  Accounts Receivable 36,000 993 51  No. o f Accounts S u b m i t t e d (Approx.) No. o f D o c t o r s S u b m i t t i n g Accounts No. o f H o s p i t a l s S u b m i t t i n g a c c o u n t s T o t a l D o c t o r s ' & H o s p i t a l A c c o u n t s as B i l l e d T o t a l D o c t o r s ' & H o s p i t a l A c c o u n t s as A s s e s s e d  $659,142.87 581*, 9 3 1 . 8 1  $2,1*02,21*3.61 2,133,281.66  Amount Amount Amount Amount  $298,526.71 1*02.1*2 12,000.00 1,899-20  $1,117,735-66 1,775.61* 1*2,000.00 9,1*07 . 87  $312,023.1*9  $1,170,919.17  Average Account as P a i d w i t h H o s p i t a l s Average t o D o c t o r s as P a i d Average t o H o s p i t a l s as P a i d  $8.29 $293-85 $131-95  $6-54 $281*. 1*5 $128.27  C o s t Per Person: M e d i c a l S t a f f V.G.H. Hospital Services Doctors i n General Reserve Contingent L i a b i l i t y Other E x p e n d i t u r e  $ .178 .100 l*-32i* .006 .028 . .175  $ .168 .095 i*.l66 .003 .035 .179  $1*.799 .107 .031  $4.61*6 .165 .030  Paid Paid Paid Paid  Doctors & Hospitals from R e s e r v e V.G.H. M e d i c a l S t a f f from C o n t i n g e n t L i a b i l i t y  T o t a l M e d i c a l Expense  Amount T r a n s f e r r e d t o Reserve Amount T r a n s f e r r e d t o C o n t i n g e n t L i a b i l i t y  r,L.6Ll Amount R e c e i v e d P e r Person P e r Q u a r t e r Reserve From L a s t Q u a r t e r C o n t i n g e n t L i a b i l i t y from L a s t Q u a r t e r  Percentages 1st 2nd 3rd Uth 5th  Year Year Year Year Year  -  Paid 67-1 56-9 52.0 60.0 53-5 -  March March March April April  1/1*9 1/50 1/51 1/52 1/53  -  Late Accounts Paid at 10$ Less  Feb. 28/50 Feb. 28/51 March 31/52 March 31/53 March 3 l / 5 u  $1*.595 .311* .028  $1*.585 .222 .031*  $1*.937  $4.81*1  1 s t Q.  2nd Q.  3 r d Q.  l*th Q.  70 55 55 61 53  65 60 5o 61* 57  70 56 50 62 52  65 58 53 56 52  SOCIAL ASSISTANCE MEDICAL SERVICE SUMMARY OF MEDICAL EXPENSE JANUARY 1/5U TO MARCH 31/5U  Fee Item  Q u a r t e r Under Review. Amount  General P r a c t i c e 0100-0110 0201-0216 Dermatology I n t e r n a l Medicine 0301-0319 Neurology oloi oia2 Paediatrics 0501-0516 0601-0621 Psychiatry Eye, E a r , Nose & T h r o a t.2001-2011 3001-3011 Neurosurgery O b s t e t r i c s & GynaecoJqgy 1.001-1*012 Orthopaedics 5001-5011 6001-6011 P l a s t i c Surgery General Surgery 7001-7011 8001-8011 Urology 7  Year t o Date  %  U6.81  $139,731.83 1,303.93 16,302.93 1+07.76 2,1*53.10 1,58k.9u 5,692.25 222.72 398.81  .1*1*. 5.146 .1I4  .82 .53  1.91 .07 .13 .25 .01 .57 ' .28  71*3.33  15.60 1,700.68 8U5.6U  Amount  %  $529,14814.71 6,208.52 57,292.0U 1,205.80 9,1489.71 5,358.02 20,672.U7 659.96 1,2014.69 2,501.27 146.77 . 5,163.91 2,885.36  U7.10 .52 5.29 .13  7,052.7U 3,733-99 U,120.3l; 147,030.02 81,965.59 3,810.1*5 33,179-37 149,U16.89 2,032.31 126,2148.50  .65 .33 • 37 k.26 6.99 .32 2.96 U.72  .81*.  .1*9 1.88 .06 .11 :2k .50 .27  Procedures Common O f f i c e 0001-002h Special 0030-001*9 0060-0081 Miscellaneous Anaesthesia • 1001-1071 Eye, E a r , Nose & T h r o a t 2100- 21+19 Neurosurgery 3020-3063 O b s t e t r i c s & Gynaecol) gyhlOO~h5U2 Orthopaedics 5020-5506 P l a s t i c Surgery 6020-6360 General Surgery 7015-7623 Urology 8030-8323 Laboratory 9000-9305 X-Ray 9500-9811 Physiotherapy 9900 M i s c e l l a n e o u s Items  1,713.02 991.96 1,207.9k 12,963-70 ' 19,870.1*7 9,128.89 114,509.79 I4I45.6O  35,71U.5U 11,650.18 2,591.16 l l * , 31*0.03 1U9.98 U0U-7U  "  -57 .33 .Uo  U.314 6.66 .17 ' 3.06 I4.86 .15 11.96 14.91 .87  9,6145-77 50,697.73 507.26 2,258.55.  100.71 .02  61,766.69  I4.80  .05 .1I4  .17'  11.78 5-12 .85 l*.5l4 .05 .17  Plus D e b i t Balance  $300,581.97 68,1*1*  100.69$1,125,639.1*3 206.66 .02  Less C o n t i n g e n t L i a b i l i t y  $300,650.1*1 2,123.70  100.71 l , 1 2 5 , 8 u 6 . 0 9 .100.73 • 73 8,110.1*3 .71  T o t a l Cheque R e g i s t e r  $298,526.71  100.00 1 , 1 1 7 , 7 3 5 . 6 6  V.G.H. M e d i c a l Board  $ 12,000.00  .-  $  1*2,000.00  The above s t a t i s t i c s i n c l u d e payment f o r O u t - P a t i e n t H o s p i t a l S e r v i c e s e x c l u s i v e o f t h e Vancouver G e n e r a l H o s p i t a l .  100.00  SOCIAL ASSISTANCE MEDICAL SERVICE  ANALYSIS OF MEDICAL EXPENSE  JANUARY 1/51* TO MARCH 31/5U Fee Schedule Item General Practice  $  Formal Consultations Repeat Consultations Initial Visits Office V i s i t s  $139,731.83  0201-0216 39.00 52.00 20.80 221.60 620.93 68.61; 3.90 277.06  1,303.93  0301-0319 2,1*21.10 • 203.50 172.80  Formal Consultations Minor Consultations Repeat Consultations Initial Visits Office V i s i t s Hospital V i s i t s Home V i s i t s Extra Patients Subsequent V i s i t s Office V i s i t s Hospital V i s i t s Home V i s i t s Emergency V i s i t s I n i t i a l E.C.G, L Interpretation E.C.G. & Interpretation a t Home Interpretation of E.C.G. Repeat E.C.G. Neurology  2,1*33.11 59,300.83 9,l81*.22 22,588.2l* 2,058.02 3,520.1*5 209.22 37,238.88 2,826.86 372.00  Formal Consultations Formal Consultation with Biopsy Minor Consultations Initial Visits Office V i s i t s Subsequent V i s i t s Office V i s i t s Hospital V i s i t s Home V i s i t s i t l l Other Forms of Treatment Internal Medicine  Total  0100-0110  Initial Visit Minor Office V i s i t s House V i s i t s F i r s t Day V i s i t Subsequent Day V i s i t s Night V i s i t s Emergency, Sunday, Holidays Extra Patients Hospital V i s i t s Nursing Home V i s i t s Consultations Dermatology '  Amount  737.56  120.21* 261.60 U.68 1*, 256.71* 3,51*5.32 2,1*37.1*8 3u3.20 1,061.56 15.60 707.75 13.80  01*01-01*12  273.60 13.00  5.20  16,302.93  (2) Fee Schedule Item N e u r o l o g y Cont'd  18.22 133.70 50.70 1.56 292.92 525.02 66.33 1,258.05  217.1*0 66.60 20.80 1*1*7.31* 1*9- ho 353-76 1*1*. 20  11*6.20 858.36 131*.02 1*.68 1,093.09 5.20 3,231.00 157.30 62.1*0  5,692.25  3001-3011 183.20 10.1*0  Formal C o n s u l t a t i o n s Minor Consultations Subsequent V i s i t s Hospital V i s i t s  Formal C o n s u l t a t i o n s Minor C o n s u l t a t i o n s Emergency C o n s u l t a t i o n f o r O b s t e t r i c s Initial Visits Office V i s i t s Home V i s i t s Subsequent V i s i t s Office Visits Hospital V i s i t s Home V i s i t s  1 , 5 8 1 * . 91*  2001-2011  Formal Consultations Minor C o n s u l t a t i o n s Initial Visits Office Visits Hospital V i s i t s Examination of L o c a l Condition Home V i s i t s Subsequent V i s i t s Office Visits Hospital Visits Home V i s i t s  O b s t e t r i c s & Gynaecology  2,1*53.10  0601-0621  Formal C o n s u l t a t i o n s I n i t i a l P s y c h i a t r y Examination Home V i s i t C o n t i n u a t i o n o f Treatment Hospital V i s i t s Shock Therapy Investigation with Certification Certification  Neurosurgery  1*07.76  91.00 10.1*0 5-20  C h i l d W e l f a r e Cases  Eyej E a r , Nose & T h r o a t  28.60 87.36 0^01-0516  Formal C o n s u l t a t i o n s Minor Consultations Repeat C o n s u l t a t i o n w i t h i n 6 Months Initial Visits Office Visits S i m p l e Problems Home V i s i t s Additional Child Subsequent V i s i t s Office Visits Hospital Visits Home V i s i t s  Psychiatry  Total  01*01-01*12  Subsequent V i s i t s Office Visits Hospital V i s i t s Paediatrics  .amount  29.12  222.72  1*001-1*012 62.1*0 99.kO • 39.00 37.00 3.15 105.08 38.1*8  lit. 30  398.81  (3) • Fee Schedule Item  Formal Consultations Minor Consultations Initial Visits Office Visits Home V i s i t s Subsequent V i s i t s Office Visits Hospital V i s i t s Home V i s i t s  •  I-  ll*2.10 216.'66  . .'  57^1* 5.20  •  ' . 259-50 •U9.92 17.. 16  7U8.38  15.60  15.60  6001-6011  Surgery  Minor Consultations General  . • 7001-7011  Surgery  306.60 U03.00  Formal C o n s u l t a t i o n s Minor Consultations Initial Visits . Office Visits Hospital V i s i t s Home V i s i t s Emergency V i s i t s Sunday V i s i t s Subsequent V i s i t s Office Visits Hospital V i s i t s Home V i s i t s Urology  Total  5001-5011  Orthopaedics  Plastic  Amount  9ii.l6 5.20 23. ho lix. 30 "'5.20 1*27.06 346.70 75.06 •  1,700.68  8001-8011 18.80 277.00  Formal C o n s u l t a t i o n s Minor Consultations Initial Visits • •Office V i s i t s Home V i s i t s Subsequent V i s i t s Office Visits Hospital Visits Home V i s i t s -  •  25.00 15.-60 1*21.81] 37.96  81*5-61;  PROCEDURES Common O f f i c e Procedures  0001-0021; 3.12 1,557.21* 107.3h 13.52  Vaccination Intramuscular Medications Intravenous Medications Venepuncture Blood Transfusion Inside Hospital S p e c i a l Procedures Stomach Gavage & Lavage A l l e r g y Skin Tests: Intradermal Scratch D e s e n s i t i z a t i o n Treatments E.C.G. by N o n - I n t e r n i s t Complete Orthodiagram B.M.R. D e t e r m i n a t i o n s : I n i t i a l Repeat.  31.80 0030-001*9 7.80 25.68 27.21* 21*. 96 1*96.17 10.95 229.1*1 10.1*0  1,713.02  (u) Fee Schedule Item S p e c i a l Procedures  (Cont'd)  Total  12U.95 10.1*0 8.1*0 15.60  991.96  16.12 166. Oil 810.12 215.66  1,207.91*  12,963.70  12,963.70  0030-001+9  Lumbar P u n c t u r e P e r i c a r d i u m Puncture B i o p s y by P u n c t u r e : Sternum V e i n D i s s e c t i o n : I.V. Therapy Miscellaneous  Amount  0060-0081  C e r t i f i c a t i o n Only A d v i c e b y Telephone Mileage Emergency Procedures Anaesthesia Eye, E a r , Nose & T h r o a t Eye Refractions Cataracts Other Ear  1001-1071 2100-21*19 2100-2139 2100 2108-2112  5,702.26 7,1*74.25 2,766.1*1*  2200-2231*  237.86  Nose & S i n u s e s  2300-2329  738.1*6  Throat  21*00-21*19  T o n s i l s & Adenoids Children Adults Tonsillectomy - Local Adenomectomy Other  2U01 21*02 2U03 2koh  Neurosurgery  3020-3063  O b s t e t r i c s & Gynaecology  1*100-1*51*2  Obstetrics Gynaecology  1*100-1*111 1*200-1*542  Orthopaedics  5020-5606  Amputations Fractures Dislocations Other  5100-5121* 5200-5278 5300-5323  Plastic  Surgery  6020-6360  General Surgery  7016-7623  C a r e . i n excess o f Surgeon's F e e Assistants General Varicose Veins Venous Thrombosis Bursae, Cysts & G a n g l i a • Abdomen Appendectomy Gail-Bladder Gastrectomy Other  7015 7016-7019 7030-711U 7200-7206 7210-7216 7230-7233 7300- 7340 7301- 7303 730U-7309 7315-7316  1,897.70 273.20 33.80 57.50 689.00  19,870.1*7  1*91.1*0  491.1*0  3,919.20 5,209.69  9,128.89  1,031*.30 11,013.27 361.80 2,100.1*2  .11*, 509.79  1*1*5.60  1*1*5.60  2,870.92 3,366.1*0 2,919.82 991.70 71.50 567.1*0 2,117.00 3,128.30 2,601.00 5,153.62  (5) Fee Schedule Item General Surgery  Total  7016-7623  (Cont'd)  Hernia Chest Head & Neck Anus & Rectum  73U1-7367 7uOO-7u53 7500-7521 7600-7623  Urology  8030-8323  Penis & Urethra B l a d d e r , P r o s t a t e &. U r e t e r Prostatectomy Other Kidney Scrotum & C o n t e n t s  8030-8055 8100-8121* 8113-8116  Laboratory  Procedures  9000-9305  Haemotology Urine Blood Chemistry Bacteriology, Parasitology, Etc. Miscellaneous  9000-9020 9050-9073 9110-91U3 9200-9203 9300-9305  X-Ray S e r v i c e s  9500-9811  No S p e c i a l i s t A v a i l a b l e Specialist R a d i a t i o n Therapy X-Ray R a d i a t i o n Radium Therapy  9500-9532 9550-9615 9700-9811 9700-9735 9800-98H  8200-8209 8300-8323  9900  Physiotherapy M i s c e l l a n e o u s Items n o t i n Book  $  6,862.80 1,519.20 i,U79.5o 2,065.38 $  35,7lU.5U  591.ho 9,693.70 3,082.22 732.16 550.70  11*, 6 5 0 . 1 3  1,916.83 96.03 1*12.91* 81.38 83.98  2,591.16  810.9k 12,608.65 782.7ii 137.70  l a , 31*0.03  lk9.98  11*9-98  uOU.7U  Balance  $300,581.97 68. kk  Contingent L i a b i l i t y  $300,650.1*1 2,123.70  Plus Debit  Less  Amount  T o t a l Cheque Re£^ i s t e r  $298,526.71  - 67 APPENDIX 0 SOCIAL ASSISTANCE MEDICAL SERVICE QUARTERLY REPORT  - 68 -  Appendix D  BIBLIOGRAPHY  General References Cassidy, Harry M.,  Public Health and Welfare Organization i n Canada, The Postwar Problem i n the Canadian Provinces, Ryerson Press, Toronto, 1945.  Morgan, John S.,  "Social Welfare Needs of a Changing Society The New Canada". The Social Service Review, Volume XXVIII number four, December, 1954.  Social Welfare Branch, Policy Manual, Department of Health and Welfare, Victoria.  - 69 -  BIBLIOGRAPHY  Specific References Bierman, Pearl,  "Medical Assistance Programs", Social Service Review, Volume XXVIII number two, June 1954. University of Chicago Press, Chicago, I l l i n o i s , U.S.A.  G-ovan, Elizabeth, Public Provision for Medical Care i n Canada. Canadian Welfare Council, Ottawa, 1952. M i l l e r , Nina C ,  Schlesinger, Rosa and Wechsler, M.D., Sylvia M., "A Medical Consultant i n a Public Assistance Agency", Public Welfare, Volume XIII number three, July, 1955. The Journal of the American Public Welfare Association, Chicago, I l l i n o i s , U.S.A.  Moscovich, J.C.  "Stocktaking", B r i t i s h Columbia's Welfare, Department of Health and Welfare, Parliament Buildings, Victoria, May-June 1953.  Page, Harry 0. and Axelrod, M.D., S.J., "Community Teamwork by Public Health and Welfare", Public Welfare. April 1955. The Journal of the American Public Welfare Association, Chicago, I l l i n o i s . Papers from the 1954 Social Welfare Forum, National Conference of Social Work. "Administration Supervision and Consultation", Family Service Association of America, New York, N.Y., U.S.A. 1955. Public Health, Annual Report of the Department of Public Health, Province of Saskatchewan, 1954. Roemer, Milton I., Feader, Carman P., and Acker, Murray S. "Medical Care for the Indigent i n Saskatchewan", A paper presented before the F i r s t Canadian Medical Care Conference i n Association with the Forty-second Annual Meeting of the Canadian Public Health Association, Quebec City, Quebec, May 31st to June 2nd, 1954.  - (70 -  BIBLIOGRAPHY  Social Welfare Branch, Annual Reports of the Social Welfare Branch, Department of Health and Welfare, Victoria, 1946, 1947, 1948, 1949, 1950, 1951, 1952, 1953, 1954. Taylor, Malcolm G.,  "Social Assistance Medical Care Programs i n Canada", American Journal of Public Health, Volume 44, number 6, June, 1954.  White, Ruth,  "Medical Services i n the Old-Age Assistance Program". Social Security Bulletin, Volume 15, Number 6, June 1952.  


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