INSURANCE BENEFITS (darker parts of bars) in 1957 covered only 19 percent of all private medical costs in national sampling survey by Health Information Foundation. A 1957 New York City survey studied two local programs, Group Health Insurance (GHI), which pays bills of the participating and other practitioners, and Health Insurance Plan (HIP), a prepayment, group-practice program. Under HIP there is considerably less hospitalization.

One of the most persuasive pieces of evidence for the link between organization, quality of medicial care and health comes from a study of the Health Insurance Plan of Greater New York conducted by Sam Shapiro, Louis Weiner, and Paul H. Densen. In this plan obstetric and pediatric care are provided by specialists brought into close collaboration by well-organized, group-practice units. Their patients proved to have a lower perinatal mortality than patients of similar means who obtained their care from the generality of physicans in

New York City. Perinatal mortality-the rate of still births plus infant deaths in the first months of life-is the accepted indicator of the effectiveness of care given to mother and child in the period of late pregnancy, delivery, and early life.

If one compares the organization of medical care in the United States with that in Great Britain, Sweden, or Germany, its most obvious characteristic is its fractionation, or, as some would say, atomization. Many, if not most, doctors are engaged in "solo" practice, working alone in their own offices and caring for their patients as best they can, both in and out of the hospital, without the formal collaboration or consultation of colleagues. The hospitals too are fractionated; many small cities have two or more small hospitals. If medicine demands specialization and the frequent collaboration of specialists, clearly it is illogical for physicians to practice alone out of offices with duplicated and often inadequate facilities and to place their patients in ill-equipped small hospitals. The physicians themselves in recent years have advanced a uniquely American solution in the form of group practice. In addition to the representation of two or more specialties, the group must have an agreed-on income distribution. If there is no plan to cut the cake, it is not a group, because the income-distribution plan serves the function of facilitating the referral of the patient from one specialist to the other. Group-practice units offer rather formidable competition to singlehanded physicians; where they exist side by side, groups and individual physicians usually have separate clienteles. Except for a few well-known examples, such as the Mayo Clinic in Rochester, Minn., group physicians deal with the humdrum as well as the more complicated medical problems their members are trained and organized to meet.

TRAINING IN MAJOR TEACHING HOSPITALS is more readily available to graduates of private medical schools and to those in upper ranks of their classes. The graduates with poorer academic standing, who need the most training, usually get the less rigorous internships. Study of graduates was made by Fremont J. Lyden, formerly of Harvard Medical School.

That a group can provide more and better technical facilities is self-evident. Through this and other economies the group probably makes care more efficient as well as more effective. Even more than a hospital, it puts its members in a goldfish bowl, in which each physician carries on his work under the scrutiny of his fellows. A group of sufficient size and diversity can sustain its own intel

lectual life and provide day-to-day education. Most important, from the patient's point of view, it provides an internist who fills the role of personal physician and whose informed diagnosis directs the patient to the specialist. When a group is organized in relation to a prepayment plan, it will have boxed the major problems of quality, organization, and finance. In the circumstances of practice prevailing in the United States today, however, the group will have isolated itself even further from the generality of medicine.

The tendency of medical practice in this country to organize itself around the hospitals presents a different and seemingly more significant development. Most physicians are already affiliated with one or more hospitals; this makes the hospital a focal point for the planning and provision of the services, facilities, and educational programs so badly needed to keep practice in step with science. hospital is the one institution that has real influence on the generality of doctors insofar as it can require that they meet universal standards of training and can demand responsible performance.

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That the quality of a hospital will vary with size is perfectly obvious, but it is a surprise to discover how great the differences can be. The hospitals in the United States are only slightly less atomized than practice itself. Of the nearly 6,800 general hospitals in the country, some 1,600 have fewer than 25 beds and only 2,300 have more than 100 beds. It is clear that 25 beds cannot justify the diverse services demanded of modern medicine and that even 100 beds fall below the border line of some of the most significant services.

Hospitals of the same size may vary considerably in quality, but there are variations in quality that correlate directly with size. The large hospital will obviously have a wide range of facilities because size makes such a range both necessary and possible. It is in this group, even outside of the universityaffiliated hospitals, that one finds an occasional research program, a full-time director of medical education and an active educational program, a relatively complete laboratory and range of treatment services, many and varied specialists and an administrator of distinction. These for the most part are the accredited hospitals-accredited for the training of nurses and for the postgraduate internships and residencies that now take as many years of a young doctor's life as his medical school education. Accreditation is conferred by a joint commission of the American Medical Association and other professional societies. This is a powerful lever for setting and elevating standards of performance. Although accreditation is a much desired minimum qualification, fewer than half of the eligible voluntary hospitals have won it. On the other hand, since withdrawal of accreditation carries such heavy sanctions, it is a police power that is difficult to exercise.

Few hospitals in the middle range of size are able to provide training for residents and interns. Many of them, however, maintain a nursing school because this provides important services to the hospital itself. In the small and very small hospitals the pathologist may be only on a part-time basis or may be replaced by a direct-mail service, and there is a corresponding dearth of other facilities. The generally lower charges of such institutions reflect a poverty of resources rather than of efficiency. In fact, hospitals with 25 or fewer beds have average occupancy rates of only about 50 percent, whereas an 80-percent rate prevails in hospitals of 200 beds or more.

The voluntary-as distinguished from Government or proprietary-general hospital of the United States is an institution sui generis; it is rare elsewhere in the world. It is usually the property of a lay board of trustees; the lay administrator to whom the trustees delegate the management of the institution has great power over every aspect of the institution but one: the medical service rendered within it. The hospital in the end is the doctors' workshop and, barring misbehavior or incompetence, they are free to use it with few restrictions. From their own number the doctors elect such important officers as chief of staff and the chiefs of the various services. Because this democratic procedure often reflects considerations other than excellence-the doctors in a community inevitably develop mutual interests and conflicts as they live and work together, refer patients to one another and so on-the quality of medical administration is variable and may amount to inaction. In one small hospital, for example, the surgeons have never elected one of themselves chief of surgery but rotate what has become a medically meaningless office among the more numerous general practitioners. Fortunately doctors tend to be conscientious and responsible men, so that results are not so bad as the process suggests.

This scheme of organization is almost unknown in hospitals abroad. In the Western European countries, where the practice of medicine as reflected in vital

statistics achieves results comparable to our own, the hospitals normally have salaried staffs with full-time chiefs of service. The rationale for this is that the patient sick enough to be admitted to the hospital needs specialist care. The system also provides a means for more careful discrimination in the admission of patients to the hospital in the first place. In the United States this arrangement is often described as tantamount to "socialized medicine." It prevails, however, in the Netherlands, where health insurance is voluntary; in Denmark, where voluntary insurance is subsidized by the Government; and in Great Britain, where medical care is almost completely socialized. The system is found also in the Henry Ford Hospital in Detroit, and in the Mary Imogene Bassett Hospital in Cooperstown, N.Y., respectively a distinguished large hospital and a distinguished small one.

Perhaps the most significant single trend in the organization of medical care in the United States in recent years has been the rapid increase in the number of physicians representing all the medical specialties who practice or are employed full time as members or chiefs of hospital staffs all over the country. Their numbers, which include trainees as well as practicing physicians, have increased from 8 percent of the profession in 1931 to 22 percent in 1959. In this respect U.S. medical care is moving toward the European pattern. Radiologists and pathologists were among the first to make the transition, and more recently members of all the other specialties have followed suit.

A measure of the trend is the degree to which it has complicated the debate on using Federal social security funds to pay hospital bills for the aged. Physicians have clearly seen that, if the Government begins to participate in paying for hospital care, it may later help to pay doctors' bills. If this happens, the Government may ask if Doctor A is qualified to hospitalize Patient B-as it already does in connection with admissions to Veterans' Administration hospitals. University hospitals have already sought to protect their excellence by careful recruitment and selection of staff, so that there is ample precedent for such action. As hospitals have been strengthened under the medical direction of full-time staff members, they have tended to specialize in the treatment and care they afford. Even the smallest hospital must be prepared to care for a variety of common medical, surgical, and obstetrical problems. There are, however, rarer problems such as those requiring the skill of a cardiac-surgery team-that can be cared for only in very large medical centers. The differential needed for various types of service has given rise to the concept of, if not a trend toward, regional organization of smaller satellite hospitals around larger medical centers and university hospitals. In the Hill-Burton Hospital Survey and Construction Act, Congress expressly called for the development of regional plans as a prerequisite to obtaining the Federal funds the act made available for the vast expansion of hospital facilities during the past two decades. One notable attempt was made in this direction in western New York, centering on the university medical center in Rochester. At this point the net result seems to be the achievement of a small measure of cooperation among the hospitals in purchasing and other services but no significant regional planning for the use of medical services and facilities. It is naturally easy to blame the system of fee-for-service payments and the economic ties that go along with the referral of patient to specialist. It was probably unrealistic, however, to expect doctors who believe they are doing the best they can for their patients to exhibit any interest in a regional organization that would, by implication, contradict that belief, particularly when the regional plan had neither stick nor carrot to encourage a change of habit.

The questions of the quality and organization of medical care in this country ultimately invoke the financing of medical care-the methods by which the patient pays for care received and by which the physician is paid for services rendered. For the period 1929 to 1932 the famous Committee on the Costs of Medical Care, headed by the late Ray Lyman Wilbur, president of Stanford University and a member of President Hoover's Cabinet, found that 10 percent of the population incurred 40 percent of all medical-care bills in any one year. A recent survey by the Health Information Foundation found an almost identical figure: 11 percent of the population in 1956 was burdened with 41 percent of the total personal expenditure for medical care. The fact that medical costs are unevenly distributed within the population, that illness and its costs cannot be predicted for any one individual and that the need and therefore the expense for medical care is, in any case, unevenly distributed throughout the individual's lifetime these are the factors that have made medical insurance popular as well as logical. About three-quarters of the population now carry some form of medical insurance, the principal outlay being made to insure hospital costs.