not allow the issue to be evaded by leaving it to the people to employ unfit physicians at all times except in cases of industrial accident, trusting to some quasiprofessional insight on the part of industry to avoid the danger by the wise choice of a physician whenever a workman happens to be hurt. Incidentally, if panels of physicians are to be made up from which an injured workman may choose, they should be made up by the board of medical examiners of the state, not by a lay body like a workman's compensation commission, and their organization should not be left to individual lay employers.

A provision found in some workmen's compensation acts requires that the fees of the physician be limited to such as are customary between physicians and patients in the particular walk of life in which the injured workman happens to be. Such a provision is binding on the workmen's compensation board in all cases coming before it for determination of the physician's charges. In principle, however, it is wrong; for it is unfair to require physicians, because they do moderate their charges for workmen with small salaries and with large families to support, to extend similar charity in cases in which they render services to a given industry that are in the end paid for by the public. The physician who treats an injured workman and brings him back to health and useful activity is entitled to a fair return for his services, and should not be penalized because in the goodness of his heart he at times extends charity to workmen in distress.

Another interesting feature of workmen's compensation acts, relating to fees, is that which provides that in determining what is the proper fee, the workmen's compensation board shall take into consideration the fact of the supposed certainty of payment. This provision seems to be based on the hypothesis that if the physician had to collect his fees from the injured workman, or from the employer through the injured workman, possibly by suit at law, he would in some cases not be paid at all; and that inasmuch as the law provides a method by which payment is to a reasonable extent assured, the employer against whom the board is to assess the physician's charges is entitled to a discount. Such a provision seems to lose sight of the time and trouble to which the physician may be put to collect his bills through the workmen's compensation boards. It seems to lose sight of the fact, too, that the employer against whom the bill is to be assessed is no more entitled to a discount because of the supposed certainty of payment than is any other person who is indebted to the physician and who pays his bills. In almost every line of industry prices are fixed on the supposition that a certain amount will be lost through bad bills, and those who pay their bills must pay enough to protect the creditor against such losses; and there is no reason why a different practice should be followed with respect to the debts due a physician.

Passing, now, from a consideration of contracts and fees under workmen's compensation acts, it may not be amiss to call attention to the tendency of such acts to break down the confidential relations that are supposed to exist between physician and patient. Disclosures that may not be tolerated in a court of law can in some cases be compelled under a workmen's compensation act. It is possibly difficult to avoid this and yet to provide for an equitable administration of the law. It would seem, however, as if provision might be made whereby, when a physician files a certificate or makes a report, or testifies before a workmen's compensation board, the evidence, so far as it may be of a confidential character, may be kept in a secret file maintained by the board for that purpose.

If our state medical associations would encourage their members to submit to the association the difficult questions that arise under workmen's compensation acts and under other acts, particularly when such acts are new, the associations would accomplish a great deal of benefit for the individual and would serve to keep workmen's compensation boards and other administrative agencies within

proper bounds. After such a board of agency has established a given practice and that practice has been tolerated by the profession for a long time, it is difficult to modify or reverse it. Questions relating to such matters and submitted by members to state associations might in many cases be answered offhand. In other cases, counsel for the state associations could very promptly settle them. In any case, if the Bureau of Legal Medicine and Legislation can be of service in connection with such matters, it is at your command.

DISCUSSION

DR. B. L. BRYANT, Bangor, Maine: A few years ago a peculiar phase of this workmen's compensation came up in the state of Maine. As Dr. Woodward has said, in this compensation act, the employer must furnish adequate medical and surgical attendance and hospitalization for the man. Various insurance companies got around this and cheated the physician out of his fee by putting all his accident cases in the free wards of the hospitals; and we as physicians were bound by a regulation of the hospital to treat all cases in the wards as charity patients without remuneration; we were obliged to treat all these cases for nothing.

It occurred to me about four years ago that this was not fair, and so I took up the matter with our attorneys and also with the compensation commission, with the result that the commission backed me to the limit in saying that the employer or the insurance company could not avoid paying the physician by taking advantage of a rule of the hospital by which we were obliged to treat all cases in the wards free of charge.

Obviously, the way to get around that was to have our hospital board change the ruling as regards patients in public wards, which they promptly did by adding a clause to their rules that they should not be interpreted, in compensation cases, as depriving a physician of his legitimate fee.

We had another peculiar incident along the same line by which a certain large corporation was accustomed to turn all their cases into the public wards, although they had a medical director on a large salary. He drew his salary; we did the work; he got the pay. I took this up with the corporation. While they did not wish to make any special ruling on it, I have noticed in the last few months that none of their cases at the present time are being treated in the public ward, but are being placed in another ward and under the supervision of this medical director who is a member of the staff.

In Massachusetts it is a little different. I think there is a legal ruling by which the compensation cases are sent into the hospitals, and I think the physician gets little or no fee out of it. In our compensation board we have a very fair and square group of men, and they tell us very frankly that they expect to pay the same rate for accidents under the compensation act as they would pay the physician in his relation with ordinary patients, and so at the present time we have had very little trouble.

They have also ruled that the physician is to take care of his patient until the patient has recovered, and that the employer and the liability association are obliged to pay the physician's fee. So now every man puts in his bill and gets his money. This also was taken up with our attorneys for the association. The association voted to back any suit that might come up with regard to this matter of liability.

DR. E. G. BALSAM, Billings, Mont.: I would like to state my case and see if any secretary has had legal advice on the proposition.

The chairman of the compensation board denies the right of the doctors in our state to make a definite contract with injured individuals. He not only does that but he sends a letter to the individuals who are injured telling them that they are not compelled to pay the doctor. In our state the maximum amount is $100 for the first two weeks. This $100 covers not only the medical charges but the hospital, nursing and any other expense incident to the case.

There is one case in particular in which a specific contract was made with the patient, and when the bill was presented the patient brought a letter to the doctor from the board telling the patient not to pay the doctor.

Of course that puts us up against a test case. I advised the doctor to wait until I came to this meeting to find out how to handle the case. If anybody can give me any light on it I would certainly appreciate it.

DR. ALBERT E. BULSON, JR., Fort Wayne, Ind.: We must not overlook the fact that the insurance companies in a very large measure are the dictators in this compensation business; and I think I am justified in saying that in practically every state in the Union the insurance companies either epenly or secretly are making every effort to limit beyond reason the compensation that shall be paid to physicians for services rendered in indus

trial cases.
Their ultimate aim, through combination of effort, is to secure not only
efficient services but less than customary fees.

I have been informed that in our state several of the large industrial insurance com-
panies have a mutual understanding to turn all industrial work to certain physicians who
are told that as a result of the amount of work that will be sent to them, they can afford
to take the work at very much reduced fees as compared to fees charged private patients.
The operation of this plan will be a hardship on younger men, many of whom are as
competent as the older ones with reputations and experience who are selected by the
insurance companies. Aside from this, the plan, if accepted by any physician or physi-
cians, is contract practice which has been condemned by the American Medical Associa-
tion through its House of Delegates, and is pernicious in its influence. In fact, the
ultimate end of contract practice will be the loss of independence and individuality of
medical men.

Another injustice practiced on the medical profession in several states, and in Indiana particularly, is that feature which limits compensation to services rendered within a thirty day period. In Indiana we have taken the stand, and will defend it in the next legislature, that an injured employee should have the right to select his own physician, and that compensation for the services shall be taken care of by the employer or his representative, the insurance company. We also have taken the stand that the fees awarded the attending physician in compensation cases shall cover all services through to the termination of the case, no matter as to the length of time. We all know that few major accident cases are sufficiently recovered so that they can be discharged within the thirty day period; but in our state many a physician has been denied compensation beyond the thirty day period, and even the fees that have been awarded in such cases have been ridiculously low.

It is unfortunate that there is no uniformity in the fee bills. In our state the fee bill governing the industrial board is one that was adopted a great many years ago when everything was low in price, and even at that time the fee bill was considered an injustice. It is ridiculous now in the light of present day standards, and yet our compensation board is being governed by it. No doubt the fee bills are arranged by insurance companies, and probably are accepted without comment by the medical profession because we have not put up a united front in opposition. In some states where the fee bill in compensation cases is low, reputable men will not take care of industrial cases, for they not only object to working for ridiculously low fees, but they object to the continual controversies with industrial boards in order to obtain reasonable compensation. Then again, individual physicians neither have the time nor the inclination to go before industrial boards to fight for their just dues, perhaps in the end being defeated as the result of the skilful manipulation on the part of the representatives of the insurance companies, so, on the whole, the industrial work is not considered desirable except by those who are willing to take it for anything that they can get out of it.

Our state medical associations should take some interest in this matter and put up a united front through their legal departments in not only protecting but assisting individual physicians in their controversies with the industrial boards. Furthermore, when a medical association puts up a united front in attempting to secure justice, the insurance companies and the industrial boards will not adopt the high handed methods of the present in dealing with the compensation claims of physicians. In Indiana we are trying to improve conditions by having a medical man appointed on the industrial board, and if we can not accomplish that we hope to secure provision for a medical referee, like they have in some states, to whom questions involving the rights and privileges of medical men will be referred for adjustment. There really is no excuse for imposing on the medical profession in this industrial work, for in the final analysis the compensation expenses, including amounts paid to employees as well as to doctors and hospitals, is charged to cost of production and passed on to the consumer. The medical end of the proposition is the football that is batted around because doctors put up with that sort of thing.

In closing his discussion, I would like to have Dr. Woodward offer recommendations concerning the question of fees for experts who may be called in consultation or actually to render services in industrial cases. For instance, it may be desired by the injured employee, the employer, or even the insurance company, to have the opinion or even the attention of an expert ophthalmologist, surgeon, alienist, or other specialist of experience and reputation, and as such men customarily receive larger fees than ordinarily are paid, shouldn't they receive larger fees than ordinarily are awarded the average attendant? I also would like to suggest that the Bureau of Legal Medicine of the American Medical Association, with the endorsement of the Board of Trustees, prepare and recommend a

general plan covering all phases of industrial work for adoption by the various states in order to have more uniformity in the rules and regulations governing professional services in industrial work. Modifications may be necessary to meet conditions in the different states, but there can be far greater uniformity than at present when everything is in a chaotic condition.

DR. JOHN B. MORRISON, Newark, N. J.: I think that Dr. Bulson has struck the keynote of this discussion when he says that the state association is representing the physicians in their state, and if they are large enough and powerful enough and have influence with the board, they can do more for the physician than the physician can do for himself.

New Jersey is an industrial state. We have had these problems to face ever since compensation went into force. First we had the compensation limited to $50 for two weeks' time. That included the hospital expense and the physician's expense, and nothing in excess of that was ever paid.

By conferences between our welfare and legislative committee and the insurance carriers we were able to have that compensation increased from $50 to $100. Then we drove farther, and, in a conference with the carriers, we had them give their consent to allow the state society to appoint a commission of physicians in districts of the state to whom all bills for treatment in excess of $100 would be submitted, and those physicians would pass on the correctness of that bill and say whether it was a proper bill for the services rendered.

For instance, in a compound fracture of the thigh, or something of that kind, the carriers promised to take those doctors' bills as submitted by this commission and pay them. That has been a great step forward.

We have tried for several years to incorporate in our law a clause stating that the injured employee should be allowed to select his own physician. That we have not been able to accomplish yet, but we have accomplished this, that the carriers have told us that the injured employee may select his own physician if he will allow them to send in their doctor as a consultant, or allow him to come in and inspect the treatment from time to time.

The danger with us in the compensation law is the danger arising from unscrupulous physicians charging too much, making too many calls and too many dressings and overcharging for small accidents. That is the thing that is driving the insurance carriers to establish their own little clinics, and even that we are successfully combating.

The better class of carriers will pay our bills without any question. The better class of carriers do not want a physician in a little clinic taking care of the cases. They would prefer to have a man whose reputation they know take care of those cases.

We have been successful, also, in having a physician appointed by the state as director of the department of labor. It took a long fight to get that. We have had a fight in New Jersey for many, many years to compel a legislature to give us medical representation on every public board in the state. For a while we were slapped in the face, and the representation taken away. In the last two or three years, by getting into politics, we have been able to put that over. We secured a medical legislative advisory committee to advise the governor on all subjects of a medical nature coming before the legislature. We were successful, as I have said, in having a prominent physician appointed commissioner of labor. In this way the medical profession is getting next to these things in a far better way than we could do individually. The way to accomplish it is through the state society, and its influence on the carriers.

DR. WILLIAM LAFAYETTE RICH, Salt Lake City, Utah: In Utah, the industrial commission asked the Salt Lake County Medical Society to give them a fee bill that would be fair for physicians to charge. The industrial commission allows the patient to select his own physician, but if, in the judgment of the industrial commission or their advisers, this physician is not capable or is not getting as good results as could be gotten, they advise having a consultant or making a change to some recognized specialist.

In order to see that our physicians are treated fairly, the state association has appointed a committee on industrial medicine. Three men are chosen to serve for three months without pay. They go every Friday morning at 10 o'clock to the industrial commission and review all the cases that have been treated by physicians. In case a patient has been dressed too frequently or too many charges have been made, they consider these things, and the physicians help the industrial commission in placing a reasonable charge on the services of the physician.

DR. FREDERICK N. BROWN, Providence, R. I.: The state of Rhode Island has no compensation board. They have felt safer in entrusting their affairs to the superior court than they have to any paid commission that may have its appointment by political preferment.

In 1912, the first compensation act was passed. I will treat with the medical aspects of it only, irrespective of any other affairs. It reads:

"During the first two weeks after injury the employer shall furnish reasonable medical and hospital service, and medicines when needed, the amount of charge for such services to be fixed, in case of failure of employer and employee to agree, by the superior court." This commenced and concluded the medical aspects of the workmen's compensation act. We had some trouble because the employer regarded the thing as literal. He was to "furnish" the physician. Then any doctor called in was apt not to get his fee unless he came under the jurisdiction, so to speak, of the employer. If the doctor tried to collect his fee from the employer, the latter might say he didn't employ him. If he tried to collect of the injured man, he couldn't, because the law said that the employer was liable for the bill.

We had a sort of gentleman's agreement (more or less gentlemanly) with the insurance companies that our fees would be paid, but still we felt that it was rather unfair to be expected to treat these cases because we didn't know when we were ever going to get our pay or whether we were going to get it at all. Again, a man might have an injury that would extend, in the case of sepsis, beyond the two weeks. So we thought a board of adjudication to act as a buffer between the employer and the court and the insurance company and employee and the physician would be a very nice thing. We thought a committee of five would be splendid thing.

So we physicians got together and met with the house of delegates of the society and thrashed it out. We thought we would have three men on the committee of five that were physicians. Some of the house asked for a good deal; they wanted all physicians. We thought if we asked for a good deal we would get nothing. Nevertheless we did ask for a good deal at the hearing; we asked for five, and that is what we did get-nothing.

We went before the legislature and we were faced there by several employers (being in an industrial community) and a coterie of lawyers. What they did to us was quite a lot. We were permitted to withdraw.

We saw we must go at this thing from another angle.

Heretofore the employee was entitled, after the first two weeks of injury, to one-half his average weekly wage.

We interested some of the trade unions. We saw we must come at it from another angle, as I have said. When we came up again before the judiciary committee of the legislature, we had a different proposition to offer, including the raising of this amount from 50 per cent. to 66% per cent. We filled the chairs and crowded the corridors; we filled the aisles and lined the walls in a room larger than this at a public hearing before the judiciary committee.

We argued that the man should be permitted to select his own physician. We thought if we did that, we would be accomplishing quite a lot. We thought the time should be extended.

In 1917 the following amendment became a part of the law:

"During the first four weeks after the injury the employer shall furnish reasonable medical and hospital services and medicine when needed, the amount of such charge for such medical and hospital services shall be determined, in case of failure of employer and employee or his physician to agree, by the superior court. The employee shall always have the right to select the physician by whom or the hospital in which he desires to be treated; but the employer shall become liable to such physician or hospital for reasonable fees for such treatment, provided, however, the physicians or such hospital shall give written notice to the employer within seven days of the beginning of their services that they have been so selected and shall present their claim to the employer for payment within three months."

That pendulum swung a little too far, and some physicians were discovered to be not altogether careful of their integrity. But if they made reasonable charges the reasonable charges did not appeal particularly to the insurance companies, and they again went before the committee and this is what they got:

"During the first eight weeks after injury the employer shall furnish reasonable medical and hospital services and medicine when needed, provided, however, that the charge for the same shall not exceed $200." That is where it stands at this time.

It has been thoroughly worked out by the statisticians that 85 per cent. of all injured workmen return to work on or before the fifteenth day, so this is not such a bad proposition after all, because for the 15 per cent. that still are secured the physician must take his chance; but for the 85 per cent. that do return to work, you can see that he is well covered under the $200 fee.