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Legislative Assembly","@language":"en"}],"DateAvailable":[{"@value":"2017","@language":"en"}],"DateIssued":[{"@value":"[1952]","@language":"en"}],"DigitalResourceOriginalRecord":[{"@value":"https:\/\/open.library.ubc.ca\/collections\/bcsessional\/items\/1.0343332\/source.json","@language":"en"}],"FileFormat":[{"@value":"application\/pdf","@language":"en"}],"FullText":[{"@value":" PROVINCE OF BRITISH COLUMBIA\nREPORT\nof the\nHospital Insurance Inquiry\nBoard\n1951-52\nVICTORIA, B.C.\nPrinted by Don McDiarmid, Printer to the Queen's Most Excellent Majesty\n1952  TABLE OF CONTENTS\nLetter of Transmittal of Report\t\nAct Setting Up the Hospital Insurance Inquiry Board-\nOrder in Council Naming Members of the Board\t\nOrder in Council Fixing Allowances to Board Members\t\nOrder in Council Designating Minister to Whom Reports Shall Be Made..\nPage\n5\n7\n9\n10\n11\nReport\nSection 1.\u2014Foreword     13\nSection 2.\u2014Matters of Policy Directly Affecting the Financing of the Service\u2014\nItems 1 to 19, Inclusive, in Accordance with Detailed Index at Front of Section..    17\nSection 3.\u2014Matters of Policy\u2014General\u2014\nItems 20 to 29, Inclusive, in Accordance with Detailed Index at Front of Section    35\nSection 4.\u2014B.C.H.I.S. Administration\u2014\nItems 30 to 37, Inclusive, in Accordance with Detailed Index at Front of Section    45\nSection 5.\u2014Hospital Operation and Management and Hospital Construction and\nExtension\u2014\nItems 38 to 51, Inclusive, in Accordance with Detailed Index at Front of Section    57\nTribute to Work of Secretary and Staff.  80\nLetter of Transmittal\u2014Signatures  81\nSection 6.\u2014Appendices\u2014\nItem I.\u2014Summary of Recommendations  82\nItem 2.\u2014Interim Recommendations Made by the Board-\nNos. 1 and 2, Dated August 11th, 1951\t\nNo. 3a, Dated October 17th, 1951\t\nNo. 4a, Dated October 17th, 1951\t\nNo. 5, Dated September 25th, 195L.._.\n  89\n  89\n  90\n  92\nNo. 6, Dated September 25th, 1951...          93\nNo. 7, Dated October 17th, 1951  94\nOrder in Council Having Reference to Interim Recommendations Nos.\n1, 2, and 7 \u2022-  95\nItem 3.\u2014Other Documents Referred to in Report\u2014\n(a) Estimated Financial Effect of the Recommendations of the Board   i 96\n(b) Excerpt from Report of Mr. Samuel Eckler, F.S.A  97\n(c) Summary of Comparative Hospital Costs  102\n(d) Summary of Comparative Hospital Staffs  103\nItem 4.\u2014Indices of\u2014\n(a) Public Hearings Held by the Board  104\n(b) Hearings Held by the Board Not Advertised as Public  104\n(c) Hospitals Visited by the Board, etc  104\n(d) Written Submissions to the Board  105  REPORT\nTo the Honourable the Minister of Health and Welfare,\nProvince of British Columbia.\nThe Hospital Insurance Inquiry Board, appointed in accordance with the provisions\nof chapter 36, Statutes of British Columbia, 1951, to inquire into, investigate, survey,\nand to furnish advice with regard to the Hospital Insurance Service and all matters\npertaining to hospital operation in the Province, and to make reports and recommendations thereon, begs to submit the following Report.  1951\nHospital Insurance Inquiry.\nChap. 36\nCHAPTER 36.\nAn Act authorizing an Inquiry into the \" Hospital Insurance\nAct \" and its Administration.\n[Assented to 18th April, 1951.]\nShort title.\nBoard constituted.\nChairman of Board.\nRemuneration of\nBoard members.\nPowers and duties\nof Board.\nWHEREAS it is in the public interest that an inquiry should be\nmade into the provisions of the \" Hospital Insurance Act\" and\nthe administration thereof:\nTherefore, His Majesty, by and with the advice and consent of the\nLegislative Assembly of the Province of British Columbia, enacts as\nfollows:\u2014\n1. This Act may be cited as the \"Hospital Insurance Act Inquiry\nAct.\"\n2. For the purposes of this Act, there shall be constituted a Board\nof not more than twelve persons to be called the \" Hospital Insurance\nInquiry Board,\" the members of which shall be appointed by the\nLieutenant-Governor in Council.\n3. One of the members shall be appointed to be Chairman of the\nBoard.\n4. (1) The remuneration of the members of the Board shall be\ndetermined by the Lieutenant-Governor in Council.\n(2) If any person appointed a member of the Board is also a member\nof the Legislative Assembly, he shall not receive any remuneration, but it\nshall be lawful notwithstanding the provisions of the \" Constitution Act \"\nfor such member to accept payment out of the public funds of such sum\nfor travelling and living expenses as may be fixed by the Lieutenant-\nGovernor in Council, and the acceptance of such sum shall not make\nsuch person ineligible as a member of the Legislative Assembly, and\nshall not disqualify him to sit and vote in the Legislative Assembly.\n5. The powers, duties, and functions of the Board shall be as\nfollows:\u2014\n(a) Generally to inquire into and investigate the system of hospital\ninsurance established by the said Act, and to make a study in\n7 Chap. 36\nHospital Insurance Inquiry.\n15 Geo. 6\ncollaboration with such persons as it may see fit as to what\namendments may be necessary to the said Act:\n(b) To make a survey of the Hospital Insurance Service, and to\nfurnish advice with regard to such Hospital Insurance Service:\n(c) To investigate the hospital-construction programme, the relations between the Hospital Insurance Service and the hospitals\nof the Province, the relations between the various professions\nand groups connected with the operation of hospitals in the\nProvince, and all matters pertaining to hospital operation in\nthe Province.\nother investigations. q xhe Board shall make such other investigations and conduct such\nother inquiries for the purposes of this Act in such manner as the\nLieutenant-Governor in Council may require and direct.\nReports and\nrecommendations.\n7. The reports and recommendations of the Board shall be made to\nsuch Minister as may be designated by the Lieutenant-Governor in\nCouncil before the first meeting of the Legislative Assembly held in the\nyear 1952.\nPowers on\ninvestigation.\n8. For the purpose of any inquiry held pursuant to the provisions of\nthis Act, the Board shall in respect of the investigation have the like\npowers as are given to Commissioners appointed under the \" Public\nInquiries Act.\"\nRegulations.\n9. For the purpose of carrying into effect the provisions of this Act\naccording to their true intent, and to supply any deficiency therein, the\nLieutenant-Governor in Council may make such regulations not inconsistent with the spirit of this Act as may be deemed necessary, advisable,\nor convenient. All regulations shall be published in the Gazette and\nshall have the same force and effect as if incorporated herein.\nAppointments. XO. Such officers, clerks, and employees as are required for the\npurposes of this Act may be appointed by the Board.\ncosts and expenses. xx. The costs and expenses incurred in the administration of this Act\nshall, in the absence of any special appropriation of the Legislature\navailable for that purpose, be paid out of the Consolidated Revenue\nFund. COPY OF MINUTE APPROVED APRIL 24th,  1951\nTo His Honour the Lieutenant-Governor in Council:\nThe undersigned has the honour to recommend that, pursuant to section 2 of the\n\" Hospital Insurance Act Inquiry Act,\" chapter 36 of the Statutes of British Columbia,\n1951, the following persons be appointed to constitute the \" Hospital Insurance Inquiry\nBoard\":\u2014\nDonald Cameron Brown, M.L.A., Vancouver.\nWalter Hendricks, M.L.A., Nelson.\nArvid Waldemar Lundell, M.L.A., Revelstoke.\nDaniel John Proudfoot, M.L.A., Victoria.\nSydney John Smith, M.L.A., Kamloops.\nRobert Cecil Steele, M.L.A., Vanderhoof.\nHerbert John Welch, M.L.A., Qualicum Beach.\nHarold Edward Winch, M.L.A., Vancouver.\nAnd that Sydney John Smith be appointed Chairman of the said Board.\nDated this 24th day of April, a.d. 1951.\nA. D. TURNBULL,\nMinister of Health and Welfare.\nApproved this 25th day of April, a.d. 1951.\nBYRON I. JOHNSON,\nPresiding Member of the Executive Council. COPY OF MINUTE APPROVED JUNE 1st, 1951\nTo His Honour the Lieutenant-Governor in Council:\nThe undersigned has the honour to recommend that-, under authority of section 4\n(2) of the \" Hospital Insurance Act Inquiry Act,\" chapter 36 of the Statutes of British\nColumbia, 1951, the scale of allowance for travelling and living expenses incurred by\nmembers of the Hospital Inquiry Board in the discharge of their duties be fixed as\nfollows: A living allowance at the rate of twenty dollars ($20) per diem for each day\nnecessarily engaged on the work of the Board, or while travelling on behalf of the\nBoard, plus actual travelling expenses.\nAnd that such expenses be paid upon production of vouchers duly certified by the\nChairman of the said Board and for which purpose an advance may be made to the\nChairman.\nDated this 1st day of June, a.d. 1951.\nA. D. TURNBULL,\nMinister of Health and Welfare.\nApproved this 1st day of June, a.d. 1951.\nBYRON I. JOHNSON,\nPresiding Member of the Executive Council.\n10 COPY OF MINUTE APPROVED SEPTEMBER 28th,  1951\nTo His Honour the Lieutenant-Governor in Council:\nThe undersigned has the honour to report that the Hospital Insurance Inquiry\nBoard appointed pursuant to the \" Hospital Insurance Act Inquiry Act\" is required by\nthe said Act to make its reports and recommendations to such Minister as may be designated by the Lieutenant-Governor in Council before the first meeting of the Legislative\nAssembly held in the year 1952:\nAnd to recommend that, pursuant to section 7 of the \" Hospital Insurance Act\nInquiry Act,\" being chapter 36 of the Statutes of 1951, the Minister of Health and Welfare is hereby designated as the Minister to whom the reports and recommendations of\nthe Hospital Insurance Inquiry Board shall be made.\nDated this 28th day of September, a.d. 1951.\nA. D. TURNBULL,\nMinister of Health and Welfare.\nApproved this 28th day of September, a.d. 1951.\nH. ANSCOMB,\nPresiding Member of the Executive Council.\n11  Report of the Hospital Insurance Inquiry Board\nSECTION 1.\u2014FOREWORD\nBritish Columbia Hospital Insurance Service had been in operation for less than\ntwo and one-half years when the Hospital Insurance Inquiry Board was set up. During\nthose first few months of its existence B.C.H.I.S. had grown into a $22,000,000 a year\nproject. It was big business from the start, and it was a new business, too. In only\none other place in the world had the hospital insurance problem been approached on a\nbroad scale, such as was attempted in British Columbia on January 1st, 1949. Two\nyears before that date there was no similar scheme in existence anywhere. So there was\nno established precedent or pattern to follow.\nDuring 1949 and 1950 B.C.H.I.S. experienced many of the difficulties that were to\nbe expected in a new undertaking of this nature. As a result, during the regular session\nof the Legislature in 1951 the Hospital Insurance Inquiry Board was appointed, and its\nterms of reference gave it broad powers to investigate, between sessions, every phase of\nthe hospital insurance problem and bring in a report before the opening of the first\nregular session of the Legislature of 1952.\nSoon after organization of the Board, Mr. Maurice Hesford, F.C.A., who had had\na wide experience in hospital accounting and auditing, was appointed Secretary of the\nBoard. Offices were opened in Vancouver. Information bearing on the subject of our\ninquiry was sought from the Federal Department of Health and Welfare at Ottawa and\nmany other sources throughout Canada and the United States. These included the\nCanadian headquarters of \" Blue Cross,\" commercial insurance companies, some Provincial Departments of Health and Welfare, Medical Associations in Canada and the\nUnited States, including the Mayo Clinic at Rochester, Minn.\nThe Board commenced its work within the Province by going to Victoria, where it\nspent a week at headquarters of B.C.H.I.S. in conference with the Administration and\ngetting acquainted with the head-office routine.\nInformation gathered from many sources brought the Board to the conclusion that\nthe task involved a tremendous lot of detail that would require a very long time to complete if every phase of the hospital insurance problem was to be fully explored.\nIt was, therefore, decided to seek the services of specialists in the fields of actuarial\npractice and business administration. After exhaustive inquiry and on the highest\nrecommendations, we appointed Mr. Samuel Eckler, F.S.A., of the nationally known\nfirm of Pipe & Eckler, of Toronto, to be our Actuarial Consultant. This was followed\nby the appointment of Messrs. Stevenson and Kellogg Limited as Management Engineer\nConsultants. This firm occupies a high place in that particular field in Canada and\ncame to us very highly recommended by important business firms who had and are still\nemploying them.\nMr. Eckler immediately commenced a comprehensive study of B.C. Hospital Insurance problems from the standpoint of an insurance actuary and Messrs. Stevenson and\nKellogg Limited started a complete survey at B.C.H.I.S. headquarters in Victoria.\nWhen the actuarial study and administration survey got under way, the Board held\nhearings throughout the whole Province, in order to get \" on the ground \" information\non the experience of citizens, hospital boards, and other organizations with B.C.H.I.S.,\nand also to hear suggestions from such persons and organizations.\n13 FF 14 BRITISH COLUMBIA\nThe itinerary commenced with a complete coverage of the Interior of the Province,\nwhich took the Board up the Coast through Prince Rupert and Prince George to the\nPeace River District and on to the Southern Okanagan and Kootenay areas. This trip\ntook three weeks to complete. It was followed by a week devoted to hearings at points\non Vancouver Island, and the Board then concluded its public hearings in the City of\nVancouver, where it sat for eight days.\nOf the seventy-six British Columbia hospitals within the B.C.H.I.S., the Board or\na section of the Board actually visited thirty-nine hospitals. In addition to these visits,\nthe Board met with the Boards of fourteen other hospitals. We held public hearings at\ntwenty-one points in the Province. A complete tabulation of all hearings will be found\nin an appendix to this Report. The public hearings were all adequately advertised, and\nthe interest of citizens was reflected in attendance. It is impossible to estimate with\naccuracy how many people were represented by spokesmen, but it is safe to say that we\nheard representatives of a majority of the entire population of the Province. A list of\nthe organizations submitting briefs and representations forms another appendix to this\nReport.\nImmediately following public hearings in British Columbia, the Board went to\nRegina in order to gather first-hand information on the Saskatchewan Hospital Services\nPlan, which had started exactly two years before the commencement of B.C.H.I.S. The\nofficials of the S.H.S.P. were extremely courteous and helpful. Saskatchewan, like British Columbia, has followed the process of trial and error, and during the five years of\ntheir operations many changes have been made, based on experience. The basic difference in the organization of the two plans is found in the methods used for registration\nand collection of premiums. The Province of Saskatchewan is blanketed by an almost\n100-per-cent organization of municipalities or local improvement districts, and registration and collection is handled almost entirely through the municipal organizations and\na commission is paid to them. In British Columbia this plan could not be followed\nbecause of the fact that we have large areas of unorganized territory. Utilizing the\nmunicipalities for registrations and collections enables the Plan in Saskatchewan to be\nhandled with a staff much smaller than has been necessary in B.C.H.I.S. To deal with\na total registration of about 310,000 in Saskatchewan, of which 280,000 or 90 per cent\npay in one annual payment, the staff numbers about 155 persons, but the total amount\nof commissions paid would equal the salaries of an additional seventy-five employees.\nIn British Columbia there are over 445,000 registrations and the staff numbers in excess\nof 640. This phase of administration has been given special attention by our Business\nManagement Consultants, and we are advised by them that implementation of our\nrecommendations in this respect would result in a reduction of B.C.H.I.S. staff from\nover 600 to 223.\nThe principal difference in the financing of the two plans is that the direct payment\nby registrants in Saskatchewan is by way of a \" tax,\" which is less than the \" premium \"\nas paid directly by the people of British Columbia. It naturally follows that a greater\nportion of the cost of the hospital plan in Saskatchewan is met by indirect taxation,\npartially covered by one-third of a 3-per-cent sales tax.\nA survey of the benefits under the two plans shows that there are certain differences. For instance, Saskatchewan covers care of chronic patients, whereas the benefits to chronic patients in British Columbia are restricted. While new-comers to the\nProvince of Saskatchewan wait six months to be eligible for benefits, there is a two\nmonths' waiting period for a new resident in British Columbia. Both plans pay the\nhospital bills of their citizens confined to hospitals outside their home Province for a\nlike period of thirty days; the Saskatchewan plan paying for such a patient at the rate\nof $5 per day, whereas the B.C. rate is $6.50 per day. An investigation of hospital\ncosts shows a major difference, largely reflected in total wages paid due to the fact that\nthe general wage scale is higher in British Columbia than in Saskatchewan. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 15\nBy this time the Board had amassed a great deal of material which was set aside\nfor study and consideration after the conclusion of public hearings. About the middle\nof October we proceeded to analyse and correlate subject-matter of the briefs and\nminutes of our hearings. It had become quite apparent that there were what might be\ndescribed as acute ailments in B.C.H.I.S. We gave first consideration to those items\nthat appeared to be the more urgent, and as we laboured on them and approached the\ndead-line date for completing our report, it became ever more apparent that the time\navailable was not sufficient to carry out an over-all survey in the intensive manner it\ndeserved. We received the report of Mr. Eckler in December, and early in January we\nwere advised by Messrs. Stevenson and Kellogg Limited that their work on the administration survey at B.C.H.I.S. headquarters could not possibly be completed and available in time for us to use in a final report before the opening of the Legislature on\nFebruary 19th.\nAs a consequence, we have completed an interim report, containing the recommendations that we consider most essential to correct many flaws in the present service\nand make B.C.H.I.S. more satisfactory to every one concerned. Many of our recommendations may reflect criticism. If so, it interprets public opinion as we have found it.\nOur approach has, from the beginning, been based on the undisputed fact that there was\na great deal of dissatisfaction with B.C.H.I.S. and that a year ago there were two\nalternatives before the Legislature: first, to abandon the scheme entirely and, second,\nto try to correct the faults so that the B.C.H.I.S. could render the great humanitarian\nservice that it was intended to do. A great majority of our citizens have expressed the\nwish that the Hospital Service be made to work satisfactorily, and we believe if our\nrecommendations are implemented, the results will go a long way toward reaching that\nobjective.\nMany of our recommendations will save costs and increase income. Others will\nincrease costs and decrease income. We have prepared a tabulation, which is included\nas an appendix to this Report, which shows as nearly as can be estimated the net effect\nof our recommendations on the finances of B.C.H.I.S. Many of the items contained in\nthe tabulation can be positively confirmed, while in the case of other items it was quite\nimpossible to arrive at exact figures but, in all such cases, we have made estimates based\non thorough study of the facts related to the particular item, and we have aimed at a\nminimum estimate rather than an exaggerated one.\nThe financial effect of the Board's recommendations if adopted is threefold: on\n(1) the citizens, (2) B.C.H.I.S., (3) the Government.\nThe citizens of British Columbia will save about $2,000,000 per annum for\nco-insurance charges. Those in lower-income brackets will be relieved of the payment\nof premiums.\nB.C.H.I.S. will lose the co-insurance income and will bear the considerable cost of\nextended benefit periods for chronic cases. The Service, however, will save on the very\nsubstantial reduction in the cost of administration and will also be relieved of the loss\non the cost of hospitalization of Social Welfare cases and Treaty Indians. The Service\nis now burdened with these costs which rightly belong to other departments of Government, and our recommendations would transfer these items from B.C.H.I.S. to the\nproper Government agency. In the case of Treaty Indians, nearly half a million dollars\nin hospitalization costs now borne by B.C.H.I.S. would be paid by the Federal Government. The B.C.H.I.S. will further gain $1,000,000 from increased per diem grants and\nan estimated $875,000 from increased premium collections, and they will lose $300,000\ndue to increased coverage of chronic cases. Other smaller items are clearly shown in\nthe tabulations referred to and the total net gain to B.C.H.I.S. is $2,100,000.\nThe effect on other departments of the Government or on the Consolidated Revenue\nFund would be the cost of the following items:\u2014 FF 16 BRITISH COLUMBIA\n(1) Increased cost to cover full hospitalization costs of\nSocial Welfare cases  '.  $1,000,000\n(2) Increased per diem grants from 70 cents to $ 1        650,000\n(3) Grants-in-aid to nursing-schools        130,000\n(4) Premiums for low-income group  70,000\nMaking a total of   $1,850,000\nGiving due consideration to all these facts, we are satisfied, therefore, that the net\nresult of the implementation of all our recommendations contained herein will be a net\nsaving.\nWe wish here to emphasize strongly that higher costs reflected in hospital budgets\nmean higher costs to B.C.H.I.S. which will have to be met, but this will occur because\nof the operation of ordinary economic and other conditions prevailing. There is, however, nothing included in the specific recommendations of this Board which will cause,\nof themselves alone, an increase in hospital costs unless it is shown in the tabulations\nreferred to above.\nMany of the recommendations made by us will necessitate amendments in Acts or\nregulations, and we wish to point out that we have neither attempted ourselves nor have\nwe sought technical advice on the details that would be involved in such amendments.\nAbove all other things that the Board learned during its deliberations is that the\npeople of British Columbia are intensely interested in the matter of hospital insurance.\nThis interest is equalled by just as keen interest beyond the boundaries of the Province.\nOne of the most interesting discoveries we made was that governments all over this\ncontinent\u2014Provincial, State, and Federal\u2014are presently engaged in trying to solve the\nproblem created by the inability of the great masses to provide individually for the\nsteadily increasing cost of hospital service. Millions of dollars have been spent and\ncountless volumes of reports have been compiled on studies and surveys aimed at meeting this new and great social problem. The attention of the North American Continent\nis directed to the experiment that is going on in our Province under B.C.H.I.S., and\nBritish Columbia has the opportunity of giving a lead in the matter of hospital insurance. If we make reasonable progress in this new field of social service, we will give\nthat lead and create for our Province an enviable record which will be a source of great\npride to our people.\nIn conclusion, the Board extends to all those individual citizens and organizations\nwho assisted us in our task our grateful thanks. We were greatly inspired in our work\nby the fine spirit of co-operation displayed by those people referred to in the register of\ncontributors accompanying this Report as an appendix. There are other persons\u2014official and otherwise\u2014who also gave us most valuable assistance but did not appear\nformally before us. In justice to all the people referred to in this connection, we refrain\nfrom singling out any for special mention. We are sure that all those who assisted us\nwill share in the satisfaction which comes from a sincere effort to place the British\nColumbia Hospital Insurance Service on a more acceptable basis. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 17\nSECTION 2.\u2014MATTERS OF POLICY DIRECTLY AFFECTING\nTHE FINANCING OF THE PLAN\n1. Completion of Unfinished Survey and Study.\n2. Continuation of Hospital Insurance Service (Basic Plan).\n3. Premium Rates.\n4. Co-insurance Charges.\n5. Financing the Over-all Deficits of the Plan.\n6. Municipal and Provincial per Diem Grants.\n7. Future Increases of Premium Rates or Curtailment of Benefits.\n8. Exemption of Groups on Religious Grounds.\n9. Exemption of Groups: Canadian Pacific Medical Association of\nBritish Columbia and Telephone Employees' Medical Services\nAssociation of British Columbia.\n10. Exemption from Premium Liability:  Low-income Groups.\n11. Exemption from Premium Liability:  Student Nurses under 21.\n12. Benefits:  Out-of-Province Hospitalization.\n13. Benefits: Out-patient Services.\n14. Charges for Non-elective Use of Private and Semi-private Wards.\n15. Premium Payable by Wives of Certain Veterans.\n16. Hospitalization of Treaty Indians\u2014Federal Government Responsibility.\n17. Payment for Hospitalization of \" Social Aid \" Cases.\n18. Educational Grants-in-Aid to Cost of Operation of Training-\nschools for Nurses.\n19. Chronic Cases: Limit of B.C.H.I.S. Liability.\nNo. 1.\u2014COMPLETION OF UNFINISHED SURVEY AND STUDY\nAccording to the terms of reference covering the duties of the Hospital Insurance\nInquiry Board, the Board is asked to file its report before the opening of the regular\nsession of the Legislature in 1952.\nThe Board has been advised by the Management Engineer Consultants, Messrs.\nStevenson and Kellogg Limited, who were engaged by the Board to make a complete\nsurvey of the administration procedures at the headquarters of the Service, that the said\nsurvey (which has been proceeding for a considerable time) will not be completed in time\nfor this Report. We have so far received from Messrs. Stevenson and Kellogg Limited\nonly interim (or partial) reports. They estimate it will take some months yet to finish\ntheir work.\nThe actuarial report of Mr. Samuel Eckler, of Toronto, who was appointed as\nActuarial Consultant to the Board, was received in December, and should be considered\nin conjunction with the final report of Messrs. Stevenson and Kellogg Limited. It is,\ntherefore, impossible for this Board to meet the requirements in its Commission, with\nrespect to submitting a complete and final report. We have accordingly restricted our\npositive recommendations in this interim report to those matters coming within our study\nto date, in respect to which we feel immediate changes should and can be made for the\nbetterment of B.C.H.I.S. and the satisfaction of the citizens of the Province.\nThe Board therefore recommends that the time for submitting its final report be\nextended so that Messrs: Stevenson and Kellogg Limited may be enabled to complete\ntheir survey, after which the Board may proceed with a combined study of the two reports\nreferred to, before filing the final report of this Hospital Insurance Inquiry Board with\nthe Minister of Health and Welfare. FF  18 BRITISH COLUMBIA\nNo. 2.\u2014CONTINUATION OF HOSPITAL INSURANCE SERVICE\n(BASIC PLAN)\nThe first basic question to command the attention of the Board was whether or not\nBritish Columbia Hospital Insurance Service should be continued. Much information\nwas submitted by individuals and representatives of various organizations bearing on this\nbasic question. The information secured from submissions, together with further facts\ngathered from a survey of the Hospital Insurance problem in other parts of Canada and\nthe United States, all pointed to the necessity for some plan that will remove the responsibility for hospital costs from the individual budget to an organized insurance plan.\nAs evidence that this necessity is agreed upon by all sections of the public, we would\nquote from the opening paragraph of the brief of the British Columbia Hospitals' Association, as follows:\u2014\nThe B.C. Hospitals' Association is now, and always has been, in favour of a compulsory\nprovince-wide Hospital Insurance Plan.\nAnd from the written submission of the College of Physicians and Surgeons of British\nColumbia:\u2014\nThere is agreement among doctors that insurance of all citizens against the possibility of a\nlarge hospital bill is in the best interests of the community. Since the inauguration of Hospital\nInsurance in British Columbia, we have witnessed numerous instances of the gratitude of patients\nwho have received expensive hospital care. The bills for this hospital care would formerly have\nthreatened their economic security.\nAnd further, from the brief of Mr. G. H. Jackson, secretary-treasurer of the Canadian\nPacific Employees' Medical Association of British Columbia:\u2014\nThere would seem to be no doubt that hospital insurance must continue. It would be contrary to the wishes of the vast majority of the electorate and disastrous to the hospitals if it was\nabandoned.\nDuring recent years there have been sensational advances in all branches of medicine, surgery, drugs, hospital services, and every other phase of health correction and\ncare. A member of the delegation which appeared before the Board, representing the\nBritish Columbia Hospitals' Association, made the statement that \" The practice of\nmedicine is fifty years behind the science of medicine \"\u2014a situation which is being rapidly\nchanged. Not so long ago, many people considered a hospital was a cross between a\nboarding-house and a pest-house, and avoided entering a hospital because it was considered the place to take a patient only when hope was abandoned. At that time, people\nof means who could afford to have nursing service made available in their homes did so\nin preference to entering hospitals. A little later on (as a matter of fact, up to five or ten\nyears ago) hospital service was deemed to consist of bed and board, with some nursing\nservice, and many hospital insurance programmes were financed on a premium of about\n$1 per month per family. That margin of fifty years which had existed between the\npractice and science of medicine has been materially reduced during the last five to ten\nyears. New techniques in the science of medicine, and particularly new developments in\ndrugs, are responsible for a substantial increase in costs.\nHigher prices of drugs and medical services, combined with the general trend to\nhigher levels in wages, salaries, and supplies of all kinds that contribute to hospital\nservice, have brought us to the point where it is almost impossible for the average head\nof a family to budget for hospital costs from their own personal income. We learn on\nthe authority of Herbert E. Klarman, Assistant Director of the Hospital Council of New\nYork, writing in the Harvard Business Review for September, 1951, that the average\ncost per patient-day in general hospitals throughout the United States was, at that time,\n$15.65. This is a nation-wide average figure. Some localities run very much higher.\nA hospital authority on the Mayo staff at Rochester, Minn., recently stated that the per REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 19\npatient-day cost, based on public-ward services, ran as high as $31 in some sections of\nthe United States.\nBased on the foregoing facts, the general consensus of opinion, as expressed to the\nBoard on behalf of the public of British Columbia, was almost unanimously in support of\nthe continuance of a hospital insurance service. Spokesmen for many other bodies who\nplay a part in hospital service, such as the College of Physicians and Surgeons, the British\nColumbia Registered Nurses' Association, and labour organizations, all stated very definitely that the organizations they represented had benefited from the inauguration of the\nHospital Insurance Service and were hopeful that it could be put on a successful operating\nbasis.\nThe conclusions of our actuary, Mr. Samuel Eckler, were set out in Chapter VIII\n(entitled \"Problems and Recommendations\") of his report, a copy of which chapter is\nto be found as an appendix to this Report.\nIn his submission, Mr. Eckler puts forward three possible approaches to the basic\nproblem of the continuance of a compulsory hospital insurance plan, as he sees the matter.\nIt will be noted that Approach No. 1 deals with the continuation of the present plan\nof a complete service benefit, with almost the entire population of the Province being\ncovered.\nApproach No. 2 contemplates that the present plan shall be fundamentally altered\nby providing a cash per diem benefit rather than the over-all cost benefit now given.\nApproach No. 3 contemplates that the compulsory hospital insurance service should\nbe terminated at some future date.\nWe wish to note first that, in view of the almost 100-per-cent support and approval\nof compulsory hospital insurance which was placed before this Board, we are entirely\nunable to conclude that Approach No. 3 would be acceptable to the citizens of the\nProvince or to the Legislature.\nIn connection with Approaches Nos. 1 and 2, Mr. Eckler has endeavoured in his\nreport, as quoted, to set out the advantages and disadvantages of each approach.\nIt will be conceded that such a report is deserving of the fullest and most serious\nstudy, but this it cannot receive until the report of Messrs. Stevenson and Kellogg Limited\nhas also been received.\nThe Board therefore recommends that the B.C.H.I.S. shall continue to follow the\npresent plan as referred to in Approach No. 1 of the Eckler Report, subject only to the\nrecommendations contained in this Report of the Board, until the Board is in a position\nto file its final report.\nNo. 3.\u2014PREMIUM RATES\nIn considering the matter of premium rates, the Board was faced with requests from\nmany quarters for a reduction in the rates at present effective, whereas the facts obtained\nregarding hospital costs and also comparative premium rates in existence throughout\nCanada and the United States indicated that it would be inadvisable to recommend any\npremium reduction at this time. However, as other recommendations of the Board will\nreveal, it has reason to believe, even while giving due consideration to rising costs, that\nthere is a distinct possibility of a fuller realization of the premium income due to the\nService and a very substantial reduction in the administration costs of the Service.\nIn anticipation that the recommendations of the Board concerning a new system of\nregistration and premium payments will be accepted and implemented, the Board is of\nthe opinion that a further period of time should elapse during which the results of the\nchanged system are experienced and on record, every effort being made during that period\nto effect the expected savings and realize the highest aggregate income.\nThe Board therefore recommends that at present there shall be no increase in the\npremium rates. FF 20 BRITISH COLUMBIA\nNo. 4.\u2014CO-INSURANCE CHARGES\nWhen the Board commenced its duties at the end of May, 1951, the matter of the\nco-insurance charge which had been introduced, effective April 1st, 1951, by Regulations\nNos. 14-1 to 14-6, inclusive, had become the cause of the liveliest controversy and\ncriticism. This criticism arose not only from the premium-paying public, but also from\nmany of the hospital boards and administrators throughout the Province.\nIn order to accurately determine the view-point of the hospitals in connection with\nthe matter, and the results accruing to hospitals up to that time, the Board caused a\nquestionnaire to be sent out to each hospital in the Province. The great majority of these\nwere returned, and in most cases adequate information and opinions were given. It may\nbe safely said that the majority of the hospitals were not in favour of co-insurance in the\nform and manner in which it had been introduced. Some of them said that increased\npremiums would have been preferable; some of them objected to the application of the\ncharge to the first ten days' stay in hospital; some believed that the imposition of such a\ncharge should be permissibly varied to meet the needs of any particular community or\nhospital; and various other suggestions for alternative plans were put forward.\nHowever, the larger number of hospitals, of those expressing an opinion, were in\nfavour of the abandonment of the co-insurance imposition.\nAs examples of the opinions expressed in written submissions received from hospitals, we quote as follows:\u2014\nCumberland General Hospital.\u2014While co-insurance may have succeeded to some extent in\nreducing hospital demands, it is doubtful whether it actually represents a source of appreciable\nrevenue, after allowing for increased paper work, cost of collection and bad debts. Further, the\ngood-will of the premium-paying public towards the scheme is lessened by the fact that coinsurance charges occur at a time when they require services for which they have already paid by\nway of premiums.\nGrand Forks Community Hospital.\u2014In theory co-insurance might have something to justify\nit, but in practice it is a monstrosity. It presupposes that doctors are so unprincipled that they\nwill fill the hospitals with patients that do not require acute care. We have not found it so.\nFurther co-insurance has greatly increased outstanding accounts receivable, and it has multiplied\nthe work of the collector. It has meant more bookkeeping, more collecting, more outstanding\naccounts, more office staff, and more operating expenses in many ways. In actual practice, coinsurance appears to be a failure, and there is certainly every proof that it antagonizes our\ncitizens.\nProvidence Hospital, Fort St. John.\u2014It would appear that a more acceptable method of\nhaving the patient share the costs of hospitalization would be to charge for at least some of the\nextras, and it is our opinion that such charges would cause less controversy. Most patients\nappear to regard co-insurance charges as a violation of their contract with the Hospital Insurance\nService.\nThe British Columbia Hospitals' Association, in effect, recommended the abandonment of the present system of co-insurance charges, by suggesting that \" The Government\npermit the hospitals to decide what co-insurance, if any, is necessary to make up any\ndeficiency in order to meet the cost of service in each hospital.\"\nOther organizations making written submissions to the Board are quoted as\nfollows:\u2014\nUnited Steel Workers of America, Trail.\u2014We wish to go on record as being resolutely\nopposed to the co-insurance per diem payments feature of the Act. This feature is, in our\nopinion, wrong in principle. The yearly premiums are paid to ensure against hospital bills, but\nnow when faced with the additional cost that is always involved by hospital treatment, additional\nlevies are made by co-insurance. ...'\u25a0'!\nVancouver, New Westminster and District Trades and Labour Council.\u2014We submit that the\npresent premium rate is far too high, and with the addition of co-insurance, the basically sound\nidea of hospital insurance becomes a nullity. In other words, the benefits of the scheme have\nbecome unattractive due to the price that must be paid for the benefits received. We submit that\nco-insurance be absolutely abolished. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 21\nNorth Sidney Property Owners' Association.\u2014We consider the government's plan for coinsurance a very objectionable feature as it places an unbearable burden on persons in the low-\nincome brackets, and will prevent many of them from receiving necessary hospital care. The fear\nof being hospitalized and having to meet the co-insurance charges, in addition to the premiums,\nmay prevent some of these people from even calling in a doctor till their case has developed to\nthe stage where such action is unavoidable, and the result may well be the loss of one of the most\nimportant benefits expected from the Hospital Insurance Service\u2014namely, the diagnoses of\ndiseases in their early stages, when they may be successfully treated.\nFarmers' Institute, District \"J,\" Peace River Block.\u2014We are opposed to any policy of coinsurance.\nC.C.F., Peace River Executive.\u2014Co-insurance added to the burden of those who have faithfully paid the premiums; and those persons in the low-income group, who have had to probably\nsacrifice in order to pay the premium now find themselves in the position of having to pay still\nmore co-insurance, in the event of sickness.   Co-insurance should be abolished.\nAnd from individuals the following are samples of written submissions received:\u2014\nMr. G. H. Jackson, Secretary, Canadian Pacific Employees' Medical Association of British\nColumbia.\u2014Co-insurance was put into effect for the avowed intention of relieving the pressure\non hospital bed-space, particularly for minor conditions and elective surgery. It is doubtful if it\nhas achieved that object. What it has done is relieve the B.C.H.I.S. of a large portion of the cost\nof the initial ten days' treatment, arouse the public to a spirit of indignation, and place on the\nshoulders of hospital authorities the responsibility of collecting the charge. If we are to have\nhospital insurance, the rates should be raised to a point where co-insurance is not necessary.\nIt must be realized that when co-insurance has been paid by an individual, or for a family group,\nin any one year, the incentive to keep out of hospital is removed.   It can only be effective once.\nMr. R. Lingford, Salmon Arm, B.C.\u2014As for this co-insurance, it is a tragic error, in my\nhumble opinion. It brings up again the phantoms of worry and fear to countless people who are\nalready having a hard struggle, even when in good health, to make ends meet. It may even\nendanger the lives of some, who would prefer to stay away from hospital rather than be forced\ninto more debt, even though hospitalization is essential for them. Co-insurance kills the whole\nprinciple of insurance. It is not insurance at all, but an unfortunate idea of extracting money\nfrom the sick for the benefit of the hospitals. The few sick have more burden placed upon them\nto pay for the many, instead of the many paying for the few.\nMr. A. H. Povah, Hospital Accounts Collector, Kelowna, B.C.\u2014Co-insurance is the greatest\nfactor. It hits a man when is down and least able to take it\u2014when his earning power is cut off\nand his expenses are mounting. It hits the young mother going to hospital for her child\u2014\nattacks on young growing families. It has been stated the reason for co-insurance is that patients\nover-stay at the hospital. This is not so. The patient is helpless. He has no say whatever in the\nmatter; the doctor orders him in, and orders him out. These patients should not be assessed an\nextra $2.50 per day at a time when they are least able to pay it.\nThese written submissions were repeated verbally throughout the length and breadth\nof the Province by individuals speaking for themselves and also acting as representatives\nof other organizations of repute.\nThe Board, when visiting Saskatchewan to study the Saskatchewan Hospital Services\nPlan, had the privilege of meeting with the executive officers of the Saskatchewan Hospitals' Association. The Board learned that no co-insurance is charged in Saskatchewan;\nand, in discussing the subject with the Board, Mr. Bassett, president of the association\nand administrator of the Prince Albert City Hospital, stated that they like the present\nsystem of the S.H.S.P. whereby the hospitals are paid a definite sum twice monthly by\nthe Plan; and he believed that this assurance of a certain monthly income acts in some\nmeasure as a deterrent to the overcrowding of hospitals and the temptation to secure as\nlarge an occupancy as is possible. He further stated that the association would not\nrecommend a co-insurance charge and would not O.K. it unless the Government showed\na definite inability to meet hospitalization costs. Mr. Bassett continued that hospitals\nwould be very unpopular with the public if they took any other stand; and, furthermore,\nthe hospitals did not desire to go back to the position of being collection agencies.\nThe Board has come to the conclusion that the weight of evidence is against the\ncontinuance of the co-insurance charge.   It is doubtful if it has accomplished its primary\n\u25a0\u25a0\u25a0\u25a0     :-     \t FF 22 BRITISH COLUMBIA\nobjective of curtailing the abuse of hospitalization. Neither has it been demonstrated\nthat the additional net revenue resulting therefrom has been sufficient to outweigh the ill\nwill created by the charge\u2014and the Board is of the opinion that if it is considered definitely necessary to obtain that additional revenue, it may be well and advisably sought\nfrom other sources.\nThe Board therefore recommends that co-insurance charges against patients in\nhospitals be completely abandoned.\nNo. 5.\u2014FINANCING OVER-ALL DEFICITS OF THE PLAN\nThe matter of whether or not the Government should subsidize the Hospital Insurance Fund substantially or should expect it to be self-supporting is a subject of basic\npolicy. Many submissions made to the Board were to the effect that hospital costs have\nreached the point where the individual is no longer able to meet hospital bills in full. By\nthe same standards, it can be assumed that no group of individuals can meet hospital\ncosts for that group without a subsidy.\nInformation gathered from many sources has convinced the Board that the premium\nincome collectable by B.C.H.I.S. can be substantially increased and that administration\ncosts can be substantially reduced. It is impossible at this time to estimate to what\nextent the net premium income will go toward meeting future over-all hospital costs, and\nuntil changes as recommended by this Board relating to registration and premium collections are actually established, it is not possible to arrive at a reliable estimate of the\namount likely to be required from consolidated revenue and the definite formula for\nGovernment support of the Service from that source.\nThe Board therefore recommends that a long-range programme of financing the\nService be developed, with a definite policy and formula of Government financial support,\nand that there be established a policy that should a deficit develop in the hospital insurance financial year for reasons over which the hospitals and B.C.H.I.S. had no control or\nwhich could not reasonably be foreseen by B.C.H.I.S. or the Government, then the said\ndeficits shall be paid from consolidated revenue.\nNo. 6.\u2014MUNICIPAL AND PROVINCIAL PER DIEM GRANTS\nA great deal of evidence was gathered, and many opinions and suggestions were\nsubmitted to the Board regarding the entire subject of municipal contributions toward\nhospital finances, not only in connection with the capital cost of construction and equipment, but also with regard to the operating costs. In view of the situations existing in\nsome localities, the main interest tended to centre on the matter of the municipal liability\nfor, or contributions to, capital outlay. This particular aspect will be dealt with elsewhere. We are here concerned with the matter of municipal contributions to hospital\noperating costs.\nWhile this subject was not referred to in many written briefs placed before the\nBoard, it was very generally discussed between the Board and those appearing before it.\nAs an example, however, of opinions verbally repeated quite frequently, we quote the\nfollowing from the written submission of the Hospital Employees' Federal Union, of\nVancouver, dated August 13 th, 1951:\u2014\nThere has been no increase in the contribution of 70 cents per day toward the upkeep of\nhospitals which the municipalities have been paying for the past ten years. A contribution of\n70 cents per day to-day is equivalent to only 35 cents as compared with ten years ago. In terms\nof purchasing power, hospitals are receiving only 50 per cent of the value of the contribution at\nthe time the figure of 70 cents was agreed upon.\nOf all municipal services, hospitals alone have not received an increased share from local\ntaxes. Roads, sewers, schools, fire and police protection, and the whole range of essential municipal services are now being financed and maintained at much higher costs.   Hospitals are no less REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 23\nimportant to citizens than any of these other services. The local community has a responsibility\ntowards its hospitals. It is scarcely logical that such an important service should be discriminated\nagainst in this way. Hospitals should share in the increased taxes which are being levied and\ncollected by local authorities.\nIt is undeniable that the municipal contribution of 70 cents per patient-day toward\nhospital expense is a figure that has remained unchanged over a considerable number of\nyears, when every comparative figure was rapidly increasing. There is perhaps not much\nneed to develop an argument to demonstrate the fact, or the opinion, that in the light of\npresent-day prices and values this 70-cent contribution is no longer fair or adequate.\nProceeding to another phase of the same subject, many suggestions were made to\nthe Board as to the desirability of changing the basis of contribution\u2014substituting for\nthe present per patient-day basis a per capita basis, enabling much simpler calculation\nand doing away with a very considerable amount of record-keeping, accounting, and\nchecking. On this particular phase of the subject, The Corporation of the City of Penticton had the following to say, in a written brief presented to the Board on August 8th,\n1951:\u2014\nFirstly, the present method of invoicing municipalities for the per diem charges on a patient-\nday basis is in our opinion a costly undertaking, costly not only for the Insurance Service in\ninvoicing municipalities on the basis of actual occupancy of a hospital bed, but also costly to the\nmunicipality being invoiced in that each item on the invoice must be checked to insure that the\nmunicipality is not being invoiced for a patient not the responsibility of the municipality concerned. It has been our experience that much correspondence is necessary in order to establish\nresponsibility in some cases and the facts when obtained are so meagre that the municipality\noriginally billed is eventually stuck with the costs.\nIt is, of course, appreciated that recourse may be had to a board of arbitration to establish\nresponsibility but the machinery is too ponderous and the delay is too great for a municipality to\nmake much use of this procedure, especially where comparatively small amounts are concerned.\nIt is further noted that there is great delay in the invoicing on a per diem basis. In some cases\nthe invoice is not received for many months after the patient has been discharged from the hospital and it will, of course, be appreciated that until the account is received by the municipality\nthe Hospital Insurance Service cannot collect the per diem charges.\nIt is suggested that the per diem charges be made on the basis of population such as this\nmunicipality enjoyed during 1950. A per capita basis of per diem charges would enable the\ncouncil to budget for the full amount which would be required to be paid during the year and\nthe Hospital Insurance Service would also have an indication of what revenue might be expected\nfrom this source.\nThe same view-point has been verbally put forward by several hospital administrators and municipal officials directly concerned with the receipt or payment of these\ncontributions. The Board was further informed by the Minister of Health and Welfare\nthat for a time the Department gave to the municipalities the option of contributing on\nthe per capita basis, but that due to a partial acceptance only of the option it was afterwards discontinued and the patient-day basis reverted to entirely.\nThe Board has become convinced that, from any point of view, what might be lost\nto the Hospital Service by placing this contribution on a per capita basis will be saved in\ncosts attachable to its operation.\nWe now proceed to a further phase of this particular problem\u2014a phase concerning\nwhich very strong opinions were expressed to the Board from time to time. This concerns\nthe entire subject of the contributions made, or not made, by a municipality or by an\nunorganized territory toward the cost of hospitalization (of residents of such municipality\nor unorganized territory) in hospitals in other municipalities, more particularly where\nthere is no hospital in the municipality or unorganized territory from which the patient\ncomes.\nAs in the case of the first phase of this entire problem, the interest and discussion\ntended to centre around the contribution to capital expenditure, but nevertheless there\nexists a firmly based opinion in the organized municipalities, and on the part of the\nhospital boards there, that the per patient-day contribution toward hospital costs from FF 24 BRITISH COLUMBIA\noutside municipalities or unorganized territories is not adequate or equitable, and that\nthe said outside municipalities or unorganized territories should be required to make a\nlarger contribution to the cost of hospital care of its residents than the contribution made\nby a municipality having a hospital within its own limits. The entire subject is a very\ninvolved and contentious one, and it is not possible to set out here all the considerations\nor arguments that are advanced from different view-points, but the Board has come to\ncertain conclusions on all these matters, and\u2014\nThe Board therefore recommends:\u2014\n(1) That the per diem contribution paid by municipalities, or by the Government in the case of unorganized territories, shall be increased from the\npresent basis of 70 cents per patient-day to the sum of $1 per patient-day:\n(2) That consideration be given to basing the contribution mentioned above\non a per capita basis rather than the present per patient-day basis, with\nthe per capita rate thereof being set to produce an approximately equal\namount of revenue to the Service:\n(3) That where a resident of a municipality or of an unorganized territory is\nhospitalized in a hospital outside the confines of his own municipality\nor territory, the said municipality, or the Government on behalf of the\nunorganized territory, shall pay an additional 25 cents per patient-day in\nconnection with such patients. This additional payment shall be made\ndirect to the hospital in question, to be treated as non-operating revenue\nof the receiving hospital, and the hospital concerned shall be required to\nbill the proper authority for this additional 25 cents per patient-day charge.\nNo. 7.\u2014FUTURE INCREASES OF PREMIUM RATES OR CURTAILMENT\nOF BENEFITS\nWhen giving consideration to the desirability or otherwise of a change in the\npremium rates now in effect, and on which point the recommendation of the Board is\nrecorded in Recommendation No. 3, the Board also took under advisement the changes\nwhich had been made in premium rates since the initial date of the operation of the\nService\u2014namely, January 1st, 1949.\nThere was an increase in the original premium rates, which increase was made\neffective during the first year of operation of B.C.H.I.S.\u2014namely, 1949. There was then\na further increase in the premium rates, effective for the year 1951. This was authorized\nby the Legislature of 1951, and its actual operation was effective from July 1st. However, the premium which was altered was the annual premium for the calendar year. The\nBoard has elsewhere made clear that it is in agreement with the principle and policy of an\nannual premium, although this may be paid or payable in two instalments. They have\ngiven careful thought and consideration to the procedure which has been followed up to\ndate in putting increases of premium rates into effect, and they are of the opinion that it\nis unfair and not in accordance with sound business practice to institute an increase in a\npremium under a Compulsory Insurance Act with the said increase having a retroactive\neffect. It is not necessary to advance all the considerations which caused the Board to\ncome to this definite opinion. It should be sufficient to point out that such a retroactive\nstep causes a very considerable resentment in the minds of the premium-payers of the\nProvince, who generally believe that they are entitled to full and adequate advance notice\nof any such changes as may be contemplated and finally approved by legislative action.\nThe Board therefore recommends that there shall be no further or future increase in\nthe premiums required to be paid annually, and no reduction of benefits conferred by the\nAct, within any premium year, and that any such changes as may be, from time to time,\nauthorized by Act of the Legislature, affecting the annual premium payments, or the REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 25\nbenefits conferred by the \" Hospital Insurance Act,\" shall have effect only at the commencement of the next premium year.\nNo. 8.\u2014EXEMPTION OF GROUPS ON RELIGIOUS GROUNDS\nIn view of the fact that application was received from another religious body for the\nsame exemption for their members as is now enjoyed by members of the Christian Science\nChurch, the Board gave the matter careful consideration. It seems obvious that if the\ndoor to exemption on religious grounds was widened by the admission of further bodies,\nthe requests for this treatment would increase and the difficulty of deciding as to the\nmerits of the application of one denomination as against that of others would be a most\nserious problem. Further, the Board takes the position that Hospital Insurance Service\nin its present form is a public service of the Province that may be compared with education, other forms of social assistance, and even the provision of highways, toward which,\nas in the case of all such public services, every citizen must contribute his fair share for\nthe general good, even if the benefits arising from such public services are not equally\ndistributed amongst individuals.\nIt should be noted that the Board has ascertained that in the Province of Saskatchewan members of the Christian Science Church are not exempted from the provisions\nof the Saskatchewan Hospital Services Plan and that no application for exemption by\nthat group has been made.\nThe Board therefore recommends that in future no group of citizens of the Province\nbe exempted from the provisions of the \" Hospital Insurance Act\" on religious grounds\nand that the present exemption extended to members of the Christian Science Church\nshall be discontinued.\nNo. 9.\u2014EXEMPTION OF GROUPS: CANADIAN PACIFIC EMPLOYEES' MEDICAL ASSOCIATION OF BRITISH COLUMBIA AND TELEPHONE EMPLOYEES' MEDICAL SERVICES ASSOCIATION OF BRITISH COLUMBIA.\nApart from the group of persons which has been up to date exempted on religious\ngrounds\u2014namely, the Christian Scientists\u2014the only other groups exempted from the\nprovisions of the Act are the members of the Canadian Pacific Employees' Medical\nAssociation of British Columbia and of the Telephone Employees' Medical Services\nAssociation of British Columbia.\nThe Board wishes to go on record as believing that it is desirable to look forward\nto the time when there shall be no group of citizens of the Province subject to special\nexemption from the provisions of the Act, and\u2014\nThe Board therefore recommends that the position of the present exempted groups\nreferred to above shall be reviewed by competent authority as soon as possible, with\na view to bringing the members of such groups directly within the operations of the\nB.C.H.I.S. at such a time as it may be found feasible and advisable to so do.\nNo. 10.\u2014EXEMPTION FROM PREMIUM LIABILITY:\nLOW-INCOME GROUPS\nAs was to be expected, many representations were made to the Board on behalf\nof those people in receipt of very low incomes who are nevertheless expected to pay\nB.C.H.I.S. premiums because they are not in any class to which exemption has so far\nbeen granted. These not only included relatives and dependents of protected veterans,\netc., but the many private people without any particular classification or standing who\nexist on a limited retirement or investment income, or on limited earnings. Dealing particularly with the first class, that of the dependents or relatives of veterans, we quote from\na brief of the British Columbia Command of The Canadian Legion, as follows:\u2014 FF 26 BRITISH COLUMBIA\nLow Income Groups (Exemptions)\nFor three years in succession we have presented requests to the B.C. Government for exemption from payment of premiums by: \u2014\n(1) Wives of recipients of War Veterans Allowance.\n(2) Widows\u2014recipients of an allowance under the regulations of the War Veterans\nAllowance Act.\n(3) Recipients of Dependent Parents Pensions paid under the regulations of the Canadian Pension Act.\n(4) Dependents of members of the Canadian Armed Forces (on overseas service).\n(5) Other low income groups not included in the groups named in this brief.\nIt should be noted that as a result of Department of Veterans' Affairs regulations, the Federal Government has relieved Provincial Governments of large expenditures of money through\nSocial Welfare sources, by paying War Veterans Allowances to veterans, and to their widows, and\nalso by granting complete hospital and medical services to war veterans, in receipt of War\nVeterans Allowance, irrespective of the cause of disability requiring treatment.\nIn addition, grant of pensions to dependent parents of deceased veterans by the Federal\nGovernment has assisted in relieving Provincial Governments from extra expenditures on Social\nWelfare.\nThe maximum allowance paid under War Veterans Allowance Act regulations is: Married\nveteran, $70.83;  single veteran, $40.41;  widow, $40.41.\nDependent parents pensions usually run around $40.00 monthly.\nPresent Exemptions\nThe Provincial Government has already recognized that low income groups should not be\ncalled upon to pay hospital insurance premiums, but such exemptions have only covered those\npeople in receipt of Old Age Pensions and the Blind who receive a pension. Persons in receipt\nof Social Assistance are also exempted from payment of premiums.\nWe submit that recipients of War Veterans Allowances, their widows, and those in receipt\nof Dependent Parents Pensions from Federal sources are in a less favourable financial position in\nBritish Columbia than people receiving Old Age Pensions, including the Blind.\nWe feel that action to exempt the groups that we have named in this brief is long overdue.\nOther Low Income Groups\nWe realize that other groups in receipt of low incomes, as well as those in whom The\nCanadian Legion is primarily interested, have a similar claim to exemption from payment of\nhospital premiums, and it will be noted that they are also included in this brief.\nCost of living is not going down, and we feel that steps should be taken at the earliest possible date to exempt low income groups from payment of hospital premiums and that they be\nprovided with a hospital card.\nAs regards the over-all body of people in the low-income groups, we quote from the\nbrief of the Vancouver, New Westminster and District Trades and Labour Council:\u2014\nThere is a large group of persons who cannot be classed as average wage earners\u2014namely,\nthe people in the low income group\u2014and we suggest that the purpose of the legislation under\nsection 7 was to alleviate the hardship of assessing pensioners and other persons for the Hospital\nInsurance premium who are not in a position to pay yet are deserving of the benefits under the\nAct.\nThis committee feels that there are many persons equally deserving of the benefits and are\nnow being assessed who are in no better position to pay the premium than the pensioner. Persons\nearning $100 per month or less are faced with a continual struggle to meet the high cost of living\nwithout the added burden of having to pay hospital premiums. As would be the case with pensioners, assessing people in this income group is in effect depriving them of the basic necessities\nof life and is not consistent with the whole tenor and purpose of the legislation which is to benefit\nall persons even those who cannot possibly meet the premium payments.\nWe submit that section 7 of the Act be amended to include all persons in receipt of income\nof $100 per month or less.\nFrom the brief of the British Columbia Retired Civil Servants' Association:\u2014\nAt the general meeting of our Association today I was directed to call your attention to\nmany of our members who receive less than the old age pension rate which entitles recipients to\nfree medical aid and hospitalization. Last year, in addressing our body, the Hon. A. D. Turnbull\nstated that those who could not pay for the hospital service would not be compelled to do so with\nno fixed limit as to income.   At the same time these of our members feel that they are actually REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 27\nunder legal compulsion to pay the premiums and are under the threat of prosecution if they fail\nto do so. What they may be given as a favor they would rather receive as a right. We would\nask therefore that your Commission take this matter into consideration, and, if possible, recommend some legislation that would relieve those in these low income brackets of their present\nanxiety.\nAnd from the brief of the B.C. Federation of Labour:\u2014\nWe ask this Committee to give serious consideration to the following proposals:\u2014\n(2) That Clause 7 (exemption from premiums) be extended to include all those whose\ntotal income is derived from compensation pensions, war pensions and pensions\nfrom other Governmental sources, or whose income is less than $100 per month.\nAlso from the North Sidney Property Owners' Association:\u2014\nWe feel, very strongly, that something further should be done to provide relief from hospitalization costs to persons in the lower income brackets.\nIn addition, we quote from letters received from individuals, which contain samples\nof many representations that were placed verbally before the Board by people all over\nthe Province in similar categories, who felt themselves to be in distressing positions:\u2014\nFrom Mrs. K. H. Ramage, Sidney.\u2014It is quite impossible for us to continue paying the\nhospital insurance. We are living on a fixed income of under $70.00 a month and we are not\nold enough to claim the old age pension.\nWe own our own house and by the time we have paid taxes, insurance, water, light and fuel\nthere is little enough left for food, let alone anything else.\nUp to now we have paid the premiums out of our capital, which of course reduced our\nincome and cannot go on.\nIn any case people in our circumstances cannot afford to call in a doctor and pay the\nenormous fees they are asking now.\nFrom Mr. Albert Flavell, White Rock.\u2014I wish to make the following submissions to your\nBoard:\nThat the recent increase in B.C.H.I.S. fees is a direct tax on the low income and low wage\ngroup for the benefit of high income groups.\nThe writer is in the very low income group and owing to the high B.C.H.I. fees is unable\nto see a doctor on necessary occasions and thus is unable to get hospitalization.\nPersons of my age\u201462\u2014and income, therefore, are condemned by B.C.H.I. to the use of\nhospitals only for the purpose of getting a passport to the cemetery.\nExcept for food the $30.00 B.C.H.I. levy is my largest yearly expense, and is 20% of my\nexpected yearly cash income.\nThe Blue Cross protection @ $12.00 per year from 1943 to 1948 was enjoyed by me and\nwas quite satisfactory.\nWe wish to make it clear that many of these submissions were made to the Board\nprior to the introduction of the Federal old-age pension for people of 70 years and over,\nand the implementing legislation passed by the special session of the British Columbia\nLegislature. Prior to this special session, the Minister of Health and Welfare appeared\nbefore the Board and discussed what general policy might be adopted concerning hospital\ninsurance premiums, etc., for the entire class of people in low-income brackets. The\nBoard had not at that date had sufficient time to give careful consideration to the subject\nbut, as a result of its further deliberations, has arrived at a decision which it thinks may\nfairly deal with the whole problem, and\u2014\nThe Board now recommends that in the case of persons not otherwise exempted\nfrom the personal payment of premiums and who can establish that their income is not\nmore than $720 for the year in the case of a single person or $1,200 for the year in the\ncase of a married person, the said persons shall be exempted from personal payment of\nthe premium but that the proper premiums for them shall be paid to B.C.H.I.S. by the\nproper Government department. FF 28 BRITISH COLUMBIA\nNo.  11.\u2014EXEMPTION FROM PREMIUM LIABILITY:      >\nSTUDENT NURSES UNDER 21\nThe position of student nurses with regard to payment of B.C.H.I.S. premiums\nwas placed before the Board in writing by one or two organizations. The Kamloops-\nTranquille Chapter of the Registered Nurses of British Columbia has the following\nto say:\u2014\nWe understand that University students are exempt from this ruling, in which case do you\nnot think that student nurses should come under the same category?\nSpeaking for several individuals, Mr. H. H. Piper, of Kamloops, wrote as follows:\u2014\nI certainly think the Hospital Insurance Service must be pretty hard up, on the other hand,\nthey should not be after collecting $15.00 from every student nurse in training in B.C. hospitals,\nwhen they have to collect from student nurses when they have already paid through the parents.\nThe Royal Columbian Hospital of New Westminster made the following suggestion:\u2014\nNurses in training be recognized by the Hospital Insurance Service as students until they\nreach 21 years and consequently remaining as dependents under coverage of parents or guardians.\nThe matter, which is an important one to those concerned, was followed up verbally\nin the discussions before the Board by such organizations as the Registered Nurses'\nAssociation of British Columbia and others, and it was agreed that the educational\nstanding of student nurses in this regard should be recognized.\nThe Board therefore recommends that student nurses, not over the age of 21 years,\nbe recognized as dependents in the same manner as those persons presently covered by\nsubsection (d) of section 1 of Regulation 1, under which dependents are defined.\nNo.  12.\u2014BENEFITS:   OUT-OF-PROVINCE HOSPITALIZATION\nThe limited benefits allowed a beneficiary under the Act for hospitalization outside\nthe Province of British Columbia were the subject of a considerable number of representations made to the Board. These had to do not only with the particular situation\nwhich exists in certain border areas such as the Peace River Block, but also with the\nentire matter of non-elective hospitalization outside the Province.\nThe following are quotations from some of the written briefs submitted to the Board,\nhaving to do with the difficulties caused by geographical location:\u2014\nDawson Creek Chamber of Commerce.\u2014Where a registrant leaves the province, the\nB.C.H.I.S. will only pay $6.50 a day for a period not exceeding thirty days. Situated as we are\nin a town adjacent to the border, this works a hardship on border residents. It is very often\nnecessary to send a patient to the City of Edmonton (which is the closest large medical centre)\nfor further treatment and it is our opinion that the benefits paid by the B.C.H.I.S. should be\nextended to persons who are attending hospitals outside the Province on the advice of their\nphysicians. They are entitled to unlimited coverage within the Province, and should not be\nprejudiced due to geographical location. This matter has been taken up with the B.C.H.I.S. by\nthe Dawson Creek Chamber of Commerce before but nothing in a remedial way has been done.\nFarmers' Union of Alberta, B.C. Section.\u2014If section 28 of the Act cannot be brought into\neffect so as to allow patients full benefits under the Act when forced to seek specialists' advice at\nEdmonton, and to be hospitalized there, then some special arrangements should be made where\nbeds can be secured at Vancouver whenever necessary and not just in case of life or death, and\nthat some allowance should be made the patient for the additional travelling costs. Our doctors\nhere are all familiar with Edmonton doctors and hospitals, and this is not the case when it comes\nto Vancouver.\nC.C.F., Peace River Block, Dawson Creek.\u2014The geographical location of the Peace River\nBlock has not only retarded development in this section of British Columbia, but has created\nproblems here such as probably will not be found in other areas of British Columbia.\nAs rural hospitals are not as well equipped as their urban counterparts, many persons who\nrequire specialist treatment must travel to Edmonton which is the nearest city to secure this\nservice, and because this city is outside the province, persons unfortunately needing treatment are\npenalized by going to Edmonton as the B.C.H.I.S. only pays $6.50 per day for thirty days, REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 29\nwhereas if they could afford to go to Vancouver then the B.C.H.I.S. would pay the rates allowed\nto the hospitals in the latter City.\nMr. W. G. Cowan, Postmaster, Field, B.C.\u2014Due to our location in the province, which is\nonly about 12 miles from the Alberta border line, we are compelled for reasons of economy in\ntransportation and at the same time to secure the services of competent doctors, to go to Banff,\nAlberta, when hospitalization is necessary, but because of this we are penalized by the B.C.H.\nCommission. We pay the same premiums as other residents of the Province but only receive\nabout half the benefits. The Commission pay $6.50 per day for hospital accommodation; all\nother extras such as medicines, X-rays, dressings, etc., has to be paid by the patient. This, you\nwill agree, is poor coverage compared to other residents. Such a set-up is causing much concern\nand bitterness against B.C. Hospital Insurance, especially to the working class in the lower income\ngroups.\nIt should, however, be clearly understood that these are not the only places which\nby reason of their geographical location find it almost essential to send residents out of\nthe Province for their hospitalization. Where this action is non-elective and not of their\nown choosing, it would certainly appear at first consideration that, having paid the same\npremiums as all other registrants, the people referred to are entitled to the same measure\nof protection against hospitalization costs, wherever that hospitalization needs to occur.\nThere is, in addition to the exigencies imposed by boundary or geographical locations,\nthe matter of persons fully covered by the payment of premiums who are absent from\nthe Province and because of circumstances over which they have no control are forced\nto use the services of hospitals elsewhere and may consequently incur bills of much\ngreater proportions than if they were hospitalized in the Province of British Columbia.\nThe allowed benefits, being limited as to both rate and time, seem to the Board to\nbe somewhat less than fair. However, the Board realizes that there must be some limitation placed on these benefits in order to prevent abuse from one source or another, and\nin an attempt to reach a more reasonable and equitable solution of the problem\u2014\nThe Board now recommends that when a registrant under B.C.H.I.S., or his dependents, in good standing is compelled by circumstances beyond his control, or on the\ndefinite advice of his physician in British Columbia, to take hospital treatment outside\nthe confines of the Province (more particularly when the home of the patient is so\ngeographically located as to make the out-of-Province hospitalization necessary or\ndesirable), B.C.H.I.S. shall pay for the said hospitalization a rate of $6.50 for each\npatient-day up to a limit of thirty days, plus a maximum of 50 per cent of the cost of all\nextras which would be covered completely by B.C.H.I.S. if the treatment was in a\nhospital in the Province.\nNo.  13.\u2014BENEFITS:   OUT-PATIENT SERVICES\nMany suggestions were made to the Board with regard to out-patient services,\nespecially those in connection with diagnostic procedures. After exhaustive consideration of these several suggestions, the Board was obliged to recognize the fact that revisions\nare desirable in the services already included or to be included in the Hospital Service\nplan, but did not consider this was a proper time for a recommendation for the extension\nof services or changes in the regulations relating to out-patient treatment.\nThe Board, however, feels that study and due consideration should be given as\nsoon as possible to this phase of hospitalization and, because of the possibility that some\nextension of out-patient benefits may be a desirable deterrent to bed occupancy and\neffect a possible net saving in total hospital costs,\u2014\nThe Board therefore recommends that careful study be given as soon as possible\nto the question of benefits having to do with out-patient services of hospitals, with a view\nto setting up the most desirable scheme from the view-point of service and the insured\npublic, and that changes as decided upon be put into effect in the Province. FF 30 BRITISH COLUMBIA\nNo. 14.\u2014CHARGES FOR NON-ELECTIVE USE OF PRIVATE\nAND SEMI-PRIVATE WARDS\nThere have been many requests for elimination of the extra charge over and above\nthe public-ward rate for private and semi-private wards when occupied by patients who\ndo not elect to occupy private or semi-private wards but are placed therein because of a\nlack of public-ward accommodation\u2014such patients having paid their premiums.\nA general opinion expressed before the Board in this matter is reflected in the\nrecommendation of the British Columbia Federation of Labour, quoted as follows:\u2014\nWe ask this committee to give serious consideration to the following proposals:\u2014\n(3)  That whenever a patient requires hospital care and beds are available, irrespective\nof the ward, that those patients be admitted without any extra cost to the patients.\nThe Board therefore recommends that in the case of non-elective use of private-\nor semi-private-ward accommodation in hospitals within the Province there be no extra\ncharge to B.C.H.I.S. registrants for the said accommodation.\nNo. 15.\u2014PREMIUMS PAYABLE BY WIVES OF CERTAIN VETERANS\nOn a point related to the treatment of pensioned veterans and other persons of low\nincome, representations were made to the Board concerning the premium payable by the\nwife of a veteran who is himself completely covered for hospitalization by the Department\nof Veterans' Affairs, and for whom, therefore, no B.C.H.I.S. premium is payable. It had\napparently become the custom, because of the changing regulations applicable to D.V.A.\npensioners, for the administration of B.C.H.I.S. to take the stand that although such\nveteran might be completely covered for D.V.A. treatment for pensionable disability, he\nmust, nevertheless, pay a premium to protect himself from charges which might be made\nby a general hospital in the event of his requiring hospitalization for some other ailment\nwhich, in many cases, might be the result of an accident. Having taken this stand, the\nB.C.H.I.S. also decided that in any case the wife, not being a single person, must be\ncovered by payment of the full premium imposed on the head of a family.\nThe entire matter is a very involved and complicated one, and it would seem impossible to lay down rules that would cover every contingency that arises in connection with\nsuch a person. The Board realizes the difficulty of stating a permanent policy in this\nregard. However, in an attempt to cover the comparatively few cases where hardship\nwould otherwise be inflicted\u2014\nThe Board now recommends that in the case of married war veterans who are\nthemselves completely covered for hospitalization by the provisions or regulations of the\nDepartment of Veterans' Affairs at the time being in force, the premium required to be\npaid by, or for, his wife (in case the family income is over $1,200 per annum) shall be\nthe premium of a single person.\nNo. 16.\u2014HOSPITALIZATION OF TREATY INDIANS\u2014FEDERAL\nGOVERNMENT RESPONSIBILITY\nThe Department of Indian Affairs of the Dominion Government pays to B.C.H.I.S.\npremiums as called for by the \" Hospital Insurance Act\" for Indians living on reservations in the Province. It has been brought to the attention of the Board that in 1950\nthe hospitalization cost of Treaty Indians exceeded the premiums received for the entire\ngroup of Treaty Indians by over $353,000, and it is estimated that the excess cost of the\nhospitalization of Treaty Indians in 1951, above the amount of premiums received for\nthe entire group, will amount to over $435,000. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 31\nAccording to information placed before the Board, it is an undoubted fact that\nTreaty Indians, as a group, show a very high incidence of illness, resulting in a longer\nlength of stay in hospital than that of the average patient.\nAt the time the members of the Board visited Regina to study the Saskatchewan\nHospital Services Plan, they were informed that the Saskatchewan Plan did not accept\nthe responsibility for hospitalization of Treaty Indians within the Province on a premium\nbasis, but that the complete cost of such hospitalization remained the responsibility of\nthe Dominion Government. The Board is of the opinion that the Province of British\nColumbia is certainly not being fairly treated in this connection, nor should it continue\nto bear the very heavy burden imposed upon it by a particular group, which, prior to the\nenactment of the \"Hospital Insurance Act,\" was the complete responsibility of the\nFederal authorities, and\u2014\nThe Board therefore recommends that arrangements be made with the proper\ndepartment of the Government of Canada for payment by it of the total cost of hospitalization of Treaty Indians of British Columbia.\nNo.  17.\u2014PAYMENT FOR HOSPITALIZATION OF \"SOCIAL AID\" CASES\nIt has been drawn to the attention of the Board, by the Commissioner of B.C.H.I.S.,\nthat the cost of hospitalization for those patients generally known as Social Welfare cases,\nand including specifically (1) Social Assistance and Japanese, (2) Old-age pensioners\nand blind pensioners, (3) Mothers' Allowance cases, and (4) Child Welfare cases, was\nvery considerably in excess of the premiums paid to B.C.H.I.S. on behalf of the total\nnumber embraced within these groups. Messrs. Stevenson and Kellogg Limited have\nsupplied the Board with the actual figures for the year 1950. The cost of hospitalization\nof persons coming within these groups during that year was $1,960,559, and the total\npremiums paid to B.C.H.I.S. to cover the complete membership of these groups was\n$1,010,857, indicating that the hospitalization of this number cost $950,000 in excess of\nthe total premiums for the entire group.\nThe Board was also given the 1951 figures on an estimated basis. At the time these\nestimated figures were compiled, the exact figures to August 31st were available. The\nestimated figures for the entire year are: Hospital costs, $2,552,860, and premium\nreceipts, $1,284,623, or an excess cost of $1,268,237. Against this, however, must be\nset the co-insurance charges, which will be, or have been, paid by or on behalf of those\npersons hospitalized, which is estimated to amount to $253,000, so that it may be said\nthat the 1951 excess of cost over revenue, as affecting this class of persons, is approximately $1,000,000.\nThe British Columbia Hospitals' Association took a keen interest in this phase of\nthe operations of B.C.H.I.S., and we quote from their brief, as follows:\u2014\nSocial Welfare\nA study of the incidence of illness and the average length of hospitalization will disclose\nthat the cost of hospital service to persons in receipt of social assistance is considerably in excess\nof the premiums paid by the Government on their behalf. We feel that this burden should not\nbe passed on to the insurance premium paid by the public. We feel that an appropriate amount\nshould be paid into the Fund through Provincial Welfare budgets to cover this.\nDespite ail efforts to restrict stay in hospital to persons really in need of hospital care, and\nfor no longer a period than is necessary, many cases of over-stay do occur. The causes almost\ninvariably come under the heading of welfare. The cost of this should not be debited against the\nhospitals. Nine times out of ten cases of this kind are the direct result of lack of suitable provision elsewhere. Thus a problem which does not properly belong to the hospitals is thrust upon\nthem. We feel that suitable Provincial-Municipal grants should be paid into the Fund to take\ncare of this.\nIt may, of course, be claimed that the fact that there is an excess of cost over\npremium income in connection with these cases does not make any difference in the long FF 32 BRITISH COLUMBIA\nrun because the Government of the Province is meeting the deficits of the B.C.H.I.S.,\nand, therefore, if it pays specifically out of welfare funds or consolidated revenue for this\nhospitalization, it would have to meet a lesser deficit of B.C.H.I.S. The Board feels,\nhowever, that it must not lose sight of the fact that it is dealing with an insurance service,\nand that these particular cases constitute what would be called in commercial insurance\ncircles a \" hazardous risk,\" which risk would be either refused by the insurance brokers\nor subjected to a special excess premium. Nor does the Board consider it is fair that\nB.C.H.I.S. (which in a measure is a separate subdivision of the Department of Health\nand Welfare and which is asked to submit its own accounts covering all operations under\nthe Act) should be compelled to include therein a particular class of operations which it\nknows is being conducted at a loss of $1,000,000 per annum.\nIt must be realized that if there were no Government Hospital Insurance Service,\nHealth and Welfare or some other agency would be responsible for the actual hospital\nbills of these people.\nThe Board therefore recommends that those persons comprising the groups of\nHealth and Welfare cases referred to above be no longer accepted by the Service on an\nordinary premium basis, but that the responsible Government department\u2014namely, the\nDepartment of Health and Welfare\u2014pay the full cost of hospitalization of all such\npersons coming within these groups, such payments to be made to the B.C.H.I.S.\nNo. 18.\u2014EDUCATIONAL GRANTS-IN-AID TO COST OF OPERATION\nOF TRAINING-SCHOOLS FOR NURSES\nThe Board heard a considerable number of representations having to do with the\nimplications arising from the fact that the cost of training student nurses (in places where\nthe hospital actually has a training-school) is included as part of the total hospital-\noperations cost and is, therefore, reflected in the estimated, and finally accepted, budgets\nand the per diem rates. It must be remembered that the number of hospitals actually\noperating training-schools for nurses is a small minority of the total number of hospitals\nin the Province.\nAmongst the written submissions placed before the Board, the British Columbia\nHospitals' Association had this to say on the subject now dealt with:\u2014\nEducation\nPart of the work of certain hospitals is purely educational. We feel that the cost of this\nshould not be a charge against insurance premiums, neither should it be permitted to place an\nunfair burden on the student. Education in hospitals is by no means limited to student nurses.\nIt includes internes, and different classes of technicians. We feel that the cost of education\nshould be assessed separately from the cost of service to patients, and that the rate paid to hospitals with approved educational programs should take the educational program into consideration. We feel that the cost of education in hospitals should be calculated and an equivalent\namount paid into the Insurance Fund from Provincial Education budgets to cover that cost.\nThe Registered Nurses' Association of British Columbia dealt with the matter as\nfollows:\u2014\nAt the present time the cost of operating schools of nursing tends to be confused with the\ncost of operating hospitals. Schools of nursing should operate under independent budgets which\nset forth clearly all sources of income and all estimated expenditures.\nGovernment has accepted responsibility for education for the professions with the exception\nof nursing. We believe that the Government has a responsibility for nursing education as well\nand we urge that where it can be shown by recognized methods of cost analysis that a school of\nnursing is costing the hospital more than the value of services given by the students of that school\nthis difference be met by Government grant-in-aid to the school.\nAnd the Royal Columbian Hospital, at New Westminster (which was not at that time a\nmember of the British Columbia Hospitals' Association), expressed a similar view-point\nin a suggestion worded as follows:\u2014 REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 33\nEducation grants (should) be provided training hospitals to subsidize student premiums,\ninstructors' salaries, cost of uniforms, food, laundry, linen, etc., rather than have these expenses\nincluded in the operating costs of such hospitals.\nIt was further pointed out to the Board that the few training-schools in existence in\nthe hospitals in British Columbia were regularly training a larger number of student\n. nurses than sufficed to supply their own year-to-year need of trained nursing personnel,\nand that they were, therefore, undertaking this educational training partly for the benefit\nof all hospitals of the Province.\nThe Board endeavoured to ascertain, with a degree of certainty, the margin of net\ncost to a hospital which operates a training-school for nurses, arising out of the difference\nbetween salary, room, board, or other costs or allowances paid to student nurses and\ninstructors (plus the cost of building upkeep and maintenance) and the value of the\nservices rendered in the hospital by the student nurses. It would appear that no positive\nfigures are available, but in the Province of Saskatchewan the Board was informed that\na study of training-school costs made in the general hospitals at Regina and Saskatoon\nshowed the services given by student nurses to have a value much less than the cost of\ntraining, the differential varying from $60 to $140 per trainee per annum. These facts\nbeing taken into consideration, there would appear to be ample justification for support\nof the suggestions and submissions made to the Board, as already outlined.\nIn addition to this, it must not be forgotten that there is a very widespread impression prevalent throughout the Province that the premium-payer in certain sections of\nthe Province, adjacent to what may be called only \" moderate \" hospitalization facilities,\nis unfairly called upon by being compelled to pay exactly the same premium as the\nresidents of an area adjacent to a hospital with far more adequate and costly facilities.\nWhile the problem of a possible classification of hospitalization facilities has not\nbeen dealt with exhaustively in this Report, the general subject may be referred to in\nother parts hereof. Confining the matter to the particular subject of the cost of training-\nschools, however, the Board feels that a case has definitely been made out, and\u2014\nThe Board therefore recommends that training-schools for nurses, in conjunction\nwith hospitals within the Province, be considered as educational institutions in so far\nas it is necessary to enable them to come within the provisions for grants-in-aid from\nthe Department of Education, to the end that the net cost of operating such training-\nschools shall in no way be a part of, or taken into account as, an operating cost to be\ncovered by B.C.H.I.S.\nNo. 19.\u2014CHRONIC CASES:   LIMIT OF B.C.H.I.S. LIABILITY\nWhile another recommendation of the Board has dealt with the matter of procedure\nnecessary in order to handle properly the very important subject of diagnosis of chronic\ncases, the Board nevertheless feels that there are very weighty considerations which justify\nfurther action to alleviate the burden that may be placed upon certain sufferers who enter\nan acute or general hospital and are later found to be in the \" chronic \" classification.\nIt has been pointed out that there are many such patients (not being the responsibility of the Social Welfare Department) whom it is found impossible to move from the\nsaid acute or general hospital at the time it is decided that the patient is a chronic case.\nThis situation arises from various causes, which will be easily understandable, the chief\namongst them being the lack of available beds in institutions for the treatment of chroni\u00a9\nailments and the inadvisability of returning the said patients to their homes.\nIt cannot be denied that the particular cases to which we have referred are still, to\nsome degree, a responsibility of the Province as a whole, and if the Province does not\nrecognize this responsibility in some degree, directly, such cases will definitely either\nbecome a charge on the Social Welfare Department or be left to suffer the very grievous\nconsequences of being faced with crippling financial liability at a time when they are FF 34 BRITISH COLUMBIA\npositively and completely unable to help themselves. Much has been said to the Board\non the tragic effects caused by financial worry pressing upon any sick person, and this\nparticular kind of case is one in which these effects are most clearly evident.\nFor these reasons, therefore, the Board has given this matter very considerable and\nearnest thought, and\u2014\nThe Board now recommends that the liability of B.C.H.I.S. for an account in a\ngeneral hospital incurred by a patient who is a registrant, or dependent of a registrant, in\ngood standing under the Act, who has been declared to be a chronic case, shall continue\nuntil they have been otherwise placed, but in no case shall it continue more than sixty\ndays beyond the effective date at which the case has been ruled otherwise to be a chronic\ncase. The ruling referred to is the decision of the Medical Board of Review, if the\ndiagnosis has been referred to them; and this recommendation is intended to apply to\ncases remaining in hospital which do not become the responsibility of the Social Welfare\nDepartment. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 35\nSECTION 3.\u2014MATTERS OF POLICY\u2014GENERAL\n20. B.C.H.I.S. Management Board and Select Standing Committee.\n21. Hospital Advisory Council.\n22. Public Relations of the Service.\n23. Field Representatives of B.C.H.I.S.\n24. Exempted Areas.\n25. Annual Accounts of B.C.H.I.S.\n26. Premium-year.\n27. \"Chronic\" Diagnosis: Provisions for Review.\n28. Provision for Permissive Use of Special Drugs.\n29. Premium-payment Enforcement:   Prosecutions and Garnishee\nProceedings.\nNo. 20.\u2014B.C.H.I.S. MANAGEMENT BOARD AND SELECT\nSTANDING COMMITTEE\nThe Board received many recommendations in connection with the administration\nof B.C.H.I.S.   A few representative suggestions are quoted herewith:\u2014\nFrom the North Sidney Property Owners' Association.\u2014A permanent Extra-Governmental\nBoard should be created to administer the B.C.H.I. Act on a basis similar to the Board administering the Workmen's Compensation Act.\nFrom the Halls' Prairie Farmers' Institute.\u2014We are strongly in favour of the provincial\nHospital Commission to take entire charge of the carrying out of the Hospital Act free of all or\nany political control; this Commission to consist of five persons, as follows:\nOne appointed by the Government;\nOne appointed by the Medical Profession;\nOne appointed by Agriculture;\nOne appointed by Labour; and\nOne appointed by Industry.\nThis Commission will be entirely responsible for the carrying out of the Act, to suggest\nchanges in the Act, and in every way endeavour to see that a compulsory hospital system for the\nProvince is made to be fair, just, and equal to all the people.\nWe consider that hospitalization for the people is altogether too important, from the public\nstandpoint, to be made a political football.\nFrom the Standard Railway Labour Joint Legislative Committee for British Columbia.\u2014\nThis Joint Committee has always opposed the principle of one-man commissions. We believe it\nborders too close to a dictatorial system for our Canadian mode of life. Therefore, however\nconscientiously the appointee may conduct his duties, he can never hope to obtain the confidence\nof a majority of the people he is sworn to serve. This being so, the purpose of his office is\nfrustrated from the beginning.\nWe sincerely believe that much of the spontaneous and contentious opposition to the present\nAct and interpretations of its administrator would have been avoided by a commission of at\nleast three members. These, we suggest, should represent a fair blend of constituents, and\ninclude one holding the full confidence of labour. This commission should, we think, apply a\nmore mature, comprehensive understanding of the problems of the people who have been obliged\nby law to provide the premiums for this insurance service.. It should also, by prompt hearing and\ndealing sympathetically with complaints, relieve much of the deplorable doubt and distrust that\nhas unfortunately invaded this very important public service.\nFrom Mr. G. H. Jackson, Secretary-Treasurer of the Canadian Pacific Railway Employees'\nMedical Association of British Columbia.\u2014The present Hospital Insurance Inquiry Board form\na Standing Committee of the Legislature with supervision over the operations of hospital insurance in all its phases. That it meet at intervals of not more than three months throughout each\nyear, at least until operations are proceeding on a smooth and sound basis. With the experience\ngained in the course of their enquiry the members of the board would be admirably suited to\ncompose this Standing Committee representing, as they do, both the Government and His\nMajesty's Loyal Opposition.\nMr. Jackson, who appeared before the Board on more than one occasion, has\nverbally stated that he is decidedly in favour of a board of management to consist of FF 36 BRITISH COLUMBIA\nthree laymen, who should hire the necessary experts; but there should be no attempt to\nmake the commission consist of one hospital administrator, one doctor, and one businessman. He definitely thought the board of three would be very desirable because, however\ngood the individual might be, the public has no confidence in the rule of one man.\nThe Board therefore recommends that B.C.H.I.S. be administered by a board of\nthree members, without legislative or judicial powers, and also that Standing Orders of\nthe Legislature be amended to provide for the appointment of a Select Standing Committee on Hospital Insurance, which shall meet at each regular session of the Legislature\nand shall review the report of the B.C.H.I.S., meet with the board of management, and\nreport to the Legislature.\nNo. 21.\u2014HOSPITAL ADVISORY COUNCIL\nA Hospital Advisory Council was appointed when B.C.H.I.S. was first organized.\nIt was reconstituted in March, 1950, and its first meeting was held in September of that\nyear. We have been advised by the Commissioner that since 1950 regular meetings of\nthe Hospital Advisory Council have been held at least every three months. The Commissioner conveyed to the Board that he was well satisfied with the services rendered by\nthe Hospital Advisory Council. On the other hand, several organizations which are\nactually represented on the Hospital Advisory Council believed that their representatives\ncould have been of greater service if the fullest advantage had been taken of their desires\nin this regard, and other organizations which did not have representation on the Hospital\nAdvisory Council believed that they could also have rendered valuable assistance. The\nopinions of these organizations are set out as follows:\u2014\nFrom the Vancouver Board of Trade.\u2014It was inevitable that under its present set-up\nB.C.H.I.S. would disturb the former relationship of doctor, hospital, patient and community.\nA satisfactory and equitable realignment of the spheres of operation and responsibility, where\ninter-dependence is as apparent, demands mutual consultation and co-operation. More effective\nutilization of the Provincial Hospital Advisory Council on policies and issues could have aided the\nGovernment in its decisions. The Provincial Hospital Advisory Council should become a more\neffective agent, and it should meet frequently and have opportunity to determine and indicate\npolicy rather than be called together to concur in fait accompli and to approve departmental\ndecisions.   The Hospital Insurance Act should be amended accordingly.\nFrom Royal Jubilee Hospital.\u2014Section 23 of the Hospital Insurance Act requires that there\nbe an Advisory Council to advise the Minister in regard to hospital insurance matters. This\nCouncil has seldom been used in an advisory capacity and does not contain a hospital administrator so that it rather serves as a sounding board than an advisory council.\nFrom the Late Dr. T. W. Sutherland, Parksville.\u2014When your commission was in Nanaimo,\nyou told me of your informal meeting with the executive of the B.C. Medical Association.\nIn the event that an Advisory Council to the B.C.H.I.S. be set up, the medical representative\nshould not be a political appointee but rather one who had the confidence and support of the\nMedical Association. To that end, I would suggest that the Medical Association be asked to\nnominate three men and that the Government appoint one of these three. The same would\napply to the B.C. Hospitals' Association, labor organizations, etc.\nThe Board therefore now recommends:\u2014\n(a) That the broad intention behind the setting-up of the Hospital Advisory\nCouncil be fully realized, and that if full advantage is not now being taken\nof the services of the Council, steps be taken to realize the maximum\nbenefit therefrom; and that, further, all proposed important changes in\npolicy or regulations be discussed with the said Advisory Council before\nthe proposed changes are put into effect:\n(b) That the Hospital Advisory Council shall in future include in its membership two private members of the Provincial Legislature, to be\nappointed or named before each regular session of the Legislature is\nprorogued, and that the said private members shall be selected from the\nmembership of the Select Standing Committee which has been in existence REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 37\nduring the said regular session, one to represent the Government and one\nto represent the Official Opposition.\nNo. 22.\u2014PUBLIC RELATIONS OF THE SERVICE\nIn view of the prominence with which the matter of the public relations of B.C.H.I.S.\nwas brought before this Board, the Board has attempted to consider each and all of the\nactivities of the Service that would be properly classified under this heading, and which\nin any way influence public opinion of the Service. These activities include many\nfeatures, ranging from newspaper releases and advertisements down to the style of letters\nthat go to the general public in the ordinary way from the offices of the Administration.\nThe evidence was that the large spaces used in newspaper advertisements, and frequently\nthe type of matter contained therein, gave to the general public impressions of waste and\nextravagance, and attempts to force the insurance scheme on the public without at the\nsame time seeking to improve the Service.\nSimilarly, representations were made to the Board in all parts of the Province as to\nthe tactless and dictatorial tone of letters received from Victoria. Not only were the\nletters referred to considered to be offensive, but there was constant complaint of the\ndelay in receiving replies of any nature from Victoria\u2014and statements that in many cases\nletters sent there had been completely ignored. There was, in addition to the above, a\ngreat deal of complaint made to the Board with respect to the general make-up of, and\nthe wording used on, premium notices. Many of these notices sent out in the past were,\nin the opinion of the Board, very difficult for a large percentage of the people concerned\nto understand, and it is certainly very annoying to the average person to have to seek out\nsomeone of superior intelligence in order to obtain an expert interpretation of something\nthat should have been plain and straightforward in the first place. This matter, alone,\nhas not made for good public relations with the ordinary registrant and premium-payer.\nB.C.H.I.S. is \" big business\" and, when functioning properly, will be dealing with\nnearly every citizen of the Province. Its success depends on public acceptance, not on\nthe ability of the Government or the Administration to make people like it. Therefore,\nthe Board wishes to point out that supervision of public relations is a highly specialized\noccupation. Volumes have been written on the subject, and intensive training courses\nhave been developed to fit people to engage in the important role of public-relations\nofficers. The proper preparation and presentation of matter to be included in press\nstatements, public addresses, advertisements, or even in the make-up of letters dealing\nwith commonplace matters is something that makes the most vital difference to any\norganization in its relations with its customers or the general public.\nWe feel that B.C.H.I.S. needs public-relations guidance, which would help sell\nhospital insurance service to the public\u2014and this is not to be confused with the mere\nhanding-out of publicity.\nWe feel that B.C.H.I.S. needs a public-relations officer, responsible directly to the\nMinister, if the present administration system is to be followed\u2014or responsible directly\nto a board, if the B.C.H.I.S. is to be administered by a board. His duties would be\nmany: they would include visiting every hospital in the Province regularly, contacts with\nthe public generally, attendance at public meetings, and every activity which would\nacquaint him with the opinions of the population of the Province as to the workings of\nB.C.H.I.S. We are sure that when visiting hospitals such an officer would learn of many\nsituations where a simple decision to be made in Victoria could wipe out much resentment, providing the said decisions were made promptly. It would therefore be the duty\nof the public-relations officer to find the things which are the subject of public concern and\nthen urge the Administration to attempt quickly to correct the source of dissatisfaction.\nWe are not suggesting that the public-relations officer is merely an official to receive FF 38 BRITISH COLUMBIA\ncomplaints and pass them on. We do think, however, that he would hear complaints at\ntimes, and he could get the difficulties smoothed over before the complainants were so\nconcerned as to take their cases to the public press. Furthermore, a public-relations\nofficer should be fully acquainted with the decisions of the Administration, and he should\nknow of these decisions well in advance of the time they will be announced to the general\npublic. He can then prepare the way for the announcement, by setting out what particular difficulties have faced the Administration in certain respects, and seek to guide\npublic opinion toward the favourable acceptance of the decisions to be announced. The\npublic-relations officer also should be the contact with the press, and should have\nauthority from the Administration to get and to hand out, where he believes it to be good\nbusiness to do so, details which the newspapers want\u2014and he should have authority to\ngo directly to the sub-department to get his information.\nAnother field of public relations to which we might allude is the work of the field\nrepresentatives of B.C.H.I.S. throughout the Province, but we have dealt with this particular matter in another recommendation.\nThe Board therefore recommends that, as it is their opinion that the scope of the\npublic relations of the B.C.H.I.S. justifies the retention of a Director of Public Relations of\noutstanding ability, steps be taken to secure the services of such a person, and that responsibility for the public relations of the Service be placed in his hands as soon as possible.\nNo. 23.\u2014FIELD REPRESENTATIVES OF B.C.H.I.S.\nDuring the first year that B.C.H.I.S. functioned, a chain of offices was opened up\nthroughout the Province. At one time these offices totalled sixty-two. Suitable persons\nwere in charge of these offices, to look after collections and serve as sources of information in connection with the Service generally. For various reasons, which the Board is\nnot in a position to question at this time, this system of district offices was changed, with\nthe result that the staff was substantially reduced and the majority of the offices were\nclosed. There is no question but that a valuable service was rendered by this system of\ndistrict offices, but it is questionable whether they justified their cost. However, their\ndiscontinuance was sorely felt by citizens in localities where they were closed, and there\nhas been a very strong appeal made by such districts for the reopening of district offices.\nThe ultimate solution to this problem depends upon whether or not the recommendation of this Board, numbered 30, is adopted and put into effect. Under subsection\n(iii) of section (c) of the plan contemplated by this recommendation\u2014\" Provisions for\nPayment of Premiums \"\u2014it is suggested that premium and arrears payments are to be\naccepted through various collection agents. Adoption of this portion of the Board's\nrecommendation would permit payments of premiums and issuance of interim receipts\nat many places, such as branches of chartered banks, express money-order offices, Government Agents, and any and all other places that would make it easy and convenient\nfor persons to pay premiums. This would result in a broader service than has ever been\navailable with respect to payment of premiums, so that the need for district offices\nwould be somewhat relieved.\nWe do, however, feel that there is a need for a field force of what might be called\n\" trouble-shooters.\" This field force should be composed of carefully selected personnel, properly trained to adjust problems of various kinds. These fieldmen would not\nnecessarily have to work out of local offices, provided there was some place, such as a\nGovernment Agent's office, to use as headquarters. The Board learned that much dissatisfaction existed throughout the Province with respect to matters that are presently\nhandled by correspondence from Victoria, and it believes that many problems at present\ndealt with by correspondence could be referred to the fieldmen for personal contact and\nadjustment. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 39\nParticular stress has been laid in another section of these recommendations on the\nmatter of public relations. This field force could be made a most important factor in\nthe field of public relations by handling problems of premium-payers with dispatch and\nbetter understanding. The number of persons to be employed in this particular work is\na matter for very careful study, and it is suggested that the force should be adequate but\nnot excessive.\nThe Board therefore recommends that the present force of district representatives\nbe enlarged to an extent necessary for them to take care of problems as outlined herein\nwithout undue delay; and, further, that the personnel of this field force be given proper\ntraining to fit them to act as \" top-notch \" public-relations officers.\nNo. 24.\u2014EXEMPTED AREAS\nSubsection 1 of section 11 of \" Hospital Insurance Act\" Regulations (revised to\nApril 10th, 1951) reads as follows:\u2014\nThe following persons shall be entitled to claim exemption pursuant to clause (\/) of subsection (1) of section 8 of the Act:\u2014\n(a) Residents of the Atlin Electoral District:\n(b) Persons residing north of the 55th parallel in the Omineca Electoral District,\nwith the exception of Manson Creek:\n(c) Persons residing north of the 55th parallel in the Fort George Electoral District:\n(d) Persons residing north of the 58th parallel in the Peace River Electoral District.\nThe areas set out in the above subsection are sparsely populated, and administration would be very difficult, and the likelihood of the people benefiting is not great.\nHowever, in accordance with the above regulations, unless they claim exemption they\nare offenders under the B.C.H.I. Act and Regulations.\nWe feel that residents of these remote northern areas should be extended the privilege of becoming registered under B.C.H.I.S. voluntarily instead of being subject to the\nregulations by which they must apply for exemption.\nThe Board therefore recommends that the necessary amendments be enacted to\nexempt all persons in the areas referred to, but that the privilege of voluntary registration and participation under the \" Hospital Insurance Act\" be extended to them.\nNo. 25.\u2014ANNUAL ACCOUNTS OF B.C.H.I.S.\nWe now refer to the matter of annual accounts of B.C.H.I.S. It has so far been\nfound necessary for the Service to keep two sets of accounts\u2014one for the calendar year\nbecause of the fact that the operations of the Service commenced on January 1st, 1949,\nand the added fact that the hospitals of the Province operate on a calendar-year basis,\nand another set for the fiscal year ended March 31st, in order to coincide with the\naccounting system of the Provincial Government.\nIt is obvious that, as a result of these two necessities, the accounts of the Service\npublished so far cannot be said to be truly and properly prepared on a revenue basis for\neither period. Reference to the First Annual Report of the Service for the year 1949\nshows that the accounts for that particular year were (subject to certain estimated\nfigures) prepared on a correct revenue basis, but when we turn to the Second Annual\nReport of the Service, January 1st to December 31st, 1950, we find that the procedure\nadopted for the calendar year 1949 has been abandoned, and the published financial\nstatement is simply a statement of cash receipts and disbursements of the fiscal year\nended March 31st, 1950. The Board has not yet obtained any published statement for\nany further period, and it may be presumed that the next statement to appear will be\nsimilar to the Second Annual Report and will carry only the receipts and payments to\nMarch 31st, 1951.\nIn the opinion of the Board, this form of statement gives entirely insufficient information to the Legislature or to the people of the Province.    Furthermore, when the FF 40 BRITISH COLUMBIA\nstatement is placed before the Legislature, the information which is contained therein is\nalready a year old, although the results of the operations of the Service for the year\nwhich is ended at a much later date are already on record at the headquarters of B.C.H.I.S.\nWhen visiting Regina to review the Saskatchewan Hospital Services Plan, the Board\nlearned that the complete accounts of the Plan for the previous calendar year were placed\nbefore the Legislature before the end of the following February and were printed and in\ncirculation prior to May 31st following.\nAnother point having a bearing on this matter was the complaint of several hospitals\nthat they were unable to obtain, until it was too late to be of any use, information concerning the operations of comparable hospitals which they felt might enable them to\ncorrect their own shortcomings and thereby benefit the Service in general.\nIn view of the impossibility of divorcing the operations of the Service from the\noperations of the hospitals of the Province, it would seem desirable that the Service should\ncontinue with the practice adopted in the first year of its operations, preparing accounts\non a proper revenue and expenditure basis for the calendar year, thus enabling the closest\ncheck of the accounts of the hospitals of the Province and also enabling a publication of\nthe detailed income and cost figures of the Service within a reasonable lapse of time after\nthe close of the period to which they refer.\nThe Board therefore recommends that it seems highly desirable to have the annual\naccounts of B.C.H.I.S. prepared on a revenue and expenditure basis for each full year of\nits operation, rather than on a cash receipts and payments basis running to March 31st\nonly, and that publication thereof should be made as early as possible in a manner clearly\nunderstandable to the general public.\nNo. 26.\u2014PREMIUM-YEAR\nA suggestion worthy of consideration regarding the commencement date of the\npremium-year was made to the Board. The matter of changing the fiscal year to coincide\nwith the calendar year and thus place the accounts of the Service on a more desirable\nbasis has already been dealt with in another recommendation.\nAfter careful consideration, the Board decided that the premium-year does not\nnecessarily have to be the same as the fiscal year of the Service, and it was pointed out to\nthe Board that many premium-payers would find it easier to meet their obligations at\nsome other times than the year-end and the month of June. The arguments advanced in\nsupport of this point of view include the suggestion that the month prior to January 1st\nis a spending season, when the resources of the average person are thereby seriously\ndepleted; that this period is also a period of seasonable unemployment; and, further, that\nas a general rule tax payments become due in the months of May and June, and that they,\nalso, cause a considerable strain on the financial resources of the average person.\nIt was also pointed out that if the premium-year started on April 1st and ended\nMarch 31st, the extra work involved in the receipt of premiums in great numbers at one\ntime would not impose as great a problem on B.C.H.I.S. as if this work was imposed on\nthe Service at the end of the calendar year, along with all the other extra work related to\nthe year-end activities.\nThe Board therefore recommends that, as soon as can effectively be done, the\npremium-year be from April 1st to March 31st.\nNo. 27.\u2014\"CHRONIC\" DIAGNOSIS:   PROVISIONS FOR REVIEW\nA very important matter, which has caused a tremendous amount of distress and\ndispute to an increasing degree during the last eighteen months, is the system in force\n(and the manner in which rulings are made by the B.C.H.I.S. Administration) regarding\nillnesses classed as \" chronic,\" which has the effect of curtailing the liability of the --.\/.::-:\u25a0     ,: %\nREPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 41\nService for the hospital account. The viewpoint of many hospitals on this matter was\nforcibly expressed, and the Board also obtained the opinions of various other organizations of repute. In addition, the Board was faced with much evidence of cases of\ndistressing hardship from the individual point of view. It may safely be said that no\nother phase of the Board inquiry has produced, to such an extent, evidence of existing\ncircumstances meriting the most careful and considerate attention of all interested\nauthorities from a humanitarian point of view.\nWe first quote the opinion of the spokesman for the medical profession\u2014the\nCollege of Physicians and Surgeons:\u2014\nIt is recognized by the doctors that B.C.H.I.S. was not set up to provide chronic hospital care\nand that controls in this respect are a \" necessary evil.\" We object strongly, on behalf of our\npatients, to the method for control that has been set up in Victoria to handle this problem.\nCertain categories of patients, in particular, may be placed in distressing circumstances when\npresent methods are followed. These categories include patients with advanced cancer, patients\nwith severe acute forms of non-pulmonary tuberculosis, mental patients above the age of seventy,\nand patients with certain conditions of long duration that may require very special hospital care,\nnotably poliomyelitis and paraplegia. \/\/ rs intolerable to us that an arbitrary ruling can be made\nby a single medical civil servant in Victoria indicating that certain individuals in any of the\nabove-mentoned groups, whom he has not seen and whose doctors assert are still requiring acute\nmedical and hospital care, are now eligible for two more weeks or four more weeks or no more\ncare at all under B.C.H.I.S. It has been apparent to us that the doctor on the staff of B.C.H.I.S.\nin Victoria is in no position to determine the eligibility of individual patients for insurance\ncoverage in these difficult and controversial problem cases.\nDecision in these matters should be made at a local level by a competent medical man or\ncommittee of medical men and should be based on the findings in each case. It will be impossible\nto find doctors to act in these capacities until more adequate services are made available for the\ncare of convalescent and chronic disease outside of the acute general hospital. No doctor in\npractice will condone or be party to the discharge of a patient from an acute general hospital\nif that discharge means gross deterioration of the standard of medical care. That, in fact, is what\nwe are being asked to do now by B.C.H.I.S. on not infrequent occasions.\nApart from consideration of patients who are sidetracked away from acute hospital, we feel\nthat the number of patients whose coverage is terminated before their doctor considers that they\nare fit for discharge, though it is a small number, is significant. It is just these cases of catastrophic hospital expense that led the majority of citizens to accept hospital insurance as a good\nmeasure. We have been told, in respect to these cases, that the Hospital Insurance Service does\nnot state that a patient should be turned out of hospital. That is true, but when a citizen of limited\nmeans is told that if he or his dependent remains in hospital he must pay eight or ten or thirteen\ndollars a day, the practical result is the same. Furthermore, there will be immediate and very\nstrong pressure from the hospital to move that patient out because the hospital does not want\nto be stuck with the bill if that citizen defaults.\nThe point of view of many hospitals is reflected in the quotations given below\nfrom their respective written submissions to the Board:\u2014\nPowell River General Hospital.\u2014The Board of Management are not in agreement with the\npresent method of a staff in Victoria determining the need for hospitalization. This method\nincurs an unnecessary amount of paper work and nuisance to a co-operative medical staff. The\nBoard of Management wishes to recommend that the decision as to whether or not a patient is\nin need of acute care in a general hospital be left to the discretion of the local hospital authority.\nPenticton Hospital.\u2014We feel that the determination of chronic from acute cases can be made\nonly at the attendant medical level. A committee of doctors from the medical staff in all hospitals should be appointed and authorized to rule on all cases in hospital over fourteen days. At\nthat time, the patient can be advised of his limited stay in hospital under hospital insurance, and\nthe many just criticisms of diagnostic practice by remote control eliminated. We are well pleased\nwith the general principles of the plan, but feel that some remedy must be found in order that\nthe humanitarian basis on which it was founded is not lost in the monetary approach.\nAnd from other organizations we select the following written submissions on this point:\u2014\nVancouver Board of Trade.\u2014Efforts now being made by B.C.H.I.S. to expedite classification\nof chronic and acute illnesses should be pursued in order to eliminate the delays which have been\nannoying, costly, and onerous to patients and hospitals alike. In large urban centres, such as\nVancouver, the appointment of a small panel of doctors or an Admission and Discharge Officer\nby the respective hospitals to rule on such cases after interview of patient, doctor, and hospital FF 42 BRITISH COLUMBIA\nofficials would, it is believed, serve a necessary and useful function. The decisions and recommendations of Admittance and Discharge Officers would, in turn, be reviewed by a department\nofficial. Rulings of a single official at Victoria, based on incomplete information, would thus be\navoided. Some hospitals have set up voluntary panels which are proving effective in the expeditious handling of admittances and discharges.\nThe Vancouver Board of Trade therefore recommends that it be made obligatory on each\nhospital to appoint an Admission and Discharge panel or officer to deal with classification of\nchronic and acute illnesses.\nImperial Veterans' Action Committee in Canada.\u2014We understand that as at present the\nB.C.H.I.S. reserve to themselves the right to decide when a case is chronic and when not chronic.\nFurthermore, we understand that the Service may decide that a case is chronic after a person is\nout of hospital, or after even receiving treatment on several different occasions, and then decide\nto bill the patient. We object to to laymen deciding when a case is chronic, which we contend\nshould be a matter purely for a doctor to decide. We also feel that a clear definition should be\ngiven as to the stage at which a case is declared chronic.\nMr. G. H. Jackson, Secretary-Treasurer, Canadian Pacific Railway Employees' Medical\nAssociation of British Columbia.\u2014Next comes the question of what might be termed \" long-stay\ncases.\" Under the Regulations of B.C.H.I.S., patients are entitled to in-patient hospital care for\n\" acute \" conditions only and coverage is terminated when active hospital treatment is no longer\nnecessary. This sounds perfect in theory; but in its application it is quite a different matter.\nThere is only one person competent to decide when a patient's condition is or ceases to be acute\nand that is the attending doctor. It is absurd to assume that a medical referee sitting in an office\nin Victoria can decide when an acute condition does not exist. The practice is unethical and is\nunfair to the patient, the hospitals and the medical profession. To promise \" unlimited \" coverage\nand then cut it off arbitrarily, or as has been done in some cases, say that coverage will not be\ncontinued beyond a pre-determined date, set by the medical referee, who has not seen the patient,\nis frankly dishonest.\nWith regard to a particular class of patient, the following from a brief of the\nBritish Columbia Polio Fund is very noteworthy:\u2014\nToday, polio treatment is a concern in at least 45 communities throughout the province and\nthe recent action of the B.C. Hospital Insurance Scheme has given grave concern to all these\npeople. In a recent ruling of the authorities of the B.C. Hospital Insurance, polio patients have\nbeen placed on a two-weeks basis for their hospitalization. For those who know the facts, this is\na shocking situation and one that shows that those who made such a decision have a complete\nlack of knowledge of the medical facts concerning polio and, in addition, no conception of the\neconomic implications of such a decision as it affects everyone concerned, except the immediate\nsaving of money for the insurance scheme. It shows no regard whatever for the long-range\nthinking that is necessary when one is dealing with a disease such as polio and seems to demonstrate that these people (B.C. Hospital Insurance) are taking any means whatever (as in this\ncase the placing of these victims in a position to possibly face a life of invalidism) to cover up\nthe more serious and basic errors of judgment and planning.\nIn appealing for these victims now, we feel that we may be speaking for other diseases later\nbecause, if no change is made, other diseases that require any length of hospitalization whatever\nwill no doubt be treated in like manner. Polio is a disease that strikes suddenly and, in many\ncases, with dramatic consequences and frequently tragic results for the victim. To put it very\nbluntly, without the long, painful, tiresome rehabilitation process now available, a good many\nvictims of polio would have been better off to die at the very outset of the disease. It is quite\ntrue that the infectious stage of the disease is quite short, usually about two weeks, and if that\nis what is considered the end of hospitalization by the authorities of the B.C.H.I.S., then they are\nlabouring under very grave and serious misconceptions. By definition, and this is a definition set\nout by the B.C. Hospital Insurance Scheme in recent newspaper advertising, a disease is said to\nhave reached the chronic stage when the patient has reached the position where they can be\nadequately cared for in some other place than the hospital, thus ending the need for hospital care\nautomatically, according to the B.C.H.I.S.'s way of thinking.\nThe victims of polio have at the end of two weeks just passed the infectious period and to\napply the definition of the B.C. Hospital Insurance at this stage of treatment is, to say the least,\nalmost ridiculous. Polio patients with any residual paralysis whatever can and do receive benefits\nfrom hospitalization for as long as two years and the help they receive can be given at no other\nplace or in no other way than in the hospital. To be specific, for example, Miss Violet Tennant\nhas been in the Vancouver General Hospital from January 1947 to the present time. She shows\ncontinuous improvement but could not possibly be cared for outside the hospital. Under present\nhospital insurance rulings, if this should happen to you, it would cost you approximately $22,400.\nIt should be pointed out that at least 90% of the citizens in B.C. could be considered indigenous REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 43\nas regards polio. The bare necessities of hospital treatment amount to $405.00 per month. If\nthese people cannot be protected under B.C.H.I.S., then there is no insurance. So to say that\na polio case has reached pernicity at the end of two weeks is not supported by any facts whatever.\nIn view of the foregoing facts, we ask this commission to intervene on behalf of the polio\nvictims of this province. We are asking that the recent arbitrary ruling of two weeks' hospitalization be changed to a no limit period subject only to recommendations as to time limit of the\nhospitalization period by a proper and competent medical authority.\nWe wish to emphasize the fact that the above represent only a portion of the written\nsubmissions made by organizations in connection with this subject, and that these and\nthe other written submissions to the Board were reiterated and confirmed in a most\nforcible manner from many sources by verbal testimony given to the Board.\nThe Board has reason to believe that there has been recently a gradual development\nof a procedure by which there is more co-operation between local medical authorities\nand the B.C.H.I.S. Administration\u2014and that there is a definite trend to improvement of\nthe situation that had arisen.\nHowever, the Board does not think that all causes for dissatisfaction have been\nremoved, and believes that a carefully studied and definite plan must be laid down for\nearly adoption to govern future action and procedure.\nThe Board therefore recommends that:\u2014\n(1) Where it is decided that a patient in an acute or general hospital is ruled\nto be, or to have become, a chronic case, and not the responsibility of\nB.C.H.I.S., advance notice of the discontinuance of benefits shall be\ngiyen in every case; and the effect of such ruling shall in no case be\nretroactive:\n(2) Before such ruling is made, any and all cases should be referred, wherever\npossible, to the medical staff of the hospital, whose opinion shall be\nfully considered by the medical consultant or administration of B.C.H.I.S.:\n(3) In all cases of difference or dispute arising at any point as to the correctness of the diagnostic decision, the final decision should be left to a\nMedical Review Board, consisting of two representatives of B.C.H.I.S.\nand three doctors appointed by the College of Physicians and Surgeons:\n(4) Provision be made for the appointment of the said Medical Review\nBoard as soon as possible.\nNo. 28.\u2014PROVISION FOR PERMISSIVE USE OF SPECIAL DRUGS\nDuring the course of its inquiries, the Board heard of many cases of severe and\neven tragic hardship arising out of the regulations by which the use of certain costly\ndrugs is not included as a benefit under B.C.H.I.S.\nThe Vancouver General Hospital has this to say in their written submission to\nthe Board in general connection with this subject:\u2014\nAnother problem involves an apparent lack of co-ordination between the B.C. Hospital\nInsurance Service and competent medical authorities. Rulings, regarding which drugs and\npharmaceuticals may be included as operating expenses, sometimes appear to be based on a\ndollar value rather than on medical necessity. Rulings, as to which type of case is not covered\nby the B.C. Hospital Insurance Service, do not always appear to have sound medical reasons as\ntheir basis.\nOne example is the present ruling on the use of ACTH and Cortisone. When these drugs\nfirst appeared on the market, it was reasonable to assume that definite restrictions regarding their\nuse were required. However, there has now been sufficient research and experience connected\nwith these drugs to permit their use under certain definite conditions, but there is no prescribed\nmethod in which application for use of these drugs may be made.\nTo establish arbitrary rules that certain treatments or conditions will be excluded is not\nalways reasonable or fair to the patient. Decisions should be made locally by competent medical\nmen, based on the findings of individual cases. In many hospitals there are competent medical\nboards which would certainly be qualified to advise on these matters and supervise the limited use\nof certain specific drugs and treatments. FF 44 BRITISH COLUMBIA\nRecommendation: That an active means of co-operation between the B.C. Hospital Insurance\nService and competent medical authorities be instituted for the purpose of deciding which drugs\nand treatments may be included in the hospitals' operations.\nMore than one case has been drawn to the attention of the Board where a patient\nhas been in distressing need of the said drugs, even to the point where the only chance\nof saving the patient's life is afforded by the use of the drugs. In addition to this\ncomes evidence that the patient and his responsible relatives have exhausted their entire\nmeans in honest and praiseworthy efforts to ensure the utmost in medical treatment,\nsometimes over prolonged periods\u2014and they now have absolutely no material resources\nor credit left by which they can, themselves, secure the vitally needed treatment or drugs.\nThe Board feels it futile to try to set down in writing the many humanitarian factors\nthat enter into the consideration of cases of this nature.\nThe Board has, however, elsewhere suggested the setting-up of a Medical Board of\nReview to work with, or for, the B.C.H.I.S., and in the hope and expectation that this\nrecommendation will be duly implemented\u2014\nThe Board therefore recommends that the Medical Board of Review, if established,\nshall have the authority to allow the use of special drugs for hospital patients, when\nvitally necessary, on the recommendation of the local medical authority.\nNo. 29.\u2014PREMIUM-PAYMENT ENFORCEMENT:   PROSECUTIONS\nAND GARNISHEE PROCEEDINGS\nThe Board notes that sub-section (2) of section 11 of the \" Hospital Insurance Act \"\nprovides that any person who, on summary conviction, is found to be guilty of an offence\nagainst the Act by reason of non-payment of premiums, in addition to being fined \" shall\nbe ordered by the Magistrate or Justice to pay the amount of the premium that is owing,\nincluding any arrears, etc., etc.\"\nIt has been drawn to the attention of the Board that, in a substantial number of\nprosecutions initiated by B.C.H.I.S. against non-premium-payers, the judgment of the\nCourt has imposed a fine plus Court costs but has not included an order for payment of\narrears in accordance with the section of the Act quoted above.\nThere is also another matter having to do with the enforcement of payment of\npremiums. Section 11b of the Act provides that the Commissioner, or any person\nauthorized by him, may require the employer to pay the premium owing by the\nemployee\u2014and pay the same to the Commissioner on account of the premium owing by\nthe employee. It would appear that this procedure of simple garnishee has not been used\nto the fullest extent, and it would also seem that the procedure of automatic garnishee\nmight be extended to be effective against any sums owing to a delinquent person, whether\nby an employer or any other person.\nThe Board therefore recommends:\u2014\n(a) That the competent authority shall call to the attention of the Magistrates\nand Justices of the Province the provisions of subsection (2) of section\n11 of the Act as referred to above, and shall require their future compliance therewith:\n(b) That the Administration of B.C.H.I.S. shall take full advantage of the\nprovisions of section 11b of the Act when such action is justified by\ncircumstances:\n(c) That the application of section 11b shall be widened so as to permit the\nprocedure of automatic garnishee by the Administration of B.C.H.I.S of\nany sums owing to a delinquent registrant (or person required to be a\nregistrant under the \" Hospital Insurance Act \"), provided that such extension is ruled by competent authority to be possible. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 45\nSECTION 4.\u2014B.C.H.I.S. ADMINISTRATION\n30. Plan of Registration and Premium Collection.\n31. Proof of Standing under the Act.    (To be required from applicants for any Provincial (annual) licence.)\n32. Limit of Liability for Premium Arrears.\n33. Collection of Arrears of Premiums.\n34. Exemption Cards:   Issue to Certain Persons and Charge Therefor.\n35. Changes of Status.\n36. Elimination of Certain \" Group \" Records.\n37. Pamphlet Covering Plan and Benefits.\nNo. 30.\u2014PLAN OF REGISTRATION AND PREMIUM COLLECTION\nOne of the major matters commanding the attention of the Board has been the overall method of collecting premiums and issuing proper identification certificates. Our\nBusiness Management Consultants, Messrs. Stevenson and Kellogg Limited, have devoted\na great deal of attention to this particular phase of the operation of B.C.H.I.S. The Board\ngave due consideration to the relationship between suggested methods and the personnel\nand general expense required to operate on the basis of the various suggestions.\nWe think it would be useful at this point to interject the remarks made in the\nwritten submission of Mr. G. H. Jackson, secretary-treasurer of the Canadian Pacific\nEmployees' Medical Association of British Columbia, as follows:\u2014\nIt would seem to be evident that the present arrangement of a combination of payroll\ndeductions and direct payment cyclic billing is not the solution. Insofar as the Hospitals are\nconcerned it is far from satisfactory. Hospitals should be assured that everyone who is registered\nwith B.C.H.I.S. has coverage. All contributors should be eligible for benefits as soon as they\nhave registered. From an employer's standpoint payroll deductions are not entirely satisfactory,\nparticularly where transients are involved. If some improved system of collection could be put\ninto effect on January 1st, 1952, it would be the best indication that the Government intends to\nplace B.C.H.I.S. on a business-like basis.\nAfter many discussions with Messrs. Stevenson and Kellogg Limited, they submitted\nto the Board the following plan as being their suggestion for obtaining the maximum\nefficiency at the minimum cost:\u2014\n(Note.\u2014The plan immediately following is referred to in the recommendation at\nthe end of this section as \" Plan No. 1.\")\n(a) That an annual premium is to apply for each calendar year, with the\nprovision that half-yearly partial payments may be accepted.\n(b) Individuals will be responsible for payment of their premiums before the\npremium due date. No bills are to be sent by B.C.H.I.S. but a Notice\nof Premium Due will be sent to all registrants at their last-known address.\n(c) Provisions for payment of premiums will include:\u2014\n(i) Allowance for payment of at least one-half the total annual\npremium semi-annually prior to January 1st and\/or July 1st.\n(ii) Premium-year (calendar year January 1st to December 31st)\nis to be distinguished from benefit period, which will be: First half,\nJanuary 1st to June 30th; second half, July 1st to December 31st.\n(iii) Both premium and arrear payments are to be accepted through\nauthorized collection agents.\n(iv) Premium payments for less than the full amount of the annual\npremium must be made before January 1st or July 1st and must be for a\nfull six months' period. No partial payments are to be permitted except\nas in subsection (\/). FF 46 BRITISH COLUMBIA\n(d) Individuals will be eligible for hospitalization benefits if payment for the\ncurrent half-yearly benefit period has been made. Seven days' grace will\nbe allowed to late premium-payers, providing they were in benefit during\nthe previous benefit period. A fourteen-day waiting period is to apply to\nnew registrants, those who were not in benefit during the previous benefit\nperiod, or those previously in benefit who have not paid the premium for\nthe current benefit period before the expiry of the period of seven days\nof grace allowed after the date of premium payment.\n(e) Arrears will apply as follows:\u2014\n(i) If premium has been paid for the first half-year's benefit period\n(January 1st to June 30th), arrears, if any, will be for the immediately\npreceding calendar year (January 1st to December 31st), unless the\nregistrant is actually liable for less than that amount according to the Act\nand basic records.\n(ii) If premium has been paid for the second half-year's benefit\nperiod (July 1st to December 31st), arrears, if any, will be the total of\nthe premium payable for the eighteen months immediately preceding July\n1st (January 1st of the preceding year to June 30th of the current year),\nunless the registrant is actually liable for less than that amount according\nto the Act and basic records.\n(iii) If a person has paid premiums for the current benefit period,\nhe will be eligible after the fourteen days' waiting period for hospitalization benefits despite owing arrears. The collection of arrears will be the\nresponsibility of a separate section of B.C.H.I.S., whose responsibility\nwill be to collect and arrange for the collection of arrears, using the various\ndevices and powers allowed by law.\n(\/) Premium payments may be made direct to B.C.H.I.S. offices in Victoria\nor to any authorized collection agent.\n(g) Certified interim receipts will be issued by all authorized collection agents\nfor all premium payments made to them..\nOfficial eligibility certificates will be issued by B.C.H.I.S. for all\npayments made direct to their offices and against all certified interim\nreceipts received from the authorized collection agents.\n(h) The employers will be responsible for seeing that all new employees are\nin benefit. If the new employee is not in benefit the employer will arrange\nto have him placed in benefit at the time of employment. The employer\nwill also be responsible for checking all his employees at stated intervals\nto ensure that they are all in benefit. Arrangements must be made to\nimmediately place in benefit any employees who may be found to be out\nof benefit.\n(0 Identity cards will be issued to all dependents upon request only. However, the B.C.H.I.S. may arrange for authorized agents or secretaries of\nany exempted groups to issue identity cards to all exempted persons in\ntheir groups, sending duplicates to B.C.H.I.S. for their records.\n(\/') There shall be no interference, implied or actual, with the right of\nemployers and employees to jointly arrange for monthly or other periodical deduction by the employer of such sums as will amount in due\ncourse to the total premium payable by the employee at the commencement of every six months' period. The employer shall under these circumstances either:\u2014\n(i) Remit the total amount of the periodical deductions to B.C.H.I.S.\nin trust for the employee; or REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 47\n(ii) Deposit the sums in a special account in trust for the employees\nand cause the total thereof to be transmitted to B.C.H.I.S. prior to the\ncommencement of the next six months' premium period.\nIrrespective of the manner in which the employer chooses to handle\nthe deductions in agreement with his employees, it shall not be necessary\nfor him to report to B.C.H.I.S. in detail the separate amounts deducted\nfrom each employee until the due date of the next six months' premium\nperiod.\nContinuance of the practice already in force between any employer\nand his employee on a purely voluntary basis is encouraged in every way.\n(k) In the case of persons entering the Province for temporary employment\nonly and without intending to take up residence therein within the meaning of the \" Hospital Insurance Act,\" it shall be permissible for an\nemployer to engage such person or persons and the requirements as to\ndeduction of an amount to cover the current hospital insurance premium\nshall be waived in the first instance\u2014but nevertheless no such person\nshall continue to be employed for a longer period than two complete\nmonths without becoming thereafter immediately liable to the premium\npayment or deduction by the employer\u2014and no employer shall waive\nsuch requirements in the first instance if he has knowledge that the said\nperson has previously been employed in British Columbia (within the\ncurrent six months) for a period of two months or longer.   And, further,\nthe employee shall sign a declaration that he has not previously been\nemployed in the Province for an aggregate of two months within the\ncurrent benefit period and setting out the periods of employment since\nhe entered the Province.\nIt will be seen that the consequence of the adoption of this plan would be that\nemployers of labour within the Province could not give employment to any person not\nproperly registered and in good standing under the \" Hospital Insurance Act,\" and that\nthis consequence would need to be enforced by the necessary enactments to make it legal\nand therefore effective.   It may, however, be thought that such action is of too dictatorial\na nature and not likely to be well received by the majority of the employed or the\nemployers of the Province.\nRecognizing that the success of any law is dependent upon the measure of public\nacceptance of its requirements, the Board believes that the desired results might be\nattained by a somewhat different approach, though it is possible that this second approach\nwould not be so fully effective and would also to some extent reduce the saving of cost to\nB.C.H.I.S. that is anticipated by this Plan No. I. The Board, therefore, sets out an\nalternative plan, as follows:\u2014\n(Note.\u2014The plan immediately following is referred to in the recommendation at\nthe end of this section as \"Plan No. 2.\")\n(a) That an annual premium is to apply for each calendar year, with the\nprovision that half-yearly partial payments may be accepted.\n(b) Individuls will be responsible for payment of their premiums before the\npremium due date. No bills are to be sent by B.C.H.I.S. but a Notice of\nPremium Due will be sent to all registrants at their last-known address.\n(c) Provisions for payment of premiums will include:\u2014\n(i) Allowance for payment of at least one-half the total annual\npremium semi-annually prior to January 1st and\/or July 1st.\n(ii) Premium-year (calendar year January 1st to December 31st) is\nto be distinguished from benefit periods, which will be: First half, January\n1st to June 30th; second half, July 1st to December 31st. FF 48 BRITISH COLUMBIA\n(iii) Both premium and arrear payments are to be accepted through\nauthorized collection agents.\n(iv) Premium payments for less than the full amount of the annual\npremium must be made before January 1st or July 1st and must be for a\nfull six months' period. No partial payments are to be permitted except\nas in subsection (\/').\n(d) Individuals will be eligible for hospitalization benefits if payment for the\ncurrent half-yearly benefit period has been made. Seven days' grace will\nbe allowed to late premium-payers, providing they were in benefit during\nthe previous benefit period. A fourteen-day waiting period is to apply to\nnew registrants, those who were not in benefit during the previous benefit\nperiod, or those previously in benefit who have not paid the premium for\nthe current benefit period before the expiry of the period of seven days of\ngrace allowed after the due date of premium payment.\n(e) Arrears will apply as follows:\u2014\n(i) If premium has been paid for the first half-year's benefit period\n(January 1st to June 30th), arrears, if any, will be for the immediately\npreceding calendar year (January 1st to December 31st), unless the registrant is actually liable for less than that amount according to the Act and\nbasic records.\n(ii) If premium has been paid for the second half-year's benefit\nperiod (July 1st to December 31st), arrears, if any, will be the total of the\npremium payable for the eighteen months immediately preceding July 1st\n(January 1st of the preceding year to June 30th of the current year),\nunless the registrant is actually liable for less than that amount according\nto the Act and basic records.\n(iii) If a person has paid premiums for the current benefit period, he\nwill be eligible after the fourteen days' waiting period for hospitalization\nbenefits despite owing arrears. The collection of arrears will be the responsibility of a separate section of B.C.H.I.S., whose responsibility will\nbe to collect and arrange for the collection of arrears, using the various\ndevices and powers allowed by law.\n(\/) Premium payments may be made direct to B.C.H.I.S. offices in Victoria\nor to any authorized collection agent.\n(g)  Certified interim receipts will be issued by all authorized collection agents\nfor all premium payments made to them.\nOfficial eligibility certificates will be issued by B.C.H.I.S. for all\npayments made direct to their offices and against all certified interim\nreceipts received from the authorized collection agents.\n(h) Employers shall be required to ascertain that all new employees are duly\nregistered and in benefit by requiring the production by them of their\neligibility certificate before the first pay-day after the commencement of\nemployment, and further required to check all employees at half-yearly\nintervals to ensure that they are all in benefit.\nIn the event of failure on the part of a new or old employee to produce the necessary evidence of good standing to the employer, it shall be\nthe duty of the said employer to forthwith report to B.C.H.I.S. in Victoria\nthe names and last-known addresses of all such employees, together with\ntheir registration numbers, if any.\nThe employer shall also be required to keep a proper record of all\nhis employees, with their B.C.H.I.S. registration numbers, which records\nshall be open to examination by properly authorized officials at all times. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 49\n(i) Identity cards will be issued to all dependents upon request only. However, the B.C.H.I.S. may arrange for authorized agents or secretaries of\nany exempted groups to issue identity cards to all exempted persons in\ntheir groups, sending duplicates to B.C.H.I.S. for their records.\n(\/) There shall be no interference, implied or actual, with the right of employers and employees to jointly arrange for monthly or other periodical\ndeduction by the employer of such sums as will amount in due course to\nthe total premium payable by the employee at the commencement of\nevery six months' period. The employer shall under these circumstances\neither:\u2014\n(i) Remit the total amount of the periodical deductions to B.C.H.I.S.\nin trust for the employees; or\n(ii) Deposit the same in a special account in trust for the employees\nand cause the total thereof to be transmitted to B.C.H.I.S. prior to the\ncommencement of the next six months' premium period.\nIrrespective of the manner in which the employer chooses to handle\nthe deductions in agreement with his employees, it shall not be necessary\nfor him to report to B.C.H.I.S. in detail the separate amounts deducted\nfrom each employee until the due date of the next six months' premium\nperiod.\nContinuance of the practice already in force as between any employer\nand his employee on a purely voluntary basis is encouraged in every way.\n(k) In the case of persons entering the Province for temporary employment\nonly and without intending to take up residence in the Province within\nthe meaning of the \"Hospital Insurance Act,\" the employer will be\nrequired to ascertain the length of the said person's stay in the Province\nup to the time of commencement of (new) employment; but the employer\nwill not be required to report the name and address of such employee to\nB.C.H.I.S. until he has knowledge that such employee has resided or been\nemployed in the Province for a period of two complete months or over, in\nwhich case due notification shall be given by the employer to B.C.H.I.S.\nas required in section (h).\n(I)  On receipt by B.C.H.I.S. of any and all such advices of non-registration\nor lapse of good standing the Administration shall forthwith take all\nnecessary steps to secure the proper registration and payment of premiums\nby the non-registrants or delinquents.\nThe Board therefore recommends that Plan No. 2 of registration of beneficiaries and\npremium collection as outlined above be adopted in its entirety at the earliest possible\ndate, and that the necessary enactments be made to define the duties of the persons therein\nreferred to and the proper penalties for failure to comply with the provisions thereof, and\nthat the said plan be given a fair trial over a predetermined period, at the end of which\nperiod the position shall be reviewed, and if the response of the persons required by the\nAct to become registered and to pay premiums is not such as to have achieved the desired\nand intended results, then consideration shall be given to the necessity of introducing a\nplan such as the other plan referred to in this section.\nNo. 31.\u2014PROOF OF STANDING UNDER THE ACT\n(To be required from applicants for any Provincial (annual) licence.)\nReverting to the basic matters of policy considered by the Board in the early stages\nof its investigation, it should be pointed out that having decided that B.C.H.I.S. must be\ncontinued in some form, it naturally follows that in order to be successful the plan FF 50 BRITISH COLUMBIA\nshould register as nearly as possible 100 per cent of those who should pay premiums\nwithin the meaning of the Act. Past experience of the Hospital Service indicates that\nthe methods used to register those who should be in the plan have failed to be 100 per\ncent effective and, at the same time, the same methods have proven very costly in that\na large staff was required to operate the plan followed.\nThe following observations are quoted from the brief of the Vancouver Board of\nTrade:\u2014\nTo ensure the successful operation of B.C.H.I.S. it is necessary that as many eligible residents\nof the Province as possible are registered under the scheme. To date reports indicate that in spite\nof legislation requiring compulsory registration there are an unduly large number of people who\nhave not complied with the law. Not only lack of enforcement of the Act has contributed to the\nfinancial problems of B.C.H.I.S., but hospitalization of delinquents who have not paid their own\nhospital bills have jeopardized the financial standing of a number of hospitals.\nThe Vancouver Board of Trade, therefore, declares that since it has been deemed necessary\nand desirable to have a government sponsored universal hospital insurance plan, it, therefore,\nfollows there should be compulsory registration of all eligible B.C. residents and recommends\nthat the government enforce the law requiring compulsory registration.\nAnd from the brief of the Vancouver General Hospital:\u2014\nThere are two main factors causing the increase in amount to be collected, one is co-insurance, and the other non-insured patients. While some of the non-insured patients are transients\nwho cannot be expected to have insurance coverage, a good portion of the increase is due to\nresidents whose insurance is not in good standing at the time of their admission to hospital. If the\ncompulsory features of the Hospital Insurance Act, regarding registration and payment of\npremiums, were enforced, there is no doubt there would be a reduction in the amount we are\nrequired to collect from patients.\nRecommendation: That the compulsory factors of the Hospital Insurance Act, regarding\nregistration and payment of premiums, be enforced in order to reduce the amount hospitals are\nrequired to collect from patients.\nHaving in mind that full registration is essential and that the scheme is compulsory,\nit is pointed out that evaders are law-breakers. Furthermore, when a substantial percentage of those who should pay premiums are evading their responsibility, they throw\nan extra load on the law-abiding citizens who are registered and paying premiums.\nBy the terms of the recommendation immediately preceding this one and entitled\n\" Plan of Registration and Premium Collection,\" the Board believes that it has set forth\nprocedures that may adequately cover the case of employed persons and render evasion\nof the plan for such persons virtually impossible. It would be unfair to this very large\npercentage of the population who are on the payrolls of the Province to take no steps to\nproperly ensure the participation of self-employed or other people who are necessarily\nnot covered by any payroll plan. There have, in the past, been evaders of the scheme\nin both classes. Having now dealt with the employed people, the Board considers that\nit must seek to ensure the same measure of co-operation and participation by the other\nsection of the public.   Such a step is only fair to the larger body of the population.\nMany suggestions have been advanced to the Board in this regard, but most of\nthese have been found to be impractical and unworkable. Two alternative schemes\nhave, however, been considered by the Board. The matter of public acceptance must\nbe taken into account, as in the immediately preceding recommendation of the Board.\nWe therefore present two alternative recommendations, believing that if the suggestion\nmade in the first alternative is considered to be inadequate or is first tried without satisfactory results, the second alternative must eventually be resorted to.\nThe Board therefore recommends:\u2014\n(a) That the necessary legislation be enacted to require that any issuer of an\nannual licence on behalf of the Province of British Columbia shall, at the\ntime of issuance thereof, ascertain the registration number or exemption\ncertificate number of the licensee in all cases where such licensee is\nrequired to be covered by the \" Hospital Insurance Act,\" and that if the\nsaid licence-issuer is unable to obtain the necessary evidence of standing REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 51\nunder the said Act, he shall thereupon forthwith report the name and\naddress of the licensee concerned to the B.C.H.I.S., whose duty it shall\nbe to ascertain that all such licensees are properly registered under the\nAct.\nIt is also recommended that the Administration of B.C.H.I.S. shall\nseek the co-operation of issuers of municipal licences within the Province, with a view to having the same procedure followed by such officers.\nOr, alternatively\u2014\n(b) That any person who is subject to registration under the \" Hospital\nInsurance Act,\" when applying for the issuance of any annual Provincial\nlicence within the Province of British Columbia, shall produce his official\neligibility certificate, certified interim receipt (current period), or exemption certificate proving his good standing under the \" Hospital Insurance\nAct\" and regulations, and in default of the production of such evidence\nof good standing shall not be entitled to the issue to him of any such\nlicence.\nNo. 32.\u2014LIMIT OF LIABILITY FOR PREMIUM ARREARS\nOn the first day on which the Board commenced their investigations and studies,\nthey were confronted with the problem of endeavouring to ascertain what percentage of\nthe population of the Province required by law to be registered and covered by the\n\" Hospital Insurance Act\" was so registered and covered. Estimates of the said percentage were placed before the Board in every public and private hearing held. In\naddition, similar estimates appeared regularly in the public press, as news reports and\neditorial comments, and in the form of \" Letters to the Editor.\" The minutes of the\nproceedings of the Board reveal opinions that the percentage of the population not\ncovered under the Act ranges from 20 to 40 per cent; and it was not unusual in certain\nareas to have a figure of 50 per cent or even 60 per cent mentioned. These estimates,\nof course, conflicted with the figures put forward by the B.C.H.I.S. Administration,\nwhich purported to show that over 90 per cent of the population was properly covered.\nIt will be obvious that the Board was in no position to arrive at an exact figure, or even\nto give definite support to any particular estimated figure. It may, however, be said\nthat the Board became convinced, and remains convinced, that at least 20 per cent of\nthe population referred to is either non-registered under the \" Hospital Insurance Act\"\nor has become and remains delinquent in the payment of the premiums called for by\nthe Act and regulations.\nIt need hardly be pointed out that this moderate calculation of the percentage of\nthe population non-registered or delinquent reflects a very heavy loss of revenue to which\nthe Service is entitled by law. In addition to this, there is undoubtedly a very serious\ndemoralizing effect upon the registered and paying public, arising from their knowledge\n(or supposed knowledge) of the delinquency of a great number of their fellow-citizens.\nThe opinion that persons complying with the law were \" suckers \" was very commonly\nheld, often expressed to the Board, and appeared to be growing day by day. It was\nnot unusual to have citizens report that they were positively aware that many of their\nneighbours had never registered under the \" Hospital Insurance Act.\" Very reliable\nevidence was given that in numerous cases men who applied for, or were offered,\nemployment by firms which had adopted the payroll-deduction system of B.C.H.I.S.\neither declined the employment offered or left the said employment as soon as they\ndiscovered that this would lead to their registration for the purposes of hospital insurance,\nand such persons frankly stated that they could go elsewhere without the slightest\ndifficulty and obtain satisfactory employment which would leave them still unfettered\nand free as far as hospital insurance requirements were concerned. FF 52 BRITISH COLUMBIA\nIn connection with both non-registrants and delinquents, it later became evident\nthat the proportion of accounts incurred by these persons, or their dependents, in the\nhospitals of the Province was increasing, and that the refusal of the B.C.H.I.S. to accept\nliability for the said accounts was placing an undue burden upon the hospitals, about\nwhich they were most seriously concerned. There was the added factor that the\nexact standing of many of these people was not readily ascertainable, and in some cases\nthe patient had left the hospital days or weeks before the hospital administration had\nascertained their current standing\u2014and the hospital administration was therefore\ndeprived of the proper opportunity to collect (or endeavour to collect) the hospital\naccount from the individual.\nFurthermore, apart from the unknown quantity of persons who had never been\nregistered under the Act and still could not be identified, was the problem of the\namounts owing individually and in the aggregate, by those persons who had been registered at late dates, whose exact previous liability was not easily ascertainable. Any\nattempt, therefore, to take into the accounts of the Service figures supposedly covering\nthe revenue due to them from such persons was futile.\nIn an endeavour to approach the problem from possibly the most practical and\nsensible point of view, this Board considered that their first duty was to attempt to\nmake recommendations which would have the effect of securing the registration of as\nmany unregistered persons as possible, and bring into the funds of the Service as much\nas was possible of the revenue to which they were definitely entitled from the non-\nregistrants and delinquents mentioned.\nThe Board considered this matter very seriously over a period of weeks, after\nbecoming acquainted with its great importance; and as a result of their deliberations,\nthey submitted to the Minister of Health and Welfare, on September 25th, 1951, their\nInterim Recommendation No. 4. The Minister discussed this interim recommendation\nvery fully with the Board at certain of its sessions, and, as a result, the Board's recommendation was amended, becoming Interim Recommendation No. 4a, which will be\nfound in the appendix to this Report (and dated October 17th, 1951).\nThis recommendation was duly implemented, and publicity was given to the\ncompromise of arrears scheme embraced therein. This scheme, however, was necessarily limited as to time, the final date of acceptance being set at November 30th, 1951.\nThe result of the compromise scheme offered will be considered as satisfactory or\nunsatisfactory, depending upon the point of view.\nThe Board was informed that, up to the expiry date, 862 persons had taken advantage of the compromise scheme. It can be easily calculated that this meant an immediate\naddition to the revenue of the Service of approximately $35,000, and while these figures in\nthemselves must be looked upon as disappointingly low, it should not be overlooked that\nthe 862 new registrants committed themselves to pay, in instalments, arrears which\nwould probably amount to a further $65,000\u2014and, more important, they would remain\nproperly registered and (it is to be hoped) satisfied persons under the provisions of\nthe Act. The Board feels that had it been possible to deal with this particular problem\nat an earlier date, and grant a more extended period of time for acceptance of the\ncompromise scheme, prior to the incidence of a new year, the results would have been\nmuch more satisfactory in every way.\nThis matter has been dealt with at considerable length because of the great interest\nof the public generally, and because the Board believes that the experiment was well\nworth while and justified, in spite of certain adverse criticism from people who did not\ntake the stand that \" half a loaf is better than no bread.\"\nThe above is preliminary to a recommendation which the Board has decided upon\nconcerning arrears still existing, or to come into existence in the future. It will be found\nthat the Board elsewhere has made certain very definite recommendations, designed to REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 53\nbring under the operation of the Act a maximum proportion of the public legally called\nupon to register, and the question as to a basic decision regarding the arrears of late\nregistrants and delinquent persons still remains. We do not believe there is any necessity\nto repeat in any way the arguments set forth above having a bearing on this entire\nquestion.\nIt would, however, appear to this Board that for the reasons above stated (and\nother reasons), there must be a limit placed upon the period, or amount, of arrears\nwhich any non-registrant or delinquent is called upon to pay. Apart, however, from\nthe position of the individual, it is the definite opinion of the Board that there is a\nmarginal value only to arrears going beyond a certain point in time or amount; and\nthat beyond that marginal value the cost of collection, not only in terms of dollars and\ncents, but also in terms of goodwill, becomes definitely prohibitive.\nThere is the further point that the Administration is faced with an impossible task\nin trying to estimate the true value of such delayed arrears, and the keeping of accounts\nof such a nature in itself entails the engagement of staff in clerical and accounting work\nfar beyond the realizable sums.\nThe Board therefore recommends that, effective not later than July 1st, 1952,\na person becoming registered under the Act, or having been registered, seeking to place\nhimself in good standing, shall be required to pay a sum equal to the premium for the\ncurrent year as regularly provided, and the arrears for the previous premium-year if he\nis liable for the same. The provisions of this recommendation are intended in no way to\ninterfere with the powers of the Minister or the Commissioner to reduce the amount of,\nor to suspend indefinitely payment of, arrears owing by any person.\nNo. 33.\u2014COLLECTION OF ARREARS OF PREMIUMS\nIn connection with the collection of arrears owing by any registrant under B.C.H.I.S.,\nthe Board points out that it has made recommendations to fix the standing of any\nperson as regards liability for arrears and participation in the benefits offered by the\nAct. These recommendations, therefore, will have the effect of clarifying absolutely the\nposition of any such person entering a hospital as a patient, and will mean the hospital\nadministration is in no way concerned with arrears of premiums owing by any patient\nregistered under B.C.H.I.S.\nThe position of the registrant in connection with the benefits of the Act will,\nproviding the other recommendations of this Board are implemented, cease to be affected\nby the arrears which the registrant owes.\nThe Board therefore recommends that the collection, or realization, of the amounts\nwhich will from this time be recognized as arrears, and kept on the books and in the\naccounts of the Service, be a matter for handling by a special collection department of\nthe B.C.H.I.S. Administration, to be segregated completely from the records of current\npremium payments and the receipt and collection thereof. The term \" arrears,\" as\nused in this recommendation, would not be intended to mean the late payment of the\npremium for the current benefit period, but those arrears defined in Recommendation\nNo. 32.\nNo. 34.\u2014EXEMPTION CARDS:   ISSUE TO CERTAIN PERSONS\nAND CHARGE THEREFOR\nIf the recommendations of this Board respecting enforcement of registration under\nthe \" Hospital Insurance Act\" are adopted, it will be necessary for all persons who\ncome within the provisions of the Act to have an eligibility card to prove registration,\nwhich card is usually issued to them on payment of the required premium. Therefore,\na special provision will need to be made for those groups who are exempt from the\nprovisions of the Act or from the payment of premiums as individuals, such as members FF 54 BRITISH COLUMBIA\nof the Canadian Pacific Employees' Medical Association of British Columbia and the\nTelephone Employees' Medical Services' Association of British Columbia, as well as\npensioners and others in low-income groups whose hospital bills or premiums are paid\nby the Government and, in addition, another group consisting of adult dependents of\nregistrants.\nThe Board therefore recommends that all adult residents of the Province coming\nwithin the provisions of the \" Hospital Insurance Act\" who are, by reason of special\nexemption or otherwise, not required to personally pay a premium in accordance with\nthe regulations shall nevertheless be required to obtain from B.C.H.I.S. an official\nexemption card or certificate covering each premium-year or benefit period, as the\ncase may be, and to pay a charge for the said card or certificate amounting to $2\nper annum.\nThis requirement shall not apply to the following persons mentioned in section 8\nof the \"Hospital Insurance Act\":\u2014\n(1) Those persons mentioned in section 8, subsection 1 (a), to whom the\nGovernment of Canada provides hospital benefits:\n(2) Those persons mentioned in section 8, subsection 1 (c), who are covered\nby the \" Canada Shipping Act, 1934 \":\n(3) Those persons mentioned in section 8, subsection 1 (d), who are\nemployed by the Government of Canada or the Government of any\nother country:\n(4) Those persons mentioned in section 8, subsection 1 (\/), who are residing\nin exempted areas:\n(5) Those persons mentioned in section 8, subsection 1 (g), who are covered\nby the \" Saskatchewan Hospitalization Act, 1948 \":\n(6) Those persons mentioned in section 8, subsection (3), who are inmates\nof Provincial institutions, gaols, or penitentiaries.\nNo. 35.\u2014CHANGES OF STATUS\nThe Board learned, from information supplied by the Administration and by\nMessrs. Stevenson and Kellogg Limited, that there were no positive regulations in force\nby which the constant and always-recurring changes in status of persons coming within\nthe requirements of the Act may be reasonably put ihto effect and subjected to reasonable control. It would appear, for example, that a person employed up to any date and\nnot being, up to that time, a member of the two exempted groups\u2014namely, the B.C.\nTelephone Company and the Canadian Pacific Railway Company\u2014has been entitled to\ndemand, consequent upon a change in his employment which places him in one of these\ntwo groups, a refund of the exact amount \" prepaid \" under the regulations which had\naffected him up to that time.\nSimilarly, changes in status from single to married, or from married to single, lapse\nof dependency owing to age, or to change of age, and many other changes have been\nrecognized as operating to change immediately the status of the person concerned under\nthe \" Hospital Insurance Act\" and regulations; and such practice has, according to the\ninformation obtained by the Board, led to innumerable refunds, the net amount of\nwhich can hardly be ascertained. However, the said net amount of refunds is a minor\nmatter compared with the effect of the very considerable correspondence, record-\nchanging, and other clerical work which must accrue to the Administration under the\npresent system. Tabulation of duties of staff employed in the Payroll Deduction Section\nshows that in 1951 eleven male and fourteen female adjustment clerks were engaged in\ndealing with such changes of status, and that five male and twenty-one female adjustment clerks were engaged in the Direct Payment Division of the Administration with\nsimilar duties. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 55\nThe Board has elsewhere recognized the fact that the Act calls for the payment of\nan annual premium, and has also recommended that this premium may be payable in\ntwo instalments, each covering a half-year term. The Board has also elsewhere recommended that there shall be no increase in premiums or reduction in benefits within any\npremium-year. In line, therefore, with what the Board considers to be the fairness of\nthe two recommendations last referred to, it seems not unfair to provide that there shall\nbe no change in the status of any beneficiary which would affect his standing under the\nAct during any current half-year period. This would eliminate the major portion of the\nrefunds now applied for and made, with the consequent tremendous volume of work in\nthe offices of the Administration, which has been referred to above.\nThe Board therefore recommends that the Act or regulations shall be amended to\nprovide that there shall be no change in the status of any beneficiary of B.C.H.I.S.\nwhich would affect his standing under the Act in any way whatsoever during any current half-year period for which the necessary premium has been paid; but any and all\nsuch changes shall have effect only at the beginning of the next half-year period after\nthe date at which a change of status did, in fact, take place.\nNo. 36.\u2014ELIMINATION OF CERTAIN GROUP RECORDS\nRepresentations of Messrs. Stevenson and Kellogg Limited to this Board have\npointed out that up-to-date group records have been kept by B.C.H.I.S. covering the\nfollowing groups:\u2014\n(1) C.P.R.   Employees'   Medical   Association,   comprising   approximately\n14,000 people.\n(2) B.C. Telephone Employees' Medical Association, comprising approximately 3,000 people.\n(These two groups are exempt from the provisions of the \" Hospital\nInsurance Act.\")\n(3) Certain war veterans exempt from the provisions of the \" Hospital Insurance Act.\"\n(4) Armed forces personnel.\n(5) T.B. patients in institutions.\n(6) Persons in mental institutions.\n(7) Inmates of infirmaries and homes for the aged.\n(8) Inmates of Provincial prisons, penitentiaries, and industrial schools.\n(9) Residents of exempted areas.\n(10) Members of the Saskatchewan Hospital Plan.\n(11) Members of the Royal Canadian Mounted Police.\nThe Board has been advised by the Management Engineers that the total number\nof individuals for whom these group records are kept is nearly 50,000, and that, if these\ngroup records were eliminated, an annual saving of approximately $15,000 per annum\nin salaries alone would result.\nThe Board believes that virtually no useful purpose is now served by the keeping\nof these group records, and that under the system covering registration and exemption\nof individuals recommended by this Board, the need for these records would be even\nless necessary.\nThe Board therefore recommends that all individuals exempted from the requirements of the \" Hospital Insurance Act,\" whether comprising the membership of the two\ngroups specifically exempted by the Act or being in another category, shall receive an\nexemption card for every benefit period or a permanent exemption card, wherever possible, and that the separate group records now being kept by B.C.H.I.S. shall be\neliminated. FF 56 BRITISH COLUMBIA\nNo. 37.\u2014PAMPHLET COVERING PLAN AND BENEFITS\nThere has been a demand from some quarters for issue of a \" policy \" which would\nset out the benefits covered by B.C.H.I.S. to the premium-payer. The Board is fully\nconscious of the need for some specific outline of benefits, but under a Province-wide\ninsurance service it is questionable whether an insurance policy, according to the\naccepted definition, is necessary to fulfil this need.\nThe alternative suggested by some is a pamphlet or booklet that would outline not\nonly the benefits extended, but also other facts of interest to all registrants. In 1949\nB.C.H.I.S. issued a 16-page booklet giving such information. The same need is taken\ncare of in connection with the Saskatchewan Hospital Services Plan by a folder which\ncan be enclosed in envelopes with notices of payments due, etc. A draft of a similar\nfolder made applicable to the B.C. plan is shown as an appendix to this Report. It is\nfelt, under the circumstances, that a revision of the 1949 booklet, patterned after the\nSaskatchewan folder, would serve the purpose requested by those who ask for \" policies \" and, in general, it would be a splendid piece of literature for general distribution.\nThe Board was advised that the Saskatchewan folder cost $3,065 for 500,000, or three-\nfifths of a cent each.\nThe Board therefore recommends that a pamphlet with details of the plan and\nbenefits, and similar in form to the Saskatchewan Hospital Services Plan pamphlet,\nentitled \" What's Your Question? \" should be sent out with all notices of premiums due,\nand that it be obtained in sufficiently large quantities as will reduce the cost to a minimum and permit it to be used for general distribution. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 57\nSECTION 5.\u2014HOSPITAL OPERATION AND MANAGEMENT\nAND HOSPITAL CONSTRUCTION AND EXTENSION\n38. Budgets and the \"Fixed Budget\" System.\n39. \" Fixed Charges \" in Hospital Budgets.\n40. System of Payments by B.C.H.I.S. to Hospitals.\n41. Comparative Costs of Hospitalization.\n42. Employees' Wage Agreements.\n43. Student Nurses:  Hours of Work.\n44. Responsibility for Hospital Accounts of Evaders.-\n45. Elimination of Social Security and Municipal Aid Tax on Hospital Supplies.\n46. Purchase of New Equipment:  Consent of B.C.H.I.S.\n47. Central Purchasing Agencies.\n48. Dispensing of Drugs.\n49. Chronic Cases (Social Welfare) Remaining in Hospital.\n50. General Relations with B.C.H.I.S.\n51. Hospital Construction and Extension, etc.:  Study of Needs and\nProvision for Hospital Improvement Districts.\nNo. 38.\u2014BUDGETS AND THE \"FIXED BUDGET\" SYSTEM\nPrior to the commencement of any public hearings, the Board held informal meetings with the representatives of certain institutions, including the boards of the Vancouver General Hospital, St. Paul's Hospital (Vancouver), and the Royal Columbian\nHospital (New Westminster). On July 26th the Board commenced a tour of the Interior of the Province which lasted until the middle of August, during which time they\nvisited thirty hospitals and heard thirty-seven submissions made by the boards of management of hospitals. During the month of September the Board continued its itinerary\nof public hearings, journeying to North Vancouver, the Fraser Valley, and Vancouver\nIsland, during that time visiting five hospitals and hearing fifteen submissions of the\nboards of management of hospitals.\nAt each and every one of these sittings and hearings, the Board endeavoured to\ndevelop fully a frank discussion of all problems having to do with hospital operation and\nmanagement as related to B.C.H.I.S., and it may safely be said that this purpose was\nfully accomplished.\nIt was evident from the outset, up to and including the last hearing of the Board,\nthat the greatest cause of concern to the hospital boards of the Province was the matter\nof hospital budgets and, more particularly, the effect of the \" fixed budget\" system\nintroduced by B.C.H.I.S. With one or two exceptions, the story placed before the\nBoard was the same on all occasions, being to the general effect that the hospitals of\nthe Province could not operate under the present \" fixed budget\" system; that they\ncould not avoid substantial deficits for the year 1951; that certain items of expenditure\nwere improperly disallowed in the said budgets; that due provision was not made or\nallowed for increasing costs of which there could be no accurate estimate or foreknowledge; and, further, that advice of cuts in the budgets submitted to B.C.H.I.S. had not\nbeen received by the hospital boards until the end of April or later in 1951, and during\nthe first four or five months of the year the operations of the hospitals had been carried\non in anticipation of a reasonable acceptance of their budgets as submitted, and they\nwere thereafter advised of the fact that they were expected to reduce their expenditures\nfor the entire year to provide for the very substantial cuts made in their previously\nanticipated income.\nAnother very important aspect of this matter was the fact that even though the\nper diem rate finally set for 1951 was a higher rate than had been in effect for 1950, FF 58 BRITISH COLUMBIA\nthe hospitals had billed the \" other agencies \" (such as the Workmen's Compensation\nBoard, the Canadian Pacific Employees' Medical Association of British Columbia, and\nthe Telephone Employees' Medical Services Association of British Columbia) at the old\nrate until the new budget rates were finally set in April or May, and the hospitals were\nunable to collect from these agencies retroactively at the increased per diem rate which\nwas made applicable to the entire year as far as B.C.H.I.S. was concerned.\nThe Board afterwards ascertained that the hospital budgets which were originally\nsubmitted were finally reduced by B.C.H.I.S. by a gross amount of $991,850, but that\nthe portion of the aggregate budgets chargeable to B.C.H.I.S. was reduced by $819,268.\nIt is impossible to set down here the entire volume of written evidence which was\nsubmitted to the Board to show the views and alleged position of the hospitals consequent upon the decisions made by the Legislature and the B.C.H.I.S. Administration,\nand it is pointed out that these written submissions were supplemented by an even\ngreater weight of evidence and opinions verbally submitted to the Board. The Board,\nhowever, feels that to deal with this matter adequately in this Report it must here record\nthe written opinions of certain hospital boards, which are a reflection of all the submissions made.   We therefore quote as follows:\u2014\nFrom the brief of the Vancouver General Hospital:\u2014\nOne of the major problems faced by all hospitals is the manner in which the budgets are\nreviewed and approved by the B.C. Hospital Insurance Service.\nThe 1951 budget of the Vancouver General Hospital was submitted to the B.C. Hospital\nInsurance Service on December 8th, 1950, but it was not until April 30th, 1951, that we were\nadvised by the B.C. Hospital Insurance Service that our rate for 1951 had been revised to $13.60.\nThe covering letter specifying the new rate implied that a reduction had been made in our budget,\nbut neither the amount nor the items to be reduced were specified. We requested advice of the\namount of the reduction verbally from members of the Service (including a trip to Victoria for\nthis purpose) but could obtain no answer. On May 31st, 1951, we were informed verbally that\nthe Vancouver General Hospital budget had been cut by $195,000 and, after further requests, we\nwere eventually notified in writing on July 16th, 1951, that our budget had been cut by $194,357.\nIt is unreasonable to expect a hospital to operate on its submitted budget for several months\nwith no official notice of change and then be forced to cut back during the balance of the year\na sufficient amount to effect a retroactive reduction in the budget.\nWe feel that some method should be devised so that the hospitals are notified prior to the\ncommencement of the fiscal year as to the final disposition of their budget. One alternative\nmethod for this latter suggestion would be that consideration be given to changing either the\nfiscal year for the hospitals or for the Hospital Insurance Service.\nRecommendation: That budgets be approved prior to the commencement of the hospital\nfiscal year.\nIf a hospital exercising careful controls over its budget is told to make an arbitrary reduction\nin that budget, service must suffer. This tren,d would develop into a most serious situation.\nMedicine is dynamic and progressive and there will be an inevitable and necessary increase in the\ncost of hospital care. To set up arbitrary controls that are going to decide what increase in\nservice, if any, may be permitted is unwise. Each hospital should be required to exercise most\nrigid economies but, that having been done, the B.C. Hospital Insurance Service should carefully\nconsider covering the full amount of the budget, and should discuss the situation with representatives of the respective hospitals before making any reductions. Unless this is done the standard\nof hospital care in the Province of British Columbia will slowly but surely deteriorate.\nWe had carefully prepared and submitted a budget for 1951, showing a total expense of five\nand three-quarter million dollars. Before submitting the budget, the original requests from our\ndepartment heads had been reduced by $174,000 and in addition another $144,000 had been\ndeducted from salaries to allow for possible vacancies (based on previous experience and current\nconditions) due to lack of available employees and turnover. While the budget estimates for\n1951 were being prepared, the Commissioner and the Assistant Commissioner visited the hospital\nand discussed with the Director and the Controller the probable costs for the coming year. At\nthat stage, the final budget had not been completed. At no time after the Vancouver General\nHospital budget for 1951 was submitted to the B.C. Hospital Insurance Service did anyone communicate with us to discuss any phase of our estimates.\nRecommendation: That the budgets be reviewed by the B.C. Hospital Insurance Service with\nthe representatives of the respective hospitals before final approval. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 59\nFrom the brief of the Royal Jubilee Hospital, Victoria:\u2014\nHospital service in this Province would have deteriorated to a dangerous level if the Government had not assisted hospitals on planned basis through the establishment of hospital insurance\nand yet the hospitals are still faced with financial problems because labour costs and the cost of\nsupplies have accelerated in line with the increased costs of other industries.\nUntil the adoption of the \" fixed budget \" principle it was incumbent on each hospital to keep\na full house in order to create additional income. It is as ridiculous to price hospital care at\na per diem rate as it would be to pay fire departments on the basis of the number of alarms or to\npay school boards in direct relation to the number of children. A hospital budget fluctuates very\nlittle in relation to the occupancy and the payment of a fixed budget is a principle used for many\nyears in hospitals. If hospitals knew with certainty at the first of the year the amount they were\nto receive from the B.C.H.I.S., there would be a greater effort to manage within the limits allowed\nand there would be no encouragement to keep a high occupancy in order to develop revenue.\nThis suggestion is made on the basis that sufficient funds would be provided to ensure a satisfactory service.\nHospital finances have been much complicated by the admission of non-insured persons who\nhave not the ability to pay their hospital charges. The amount of \" free work \" varies in the\ndifferent parts of the Province but it is unthinkable that a hospital would refuse admission or\nnecessary available service to a sick or injured person because of indigent circumstances. By\nusing a truly \" fixed budget\" basis the hospitals would be able to absorb the free work.\nHospitals have found it difficult to proceed with capital expenditures because the net result\nof operations cannot be accurately measured until the end of the year and then the funds on hand\nmay not be sufficient to permit capital expenditures until the accounts are finally settled by the\nB.C.H.I.S. many months later.\nWith an assured basic income which would allow for a basic minimum of service the\nhospitals could operate with confidence and gradually improve their services by planning new\nservices with the B.C.H.I.S.\nOur ratio of expense in the various main divisions of hospital costs are found to be within\nthe ratios prescribed for standard hospital costs and the budget is within .3 per cent of the\nestimate prepared by the board of directors. However, it should be noted that the budget\nfigures given here for the six months period do not reflect the deduction of $58,000.00 made\narbitrarily by the B.C.H.I.S. Costs for the year 1950 amounted to $11.95 per diem and we have\nbeen awarded $11.95 for 1951 and do not see how we can keep within this figure for 1951 in\nview of labour negotiations and other increases in costs without reducing service. Although our\ncosts for 1951 are 10 per cent greater than for 1950, it would appear from available figures that\nthe B.C.H.I.S. intends to pay us less than last year. We contend that this is unrealistic, especially\nin view of the increased number of patient days.\nFrom the brief of the Royal Columbian Hospital, New Westminster:\u2014\nThe Minister of Health and Welfare has stated in the Provincial House that during 1951\nhospitals would be asked to operate on a fixed budget. After this budget has been approved by\nthe B.C.H.I.S. the hospital would be expected to live within it. By definition, a budget is a plan\nto establish and organize a programme of operating performance. As directed, the hospital\nprepared its budget for 1951 which was submitted to B.C.H.I.S., but no approval of this or an\namended budget has been received. How then can a budget plan be implemented and adhered\nto without some indication of the nature of hospital services and facilities to be provided. The\nonly notification received from B.C.H.I.S. was that the per diem rate for 1951 had been established and that the Royal Columbian Hospital would be required to reduce the over-all estimated\nexpenditures by $146,000.00. No indication was given as to how the per diem rate was arrived\nat, nor where it was expected that the saving required could be made. It would seem that if the\nHospital Insurance Service is to be placed in the position of determining the amount of money\nany hospital may spend on its operations, then B.C.H.I.S. should also determine the standards of\nhospital care which they expect the participants in the hospital insurance scheme to receive.\nAdmittedly, such standards would be very difficult to establish, due to the fact that the medical\nstaff of any hospital is primarily concerned with the needs of the patients and they would take\nlittle or no cognizance of any predetermined standard, if they felt that such standards were not\nin the best interests of the patient. This factor alone would tend to defeat the practicability of\nfixed budgeting. Again, the standard of hospital care will vary from hospital to hospital (some,\nas our own, providing such services as radiology, pathology, cardiology, etc.), depending on the\ncharacter of the community it serves, and the types of sicknesses and injuries for which care is\nrequired. The Royal Columbian Hospital, situated at the confluence of three major highways,\nhas a prevalence of automobile accidents, which in all probability would not be experienced to\nto the same degree by any other hospital in British Columbia. FF 60 BRITISH COLUMBIA\nB.C.H.I.S. has stated on several occasions that it does not wish to disturb the autonomy of\nthe Hospital Board of Management, despite the fact that by virtue of the controls which it\nexercises over the hospital's finances, such autonomy can not possibly exist. The hospital's\nrevenue is indirectly controlled by the B.C.H.I.S., and consequently this factor predetermines the\namount of money which can be expended on the operation of the hospital. The B.C.H.I.S. in its\ncircular dealing with the hospital budgets has left to the Hospital Board of Management the\nproblem of determining where economies are to be made in order to operate within the per diem\nrate established. Whether or not the B.C.H.I.S. established standards for hospital care, it would\nseem that the standard should be consistent among all British Columbia hospitals, but the variation in asked-for-expenditure cuts does not appear to permit such consistency. However, neither\nthe directives received from B.C.H.I.S. nor conversations with the officials elicited any information with respect to the standards of hospital care or services to be provided.\nFrom the brief of the Vernon Jubilee Hospital, Vernon, B.C.:\u2014\nWe do not object to the present policy of operating on a fixed budget, subject to adjustments\nto meet unforeseen circumstances or conditions, but we do object to having our budget cut arbitrarily by the Commission. For 1951, our budget was cut by $9,300.00. It was suggested\nby the Commission that we cut down our wage bill to meet the greater amount of this cut. As all\nemployees are covered by union contracts, wages could not be reduced even if the board should\nwish to do so. The only alternative would be to reduce our staff. Our administrator states that\nthe staff cannot be cut and still give service. If the Commission provides our funds then we\nrecognize, even if we dislike to do so, that we must accept a certain measure of control over our\nexpenditures. But our objection is to remote control; if we are told to cut our staff, and we\ndo not think that any cuts can be made, then there should be a proper analysis of our operations\nmade on the ground by some one competent to do so. The Commission this year has fixed our\nrate at a sum at which we claim to be unable to operate. Our rate should either be adjusted to\nprovide the required funds or the Commission should have an expert to tell us where we are going\nwrong. The policy of having to operate on a certain fixed amount and not on what is actually\nrequired to maintain service is wrong.\nFrom the brief of the Powell River General Hospital, Powell River, B.C.:\u2014\nThis hospital, in preparing its 1951 budget, did so with aview to the most economic operation, and followed the instructions of the Hospital Insurance Service not to take into account\nincreases in commodity prices or wage increases. The budget for this hospital amounted to\n$268,685.00\u2014and was cut by $18,000.00. There is no doubt in the minds of this board of\nmanagement that this cut was made necessary by the lack of funds, caused in some measure by\nthe inability of the Hospital Insurance Service to collect premiums and other Government departments not paying their full share in their incurred liabilities.\nFrom the brief of the Penticton Hospital, Penticton, B.C.:\u2014\nOur bad debts this year will approximate $6,000.00 to $7,000.00 and will account for the\ngreatest per cent of our operating deficit. During the year 1950, proven bad debts were considered as an operational expense. With this in mind, when preparing our 1951 budget, we made\nonly a nominal allowance for those bad debts not acceptable to B.C.H.I.S. The term \" fixed \" as\napplied to our budgets as of May 1 st this year was not anticipated. We are well pleased with the\ngeneral principles of the plan but feel that some remedy must be found in order that the humanitarian basis on which it was founded is not lost in the monetary approach.\nFrom the brief of the Chilliwack General Hospital, Chilliwack, B.C.:\u2014\nThe deficit with which we are at present faced and which, in spite of every effort to economize, we are unable to reduce and can see no hope of so doing, as long as we are forced to try\nto operate on a fixed budget, is our chief concern; for we cannot imagine how this can be made\nup out of hospital funds, of which we have none, or by the community. Revenue by way of\ndonations has ceased.\nTo the end of July we had exceeded our submitted budget by over $18,000.00. This estimate\nwas submitted in November, 1950, and based on our experience to September, 1950. What was\nthought at that time to be a fair increase to cover rising costs was added. We were advised that\n$7,500.00 had to be cut from the budget as submitted with the suggestion that it could be cut\nfrom salaries and wages, repairs and linen.\nFrom the brief of the Creston Valley Hospital, Creston, B.C.:\u2014\nUnder the fixed budget arrangement made by B.C.H.I.S. our estimates for 1951 were slashed\nby the amount of $7,000 or 11.2 per cent of our total estimated expenditures, which action we\nvigorously protested to BCH. Since that time we have repeatedly pointed out that we have\nattempted but are unable to reduce expenditures to in any way approach this required reduction. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 61\nHowever, whether we are financially able to absorb this reduction or not, we have been forced to\ndo so by monthly reduction of advance expenditure payments by BCH, which places us in the\nposition today of being forced to ask our creditors to carry as unpaid purchase bills our accounts\nfor the month of June\u2014$1,900.00, July\u2014$2,000.00, and a bank overdraft of $1,100.00. You\ngentlemen are business men, and if you were asked to operate your private concerns as BCH\nforces hospitals to operate, you would undoubtedly consider closing your doors to further business, as we must at this time seriously consider doing. We members of the (hospital) board are\nforced in day to day contact to face hospital creditors, and we are sure that if our own businesses\nwere in the same financial position as the hospital is at present, our only recourse would be to\nturn the key in the front door. BCH has repeatedly insisted that the day to day operation of the\nhospital is the concern solely of the board, but when our day rate is set for us at a definite figure\nand our allowed expenditures are cut to meet the revenue supplied by that rate, we fail to see\nhow in any measure we may be held responsible for any deficit that might occur.\nFrom the brief of the Rest Haven Hospital, Sidney, B.C.:\u2014\nThe British Columbia Hospital Insurance Service was introduced to help hospitals financially, with definite and repeated promises that the hospital autonomy would not be affected.\nThe opposite has developed.\nUnder the present plan, our entire current working capital has been liquidated, including\nnon-operating funds, due to the factors which follow:\n1. Daily rates set by British Columbia Hospital Insurance Service below cost for three consecutive years.\n(a) Our average gross operating income per adult, child, and newborn patient day\nduring 1948 was approximately $10.75.\n(b) In spite of inflation and with increased expense during 1949, our gross operating\nadult and child patient day was reduced to about $9.25, by the Insurance Service.\n(Public ward rate\u2014$6.70 per day.)\n(c) In 1950, with the continued inflation spiral, our average gross operating income\nfor adult and child patient day was only $10.15\u2014still below 1948. (Public ward\nrate\u2014$9.00.)\n(d) In 1951, our present average is still below the 1948 patient day average income.\nWe are asked to do the impossible\u2014reduce our budget by $10,800.00. (Public\nward rate\u2014$9.67.)\nThe inflation spiral is beyond our control, yet the Insurance Service has continually established a rate below our very conservative estimate, and rejected legitimate operating expenses\nwhich have been in effect for years.\nFrom the brief of St. Joseph's General Hospital, Dawson Creek, B.C.:\u2014\nWe strongly suggest that the fixed budget recently suggested be discontinued and the hospitals be allowed to budget for the ensuing year on a basis of actual previous cost and expected\nincrease, or otherwise.\nReferring to the fixed budget, we are convinced that this is definitely the wrong approach to\nthe problem, as a fixed budget is an impossibility in hospital work due to the unpredictable circumstances which might arise. Application to the Hospital Management is made for a true\nstatement of expected expenditures and in the case of this Hospital a true statement is given; the\nconsequence is that if this budget is not approved, reduction in the services of the hospital must\nnecessarily ensue. These services have always been at a high standard, economically supplied,\nand we feel that no cut should be made in the budget as submitted.\nAnd finally from the brief of the British Columbia Hospitals' Association:\u2014\nWe would draw attention to the fact that the existing plan commenced with the intention of\nreimbursing all hospitals at cost for services rendered (section 13, Hospital Insurance Act). It\nwas not long before this ambition was modified by restrictions in services; by refusing to pay\ninterest on borrowed capital; then by disallowing depreciation and, more recently, by arbitrarily\ncutting down hospital budgets to protect the Hospital Insurance Fund from further deficits.\nToday the hospitals are trying to carry on their work dressed in strait-jackets. The original\nintention of the Act was to provide money to meet the needs of hospital patients. This has now\nchanged to cutting down services to patients to meet the needs of the Hospital Insurance Fund.\nThe end product, particularly from the point of view of the individual patient, is an\nintangible. It is not only intangible, but it is a constantly fluctuating thing. Medical and\nsurgical science is constantly changing. Advances in science are increasing the chance of\nsurvival; increasing the chance of complete restoration to health; and reducing the length of\ntime it is necessary for a patient to remain in hospital. Hospitals cannot be efficient and, at the\nsame time, postpone important improvements in treatment until the end of the current fiscal year.\nThere is another facet of hospital work that makes its objectives even more intangible.   While FF 62 BRITISH COLUMBIA\nadvances in science and professional and technical skill are important, tender and sympathetic\ncare of the individual is still a vital factor in restoration to health. Psycho-somatic illnesses are\nnumerous. The attitude of the patient towards his illness is a major factor in recovery. It is\nin this field that our small hospitals have an opportunity to perform a great service, and they do.\nWho shall assess the exact value of this in terms of dollars and cents?\nHaving thus exhibited the view-point of the hospitals of the Province, the Board\nnow wishes to quote from the submissions made to it in writing on behalf of the College\nof Physicians and Surgeons and the Hospital Employees' Federal Union:\u2014\nThe College of Physicians and Surgeons of British Columbia.\u2014The financing of hospital\ncare is not our business. We wish to point out, however, that in any hospital a rigid budget,\npre-fixed at an arbitrary level by an agency outside that hospital may have a deleterious effect on\nthe standard of medical care. A hospital is a community service institution and cannot be\nregarded as a boarding-house for the sick. If a hospital exercising careful controls over its\nbudget is told to make an arbitrary reduction in that budget, service must suffer. There is, and\nwill continue to be, an inevitable and necessary increase in the cost of medical care because the\neconomics that result from more efficient means of treatment do not affect the increased costs\nof more complex methods. The setting up of arbitrary controls at Victoria to decide what\nincrease in service, if any, may be permitted, will have an ill-effect, in time, on the standards\nof hospital care in British Columbia.\nThe Hospital Employees' Federal Union, Local 180.\u2014While a fixed budget policy may be\nsound and workable, in a normal period of stable prices, and enable the Government to achieve\nits apparent aim of stabilization of hospital costs, in our view it is neither desirable nor workable\nin the present inflationary period. And surely no one will deny that we are in a definite inflationary period. The cost-of-living index recorded for the month of January, 1951, was 172.5;\nthe index as released by the Dominion Bureau for the month of July was 187.6, an increase of\n8.8 per cent. Assuming that a reasonable budget for the operation of a hospital in January was\n$200.00 per month, obviously that same figure would be out of line for the month of July.\nSimple mathematics would reveal that the budget should now be $217.60 per month. If we can\njudge from the trend during the first seven months of this current year, a budget established on\nthe basis of January 1st to December 31st, rigid and unyielding, would be still further out of line\nby the end of the year.\nIt should here be said that the complaint was made in many instances to the Board\nthat whereas the position of hospitals existing (or thought to exist) as at June 30th or\nJuly 31st, 1951, had been called to the attention of the Commissioner of B.C.H.I.S., no\nsatisfactory answers had been received by the hospital boards concerned.\nIt was further pointed out that under the regulations in effect concerning the exact\noperation of the \" fixed budget\" system, it was not possible for any hospital board or\nadministrator to gauge with any certainty the exact amount of income to be received for\nthe calendar year from B.C.H.I.S. until after the closing of the hospital's books and\naccounts at the end of the said year.\nIn view of the apparent seriousness of the position of the hospitals of the Province,\nas presented to this Board, the Board felt it incumbent to give earnest consideration at\nonce to the representations made to them, and to take some action. Consequently, the\nBoard, on September 25th, 1951, caused to be transmitted to the Minister of Health and\nWelfare its Interim Recommendation No. 5, which will be found in the appendix to this\nReport.\nAt the conclusion of all its hearings the Board again gave this entire matter of\nhospital budgets the fullest possible measure of study and consideration. By the time\nthis Report is presented to the Legislature, the true results of hospital operation for the\nyear 1951 may be known, and will reveal the justification, or otherwise, of the importance\nattached to the matter by the Board and the submissions made to the Board during the\nsummer months.\nThe Board, however, feels that it must endeavour to make a contribution toward the\nfixing of a reasonable, satisfactory, and acceptable long-range solution of the problems\nwith which the hospitals are confronted in this regard.\nThe Board learned, when investigating the Saskatchewan Hospital Services Plan,\nthat 60 per cent of the finally accepted hospital budgets in the Province are set after REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 63\ndiscussion by a delegation of the hospital board with the administrators of the Plan, the\nsaid delegation visiting Regina for that purpose. The Board was told that no flat cuts\ntook place in any hospital budget without discussion as between the Plan and the hospital\nconcerned. They were further told that the administrators of the Plan are willing to\nnegotiate at any time of the year to make retroactive adjustments if necessary.\nThe Board therefore makes the following recommendations:\u2014\n(a) That the budgets of the hospitals of the Province, when submitted to\nB.C.H.I.S., must include therein all the anticipated costs of efficient\noperation, and if the B.C.H.I.S. Administration, upon examination of any\nbudgets so submitted, disagrees with the figures submitted, they shall make\nprompt arrangements for consultation with the hospital board concerned\nso that adjustments may be studied and considered; and only after such\nconsultation shall the figures then agreed upon become a \" fixed \" budget.\n(b) Such \" fixed \" budget, nevertheless, still remains subject to agreed changes\narising as the effect of circumstances over which the hospital board has\nno control.\n(c) There shall be no reduction of a per diem rate set by B.C.H.I.S. and\nexisting in any hospital, made effective until the time when the new budget\nof the said hospital is fully agreed upon for the year in accordance with\nclause (a) hereof.\n(d) That at the commencement of each year the \" other agencies \" shall be\nnotified by B.C.H.I.S. that accounts rendered to them for hospitalization\nfor which they are liable are on an interim basis until the hospital budgets\nand rates are fixed for the year by B.C.H.I.S., and that such accounts are\nthereafter subject to increase or decrease in accordance with the new\nrates set.\nNo. 39.\u2014\"FIXED CHARGES\" IN HOSPITAL BUDGETS\nThe general matter of the \" fixed budget\" system for hospitals and the manner of\npayments applicable thereto has already been dealt with by the Board in this Report. It\nwas felt unwise to complicate the Board's previous treatment of this subject by injecting\narguments or detail having to do only with parts of hospital expenditure.\nFor this reason, therefore, we deal now with the matter of what are generally called\nfixed charges, usually of an annual nature, to be found in the accounts of all hospitals, as\nthey are found in the accounts of practically any business or institution. The charges we\nhave reference to include allowances or reserves for depreciation on buildings, furnishings, and equipment, allowances or reserves for bad and doubtful debts, provision for\ninterest or carrying charges on capital debts which are the responsibility of the hospital,\nand any other legitimate reserves or allowances of a like nature.\nAs concerning the submissions made to the Board, in general it may be said that the\nallegation is that under the \"fixed budget\" system now in force proper treatment is\nnot accorded to those items by B.C.H.I.S. Throughout the length and breadth of the\nProvince, the Board did not find any hospitals willing to admit that the present rate of\nallowance for depreciation was in any degree reasonable or sensible.\nRegarding the allowances for bad and doubtful debts, it would appear that the\nprincipal objection arises from the fact that there is no assurance of any certain method of\ntreatment to cover these debts, which may have been incurred from a variety of different\ncauses, such as delayed advice of non-acceptance of a patient's account by B.C.H.I.S.,\nopposition to co-insurance charges, as well as ordinary hazards pertaining to the collection of any business account.\nAnother factor inherent in the whole subject may be mentioned: Due to the rising\nprice level more and more of a hospital's working capital is being tied up in inventories. FF 64 BRITISH COLUMBIA\nFurthermore, the amount tied up in accounts receivable has been increasing to considerable proportions. As time goes on, therefore, the working capital of hospitals is becoming\nmore and more depleted. The question may well be asked whether the hospitals are\nexpected to find replacement of or additional working capital themselves, or will it be\nsupplied through the Insurance Service?\nWith regard to the matter of interest or carrying charges on capital debts which are\nthe responsibility of the hospital; this, of course, does not affect certain hospitals, particularly municipal hospitals throughout the Province. However, we wish to let the\nattitude of the hospitals, expressed in many written briefs, speak for itself on all these\npoints by quoting from the submissions made to the Board, as follows:\u2014\nNanaimo Hospital, Nanaimo, B.C.\u2014Furthemore, no allowance is admitted for depreciation\non the buildings or equipment other than an arbitrary 10 cents per bed-day on occupancy. In the\ncase of this hospital, this will amount to not more than $3,000.00 a year. The building and\nequipment have recently been appraised at a valuation of close to half a million dollars, and the\ndepreciation, which would normally be taken on this investment by any commercial concern,\nwould be in the neighborhood of $25,000.00 a year. Similarly the Commission will not allow\ninterest on the bonded indebtedness as an expense in calculating the day date, although it is an\nactual cash outgo, and must be made up from funds other than those received from the Commission. Fortunately, up to the present, our donations and bequests have been sufficient to meet this\nexpense. But it does not seem reasonable that the Commission should be arbitrarily allowed to\nexpropriate our services without including in the per diem rate items of expense such as depreciation and bond interest, which are indisputably a part of the expense of running the institution\njust as much as are wages, materials and supplies.\nSt. Martin's Hospital, Oliver, B.C.\u2014The building was designed by the government architect\nand the government subsequently made a grant of fifty thousand dollars towards the cost of the\nbuilding which ultimately amounted to one hundred and thirty thousand dollars. The Sisters\nof St. Ann, therefore^ had to raise by way of a loan from the Credit Foncier, some eighty thousand\ndollars, which the hospital society reduced by some ten thousand dollars through public subscriptions. In the course of negotiations with the Sisters of St. Ann, the board of management was\nconstituted by the election of four members from the community, four nominated by the Sisters\nof St. Ann (two of whom are local citizens) and one member nominated by the Lieutenant-\nGovernor in Council, completing a board of nine members.\nThe hospital society agreed that any money contributed by the Sisters of St. Ann towards\nthe cost of the building should be repaid out of the depreciation account, until this indebtedness\nhad been liquidated. It was further agreed that the hospital should be operated by the Sisters\nof St. Ann without recourse to public support.\nPrior to the advent of the B.C.H.I.S., depreciation at the rate of five per cent was set up\nto amortize the debt and the balance remaining as at the 31st of December, 1949, was $40,100.00.\nThe B.C.H.I.S. makes no allowance for depreciation, the only means therefore of repaying the\ndebt is out of the Sisters' personal salaries. Some argument may be advanced to commend this\nmethod of repayment, but the board of management feels that such an argument cannot be\njustified, either legally or ethically.\nRoyal Inland Hospital, Kamloops, B.C.\u2014Amounts allowed for depreciation of buildings and\nequipment are not adequate and in view of the fact that working capital of the hospital has disappeared entirely, in meeting increased costs and annual deficits, a substantial change should be\nmade allowing sufficient funds to avoid accumulation of replacement, maintenance and renewal\nexpenditures for which no money is or will be available under the present method in use.\nVernon Jubilee Hospital, Vernon, B.C.\u2014It is suggested that the present policy of the Commission with regard to depreciation allowance is not good business practice. Hospital boards are\nnot permitted to charge any depreciation as an operating cost, except an allowance of 10 cents\nper patient day. This is far from adequate, and we cannot help feeling that the present policy is\ndictated not by sound business principles but by motives of expediency.\nRest Haven Hospital, Sidney, B.C.\u2014The following changes would materially strengthen the\nplan and give hospitals a foundation on which to operate.\nMake provision for proper depreciation expense based on regular established depreciation\nschedules, at least for those hospitals where capital investments were financed by the hospital.\nSt. Joseph's General Hospital, Dawson Creek, B.C.\u2014(1) We strongly suggest that the\ndepreciation allowance formerly in force in the Hospital Insurance rules, or some form thereof,\nbe restored immediately.\nReferring to item number (1) above, we can only refer to the experience of the St. Joseph's\nGeneral Hospital and the difficulties that have been met since the Hospital Insurance Plan has ^\u25a0\u25a0ppp\nREPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 65\nbeen put into effect. At the inception of Hospital Insurance Service there was a deficit of\napproximately $46,000.00 which had been incurred by the Hospital with a view at that time of\nrepaying to the loaning organization, with interest. Since the Hospital Insurance Service merely\nreimburses at operating cost, there has been no possibility of any repayment of the loan. It is\nfelt therefore that in all fairness interest should be considered as an operating cost, and the only\nfeasible way would be to pay the loan out of a depreciation fund.\nFinally, the British Columbia Hospitals' Association may be said to have summed\nup the situation in the following introductory remarks to their brief presented to this\nBoard:\u2014\nWe would draw attention to the fact that the existing Plan commenced with the intention\nof reimbursing all hospitals at cost for services rendered (Section 13, Hospital Insurance Act).\nIt was not long before this ambition was modified by restrictions in services; by refusing to pay\ninterest on borrowed capital; then by disallowing depreciation and, more recently, by arbitrarily\ncutting down hospital budgets to protect the Hospital Insurance Fund from further deficits.\nToday the hospitals are trying to carry on their work dressed in strait-jackets. The original\nintention of the Act was to provide money to meet the needs of hospital patients. This has now\nchanged to cutting down services to patients to meet the needs of the Hospital Insurance Fund.\nThe Board fully realizes that the matters referred to are most important, and have\na considerable bearing on the operations of hospitals and likewise on the operations of\nB.C.H.I.S. The Board is not prepared to put forward any recommendation which makes\npossible a complete solution of the whole problem. In view of other recommendations\nmade by the Board, it feels that the question of bad debts and allowances therefor will\nassume a minimum importance in the near future, and with regard to the other two\ndivisions of this subject,\u2014\nThe Board now makes the following recommendations:\u2014\n(a) That in the case of hospital equipment, full depreciation allowance (in\naccordance with the classification thereof) shall be permitted as an annual\noperating cost in hospital budgets, in order to cover equipment replacement; and\n(b) That the entire question of allowances for depreciation on buildings, and\ncarrying charges on capital debts which are the responsibility of the\nhospital board, shall be the subject of serious study by the Administration\nof B.C.H.I.S. at the very earliest possible date, with a view to a more\nsatisfactory agreement being reached concerning these charges between\nthe hospital boards and the B.C.H.I.S.\nNo. 40.\u2014SYSTEM OF PAYMENTS BY B.C.H.I.S. TO HOSPITALS\nThis is a matter which is, of course, definitely bound up with the general subject of\nhospital budgets, and particularly with the present system of \" fixed budgets,\" on which\nsubject other recommendations are elsewhere made by the Board.\nThis phase of the matter has been the subject of thorough discussion with the boards\nand administrators of many hospitals. It is a somewhat involved matter, and a variety\nof opinions has been expressed in connection therewith. The arguments advanced take\ninto account the effect of the depleted working capital of many hospitals, the fact that\nadvances made on earlier dates by B.C.H.I.S. to hospitals are in many cases deducted\nfrom the current payments due to these hospitals, and a great many other factors.\nIt has been suggested that the system in force should be changed in various ways,\nand the extreme position taken is, of course, that the hospitals should be paid by\nB.C.H.I.S. on a month-by-month basis for all services rendered. The Board has looked\nclosely into the manner of payments now in force in conjunction with the \" fixed budget\"\nsystem. Briefly, it may be stated that the total amount of the \" fixed budget\" of any\nhospital having been arrived at, it is reduced to a per patient-day basis, and this is broken\ndown into two distinct parts\u2014namely, the constant cost and the variable cost.   The said\n3 FF 66 BRITISH COLUMBIA\nconstant cost is then supposedly paid to the hospital concerned in twenty-four semimonthly instalments, and the variable cost is paid to the hospital in monthly instalments,\nin amounts depending on the accounts submitted for patients actually passing through\nthe hospital. We find, however, that the payment (of the constant instalment) is, each\nmonth, based upon the occupancy for the previous month. This has led to dissatisfaction\non the part of the hospitals because of the complications which ensue. It should be clear\nthat a hospital may receive in July a \" constant\" instalment payment based on a very\nlow occupancy experienced in the month of June, whereas the July rate of occupancy may\nhave gone to a much higher level, and the consequent cost of the hospital operation for\nthe second month is in many respects increased, and to meet these increases promptly\nthe hospital does not have immediately available the adequate funds.\nThe Board fully realizes that this is not a simple matter to any but accountants, and\nhas no desire to set down here all the technicalities involved. It does, however, seem to\nthe Board that the approach made to a proper system of payments to hospitals is somewhat in the nature of a negative rather than a positive approach. Furthermore, the\nBoard must report that it has been impressed by the apparent superiority of the system\nin force in the Province of Saskatchewan. Under this system the \" fixed budget\" of the\nhospital, arrived at on an agreed-occupancy basis, is also broken down into the constant\nand variable factors, but payment of the portion of the \" fixed budget\" which covers the\nconstant factors is made to the hospital in twenty-four equal and unvarying instalments\nthroughout the year. The \"variable\" cost is then paid to the hospitals as the actual\n\" occupancy \" bills are rendered and passed. It should be mentioned that the Board was\ntold that the straight payment of the entire per diem rate had had a tendency to encourage\nthe overcrowding of hospitals, and that therefore the system of \"hold-back\" of the\n\" variable \" cost was instituted.\nIt appears to the Board that this system has at least the merit of giving exact knowledge to the hospital of a minimum monthly cash income which it will receive from the\nService, thereby enabling the hospital administration, as far as possible, to fit their operations into this definite pattern; and it is possible that there is considerable inducement to\nthe hospitals to operate as closely as possible to this fixed sum, with the result that a\nconsiderable measure of economy is effected.\nFor these reasons, the Board now recommends that the system of B.C.H.I.S. payments to hospitals be reviewed, with the object of arriving at a more satisfactory plan;\nand the Board is of the opinion that the system in use in Saskatchewan should be followed,\nunless specific and valid reasons exist in favour of some other system.\nNo. 41.\u2014COMPARATIVE COSTS OF HOSPITALIZATION\nIn the course of its work the Board obtained from various sources outside the\nProvince information as to hospital costs, but probably of the greatest interest, and most\nclosely comparable to the British Columbia costs, were figures obtained from the\nProvince of Saskatchewan. The Director of the Saskatchewan Hospital Services Plan\nsupplied the Board with fully detailed figures of several hospitals in that Province, both\nas regards actual costs for 1950 and approved budgets for 1951.\nIt is not possible to say that the operations of any hospital in Saskatchewan are\nexactly comparable to the operations of any one hospital in British Columbia because\nthere will necessarily be some varying features. For instance, two hospitals with the\nsame rated bed capacity will not necessarily have the same percentage of occupancy or\ntotal of patients' days. Then a hospital of a certain size in Saskatchewan might have\na training-school, whereas there might not be any training-school in conjunction with\na hospital of comparable size in British Columbia; or, again, a hospital of a certain\nsize in Saskatchewan might be in the \" Catholic Conference \" group, but the comparable\nhospital in British Columbia might be under a different form of management. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 67\nHowever, the Board caused certain comparisons to be made. In the appendix\nto this Report there will be found a Summary of Comparative Figures for Hospital\nOperation for 1950, in which are the figures of actual operation of a Saskatchewan-town\nhospital with a rated capacity of sixty-one beds, and the actual figures of seven hospitals\nin British Columbia of reasonably similar rated bed capacity. It will be noted that\nthe actual patients' days vary considerably in most of the comparative figures, and,\nnecessarily, the percentage of occupancy also varies.\nBearing these variations in mind, the study of comparative costs is nevertheless\nmost interesting and informative. It will be particularly noted that the cost to\nB.C.H.I.S. of the hospital in British Columbia having the number of patients' days\nmost nearly equivalent to the figure for the Saskatchewan institution cost the B.C. Service\nslightly over 60 per cent more than the Saskatchewan hospital cost the Saskatchewan\nHospital Services Plan, although the actual patients' days of the B.C. institution was\nless than SVi per cent in excess of those of the Saskatchewan institution. The detailed\nfigures set out in this comparative summary are quite clear and need not be repeated\nhere.\nIt is, however, quite apparent that the very considerable excess of costs in British\nColumbia over those in Saskatchewan arises chiefly from the difference in the amount of\nnet wages and salaries paid in the comparable institutions. In the case of the two\nhospitals quoted, it will be noted that the total net wages paid in the B.C. hospital was\n120 per cent higher than the total paid in the Saskatchewan institution. For this reason,\nthe Board also presents, as an appendix to this Report, a comparative statement of staff\nemployed for the year 1951 in a hospital in a B.C. city and in a city hospital in the\nProvince of Saskatchewan. It will be noted that the rated capacity of these two\nhospitals is not exactly the same, but the figures covering the percentage of occupancy,\nthe total patients' days, and costs are plainly set out. It is felt that these comparisons\nwill be of very great interest to all concerned with the problem of hospital costs in the\nProvince of British Columbia. The Board, of course, knows that there are certain basic\ncircumstances existing which cause, and partly account for, the very great difference in\ncosts as between Saskatchewan and British Columbia.\nOne or two of these factors that might be mentioned are the over-all higher wage\nrates in British Columbia and the high standard of hospital service in British Columbia.\nThe last-mentioned factor necessarily includes the use or allocation of a considerably\ngreater measure of nursing service per patient per day, with the resultant numerical\nincrease in nursing staff.\nThe Board, however, is not completely satisfied that the wide variance shown in\nthe total-cost figures of similar institutions can be entirely and completely justified\nor approved. As already stated, the Board could put forward many factors and\narguments in support of the position of the B.C. institutions, but this does not mean\nthat the Board has had the opportunity of going thoroughly into all phases of the matter,\nand the Board believes that such thorough investigation and study would be a most\ndesirable undertaking.\nApart from any other consideration, the evidence obtained and referred to here\ncertainly seems to support the views of the Board as expressed in another recommendation, concerning the development by B.C.H.I.S. of an organization of trained personnel\nthat may render maximum assistance to hospital boards and administrators in connection\nwith various phases of hospital operation and management.\nIt is, however, believed that the importance of the matters referred to above is\nsuch as to call for positive consideration, and\u2014\nThe Board therefore recommends that the Administration of B.C.H.I.S. shall\narrange, at as early a date as possible, for adequate and full conference with the executive\nof the British Columbia Hospitals' Association and other interested parties, with a view FF 68 BRITISH COLUMBIA\nto giving intensive study to the matters referred to above, and to arrive at conclusions as\nto whether or not the comparative position of the hospitals of the Province is sufficiently\njustified.\nNo. 42.\u2014EMPLOYEES' WAGE AGREEMENTS\nOne of the most important matters considered by the Board was the entire subject\nof wage rates negotiated by the duly authorized bargaining agents for hospital employees\nwith the various hospital boards, and the manner in which they are affected by the\n\" fixed budget\" policy of B.C.H.I.S. Very strong representations were made in this\nconnection. Most of these submissions were made verbally to the Board by many\nhospital boards and administrators, and by the representatives of the Hospital Employees'\nFederal Union.\nDealing first with the view-point of the hospitals, we quote from four briefs which\nwere submitted in writing, and which, to some extent, may be said to set out the views\ngenerally held by hospital boards throughout the Province.    It will be noted that, in\naddition to the main subject of wage and salary rates, a great deal of attention has been\ngiven to the question of employers' contributions to pension or superannuation funds:\u2014\nNorth Vancouver General Hospital.\u2014Causes of additional cost are brought about by the\nformation of unions which have attained very high percentage increases as compared with the\ncost of living.    Our agreement with labour unions, according to the Act, should be carried out,\nbut the B.C.H.I.S. will not allow us to do this because they have materially cut our budget.\nWe feel that the only fair way for labour-union agreements is to work on the cost-of-living\nbasis, which we are endeavouring to do.\nRoyal Columbian Hospital, New Westminster, B.C.\u2014Other problems requiring consideration\nare:\n(1) The need for regional union bargaining annually with each hospital in a given\narea represented at negotiations.\n(2) The establishment of one approved superannuation scheme.\nRest Haven Hospital, Sidney, B.C.\u2014Assurance was given to all hospitals that the advent of\nB.C.H.I.S. would not affect regular, established, legitimate operating expenses. After a period\nof two years, B.C.H.I.S. rejected certain of our operating expenses without any reason. The main\nitem was an inexpensive but comprehensive pension plan which has been part of our regular\noperating expenses since 1922. The Board feels this should be accepted as an operating expense\nfor the following reasons\u2014the Hospital Insurance Service's original policy provided for the\nacceptance of hospital operating expenses that were in effect before the advent of the Service.\nOur employees' pension plan has been in effect in this hospital for the past thirty years.\nThe Honourable George S. Pearson promised that \" Services existing in hospitals prior to\nthe advent of compulsory hospital insurance would not be curtailed or interfered with.\" The\nHospital share of our pension fund is only 3 per cent of our payroll, which is very much\nlower than other hospitals with pension plans. Pension plans of other hospitals which were\nin effect before 1949 are being allowed.\nAnother view-point is expressed by the Royal Jubilee Hospital, Victoria, as follows:\u2014\nDuring the past few years hospital employees have taken advantage of the I.C.A. Act to\nsecure adequate bargaining privileges with hospital management and the employees no longer\nfeel that they should make a contribution to the community because hospitals cannot afford\nhigher wages. There can be no doubt that hospital employees are entitled to a fair wage but the\nhospital employees generally feel that they should retain all of the privileges which are traditional\nto hospital employment because of the low wage structure, and also receive wages comparable\nto modern industry.   Hospitals are giving more in perquisites than most types of occupation.\nHospital employment has become more popular since the inception of B.C.H.I.S. and it is\nnot difficult to recruit good personnel in most urban hospitals at the present time. To better\nunderstand the labour problem and the mounting cost of hospital payrolls, it is suggested that\nthe Hospital Inquiry Board might meet with official committees from properly organized employee\ngroups.\nThen, turning to the employees' point of view, the main submissions on their behalf\nwere made by the Hospital Employees' Federal Union, Local 180, which, we understand,\nis the bargaining agent for the majority of hospitals organized under the \" Industrial\nConciliation and Arbitration Act.\" REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 69\nThe representatives of this body first appeared before the Board in Vancouver in\nSeptember, when they made urgent representations to the Board in support of a written\nbrief, from which we quote somewhat extensively as follows:\u2014\nWe feel however that the burden of maintaining a service which is for the benefit of all\nshould be borne by all on a fair and equitable basis. No group of employees should be singled\nout to make special sacrifices or to subsidize a service which all enjoy. In our opinion, hospital\nemployees are being singled out and penalized. Regulations have been issued by the Hospital\nInsurance Service which seriously curtail the power of hospital employees to negotiate effectively\nfor wage increases which are necessary to offset the continued rapid rise in the cost of living.\nIn 1950 the government introduced its \" fixed budget\" policy to control the financial operations of hospitals in British Columbia. The introduction of this policy, coupled with an\namendment to the Hospital Act, passed at the last session of the Legislature, seriously weakens\nthe bargaining position of hospital workers. Under the amendment referred to above, hospital\nworkers are required to complete their negotiations by November 30th for all agreements for\nthe next calendar year. This means, for example, that all our negotiations with hospital boards\non wage contracts for the year 1952 must be completed on November 30th, 1951.\nAs a result of this regulation, also, the wage negotiations of hospital employees are now\ngoverned by the provisions of two separate statutes\u2014the Industrial Conciliation and Arbitration\nAct and the Hospital Act. In order to meet the deadline of November 30th, set out in the\nHospital Act, and at the same time comply with all the steps required in the conciliation and\narbitration under the ICA Act, negotiations on wage agreements must commence not later than\nSeptember 1st, four months before the annual contracts being negotiated are to go into effect.\nIn normal times it would be difficult enough to begin negotiations at such an early date.\nIn the present uncertain inflationary period, it places us in an almost impossible position. We\nare forced to \" guess \" what economic trends will be, and their possible effect on the cost of living,\nfour months before the wage agreement is to become operative, and sixteen months before it will\nexpire. Even a competent economist would hesitate to make such a prediction with any degree\nof accuracy.   It is neither fair nor reasonable to expect hospital workers to do so.\nWe also find ourselves set apart from the rest of the organized labour movement, with\nadditional handicaps placed on our wage negotiations. We are now required to negotiate all our\nwage contracts simultaneously during a concentrated three-month period of the year with\nnumerous local hospital boards located in many distant parts of this large province.\nFurthermore, there is no guarantee that even if an agreement on wages is reached between\na local hospital board and its employees, the decision is final and binding. The budget is subject\nto review, and possible revision or veto by the authorities in Victoria. This right to veto has\nalready been exercised by the Insurance Service when it disallowed a concession gained by the\nemployees of the Royal Columbian Hospital in New Westminster. But, ten miles away, the\nemployees of the Vancouver General Hospital are covered by this same condition of employment\nand the cost recognized by the Hospital Insurance Service.\nThus the position is that a budget drawn up by a local hospital board, including estimates for\nwage increases agreed upon after lengthy negotiations, may be curtailed. Such a reduction in the\nbudget may wipe out the estimates providing for a wage award. Under these circumstances, we\ncontend that the rights guaranteed to employees under the labour legislation of the province are\ndenied to hospital workers under the regulations of the Hospital Act, inasmuch as the authorities\nin Victoria, through control of the budget, can over-rule the decisions of the local hospital boards,\nthe bodies with whom the negotiations must be carried on. Apparently for us free trade union\nbargaining no longer exists.\nThrough their union, hospital workers seek first to establish reasonable wage scales, and\nsecond, to maintain their real wages in a period of rising prices through the negotiations of wage\nincreases. Under existing conditions, we do not see how the fixed budget policy of the government can operate without interfering with the opportunities of workers to ensure and maintain\na reasonable standard of living. This is clearly illustrated in cases where local hospital boards\ngrant, as some have, a cost of living bonus which calls for adjustments to keep pace with the rise\nin the cost of living. If the local hospital board is to live up to its agreement and grant the\nincreases provided for under the contract, the Hospital Insurance Service will have to deviate\nfrom its \" fixed budget \" policy.\nWe believe that a continual attempt on the part of the government to adhere rigidly to a fixed\nbudget in the face of unpredictable price increases in all hospital costs, supplies, and equipment\nas well as wages, will be an added threat to the wage levels and living standards of hospital\nemployees. Governments themselves find that they cannot function without supplementary\nestimates. In our opinion, some method must be provided to ensure flexibility in hospital budgets\nin order that the health service and wage standards will not suffer.\nThere has been no increase in the contributions of 70 cents per day toward the upkeep of\nhospitals which the municipalities have been paying for the past ten years. A contribution of\n4 FF 70 BRITISH COLUMBIA\n70 cents today is equivalent to only 35 cents as compared with ten years ago. In terms of purchasing power, hospitals are receiving only 50 per cent of the value of the contribution at the time\nthe figure of 70 cents was agreed upon.\nOf all municipal services, hospitals alone have not received an increased share from local\ntaxes. Roads, sewers, schools, fire and police protection, and the whole range of essential\nmunicipal services are now being financed and maintained at much higher rates. Hospitals are\nno less important to citizens than any of these other services. The local community has a\nresponsibility towards its hospitals. It is scarcely logical that such an important service should\nbe discriminated against in this way. Hospitals should share in the increased taxes which are\nbeing levied and collected by local authorities.\nWe cannot allow this opportunity to pass without some reference to the charge which is\nrepeatedly being made that wage costs are the cause of the rise in hospital costs. It is true that\nsubstantial improvements have been made in the wages and working conditions of hospital\nemployees. This was a necessary step. Hospital employees were a group of depressed workers\nin a depressed industry. Their wage increases were long overdue. But higher wages do not\nnecessarily mean higher operating costs. On the contrary, higher wages promote greater efficiency and can contribute to lower costs of operation.\nWe come back to the vital matter of wage negotiations for hospital employees. The British\nColumbia Hospital Insurance Service places the responsibility for wage negotiations in the hands\nof local hospital boards. The former does not enter directly into these negotiations. If local\nhospital boards have autonomy in regard to the wages of their employees, as contended by the\nHospital Insurance Service, then agreements arrived at between local hospital boards and their\nemployees in regard to wages should be accepted by the Hospital Insurance Service. If the\nHospital Insurance Service reserves the right to control the budget, as it does, and through this\ncontrol upset the basis on which wages are financed, then local hospital boards do not enjoy\nautonomy in regard to wages, nor do hospital employees enjoy the rights of collective bargaining\nto which they are entitled under the provision of the ICA Act. If the results of negotiations\ncarried out strictly in accordance with the Labor Act of the province can be arbitrarily wiped\nout by a body to which we do not have access and which was not a party to the wage negotiations, a situation exists which is a serious threat to the bargaining rights and wage standards of\nhospital employees.\nIn conclusion, our membership respectfully submits the following recommendation\u2014that\nlocal hospital boards should have autonomy in regard to wages and working conditions included\nin wage agreements with their employees and the cost of wage awards shall be incorporated in\nbudgets of the hospitals concerned.\nThe Board at that time promised to give due study and consideration to the representations which had been made. However, during further deliberations of the Board in\nVancouver, toward the end of October, representatives of this organization asked to be\nallowed to again appear before the Board, and this privilege was granted.\nWhile the contentions of the hospital boards and the hospital employees' representatives are set forth at some length above, and possibly do not need to be enlarged\nupon, it might be stated, to simplify the matter, that the chief causes of complaint are that\nthe hospital boards of the Province have been rendered virtually impotent to agree to\nwage and salary increases, cost-of-living provisions, etc., duly negotiated with the bargaining agents of their employees in accordance with the laws of the Province, because of\nthe effect of the \" fixed budget\" policy of B.C.H.I.S., and the directives issued thereunder.\nAttention was specifically drawn to the circular letter, dated July 13th, 1951, addressed\nto hospitals by the Commissioner of B.C.H.I.S., which reads as follows:\u2014\nTo all Approved Hospitals:\nSome time ago, hospitals were notified that the government was adopting a policy of fixed\nbudgets with regard to the operation of hospitals in this province. This policy was deemed\nnecessary in order to make it possible to coordinate the financing of hospital operation through\nthe Insurance Service with the overall policy of government finances.\nThe Hospital Insurance Fund is supported by premium payments, municipal and provincial\nper diem grants and additional assistance from the provincial government. The total amount of\nmoney available to the Service through the fund is decided upon during the session of the legislature each year, and there are no additional monies available during the year for hospital operation. It is essential then that the expenditures from this fund to hospitals be kept within the\namount provided in the fund each year. To achieve this, the policy of firm budgets has been\nadopted and it is desirable to call your attention at this time to the fact that the Hospital Insur- REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 71\nance Service has been directed by the government to adhere to the decision to institute and carry\nout this fixed budget policy. ,\nUnder these circumstances then, hospitals will readily realize that this policy is not compatible with any arrangements whereby expenses might vary in accordance with any proposal\nwhich embodies an escalator clause necessitating increased expenditure during a year of operation.\nIf a hospital board enters into a wage agreement which contains a cost-of-living clause, or\nextends the life of an existing agreement containing such a clause, and it becomes necessary\nduring 1951 and following years to make an upward salary adjustment as a result of the\ncost-of-living bonus clause, it will be the responsibility of the hospital board to provide the\nadditional funds required to finance the salary adjustment or, alternatively, to reduce other\nexpenses by a like amount. The application of the fixed budget policy does not make available\nfunds for interim adjustments of this nature during a financial year, and it is therefore essential\nthat hospitals adhere to the budget which has been approved for the year's operations.\nThis directive, properly read, is, of course, quite clear; it says that by virtue of the\n\"fixed budget\" policy adopted by the Government, responsibility for finding the funds to\ncover any form of wage increases not included in the accepted budget must rest with the\nhospital board concerned and cannot be accepted by the B.C.H.I.S.\nAt its last interview with the Board the Hospital Employees' Federal Union drew\nthe attention of the Board to the fact that they had negotiated wage agreements for 1952\nwith the Vernon and Kelowna Hospitals, and that a few days later they had received from\nthe Administrator of the Vernon Jubilee Hospital a letter, dated October 12th, 1951,\nfrom which the following is quoted:-\u2014\nI have been instructed by Mr. K. W. Kinnard, Chairman of the Board of Directors of this\nhospital, to advise you that the B.C. Hospital Insurance Service is not willing to accept the terms\nof the agreement as tentatively agreed upon at the meeting held with you on October 2nd.\nI am not in a position to give you any detail at this time as it is the intention of the President\nto confer with representatives of the B.C.H.I.S., who will be in attendance at the B.C. Hospitals'\nAssociation's convention which is to be held in Vancouver from October 16th to 19th.\nThe representatives of the Hospital Employees' Union interpreted the statement in\nthe two documents referred to as being a denial by the Commissioner of B.C.H.I.S. of the\nrights of hospital boards and hospital employees to agree upon wage rates and conditions\nin accordance with powers conferred by the laws of the Province. It must be admitted\nthat in view of the position in which the hospital boards are placed by the \" fixed budget\"\nprovisions of B.C.H.I.S., the factual result is as stated by the Hospital Employees' Union.\nIt should also be stated quite clearly, in all fairness, that the union representatives frankly\nadmitted that because of the nature of the duties of hospital employees, strike action on\ntheir part was unthinkable.\nIn consultation with Dr. Baird, Administrator of the Regina General Hospital, the\nBoard learned that the Saskatchewan Hospital Services Plan does not tell the hospital\nwhat it can and must do in connection with wage agreements, but rather insists on the\nhospital board negotiating the best deal it can get.\nThe Board laboured long and arduously in an effort to find some satisfactory solution (or recommendation) concerning this very important subject. The Board has\nelsewhere dealt with the matter of future hospital budgets and, in the hope that their\nrecommendations in connection therewith will be accepted and implemented, the Board\nbelieves that this entire matter of wage rates, in all its detail, may thereafter be brought\nto a completely satisfactory conclusion. The Board does not feel that it is now in a\nposition to pronounce final judgment upon the very important question with which it\nhas been grappling, and the best it can do is look forward to satisfactory action being\npossible when its other recommendations for changes in the Service have been studied\nand adopted, and to some extent put into effect.\nThe Board now therefore recommends that, because of the evidence of a great deal\nof dissatisfaction on the part of the hospital boards of the Province and the employees\nthereof, as represented by their bargaining agents, with the attitude and actions of\nB.C.H.I.S. concerning wage agreements, and because the Board believes it is not the FF 72 BRITISH COLUMBIA\nfunction of B.C.H.I.S. to interfere directly or indirectly in the matter of wage negotiations, an early conference of all interested parties be held\u2014namely, the hospital boards\nor Hospitals' Association, the hospital employees or their bargaining agents, and representatives of the Department of Labour\u2014in which conference the Administration of\nB.C.H.I.S. shall take no part:\nAnd, further, that the Board point to the agreements which have been arrived at\nand are now in force with policemen's and firemen's organizations in various parts of\nthe Province, as forming a possibly acceptable solution on which to base a permanent\npolicy as regards hospital employees and the terms of their employment. It is intended\nthat the aforementioned conference shall deal with all matters having to do with the\nposition of employees of hospitals, including the matter of pension and superannuation\nfunds and the allowable contributions thereto of hospital boards.\nNo. 43.\u2014STUDENT NURSES:   HOURS OF WORK\nThe Registered Nurses' Association of British Columbia submitted a most constructive brief to the Board. Many of their suggestions are reflected in the Board's recommendations. Their submission contained a reference to hours of work of student nurses,\nas follows:\u2014\nThe Registered Nurses' Association has drafted recommendations concerning hours of duty\nand health protection for student nurses. These with certain modifications have been approved\nby the Association's Committee on Educational Policy (on which each school of nursing and\nthe British Columbia Hospitals' Association have representation) and by the Government Committee on Nursing Service. During the past five years the Association has periodically discussed\nwith the Honorable Minister of Health the great need for implementation of clause 29 of the\nRegistered Nurses' Act which reads:\n\" The Lieutenant-Governor in Council may make regulations governing the hours of duty\nfor student nurses in schools of nursing.\"\nWe believe that the cost of decreasing the students' hours of duty from 48 hours to 44 hours\nper week (the major change proposed and one which would necessitate additional graduate staff)\nhas been the reason no action has been taken. We therefore strongly urge that monetary\nconsideration not be permitted to postpone implementation of this clause, in line with the\nrecommendations made by the Association.\nIn reviewing the subject of hours of work for student nurses, the Board learned\nthat at the Regina General Hospital, where there is a training-school for nurses with an\nenrolment of 215 students, a forty-four-hour work-week is in force, with a three-week\nvacation, plus statutory holidays.\nThe Board therefore recommends that the request of the Registered Nurses' Association of British Columbia with reference to hours of work of student nurses be given\nfavourable consideration.\nNo. 44.\u2014RESPONSIBILITY FOR HOSPITAL ACCOUNTS\nOF EVADERS\nThe Board has elsewhere recommended that, subject to certain conditions, a registrant under B.C.H.I.S. shall be entitled to the benefits thereof in any benefit period for\nwhich he has paid the current premium; and, further, the Board has recommended that\nthe arrears of premiums for which any person is liable shall cover only a certain fixed\nand definite period prior to his original registration. The Board has further recommended that the collection or realization of such arrears shall be the responsibility of\na special department of B.C.H.I.S. The Board has also suggested and recommended\ncertain improved methods and procedures by which it is hoped that a maximum percentage of the population of the Province will be registered and covered under the Act\nand regulations.\nIt is nevertheless recognized that there will be some small percentage of evaders of\nthe scheme still in existence, and it is further recognized that from time to time some of\nthese evaders will enter the hospitals of the Province for acute or general treatment. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 73\nThe Board believes that, under a scheme made compulsory by Provincial legislation, such evaders are not the final responsibility of local hospital authorities in any way.\nMany representations have been made to this effect by individual hospitals. These are\ntoo numerous to be quoted here, but the whole sense of the matter may be considered\nto be covered by the following remarks found in the brief of the British Columbia\nHospitals' Association:\u2014\nFailure to cover all persons liable to pay premiums has created one of the most expensive\nand difficult problems now facing both B.C.H.I.S. and the hospitals, namely, identification of\npersons entitled to hospitalization under the plan. If all liable persons were covered, it would\nonly be necessary for the hospital to prove residence and length of residence.\nBeing in agreement with the reasoning behind these representations\u2014\nThe Board now recommends that, since the collection of premiums under the\n\" Hospital Insurance Act\" is the function of the B.C.H.I.S., then the final responsibility\nfor the collection or coverage of any hospital accounts incurred by evaders of the provisions of the Act is for the Service to assume, and that such a policy should be\ndefinitely adopted, but nevertheless the hospital board or administration concerned shall\ninitiate and exhaust all reasonable steps in their endeavours to collect the said accounts\nfrom the patient or his responsible relatives in the first instance.\nNo. 45.\u2014ELIMINATION OF SOCIAL SECURITY AND MUNICIPAL AID\nTAX ON HOSPITAL SUPPLIES\nIt has been pointed out by many hospital boards that drug supplies and hospital\nequipment generally are exempt from Federal sales tax of 10 per cent but the Provincial\nsocial security and municipal aid tax applies to all such items going into a hospital,\nexcept drugs that are specifically prescribed by a physician. In other words, hospital\nequipment and supplies such as are exempted from the Federal sales tax are assessed\nthe Provincial tax, with this single exception.\nAs all hospitals are non-profit institutions and as Government subsidies are made\ntoward hospital deficits, it is suggested that exemption from the Provincial tax to the\nsame degree as is granted in the case of the Federal tax would eliminate a lot of clerical\nand paper work and result in a net saving to the British Columbia Government.\nThe Board therefore recommends that the cost of purchases made by the hospitals\nof the Province covering articles or supplies which are exempted from the Federal sales\ntax be also exempt from the imposition of the social security and municipal aid tax.\nNo. 46.\u2014PURCHASE OF NEW EQUIPMENT:   CONSENT\nOF B.C.H.I.S.\nA somewhat minor matter which appeared to be causing concern to some hospital\nboards and administrators was the procedure outlined to be followed in order to secure\nthe necessary permission from B.C.H.I.S. for the purchase of new equipment toward\nthe cost of which a Government grant could be expected. It would appear that a capital\nexpenditure of practically any amount for equipment which has a certain life expectancy\nmust be first authorized by the Commissioner of B.C.H.I.S. if the hospital in question\nexpects to receive a Government grant covering a portion of the cost.\nAs can be understood, this procedure technically applies to items of comparatively\nsmall cost, but nevertheless essential to the hospitals concerned. In many of these cases\nthe purchase of the required equipment is necessary on short notice, and the complaint\npresented to the Board was that there is undue delay in obtaining the needed permission.\nThe hospital is required to submit a form of application showing the specifications of\nthe article in question, the life expectancy, and the tenders received to cover its cost.\nIn certain cases, even of expenditures of comparatively large amounts, it could (according to the hospital board or administrator) be demonstrated that the said cost would be FF 74 BRITISH COLUMBIA\nfully recovered in savings effected by the use of the new article, in even one operating\nyear\u2014and, in many cases, over a slightly longer period.\nIn view of rising prices, and the fact that it is not always possible to get a fixed and\ndefinite tender which is not subject to upward revision, it appeared from testimony given\nto the Board that annoying consequences had followed the delay in granting of permission by B.C.H.I.S.\nAs already stated, this would seem to be somewhat of a minor problem, and we\nfind that in the larger hospitals adjacent to the centre of B.C.H.I.S. Administration,\nthe problem has not caused any serious difficulties. Nevertheless, the Board considers\nthat the position of the smaller and more remote institutions is worthy of note, and for\nthis reason\u2014\nThe Board now recommends:\u2014\n(a) That the mechanics or operation of the rules and regulations pertaining\nto the granting of permission to purchase new hospital equipment shall\nbe examined with a view to eliminating the difficulties and delays so far\nencountered, and thereby remove the cause for any complaint in the\nfuture:\n(b) That purchases by the hospitals of such new equipment not having a cost\nvalue higher than $100 be made permissible without the prior consent of\nthe B.C.H.I.S. Administration having to be obtained.\nNo. 47.\u2014CENTRAL PURCHASING AGENCIES\nPractically all submissions made to the Board showed a keen general interest in\nrapidly rising costs of operating hospitals, and there was a genuine desire expressed to\ncontribute suggestions that would help to counteract this tendency.\nA suggestion that came from many quarters was that central purchasing on some\nplan be resorted to by the hospitals of the Province.\nA study of the matter revealed to the Board that such a policy was fraught with\nsome difficulty, but, nevertheless, it is believed that it holds great possibilities. Certain\nitems, no doubt, could be purchased collectively on behalf of all hospitals in the Province, whereas in some cases this would be impractical. In the latter case, pool-purchasing would only be possible by smaller groups of hospitals located in particular zones\nthroughout the Province.\nThe Board has ascertained that the system of pool-purchasing of supplies, etc., for\nhospitals has been found to be successful in certain cities, with special reference to the\nCity of Cleveland, Ohio, and also that plans are being laid to inaugurate a system of\npool-purchasing on a regional basis for the hospitals in the Province of Saskatchewan.\nMr. Cox, Assistant Commissioner of B.C.H.I.S., in discussing this matter with the\nBoard, stated that he had continually urged hospitals to try some measure of pool-\npurchasing, at least in different zones. He believed they could perform a good service.\nHe said individual hospital administrators in many cases did not know the mechanics of\ngood purchasing.\nThe Board therefore recommends that B.C.H.I.S. encourage hospitals to develop,\nto the greatest extent possible, a system of bulk centralized purchasing of supplies.\nNo. 48.\u2014DISPENSING OF DRUGS\nThe matter of dispensing of drugs in hospitals was reviewed in great detail by the\nPharmaceutical Association of the Province of British Columbia. The highlights of their\nsubmission in this regard are as follows:\u2014\nThe Pharmacy Act of the Province of British Columbia was passed on March 3, 1891.\nIt is obvious, even from the date of this earlier legislation, that the Act was intended for the\nprotection of the health of the public. It was designed to see that the persons who were\ndispensing medicines for the public in drug-stores throughout the province should only be REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 75\npersons who had adequate training and technical and professional knowledge to enable them to\ndischarge these duties in a careful, efficient and capable manner.\nConditions have changed throughout the years and, even before the advent of the B.C.\nHospital Insurance Service, persons were entering hospitals for treatment for many diseases\nwhich in former years were treated at home. At the same time, medical and pharmaceutical\nresearch was proceeding apace and new therapeutic discoveries were made. Today, more than\never before, the compounding and dispensing of prescriptions calls for a very high standard\nof professional skill and knowledge which is reflected in the extension of pharmaceutical training\nacross Canada through practical experience under the College of Pharmacy to a five-year course.\nAs the Pharmacy Act exists and has been passed by the legislature of British Columbia,\nand of all other provinces across Canada, for the protection of the public, it is but logical that\nunder a hospital insurance scheme, sponsored and directed by the Government, the same margin\nof protection for the health of the public in regard to the dispensing of prescriptions by competent\nand trained personnel must be afforded.\nThe Pharmaceutical Association of British Columbia embraces every pharmaceutical chemist\nin the province of British Columbia and licences under the authority of the Pharmacy Act\nall retail pharmacy and hospital dispensaries operating in British Columbia. The Association\nis entrusted by the Government with the responsibility for maintaining the high standards of\nservice for such establishments as are established under the authority of the Pharmacy Act. The\nAssociation is one of the most democratic in Canada in that all employers and employees have\nan equal vote in the affairs and administration of the Association.\nThe principle that pharmacists should handle the dispensing of prescriptions has been\napproved under the British scheme, by the Canadian Government, and by our own British Columbia Government.\nThe situation in British Columbia since the advent of hospital insurance has become steadily\nworse from the standpoint of protecting the health of the public in regard to the dispensing of\ndrugs in hospitals. The reasons for this situation are undoubtedly economic. In the first place\nit is now quite apparent that innumerable hospital boards, in determining their per-patient per-day\nrate for submission to the Hospital Insurance Commission, did not include drugs in their estimated costs. To overcome this situation, many of these smaller hospitals, and some larger\nhospitals of 100 beds or more, operating without a dispensary, have started the purchasing of\nincreasing quantities of drugs from manufacturers and wholesalers, and these drugs are being\ndispensed for patients in the hospitals by nurses and other persons who are not qualified, either\nby training or through legal standing, for the dispensing of such drugs. The development of this\npractice is seriously endangering the lives of patients in hospitals. A number of minor accidents\nhave already occurred, and a serious accident may take place at any time.\nIt would appear that there has been a tendency on the part of the Hospital Insurance Commission to condone this situation in view of the alleged economy in operations. In actual practice it is extremely doubtful that any real economies are effected. The buying of pharmaceuticals\nfor a dispensary or hospital is a very complicated problem, requiring professional knowledge.\nThere are an enormous number of duplications and a matron, or nurse, or other unqualified\npersons, doing the buying of pharmaceuticals and drugs for hospitals, may pile up a very considerable stock, which would not be necessary if some person with the proper skill and knowledge\nwas handling the actual buying. In addition, many pharmaceutical preparations go bad in\na short period of time, and knowledge of the proper storage and the length of time which\nquantities of certain drugs can be stored is essential in order to maintain these drugs in their full\nstrength, and to be sure that when used in dispensing, they have their full therapeutic efficiency.\nNumerous pharmacists have reported to this office that they have on occasions been called\nin by the local hospitals to advise them regarding a large accumulation of drugs. In many cases\nthese pharmacists state they had found the drugs had been in stock so long they were useless and\nthey have consequently been destroyed by the matron on the advice of the pharmacist concerned.\nIt has been suggested that every hospital in British Columbia should have a pharmacist.\nIn actual practice this does not seem possible. However, it would seem essential that the B.C.\nHospital Insurance Commission should accept the responsibility for seeing that drugs are dispensed to patients in hospitals under legal conditions and in compliance with the regulations of\nthe province, and of Canada. The subject of hospital insurance is receiving increasing study from\npharmacists, and the College of Pharmacy of the University of British Columbia is now preparing\na post-graduate course, which will give particular instructions to those interested in the development of this field of pharmacy.\nIn the Province of Saskatchewan, a plan has been worked out whereby hospitals under 100\nbeds can make an arrangement with the local pharmacist, and he will purchase their stock of what\nis described as ward stocks in the name of the hospital, thereby securing the benefit of exclusion\nof the 10 per cent Sales Tax, granted on hospital purchases by the Federal Government, and at\nthe same time taking advantage of quantity prices and lower quotations, extended by manufac- FF 76 BRITISH COLUMBIA\nturers to the hospitals. While thus buying, in the name of the hospital, drugs which are used in\nlarger quantities by the hospital, these pharmacists handle the actual preparation and control\nof the stock of such drugs as are turned over to the wards of the hospital, and other prescriptions\nwhich have to be individually compounded or dispensed on a scale or prescription basis in their\nown drug-stores for the patients in such hospitals. This scheme has worked out satisfactorily\nin Saskatchewan, and has permitted the compliance with the requirements of the Pharmacy Act\nthere; maintained a high standard of pharmaceutical service for the patients; and resulted in\ndefinite economy in hospital operations.\nIn one of the largest hospitals in British Columbia it has been found that through the efficient\noperating of a committee composed of representatives of every group of specialists in the professions, it has been more economical to eliminate duplications there and to permit free supply\nof all drugs to patients in that hospital. In effect this arrangement has made it possible to avoid\ncarrying possibly a dozen or more competitive brands of pharmaceuticals, thereby reducing the\noverhead of the hospital. It is also maintained that if it were necessary to keep separate records\nand to bill hospital patients for some drugs, while supplying others free, it would greatly increase\nthe overhead of the dispensary, as it would involve charging for these drugs on a basis of retail\nprices instead of the cost-plus-time basis which is in effect under the more embracive scheme.\nWhile such an arrangement as this, we have been assured, can be worked out with the utmost\neconomy in a larger hospital, it would seem that the publication of an enlarged B.C. Formulary\nwould provide the solution in the smaller hospitals. It has been found under the Medical\nAssistance Branch of the Department of Health and Welfare, that our present Formulary is\ninadequate, and a large number of additional items have been included. In fact the scheme is\nnow so broad that almost anything within reason, which is ordered by a doctor and can be\njustified by the medical director of the scheme, is approved. A joint committee of the B.C.\nMedical Association and the B.C. Pharmaceutical Association has been at work for many months\non the preparation of a new edition of the B.C. Formulary, which should go a long way to solve\nmany of the problems involved in hospital dispensing at the present time.\nIn connection with the employment of pharmacists in hospitals, there is no doubt that even\nsmaller hospitals could, under many circumstances, employ a pharmacist profitably. The following are but a few suggestions which have been supplied by hospital pharmacists in this\nconnection:\n1. Besides their duties of dispensing prescriptions and supplying and keeping records of\nmedicines used in different ways, a pharmacist in a smaller hospital can improve on\nprocedures and techniques used in laboratories, and arrangement and preparation of\nstock preparations.\n2. Advise the physician which type of medication will be most economical for treatment\nto long-term patients (cancer patients, control of pain, etc.).\n3. Assisting or taking care of purchases of supplies or equipment for the hospital.\n4. Keep physicians, internes, and, to some degree, nurses posted on the latest information on new pharmaceuticals.\n5. Use his knowledge along research lines and in many cases possibly develop new\nmethods and improved equipment which will result in economies.\n6. In some cases, he could act as hospital accountant and also keep hospital records.\nThere are possibly many other points that will occur.    I think one of the most important is\nthe fact that by his knowledge a pharmacist in a hospital may be in a position to supply some\neffective medication which will reduce the time of the stay of the patient in the hospital, thus\neffecting economies in the per-patient cost and making a larger number of beds available more\nquickly, and by eliminating the necessity for increasing the hospital overhead by the provision\nof additional beds.\nIt is quite evident that the present situation in regard to the steady increase of indiscriminate\ndispensing of drugs in hospitals cannot continue without serious consequences. Hospitals themselves cannot expect to collect on public liability insurance where dispensing, resulting in an\naccident, is the consequence of a deliberate violation of the laws of the province. Hospitals at\nthe present time have no other revenue than from the government, and any extensive litigation\nwould be directly reflected in the expenses which the government would be called on to pay in\nconnection with hospital operations. At the same time the B.C. Pharmaceutical Association,\nentrusted as it is with the responsibility for the health of the public, cannot sit by indefinitely and\nsee the practice of dispensing prescriptions by unauthorized persons continuing to increase in\nhospitals throughout the province.\nIt is apparent to the Board that the recommendations of the Pharmaceutical Association of the Province of British Columbia are soundly based\u2014\nAnd the Board therefore recommends that all dispensing of drugs in hospitals, or\nfor hospital patients, should be done by registered pharmacists or qualified physicians. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 77\nNo. 49.\u2014CHRONIC CASES (SOCIAL WELFARE)\nREMAINING IN HOSPITAL\nA great deal of attention was drawn by various organizations and individuals to\nanother phase of the general subject of hospitalization of chronic cases.\nIt is an admitted fact that where a case has been ruled chronic, a patient cannot, in\nmany instances, be quickly removed from the general hospital because of the fact that\nno suitable place is available to which he might be transferred. The Board has dealt\nwith the extension of the liability of B.C.H.I.S. for cases which do not come as a responsibility of the Social Welfare Branch. There remains, therefore, a consideration of the\nposition of the general hospital in numerous cases, where such persons who are the\nresponsibility of the Social Welfare Branch are concerned. It has apparently not been\nthe custom of the Social Welfare Department to accept any liability for costs incurred\nin the time elapsing before the chronic patient is removed from the general hospital.\nIn the meantime, B.C.H.I.S. has terminated its liability, with the result that the hospital\nhas been providing facilities and treatment in many cases, with no source from which\nto collect the cost thereof.\nArising out of this situation, it was pointed out that in some hospitals in the Province\nwhere the bed occupancy is not overtaxed, it is quite possible for the said hospitals to\nretain these patients without adversely affecting the admittance of acute cases, and\nthereby relieve the urgency of the demands on the Social Welfare Department to remove\nthe said patient.\nWhile the Board does not consider it desirable to recommend any policy which\nwould encourage the utilization of hospital beds ordinarily intended for acute cases by\nsuch chronic cases, they are nevertheless confronted with certain conditions existing at\nthe present time, and in view of these\u2014\nThe Board therefore recommends that where B.C.H.I.S. acknowledges that there\nis a surplus of beds in any general hospital, and the board of the hospital affected comes\nto an amicable agreement with the Social Welfare Branch to accept chronic cases at\na certain rate differing from the fixed per diem rate approved by B.C.H.I.S., the consent\nof B.C.H.I.S. be given. The policy enunciated by the foregoing is predicated on the\nassumption that the beds so acknowledged to be surplus may be set apart for the use of\nchronic or convalescent cases, and will remain in that classification until the entire bed\nsituation of the hospital concerned is reviewed by the hospital administration and\nB.C.H.I.S.\nNo. 50.\u2014GENERAL RELATIONS WITH B.C.H.I.S.\nThe success of our Hospital Insurance Service is dependent on the establishment\nof good relations with those who play a part in rendering hospital service. There is no\nclass of people who are in a more important position in this respect than the hospital\nboards and administrators. It is therefore essential that negotiations, correspondence,\nand all relations between B.C.H.I.S. and the hospitals should be on a most harmonious\nplane. We have learned that this fact is appreciated by the Commissioner, and some\nheadway has been made in establishing an over-all co-operative relationship with\nhospitals.\nHowever, shortages of personnel and other difficulties related to the embryo stage of\nthe whole service are responsible for a serious lack of accomplishment in this direction.\nThe average hospital needs counsel and advice on many matters, including administration, purchasing, dietary, and other phases of hospital operation. Improved conditions\nin the operation of the hospital will result in economies which will reflect in the budget,\nand we feel sure that a reasonable expenditure in this field of service to hospitals will be\namply repaid. To express the opinion of a representative hospital in regard to this\nmatter, we quote from a submission to the Board from the Vancouver General Hospital,\nas follows:\u2014 FF 78 BRITISH COLUMBIA\nIt is our feeling that closer co-operation between the B.C. Hospital Insurance Service and\nthe Administration of the hospitals would assist in breaking up a great many of the problems\nwe have mentioned in our brief.\nWe know that the B.C. Hospital Insurance Service has the problems of the hospitals at\nheart and, now that the first pressure of getting the plan under way is over, we believe the time\nis opportune for representatives of the B.C. Hospital Insurance Service and the hospitals to sit\ndown and work out the remaining problems.\nRecommendation: That a procedure be established whereby representation of the Boards\nof the hospitals could confer with representatives of the B.C. Hospital Insurance Service to\ndiscuss problems.\nThe Board therefore recommends that the B.C.H.I.S. round out, as soon as possible,\na complete organization of specialists in the various phases of hospital operation and\nmanagement, to the end that they may render maximum assistance to hospitals and\nreceive full co-operation in return.\nNo. 51.\u2014HOSPITAL CONSTRUCTION AND EXTENSION, ETC.:   STUDY OF\nNEEDS AND PROVISION FOR HOSPITAL IMPROVEMENT DISTRICTS\nUnder the terms of reference set out in the Act authorizing an inquiry into the\n\" Hospital Insurance Act\" and its administration, clause (c) of section 5 specifically\ngave the Board power to investigate the matter of hospital-construction.\nThe Board regrets that time has not permitted this particular phase of its commission\nto be carried out in anything like a completed manner, and the subject must therefore\nbe dealt with in this Report in somewhat general terms. The conclusions arrived at by\nthe Board are set out as follows:\u2014\n(1) Due to the rapid growth of population and industry, the Province is in\nurgent need of some new and additional construction of both acute or\ngeneral hospitals and chronic or convalescent institutions.\n(2) In view of the urgent need, it is suggested by the Board that there should\nbe, at the earliest possible date, a very intensive study of the present needs,\nthe advantages to be derived from a zoning scheme to cover the hospital\nfacilities of the Province, and with particular reference to the debatable\nquestion of centralization or decentralization; and that this study should\nalso definitely go into the nature of, and the best place in which the\nprovision of, additional accommodation for chronic and convalescent\ncases may be provided; and, further, that the best advice should be\nsecured on the controversial subject of the percentage of private, semi-\nprivate, and public wards in general- and acute-hospital construction.\nThe Board further suggests that the main stumbling-block to proceeding at a satisfactory pace to meet the demand existing for extended hospital facilities is the lack of\nproper legislation which will outline the responsibilities of various departments of\nGovernment. It would appear essential, for instance, to provide by law that all municipal\ngovernments shall take their full share of responsibility in this connection. It would\nfurther appear desirable to provide a legal plan by which action may be speedily, simply,\nand efficiently taken in cases where more than one municipality or department of\ngovernment is concerned.\nThe Board is of the opinion that the amendments to the \" Water Act,\" passed by\nthe 1951 Session of the Legislature, which were intended to help in this connection, have\nproven by subsequent experience to be unsatisfactory and inadequate. The Board has\nbecome acquainted with the \" Union Hospitals Act\" of Saskatchewan. The evidence\nis that this Act, which was instituted in 1916 and is, therefore, not new legislation, has,\nduring the years since 1939 (and more particularly since 1945), worked in a very\nsatisfactory manner. The provisions are simple and straightforward, and the responsibilities of all concerned are clearly defined. It is suggested, therefore, by the Board that\na new Act be provided for the Province of British Columbia, to be known specifically REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 79\nas the \" Hospital District Improvement Act,\" which will follow very much along the lines\nof the \" Union Hospitals Act\" of Saskatchewan; and that upon its adoption the provisions\nnow in force, particularly those having to do with the \" Water Act,\" shall be rescinded.\nBefore leaving this suggestion of increased or expanded hospital facilities, the Board\nwishes to state that it has studied, with a very considerable degree of interest, plans for\nthe establishment of health units within the Province, under the control of the Department\nof Health and Welfare, of which the first full unit is now operating in the Vernon area.\nThe information available in this connection leads the Board to believe that the intended\nservices in these health units will, no doubt, in time be of great benefit to the Province,\nand that the results thereof will be sufficient to cause an appreciable lightening of the\nburden placed upon hospitals by overoccupancy and undue length of stay.\nThe Board further would say that it has had called to its attention other developments of home-care treatment which have taken place, particularly in the United States.\nIt would appear that this development probably originated from plans similar to the\none now being tried in the health units of the Province. In this connection, attention\nis particularly called to the home-care programme of the Montefiore Hospital of New\nYork City, which was commenced on January 1st, 1947, and which, before the end of\n1949 (according to material studied by the Board), had definitely proved its worth and\neffected savings in the net total of hospitalization costs.\nDealing with the allied phases of hospital construction and service, we would here\nbring to notice a paragraph from the brief submitted to the Board by the Registered\nNurses' Association of British Columbia, which is concurred in by this Board:\u2014\nStandards under which hospital construction grants are made available to hospitals are\na responsibility of the Hospital Insurance Service and we assume that the Service will carry\nsimilar responsibility in respect to grants-in-aid for schools of nursing. We urge that standards\nin regard to facilities for instruction, residence and recreation be developed in collaboration\nwith representatives of the Registered Nurses' Association.\nThe Board now recommends that a more intensive study of the whole matter of\nhospital construction than was possible in the limited time available to the Board be made;\nand\nIt is further recommended that this study be proceeded with as soon as possible.\n\/\/ is further recommended that new legislation be enacted, similar to the \" Union\nHospitals Act\" of the Province of Saskatchewan referred to in the preamble to this\nrecommendation, which will enable the setting-up of hospital improvement districts in\nthe Province of British Columbia. FF 80 BRITISH COLUMBIA\nThe Board wishes to record a high tribute to our\nSecretary, Mr. Maurice Hesford, F.C.A. His devoted\ninterest, sincere loyalty and broad experience has been\nof invaluable assistance to us in our task. We also wish\nto express our sincere thanks to all other members of\nour staff for their efficient service. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 81\nAll of which we respectfully submit.\nS. J. SMITH, Chairman.\nDON. C. BROWN.\nWALTER HENDRICKS.\nA. W. LUNDELL.\nD. J. PROUDFOOT.\nR. C. STEELE.\nH. J. WELCH.\nHAROLD E. WINCH.\nMaurice Hesford, Secretary.      February, 1952. FF 82 BRITISH COLUMBIA\nSECTION 6.\u2014APPENDICES\nSUMMARY OF RECOMMENDATIONS OF THE BOARD\n1. Completion of Unfinished Survey and Study.\u2014That the time for submitting its\nfinal report be extended so that Messrs. Stevenson and Kellogg Limited may be enabled\nto complete their survey, after which the Board may proceed with a combined study of\nthe two reports referred to before filing the final report of this Hospital Insurance\nInquiry Board with the Minister of Health and Welfare.\n2. Continuation of Hospital Insurance Service (Basic Plan).\u2014That the B.C.H.I.S.\nshall continue to follow the present plan as referred to in Approach No. 1 of the Eckler\nReport, subject only to the recommendations contained in this Report of the Board,\nuntil this Board is in a position to file its final report.\n3. Premium Rates.\u2014That at present there shall be no increase in the premium\nrates.\n4. Co-insurance Charges.\u2014That co-insurance charges against patients in hospitals\nbe completely abandoned.\n5. Financing Over-all Deficits of Plan.\u2014That a long-range programme of financing\nthe Service be developed, with a definite policy and formula of Government financial\nsupport, and that there be established a policy that should a deficit develop in the\nhospital insurance financial year for reasons over which the hospitals and B.C.H.I.S.\nhad no control or which could not reasonably be foreseen by B.C.H.I.S. or the Government, then the said deficits shall be paid from consolidated revenue.\n6. Municipal and Provincial per Diem Grants.\u2014(1) That the per diem contribution paid by municipalities or by the Government, in the case of unorganized territories,\nshall be increased from the present basis of 70 cents per patient-day to the sum of $1\nper patient-day.\n(2) That consideration be given to basing the contribution mentioned above on\na per capita basis rather than the present per patient-day basis, with the per capita rate\nthereof being set to produce an approximately equal amount of revenue to the Service.\n(3) That where a resident of a municipality or of an unorganized territory is\nhospitalized in a hospital outside the confines of his own municipality or territory, the\nsaid municipality, or the Government on behalf of the unorganized territory, shall pay\nan additional 25 cents per patient-day in connection with such patients. This additional\npayment shall be made direct to the hospital in question, to be treated as non-operating\nrevenue of the receiving hospital, and the hospital concerned shall be required to bill the\nproper authority for this additional 25 cents per patient-day charge.\n7. Future Increase of Premium Rates or Curtailment of Benefits.\u2014That there shall\nbe no further or future increase in the premiums required to be paid annually, and no\nreduction of benefits conferred by the Act within any premium-year; and that any such\nchanges as may be, from time to time, authorized by Act of the Legislature, affecting\nthe annual premium payments or the benefits conferred by the \" Hospital Insurance\nAct,\" shall have effect only at the commencement of the next premium-year.\n8. Exemption of Groups on Religious Grounds.\u2014That in future no group of citizens\nof the Province be exempted from the provisions of the \" Hospital Insurance Act\" on\nreligious grounds, and that the present exemption extended to members of the Christian\nScience Church shall be discontinued.\n9. Exemption of Groups: Canadian Pacific Medical Association of British Columbia\nand Telephone Employees' Medical Services Association of British Columbia.\u2014That the\nposition of the present exempted groups referred to above shall be reviewed by competent authority as soon as possible, with a view to bringing the members of such groups\ndirectly within the operations of the B.C.H.I.S. at such a time as it may be found\nfeasible and advisable to so do. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 83\n10. Exemption from Premium Liability: Low-income Groups.\u2014That in the case\nof persons not otherwise exempted from the personal payment of premiums and who\ncan establish that their income is not more than $720 for the year in the case of a single\nperson or $1,200 for the year in the case of a married person, the said persons shall\nbe exempted from personal payment of the premium, but that the proper premiums for\nthem shall be paid to B.C.H.I.S. by the proper Government department.\n11. Exemption from Premium Liability: Student Nurses under 21.\u2014That student\nnurses, not over the age of 21 years, be recognized as dependents in the same manner\nas those persons presently covered by subsection (d) of section 1 of Regulation 1, under\nwhich dependents are defined.\n12. Benefits: Out-of-Province Hospitalization. \u2014 That when a registrant under\nB.C.H.I.S., or his dependent, in good standing, is compelled by circumstances beyond\nhis control, or on the definite advice of his physician in British Columbia, to take hospital treatment outside the confines of the Province (more particularly when the home of\nthe patient is so geographically located as to make the out-of-Province hospitalization\nnecessary or desirable), B.C.H.I.S. shall pay for the said hospitalization a rate of $6.50\nfor each patient-day up to a limit of thirty days, plus a maximum of 50 per cent of the\ncost of all extras which would be covered completely by B.C.H.I.S. if the treatment was\nin a hospital in the Province.\n13. Benefits: Out-patient Services.\u2014That careful study be given as soon as possible\nto the question of benefits having to do with out-patient services of hospitals, with\na view to setting up the most desirable scheme from the view-point of service and the\ninsured public;  and that changes as decided upon be put into effect in the Province.\n14. Charges for Non-elective Use of Private and Semi-private Wards.\u2014That in the\ncase of non-elective use of private- or semi-private-ward accommodation in hospitals\nwithin the Province, there be no extra charge to B.C.H.I.S. registrants for the said\naccommodation.\n15. Premiums Payable by Wives of Certain Veterans.\u2014That in the case of married\nwar veterans who are themselves completely covered for hospitalization by the provisions\nor regulations of the Department of Veterans' Affairs at the time being in force, the\npremium required to be paid by, or for, his wife (in case the family income is over\n$1,200 per annum) shall be the premium of a single person.\n16. Hospitalization of Treaty Indians\u2014Federal Government Responsibility.\u2014That\narrangements be made with the proper department of the Government of Canada for\npayment by it of the total cost of hospitalization of Treaty Indians of British Columbia.\n17. Payment for Hospitalization of \" Social Aid \" Cases.\u2014That these persons comprising the groups of Health and Welfare cases referred to above be no longer accepted\nby the Service on an ordinary premium basis, but that the responsible Government\ndepartment\u2014namely, the Department of Health and Welfare\u2014pay the full cost of hospitalization of all such persons coming within these groups, such payments to be made\nto the B.C.H.I.S.\n18. Educational Grants-in-Aid to Cost of Operation of Training-schools for\nNurses.\u2014That training-schools for nurses, in conjunction with hospitals within the\nProvince, be considered as educational institutions in so far as it is necessary to enable\nthem to come within the provisions for grants-in-aid from the Department of Education,\nto the end that the net cost of operating such training-schools shall in no way be a part\nof, or taken into account as, an operating cost to be covered by B.C.H.I.S.\n19. Chronic Cases: Limit of B.C.H.I.S. Liability.\u2014-That the liability of B.C.H.I.S.\nfor an account in a general hospital incurred by a patient who is a registrant, or dependent of a registrant, in good standing under the Act, who has been declared to be\na chronic case, shall continue until they have been otherwise placed, but in no case shall\nit continue more than sixty days beyond the effective date at which the case has been\nruled otherwise to be a chronic case.    The ruling referred to is the decision of the FF 84 BRITISH COLUMBIA\nMedical Board of Review, if the diagnosis has been referred to them; and this recommendation is intended to apply to cases remaining in hospital which do not become the\nresponsibility of the Social Welfare Department.\n20. B.C.H.I.S. Management Board and Select Standing Committee.\u2014That B.C.H.I.S.\nbe administered by a board of three members, without legislative or judicial powers, and\nalso that Standing Orders of the Legislature be amended to provide for the appointment\nof a Select Standing Committee on Hospital Insurance, which shall meet at each regular\nsession of the Legislature and shall review the report of the B.C.H.I.S., meet with the\nboard of management, and report to the Legislature.\n21. Hospital Advisory Council.\u2014(1) That the broad intention behind the setting-up\nof the Hospital Advisory Council be fully realized, and that if full advantage is not now\nbeing taken of the services of the Council, steps be taken to realize the maximum\nbenefit therefrom; and that, further, all proposed important changes in policy or regulations be discussed with the said Advisory Council before the proposed changes are put\ninto effect.\n(2) That the Hospital Advisory Council shall in future include in its membership\ntwo private members of the Provincial Legislature, to be appointed or named before\neach regular session of the Legislature is prorogued, and that the said private members\nshall be selected from the membership of the Select Standing Committee which has been\nin existence during the said regular session, one to represent the Government and one\nto represent the Official Opposition.\n22. Public Relations of the Service.\u2014That, as it is their opinion that the scope of\nthe public relations of the B.C.H.I.S. justifies the retention of a Director of Public\nRelations of outstanding ability, steps be taken to secure the services of such a person,\nand that responsibility for the public relations of the Service be placed in his hands as\nsoon as possible.\n23. Field Representatives of B.C.H.I.S.\u2014That the present force of district representatives be enlarged to an extent necessary for them to take care of problems as outlined herein without undue delay; and, further, that the personnel of this field force be\ngiven proper training to fit them to act as \" top-notch \" public-relations officers.\n24. Exempted Areas.\u2014That the necessary amendments be enacted to exempt all\npersons in the areas referred to, but that the privilege of voluntary registration and\nparticipation under the \" Hospital Insurance Act \" be extended to them.\n25. Annual Accounts of B.C.H.I.S.\u2014That it seems highly desirable to have the\nannual accounts of B.C.H.I.S. prepared on a revenue and expenditure basis for each\nfull year of its operation, rather than on a cash receipts and payments basis running to\nMarch 31st only, and that publication thereof should be made as early as possible in\na manner clearly understandable to the general public.\n26. Premium-year.\u2014That as soon as can effectively be done, the premium-year be\nfrom April 1st to March 31st.\n27. \"Chronic\" Diagnosis: Provisions for Review.\u2014(1) That where it is decided\nthat a patient in an acute or general hospital is ruled to be, or to have become, a chronic\ncase, and not the responsibility of B.C.H.I.S., advance notice of the discontinuance of\nbenefits shall be given in every case; and the effect of such ruling shall in no case be\nretroactive.\n(2) Before such ruling is made, any and all cases should be referred, wherever\npossible, to the medical staff of the hospital, whose opinion shall be fully considered by\nthe medical consultant or Administration of B.C.H.I.S.\n(3) In all cases of difference or dispute arising at any point as to the correctness\nof the diagnostic decision, the final decision should be left to a Medical Review Board,\nconsisting of two representatives of B.C.H.I.S. and three doctors appointed by the College\nof Physicians and Surgeons.\n(4) That provision be made for the appointment of the said Medical Review Board\nas soon as possible. .: \u2122 ' , ? --.:\u2014-< \u2122 \u2122\nREPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 85\n28. Provision for Permissive Use of Special Drugs.\u2014That the Medical Board of\nReview, if established, shall have the authority to allow the use of special drugs for\nhospital patients, when vitally necessary, on the recommendation of the local medical\nauthority.\n29. Premium-payment Enforcement: Prosecutions and Garnishee Proceedings.\u2014\n(1) That the competent authority shall call to the attention of the Magistrates and\nJustices of the Province the provisions of subsection (2) of section 11 of the Act as\nreferred to above, and shall require their future compliance therewith.\n(2) That the Administration of B.C.H.I.S. shall take full advantage of the provisions of section 11b of the Act when such action is justified by circumstances.\n(3) That the application of section 11b shall be widened so as to permit the\nprocedure of automatic garnishee by the Administration of B.C.H.I.S. of any sums owing\nby a delinquent registrant (or person required to be a registrant under the \" Hospital\nInsurance Act\"), provided that such extension is ruled by competent authority to be\npossible.\n30. Plan of Registration and Premium Collection.\u2014That Plan No. 2 of registration\nof beneficiaries and premium collection as outlined above be adopted in its entirety at the\nearliest possible date, and that the necessary enactments be made to define the duties of\nthe persons therein referred to and the proper penalties for failure to comply with the\nprovisions thereof; and that the said plan be given a fair trial over a predetermined\nperiod, at the end of which period the position shall be reviewed, and if the response of\nthe persons required by the Act to become registered and to pay premiums is not such\nas to have achieved the desired and intended results, then consideration shall be given\nto the necessity of introducing a plan such as the other plan referred to in this section.\n31. Proof of Standing Under the Act (to be required from applicants for any\nProvincial (annual) licence).\u2014(1) That the necessary legislation be enacted to require\nthat any issuer of an annual licence on behalf of the Province of British Columbia shall,\nat the time of issuance thereof, ascertain the registration number or exemption certificate\nnumber of the licensee in all cases where such licensee is required to be covered by the\n\" Hospital Insurance Act\"; and that if the said licence-issuer is unable to obtain the\nnecessary evidence of standing under the said Act, he shall thereupon forthwith report\nthe name and address of the licensee concerned to the B.C.H.I.S., whose duty it shall be\nto ascertain that all such licensees are properly registered under the Act.\nIt is also recommended that the Administration of B.C.H.I.S. shall seek the co-operation of issuers of municipal licences within the Province, with a view to having the same\nprocedure followed by such officers.\nOr, alternatively\u2014\n(2) That any person who is subject to registration under the \" Hospital Insurance\nAct,\" when applying for the issuance of any annual Provincial licence within the Province\nof British Columbia, shall produce his official eligibility certificate, certified interim\nreceipt (current period), or exemption certificate proving his good standing under the\n\" Hospital Insurance Act\" and regulations, and in default of the production of such\nevidence of good standing shall not be entitled to the issuance to him of any such licence.\n32. Limit of Liability for Premium Arrears.\u2014That, effective not later than July 1st,\n1952, a person becoming registered under the Act, or having been registered, seeking to\nplace himself in good standing, shall be required to pay a sum equal to the premium for\nthe current year as regularly provided, and the arrears for the previous premium-year\nif he is liable for the same. The provisions of this recommendation are intended in no\nway to interfere with the powers of the Minister or the Commissioner to reduce the\namount of, or to suspend indefinitely payment of, arrears owing by any person.\n33. Collection of Arrears of Premiums.\u2014That the collection or realization of the\namounts which will from this time on be recognized as arrears, and kept on the books\nand in the accounts of the Service, be a matter for handling by a special collection FF 86 BRITISH COLUMBIA\ndepartment of the B.C.H.I.S. Administration, to be segregated completely from the\nrecords of current premium payments and the receipts and collection thereof. The term\n\" arrears,\" as used in this recommendation, would not be intended to mean the late\npayment of the premium for the current benefit period, but those arrears defined in\nRecommendation No. 32.\n34. Exemption Cards: Issue to Certain Persons and Charge Therefor.\u2014That all\nadult residents of the Province coming within the provisions of the \" Hospital Insurance\nAct \" who are, by reason of special exemption or otherwise, not required to personally\npay a premium in accordance with the regulations shall nevertheless be required to obtain\nfrom B.C.H.I.S. an official exemption card or certificate covering each premium-year or\nbenefit period, as the case may be, and to pay a charge for the said card or certificate\namounting to $2 per annum.\nThis requirement shall not apply to the following persons mentioned in section 8\nof the \" Hospital Insurance Act \":\u2014\n(1) Those persons mentioned in section 8, subsection (1) (a), to whom the\nGovernment of Canada provides hospital benefits:\n(2) Those persons mentioned in section 8, subsection (1) (c), who are\ncovered by \" Canada Shipping Act, 1934 \":\n(3) Those persons mentioned in section 8, subsection (1) (d), who are\nemployees of the Government of Canada, or the government of any other\ncountry:\n(4) Those persons mentioned in section 8, subsection (1) (\/), who are\nresiding in exempted areas:\n(5) Those persons mentioned in section 8, subsection (1) (g), who are\ncovered by the \" Saskatchewan Hospitalization Act, 1948 \":\n(6) Those persons mentioned in section 8, subsection (3), who are inmates\nof Provincial institutions, gaols, or penitentiaries.\n35. Changes of Status.\u2014That the Act or regulations shall be amended to provide\nthat there shall be no change in the status of any beneficiary of B.C.H.I.S. which would\naffect his standing under the Act in any way whatsoever during any current half-year\nperiod for which the necessary premium has been paid, but any and all such changes\nshall have effect only at the beginning of the next half-year period after the date at which\na change of status did, in fact, take place.\n36. Elimination of Certain Group Records.\u2014That all individuals exempted from\nthe requirements of the \" Hospital Insurance Act,\" whether comprising the membership\nof the two groups specifically exempted by the Act or being in another category, shall\nreceive an exemption card for every benefit period, or a permanent exemption card,\nwherever possible, and that the separate group records now being kept by B.C.H.I.S.\nshall be eliminated.\n37. Pamphlet Covering Plan and Benefits.\u2014That a pamphlet with details of the\nplan and benefits, and similar in form to the Saskatchewan Hospital Services Plan\npamphlet, entitled \" What's Your Question? \" should be sent out with all notices of\npremiums due, and that it be obtained in sufficiently large quantities as will reduce the\ncost to a minimum and permit it to be used for general distribution.\n38. Budgets and the \"Fixed\" Budget System.\u2014(1) That the budgets of the\nhospitals of the Province, when submitted to B.C.H.I.S., must include therein all the\nanticipated costs of efficient operation, and if the B.C.H.I.S. Administration, upon\nexamination of any budgets so submitted, disagrees with the figures submitted, they shall\nmake prompt arrangements for consultation with the hospital board concerned so that\nadjustments may be studied and considered; and only after such consultation shall the\nfigures then agreed upon become a \" fixed \" budget.\n(2) Such \" fixed \" budget, nevertheless, still remains subject to agreed changes\narising as the effect of circumstances over which the hospital board has no control. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 87\n(3) There shall be no reduction of a per diem rate set by B.C.H.I.S. and existing\nin any hospital, made effective until the time when the new budget of the said hospital\nis fully agreed upon for the year in accordance with clause (1) hereof.\n(4) That at the commencement of each year the \" other agencies \" shall be notified\nby B.C.H.I.S. that accounts rendered to them for hospitalization for which they are liable\nare on an interim basis until the hospital budgets and rates are fixed for the year by\nB.C.H.I.S., and that such accounts are thereafter subject to increase or decrease in\naccordance with the new rates set.\n39. \"Fixed Charges\" in Hospital Budgets.\u2014(1) That in the case of hospital\nequipment, full depreciation allowance, in accordance with the classification thereof,\nshall be permitted as an annual operating cost in hospital budgets, in order to cover\nequipment replacement; and\n(2) That the entire question of allowances for depreciation on buildings and carrying charges on capital debts, which are the responsibility of the hospital board, shall be\nthe subject of serious study by the Administration of B.C.H.I.S. at the very earliest\npossible date, with a view to a more satisfactory agreement being reached concerning\nthese charges between the Hospital Boards and the B.C.H.I.S.\n40. System of Payments by B.C.H.I.S. to Hospitals.\u2014That the system of B.C.H.I.S.\npayments to hospitals be reviewed, with the object of arriving at a more satisfactory\nplan; and the Board is of the opinion that the system in use in Saskatchewan should be\nfollowed, unless specific and valid reasons exist in favour of some other system.\n41. Comparative Costs of Hospitalization.\u2014That the Administration of B.C.H.I.S.\nshall arrange, at as early a date as possible, for adequate and full conference with the\nexecutive of the British Columbia Hospitals' Association and other interested parties,\nwith a view to giving intensive' study to the matters referred to above, and to arrive at\nconclusions as to whether or not the comparative position of the hospitals of the Province\nis sufficiently justified.\n42. Employees' Wage Agreements.\u2014That because of the evidence of a great deal\nof dissatisfaction on the part of the hospital boards of the Province and the employees\nthereof, as represented by their bargaining agents, with the attitude and actions of\nB.C.H.I.S. concerning wage agreements, and because the Board believes it is not the\nfunction of B.C.H.I.S. to interfere directly or indirectly in the matter of wage negotiations,\nan early conference of all interested parties be held\u2014namely, the hospital boards or\nHospitals' Association, the hospital employees or their bargaining agents, and representatives of the Department of Labour\u2014in which conference the Administration of\nB.C.H.I.S. shall take no part.\nAnd, further, that the Board point to the agreements which have been arrived at\nand are now in force with policemen's and firemen's organizations in various parts of the\nProvince, as forming a possibly acceptable solution on which to base a permanent policy\nas regards hospital employees and the terms of their employment. It is intended that the\naforementioned conference shall deal with all matters having to do with the position of\nemployees of hospitals, including the matter of pension and superannuation funds and\nthe allowable contributions thereto of hospital boards.\n43. Student Nurses: Hours of Work.\u2014That the request of the Registered Nurses'\nAssociation of British Columbia with reference to hours of work of student nurses be\ngiven favourable consideration.\n44. Responsibility for Hospital Accounts of Evaders.\u2014That since the collection of\npremiums under the \" Hospital Insurance Act\" is the function of the B.C.H.I.S., then\nthe final responsibility for the collection or coverage of any hospital accounts incurred\nby evaders of the provisions of the Act is for the Service to assume; and that such a policy\nshould be definitely adopted; but nevertheless the hospital board or administration\nconcerned shall initiate and exhaust all reasonable steps in their endeavours to collect the\nsaid accounts from the patient or his responsible relatives in the first instance. FF 88 BRITISH COLUMBIA\n45. Elimination of Social Security and Municipal Aid Tax on Hospital Supplies.\u2014\nThat the cost of purchases made by the hospitals of the Province covering articles or\nsupplies which are exempted from the Federal sales tax be also exempt from the\nimposition of the social security and municipal aid tax.\n46. Purchase of New Equipment: Consent of B.C.H.I.S.\u2014(1) That the mechanics\nor operation of the rules and regulations pertaining to the granting of permission to\npurchase new hospital equipment shall be examined with a view to eliminating the\ndifficulties and delays so far encountered, and thereby remove the cause for any complaint\nin the future.\n(2) That purchases by the hospitals of such new equipment, not having a cost value\nhigher than $100, be made permissible without the prior consent of the B.C.H.I.S. Administration having to be obtained.\n47. Central Purchasing Agencies.\u2014That B.C.H.I.S. encourage hospitals to develop,\nto the greatest extent possible, a system of bulk centralized purchasing of supplies.\n48. Dispensing of Drugs.\u2014That all dispensing of drugs in hospitals, or for hospital\npatients, should be done by registered pharmacists or qualified physicians.\n49. Chronic Cases (Social Welfare) Remaining in Hospital.\u2014That where B.C.H.I.S.\nacknowledge that there is a surplus of beds in any general hospital, and the board of the\nhospital affected comes to an amicable agreement with the Social Welfare Branch to\naccept chronic cases at a certain rate differing from the fixed per diem rate approved by\nB.C.H.I.S., the consent of B.C.H.I.S. be given. The policy enunciated by the foregoing\nis predicated on the assumption that the beds so acknowledged to be surplus may be\nset apart for the use of chronic or convalescent cases, and will remain in that classification\nuntil the entire bed situation of the hospital concerned is reviewed by the hospital administration and B.C.H.I.S.\n50. General Relations with B.C.H.I.S.\u2014That the B.C.H.I.S. round out, as soon as\npossible, a complete organization of specialists in the various phases of hospital operation\nand management, to the end that they may render maximum assistance to hospitals and\nreceive full co-operation in return.\n51. Hospital Construction and Extension, etc.\u2014That a more intensive study of the\nwhole matter of hospital-construction than was possible in the limited time available to\nthe Board be made; and that this study be proceeded with as soon as possible; and that\nnew legislation be enacted, similar to the \" Union Hospitals Act\" of the Province of\nSaskatchewan referred to in the preamble to this recommendation, which will enable the\nsetting-up of hospital improvement districts in the Province of British Columbia. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 89\nINTERIM RECOMMENDATIONS MADE BY THE BOARD\nInterim Recommendations No. 1 and No. 2\nThis Board, in accordance with section 7 of the \" Hospital Insurance Act Inquiry\nAct,\" makes certain interim recommendations which it considers should be submitted\nat this time, and which, if implemented, will remove what the Board considers to be\ninjustices and will also change phases of present policy which are necessarily resulting\nin public antagonism to the British Columbia Hospital Insurance Service.\nIt has been drawn to the Board's attention repeatedly at hearings of the Board, and\nconclusive evidence has been produced to amply demonstrate, that many persons have\nbeen denied benefits when they honestly considered themselves to be fully paid on\npremiums, or when their ineligibility was due to circumstances over which they themselves\nhad no control.\nTherefore, in accordance with a motion properly moved, seconded, and unanimously\ncarried at a meeting of the Board held at Nelson, B.C., on Saturday, the 11th day of\nAugust, 1951, it is now recommended to the Minister of Health and Welfare:\u2014\nIf a premium payment, or a premium payment and arrears, is received by\nthe British Columbia Hospital Insurance Service within seven (7) days after\ndue date, that the insured person or persons be considered as having remained\nin \" good standing \" for purposes of benefits under the British Columbia\n\" Hospital Insurance Act,\" and not subject to section 9-1 of the regulations\nunder the said Act; and it is also further recommended that the seven (7) days'\ngrace be further extended where necessary to meet circumstances when distance\nand postal-delivery circumstances or services cause additional difficulties affecting the receipt of the said premium payments by the British Columbia Hospital\nInsurance Service.\nThat in cases brought to the attention of the British Columbia Hospital\nInsurance Service where hospitalization bills have not been accepted as a valid\nresponsibility of the Service, where it can be shown that premium payment after\ndue date was due to uncontrollable factors respecting receipt of premiums, that\nthe said accounts be accepted for payment by the British Columbia Hospital\nInsurance Service [this policy to be publicized].\nThat publicity be given to a British Columbia Hospital Insurance policy\nthat anyone making payment of premium or premium and arrears to any\nauthorized Government official, such as a Government Agent, will be in \" good\nstanding \" from the date of the receipt given by the said official, subject to the\nterms of the recommendation numbered one (1) above.\nSubmitted on behalf of the Board.\nS. J. Smith,\nChairman.\nInterim Recommendation No. 3a\n(Amendment of Recommendation No. 3)\nWhereas there are numerous cases of pensioners and other persons subject to a very\nlimited income, who are making every attempt to pay the necessary premium for the\ncurrent period, but who find it completely impossible for the time being to meet the\npremiums which should have been paid for the years 1949 and 1950, and in which cases\nit is within the power of the Commissioner to suspend indefinitely the payment of such\narrears: FF 90 BRITISH COLUMBIA\nTherefore be it Resolved, That this Board recommends to the Minister that where\nthe Commissioner uses the authority conferred under Regulation 2-13, and applies a payment by any registrant to the premium due for the current six months' period, and there\nis still a payment necessary to meet fully the said premium for the current period, upon\npayment of same being made, the insured person or persons shall be considered to be\na beneficiary pursuant to the Act, and entitled to the benefits provided by the Act,\nimmediately after the lapse of fourteen (14) days from the date upon which the payment\nof the said premium for the current period has been made or completed, notwithstanding\nthe fact that the registrant may still be in arrears of premiums for prior periods, which\narrears have been indefinitely suspended.\nAt a properly constituted meeting of the Hospital Insurance Inquiry Board held in\nVancouver on Wednesday, October 17th, 1951, the above recommendation was approved\nand adopted.\nOn behalf of the Board.\nS. J. Smith,\nChairman.\nInterim Recommendation No. 4a\n(Amendment of Recommendation No. 4)\nDuring the hearings of the Hospital Insurance Inquiry Board throughout the Province\nsince the 27th day of July, considerable evidence has been presented to the Board indicating that a substantial percentage of persons who are required to be insured under the\nAct are not so covered.\nThe Board is informed that the statistics of the British Columbia Hospital Insurance\nService show that, of the persons admitted to hospitals during the first half of 1951, the\npercentage of persons referred to above is 7.03 per cent. Attempts by this Board to\nascertain the percentage of the total population in this category have resulted in estimates\nbeing given to them which vary from district to district all the way from 10 to 40 per cent.\nWhile this Board is not in a position to pass judgment as to the exact percentage, it is\nnevertheless satisfied that this exact percentage is considerably higher than that estimated\nby the British Columbia Hospital Insurance Service. It would therefore seem desirable\nto establish some method or procedure by which a betterment of the existing situation\nis made possible, both from the point of view of the British Columbia Hospital Insurance\nService and that of the general public. It has been represented to the Board that as far\nas people in this category are concerned, many would like to register themselves, but\nare deterred by the fact that payment (at the time of registration) of arrears of premiums\nwould be a financial impossibility, and the knowledge that until the said arrears of\npremiums are paid they could not receive any of the benefits of the British Columbia\nHospital Insurance Service.\nIt seems evident to the Board that the premiums of this group of people, for the\ncurrent year alone, if secured by the British Columbia Hospital Insurance Service, would\nprovide an addition to the cash income of the British Columbia Hospital Insurance\nService amounting to a very considerable sum.\nIn addition, the gap in the difference between the total population and those\nregistered under the Service would be narrowed down, and this would result in a larger\nrevenue after the current year, at a reduced collection cost.\nMany suggestions have been advanced to this Board as to methods of settling the\nmatter of arrears of these people, ranging from \" wiping the slate clean, and starting REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 91\nafresh \" to \" prosecuting with the utmost rigour of the law.\" The Board is of the opinion\nthat some reasonable plan is possible, whereby the problem may be very largely resolved\nwith immediate benefit to the British Columbia Hospital Insurance Service, satisfaction\nto most of the delinquents, and safe from any justified criticism of a severe nature by\nthose who have done their full duty under the \" Hospital Insurance Act.\" It should be\nborne in mind that some of the persons referred to in the first part hereof have not at any\ntime had the protection of the \" Hospital Insurance Act,\" and that a number of them may\nhave incurred penalties through the loss of that protection, by reason of personal payment\nof hospital bills, or by deferment of hospitalization which they might otherwise have\nsought and obtained.\nTherefore, we recommend to the Honourable Minister of Health and Welfare that\nchanges be made in the regulations referred to in section 35 of the \" Hospital Insurance\nAct,\" so that:\u2014\n(1) Upon payment in full of the necessary premiums for the last six months\nof 1951, and the first six months of 1952, the persons referred to in the\npreamble to this recommendation be placed in good standing at the\ntermination of a waiting period of fourteen (14) days, subject to the\nfollowing further conditions, namely:\u2014\n(2) That the said persons shall agree, in a form and manner to be set out by\nthe Commissioner of the British Columbia Hospital Insurance Service, to\npay to the British Columbia Hospital Insurance Service the amount of\ntheir premiums, in accordance with the Act and regulations, for the years\n1949, 1950, and the first six months of 1951, such payment to be made, as\nfar as possible, by regular periodical instalments, from time to time, as may\nbe arranged.\n(3) Nothing in the above recommendations shall be construed as affecting\nthose cases in which the Commissioner has or otherwise would, because of\nexceptional circumstances, grant indefinite suspension of the payment of\narrears.\n(4) That the easement afforded by the changes in the regulations which are\nrecommended above shall be extended only up to and including the 30th\nday of November, 1951, after which they shall cease to have force and\neffect.\n(5) That, as from the date last mentioned, it shall be the policy of the Commissioner of the British Columbia Hospital Insurance Service to secure\nthe compulsory registration of all persons liable to registration under the\nAct who still remain unregistered, and to collect all arrears of premiums\nfrom such persons, without remission, and to take any and all steps as will\nresult in complete registration of all persons coming under the Act, without\nfurther delay, and at the earliest possible date.\n(6) That suitable publicity be given at once, through the British Columbia\nHospital Insurance Service, to these recommendations, if approved by the\nMinister, such publicity to first receive the approval of the Chairman of\nthis Board, acting on behalf of the Board.\nAt a properly constituted meeting of the Hospital Insurance Inquiry Board held in\nVancouver on Wednesday, October 17th, 1951, the above recommendation was approved\nand adopted.\nOn behalf of the Board.\nS. J. Smith,\nChairman.. FF 92 BRITISH COLUMBIA\nInterim Recommendation No. 5\nThe Hospital Insurance Inquiry Board has met with fifty-six hospital boards. In\nthe majority of hospitals it is found that they have incurred deficits over a six- or seven-\nmonth period in the 1951 year which .approximate, equal, or exceed the amount by\nwhich their budget estimates were mandatorily cut by the British Columbia Hospital\nInsurance Service, or are incurring deficits to an extent which, if continued for the\nremaining period of the current year, will equal or exceed the amount by which their\nbudget estimates were cut.\nIn the opinion of the Hospital Insurance Inquiry Board the estimated budgets submitted to the British Columbia Hospital Insurance Service, except in a few cases, were\naccurately and conservatively prepared. The Board has been unable to obtain any\nexplanation as to the factual, actuarial, or reasonable basis upon which the budget cuts\nwere made.\nThe Board, after a great deal of consideration, finds it impossible to understand\nwhy the British Columbia Hospital Insurance Service made disproportionate cuts in\nbudgets of hospitals of similar bed capacity in almost identical districts or to find any\nreasonable or factual explanation as to why a budget of $66,000 should be cut by $1.\nThe Board supports the principle of hospital budgeting and review by the British\nColumbia Hospital Insurance Service, but is definitely of the opinion, based upon all\ninformation before it, that there has been neither rhyme, reason, nor understanding\ngiven to the budget cuts made by the British Columbia Hospital Insurance Service on\nthe hospital budgets for 1951. The Board believes that in the majority of cases budget\nsubmissions of the hospital boards evidenced a greater real appreciation of facts and\nevaluation of future costs than that of the Rate Board of the British Columbia Hospital\nInsurance Service.\nThe Hospital Insurance Inquiry Board strongly feels that present hospital deficits\nhave, in the main, been incurred because of British Columbia Hospital Insurance Service\nbudget cuts and rising costs in both labour and materials beyond the control of the\nhospital boards, and in the opinion of the Board the hospital boards have done everything possible to meet the British Columbia Hospital Insurance Service budget cuts.\nThe Board is further convinced that sufficient evidence has been introduced to conclusively demonstrate the hospital boards in their original budget submissions were close\nin estimating increased costs.\nA further factor to be borne in mind is that although, in general, hospital budgets\nfor 1951 were submitted to the British Columbia Hospital Insurance Service prior to the\nend of November, 1950, earliest advices sent to the hospital boards regarding the Rate\nBoard cuts were dated approximately April 30th, 1951, and in numerous cases later\nthan that date, and that, therefore, the hospital boards, in ignorance of the subsequent\naction, continued to operate for at least four months on the basis of their first budgets,\nand that this factor in itself is a legitimate explanation of some portions of the deficits\nreported up to the present time.\nThe Hospital Insurance Inquiry Board feels that note should be taken of the fact\nthat although the British Columbia Hospital Insurance Service increased hospital budget\nestimates by $199,591, the Rate Board decreased estimates by $1,191,441, thereby\nleaving a reduction from the actual budget submissions of $991,850.\nThe Hospital Insurance Inquiry Board is strongly of the opinion that the consequences of the deficits already incurred are serious and deplorable, and are resulting in\na pessimistic attitude on the part of the hospital boards and administrators, thereby\ncurtailing their ability to provide services of the quality and extent to which the public\nis entitled. Furthermore, the Board feels that the situation is such as to create bad\npublic relations, as instanced by the fact that many hospitals have not paid their\naccounts for two or three months and have thereby brought both the name of the hospitals and the British Columbia Hospital Insurance Service into ill repute. \u2014\u2014\nREPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 93\nIt is therefore recommended by the Hospital Insurance Inquiry Board to the\nMinister of Health and Welfare:\u2014\n(1) That immediate steps should be taken to establish a policy that will give\nto all hospitals at present operating on a deficit, or that may have an\noperating deficit at the end of the year, a grant or grants not to exceed\nthe difference between their original budget estimate for 1951 and the\nbudget decided by the British Columbia Hospital Insurance Service:\n(2) That any hospital operating on a greater deficit than its budget cut by\nthe British Columbia Hospital Insurance Service shall have the opportunity to present its case for additional consideration through the Minister\nof Health and Welfare to the Executive Cabinet:\n(3) That should the funds of the British Columbia Hospital Insurance Service\nnot be sufficient to pay in accordance with the aforementioned recommendations, same should be paid from the consolidated revenue:\n(4) That it should be made clear to all concerned that should the recommendations of the Hospital Insurance Inquiry Board on this matter be implemented, it be understood that they are only interim recommendations to,\nin part at least, take care of the immediate hospital situation; and that\nfuture financial arrangements between the hospitals and the British\nColumbia Hospital Insurance Service or the Government will be as may\nbe recommended by the Hospital Insurance Inquiry Board as accepted\nor amended by the Government or the British Columbia Legislature.\nAt a properly constituted meeting of the Hospital Insurance Inquiry Board held in\nVancouver on Tuesday, September 25th, 1951, it was moved and seconded that this\nrecommendation be approved and adopted.\nMotion carried unanimously.\nS. J. Smith,\nChairman.\nInterim Recommendation No. 6\nThe Board has received numerous representations from hospital boards, doctors,\norganizations, and individuals strongly protesting what was generally termed \" remote\ncontrol diagnosis\" relative to the classification of a sick person as \" acute\" or\n\" chronic.\"\nThe Board is not yet prepared to suggest a policy on this matter, but as an interim\nrecommendation is unanimous in resolving that all patients admitted to a hospital who\nare in good standing as to premium payments and whose doctors declare them to be\n\" terminal cases \" requiring acute hospital care be accepted as the responsibility of the\nBritish Columbia Hospital Insurance Service for payment of hospitalization costs.\nAt a properly constituted meeting of the Hospital Insurance Inquiry Board held in\nVancouver on Tuesday, September 25th, 1951, it was moved and seconded that this\nrecommendation be approved and adopted.\nMotion carried unanimously.\nOn behalf of the Board.\nS. J. Smith,\nChairman. FF 94 BRITISH COLUMBIA\nInterim Recommendation No. 7\nBe it Resolved, That this Board recommends to the Minister:\u2014-\n(1) That Regulation No. 9-1 (Restriction of Benefits), of the regulations\nunder the \"Hospital Insurance Act,\" be amended to read as follows:\u2014\n\" Where the required premium payment is made by, or on behalf of,\na person on or after the first day of the hospital insurance period to\nwhich it is applicable, such a person shall not be deemed to be a beneficiary pursuant to the Act until fourteen (14) days from the date on\nwhich the payment was made.\n\" Where an overdue premium is paid within the last fourteen (14)\ndays of the hospital insurance period to which it is applicable, the fourteen-day term during which benefits are withheld, as provided herein,\nshall extend into the subsequent hospital insurance period, regardless of\nthe fact that the premium applicable to the subsequent hospital insurance\nperiod is paid on or before the due date thereof.\"\n(2) That upon adoption of this recommendation by the Minister, suitable\npublicity be given thereto at the earliest possible date:\n(3) That publicity now be given to the recommendation of the Board, dated\nthe 12th day of August, 1951, which recommendation has already been\nadopted, whereby a period of seven (7) days of grace is allowed after\nthe due date for the receipt of a premium payment.\nAt a properly constituted meeting of the Hospital Insurance Inquiry Board held in\nVancouver on Wednesday, October 17th, 1951, it was moved and seconded that this\nrecommendation be approved and adopted.\nMotion carried unanimously.\nOn behalf of the Board.\nS. J. Smith,\nChairman. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 95\nCOPY OF MINUTE APPROVED, OCTOBER 23rd, 1951\nTo His Honour the Lieutenant-Governor in Council:\nThe undersigned has the honour to recommend That, pursuant to section 35 of the\n\"Hospital Insurance Act,\" being chapter 151 of the \"Revised Statutes of British\nColumbia, 1948,\" the \" Hospital Insurance Act \" Regulations, made by Order in Council\nNo. 900, approved May 5th, 1950, as amended, be further amended by striking out\nRegulation 9-1, and inserting the following as Regulations 9-1 and 9-2:\u2014\n\"9-1. Where the required premium payment is made by, or on behalf of, a person\non or after the first day of the hospital insurance period to which it is applicable, such\na person shall not be deemed to be a beneficiary pursuant to the Act until fourteen days\nfrom the day on which the payment was made. Where an overdue premium is paid\nwithin the last fourteen days of the hospital insurance period to which it is applicable,\nthe fourteen-day term during which benefits are withheld, as provided herein, shall extend\ninto the subsequent hospital insurance period, regardless of the fact that the premium\napplicable to the subsequent hospital insurance period is paid on or before the due date\nthereof.\n\" 9-2. Notwithstanding any other provision of these regulations, the period of time\nallowed for payment of a premium shall be extended until the seventh day of the hospital\ninsurance period to which the premium payment is applicable, and if payment of the said\npremium is made on or before that day, the provisions of Regulation 9-1 shall not apply\nto the person on whose behalf the premium payment is made. Where a premium is paid\nafter the commencement of the hospital insurance period to which it is applicable but\nprior to the expiration of the seven-day period of grace provided herein, the person on\nwhose behalf the payment is made shall not be entitled to benefits pursuant to the Act\nduring those days in the said hospital insurance period prior to the day on which the said\npayment was made.\"\nDated this 23rd day of October, a.d. 1951.\nA. D. TURNBULL,\nMinister of Health and Welfare.\nApproved this 23rd day of October, a.d. 1951.\nH. ANSCOMB,\nPresiding Member of the Executive Council. FF 96\nBRITISH COLUMBIA\nTABULATION OF ESTIMATED INCREASES TO THE INCOME AND EXPENDITURES OF THE B.C.H.I.S. CONSEQUENT UPON THE ADOPTION OF THE\nRECOMMENDATIONS OF THE HOSPITAL INSURANCE INQUIRY BOARD\nAS CONTAINED IN ITS INTERIM REPORT, FEBRUARY, 1952.\nNo. and Subject of Recommendation\nIncreased\nIncome\nDecreased\nIncome\nIncreased\nExpense\nDecreased\nExpense\n4. Elimination of co-insurance charges\n(increase in hospital budgets)\t\n6. Municipal and Provincial per diem\n$2,000,000.00\n$1,000,000.00\n50,000.00\n8. Inclusion of Christian Scientists as\n11. Exemption  of  student  nurses  as\n$25,000.00\n12. Out-of-Province   hospitalization \u2014\n87,000.00\n16. Hospitalization of Treaty Indians:\nFederal Government responsibility-\n17. Hospitalization of Social Welfare\ncases\u2014payment in full\t\n$436,500.00\n1,000,000.00\n18. Grants-in-aid to schools of nursing\n(reduction in hospital budgets)\t\n130,000.00\n19. Chronic cases\u2014increased limit of\nB.C.H.I.S. liability\t\n300,000.00\n25,000.00\n20,000.00\n50,000.00\n20. Management board for B.C.H.I.S.\n27. \" Chronic case \" diagnosis\u2014Medical\nReview Board  \t\n28. Special drugs\u2014permissive use\t\n30. Plan of registration and premium\ncollection \t\n875,000.00\n50,000.00\n1,065,000.00\n34. Exemption cards\u2014annual charge  .\n$2,975,000.00\n25,000.00\n$25,000.00\n$2,482,000.00\n1,631,500.00\n$1,631,500.00\nNet increase  .\n$2,950,000.00\n$850,500.00\nNet increase in B.C.H.I.S. income.\nNet increase in B.C.H.I.S. expense\nNet gain to B.C.H.I.S\t\n$2,950,000.00\n850,500.00\n$2,099,500.00\nIt is to be cleariy understood that the above calculations are set out to show only the effect of\nthe proposed changes on the B.C.H.I.S. itself. The following items, showing a saving to the Service,\nwould become a responsibility of other departments of the Provincial Government:\u2014\nProvincial Government per diem grants\u2014increase      $650,000.00\nDifference between premium payments and cost of full hospitalization of Social Welfare cases\t\nGrants-in-aid for schools of nursing .\nPayment of premiums for low-income groups (Board's Recommendation No. 10)\t\n1,000,000.00\n130,000.00\n70,000.00\n$1,850,000.00\nIn addition to these four items the Provincial Government (Department of Municipal Affairs)\nwill pay the cost of the extra 25 cents per patient-day grant referred to in the last paragraph of\nRecommendation No. 6 (if implemented). The best estimate which the Board can make as to the\naggregate amount of this item to be paid by the Government is $150,000 per annum. Note, however,\nthat this item does not affect the finances of B.C.H.I.S. because the payment is intended to go direct\nto the hospitals concerned and to become \" non-operating \" revenue to them.\nIt is also to be clearly understood that these calculations are based on the positive recommendations of the Board as found in its Report. They do not take into account any (other) increased costs\nof hospital operation which come into effect by reason of ordinary economic factor's reflected in\nhospital budgets for 1952 and future years. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 97\nEXCERPT FROM THE ACTUARIAL REPORT OF MR. SAMUEL ECKLER,\nF.S.A., OF TORONTO, ON THE BRITISH COLUMBIA HOSPITAL INSURANCE SERVICE, DATED DECEMBER 1st,  1951.\nCHAPTER VIII. PROBLEMS AND RECOMMENDATIONS\nA. Summary of Problems\nAt the meeting of the Inquiry Board that I attended on June 25th, 1951, I stated that part of\nmy job would be to clarify the basic problems of the Hospital Insurance Plan. At that time, and in\na letter to the Chairman of the Inquiry Board, I reviewed some of these problems. As a result of\nmy investigation of the plan and its operation, I have modified my original conception of the problems\nand I regard the following as the important ones.\n1. Should the universal compulsory hospital insurance plan be continued? If it should be\ncontinued, should any modifications be made in it? If not, what other techniques would\nsolve the problem of health insecurity and hospital deficits?\nIf the plan is to be continued, there are the following additional problems:\n2. Finances.\nHow should the moneys for financing the benefits under the plan be raised?\nIs the present proposed plan of raising approximately two-thirds by premiums, 30 per\ncent by provincial subsidy and 4 per cent by municipal grants satisfactory?\nIs the premium structure reasonably equitable?\nShould the provincial subsidy come from consolidated revenue or should it be an\nearmarked tax?   Should a special tax be levied to cover the provincial subsidy?\nWhat provision, if any, should be made for the payment of premiums by low income\nand indigent groups?\n3. Benefits.\nShould a service or cash benefit be provided?\nAre deterrents to hospital admission and prolonged stays desirable and, if so, how should\nthey be arranged?\nShould hospital care be provided for chronic diseases?\nShould a maximum limit be put on hospital stays?\n4. Hospital relationships.\nWhat method of payment should be used to reimburse the hospitals for benefits under\nthe plan?\nWhat administrative relationships between the hospitals and the plan will produce the\nbest results?\n5. Should the plan be administered by a semi-independent agency composed of more than\none person?\nB. Recommendations\nMany of the above problems have been discussed in previous chapters and some answers have\nbeen given. At this stage, I should like to summarize many of the conclusions I have drawn and\ngive recommendations under three alternative courses of action.\nThe first two approaches assume that it is desirable to continue the state-operated compulsory\nhospital insurance plan. The third approach involves the discontinuance of the hospital insurance\nplan and the substitution therefor of other methods to meet the hospital insurance needs of the citizens.\nIf the compulsory hospital plan is continued under either one of the first two approaches, the\nfollowing conditions should be satisfied, that\n(a) the rate of hospital utilization does not become excessive. Otherwise, the plan may be\nuneconomic in relation to alternative expenditures of the same amount of money.\nIn order to accomplish this condition, deterrents to hospital utilization, both for admissions and long stays, are necessary. For example, I consider that the Saskatchewan\nutilization rate is excessive and that clearly too much emphasis has been placed there\non hospital care as a method of improving the health of the people.\n(b) a reasonable amount of hospital autonomy be preserved. Otherwise, the insurance plan\nbecomes a dispenser of hospital services as well as an insurance organization.\n(c) hospital per diem costs remain reasonable. Otherwise, the over-all cost of the plan\nwould be too expensive.\nApproach 1.\nThe present plan with minor modifications\u2014that is, a service benefit plus almost universal coverage\u2014should be continued. The chief advantage of this approach is that the beneficiary, except for\nhis co-insurance payments, will have all his hospital costs paid for.    The advent of co-insurance has FF 98 BRITISH COLUMBIA\nreduced this advantage somewhat but it is still an advantage. The chief objections to the plan are\nthat it seriously reduces the autonomy of hospitals, the value of the service benefit varies from\ncommunity to community and the beneficiaries do not understand the exact money value of the\nbenefits they receive. If the Hospital Insurance Service promises a service benefit, then it must be\nprepared to pay what the local hospital says that benefit costs or step in and rule what those costs\nshall be. Basically, there is no other course. Nevertheless, this process can be effected on a reasonably equal partnership basis with the local hospitals participating in the affairs of the Insurance\nService. The Blue Cross Plans, which usually provide service benefits, are almost in all cases owned\nand operated by the hospitals themselves. Undoubtedly, that is one of the reasons why the Plans are\nworking satisfactorily.\nPractically, premiums cannot vary geographically and the defect of invariable premiums and\nvariable benefits from locality to locality cannot be overcome. However, the fact of a substantial\ngovernment subsidy and a different level of premiums might solve this problem to a large degree.\nThe provincial Blue Cross Plans have the same difficulty.\nThe fact that the beneficiaries do not know the money value of the service benefits they receive\ncan be readily overcome by proper public relations.\nUnder this approach, I suggest the following:\n(1) I see no strong reason for making any important change in the present exemptions. Some\nminor changes might be desirable. Administratively, it would undoubtedly be simpler to exempt no\npersons from the payment of premiums. For example, the exemption of approved plans might be\nwithdrawn but I think there is some advantage from, a public relations point of view in offering the\noption of joining another plan to any group that qualifies. The hospital insurance costs of the\nemployees of the British Columbia Telephone Company and the Canadian Pacific Railway are\nprobably less than those of the members of the general population because the employees are select\ngroups (any group of employees is, on the average, in. better health than the general population\nbecause they are younger and because the group excludes invalid persons). If the premiums are\ngreater than the hospital insurance costs of those employees\u2014and at the present level they may very\nwell be\u2014the Hospital Insurance Service would benefit financially by withdrawing the exemption from\nthese two groups. However, if the premiums are reduced so that they are lower than the hospital\ninsurance costs of these groups, then the Insurance Service would gain by continuing the exemption.\nThe question of exempted persons should be constantly reviewed and individual equity arid the\nmechanics of administration should be balanced against the rights of members of certain groups.\n(2) The benefits provided beneficiaries suffering chronic diseases should be clarified. If any\nchronic diseases are excluded, they should be clearly named and listed. A definite maximum limit\nshould be placed on the benefits for an insured chronic disease. Although I understand such a limit\nis being used now, by administrative discretion, it would be preferable to specify this limit in published\nregulations.\nI hesitate to recommend a basic liberalization of the coverage for chronic diseases in view of the\nage distribution of the British Columbia population and the high per diem cost. It is also important\nfrom a cost point of view to keep the hospital utilization rate at a minimum. I consider it very\nimportant to obtain the complete co-operation of the local hospitals and the medical profession in the\nmatter of chronic diseases and to make certain that the public thoroughly understand the reasons for\n. limitations on chronic cases.\n(3) Some plan of co-insurance is essential to keep the hospital utilization rate at a minimum.\nThe system of co-insurance should be designed to reduce admissions and long stays. In addition, it\nshould be easily understood and administered. For each admission, I suggest that the beneficiary\npay the hospital a fee of a specified amount\u2014possibly the cost of one day's hospitalization for stays\nof more than one day and something less for a one-day stay\u2014and so much per day for each day of\nhospital stay over a certain period. The amount of the admission fee, the number of days' stay\nbeyond which additional payments by the beneficiary are required, and the amount of the additional\npayments can be determined by the condition that the total income to the hospitals from this source\nshould equal approximately the present estimated co-insurance income. Before a change of this sort\nis effected, it should be discussed and approved by the hospitals involved.\n(4) The definition of \" dependents\" should be changed to include only spouse, unmarried\ndependent children under 19, unmarried dependent children between 18 and 21 going to school and\nunmarried incapacitated children. This change should not be introduced until provision is made for\npremium payment by indigents and low income groups.\n(5) The pattern of financing the hospital plan should be revised so that single persons pay\na premium equal to about 50 per cent of the head of family rate (with dependents defined as in\nprevious paragraph) and the provincial and municipal governments pay the remainder. I estimate\nthat during 1950 the value of the hospital benefits paid to single persons was about $18. Whatever\nthe single person paid over this amount was really in the nature of a poll tax, the proceeds of which\nwere used to subsidize the hospital insurance costs of families.\nAt this stage, I am not prepared to say more than that no premium rate charged any group of\npersons should be very much in excess of the value of benefits received by that group.   It is clear that REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 99\nthe present premium rate structure does not meet this condition. The actual level of premiums\ndepends on the amount of the subsidy the government wishes to provide for the plan. As an\nillustration, the single person premium might be $24 a year and the family premium $48. Under\nsuch rates, the government subsidy, exclusive of the premiums paid on account of indigents and low\nincome groups, would probably be less than the 1951-1952 fiscal year estimate because of the\nsuggested limitation in the definition of dependents. On the other hand, if the premiums are set at\n$21 for single persons and $42 for families, the government subsidy might be greater than estimated\nin the 1951-1952 budget\n(6) The Hospital Insurance Act should include a specific provision that employers be permitted\nvoluntarily to share in the premiums required from employees who are covered under the plan.\nI understand that the British Columbia Electric and the Consolidated Mining & Smelting Companies\npay 50 per cent of the premiums of their employees. There are probably a few other employers\nwhich pay part of their employees' premiums. The insurance plan should actively encourage this\nprocess, possibly by employing representatives to visit various employers.\n(7) The Act should be amended to provide that the hospital insurance premiums will be adiusted\nregularly in relation to changes in hospital utilization and per diem hospital costs. I consider this\naspect important from a public relations point of view to make it clear that increases in hospital costs\nand hospital utilization may result in greater premiums.\n(8) Consideration might be given to special or earmarked taxes to finance the government subsidy to the plan. Such special taxes might be accompanied by a significant reduction in the proportion of the total hospital insurance costs raised by premiums, in which case the need for assistance in\nthe payment of premiums to low income and indigent persons would be reduced.\n(9) Provision should be made for either municipal or provincial agencies to pay part or all of\nthe premiums of persons unable to pay premiums and who request assistance. These persons include,\namong others, the needy aged, the needy unemployed and low income employees. A means test\nrelated to income only might be applied; for example, the rule might be that the hospital insurance\npremium should not exceed 2 to 3 per cent of the annual income of the person making application for\npayment of part or all of this premium.\nThere are probably other methods of meeting this problem but I do not think that any of them\nare administratively as direct and simple as the above suggestion. Another method might be to provide that the premiums at no time exceed a certain percentage of a person's income. And still another\nsolution might be to express the premiums as a percentage of income but never to exceed a certain\nspecified maximum. My objections to both these methods are that they require a knowledge of every\nperson's income and would also complicate collections.\n(10) The method of payment to hospitals should be designed so as to discourage unnecessarily\nlong stays and encourage economy of hospital operation. The method adopted should also be\naccepted and understood by the local hospitals.\n(11) It is essential to set up a closer formal relationship between the local hospitals and the\ninsurance plan than exists at the present time. Although the Hospital Advisory Council, which represents the interested groups, has an important role to play in the successful administration of the plan,\nI think some other liaison body should be established to effect harmonious relationships between the\nhospitals and the plan. I consider this suggestion important for the successful and economic administration of a service type of hospital insurance benefit.\n(12) The annual reports prepared by the Hospital Insurance Service should give a complete\npicture of the year's operations of the plan and a description of items, administrative and otherwise,\nof interest to the public. Among the operational items covered in the report should be included an\nanalysis of the insured persons by age, sex, single and head of family, a breakdown of the gap between\nthe total insured persons and the total estimated population by those exempted and those delinquent\nin premium payments, calendar year financial statements, statistics of per diem hospital costs, hospital\nutilization by age and sex, tabulation of admissions by length of stays, and admission rates.\nApproach 2.\nThe present plan should be altered fundamentally by providing a cash per diem benefit to the\nhospital.\nThe advantages of this plan are:\n(1) It effects a closer control of costs. The cost of the insurance plan would depend entirely on\nhospital utilization which can be kept reasonably level. An increase in hospital costs would mean\ngreater hospital payments by the beneficiaries to the hospitals. Undoubtedly, rising hospital costs\nwould bring about a demand for an increase in the per diem cash benefit but it would then be clearly\nunderstood by the beneficiaries that the increase in premiums is due to a rise in hospital costs. The\npayments for the services provided by the hospitals outside of room and board and general nursing\ncould be better controlled.\n(2) The affairs of the local hospitals would not have to be as closely scrutinized under a cash\nbenefit plan as they have to be under a service benefit plan. Accordingly, the Boards of Management\nof local hospitals would be able to exercise more independence in guiding the affairs of the hospitals FF 100 BRITISH COLUMBIA\nthan under a service benefit. In effect, they would establish the payments required by the insured\npatients to the hospitals for the difference between the cash benefit allowed by the insurance plan and\nthe actual rates charged by the hospitals.\n(3) Although the cash benefits allowed by the plan would probably have to vary from hospital\nto hospital, there could be a closer relationship than under the service benefit plan between the\npremium charged and the benefits allowed.\n(4) Under a cash benefit plan, the insurance plan would operate strictly as an insurance service\nand would not be directly concerned with hospital administration. Matters of improvement in hospital accounting and administration would then be looked after by a department of government\nespecially trained and equipped for this service.\nThe chief defects of the cash benefit plan are that:\n(i)  many beneficiaries would probably still find it difficult to meet the deficiency payments\nrequired;\n(ii) unless the insurance plan interferes with the hospital's rights to establish rates charged\nits patients, many insured persons might feel that the rates charged are excessive.\nThe recommendations under the first approach that would apply equally to the second are those\nrespecting exemptions, chronic diseases, definition of dependents, financial basis of premiums, voluntary employer contributions, special taxes for government subsidy, assistance for indigent and low\nincome groups, complete annual reports.   In addition to the applicable recommendations made under\nthe first approach, I suggest the following for this second one.\n(1) The per diem cash benefit should be established at a level slightly under the standard ward\nper diem rate. More than one per diem rate should be used with different rates for small, medium\nsize and large hospitals. The reimbursements for special services should be either a multiple of the\nper diem cash benefit, for example 20 times, or a fiat amount such as $100 or $150. The per diem\ncash benefit should be reduced after a specified period, for example 30 days, to bring it in line with\nthe lower hospital'costs for long stays and in order to discourage long stays.\n(2) A liaison would still be necessary between the local hospitals and the Insurance Service but\nit probably could be adequately arranged through an agency such as the Hospital Advisory Council.\n(3) Hospital deficits would no longer be a concern of the Insurance Service. If the government\ndecides that some action has to be taken on this problem, it should be attacked by another agency of\nthe government.\n(4) If this approach is followed, the change-over should be carefully prepared and understood\nby all institutions and persons concerned.\nApproach 3.\nThe compulsory Hospital Insurance Service should be terminated at some future date. The\nadvantages of this approach have already been examined in Chapter VII. They might be summarized\nas follows. Part of the hospital insurance needs of many people can be met by voluntary insurance\nagencies without involving the government in increasingly costly activity and without interfering with\nthe rights of individuals. In addition, the government subsidy under the present insurance plan would\nprobably produce a greater long range improvement in health if it were spent on preventive health\nmeasures and medical research.\nThe objections to this approach are that voluntary insurance leaves large gaps in coverage and\nthat the compulsory hospital plan has still not been given a fair trial. Possibly, with proper safeguards\nand more effective administrative procedures, some of the criticisms of the present plan might be\novercome.\nIf the plan is to be discontinued entirely, I suggest that an effort be made by the government to\nencourage voluntary insurance to cover as many persons as possible. Possibly some techniques could\nbe devised to cover aged persons and persons in rural communities, which are the two large groups not\npresently adequately covered by the voluntary hospital insurers in other provinces.\nIn place of compulsory hospital insurance, the feasibility of a state operated catastrophe medical\ncare insurance plan might be considered. This type of state health insurance is being actively promoted in the United States by many groups. Under such a plan of insurance, all medical care expenditures, including all hospital payments and fees to health personnel (doctors, physicians-surgeons,\nnurses, etc.) in any one year in excess of a specified percentage of a person's income, would be paid\nas a benefit. Most of these plans contemplate that something less than the total catastrophe expenditures would be paid to the insured in order to prevent abuse of the plan. The cost of such a plan\nwould depend chiefly on the percentage figure of income above which the insurance benefits are paid.\nA very high percentage might not cost very much more than the present government subsidy to the\nHospital Insurance Plan. This plan might have popular appeal. In considering it, many aspects\nwould have to be investigated\u2014a careful analysis of the relation of medical care expenditures to\nfamily income, the distribution of family incomes and the method of financing and administration. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD\nFF 101\n? WHAT SERVICES\nARE NOT INCLUDED\nIN THE PLAN ?\n? HOW DO I BECOME\nDefinite Outline of those\nA BENEFICIARY ?\nB.\nC.\nH.\nI.\nS.\nHospitalization Services\nwhich the Plan does not\n\t\ncover.\n-   ?\n? WHAT ARE THE\nPREMIUM RATES ?\nOutline of Premiums\u2014\n(a) Single Persons:\n(b) Families:\nWith details of Dependent\nCoverage included.\no\no\nft\nFull Outline of Plan of Registration and Payment of\nPremiums, including the\nprivilege of arranging Payroll Deductions between\nEmployer and Employee.\n3\no\nft\nYOU\nWERE\nASKING\n? WHAT HAS THE\nINSURANCE SERVICE\nDONE TO DATE ?\n? WHAT ARE THE\nBENEFITS INSIDE\nB.C. ?\n? WHAT ARE THE\nBENEFITS OUTSIDE\nB.C. ?\nA.\nNumber of Claims Paid\nto Date\nAmount Involved\nNumber of Claims over\n$2,000 etc. etc. etc.\na\no\nDescription of Benefits allowed to all Beneficiaries\nhospitalized within the\nProvince.\na\nft\nOutline of Benefits provided\nfor Registered Citizens of\nB.C. who enter hospitals\noutside the Province.\nFROVu\nUMiAtar, FF 102\nBRITISH COLUMBIA\no\nin\nPi\n<\nS\nm\nH\nPi\nO\nft\nfc\nO\n2\nW\nPh\nO\n3\n!\/\">   O   H\nNO   -H\n>r>\n<n\no\nON\nON\no\nfN\nc\n<~- iS> \">\no &\u2022* cn\nCN O ON\nrn cn\n00\ncn\nCN\nr-l\no\no\nC-;\no\nON rn 'nI-\nr~: lo\nrH\n\u2014:\ncn\n>n\nCN\nd\nen CN\no\no -igrod\nrH p~ \u2014,\no o\nO\no\no\nr)\nCN\ncn\no \u25a0*\n1\n>\/-> \u25a0* r~_\nt^. >o\nCN\ncn\n>ri\n\u25a0*\nON\n\u25a0\".ON\ncn no\no\" no\" oo\"\n\u00abvn cn\"\nCN\non\"\no\noo\"\ncn\nON 69\nPi\no\nt-- \u25a0*\nCN   rH\n.\u20141\nCN\ncn\nVi\nON\ncn\n1\u20141\nCN\nCN\nCN\nCNl\n69\n\u00ab\u25a0\n69\n69\n69\n69\nH\no o t-~\nr^ cn\nTl\nO\n\"*\nT^\niH\ncn\no\n\u25a0*\nNKoO\n\"t f~: 1\ncn on\nTT\n<r~,\nON\n\u25a0*\n>n\nO\nON\ni2\nTj- oo oo\nrn cn\nr-:\n^f\nrH\n\u25a0rf\nr^\nd\n00 CN\n^\u2022^goN\nen tj- o\nOn cn\nV~l\ncn\nOn\n^r\n\u25a0*\ncn ._\nr^ cn\n'S\ntt oo^ oo^\nO rH\nON\nO\n\u00b0\\\ni^)\n-*\n\u00b0\u00b0\u00a3\nm.d\n0\ncn (si\n\"OON (N\noo\"cn\n\u25a0*\"\n>n\nxr\"\nr~-\nCN  rH\non\noo CN -3\"\nU\")   T-H\n\"*\n,\u2014t\nin\n<n\nVi\nON\n\u2022* 69\nPh\nrH\nCN\nCN\nCN\nCN\n--t\n69\n\u00ab\u25a0\n*\/5-\n69\n69\n69\nU t-i\nO  NO   K-i\nrH   ^\nr-~\noo\nm\n\u25a0*\nON\no\n>\/->\nZ\u00a3\no\\ yCj -H\nn- sn o\n\u00a9  \u00bbH   P~\nON CN\nNO\n\u25a0*\nrH\noo\nNO\nq\ncn\nja\u00a3\n-ct r-^ on\nO NO\n^\n\u25a0*\nON\ngo'\nON\nr~:\nOn \u25a0*\nNO   Tf   \u00b0\u00b0.   rH\ncn -h en\nON TC\n\u25a0\u00ab\n>o\nON\n^J-\n\"*\n2^\n- oo\n-H   NO\noo On rH\n0O NO\nCN\niO\n00\n00\nON\n\u00b0Vd\n*2 M\nCN fN <S*\noC no\" >o\"\nrn\"o\"\n>o\nNO\"\nNO\nON\no\nNO ^\nOO\n00 CN\nCN   rH\n.\u2014I\nCI\n69\nON\n^r ^5-\n^H\nCN\nCN\nCN\nCN\nw\n^\n^5-\n69\n69\n69\n69\nlO  ON  ON\ncn cn\no\no\no\n^\no\nNO\nt3\n\u2014i Sn on\nCN O oo\ncN O\nCN\nON\nrH\noo\n(N;\nq\n[^\ns\nno d r^\nTf d\nxr\noo\nC^l\ncn\nd\nen\noo' t^\nrt\noo fig ^\n\u2022o >n ~ 69\nlO  \u2014  0O\n>n cn\nCN\nC^l\n<n\no\n\u00abo\nr^ cn\nU3\nit O^ <r\\\nO M\noo\nON\nf~\n^S\"\nNO\n\"\"'On'\n1\nrH     IO\non* on\" oo\"\n[C rH\nun\"\n\u2022*\no\"\nt~-\"\n\u2022\u00a3\non\"\nCN ^^\nVO\nO    rH\nCn   rH\nCN\ncn\nc->\n69\no\nr^\nV3-\n\u00ab\u25ba>\nVi\n69\n69\n&9\nO On no\n<n oo\nt-\no\nr-\nNC\nON\no\n00\ns\nvo.oin\nm en ^cf\nrH   0O\nCN\no\nCN\n\u25a0V,\nCN\no\n>\/-)\nio on io\nO cn\nNO\n\u2014:\nt~:\nC>\nC~i\n^H*\n't \u25a0*\nNO ^ god\nno o r-\n\"O no\n00\nt-~\n\u00ab->\nwn\nc\n^   r^\nio On\n1\nCN C~-_ >o\n1\/V-rH\ncn\nn\nNO_\nr-^\n*Jn\n\u00b0\u00b0od\n\u00ab r-\no\" o\" r-\"\noo\" irT\ncn\nno\"\non\"\nno\"\nt-~\"\nv-i\n00 69\nNO\nHHCfJ\n<o\n>o\n\u00bbo\nNO\n69\n00\n69\n69-\n\u00ab\/^\n69\n69\n69\nWMn\nrH   00\ncn\nW)\nOO\nCNl\n\u25a05f\nO\nCN\n0\\ ^s, O\nrH \u00a9 ON\nCN 00\ncn\n\u2014\n->t\nCN\nP-;\no\n\"!\n0\nS\no\nO NO CN\nON \"O\ncn\nNO\nOn\nr~:\nI-h1\nCN\noo' -^t\nno no ^ 69\nr-- no cn\nNO ON\nr^\ntN\nON\nIf,\n'A-,\n\u00a3\u201e\u00a3\nrH   CN\nr-^ \u2022* cn\n\u25a0* NO^\nts\nCN\n\u00b0\u00bb\no\nC\nO.00\n0\nrH   ON\ncn oo\" ^h\"\ncncN\no\"\nr--\"\nr-\"\no\"\n<nP\nCN\n\"O 69\n\u25a0o\nO -h\nCN\nCN\n.\u2014i\ncn\n^f\nB9\nO\nOO\ni\u2014i\n69\n69\n69\n69\n\u00ab\u25a0\n69\non cn o\nCN O\nCN\n^_,\ncn\n\"~>\nCN\nO\n\u2022*\n>>\n00   .O   IT,\nt~- S^ ON\nO \u00abo \u00abo\nrH  In\nNO_\n-c\nCN\n>o\nen\nq\n00\ncd\noo CN ^\ny\/i t^.\nt~:\n00\nNO\nOC\nCN\nNO\noo On\nrH   ^od\nO O cn\n~rf  >0\n00\nCO\nt~-\n\u2022*\nt~\no _\nf- NO\nC\n\"\\ ^ ^\nOO ON\n00\nNO\n\u00bbn\nCN\nNO\n\u00bb?\n^on'\n4-\nrH   t\u2014\non\" \u00bbo cn\noo\"cn\"\n<rT\nOO\nTf\"\nno\"\nC^l\n\"O V}\n\u20223\n>\/->\nOO  CN\n'\u20141\n1\u20141\nCN\ncn\n\u2014\nNO\n69-\n\u20ac^\n69\n69\n69\nb^\n69\n0*N\nno cn\ncn\ncn\n\u25a0*\nO\nCN\n-*.oCN\noo cn On\no cn\nC~;\nC~;\ncni\n<o\n30\nOn\nON OO ^-'\nO  NO*\ncn\ncn\n\u25a0*\nd\n1J\\\nno' cn\n\u25a0si\n\u2022y \u00b0\n09\nCN r-- ON\nO NO\ncn\ncn\nTf\n\"9\nOn >o\nNO CN rH\nTj,*-i\n\u00b0i.\nOn\n'NO\nr-\n^NO\nCN cn\nno\" o\" ^-\"\nrH  i\u2014i\non\"\nOn\"\nrf\ncn\"\n50\n^r ^\u25a0\nON\nT^   ^H\ncr\\\ncn\nCN\ncn\n69\nNO\ncj\n69\nCO\n^e-\nSr}\n69\n69\n39\nCJ\nT3\n!         -h\n3\nCJ\n:        \u00ab\n4H\n\u20223\no\n00\n_3\n_>.\nc\nCJ\n3\nEfl        |\n*c3\nCd\n\u2022a\n3\n.\u00b0        1\n.&\nCJ\noo\n,\u2014,\n>\n1\nCJ              C\n.cj\nCJ\n>\no     I\n<u    :\n>\n^3\n. cs   :\n\u00ab\ns\no\n%       -3\n5\n>\ncr\nCJ\n3   1)\no  w\nCJ\nt\nA  h         t-i         z;\noS       \u00a7    . g\nfJ            CO\nIh           o\n\u25a0a       o\n3\n3\noj   \u25a0\n-\nt    '-\n\u2014   +\nCJ         L\na.   '\nJ\nJ\nr\n3 ft\n1  a\ni *\nJ   0\n\u25a0d\nCO\nrJ\nCO\no\nCJ\n8 \u00a3 \u00b0 -S   8\n\"3   ccj   00\nTB1 8 o 1\n\u2122   ctj   rn nv     rt\nS   S           3           >-\nS   \u25a0\"    ffl            \u00ab\u25a0>            O\n\"Stj 9<     ^     -3\nffi Ph O          ^          l\u00a7\no         S\nrn          rt\nco        n,\n.3       \u00b0\ncj         ca\n5\n|;\n.2\n'o\nCJ  .\n\u2022-.\nCh\nCJ\n\u2014\nU\nto\nCD\n3\n5\no\n60\nC   r.\n\u25a0Jjj    CJ\ncU   \u00ab\nCJ   \u00a3\nD,   Cd\n0    ^\n(2\nPh\n(X\nrt\nw\nX\nH\n<\n5 c\nJH\nH\n\u2014\nu\nPh\nS\nD\n,^\nu\nu\nrt\nM\n|\nC\nc\ns\ncd\ncd\na\nU5\na\no\n\u00a3\n^\n3   W   O\n^3 cd cq\n7\u00a7f\nu S3 > REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 103\nSUMMARY REGARDING COMPARATIVE HOSPITAL STAFFS\n.    .      , ,          ...               .. Hospital in Hospital in\nActual hospital Capacity  British Columbia City Saskatchewan City\nBeds and cribs  405 503\nBassinets      66 50\n         471   553\nRated capacity (beds)                  405 466\nPercentage of occupancy, 1950^                   86.73 98.9\nTotal patient-days           123,934 168,220\nGross operating expenses as per\nfixed budget, 1951      $1,854,003.00 $1,518,916.00\nNet cost to service (estimated)_'    $1,507,226.00 $1,368,673.00\nNet wages and salaries (estimated)       $1,204,903.00 $85.8,000.00\nPer diem rate set for 1951                 $11.95 $8.14\n1951 Staff\nAdministration and switchboard    53 44\nSocial service       4 2\nMedical records       8.7 2\n  65.7        48\nGraduate nurses  147.5 65\nStudent nurses  221 223\nPractical nurses and nurses' aides 48 72\nOrderlies   26 16\n442.5        376\nLaboratory\u2014\nPathologist        1 1\nTechnician and others     22 17\nStudents _'  10\n\u25a0         23   28\nPhysiotherapy   4                            4\nRadiology\u2014\nRadiologists       3 2\nTechnicians and others     14.5 11\n         17.5        13\nPharmacy        9.5 3\nInterns       9.5 14\nNursing-school        9.0 \t\n         28   17\nDietary  47 61\nHousekeeping, gardeners  100 50\nPower plant, laundry  40 32\nTotal staff  767.7 629 FF 104\nBRITISH COLUMBIA\nPUBLIC HEARINGS HELD BY THE BOARD\nJuly 28th, 1951-\nJuly 28th, 1951-\nJuly28th, 1951\u2014\nJuly 30th, 1951-\nAugust 1st, 1951-\nAugust4th, 1951\nOcean Falls.\nPrince Rupert.\nWilliams Lake.\nDawson Creek.\n\u2014Prince George.\n\u25a0Kamloops.\nAugust 6th, 1951\u2014Vernon.\nAugust 7th, 1951\u2014Kelowna.\nAugust 8th, 1951\u2014Penticton.\nAugust 10th, 1951\u2014Trail.\nAugust 11th, 1951\u2014Nelson.\nAugust 13th, 1951\u2014Cranbrook.\nAugust 13th, 1951\u2014Fernie.\nAugust 15th, 1951\u2014Nakusp.\nSeptember 5th, 1951\u2014Abbotsford.\nSeptember 8th, 1951\u2014Victoria.\nSeptember 10th, 1951\u2014Nanaimo.\nSeptember 11th, 1951\u2014Port Alberni.\nSeptember 11th, 1951\u2014Courtenay.\nSeptember 12th, 1951\u2014Powell River.\nSeptember 17th, 1951\u2014Vancouver.\nSeptember 18th, 1951\u2014Vancouver.\nSeptember 19th, 1951\u2014Vancouver.\nSeptember 20th, 1951\u2014Vancouver.\nSeptember 21st, 1951\u2014Vancouver.\nSeptember 24th, 1951\u2014Vancouver.\nHEARINGS HELD BY THE BOARD NOT ADVERTISED AS PUBLIC\nJuly 29th, 1951\u2014Quesnel.\nJuly 30th, 1951\u2014Pouce Coupe.\nJuly 31st, 1951\u2014Fort St. John.\nAugust 9th, 1951\u2014Grand Forks.\nAugust 14th, 1951\u2014Golden.\nHOSPITALS VISITED AND HOSPITAL BOARDS HEARD\nAbbotsford\t\nAlert Bay - \t\nVisited\n    No\n    No\n__       . Yes\nHeard\nYes\nYes\nArmstrong\nYes\nAshcroft     -   -           \u2014   \t\n  Yes\nYes\nBurns Lake                     -\n    _ Yes\nYes\nChemainus \t\nChilliwack \t\nComox\n  Yes\n    No\n    .   No\nYes\nYes\nYes\nCranbrook          ..\n    Yes\nYes\nCreston\t\nCumberland     \t\nDawson Creek _ _     \t\n  Yes\n    No\n    . Yes\nYes\nYes\nYes\nDuncan       - - -    ~\n     __          Yes\nYes\nFernie      \t\n           No\nYes\nFort St. John\t\n  Yes\n'        .__                    Yes\nYes\nGolden            ..     .\nYes\nGrand Forks \u2022 _    - _\n      .             No\nYes\nHazelton -     \t\n                    Yes\nYes\nInvermere       -\n--   -                    Yes\nYes\nKamloops _   \t\n    -.                    No\nYes\nKaslo    - _\u201e \t\n                      Yes\nYes\nKelowna      -.    -     . .\nYes\nYes\nKimberley\t\nLadysmith  \t\n  Yes\n           Yes\nYes\nYes\nLangley -   \t\n     .._           No\nYes\nMission\t\n           No\nYes\nNakusp\t\n    No\nYes REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD\nFF 105\nHOSPITALS VISITED AND HOSPITAL BOARDS HEARD\u2014Continued\nVisited\nHeard\nNanaimo      .\n    No\nYes\nNelson          \t\n  Yes\nYes\nNew Denver - -  \t\n  Yes\nYes\nNorth Vancouver             _\nYes\nYes\n  Yes\nYes\nOcean Falls      . ,       \t\nYes\nOliver \u2014-      \t\nYes\nPenticton  \t\n  Yes\nYes\nPort Alberni      _       _ \t\n    No\nYes\nPowell River     \u2014          \t\n- Yes\n  Yes\nYes\nPrince George         \u2014\nYes\nPrince Rupert _\u2014       \t\n  Yes\nYes\nPrinceton         _ \u25a0      \u2014_              -   -      .\n   No\nYes\nQuesnel                       ..       -      -    - \t\n- Yes\nYes\nRevelstoke\t\n  Yes\nYes\nRossland \t\n  Yes\nYes\nSalmon Arm            _ _\n  Yes\nYes\nSmithers     \t\n  Yes\nYes\nSummerland    \u201e-           ____   _ \t\n-    - Yes\nYes\nTerrace               '\nYes\nYes\nTrail \t\n  Yes\nYes\nVancouver\u2014\nRoyal Columbian, New Westminster\t\n  Yes\nYes\nVancouver General\t\n  Yes\nYes\nSt. Paul's    \t\n_ Yes\nYes\nVanderhoof\t\n  Yes\nYes\nVernon\t\n  Yes\nYes\nVictoria\u2014\nRoyal Jubilee\t\n    No\nYes\nSt. Joseph's\t\n    No\nYes\nWilliams Lake\t\n  Yes\nYes\nWRITTEN SUBMISSIONS TO THE BOARD\nHospitals\nAbbotsford Hospital, Abbotsford, B.C.\nArrow Lakes Hospital, Nakusp, B.C.\nCreston Valley Hospital, Creston, B.C.\nGeneral Hospital, Chilliwack, B.C.\nGeneral Hospital, Kelowna, B.C.\nGeneral Hospital, Ladysmith, B.C.\nGeneral Hospital, North Vancouver, B.C.\nGeneral Hospital, Princeton, B.C.\nGeneral Hospital, Powell River, B.C.\nGeneral Hospital, Salmon Arm, B.C.\nGeneral Hospital, Vancouver, B.C.\nGrand Forks Community Hospital, Grand Forks, B.C.\nHawthorne Private Hospital, Vancouver, B.C.\nLangley Memorial Hospital, Murrayville, B.C.\nMcDougall Memorial Hospital, Kimberley, B.C. FF 106 BRITISH COLUMBIA\nMission Memorial Hospital, Mission, B.C.\nNanaimo Hospital, Nanaimo, B.C.\nPenticton Hospital, Penticton, B.C.\nRest Haven Hospital, Sidney, B.C.\nRoyal Columbian Hospital, New Westminster, B.C.\nRoyal Inland Hospital, Kamloops, B.C.\nRoyal Jubilee Hospital, Victoria, B.C.\nSlocan Community Hospital, New Denver, B.C.\nSt. Joseph's Hospital, Victoria, B.C.\nSt. Joseph's General Hospital, Dawson Creek, B.C.\nSt. Martin's Hospital, Oliver, B.C.\nTofino Hospital, Tofino, B.C.\nVernon Jubilee Hospital, Vernon, B.C.\nWest Coast General Hospital, Port Alberni, B.C.\nWar Memorial Hospital, Williams Lake, B.C.\nLabour Organizations\nB.C. Federation of Labour, Vancouver, B.C.\nHospital Employees' Federal Union, Vancouver, B.C.\nLocal 7310, United Mine Workers' Association, Fernie, B.C.\nStandard Railway Labour Joint Legislative Committee, Vancouver, B.C.\nVancouver and New Westminster Trades and Labour Council, Vancouver, B.C.\nVictoria and District Trades and Labour Council, Victoria, B.C.\nUnited Steelworkers of America, Trail, B.C.\nVeterans' Organizations\nArmy and Navy and Air Force Veterans, Gambier Harbour, B.C.\nCanadian Legion, B.C. Command, Vancouver, B.C.\nCanadian Legion, Rivers Inlet, B.C.\nImperial Veterans' Action Committee in Canada, Vancouver, B.C.\nImperial Veterans' Corps of B.C., New Westminster, B.C.\nLangley Legion No. 21, Langley, B.C.\nWomen's Organizations\nBritish Columbia Women's Institutes (Bulkley-Tweedsmuir District), Decker Lake, B.C.\nB.C. Women's Institutes, Cariboo District, Quesnel, B.C.\nB.C. Women's Institutes, Peace River Block.\nCongress of Canadian Women, Vancouver, B.C.\nMiscellaneous\nB.C. Hospitals' Association, Vancouver, B.C.\nB.C. Hospitals' Association, Yale-Cariboo Zone.\nB.C. Polio Fund, Vancouver, B.C.\nB.C. Retired Civil Servants' Association, Victoria, B.C.\nCapitol Hill Ratepayers' Association, Vancouver, B.C.\nC.C.F. Peace River Executive, Dawson Creek, B.C.\nCollege of Physicians and Surgeons, Vancouver, B.C.\nCommunity Chest and Council of Greater Vancouver, Vancouver, B.C.\nCanadian Temple of the More Abundant Life, Vancouver, B.C.\nComox South Liberal Association, Vancouver Island, B.C.\nDawson Creek Chamber of Commerce, Dawson Creek, B.C. REPORT OF THE HOSPITAL INSURANCE INQUIRY BOARD FF 107\nDominion Income Tax Staff Association, Vancouver, B.C.\nFarmers' Institutes, District \"J,\" Peace River Block.\nFarmers' Institutes, District \" B,\" Bulkley Valley, Skeena Valley, B.C.\nFarmers' Union of Alberta (B.C. Section), Rolla, B.C.\nHalls Prairie Farmers' Institute, Cloverdale, B.C.\nLangley Ratepayers' Association, Fort Langley, B.C.\nNorth Sidney Property Owners' Association, North Sidney, B.C.\nProvincial Junior Chamber of Commerce.\nPacific Coast Pipe Co. Ltd., Vancouver, B.C.\nPenticton City Council, Penticton, B.C.\nPharmaceutical Association of B.C., Vancouver, B.C.\nRegistered Nurses' Association of British Columbia, Vancouver, B.C.\nRegistered Nurses' Association of B.C. (Kamloops-Tranquille Chapter), Kamloops, B.C.\nSurrey Property Owners' Association, Cloverdale, B.C.\nSouth Cowichan Taxpayers' Association, Vancouver Island, B.C.\nThe Canadian Life Insurance Officers' Association, Toronto, Ont.\nUnion of B.C. Municipalities, Victoria, B.C.\nVancouver Board of Trade, Vancouver, B.C.\nWhite Rock Ratepayers' Association, White Rock, B.C.\nYarrows Ltd., Victoria, B.C.\nIndividual\nH. E. Andrew, City Clerk, Penticton, B.C.\nC. P. Bagnall, Vernon, B.C.\nH. A. Breen, Prince Rupert, B.C.\nW. G. Cowan, Postmaster, Field, B.C.\nDonald F. Gower, Dawson Creek, B.C.\nG. H. Jackson, Secretary-Treasurer, Canadian Pacific Employees' Medical Association\nof British Columbia, Vancouver, B.C.\nH. R. Matthews, 12 Marine Avenue, Westview, B.C.\nG. T. McKay, Supervisor, Settlement Service, Department of Citizenship and Immigration, Vancouver, B.C.\nJ. A. Ploos, Secretary-Manager, Fernie Memorial Hospital, Fernie, B.C.\nA. H. Povah, Kelowna, B.C.\nDr. C. M. Robertson, Osoyoos, B.C.\nA. E. P. Stubbs, Chemainus, B.C.\nDr. T. W. Sutherland, Parksville, B.C.\nT. A. Titchmarch, Penticton, B.C.\nAnd many others.\nvictoria, B.C.\nPrinted by Don McDiarmid, Printer to the Queen's Most Excellent Majesty\n1952\n1,500-252-3119 ","@language":"en"}],"Genre":[{"@value":"Legislative proceedings","@language":"en"}],"Identifier":[{"@value":"J110.L5 S7","@language":"en"},{"@value":"1952_V03_09_FF1_FF107","@language":"en"}],"IsShownAt":[{"@value":"10.14288\/1.0343332","@language":"en"}],"Language":[{"@value":"English","@language":"en"}],"Provider":[{"@value":"Vancouver : University of British Columbia Library","@language":"en"}],"Publisher":[{"@value":"Victoria, BC : Government Printer","@language":"en"}],"Rights":[{"@value":"Images provided for research and reference use only. For permission to publish, copy or otherwise distribute these images please contact the Legislative Library of British Columbia","@language":"en"}],"SortDate":[{"@value":"1952-12-31 AD","@language":"en"},{"@value":"1952-12-31 AD","@language":"en"}],"Source":[{"@value":"Original Format: Legislative Assembly of British Columbia. Library. Sessional Papers of the Province of British Columbia","@language":"en"}],"Title":[{"@value":"PROVINCE OF BRITISH COLUMBIA REPORT of the Hospital Insurance Inquiry Board 1951-52","@language":"en"}],"Type":[{"@value":"Text","@language":"en"}],"Translation":[{"@value":"","@language":"en"}],"@id":"doi:10.14288\/1.0343332"}