Hospital Care in New York City: The Roles of Voluntary and Municipal Hospitals 9780231883894

Citation preview

HOSPITAL CARE IN NEW YORK CITY

HOSPITAL CARE IN NEW YORK CITY THE

ROLES

OF

VOLUNTARY

AND

MUNICIPAL

HOSPITALS

By H E R B E R T E.

NEW

YORK

AND

COLUMBIA

KLARMAN

LONDON

1963

UNIVERSITY

PRESS

PUBLISHED FOR HOSPITAL

COUNCIL

3 EAST 5 4

OF

GREATER

NEW

STREET, NEW YORK 2 2 ,

YORK,

NEW

INC.

YORK

A nonprofit organization incorporated to coordinate and improve the hospital and health services of New York City and to plan the development of these services in relation to community needs

COPYRIGHT C

1963

COLUMBIA UNIVERSITY

PRESS

LIBRARY OF CONGRESS CATALOG CARD NUMBER: 6 2

19901

MANUFACTURED IN THE UNITED STATES OF AMERICA

HOSPITAL

COUNCIL

OF G R E A T E R

NEW

YORK

O F F I C E R S

MAYOR ROBERT F.

ALVIN C .

Vice-President

EURICH

Vice-President

FITZPATRICK

PETER

MARSHALL

CLOYD

LAPORTE

MURRAY,

Vice-President

M.D.

Treasurer

HAYDEN C . NICHOLSON,

B O A R D

Secretary

M.D.

O F

D I R E C T O R S

ARON

GEORGE BAEHR,

M.D.

MRS. GEORGE M . MILTON J.

President

President

R F V . JAMF.S H .

JACK R .

Honorary

WACNER

THOMAS J. R o s s

BILLINGS

NORMAN

S.

JOHN

HAYES

H.

R. O.

D.

CLOYD

BLUESTEIN

GOETZ

HOPKINS

LAPORTE

JOHN F.

BROSNAN

MAXIMILIAN

GEORCF.

BUGBEE

PETER MARSHALL MURRAY, Miss

EDWARD F .

BUTLER

J . DOUGLAS

COLMAN

HOWARD R .

CRAIG,

CARROLL J .

DICKSON

ALVIN C .

M.D.

EURJCH

REV. JAMES H .

MOSS

HARRIET

ROSS

EDWARD J .

SOVATKIN

MARTIN

STEINBERG,

R.

FITZPATRICK

STEPHENS,

SAMUEL A . FRAWLEY

REPRESENTING

THE

JOSEPH

CITY

OF

L A W R E N C E E . GF.ROSA,

JAMES FELT, Chairman,

NEW

TURVEY WALSH

YORK

Comptroller

City Planning

Commission

LEONA BAUMCARTNER, M . D . , Commissioner

of

RAY E. TRUSSELL, M.D., Commissioner JAMES R . DUMPSON, Commissioner

P.

of of

Health

Hospitals Welfare

M.D.

PICKENS

THOMAS J.

FRANCIS X .

VERY R E V . MSCR. PATRICK J .

I.

M.D. JR.

HOSPITAL

COUNCIL

C O M M I T T E E

T O

OF G R E A T E R

S T U D Y

M U N I C I P A L

R E L A T I O N S

A N D

GEORGE

EDRICH,

Chairman HAYDEN

DICKSON

MISS

FELT

C.

NICHOLSON,

HARRIET

M.D.

• NATHAN

LAPORTE

PETF.R M A R S H A L L

MARTIN MURRAY,

M.D.

JOSEPH

S.

M.D.

PICKF.NS

SACHS

R. P.

I.

Ross

THOMAS J .

MORRIS A . JACOBS, CLOYD

B E T W E E N

S Y S T E M S

BUGBEE

CARROLL J . JAMES

C.

YORK

V O L U N T A R Y

H O S P I T A L ALVIN

NEW

STEINBERG,

M.D.

WALSH

• Deceased S T A F F HAYDEN

C.

NICHOI^ON,

Executive HERBERT E .

Associate SIGMUND L .

M.D.

Director KLARMAN

Director

FRIEDMAN

JOSEPH

Staff Consultant FRANCISCA

K.

THOMAS

Senior Research ROBERT

R.

Research

Staff

P.

PETERS

Consultant

MARGARET A .

Associate

Research

Associate

MURPHY

DOROTHY A.

Associate

Statistical DOROTHY

L.

COLEMAN

WOODHF.AD

Assistant

WILLIAMS

Librarian NADIA D E N I S S O F F

JOSE

JOHN

MARIANNE

H.

FRAZIER

JOAN GREENBERG

GONZALEZ J.

JACKFR

LEO J.

MORÖN

VERNA

R.

CLAIRE

M.

MORÖN MORRISSETTE

FOREWORD

T h i s book on hospital care in New York City was completed just prior to the reorganization of the Hospital Council of Greater N e w York into the Hospital Review a n d Planning Council of Southern New York. (The manuscript was edited for the last time a n d completely retyped early in March, 1962, while the new organization was formally established a few weeks later.) We thought it important to have the book published, because it serves several purposes rather well. I commend it as a summary of trends in hospital care during the generation in which the original Hospital Council was active in New York; as a statement and discussion of the prominent issues in hospital care in the late 1950s and early 1960s; as a factual base for the f u t u r e planning of hospital care in New York; and as a prototype of the variety and levels of information and analysis that may be required to achieve effective planning in the enlarged fourteen-county area served by the new Hospital Review and Planning Council. T h e Hospital Council of Greater New York was founded in 1938 as a voluntary nonprofit agency to guide the coordinated development of hospital facilities in accordance with measured needs and was u n i q u e among hospital organizations in this country for many years. Its corporate members were not hospitals or physicians b u t civic and professional organizations. T h e board of directors consisted of individual citizens who were concerned with the provision of adequate hospital services and had some knowledge in the field b u t who were selected mostly for their objectivity and independence of judgment. Although without official powers or sanctions, the Hospital Council's board derived its authority from the respect that the community accorded to its studies and recom-

viii

FOREWORD

mendations. Government manifested its regard when New York State asked the Hospital Council to serve as its local agent in the administration of the Hill-Burton program and incorporated The Master Plan for Hospitals and Related Facilities for New York City into the State's plan. T h e Hospital Council employed a full-time professional staff, drawn from a variety of academic disciplines, to gather data and analyze them. T h e Board of Directors usually relied on a standing or special committee to provide detailed and continued guidance to the staff, always reserving a full and detailed review of recommendations. For this study we were fortunate to have a special committee of distinguished board members, including officers, headed by Alvin Eurich. New York City has been fortunate in its long tradition of partnership of voluntary and municipal hospitals in caring for the sick poor in their wards and outpatient departments. T h e question was whether numerous changes in medical care, technology, finances, and medical education had changed the conditions conducive to effective cooperation. If so, there was an urgent need for study and appropriate remedial action. T h e idea of a study of the roles of the voluntary and municipal hospitals in New York City—their relationships, their problems, and their prospects—first emerged in the summer of 1955, shortly after Dr. Hayden C. Nicholson came to the Hospital Council as Executive Director. After the Board of Directors voted in November 1955 to conduct a broad study of the roles of voluntary and municipal hospitals, a committee was appointed and an outline of study was developed. T h e sections outlining the study's objectives and a statement of issues, current and long-range, were submitted for endorsement to several organizations, including the New York Academy of Medicine, the Department of Hospitals of the City of New York, the Greater New York Hospital Association, and the United Hospital Fund. T h e y promptly gave their endorsement and proferred their help. It was not until the winter of 1959 that it became possible to free the Associate Director, Dr. Klarman, to devote himself to this study exclusively. Within two months Dr.

FOREWORD

ix

Eurich's committee started to meet at f r e q u e n t intervals to review a n d criticize the several sections of the report as they were prepared and circulated by the staff. Most of the report was completed by the summer of I960, when a summary was prepared. T h e chapters dealing with population and hospital services were written in the fall of 1960. In December, 1960, the Hospital Council's report New York City and Its Hospitals was published, incorporating major findings and recommendations. T h e basic report was then edited, with some of the chapters rewritten in part or in full, in response to criticisms by experts and friends. T h e summer and fall of 1961 saw further editing of text and checking of tables, b u t there was no attempt to up-date information beyond December, 1960. T h e result of all this work is a big book, much bigger than we had anticipated or desired. It would not, however, have been possible to present the large volume of data collected and analyzed in a book with significantly fewer pages. In its present form the book may be considered a successor volume to the Hospital Survey for New York (1935-37) and the New York State Hospital Study (1948-49), as a benchmark for f u t u r e research in this field. T h e many headings—center, side, and paragraph—and a detailed index should be of some assistance to the reader. As a layman, I claim no competence in handling data or in technical analysis. W h a t does impress me is the light that the judicious selection and presentation of data can shed on problem areas that are otherwise difficult to understand. Why were the hospitals in New York so dissatisfied with the Blue Cross payment formula which, when adopted in 1948, seemed so objective, so fair, so automatic in application? W h y have municipal hospitals experienced increasing difficulty in attracting medical staff? Why is the patient load in hospital wards so high in New York City when more than 70 percent of the population has some form of hospital care insurance? I have mentioned the Hospital Council's report New York City and Its Hospitals. T h a t report, n o t this book, presents the official views of the Hospital Council. We are pleased to sponsor this book for the wealth of statistical materials it presents and for the quali-

FOREWORD

X

ties of technique and analysis applied to the data. However, the opinions and suggestions are those of Dr. Klarman and not of the Hospital Council. Finally, it is my pleasant duty to acknowledge the contributions that various organizations and individuals have made toward this book. T h e very size of the book speaks for Dr. Klarman's industry. Dr. Nicholson was constantly available to Dr. Klarman and kept the chairman and me informed of what was taking place. Dr. Eurich led the committee in an extensive review of the text, raising questions and suggesting improvements. I leave it to Dr. Klarman to list his helpers and critics. T h e United Hospital F u n d and the New York Foundation made special grants toward publication of this book. However, the staff's salaries and supplies were paid from the Hospital Council's regular budget. Once again, I take the opportunity to express our appreciation of the continuing financial support offered by the United Hospital Fund, the Greater New York Fund, Associated Hospital Service, Federation of Jewish Philanthropies, Federation of Protestant Welfare Agencies, Catholic Charities of the Archdiocese of New York, Catholic Charities of the Diocese of Brooklyn, and the Medical Societies of the Counties of New York, Bronx, Kings, and R i c h m o n d and the State of New York. Such support has enabled the Hospital Council to work with independence and freedom from financial worries. THOMAS J .

July 3,

1962

President

ROSS

PREFACE

As a result of this comprehensive study, the principles that guide the physical development of hospitals in a community may never be quite the same again. Even in a city as well endowed with medical resources as New York City, we can no longer take for granted the availability of physicians, nurses, and interns and residents to staff hospitals. We can no longer assume that a liberal tradition of free care is enough to provide needed services without improved hospital management and leadership. W e know that money is important, not in and of itself, but because its unequal distribution among hospitals means unequal capacities to command the real physical and personnel resources required for high quality medical care. Even when money is centrally collected, its distribution must be governed by priorities: what is spent for one purpose cannot be spent for another. Many of us who were active in this study believe that it has meaning, perhaps even direct applicability, outside New York City. T h i s is certainly true of the basic principles of operation, of the technical innovations, and may even be true of some of the findings. T h e data on finances, on means of paying for the care of the indigent, on changes in graduate medical education, on staffing of the nursing service, and on hospital utilization can at least serve other large cities as bases for comparison. Wherever there is more than a single hospital serving a community and where differences exist in their ownership and in sources of support, the discussion of hospital management, regionalization, and coordination of services, and of methods of payment employed by Blue Cross and government will be relevant. T h e task of the study committee was to guide the staff in its

xii

PREFACE

work, to report to the board of directors about progress and problems, and to screen the manuscript before it reached the board for final review and approval. T h e relationship between the chairman and the Executive Director of the Hospital Council has been particularly close, and I wish to express here my deep appreciation of Dr. Nicholson's many kindnesses and his constant, willing, and discerning help. T h e report accurately reflects the Hospital Council's aim to base policy recommendations on fact rather than on surmise, however authoritative the latter's source may be. It is often not possible to have all the evidence needed for reaching decisions, b u t we tried to gather a large part of it by paying close attention to problems that are just emerging and by anticipating their probable importance. T h u s this study is problem-oriented, and to the extent that some emerging problems were missed the study has gaps. For example, it is now clear that the development of proprietary hospitals should have received more attention than it did. On the other hand, absence of data and discussion on community planning for hospital care in the traditional sense—need for and availability of suitable physical facilities plus provision for their geographic distribution—is a deliberate omission. T h e Hospital Council knows a great deal about physical facilities and intended to learn more in a special study designed as a forerunner to the revision of its Master Plan. W e felt that we knew too little about other elements of the hospital scene, including programs of care, staffing, finances, and organization. Accordingly, these were emphasized in this study of the roles of voluntary and municipal hospitals. I have been impressed by the economy with which the voluminous and diverse data were compiled. T h e r e were very few special surveys conducted for this study, and none was on a large scale. Most of the data were obtained from the records and reports that agencies prepared for routine administrative purposes. Where data were incomplete or suspect, estimates were developed. Methods of making estimates are described in the appendixes. T h e book contains innovations in technique, some of which may have lasting value. For example, the bed turnover rate is employed both as an additional measure of hospital use and in relation to the two older indexes of hospital use, rate of occupancy

PREFACE

Xlll

and length of stay. In fact, the new measure is defined in terms of the other two. An index of obsolescence of physical plant is employed, which assumes that the only useful way of comparing the status of several physical plants is to compare the relative size of expenditures required to bring each to a satisfactory condition. There is no shorter way to obtain commensurability among hospital plants or among departments in the same hospital. T h e discussion of rates of occupancy by type of accommodation suggests that such rates should be viewed with great caution and that no policy conclusions can be drawn from them without concrete knowledge of the ways in which patients are distributed in an institution. T h e analysis of increases in hospital cost employs the usual data by major departmental groupings. But instead of examining rates of increase in each grouping, the author looks at the percentage distribution of the increase in cost among the several departmental groupings. Dr. Klarman makes numerous suggestions for further research. I should like to call attention especially to the discussion on measuring the quality of care and how difficult that is in practice. T h e suggestion is made that a large sum of money, as much as one million dollars, be spent in an attempt to evaluate and compare the quality of care furnished in several types of hospital. Such a study could well lead to more efficient, economical, and higher quality hospital care. Mr. Ross has noted how long this study took. One of the factors involved, both irritating and exhilarating, was the constant changing in the relative importance of issues. As described in the Introduction, some issues declined in urgency (sometimes because they were resolved) while others assumed importance, or even emerged for the first time, during the investigation. But the study took as long as it did mainly because of its size and scope. It takes time to gather data, even more to conduct interviews, and still more to digest what is learned and to write it down. T h e extent to which additional staff may be substituted for calendar time soon reaches the point of diminishing returns. In a planning organization like the Hospital Council, arrangements for staffing such a study present a further difficulty. If new, temporary staff is hired, it takes longer to get under way and there is no transfer of learning to the

PREFACE

xiv

regular operations of the organization upon completion of the study. If permanent staff is to be used, provision must be made for divesting them of other duties. In retrospect, it would seem that perhaps the best arrangement is a judicious mixture of regular and special staffs. It remains for me to acknowledge the assistance received by the chairman from the members of the committee—and especially from Mr. Ross, President of the Council—who added the review of this manuscript to their heavy regular schedules. In addition, I should like to single out the contribution of Mr. George Bugbee, chairman of the Master Plan Committee, who initially was not a regular member of the committee. His broad and practical knowledge of research in hospital and medical care, of hospital administration, and of area-wide planning made his contribution to the deliberations of a distinguished committee so exceptional as to warrant special commendation. July 31,1962

A L V I N C.

EURICH

Chairman

of

Committee

ACKNOWLEDGMENTS

T h i s book could be written only because many people—more than 200—gave freely of their time, knowledge and judgment. Mine was the task of bringing together the information they supplied and the explanations they suggested, and then of selecting among alternative hypotheses. It is not practicable to thank by name every person who contributed to this volume. Here I should like to list those who provided substantial bodies of data, spent considerable time talking to me, or read and criticized drafts of chapters. One person, Mrs. Francisca K. Thomas, did all these things. She was my teacher and guide from the day I joined the staff of the Hospital Council in the fall of 1949 to the time of her retirement in the summer of 1960. For this study she developed the basic data for several chapters, particularly Chapters 5 and 8. She read the first draft of the entire manuscript, made numerous criticisms, and rewrote a good part of Chapter 10. Other colleagues on the staff of the Hospital Council made specific contributions, in addition to reading the drafts of various chapters as they appeared. Dr. Hayden C. Nicholson's background as a medical educator is reflected in Chapter 6, and his comments influenced the discussion in Chapters 11 and 21. Joseph P. Peters did the initial analysis of the data for Chapter 6 and prepared memoranda for the historical sections of Chapters 14 and 15. Chapter 8 reflects Dr. Sigmund L. Friedman's contributions to the evaluation of physical plant, and his comments influenced the revision of Chapter 10. Miss M. Ann Coleman's work on services for ambulatory patients and for long-term patients appears in Chapter 2. Robert W. Murphy, first as a resident, worked on the data for

XVI

ACKNOWLEDGMENTS

Chapter 20 and, later as a staff member, helped with Chapter 19. Mrs. Dorothy A. Woodhead supervised or herself performed most of the large-scale tabulations and took special pains to assure the accuracy of tables a n d uniformity of headings. Leonard Zeitz performed the tabulations on inpatients in Chapters 2 and 3, a n d J o h n H . Frazier did the tabulations for Chapters 1 and 17. H o w a r d H. Moses, as a resident, did additional tabulations for the revision of Chapter 19. A m o n g those who taught me what I have learned about the financial and management aspects of the voluntary and municipal hospitals in New York City the names of Edward Bauer of the U n i t e d Hospital F u n d of N e w York and J a c o b Levine of the N e w York City Department of Hospitals are foremost. On innumerable occasions they accompanied their statistical reports with detailed descriptions of the underlying report forms and with patient explanations of the m e a n i n g of individual accounts. I also had the privilege of witnessing the deliberations of several groups involved in planning the development of better hospital care in New York City. For ten years I regularly attended the monthly meetings of the board of directors of the Hospital Council and for twelve years the meetings of its Master Plan Committee. In 1958-59, as technical consultant to the study director, I attended the meetings of the subcommittee on hospitals and health agencies of the study committee of Federation of Jewish Philanthropies of New York; and in 1961-62, serving as its consultant on medical care for the aged, I attended the meetings of the Interdepartmental Health Council of the City of New York. Frequently I attended the monthly meetings of the Greater New York Hospital Association, which shares a floor with the Hospital Council and the United Hospital F u n d . T h e meetings of Dr. Eurich's special committee were, of course, a source of criticism, stimulus, and advice. I also wish to acknowledge the help received from several members of the committee in their individual capacities, namely, George Bugbee, Dr. Peter Marshall Murray, and Dr. Martin R . Steinberg. A m o n g other board members, Dr. George Baehr explored certain aspects of Chapter 9, and Milton Bluestein's thinking influenced the argument in Chapter 11. Dr. George Reader of the Master Plan Com-

ACKNOWLEDGMENTS

xvii

mittee discussed with me medical education and the quality of care. A number of persons, besides Messrs. Bauer and Levine, went well beyond the call of duty in furnishing basic data and in responding to repeated requests for additional information and interpretation. Among them are: James C. Ingram and Harry Sesan of the Associated Hospital Service of New York; Dr. Blanche Bernstein and Florence E. Cuttrell of the Community Council of Greater New York; Dr. Eli Ginzberg and Dr. Peter Rogatz of the subcommittee on hospitals and health agencies of the study committee of Federation of Jewish Philanthropies of New York; Dr. Paul M. Densen, Carl L. Erhardt, Dr. George James, Mrs. Frieda Greenstein Nelson, and Louis Weiner of the New York City Department of Health; Dr. Herman E. Bauer, Robert J . Carlin, Dr. Marta Fraenkel, Dr. Harvey Gollance, and Miss Dorothy Weddige of the Department of Hospitals; Henry J . Rosner and Harry Sussman of the New York City Department of Welfare; Henry Cohen and Marvin D. Roth of the New York City Office of the City Administrator; Grant Adams and Charles G. Roswell of the United Hospital Fund; William J. Dann and Daniel I. Rosen of the United States Veterans Administration; and Dr. C. Rufus Rorem of the Hospital Planning Association of Allegheny County, Pittsburgh, Pennsylvania. T h e following furnished unpublished data, tabulations, punch cards, or completed questionnaires: Dr. Frank G. Dickinson, Dr. Leonard W . Martin, Dr. John C. Nunemaker, and Dr. Walter S. Wiggins of the American Medical Association; Mrs. Agnes W . Brewster of the United States Department of Health, Education, and Welfare; Mrs. Eva Balamuth and Sam Shapiro of the Health Insurance Plan of Greater New York; Charles M. Royle of the Hospital Association of New York State; Herbert H. Rosenberg of the National Institutes of Health; Mrs. Evelyn S. Mann and Louis Winnick of the New York City Department of City Planning; Henry G. McCormick of the New York City Office of the Comptroller; Mrs. Gladys Webbink of the New York State Department of Labor; Dr. Alvin I. Goldfarb and Robert E. Patton of the New York State Department of Mental Hygiene; Peter Kasius, Dr. David M. Schneider, and Miss Sadie Zuchovitz of the New York

ACKNOWLEDGMENTS

xviii

State Department of Social Welfare; and Arthur H. Jette of the United Community Funds and Councils of America. At different stages the manuscript was read in its entirety by Mrs. Marian Weinart and by Jacqueline Mueller. Both made editorial changes and suggested deletions. T h e manuscript was dictated to Mrs. Nadia Denissoff and Miss Claire M. Morrissette. Between them they did all the typing or saw to it that it was done, again and again. Mrs. Denissoff also produced many of the memoranda that underlie the study and designed the tables for typing. Miss Morrissette spent many a Saturday and Sunday and holiday taking dictation and typing. They read proof, as did at various stages Messrs. Murphy and Moses and Leonard S. Machtinger. Much of the work on this book was done outside regular office hours. For this contribution of time I am indebted to my wife and children. T o all those named above, and to the many not named, I offer my sincere thanks. As always, I am responsible for the final product. T h e defects of this volume, and perhaps even some of its good points, are mine. August

1,

1962

HERBERT E.

KLARMAN

CONTENTS

Introduction Part I.

1

Background

1. Population, Income, and Health Insurance

9

2. Patterns of Hospital Use

32

3. Characteristics of Patients in Short-Term Hospitals

92

4.

Use of Ward Service by Health Insurance Subscribers

Part II. Personnel,

Plant, and

130

Organization

5. Attending Staff

143

6. Interns and Residents

163

7. Nursing Personnel

221

8. Condition of Plant and Expenditures for Construction

246

9. Problems in Hospital Management

273

10. Quality of Care

295

11. Affiliation, Regionalization, and Coordination

315

Part III.

Financing

Hospital

Care

12. Trends in Income, 1934-57

341

13. Sources of Income of Voluntary Hospitals

352

CONTENTS

XX

14. Financial Position of Voluntary Hospitals

367

15. Income of Municipal Hospitals

388

16. Role of Government

398

17. Role of Blue Cross

415

18. Role of Philanthropy

437

19. Cost of Hospital Care

460

20. Comparisons with Other Areas

491

21. A Pattern for Financing Hospital Care in New York City 511 Notes

529

Index

557

TABLES

POPULATION,

I N C O M E , AND H E A L T H

INSURANCE

(CHAPTER

1)

1. Population, New York City, 1900-60 2. Population, Four Suburban New York Counties, 1940-60 3. Distribution of Population by Ethnic Group, New York City, 1957 4. Distribution of Population by Age Group, New York City, 1940, 1950, and 1960 5. Distribution of Population by Borough, New York City, 1940, 1950, and 1960 6. Distribution of Puerto Rican and Nonwhite Population by Borough, New York City, 1940 and 1957 7. Per Capita Income, New York City and Selected Areas, 1939, 1947, and 1956 8. Percentage Distribution of Families by Income, New York City, New York State, and United States, 1949 and 1956 9. Per Capita Income by Borough, New York City, 1939, 1947, and 1956 10. Median Money Earnings of Persons Fourteen Years Old and Over by Ethnic Group, New York City, 1949 and 1956 11. Percentage Distribution of White, Nonwhite, and Puerto Rican Families by Income, New York City, 1956 12. Median Income of White and Nonwhite Income Recipients by Sex, New York City, 1949 and 1956 13. Median Income of White and Nonwhite Income Recipients by Sex, New York City, United States Total, and United States Urban, 1956 14. Percentage Distribution of Persons Eligible for Care in Union Health Centers by Type of Service, New York City, 1957 P A T T E R N S O F H O S P I T A L USE ( C H A P T E R

10 11 15 16 17 18 20 21 22 23 23 24 25 29

2)

1. Distribution of All Hospital Facilities by Ownership, New York City, 1958

34

xxii

TABLES

2. Distribution of Short-Term Hospital Facilities and Services by Ownership, New York City and United States, 1958 3. Percentage of Facilities and Services in Short-Term Hospitals in New York City to Those in United States, and Ratios per 1,000 Population, 1958 4. Distribution of Facilities and Services by Hospital Ownership, New York City, 1930, 1940, 1950, and 1958 5. Distribution of General-Care Facilities and Services by Hospital Ownership, New York City, 1940, 1950, and 1958 6. Computed Measures of Hospital Use in General-Care Facilities by Ownership, New York City, 1940, 1950, and 1958 7. General-Care Facilities and Services in Voluntary Hospitals by Type of Accommodation, New York City, 1940, 1950, and 1958 8. Computed Measures of Hospital Use in General-Care Facilities of Voluntary Hospitals by Type of Accommodation, New York City, 1940, 1950, and 1958 9. General-Care Facilities and Services in All Hospitals by Type of Accommodation, New York City, 1940, 1950, and 1958 10. Private (including Semiprivate) General-Care Facilities and Services by Hospital Ownership, New York City, 1940, 1950, and 1958 11. Ward General-Care Facilities and Services by Hospital Ownership, New York City, 1940, 1950, and 1958 12. Outpatient Department Visits by Hospital Ownership, New York City, 1925-58 13. Emergency Department Visits by Hospital Ownership, New York City, 1948, 1950, and 1958 14. Emergency Ambulance Calls by Hospital Ownership, New York City, 1930, 1940, 1950, and 1958 15. Patient Days Reported for Patients on Home Care by Hospital Ownership, New York City, 1949, 1950, and 1958 16. Distribution of Facilities and Services for Non-General-Care Patients by Hospital Ownership, New York City, 1940, 1950, and 1958 17. Proportion of Facilities and Services for Non-General-Care Patients to Total by Hospital Ownership, New York City, 1940, 1950, and 1958 18. Distribution between General Care and Other Care of Increase in Bed Complement, by Hospital Ownership, New York City, 1940-58 19. Distribution between General Care and Other Care of Increase in Patient Days, by Hospital Ownership, New York City, 1940-58

35

36 38 40 42

46

47 49

50 51 52 56 58 61

64

65

66

66

TABLES 20. Distribution of Non-General-Care Beds and Services by T y p e of Program, New York City, 1958 21. Distribution of Facilities and Services for Psychiatric Inpatients by Hospital Ownership, New York City, 1940, 1950, and 1958 22. Visits to Psychiatric Clinics of Outpatient Departments by Hospital Ownership, New York City, 1940, 1950, and 1958 23. Distribution of Facilities and Services for Patients with T u b e r c u l o s i s by Hospital Ownership, New York City, 1940, 1950, and 1958 24. Distribution of Facilities and Services for Patients with T u b e r c u l o s i s by Hospital Ownership, New York City and Environs, 1940, 1950, and 1958 25. Distribution of Rehabilitation Facilities and Services for Inpatients by Hospital Ownership, New York City, 1958 26. Distribution of Hospital Facilities and Services for Chronically 111 by Hospital Ownership, New York City, 1940, 1950, and 1958 27. Distribution of Nursing-Home Beds in Hospitals by Ownership, New York City, 1958 28. Distribution of Nursing-Home Facilities Outside Hospitals and T h e i r Services by Ownership, New York City, 1958 29. Distribution of Facilities and Services for L o n g - T e r m Care by Ownership and by Location with Respect to Hospitals, New York City, 1958 30. Percentage Distribution of T o t a l Facilities and Services for L o n g - T e r m Care by Ownership, New York City, 1958

XXUl

67

69 70

73

75 77

79 80 82

83 84

CHARACTERISTICS OF PATIENTS IN SHORT-TERM HOSPITALS (CHAPTER 3 )

1. R a t e per 100 Discharges and R a t e per 100 Patient Days According to Pay Status of Patients in General-Care Hospitals, by Hospital Ownership and T y p e of Accommodation, New York City, 1957 2. Proportion (Percent) of Nonresidents a m o n g Discharges from Voluntary, Municipal, and Proprietary General-Care Hospitals, New York City, 1933 and 1957 3. Distribution by Hospital Ownership of Nonresident Discharges from General-Care Hospitals, New York City, 1957 4. Distribution by Hospital Ownership of Puerto Rican, Nonwhite, and Other White Resident Admissions, New York City, 1951 5. Distribution by Ethnic Status of Resident Admissions to Voluntary, Municipal, and Proprietary Hospitals, New York City, 1951

94

95 96

97

98

XX i v

TABLES

6. Distribution of P u e r t o Rican, Nonwhite, and Other W h i t e Admissions to General-Care Hospitals by Hospital Ownership and T y p e of Accommodation, New York City, 1957 7. Distribution by Ethnic Status of Admissions to Voluntary, Municipal, a n d Proprietary General-Care Hospitals, New York City, 1957 8. Percentage Distribution by Age G r o u p of One-Day Patient Census in Voluntary, Municipal, and Proprietary GeneralCare Hospitals, New York City, 1953 9. Percentage Distribution by Age G r o u p of Admissions to Voluntary General Hospitals by T y p e of Accommodation, a n d of Discharges f r o m Municipal General Hospitals, New York City, 1958 a n d 1957 10. Distribution of Age Groups in One-Day Patient Census in General-Care Hospitals by Hospital Ownership and T y p e of Accommodation, New York City, 1958 11. Distribution by Age G r o u p of One-Day Patient Census in Voluntary, Municipal, and Proprietary General-Care Hospitals, New York City, 1958 12. Percentage Distribution by Age G r o u p of One-Day Patient Census in W a r d s of Voluntary and Municipal General-Care Hospitals, N e w York City, 1958 13. Distribution by L e n g t h of Stay of Discharges f r o m Voluntary, Municipal, a n d Proprietary Hospitals, New York City, 1951 14. Distribution by Length of Stay of Patient Days of Discharged Patients, Voluntary, Municipal, and Proprietary Hospitals, New York City, 1951 15. Percentage Distribution by Length of Stay of Old Age Assistance Recipients, General-Care Voluntary and Municipal Hospitals, New York City, 1957 16. R a t e per 100 Discharged Patients for Selected Diagnostic Categories in Voluntary, Municipal, and Proprietary General-Care Hospitals, New York City, 1954 17. R a t e per 100 Discharges or per 100 in One-Day Patient Census for Selected Patient Characteristics in Wards of Voluntary and Municipal General-Care Hospitals, New York City, 1957 or 1958 18. Distribution by Age G r o u p of Discharges f r o m Voluntary a n d Municipal General Hospitals, New York City, 1933 19. Distribution by Age G r o u p of Resident Admissions to Voluntary, Municipal, and Proprietary Hospitals, New York City, 1951 20. Distribution by Age G r o u p of One-Day Patient Census in Municipal General Hospitals, New York City, 1955

99

100

105

106

107

108

108 111

111

112

113

118 126

126 127

TABLES

XXV

21. Distribution by Age Group of Discharges from All Municipal Hospitals, New York City, 1952, 1956, and 1957

128

USE O F WARD SERVICE BY H E A L T H INSURANCE

SUBSCRIBERS

(CHAPTER 4)

1. Proportion of AHS Patients in Ward, Voluntary and Municipal General-Care Hospitals, New York City, 1958

132

A T T E N D I N G STAFF ( C H A P T E R 5 )

1. Number of Physicians by T y p e of Practice, New York City, 1950 and 1958 2. Physicians with Regular Staff Appointments in Voluntary or Municipal Hospitals, or Both, New York City, 1948 and 1958 3. Cross-Classification by Teaching Class of Hospital of Staff Appointments Held by Physicians Affiliated with Both Hospital Systems, New York City, 1958 4. Comparison between Ranks Held in Voluntary and Municipal Hospitals of Specified Teaching Class by Physicians with Appointments in Both Systems, New York City, 1958 I N T E R N S AND RESIDENTS ( C H A P T E R

146 147 152 153

6)

1. Interns and Residents in Approved T r a i n i n g Programs, United States, 1930-58 2. Interns and Residents in Approved T r a i n i n g Programs in New York City and United States, 1935 and Fiscal 1959 3. Distribution of House Staff in Approved T r a i n i n g Programs by Location of Medical School of Graduation and by Citizenship Status, New York City and United States, Fiscal Year 1959 4. Distribution of Interns in Approved T r a i n i n g Programs by Medical School Affiliation Status of Hospital, New York City, 1936 and Fiscal 1959, and United States, Fiscal 1958 5. Distribution of Residents in Approved T r a i n i n g Programs by Medical School Affiliation Status of Hospital, New York City, 1936 and Fiscal 1959, and United States, Fiscal 1960 6. House Staff in Approved T r a i n i n g Programs in Voluntary and Municipal Hospitals, New York City, 1935, 1951, 1955, and 1959 7. Interns in Approved T r a i n i n g Programs in Voluntary and Municipal Hospitals, New York City, 1935, 1951, 1955, and 1959 8. Residents in Approved T r a i n i n g Programs in Voluntary and Municipal Hospitals, New York City, 1935, 1951, 1955, and 1959

169 174

176 177 178 179 180 181

xxvi

TABLES

9. House Staff in Approved T r a i n i n g Programs by Citizenship Status in Voluntary and Municipal Hospitals, New York City, 1951, 1955, and 1959 10. Changes in House Staff in Approved T r a i n i n g Programs by Citizenship Status in Voluntary and Municipal Hospitals, New York City, 1951-59, 1951-55, and 1955-59 11. Percentage of Alien Physicians in Approved T r a i n i n g Programs in Voluntary and Municipal Hospitals, New York City, 1951, 1955, and 1959 12. Percentage of Alien Physicians among Interns and Residents in Approved T r a i n i n g Programs in Voluntary and Municipal Hospitals, New York City, 1951, 1955, and 1959 13. Distribution of Interns and Residents in Approved T r a i n i n g Programs by Location of Medical School of Graduation and by Citizenship Status for Graduates of Foreign Schools in Voluntary and M u n i c i p a l Hospitals, New York City, 1959 14. Distribution of Voluntary and Municipal Hospitals with Approved Internships by Percentage of Total Budgeted Positions Filled by Graduates of American Medical Schools and by Medical School Affiliation, New York City, 1959 15. Distribution of Voluntary and Municipal Hospitals with Approved Residencies by Percentage of T o t a l Budgeted Positions Filled by Graduates of American Medical Schools and by Medical School Affiliation, New York City, 1959 16. Percentage of T o t a l Interns and Residents in Approved Programs W h o Graduated from American Medical Schools, by Hospital Ownership and by Medical School Affiliation, New York City, 1959 17. J o i n t Distribution of Voluntary and Municipal Hospitals with Approved T r a i n i n g Programs by Percentage of American Graduated Interns and American Graduated Residents, New York City, 1959 18. Changes between 1951 and 1959 in Number of Interns and of Residents in Approved T r a i n i n g Programs, by Medical School Affiliation of Hospital and by Citizenship Status of Physician, in Voluntary and Municipal Hospitals, New York City 19. Percentage of Alien Physicians among Interns and Residents in Approved T r a i n i n g Programs, by Hospital Ownership and by Medical School Affiliation, New York City, 1951 and 1959 20. Distribution of Interns in Approved T r a i n i n g Programs (American Medical School Graduates and Others by Citizenship Status) among Hospitals, by Ownership and by Medical School Affiliation, New York City, 1959

183 183 184 185

186

188

192

194

195

196

198

201

xxvii

TABLES 21. Distribution of Residents in Approved T r a i n i n g Programs (American Medical School Graduates and Others by Citizenship Status) among Hospitals, by Ownership and by Medical School Affiliation, New York City, 1959 22. Interns in Approved T r a i n i n g Programs by Citizenship Status in Voluntary and Municipal Hospitals, New York City, 1951, 1955, and 1959 23. Residents in Approved T r a i n i n g Programs by Citizenship Status in Voluntary and Municipal Hospitals, New York City, 1951, 1955, and 1959 24. House Staff in Approved T r a i n i n g Programs by Citizenship Status and by Medical School Affiliation in Voluntary and Municipal Hospitals, New York City, 1951 and 1959 25. Interns in Approved T r a i n i n g Programs by Citizenship Status and by Medical School Affiliation in Voluntary and Municipal Hospitals, New York City, 1951 and 1959 26. Residents in Approved T r a i n i n g Programs by Citizenship Status and by Medical School Affiliation in Voluntary and Municipal Hospitals, New York City, 1951 and 1959 NURSING PERSONNEL (CHAPTER

217 218 218 219 220

7)

1. Distribution of Staff of Nursing Services in Voluntary and Municipal General-Care Hospitals by Category of Nursing Personnel and Ratio of Staff to 100 Daily Patients, New York City, 1958 2. Distribution of Voluntary and Municipal General-Care Hospitals by Ratio of Registered Nurses to 100 Daily Patients, New York City, 1958 3. Annual Cost and Income per Hospital Student Nurse CONDITION O F P L A N T AND EXPENDITURES FOR (CHAPTER

202

228 231 245

CONSTRUCTION

8)

1. Distribution of T o t a l Bed Capacity by Hospital Ownership, New York City, 1945 and 1958 2. Distribution of T o t a l Bed Capacity in Suitable Buildings by Hospital Ownership, New York City, 1945 and 1958 3. Distribution of T o t a l Bed Capacity in Unsuitable Buildings by Reason of Unsuitability, New York City, 1945 and 1958 4. Distribution of General-Care Bed Capacity by Hospital Ownership, New York City, 1945 and 1958 5. Distribution of General-Care Bed Capacity in Suitable Buildings by Hospital Ownership, New York City, 1945 and 1958 6. Proportion of General-Care Bed Capacity in Suitable Buildings by Hospital Ownership, New York City, 1945 and 1958

249 249 250 251 252 252

xxviii

TABLES

7. D i s t r i b u t i o n of L o n g - T e r m Bed Capacity by Hospital Ownership, New York City, 1945 and 1958 253 8. D i s t r i b u t i o n of L o n g - T e r m Bed Capacity in Suitable Buildings by H o s p i t a l Ownership, New York City, 1945 and 1958 253 9. D i s t r i b u t i o n of All General-Care Hospitals and T h e i r Bed Capacity by Size of Hospital, New York City, 1943 and 1956 254 10. D i s t r i b u t i o n of Voluntary, Municipal, and Proprietary General-Care Hospitals a n d T h e i r Bed Capacities by Size of Hospital, N e w York City, 1956 255 11. D i s t r i b u t i o n of Beds in Voluntary General-Care Hospitals by Size of A c c o m m o d a t i o n , New York City, 1946 and 1954 256 12. D i s t r i b u t i o n of E x p e n d i t u r e s for Construction by Four-Year Periods a n d by Hospital Ownership, New York City, 1945-56 257 13. D i s t r i b u t i o n of E x p e n d i t u r e s for Construction in Selected T i m e Intervals by Hospital Ownership, New York City, 1920-56 259 14. D i s t r i b u t i o n of E x p e n d i t u r e s for Construction by Hospital Ownership, N e w York City, 1945-56, a n d U n i t e d States, 1948-57 262 15. Distribution of E x p e n d i t u r e s for Construction by Source of Funds, New York City, 1945-56, and U n i t e d States, 1948-57 264 16. E x p e n d i t u r e s for H o s p i t a l Construction, New York City, 1945-56 270 17. Value of Hospital Construction Contracts Let in New York City, Original Data by F. W . Dodge Corporation and D a t a A d j u s t e d for Value of E q u i p m e n t a n d Architects' Services, 1945-56 270 P R O B L E M S IN H O S P I T A L M A N A G E M E N T

(CHAPTER

9)

1. N u m b e r of V o l u n t a r y Hospitals with Specified Size of Board, Authorized a n d Actual, N e w York City, 1957 Q U A L I T Y O F CARE ( C H A P T E R

274

10)

1. D i s t r i b u t i o n by Hospital Ownership of Medical Research E x p e n d i t u r e s in Non-Medical-School Hospitals, New York City, Fiscal Year 1958 2. Distribution by Hospital Ownership of N I H Research G r a n t s to Non-Medical-School Hospitals, New York City, Fiscal Years 1951 a n d 1956-59 3. P r o p o r t i o n of T o t a l N I H Research Grants Received by Voluntary Hospitals Not Staffed by Medical Schools, New York City, Fiscal Years 1951 and 1956-59

312

313

313

TABLES

XX i x

1934-57 (CHAPTER 12) 1. Distribution of Income by Source for All Hospitals, New York City, 1934, 1948, and 1957 2. Distribution of Income by Source for All Long-Term Hospitals, New York City, 1934, 1948, and 1957 3. Distribution of Income by Source for All General-Care Hospitals, New York City, 1934, 1948, and 1957 4. Distribution of Income by Hospital Ownership for All Hospitals, New York City, 1934, 1948, and 1957 5. Distribution of Income by Hospital Ownership for All LongT e r m Hospitals, New York City, 1934, 1948, and 1957 6. Distribution of Income by Hospital Ownership for All General-Care Hospitals, New York City, 1934, 1948, and 1957

TRENDS IN I N C O M E ,

SOURCES O F INCOME O F VOLUNTARY HOSPITALS (CHAPTER

345 346 347 348

348

13)

1. Distribution of Income by Source for All Voluntary Hospitals, New York City, 1934, 1948, and 1957 2. Distribution of Income by Source for Voluntary Long-Term Hospitals, New York City, 1934, 1948, and 1957 3. Distribution of Income by Source for Voluntary GeneralCare Hospitals, New York City, 1934, 1948, and 1957 4. Distribution of Private Payments by Source for Voluntary General-Care Hospitals, New York City, 1957 5. Distribution of Income from T a x Funds by Program of Payment for Voluntary General-Care Hospitals, New York City 6. Distribution of Income from P h i l a n t h r o p y by C o m p o n e n t for Voluntary General-Care Hospitals, New York City, 1957 FINANCIAL POSITION O F VOLUNTARY HOSPITALS (CHAPTER

344

353 354 355 356 357 360

14)

1. Relationship of Operating Deficit to Expenditures for Voluntary General-Care Hospitals, New York City, 1934, 1948, and 1957 2. Relationship of Operating Deficit to E x p e n d i t u r e for Patient Care for United Hospital F u n d M e m b e r General Hospitals, New York City, 1956, 1957, and 1958 3. Average Patient Day Income by T y p e of Accommodation and Pay Status within the W a r d for United Hospital F u n d Member General Hospitals, New York City, 1948 and 1958 4. Income from Philanthropy for General Purposes and Size of Operating Deficit for United Hospital F u n d Member General Hospitals, New York City, 1956, 1957, a n d 1958

368

368

376

377

TABLES

XXX I N C O M E O F M U N I C I P A L HOSPITALS (CHAPTER

15)

1. Distribution of Income by Source for All Municipal Hospitals, New York City, 1934, 1948, and 1957 2. Distribution of Income by Source for Municipal Long-Term Hospitals, New York City, 1934, 1948, and 1957 3. Distribution of Income by Source for Municipal GeneralCare Hospitals, New York City, 1934, 1948, and 1957 4. Distribution of Private Payments by Source for Municipal General-Care Hospitals, New York City, 1957 ROLE OF GOVERNMENT (CHAPTER

388 390 390 391

16)

1. Proportion of Expense Budget of City of New York Devoted to Hospital Care, 1948 and 1957 403 2. Distribution of Income from T a x Funds by Level of Government according to Type of Hospital, New York City, 1957 406 3. Expenditures from T a x Funds in General-Care Hospitals by Category of Recipient and Hospital Ownership, New York City, 1957 409 4. Daily Rate of Payment by City to Voluntary General Hospitals for Medical and Surgical Treatment of Public Charges, New York City, 1900-61 414 R O L E O F B L U E CROSS ( C H A P T E R

17)

1. AHS Patients, Patient Days, and Payments for All GeneralCare Hospitals, New York City, 1950-58 417 2. Distribution of Total Patients, Private and Semiprivate Patients, and AHS Patients by Hospital Ownership for General-Care Hospitals, New York City, 1957 418 3. Distribution of AHS Patient Days and Payments for Inpatients by Hospital Ownership for General-Care Hospitals, New York City, 1957 418 4. Proportion of AHS Patients and Patient Days to Total Patients and Patient Days in Each Ownership Group for General-Care Hospitals, New York City, 1957 420 5. Proportion of AHS Payments to Total Income and to Operating Income in Each Ownership Group for GeneralCare Hospitals, New York City, 1957 421 6. Proportion of AHS Patient Days and of Income from AHS Patients in Each Type of Accommodation for United Hospital Fund Member General Hospitals, New York City, 1957 424

TABLES

xxxi

7. Estimated Distribution of Supplementary Charges to AHS Patients by Category of Charge for United Hospital Fund Member General Hospitals, New York City, 1958 8. AHS Patients, Patient Days, and Payments for Voluntary General-Care Hospitals, New York City, 1950-58 9. AHS Patients, Patient Days, and Payments for Municipal General-Care Hospitals, New York City, 1950-58 10. AHS Patients, Patient Days, and Payments for Proprietary General-Care Hospitals, New York City, 1950-58 ROLE O F PHILANTHROPY

(CHAPTER

431 435 436 436

18)

1. Distribution by Component of Income from Philanthropy for Voluntary General-Care Hospitals, New York City, 1934, 1948, and 1957 439 2. Percentage Increases in Components of Income from Philanthropy for Voluntary General-Care Hospitals, New York City, 1934-48, 1948-57, and 1934-57 440 3. Distribution by Source of Centrally Raised Funds Received by United Hospital Fund Member General Hospitals, New York City, 1940, 1948, and 1957 441 4. Allocation of United Hospital Fund Moneys to Member General-Care Hospitals according to Basis of Distribution, New York City, 1940, 1948, 1957, and 1959 444 5. Allocation of Greater New York Fund Moneys to United Hospital Fund Member General-Care Hospitals According to Basis of Distribution, New York City, 1940, 1948, 1957, and 1959 447 6. Value of Permanent and Temporary Funds Held by United Hospital Fund Member General Hospitals, by Purpose, New York City, 1948 and 1957 453 COST O F H O S P I T A L C A R E ( C H A P T E R

19)

1. Changes in Patient Day Cost of General Hospitals by Ownership, New York City, 1934, 1948, and 1957 2. Distribution of Direct Departmental Expenses for Inpatients per Patient Day by Major Departmental Grouping for United Hospital Fund Member General Hospitals, New York City, 1949 and 1958 3. Distribution of Patient Day Cost by Major Departmental Grouping for Municipal General Hospitals, New York City, 1948 and 1958

461

464 465

xxxii

TABLES

4. Derivation of Patient Days, Patient Day Cost, and Expenditures for Inpatients in General Hospitals, New York City, 1934, 1948, and 1957 5. Values of T e r m s in Equation for Distributing Increase in Expenditures for Inpatients in General Hospitals, New York City, 1934, 1948, and 1957 6. Division of Increase in Expenditures for Inpatients between Increase in Patient Days and Increase in Patient Day Cost in General Hospitals, New York City, 1934-48, 1948-57, and 1934-57 7. Depreciation as Proportion (Percent) of Expenditures, with Variation in Patient Day Cost and in Lives of Building and of Equipment, under Specified Assumptions 8. Distribution of Direct Departmental Expenses for Inpatients per Patient Day by M a j o r Departmental Grouping for Voluntary General-Care Hospitals, New York Area, 1947 and 1957 COMPARISONS W I T H O T H E R AREAS ( C H A P T E R

483

484

484

488

490

20)

1. Distribution of Income by Source for Nonfederal ShortT e r m Hospitals, United States, 1935, 1950, and 1958 492 2. Distribution of Income by Source for General-Care Hospitals, New York City, 1934, 1948, and 1957 493 3. Percentage Distribution of Income of Short-Term Hospitals by Hospital Ownership and Source of Income, New York City and United States, 1957 and 1958 494 4. Proportion (Percent) of T a x Funds and Income from Philanthropy to T o t a l for General Hospital Care in Selected Large Cities in New York State, 1948 501 5. Percentage Distribution of Income by Source for S h o r t - T e r m Hospitals in Fifteen Large Cities Classified by Region and in New York City, 1957-58 502 6. J o i n t Distribution of Fifteen Large Cities by Proportion of Income from Philanthropy and by Proportion of T a x Funds to T o t a l Hospital Income, 1957-58 504 7. J o i n t Distribution of T h i r t e e n Cities by Proportion of T a x Funds to Hospital Income and by Proportion of Such Income Spent in Government Hospitals, 1957-58 505 8. J o i n t Distribution of T h i r t e e n Cities by Proportion of Private Payments to Hospital Income, 1957-58, and by Proportion of Population Insured for Hospital Care, 1959 506 9. Income of Short-Term Hospitals by Source of Income and Hospital Ownership, New York City and United States, 1957 and 1958 510

HOSPITAL CARE IN NEW YORK CITY

INTRODUCTION

T h e study of the relations between the voluntary and municipal hospitals in New York City was intended to develop a body of facts and judgments that might help to appraise alternative policies and programs. By the summer of 1955 certain evidences of strain had appeared, suggesting serious weaknesses in the traditional pattern of providing hospital care for the people of New York City. It was hoped that a systematic inquiry might detect some of these weaknesses at an early stage and make possible preventive or mitigating action; in situations where curative action was called for, such an inquiry might offer the opportunity to formulate a coordinated program, rather than a series of discrete measures. Illustrative of the strains visible at the time were the continued, marked rise in the cost of hospital care; a lag in the daily rate paid by the City to voluntary hospitals for the care of public charge inpatients; the decision by several voluntary hospitals to terminate their participation in the city's emergency ambulance service; the unilateral action by the City in distributing among hospitals the declining n u m b e r of patients with tuberculosis; a decline in the availability of patients for teaching purposes; and persistence of the shortage in registered (professional) nurses. T h e scope of study, as originally envisioned, was both broad and limited. It was limited at least in the sense that the total volume of hospital services needed by the people of the city was not to be the object of study b u t would be determined according to accepted principles of master planning. Although a review of these principles was then contemplated for the near future, it was to take the form of a separate project.

INTRODUCTION

2

T h e scope of study was b r o a d in that it was to a t t e m p t to assess in each hospital system the adequacy of available resources to p e r f o r m its share of the total task. T h e respective roles of the voluntary a n d m u n i c i p a l hospital systems were to be ascertained by c o m p a r i n g t h e characteristics of patients served as well as trends in the v o l u m e of services rendered. Appraisal of resources was to include the availability of money a n d of real resources, such as key personnel a n d physical plant, and also their organization a n d coordination. T h e questions to be raised in the proposed study seemed so basic that e n d o r s e m e n t a n d s u p p o r t f r o m allied organizations were considered essential. E n d o r s e m e n t was sought and received from the N e w York Academy of Medicine, D e p a r t m e n t of Hospitals of the City of N e w York, G r e a t e r N e w York Hospital Association, a n d U n i t e d Hospital F u n d . Much h e l p was forthcoming from these organizations and f r o m others, notably the following: Associated Hospital Service of N e w York; D e p a r t m e n t of Health, City of New York; D e p a r t m e n t of Welfare, City of New York; H e a l t h Insurance Plan of G r e a t e r N e w York; Office of the Comptroller, City of N e w York; N e w York State Hospital Association; New York State D e p a r t m e n t of Social Welfare; American Hospital Association; American Medical Association; National Institutes of H e a l t h ; U n i t e d States P u b l i c H e a l t h Service; Social Security A d m i n i s t r a t i o n ; Veterans Administration; hospital councils in m e t r o p o l i t a n areas t h r o u g h o u t the country; and, most important, m a n y hospitals in N e w York City. In the original o u t l i n e of the study the questions at issue were divided into i m m e d i a t e (those that "face us today") and long range (subjects "likely to arise"), d e p e n d i n g on their relative urgency at the time. T h e questions follow. Questions

That Face Us

Today

1. Methods of effecting changes in the distribution of public charge inpatients between voluntary and municipal hospitals 2. Selective admission policies and practices of voluntary hospitals 3. Admission policies a n d practices of municipal hospitals 4. P r o b l e m s in the e q u i t a b l e distribution of a given patient

3

INTRODUCTION

load between voluntary and municipal hospitals, including methods of transferring nonemergency patients who can pay for their care from municipal to voluntary hospitals 5. T h e effect of hospital care insurance and other factors on the availability of beds and patients for teaching and research 6. Flexibility in using hospital facilities in response to medical advances and other changes 7. Bases for setting City rates for the care of public charges in voluntary hospitals 8. Consideration by the City of New York of payment for outpatient department care in voluntary hospitals 9. State reimbursement of the City's expenditures for hospital care Other

Subjects

That

Are Likely

to

Arise

1. T h e respective roles of voluntary and municipal hospitals in the provision of the several types of care, for example, general, long term, psychiatric, and tuberculosis 2. Equitable distribution of patients for teaching among qualified voluntary and municipal hospitals 3. If governmental responsibility for financing a certain program is accepted, criteria for determining whether the City should buy services from voluntary hospitals or provide them in its own hospitals 4. Consideration of other methods, additional to those now in use, whereby the City might contribute to the income of voluntary hospitals for operating or capital purposes 5. T h e City's policies and practices in approving for payment patients in voluntary hospitals 6. Division of ward patients between voluntary and municipal hospitals during an economic d o w n t u r n 7. Care of private patients in municipal hospitals (in all of them or in major teaching institutions only) 8. Factors entering into the continuing availability of top management personnel for municipal hospitals 9. Means by which hospital staff appointments for practicing physicians can be integrated between the two groups of hospitals. In the course of the study certain of these issues were resolved

4

INTRODUCTION

in full or in part. For example, the City's decision to allow Sea View Hospital to close by stages postponed for several years the urgency of the problem of allocating tuberculosis patients among the hospitals. Similarly, a first step was taken in the fall of 1958 to pay voluntary hospitals for the care of outpatients when a fee of $5 per visit was authorized for recipients of public assistance. Conversely, certain issues that did not seem pressing at the outset came to the fore. Examples are proposals that facilities for private patients be provided in certain nonuniversity municipal hospitals and measures to assure the continuing availability of top management personnel to municipal hospitals. Finally, some issues emerged and assumed importance d u r i n g the study that did not even appear in the outline. Examples are the inability of some hospitals to recruit graduates of American and Canadian medical schools as interns and residents, attrition of the attending staffs of certain municipal hospitals, and increasing evidence of obsolescence of physical plant in both hospital systems. Ultimately, the scope of study was fixed not by the initial list of questions b u t by the basic objective of the study. T h i s was stated in the outline: "It is the purpose of the Hospital Council in this study to try to determine the facts as they are a n d by analyzing their implications objectively to contribute to an understanding of the conditions under which this joint, cooperative use of [voluntary and municipal] hospital facilities in New York City can best be fostered and improved." T h e Hospital Council has proceeded on the assumption that voluntary and municipal hospitals will continue to operate in New York City side by side and that cooperative behavior among hospitals is more likely than separate, unrelated action or competition to further the goal of an adequate volume of hospital care of good quality provided at economical cost, "without gaps and without waste." T h e r e was no question about the goal. T h e problem was how to promote the goal and a complementary set of relationships between the two hospital systems. It was decided to try to develop as complete and accurate a picture as possible of the hospital scene in New York City and of the various influences shaping it. T h i s was to be supported by a

INTRODUCTION

5

study of trends over a generation or longer. It was also decided to compare the pattern and experience of New York City with those in other parts of the country, both to validate judgments regarding probable future developments and to illustrate policies and practices that have been tested elsewhere and found to be workable. T h e book is organized in three parts: I. Background. This section contains chapters on trends in the population of New York City and on certain characteristics of the population that bear most directly on the use of hospitals; trends in hospital service; characteristics of patients in the two hospital systems; and some of the reasons why patients with hospital care insurance continue to seek care in the ward. II. Resources and Organization. T h e chapters in this section deal, in order, with physicians as members of the attending staff, including a discussion of hospital staff appointments in the two hospital systems and of trends in the number of practicing physicians in New York City; availability of American-educated and foreign-educated physicians as interns and residents, including a discussion of the teaching role of the hospital; staffing of the nursing service, including discussion of the private duty nurse in the hospital and of nursing education; trends in the suitability of physical plant and in expenditures for hospital construction; selected problems in hospital management, with special emphasis on the location of responsibility and authority in government hospitals; methods and problems in appraising the quality of care in hospitals, including the contribution of medical education and research; and alternative proposals for coordinating hospitals in New York City, both to effect economies and to improve service. III. Financing Hospital Care. This section deals, in order, with trends in total expenditures for hospital care in New York City and in the distribution of the total by source of income and by hospital ownership; trends in the income of voluntary hospitals; the net deficit and surplus position of voluntary hospitals in recent years; trends in income of municipal hospitals; the role of government, with particular reference to reimbursement of the City by the State of New York and by the federal government; the role of Blue Cross and its subscribers in the hospital's econ-

INTRODUCTION

6

omy; trends in i n c o m e f r o m philanthropic sources;

factors

in

rising hospital cost and selected comparisons between certain types of cost; how hospital care is financed in the U n i t e d States as a whole and in other large cities of the country, in comparison with N e w Y o r k City; and a discussion of certain proposals for improving hospital finances in N e w Y o r k City. F o r convenience each c h a p t e r has its own summary. A general summary of the findings of this report and their implications for policy was presented by the Hospital Council in D e c e m b e r , I 9 6 0 . 1

Parti.

BACKGROUND

I

POPULATION, INCOME, AND H E A L T H INSURANCE

T h e a m o u n t and types of hospital service used are determined by the size of population and by certain of its characteristics, such as age, socioeconomic status, and health insurance enrollment. It is known, for example, that the aged use more hospital care than other groups do. T o some degree, however, aging is associated with changes in marital status, and the one factor may in part obscure the effects of the other. Financial status and educational level may be associated with differences in the amount of hospital care used and are most certainly associated with differences in the type of hospital accommodation sought—private, semiprivate, or ward. Persons with voluntary health insurance generally use more hospital care than those without insurance, b u t the opposite has been reported when health insurance is combined with g r o u p medical practice. In any event, insured persons are more likely than uninsured persons to occupy private (including semiprivate) accommodations. For purposes of this study it suffices to note that the important problem facing N e w York City today and for the foreseeable future is not the total volume of hospital facilities and services but their distribution—by pay status, type of accommodation, hospital ownership, type of program, and geographic location. T h e principal emphasis of this report is on the distribution of the total volume of hospital services by pay status (insured, public charge, and so forth), type of accommodation, and hospital ownership (voluntary, municipal, and proprietary), and on the factors that influence such distribution. T h i s emphasis governed the selection of data for inclusion in this chapter on the population of New

10

BACKGROUND

York City. T h e chapter consists of three parts: (1) demographic characteristics, (2) income, and (3) voluntary health insurance. Demographic

Characteristics

SIZE O F P O P U L A T I O N

T h e United States Bureau of the Census reported the population of New York City in 1960 as 7,782,000-a decline of 110,000 since 1950. This is the first time that the decennial census recorded a loss of population in New York City. The largest numerical gains in the City's population took place between 1900 and 1910 and between 1920 and 1930, but even the 1930s and the 1940s showed increases of the order of one-half million. By the 1930s the upTable

1.1. POPULATION, NEW YORK CITY, 1900-60 Change from Preceding

Census Year 1900 1910 1920 1930 1940 1950 1960

Number 3,437,202 4,766,883 5,620,048 6,930,446 7,454,995 7,891,957 7,781,984

Amount + 929,788 + 1,329,681 + 853,165 +1,310,398 + 524,549 + 436,962 - 109,973

Decade

Percent + 37.1 + 38.7 + 17.9 + 23.3 + 7.6 + 5.9 - 1.4

SOURCE: U.S. Bureau of the Census.

ward trend in the city's population had slowed down considerably; and between the 1940s and 1950s the direction of the curve was reversed. A decline in population was first reported in 1957. This caused surprise. T h e decline could be reconciled with the large increase in dwelling units (one quarter of a million homes or apartments for the decade, all occupied) only on the assumption that a sizable decline in the average size of household had occurred. T h e ratio of persons to households was 3.52 in 1940, 3.20 in 1950, 3.07 in 1957,1 and probably fell below 3.00 in 1960. T h e decline in household size is, in turn, attributable to the sharp increase in one- and two-person households in the city, owing to the

POPULATION AND

11

INCOME

disproportionate out-migration of families with children and an increased life expectancy for the aged. New York City is not u n i q u e in having lost population in the 1950s. Its loss of 1.4 percent is smaller than that incurred by many large cities in the eastern and midwestem regions of the United States. For half a century or longer s u b u r b a n counties grew at a higher rate than the central cities of their metropolitan areas. In the 1950s, while the suburbs continued to gain in population, many cities incurred losses.2 In the New York area the neighboring s u b u r b a n counties have continued their rapid population growth. Illustrative are the increases in the four New York State counties that are part of the metropolitan area. Although the rates of increase in the 1940s Table

1.2. P O P U L A T I O N , F O U R S U B U R B A N N E W Y O R K C O U N T I E S , 1940-60 Number

Percent

County

1940

1950

1960

Total Nassau Suffolk. Westchester Rockland

1251222 406,748 197,355 573,558 74,261

1,663 £86 672,765 276,129 625,816 89,276

2^12,649 1,300,171 666,784 808,891 136,803

Increase

1940-50

1950-60

32.9 65.5 40.0 9.1 20.2

75.0 93.4 141.8 29.3 53.2

SOURCES: Regional Plan Association, Population 1954-1975 (Bulletin No. 85; New York, 1954), p. 7, and U.S. Bureau of the Census, Advanced Reports, 1960 Census of Population, Population Counts for New York State, PC (Al)-34 (Washington, D.C., 1960).

were substantial, they were still higher in the 1950s. NET MIGRATION

Closer analysis of population trends indicates that in New York City the 1950s represented a continuation, and perhaps acceleration, of past tendencies, rather than a reversal. Among the persistent tendencies is a decline in the average size of household noted above. Other factors are net out-migration, numerical and relative increases in the Puerto Rican and nonwhite population groups and decreases in the non-Puerto Rican white group, increases in the n u m b e r of children and aged (65 years and over), and redistribution of population among the five boroughs.

12

BACKGROUND

It is helpful to analyze population changes in terms of two components: natural increase and net migration. Natural increase is the difference between the n u m b e r of births and the n u m b e r of deaths. Net migration is the balance between the n u m b e r of persons moving into an area and the n u m b e r leaving it. In most civilized countries today natural increase is positive, that is, the n u m b e r of births exceeds the n u m b e r of deaths. Since deaths are the relatively more stable factor, it is the n u m b e r of births that largely determines the direction and size of natural increase. In the 1930s the birth rate in New York City was low. T h e birth rate rose substantially in the 1940s and has remained at the new level (19 live births per 1,000 population) in the 1950s, with small fluctuations from year to year. In the 1930s net migration to New York City was positive; the n u m b e r of persons coming into New York exceeded the n u m b e r leaving it by 237,000. 3 In the 1940s, for the first time, New York City lost more persons through out-migration than it gained through in-migration, so that the increase in population was entirely due to natural increase. Over-all net migration in the 1940s amounted to 139,000,4 but net out-migration for the nonPuerto Rican white population was approximately 500,000.® T h e tendency toward net out-migration became accentuated in the 1950s. During the period 1950-57 over-all net out-migration amounted to 621,000, and for the non-Puerto Rican white population alone it amounted to 970,000. If these figures were applicable to the full decade 1950-60, net out-migration for the entire population would approach 900,000 and for the non-Puerto Rican white population alone, 1,250,000. It should be noted that some of the difference in the rate of out-migration between the 1940s and 1950s is more apparent than real. A large share of the out-migration in the 1940s occurred in the second half of the decade, after World W a r II. Much of the out-migration from New York City has flowed to suburban counties. T h e fact that some of the new residents of these counties formerly lived in New York City has implications for the use of the city's hospitals. Persons who continue to work

P O P U L A T I O N AND I N C O M E

IS

in New York City are likely to retain some association with hospitals here, whether as patients, financial contributors, members of the medical staff, or trustees. Even those who leave the city for the suburbs and do not commute to work here may retain ties with hospitals in New York City, at least during a transitional period, pending the development of new ties with physicians and the expansion of hospital facilities in the suburbs. I n time, however, residents of the suburbs build hospitals near their homes. In relocating hospitals in relation to m a j o r geographic shifts in population, planning on an area-wide basis becomes necesary in order to avoid constructing numerous small hospitals in the suburbs, wasting existing suitable and efficient hospital plants in the city, and weakening the educational and research potential of established medical centers in the city. It is significant that the Hospital Survey for New York, which was instrumental in establishing the Hospital Council of Greater New York, was conducted in New York City and in eight neighboring counties in New York State, New Jersey, and Connecticut. T h e Hospital Council is now reviewing the geographic scope of its planning mission, with a view to extending both the area of study and the area of planning for hospital care beyond the confines of the five boroughs. NEGRO AND PUERTO RICAN CROUPS

T h e particular problem of the Puerto R i c a n and nonwhite population groups lies in their being predominantly newcomers to the community and in their being handicapped educationally and in j o b opportunities. Some of their characteristics are as follows: they tend to occupy positions at the bottom of the economic ladder 6 and to earn low incomes; their ability to pay for hospital care is impaired by a relatively low rate of enrollment in voluntary insurance; and, to a greater extent than do other groups in similar financial circumstances, they receive hospital care in the ward and, especially, in municipal hospitals (see Chapter 3). Moreover, the needs of the Puerto Ricans and nonwhites for certain types of medical and hospital services may exceed those of other groups, as, for example, in the field of tuberculosis and in maternal and child health. In 1957 they constituted 7 and 12

14

BACKGROUND

percent, respectively, of the city's population. In the same year they contributed 13 and 31 percent, respectively, of all new cases of active tuberculosis 7 (and of tuberculosis inpatients) and 12 and 18 percent, respectively, of all live births in New York City (as compared with 13 and 19 percent of all live births to resiidents). Indicative of greater need, perhaps as well as of greater neglect, is the fact that they contributed 15 and 29 percent, respectively, of total perinatal mortality (defined as infant deaths u n d e r seven days plus stillbirths of 20 or more weeks of gestation). 8 O n the other hand, P u e r t o Ricans and nonwhites need relatively fewer facilities for the aged at this time. In 1957, when 13 percent of the non-Puerto Rican white adult population was 65 years old and over, the corresponding proportion of Puerto Rican adults was 3 percent and of nonwhite adults, 7 percent.® Negroes have been moving north and settling in large cities since World W a r I, and P u e r t o Ricans have been arriving in sizable numbers in the United States, especially in New York City, since W o r l d W a r II. As a result, the combined nonwhite and Puerto Rican component of the city's population has increased from 2 percent in 1910 to 7 percent in 1940 and to 13 percent in 1950.10 For April, 1957, the date of the special United States census, the Department of City Planning estimated the ethnic composition of the population of New York City. ( T h e Census counted the population as white and nonwhite. T o have a P u e r t o Rican component, it had to be estimated. T h e estimates prepared by the Department of City Planning tend to be lower than some other estimates, because they allow for the departure of Puerto Ricans from New York City to other cities on the mainland.) T h e categories in T a b l e 1.3 are mutually exclusive, so that the "nonwhite" group is really "nonwhites other than Puerto Rican" and the "other whites" g r o u p is "whites other than Puerto Rican." T h e United States census of 1950 reflected for the first time the large influx of P u e r t o Ricans into New York City. On the basis of what was then known about migration from P u e r t o Rico to the mainland, the Department of City Planning made certain projections in 1954 of the probable ethnic composition of the

POPULATION AND

15

INCOME

Table

1.3. D I S T R I B U T I O N OF P O P U L A T I O N N E W Y O R K CITY, 1957

Ethnic

Group

BY E T H N I C

Number

Total 7,795,471 Puerto Rican 566,000 Nonwhite 938,651 Other white 6,290,820 SOURCE: New York City Department of City Planning, unpublished data.

GROUP, Percent 100.0 7.3 12.0 80.7

population of New York City in I960. 11 These are not inconsistent with the figures presented in T a b l e 1.3 for the Puerto Rican and nonwhite groups but are too high for the non-Puerto Rican white population. T h e last signifies that a larger out-migration has occurred than was expected. Seventy percent of the increase in the city's P u e r t o Rican population in the 1950s came from in-migration. D u r i n g the decade a pronounced shift took place in the sources of increase: in 1950 natural increase contributed 20 percent of that year's population growth and in-migration 80 percent; in 1959, it is estimated, the two sources were approximately equal. 1 2 It may be that the peak of the P u e r t o Rican migration to New York City has passed. Although net migration from the Island fluctuates with employment opportunities on the mainland, there were 10,000 fewer migrants a year in the second half of the 1950s than in the first half. 13 In addition, the proportion of Puerto Rican migrants settling in New York City is believed to have declined from 85 percent in 1950 to 60 percent in 1958.14 O n e aspect of the Puerto Rican migration that may have escaped adequate notice is its two-way, or even three-way, character. Migrants leave the Island, b u t some also return. For fiscal year 1959 net migration from the Island to the United States is estimated at 37,000, but the n u m b e r of new migrants leaving the Island is estimated to have been at least 10,000 higher and possibly 35,000 higher. 18 T h e Puerto Rican study of school children has similarly reported a substantial reciprocal flow between New York City and Puerto Rico. 16 In addition, as previously noted, some of the Puerto Ricans who leave New York City relocate elsewhere on the mainland. Much of the increase in the nonwhite population in New

16

BACKGROUND

York City during the 1950s (two thirds) was the result of natural increase. At the same time there was some out-migration to the suburbs, in which the numbers of nonwhites have increased at the same high rate as the total population (see T a b l e 1.2). In 1957, though, nonwhites still were fewer than 5 percent of the total population of these areas. 17 C H I L D R E N A N D ACED

Children tend to use less hospital care than the rest of the population, whereas the aged use more. Children tend to have the same rate of enrollment under voluntary health insurance as the rest of the population, whereas the aged have a lower rate. Both children and aged persons are relatively large users of ward accommodations in New York City (see Chapter 3). Children increased both in n u m b e r and in proportion to the city's total population in the 1940s and 1950s. Simultaneously, the n u m b e r and proportion of aged persons (65 years and over) also increased. A substantial decline has occurred in the n u m b e r and proportion of persons in age class 15 to 44. Table

1.4. D I S T R I B U T I O N OF P O P U L A T I O N BY AGE G R O U P , N E W YORK CITY, 1940, 1950, A N D 1960 1940

Age

Group

Total 0 - 1 4 years 15-44 45-64 65 years and over

Number 7,454295 1,465,558 3,942,410 1,632,608 414,419

Percent 100.0 19.7 52.8 21.9 5.6

1950 Number 7,891257 1,644,527 3,680,187 1,962,008 605,235

1960

Percent 100.0 20.8 46.6 24.9 7.7

Number 7,781284 1,857,885 3,097,118 2,013,154 813,827

Percent 100.0 23.9 39.8 25.9 10.4

SOURCE: U.S. Bureau of the Census.

A m a j o r difference between the period 1940-50 and 1950-60 is in the behavior of age class 45 to 64. T h i s g r o u p increased by 33,000 a year, on the average, in the former period and only by 5,000 in the latter. REDISTRIBUTION OF P O P U L A T I O N A M O N G T H E

BOROUGHS

T h e geographic distribution of the population is an important consideration in locating and relocating hospitals. In New York City the boroughs of Queens and Richmond (Staten Island) have

POPULATION AND

17

INCOME

been gaining in population in recent years at the expense of Manhattan, the Bronx, and Brooklyn, which were settled at much earlier dates. Manhattan reached its peak population in 1910, when it contained almost one half of the city's population. It lost population between 1910 and 1920 and between 1920 and 1930 b u t gained in the 1930s and 1940s. Each of the other four boroughs continued to gain in population through the United States census of 1950. T h e special census of 1957 reported losses for the first time for the Bronx and Brooklyn, and again for Manhattan. T h e census of 1960 seems to confirm the findings of 1957 and points to continuing gains for Queens and Richmond. T a b l e 1.5 shows the distribution of the city's population among the boroughs in 1940, 1950 and 1960. T h e major shift among the boroughs has occurred between Manhattan and Queens, the former losing and the latter gaining. Table

1.5. D I S T R I B U T I O N OF P O P U L A T I O N BY B O R O U G H , N E W Y O R K CITY, 1940, 1950, A N D 1960 1940

Borough N e w York City Bronx Brooklyn Manhattan Queens Richmond SOURCE:

1950

1960

Number

Percent

Number

Percent

Number

Percent

7,454^95 1,394,711 2,698,285 1,889,924 1,297,634 174,441

100.0 18.7 36.2 25.4 17.4 2.3

7,891257 1,451,277 2,738,175 1,960,101 1,550,849 191,555

100.0 18.4 34.7 24.8 19.7 2.4

7,781^84 1,424,815 2,627,319 1,698,281 1,809,578 221,991

100.0 18.3 33.8 21.8 23.3 2.8

U.S. Bureau of the Census.

Another important development is the dispersal of the nonwhite and Puerto Rican populations among the four major boroughs. This is shown in T a b l e 1.6. In 1940 Mahattan contained 70 percent of the city's Puerto Ricans. Its proportion declined to 56 percent in 1950 and 46 percent in 1957. T h e nonwhite population has also been extending to the other boroughs. Mahattan's share of the city's nonwhite population has declined from almost two thirds in 1940 to two fifths in 1957. Indeed, between 1950 and 1957 the n u m b e r of nonwhites in Manhattan declined.

BACKGROUND

18 Table

1.6. D I S T R I B U T I O N O F P U E R T O R I C A N AND N O N W H I T E P O P U L A T I O N BY B O R O U G H , N E W Y O R K C I T Y , 1940 AND 1957 Puerto

Borough New York City Bronx Brooklyn Manhattan Queens Richmond

Nonwhite

Rican

1940

1940

1957

Number 76,800 10,100

Percent 100.0 13.1

11,200

14.6 70.3 1.7 0.3

54,000 1,300

200

Num ber

Percent

566,000 100.0 145,000 25.6 150,000 26.5 260,000 45.9 10,000 1.8 1,000 0.2

Num ber 469,811 23,892 108,834 307,299 26,803 2,983

1957 Percent

Number

Percent

100.0 5.1 23.2 65.4 5.7 0.6

936,000 100.0 126,000 13.5 300,000 32.0 382,000 40.8 120,000 12.8 0.9 8,000

SOURCE: New York City D e p a r t m e n t of City Planning, unpublished data.

I n 1957 B r o o k l y n had a p p r o x i m a t e l y one third of the city's n o n w h i t e s and o n e q u a r t e r of the P u e r t o R i c a n s . T h e B r o n x had almost as large a n u m b e r of P u e r t o R i c a n s as B r o o k l y n , but fewer than one half as m a n y nonwhites. B y contrast, Q u e e n s had almost as m a n y n o n w h i t e s as the B r o n x , b u t relatively few P u e r t o Ricans. Despite the dispersal of nonwhites a m o n g the boroughs, t h e i r basic pattern of s e t t l e m e n t is still one of c o n c e n t r a t i o n in H a r l e m and in several o t h e r n e i g h b o r h o o d s , such as the

Bedford-Stuy-

vesant district in B r o o k l y n and the South J a m a i c a - S t . district in Q u e e n s .

18

Albans

A l m o s t from the outset the P u e r t o

Rican

p o p u l a t i o n has b e e n m o r e widely scattered t h r o u g h o u t the city's many n e i g h b o r h o o d s . PROJECTIONS OF

POPULATION

I n 1954 the R e g i o n a l P l a n Association projected that the population of N e w Y o r k City would be 8 , 7 0 0 , 0 0 0 in 1975. 1 9

This

was broadly consistent with the estimate of 8 , 5 7 0 , 0 0 0 then proj e c t e d by the City's D e p a r t m e n t of City P l a n n i n g for the year 1970, b u t the d i s t r i b u t i o n by borough was n o t . 2 0 I n

1957

the

R e g i o n a l P l a n Association reduced its population estimates for 1975 to 8 , 4 0 0 , 0 0 0 m a i n l y because of a lower estimate for R i c h m o n d . 2 1 T h e p r o j e c t e d p o p u l a t i o n for 1975 that is associated with zoning revision is 8 , 3 4 0 , 0 0 0 . 2 2 T h e m a j o r differences between this p r o j e c t i o n and the 1957 p r o j e c t i o n by the R e g i o n a l P l a n Associa-

POPULATION AND INCOME

19

tion are a f u r t h e r reduction in the estimate for R i c h m o n d f r o m 500,000 to 315,000 and an increase in the estimate for Queens f r o m 1,900,000 to 2,200,000. All of these projections of p o p u l a t i o n may be on the high side. Vacant land is scarce, and the old settled areas of the city are likely to experience declines in p o p u l a t i o n as result of redevelopm e n t at lower rates of density, changes in land use f r o m residential to nonresidential, and a f u r t h e r reduction in the average n u m b e r of persons per household. 2 3 Projection of the ethnic composition of the population cannot be divorced f r o m the projection of the total. T h i s is a necessary qualification to the most recent projection of the city's population in 1975 by ethnic status: 24 Total number: 8,815,000 Puerto Rican Nonwhite Other white

Percent 13.2 14.6 72.2 100.0

I n the s u b u r b s the outlook is for f u r t h e r p o p u l a t i o n growth, probably at a reduced rate. In the f o u r counties listed in T a b l e 1.2, the Regional Plan Association projects a total p o p u l a t i o n of 3.5 million in 1975, 25 an increase of 20 percent f r o m 1960. Individual

and Family

Income

Income is the best single measure of the ability of a commun i t y or g r o u p to pay for goods a n d services, i n c l u d i n g hospital care. T h i s section examines the income of t h e residents of N e w York City, compares income trends in the city w i t h income trends in other parts of the country, a n d describes differences a m o n g the three ethic groups. TRENDS IN I N C O M E , NEW YORK CITY AND E L S E W H E R E

T h e Metropolitan Region Study developed estimates of per capita income for each of the c o n s t i t u e n t counties for t h r e e years. T a b l e 1.7 compares per capita income in N e w York City, the N e w York metropolitan region, N e w York State, a n d the U n i t e d States. I n 1939 a n d 1947 N e w York City's per capita income was

20 Table

BACKGROUND 1.7. P E R CAPITA INCOME (IN DOLLARS), N E W YORK C I T Y AND S E L E C T E D AREAS, 1939, 1947, AND 1956

Area New York City New York metropolitan region New York State United States

1939

1947

1956

997 912 825 556

1,892 1,789 1,715 1,316

2,562 2,592 2,428 1,979

SOURCES: R o b e r t E. Graham, J r . , "General Rise in State Income in 1959," Survey of Current Business, X L , No. 8 (August, 1960), 17; Charles F. Schwartz and R o b e r t E. Graham, J r . , Personal Income by State, Supplement to Survey of Current Business (Washington, D.C., 1956), pp. 1 4 2 ^ 3 ; and Harvey H. Segal, "Personal Income of the New York Metropolitan R e g i o n " (New York Metropolitan Region Study; New York, 1958; mimeographed), p. 49.

higher than in the entire metropolitan region, the state, or the nation. In 1956 the city's per capita income was slightly lower than in the metropolitan region, but higher than in the state or nation. Clearly, per capita income has increased more slowly in New York City than in the Metropolitan Region. It has also increased more slowly in New York City than in the state or nation. Indeed, per capita income has increased more slowly in the New York metropolitan region and in New Y o r k State than in the United States as a whole. T h e explanation lies in part in a general tendency toward equalization of income between poorer states and richer states, 26 among sections of the country, and between metropolitan and nonmetropolitan areas within sections. 2 7 T h e s e developments reflect certain broad economic forces, which are sometimes reinforced by local influences, such as the growth of the Puerto R i c a n and nonwhite population in New York City. I n 1956 per capita income in New York City exceeded the nation-wide average by 30 percent and the New Y o r k State average by 5 percent. Although other sources present somewhat different figures, trend data indicate that these relationships have not changed materially since 1956. 2 8 H i g h e r per capita income is likely to be associated with a relatively larger proportion of income recipients in the upper brackets and fewer recipients in the lower brackets. T a b l e 1.8 compares the percentage distribution of families by income in New Y o r k City, New York State, and the United States. Compared with the United States as a whole, N e w Y o r k City

21

POPULATION AND INCOME Table

1.8. P E R C E N T A G E D I S T R I B U T I O N OF FAMILIES BY INCOME, N E W YORK CITY, N E W YORK STATE, A N D U N I T E D STATES, 1949 A N D 1956 1949

Annual

Income

Under $2,000 $ 2,000- 3,999 4,000- 5,999 6,000- 9,999 10,000 and over Total Median

Income

New York City 19.3 38.8 24.1 12.8 5.0 100.0 $3,526

New York State 19.6 39.7 23.6 12.1 4.8 100.0* $3,487

1956 United States

New York City

New York State

29.3 38.5 19.9 9.2 3.1

7.0 19.8 31.6 30.0 11.6

7.1 19.1 31.6 31.0 11.2

United States 15.4 22.7 28.6 25.4 7.9

100.0 $3,073

100.0 $5,478

100.0 $5,523

100.0 $4,783

• D u e to rounding, does not add to 100 percent. SOURCE: N e w York State Interdepartmental Committee o n Low Incomes, Family Income in New York State, 1956 (Bulletin No. 1, Pt. 1; N e w York, 1958), T a b l e s 1, 12. and 13.

has had—and still has—a large proportion of families with income of $6,000 or more and a smaller proportion of families with low income. Between New York City and New York State differences in the distribution of income are small. T h e above distributions are based on information collected through household surveys. It is recognized that these do not account for all the income received by respondents 29 and that more complete data would increase the n u m b e r of families with income of $6,000 or more. Increases in income overstate improvement in economic welfare to the extent that prices of goods and services have risen. W h e n allowance is made for the rise in the Consumer Price Index between 1949 and 1956, median family income is f o u n d to have increased in New York City by 38 percent, compared with 55 percent without such an allowance; and the proportion of families with annual income of $6,000 or more is found to have increased to 42 percent in 1956 from 24 percent in 1949, rather than f r o m 18 percent, as shown in T a b l e I.8. 30 T h e Metropolitan Region Study also developed estimates of per capita income in each of the city's five boroughs. Manhattan, which has relatively more low-income recipients as well as high-income recipients than the other boroughs, has

BACKGROUND

22

Table

1.9. PER CAPITA INCOME (IN DOLLARS) BY B O R O U G H , N E W YORK CITY, 1939, 1947, A N D 1956

Borough

1939

Bronx Brooklyn Manhattan Queens Richmond

768 917 1,489 723 733

1947 1,658 1,622 2,662 1,656 1,489

1956 2,318 2,317 2,964 2,749 2,250

SOURCE: Harvey H. Segal, Personal Income of the New York Metropolitan Region (New York Metropolitan Region Study; New York, 1958; mimeographed), p. 49.

always led in per capita income, and still does. However, its lead is diminishing. Between 1939 and 1956 there was considerable shifting about in the ranks of the three other major boroughs. T h e rise of Queens from last place to second is noteworthy. If the boroughs are ranked by cash income per household (exclusive of certain types of noncash income as well as institutional income that does not accrue to households) rather than by per capita income (as defined by the United States Department of Commerce), the borough of Queens assumes top rank, with Richmond joining Manhattan in the second rank. 31 T h i s is pertinent to another finding, namely, that the residents of Richmond (Staten Island) have a relatively low proportion of ward to total hospital admissions (see Chapter 4). INCOME O F PUERTO RICANS AND NONWH1TES

Income data for each of the ethnic groups in New York City are available from the United States Bureau of the Census for the year 1949. In the spring of 1957, the State Interdepartmental Committee on Low Incomes sponsored a sample survey of households in New York State, including New York City. From this survey, separate income data were derived for whites and nonwhites. A supplementary survey, conducted in New York City, was designed to yield information on Puerto Ricans and augmented information on nonwhites. Although the findings of the supplementary survey have not yet been published, they were kindly made available by the Division of Research and Statistics of the New York State Department of Labor. Comparisons among Puerto Ricans, Nonwhites, and Other Whites. Data are available for the three ethnic groups on the

POPULATION AND INCOME

23

m e d i a n i n c o m e of earners in 1949 a n d 1956. T h e incomes of all groups have risen b u t not at e q u a l rates. R e l a t i o n s h i p s a m o n g the ethnic groups have, therefore, c h a n g e d somewhat. T h e med i a n income of nonwhites relative to whites has i m p r o v e d slightly. Because of sampling variation, this may n o t be statistically significant. T h e m e d i a n income of P u e r t o Ricans relative to whites has declined. H e r e , too, s a m p l i n g variation is involved. Moreover, n o t enough is k n o w n of the forces at play, such as possible changes in the sex composition of income recipients a n d in the i m p o r t a n c e of part-time workers. Table

1.10. M E D I A N MONEY E A R N I N G S (IN D O L L A R S ) OF P E R S O N S F O U R T E E N YEARS O L D A N D OVER BY E T H N I C G R O U P , N E W YORK CITY, 1949 A N D 1956 1956

1949 Ethnic Group Puerto Rican White Nonwhite Other nonwhite Other white

Amount n.a. 1,657 1,513 1,707 2,517

Percent of White Income n.a. 65.9 60.3 68.0 100.0

Amount 2,505 n.a. n.a. 3,069 4,430

Percent of White Income 56.5 n.a. n.a. 69.5 100.0

SOURCE: U.S. B u r e a u of the Census a n d N e w York State D e p a r t m e n t of L a b o r , D i v i s i o n of R e s e a r c h a n d Statistics, u n p u b l i s h e d t a b u l a t i o n s .

For 1956 income d i s t r i b u t i o n s of families are available for each ethnic group. Table

Annual

1.11. P E R C E N T A G E D I S T R I B U T I O N OF W H I T E , N O N W H I T E , A N D P U E R T O R I C A N FAMILIES BY INCOME, N E W YORK CITY, 1956 Income

Under $2,000 $ 2,000- 3,999 4,000- 5,999 6,000- 9,999 10,000 and over Total • Median Income

All

Families

Puerto

Rican

White

Nonwhite

2.5 17.9 33.8 32.9 12.8

1.7 13.8 33.8 35.7 14.9

8.2 41.6 30.3 18.9 1.1

11.8 46.2 27.6 13.1 1.1

100.0* $5,752

100.0 • $6,050

100.0 • $4,016

100.0* $3,510

• D u e to r o u n d i n g , does n o t a d d to 100 p e r c e n t . SOURCE: N e w York State D e p a r t m e n t of Labor, D i v i s i o n of R e s e a r c h a n d Statistics, unpublished tabulations.

T h e m e d i a n income of n o n w h i t e families in 1956 was 66 percent of the m e d i a n income of w h i t e families a n d t h a t of P u e r t o

BACKGROUND

24

R i c a n families was 58 p e r c e n t . T h e i n c o m e s of all families s h o w n h e r e are h i g h e r t h a n t h e c o r r e s p o n d i n g figures f o r N e w Y o r k City f a m i l i e s s h o w n in T a b l e 1.8. T h e d i f f e r e n c e b e t w e e n t h e two m e d i a n s is $275, o r five p e r c e n t of t h e lower one. T h e r e l a t i o n s h i p b e t w e e n t h e i n c o m e d i s t r i b u t i o n s of w h i t e a n d n o n w h i t e f a m i l i e s is, h o w e v e r , consistent w i t h t h e findings of t h e N e w York State i n t e r d e p a r t m e n t a l C o m m i t t e e o n L o w Incomes. 3 2 O n e half of all w h i t e families e a r n a b o v e $6,000. By contrast, o n e half of t h e n o n w h i t e families e a r n u n d e r $4,000 a n d o n e half of t h e P u e r t o R i c a n families e a r n u n d e r $3,500. T h e figure of $6,000 is exceeded by 20 p e r c e n t of t h e n o n w h i t e families a n d by 14 p e r c e n t of t h e P u e r t o R i c a n families. Comparisons

between

Nonwhites

and

Whites

D a t a on t h e i n c o m e of whites a n d n o n w h i t e s , w i t h o u t a sepa r a t e b r e a k d o w n for P u e r t o Ricans, are m o r e p l e n t i f u l f o r N e w Y o r k City a n d also for o t h e r areas. It is possible, for e x a m p l e , to c o m p a r e t r e n d s in the m e d i a n i n c o m e of w h i t e a n d n o n w h i t e inc o m e r e c i p i e n t s in N e w York City by sex. Table

1.12. MEDIAN INCOME (IN DOLLARS) OF W H I T E AND N O N W H I T E INCOME RECIPIENTS BY SEX, NEW YORK CITY, 1949 AND 1956 Increase 1949-56

Color and Sex All income recipients White Nonwhite Total men White Nonwhite Total women White Nonwhite

1949 2,410 2,517 1,707 2,907 3,017 2,099 1,758 1,844 1,339

1956 3,035 3,210 2,362 4,036 4,216 3,015 2,037 2,084 1,848

Amount 625 693 655 1,129 1,199 916 279 240 509

Percent 25.9 27.5 38.4 38.8 39.7 43.6 15.9 13.0 38.0

SOURCE: New York State I n t e r d e p a r t m e n t a l C o m m i t t e e o n Low Incomes, Income of Persons by Sex and Color, New York State ( B u l l e t i n No. 3, Pt. 1; N e w York, 1958), T a b l e s D, 1, a n d 2; a n d Gladys E n g e l L a n g , Minority Groups and Economic Status in New York State a n d Working Tables, p r e p a r e d f o r t h e N e w York State C o m m i s sion against D i s c r i m i n a t i o n (New York, 1958; m i m e o g r a p h e d ) , T a b l e 28.

I n relative terms, t h e m e d i a n i n c o m e of n o n w h i t e s has s h o w n slightly m o r e i m p r o v e m e n t t h a n that of whites in t h e case of

POPULATION AND

INCOME

25

men and much more improvement in the case of women. In terms of dollar amounts, the larger increase in median income has been shown by whites in the case of men and by nonwhites in the case of women. T h e data on white women should be interpreted with care, because they reflect a large increase in part-time employment. 3 3 T h e improvement shown by nonwhite women is, however, a real one. As for the income position of men, any conclusion concerning the relative progress of whites and nonwhites depends on whether changes in dollar amounts or in percentages are considered the more appropriate criterion. T h e r e is no doubt whatever that the income position of nonwhites relative to whites is better in New York City than in the country as a whole. For both men and women the difference in income between whites and nonwhites, whether expressed as an amount or as a percentage, is smaller in New York City than in the United States as a whole or in the urban areas of the United States. Table

1.13. M E D I A N I N C O M E (IN D O L L A R S ) OF W H I T E A N D N O N W H I T E I N C O M E R E C I P I E N T S BY SEX, N E W Y O R K C I T Y , U N I T E D STATES TOTAL, AND UNITED STATES U R B A N , 1956 Women

Men

Area N e w York City United States T o t a l U n i t e d States Urban

White

Nonwhite

Percent Nonwhite to White

4,216 3,827 4,165

3,015 2,000 2,624

71.4 52.2 63.0

White 2,084 1,267 1,486

Nonwhite

Percent Nonwhite to White

1,848 727 994

88.5 57.5 66.8

SOURCE: New York State Interdepartmental Committee on Low Incomes, Income of Persons by Sex and Color, New York State (Bulletin No. 3. Pt. 1; New York, 1958), Tables A, D, 1, and 2. DISCUSSION AND IMPLICATIONS

T h e data show that although nonwhites in New York City are better off than nonwhites elsewhere, the average income of nonwhites in New York City is substantially below that of whites. T h e disparity between Puerto Ricans and other whites is even greater. Incomes of nonwhites and of Puerto Ricans in New York City have increased. Because of variation due to sampling size, it is

BACKGROUND

26

not certain that the ratio of P u e r t o Rican income to that of other whites has declined. T h e relative change in the income position of nonwhites cannot be interpreted without ambiguity. A study of the 1949 income statistics for New York City found that a much larger proportion of nonwhites than of whites had low income (as defined in the study), b u t that the large majority of families with low incomes—85 percent of the total—were white. T h e key factor to the lower income of nonwhites was f o u n d to be unequal job opportunity. 8 4 Less is known about the factors affecting the income of Puerto Ricans. T h e outlook for the f u t u r e is complicated by the two-way and perhaps three-way flow of population. It is conceivable that the average income of Puerto Ricans in New York City might be depressed by a continuing stream of new immigrants starting anew at the bottom of the economic ladder, despite improvement in the income position of long-term P u e r t o Rican residents. 36 T h e n u m b e r and proportion of long-term residents is likely to increase, however. Voluntary

Health

Insurance

Enrollment

T o d a y membership in health insurance plans may be, or is becoming, a better index than personal income of consumer ability to pay for hospital care. From the inception of the voluntary health insurance movement in this country the emphasis has been on covering employee groups. More recently, health insurance premiums are increasingly being paid for, in full or in part, by employer contributions to welfare funds, and enrollment of the individual worker is influenced more by his participation in the labor force than by his earnings. In May, 1958, a household survey f o u n d that 71 percent of the residents of New York City had insurance for hospital care. 38 This is approximately the same proportion as for the nation as a whole. 37 An outstanding difference between New York City and the United States is that the former has a much higher proportion of Blue Cross enrollment (see Chapter 17). In the spring of 1952 a household survey conducted by a special committee u n d e r the auspices of the Health Insurance Plan of Greater New York found that 56 percent of the popula-

POPULATION A N D INCOME

27

tion of New York City had some type of voluntary health insurance. 38 At that time the nation-wide proportion was also 56 percent. T h e 1952 finding was consistent with more selective data compiled by the United States Bureau of Labor Statistics for 1950, which showed that the proportion of the population with voluntary health insurance was significantly lower in New York City than in other large cities of the north. 8 8 Contributing in part to the relative lag of health insurance enrollment in New York City has been the increase in the Puerto Rican and nonwhite population. It is estimated that enrollment among these groups is one half or less of the rate for the nonPuerto Rican white population. 4 0 In addition to lower income, higher rates of unemployment are undoubtedly one factor, and the distribution of members of the labor force by industry is another. Growth in the proportion of the population of New York City with insurance is hampered by a lag in employer participation in the payment of voluntary health insurance premiums. T h e proportion of insured persons with some employer contribution to premiums was no higher in New York City in 1958 than in the nation in 1955.41 It should be noted that for one half of the employees in New York City whose premiums are paid, in full or in part, by their employers the contributions are directed to multiemployer u n i o n funds (those that receive contributions from two or more employers in an industry). T h i s is a much higher frequency than in upstate New York, where employer contributions accrue to multiemployer union f u n d s for one sixth of the employees involved and to single employer f u n d s for five sixths. 42 Altogether, multiemployer union f u n d s are encountered more frequently in New York State than in the country as a whole. 43 By pooling p r e m i u m payments on behalf of employees in two or more firms, the multiemployer union f u n d increases the flexibility with which a given amount of money can be spent and enhances the leverage that can be applied. In 1958, 63 percent of New York City's population had some type of insurance for doctors' bills. 44 T h i s is approximately the same as the proportion of the population of the U n i t e d States with surgical care insurance. 4 5 T h e comparison is not entirely valid,

28

BACKGROUND

however, because a good many of the persons with medical care insurance in New York City have coverage for more than surgical care in the hospital. Coverage for many extends also beyond medical expense insurance in the hospital, as in the case of all subscribers to the Health Insurance Plan of Greater New York (HIP), one third or more of the subscribers to G r o u p Health Insurance (GHI), and 7 percent of the subscribers to U n i t e d Medical Service (Blue Shield). O n the other hand, New York City lags in enrollment u n d e r m a j o r medical insurance. (Major medical insurance is characterized by its broad scope, a deductible feature, and a coinsurance factor, as in fire insurance. Most often it supplements the benefits of regular health insurance.) In New York City 11 percent of all g r o u p subscribers to health insurance had major medical insurance in 1958, compared with 17 percent in the rest of New York State 46 and also in the nation. 47 New York City has an unusually high proportion of the population enrolled under prepaid group practice plans—28 percent of the nation-wide total. 48 Included are the one-half million and more subscribers to H I P and approximately one-half million persons, employees and dependents, who are eligible for care in union health centers. W i t h one exception, union health centers in New York City are relatively new. Mostly they serve members of the union who are employees of a given industry, b u t frequently dependents are also eligible for care. Typically, they offer diagnostic and treatment services or diagnostic services only for ambulatory patients. Only one center provides services in the hospital as well. T a b l e 1.14 shows the estimated distribution of persons eligible for care in union health centers in New York City by type of service. Of 13 centers included in the above data, 12 were established after 1947 and 9 after 1950. Every center established a f t w 1952 is limited by state statute to the provision of diagnostic services only. Of some importance for hospitals in New York City are the estimated 370,000 persons who work b u t do not reside here. 49 T h e Roper Survey found that, in 1958, 85 percent of commuters carried hospital care insurance, compared with 83 percent for

29

P O P U L A T I O N AND INCOME Table

1.14. P E R C E N T A G E D I S T R I B U T I O N O F P E R S O N S E L I G I B L E F O R CARE IN U N I O N H E A L T H C E N T E R S BY T Y P E O F SERVICE, N E W Y O R K CITY, 1957

Type of Service T o t a l n u m b e r : 511,000 Diagnosis and treatment for ambulatory patients plus inpatients Diagnosis and treatment for ambulatory patients Diagnosis only

Eligible Persons Percent

7.1 53.5 39.4 100.0

Margaret C. Klem, Care Provided for Nervous and Mental Diseases at Union Health Centers in New York City, 1957, paper delivered before Community Council of Greater New York, April 11, 1958 (mimeographed). SOURCE:

other residents of the suburbs, and 71 percent for the residents of New York City.50 T o the extent that commuters make use of hospitals in the city, they increase the demand for private and semiprivate accommodations and reduce the demand for ward accommodations. Summary

1. T h e population of New York City declined for the first time in the 1950s, dropping to 7,780,000 in 1960. 2. T h e loss of 1.4 percent during the decade was smaller than that incurred by many large cities in the nation. T h e suburban counties of the metropolitan region gained in population here, as they did elsewhere. This points to the need for planning hospital care for an area larger than the city. 3. T h e decline in New York City's population reflected a continuing decline in average household size and accelerated outmigration of non-Puerto Rican whites. 4. Puerto Ricans and nonwhites increased in number during the 1950's. Both groups tend to occupy positions at the bottom of the economic ladder and have greater need for certain types of health service than the rest of the population. 5. T h e number and proportion of children and of aged (65 years and over) have increased in New York City. 6. T h e city's population has been redistributed among the five

30

BACKGROUND

boroughs, with Queens being the chief gainer and Manhattan the chief loser. Simultaneously, there has been some dispersal of Puerto Ricans and nonwhites from Manhattan to the other major boroughs. T h e nonwhite population continues to show evidence of concentration in certain neighborhoods. 7. T h e most recent projection of population for New York City envisages a population of 8,340,000 in 1975. T h i s figure may prove to be on the high side. Puerto Ricans and nonwhites, it is projected, will constitute 28 percent of the total. 8. Per capita income of the residents of New York City has always exceeded that of the population of the United States and of New York State. Until recently, per capita income in New York City has also exceeded that of the New York metropolitan region. 9. T h e median income of the Puerto Rican and nonwhite earner in New York City is approximately three fifths and two thirds, respectively, of the median income of the non-Puerto Rican white earner. 10. T h e proportion of families with low income is larger for Puerto Ricans and nonwhites than for non-Puerto Rican whites, and the proportion of families with higher income is considerably smaller for Puerto Ricans and nonwhites than for non-Puerto Rican whites. Nevertheless, one fifth of nonwhite families in New York had income of $6,000 or more in 1956. 11. T h e ratio of income of nonwhite earners to that of white earners is much higher in New York City than in the United States as a whole or in urban sections of the United States. 12. Between 1949 and 1956 the ratio of the median income of nonwhite women in New York City to that of white women increased. T h e trend in income of Negro men relative to that of white men is more ambiguous. 13. Between 1949 and 1956 the median income of all familes in New York City increased 55 percent in money terms and 38 percent in real terms, after allowance for the rise in prices. 14. T h e ranks of the boroughs with respect to per capita income have changed. Although Manhattan is still in the lead, its margin is narrower than in the past. T h e other boroughs have shifted ranks, with the greatest gain occurring in Queens. T h e borough of Richmond ranks fifth when income is measured per

POPULATION AND INCOME

31

capita, b u t second when income is measured as cash income per household. 15. Seventy-one percent of the p o p u l a t i o n of New York City is enrolled in hospital care insurance, the same p r o p o r t i o n as in the c o u n t r y as a whole. T h e rate of e n r o l l m e n t in the s u b u r b s is higher—83 percent. T h e m a j o r difference between N e w York City a n d the rest of the n a t i o n is the larger role played here by Blue Cross relative to commercial insurance. 16. H e a l t h insurance e n r o l l m e n t has lagged in N e w York City relative to other large cities in the n o r t h . T h i s may b e attributable, in part, to the increase in New York City's P u e r t o Rican and n o n w h i t e p o p u l a t i o n , whose rate of e n r o l l m e n t is only one half that of the rest of the p o p u l a t i o n . In part, it may b e attribu t a b l e to a lower degree of employer participation in paying health insurance p r e m i u m s . 17. A larger p r o p o r t i o n of employer c o n t r i b u t i o n s t h a n elsewhere is directed in N e w York City to m u l t i e m p l o y e r u n i o n funds. T h i s enhances the leverage that welfare f u n d s can apply. 18. I n comparison with the rest of N e w York State a n d the U n i t e d States as a whole, New York City is f u r t h e r distinguished by a lower p r o p o r t i o n of the p o p u l a t i o n enrolled u n d e r m a j o r medical insurance, a higher p r o p o r t i o n of the p o p u l a t i o n with insurance for doctors' services outside the hospital, a n d a high p r o p o r t i o n of the p o p u l a t i o n eligible for services in u n i o n health centers. 19. T h e last decade has witnessed a substantial expansion of u n i o n h e a l t h centers. Every center chartered after 1952 is authorized to provide diagnostic services only.

2

PATTERNS OF HOSPITAL USE

T h i s chapter deals with the services rendered by hospitals in New York City. Its primary aim is to assess the changing relative importance of the two m a j o r hospital systems, voluntary and municipal. Since proprietary hospitals also play a significant role in New York City, they are included in the data. It is important to be clear about the terms employed. A voluntary hospital is operated by a nonprofit corporation; a municipal hospital is operated by the Department of Hospitals of the City of New York; and a proprietary hospital is operated by its owners for profit. T h e r e is a traditional division of patients by financial status among the three hospital systems. Briefly, municipal hospitals are by law intended primarily for the sick poor; proprietary hospitals care for patients able to pay; and voluntary hospitals typically care for all segments of the population. In turn, the classification of patients by pay status is associated with their classification by type of hospital accommodation—private, semiprivate, and ward. Hospital

Services

in

1958

T h e most recent year for which complete data were available is 1958. T h e r e were then 151 voluntary, municipal, and proprietary hospitals in New York City, with approximately 50,000 beds. Serving both residents of the city and patients from other areas, they admitted 1,050,000 inpatients and provided 14,435,000 days of care, an average daily census of almost 40,000. These hospitals also carried an average of 2,240 patients a day on home care, received 7,265,000 visits d u r i n g the year in their outpatient

P A T T E R N S OF H O S P I T A L USE

SS

and emergency departments, and responded to 345,000 calls with their emergency ambulances. Excluded from the above are the following categories of hospitals and related facilities: 1. All federal hospitals in the city. Of particular importance are the three Veterans Administration general hospitals with 3,600 beds. Almost 85 percent of their patients are residents of N e w York City. 1 2. All state hospitals. In New York City the four state hospitals are exclusively devoted to the care of psychiatric patients. Although 98 percent of their patients come from New York City, these hospitals, in turn, care for only 22 percent of all New York residents in the state mental hospital system. State hospitals with large numbers of patients from New York City are located in suburban Suffolk and R o c k l a n d counties, and with smaller n u m b e r s of New York City residents in Broome, Dutchess, and Orange counties. 2 3. Most related facilities. All nursing homes or infirmaries apart from hospitals are excluded from the data. Included are those infirmary and nursing-home units that are integral parts of hospitals. DISTRIBUTION OF SERVICES BY O W N E R S H I P

T h e tables in this chapter present data on beds as well as on services, b u t the former serve mainly as bases for c o m p u t i n g measures of hospital use. T h e focus of this chapter is on hospital services. Facilities as such are dealt with in Chapter 8. T a b l e 2.1 shows the volumes of services rendered by hospitals in New York City in 1958 and distributes the total for each type of service a m o n g the three hospital systems. Absent from the compilation are figures on services rendered to private ambulatory patients for which existing reporting fails to yield reliable information (see pages 57-58). In 1958 voluntary hospitals provided one half or more of all inpatient and outpatient department services in N e w York City. Municipal hospitals provided one quarter to two fifths of inpatient services (depending on the criterion employed) and one half or more of all home-care patient days, emergency department

34

BACKGROUND

Table

2.1. D I S T R I B U T I O N O F A L L H O S P I T A L F A C I L I T I E S B Y O W N E R S H I P , N E W Y O R K C I T Y , 1958 Percent

Facility

or

Service

B e d capacity Bed complement Discharges, inpatients P a t i e n t days, i n p a t i e n t s P a t i e n t days, h o m e care Visits, o u t p a t i e n t departments Visits, e m e r g e n c y departments Calls, e m e r g e n c y a m b u l a n c e service

All Hospitals

Voluntary Hospitals

49,959 48,672 1,050,570 14,435,675 817,431

100.0 100.0 100.0 100.0 100.0

50.8 51.2 59.2 50.9 5.3

39.7 39.1 24.7 40.2 94.7

9.5 9.7 16.1 8.9 0

5,445,709

100.0

51.4

48.6

0

1,820,844

100.0

46.3

53.1

0.6

345,911

100.0

41.3

58.7

0

Number, All Hospitals

Municipal Hospitals

Proprietary Hospital

SOURCE: Hospital Council of Greater New York, a n n u a l inventory.

visits, and emergency ambulance calls. Proprietary hospitals provided 9 to 16 percent of inpatient services and a negligible fraction, or none, of the other types of service. C O M P A R I S O N W I T H S H O R T - T E R M H O S P I T A L S IN U N I T E D S T A T E S

It is not practical to compare New York City and the nation in total hospital services, because the residents of New York City receive so large a proportion of their mental hospital services outside the city. T h e obvious solution would be to exclude state mental hospitals f r o m the comparison. T h i s cannot be done, because the nation-wide data combine the figures for state and local government hospitals. It was, therefore, decided to limit the comparison to short-term hospitals, in which state hospitals usually play a small part. Data are available to compare New York City and the nation in five categories of hospital beds and services, as shown in Tables 2.2 and 2.3. T h e comparison is made in two stages: (1) a percentage distribution of a given total by hospital ownership; and (2) a ratio of beds or services per 1,000 population. For this comparison municipal hospital centers, such as Bellevue, are treated as single institutions and classified as short-term hospitals, inasmuch as this is the way the institution and its

P A T T E R N S OF H O S P I T A L USE

35

c o u n t e r p a r t s r e p o r t to the A m e r i c a n Hospital Association and appear in the a n n u a l " G u i d e Issue" of the magazine Hospitals. U n d e r this scheme of classification certain large facilities for longt e r m patients are parts of short-term hospitals, affecting the comp u t e d measures of hospital use, especially the average d u r a t i o n of patients' stay. Table

2.2. D I S T R I B U T I O N O F S H O R T - T E R M H O S P I T A L F A C I L I T I E S A N D SERVICES BY O W N E R S H I P , N E W Y O R K C I T Y A N D U N I T E D S T A T E S , 1958 Percent

Facility or Service Bed c o m p l e m e n t

Number,* All Hospitals

N e w York City 40,308 U n i t e d States 609,732 Admissions or discharges, inpatients N e w York City 1,036 U n i t e d States 21,684 Patient days, inpatients N e w York City 11,785 U n i t e d States 164,668 Visits, outpatient departments N e w York City 5,407 U n i t e d States 34,276 Visits, emergency departments N e w York City 1,819 U n i t e d States 17,094

All Hospitals

Voluntary Hospitals

Government Hospitals

Proprietary Hospitals

100.0 100.0

54.3 69.5

34.7 24.6

11.0 5.9

100.0 100.0

59.6 73.0

24.4 19.9

16.0 7.1

100.0 100.0

54.0 71.4

35.7 23.4

10.3 5.2

100.0 100.0

51.3 55.2

48.7 39.2

0 5.6

100.0 100.0

46.2 65.8

53.2 31.7

0.6 2.5

• In thousands, except for beds. SOURCE: American Hospital Association, Hospitals, X X X I I I , No. 15 (August 1, 1959), Pt. 2 (Guide Issue), and Hospital Council of Greater New York, annual inventory.

Distribution by Ownership. Because short-term g o v e r n m e n t hospitals in the U n i t e d States i n c l u d e some state hospitals, t h e table understates the actual difference b e t w e e n N e w York City and the n a t i o n in the relative i m p o r t a n c e of m u n i c i p a l hospitals. Even so, m u n i c i p a l hospitals play a larger role h e r e t h a n in the n a t i o n for every category of service c o m p a r e d . Conversely, voluntary hospitals play a smaller role here. Services in Relation to Population. In 1958 N e w York City had 4.5 percent of the p o p u l a t i o n of t h e U n i t e d States. T a b l e 2.3

BACKGROUND

36

shows the percentages of beds and of each type of service in New York City to the nation-wide total and compares the ratios of beds and services per 1,000 population in the two areas. T h e Table

2.3. P E R C E N T A G E O F F A C I L I T I E S A N D SERVICES I N S H O R T T E R M HOSPITALS IN N E W YORK CITY T O T H O S E I N U N I T E D S T A T E S , A N D R A T I O S P E R 1,000 P O P U L A T I O N , 1958 PCTCCTlt

Facility or Service

New York City to United States

R^ios per 1,000 Population New York City United States

Bed c o m p l e m e n t 6.6 5.2 3.5 Admissions or discharges 4.8 133 125 Patient days 7.1 1,510 917 197 Visits, o u t p a t i e n t d e p a r t m e n t s 15.8 693 Visits, emergency d e p a r t m e n t s 10.6 233 98 SOURCE: Table 2.2 and U.S. Bureau of the Census, Statistical Abstract of the United States.

proportion of New York City's services to the nation's has a wide range—5 to 16 percent. It is lowest in inpatient services and highest in outpatient services. T w o factors that affect the comparisons in T a b l e 2.3 deserve elaboration: (1) the proportion of all medical services rendered in hospitals; and (2) the proportion of hospital services in New York City rendered to nonresidents. O u t p a t i e n t departments of hospitals offer medical services to the sick poor. According to T a b l e 2.3, they are used 3.5 times more often in New York City than in the nation. T h i s ratio would rise if cognizance were taken of the large volume of services rendered to the sick in New York City by nonhospital clinics, including those operated by the Department of Health and by independent dispensaries (see page 53). T h e r e is apparently a real difference between New York City and the nation in the manner of providing medical care to ambulatory patients who are indigent or medically indigent. T h i s difference is consistent with the higher proportion of inpatients in New York City who receive care in the ward (see Chapter 4). A significant proportion of inpatient services rendered by short-term hospitals in New York City—almost one-tenth (see Chapter 3)—is received by nonresidents. In turn, some of the

37

PATTERNS OF HOSPITAL USE

r e s i d e n t s of N e w York City receive h o s p i t a l care elsewhere. T h e n e t result is an a n n u a l r a t e of a d m i s s i o n of 125 p e r 1,000 p o p u l a t i o n , t h e same as in the n a t i o n (see below). T h e c o m p a r i s o n of p a t i e n t days in T a b l e 2.3 is also invalid, b e c a u s e the m u n i c i p a l h o s p i t a l c e n t e r s in N e w Y o r k C i t y i n c l u d e a m u c h larger v o l u m e of beds a n d services f o r l o n g - t e r m p a t i e n t s t h a n d o s h o r t - t e r m hospitals in t h e n a t i o n at large. T o a n t i c i p a t e the findings of a later section o n g e n e r a l c a r e facilities a n d services, average l e n g t h of p a t i e n t stay in N e w Y o r k C i t y exceeds t h a t in the n a t i o n by o n e t h i r d o r m o r e . W i t h rates of a d m i s s i o n identical, h o s p i t a l use is h i g h e r in N e w York C i t y t h a n in t h e n a t i o n by t h e same o n e t h i r d o r more—1,310 p a t i e n t days p e r 1,000 p o p u l a t i o n p e r year c o m p a r e d with 950. T a b l e 2.3 also shows t h a t t h e use of e m e r g e n c y d e p a r t m e n t services is two-and-one-third times g r e a t e r in N e w Y o r k C i t y t h a n in t h e n a t i o n . T h e 1958 d i f f e r e n c e is s m a l l e r t h a n in t h e past. 3 It is k n o w n , a l t h o u g h an exact q u a n t i t a t i v e c o m p a r i s o n is n o t possible, that N e w York City uses m o r e e m e r g e n c y a m b u l a n c e services t h a n d o o t h e r large cities in t h e n a t i o n . 4 Trends

in Total Hospital

Services,

1930-58

T h e s i t u a t i o n in N e w York City in 1958 r e p r e s e n t s t h e culm i n a t i o n of d e v e l o p m e n t s o v e r t h e years. M o r e o v e r , t h e total f o r all hospitals is the s u m of the several types of h o s p i t a l p r o g r a m . T h e r e m a i n d e r of this c h a p t e r traces t h e t r e n d in total hospital b e d s a n d services as f a r back as it was possible to go t o d e v e l o p r e l i a b l e figures f o r each h o s p i t a l system. T h i s o r d e r of discussion is f o l l o w e d : (1) total h o s p i t a l services f o r i n p a t i e n t s ; (2) services for i n p a t i e n t s in g e n e r a l - c a r e facilities; (3) services f o r a m b u l a t o r y p a t i e n t s a n d in t h e h o m e ; (4) services f o r i n p a t i e n t s in non-general-care facilities. F o r total hospital facilities a n d services it was possible to c o m p i l e d e c e n n i a l data b e g i n n i n g in 1930, a n d f o r facilities only, b e g i n n i n g in 1920. For i n d i v i d u a l p r o g r a m s , h o w e v e r , d a t a a r e usually p r e s e n t e d b e g i n n i n g in 1940, e x c e p t w h e n they first became available at a later date. T a b l e 2.4 shows beds, discharges, a n d p a t i e n t days b y h o s p i t a l o w n e r s h i p in 1930, 1940, 1950, a n d 1958.

BACKGROUND

38 Table

2.4. D I S T R I B U T I O N O F F A C I L I T I E S AND SERVICES BY H O S P I T A L O W N E R S H I P , NEW YORK CITY, 1930, 1940, 1950, AND 1958 1930

Facility or Service Bed complement All hospitals Voluntary Municipal Proprietary Discharges All hospitals Voluntary Municipal Proprietary Patient days All hospitals Voluntary Municipal Proprietary

Number*

Percent

1940 Number*

Percent

1950 Number*

1958 Number*

Percent

Percent

36,575 100.0 19,466 53.2 13,614 37.2 3,495 9.6

41,160 100.0 22,017 53.5 15,609 37.9 3,534 8.6

43,493 100.0 22,559 51.9 16,735 38.5 4,199 9.6

48,672 100.0 24,883 51.2 19,059 39.1 4,730 9.7

627 100.0 384 61.2 176 28.1 67 10.7

756 100.0 427 56.5 253 33.5 76 10.0

921 100.0 525 57.0 251 27.3 145 15.7

1,051 100.0 622 59.2 259 24.7 170 16.1

10218 100.0 5,062 49.6 4,448 43.5 708 6.9

12,637 100.0 6,116 48.4 5,785 45.8 736 5.8

13,743 100.0 6,525 47.5 6,095 44.3 1,123 8.2

14,436 100.0 7,350 50.9 5,796 40.2 1,290 8.9

• In thousands, except for beds. SOURCE: For \930-Hospital Survey for New York, II (New York, 1937), pp. 116, 142, and Eli Ginzberg, A Pattern for Hospital Care (New York, 1949), p. 151; for 1940see Appendix 2.A; for 1950 a n d 1958—Hospital Council of Greater New York, annual inventory.

T h e estimated bed figures for 1920 follow: 5 Hospital Ownership All hospitals Voluntary Municipal Proprietary

Number 30,231 16,636 12,299 1,296

Percent 100.0 55.0 40.7 4.3

It is clear that the use of hospitals in N e w York City has been rising. T h i s was t r u e even in the 1950s, a f t e r the resident population h a d ceased to grow (see C h a p t e r 1). A l t h o u g h changes in the p r o p o r t i o n of beds, discharges, a n d p a t i e n t days held by each hospital system have n o t always t e n d e d in the same direction, it may be generalized that (1) in the past 40 years the relative i m p o r t a n c e of p r o p r i e t a r y hospitals has increased, with m u c h of the increase taking place in the 1920s a n d again in the 1940s; (2) the relative i m p o r t a n c e of m u n i c i p a l hospitals in the provision of i n p a t i e n t services has declined since W o r l d W a r II, a n d (3) the relative

39

PATTERNS OF HOSPITAL USE

importance of voluntary hospitals has been reasonably constant over the long run, with some interim fluctuations. In both beds and patient days, if proprietary hospitals received a weight of 1 in 1958, the weight of voluntary hospitals would be 5 and that of municipal hospitals 4. In discharges the corresponding weights would be 1.5, 6.0, and 2.5, respectively. These differences in relative weights between discharges, on the one hand, and patient days and beds, on the other, signify that municipal hospitals have by far the longest duration of patient stay. This reflects in part the longer stay of general-care patients in municipal hospitals than in other hospitals and in part the larger proportion of municipal hospital facilities devoted to non-generalcare patients. Services for General-Care

Inpatients

For an analysis of trends in hospital use in New York City, without reference to other geographic areas, a more refined set of distinctions is available than that between short-term and longterm hospitals. One may classify facilities and services in terms of organized nursing units within a hospital by employing the classification scheme developed in the Hospital Council's Master Plan for Hospitals and Related Facilities for New York City," as modified by subsequent usage. Broadly, inpatient facilities are classified into (1) general care and (2) all other, with the latter further subdivided among psychiatric, tuberculosis, chronic, rehabilitation, and nursing home. General care has come to include acute communicable diseases. A general-care facility is usually housed in a general or allied special hospital, such as maternity or children's. Since a general hospital may also contain units for patients with tuberculosis or psychiatric illness, the total number of beds and services reported by a general hospital may exceed the number of its general-care beds and services. In 1958, for example, the general care (general and allied special) hospitals in New York City had 40,300 beds in complement, 1,036,000 discharges, and 11,785,000 patient days (Table 2.2). T h e corresponding figures for general-care facilities

BACKGROUND

40

were lower-35,700, 993,000, and 10,200,000, respectively (Table 2.5, below). DISTRIBUTION

BY H O S P I T A L

OWNERSHIP

Data on general-care beds, discharges, and patient days by hospital ownership for the years 1940, 1950, and 1958 are shown in T a b l e 2.5. Table

2.5. D I S T R I B U T I O N O F G E N E R A L C A R E F A C I L I T I E S A N D SERVICES BY H O S P I T A L O W N E R S H I P , N E W Y O R K C I T Y , 1940, 1950, A N D 1958

Facility or Service Bed c o m p l e m e n t All hospitals Voluntary Municipal Proprietary Discharges All hospitals Voluntary Municipal Proprietary Patient days All hospitals Voluntary Municipal Proprietary

Number•

1958

1950

1940 Percent

Number*

Percent

Number

* Percent

32,542 19,005 10,238 3,299

100.0 58.4 31.5 10.1

32,584 19,180 9,816 3,588

100.0 58.9 30.1 11.0

35,670 21,220 10,245 4,205

100.0 59.5 28.7 11.8

707 422 210 75

100.0 59.7 29.7 10.6

870 520 209 141

100.0 59.8 24.0 16.2

993 612 216 165

100.0 61.6 21.7 16.7

9J87 5,070 3,638 679

100.0 54.0 38.8 7.2

9,785 5,411 3,437 937

100.0 55.3 35.1 9.6

10J17 6,102 2,976 1,139

100.0 59.7 29.1 11.2

• In thousands, except for beds. SOURCE: For 1940—see A p p e n d i x 2.A; for 1950 and 1958—Hospital Council of Greater New York, annual inventory.

General-care beds remained constant in the 1940s b u t increased 10 percent between 1950 and 1958, while the city's population declined slightly. T w o thirds of the bed increase occurred in voluntary hospitals. General-care discharges increased by 163,000 in the 1940s and by 123,000 between 1950 and 1958. Voluntary hospitals reported a substantial increase in each time interval, while proprietary hospitals had a substantial increase in the first interval and a moderate one in the second. Municipal hospitals had no appreciable change in either period.

PATTERNS OF HOSPITAL USE

41

Patient days increased by 400,000 in the 1940s and by more than 400,000 between 1950 and 1958. Voluntary and proprietary hospitals had substantial increases in both time intervals. Municipal hospitals had a decline of 200,000 in the first interval and a much larger one in the second. If the n u m b e r of general-care beds in proprietary hospitals were given a weight of 1, the respective weights of the voluntary and municipal systems would be roughly 6 and 3 (compared with weights of 1, 5, and 4 for total beds). Over the years the proportion of all general-care beds in voluntary hospitals has increased slightly, that in proprietary hospitals has increased somewhat, and that in municipal hospitals has declined. In 1958 the percentage distribution of general-care patient days by hospital ownership was similar to that of beds. T h i s had not been true in earlier years, when the municipal system's share of patient days exceeded its share of beds. T h e shift signifies that today the rate of occupancy in municipal hospitals is close to that in the other hospital systems and not much higher, as in the past. Proprietary hospitals have always had a larger share of discharges than of patient days, whereas the converse is true of municipal hospitals. These relationships signify that the average duration of patient stay is longer in municipal than in proprietary hospitals. Since the difference between each hospital system's proportion of discharges and of patient days was smaller in 1958 than in 1950, the decade must have witnessed a narrowing of differences among the three hospital systems in average length of patient stay (see below for computed measures of hospital use). In 1940 the percentage distribution of general-care discharges was similar to the distribution of beds. T h i s is no longer true. I n 1958 voluntary hospitals had approximately the same share of discharges as of beds. Municipal hospitals, however, had a lower proportion of discharges than of beds, while proprietary hospitals had a higher proportion of discharges than of beds. T h e s e shifts bear on changes in the average rate of bed turnover (the n u m b e r of patients served by a bed d u r i n g a specified period of time). T h e y signify that the largest gains have occurred in proprietary hospitals and the smallest gains, if any, in municipal hospitals.

BACKGROUND

42 C O M P U T E D M E A S U R E S O F H O S P I T A L USE

T h e n u m e r i c a l values of the changes in rate of occupancy, length of stay, a n d rate of b e d turnover in each hospital system can only be d e t e r m i n e d by c o m p u t a t i o n . For present purposes the figures need n o t b e exact. M u c h effort has been obviated by comp u t i n g rate of occupancy on b e d complement at the end of t h e year, r a t h e r than on the average n u m b e r of beds in operation d u r i n g the year. L e n g t h of stay was c o m p u t e d in the usual m a n n e r by relating discharges to total patient days for the year; this short cut yields acceptable results w h e n applied to short-term hospitals. It should be p o i n t e d o u t that the three measures of hospital use are interrelated mathematically, with the rate of b e d turnover directly p r o p o r t i o n a l to length of stay. T h e equation is this (see A p p e n d i x 2.B for its derivation): . . , _ , _ , ^ 365 x Rate of Occupancy Average A n n u a l Rate of Bed T u r n o v e r = Length of Stay

T h e measures of hospital use are shown in T a b l e 2.6. Table

2.6. C O M P U T E D M E A S U R E S OF H O S P I T A L USE I N G E N E R A L C A R E F A C I L I T I E S BY O W N E R S H I P , N E W Y O R K C I T Y , 1940, 1950, A N D 1958

Measure

of Hospital

Use

Rate of occupancy (percent) All hospitals Voluntary Municipal Proprietary Length of stay (days) All hospitals Voluntary Municipal Proprietary A n n u a l rate of bed turnover (ratio) All hospitals Voluntary Municipal Proprietary

1940

1950

1958

79.0 73.2 97.4 56.4

82.5 77.4 96.0 72.1

78.5 78.8 79.8 74.3

13.3 12.0 17.3 9.1

11.2 10.4 16.4 6.7

10.3 10.0 13.8 6.9

21.7 22.2 20.5 22.7

26.8 27.1 21.3 39.3

27.8 28.8 21.1 39.2

SOURCE: T a b l e 2.5.

Rate of Occupancy. For the three hospital systems c o m b i n e d the rate of occupancy of general-care beds in 1958 was a b o u t

PATTERNS OF HOSPITAL USE

43

the same as in 1940 b u t lower than in 1950. T h e reason is that in the 1950s beds increased at a faster rate than patient days. Formerly municipal hospitals were overcrowded, operating at an annual rate of occupancy of 95 to 100 percent. It is recognized that a short-term hospital cannot be operated efficiently at so high an average occupancy for the year. T o o many factors militate against this, including random fluctuations in patient load; seasonal variations in the incidence of illness; vacation on the part of patients, physicians, or hospital personnel; weekend lulls; segregation of patients by pay status, sex, and clinical department; and maintenance of stand by facilities for emergency admissions. An annual rate of occupancy of 95 or 100 percent signifies the presence of patients in beds in the corridors of patients' rooms and in hallways on many days in the year. At a rate of occupancy of 80 percent, municipal hospitals are operating at a level that was once regarded as optimum. 7 Today it is believed that general-care facilities can be effectively operated at a higher annual rate of occupancy, perhaps 85 percent or more. W h a t the optimum rate of occupancy is for an individual institution depends on (1) the relative size of its obstetrical service, which tends to operate at a lower rate of occupancy than other clinical departments; (2) the extent to which physical plant lends itself to flexible use and the extent to which administration takes advantage of the plant's capabilities; and perhaps also (3) the average length of patient stay, with a longer stay being conducive to a higher rate of occupancy. In any event, with a complement of 10,200 general-care beds in the municipal system, improved occupancy may be expected to reduce the n u m b e r of vacant beds by no more than 500 to 800. T h e rate of occupancy in voluntary hospitals has steadily improved, but it is still slightly lower than in municipal hospitals. Rate of occupancy in voluntary hospitals by type of accommodation is discussed in the next section. Occupancy in proprietary hospitals improved strikingly in the 1940s and continued to improve, more slowly, in the 1950s. T h e rate of occupancy in proprietary hospitals is still lowest but is now within four to five percentage points of the rate in the other two systems.

44

BACKGROUND

Length of Patient Stay. T h e average length of stay of generalcare patients in all hospitals in New York City declined in the 1940s and also in the 1950s. However, the rate of decline in the second interval was only one half that in the first. In the voluntary and proprietary systems all or most of the decline in patient stay occurred in the 1940s. T h e r e was hardly any change in the 1950s. T h e experience of municipal hospitals was reversed. Here length of stay declined by one day in the 1940s and by two and one half days in the 1950s. Immediately after World W a r II municipal hospitals were crowded, and bottlenecks in diagnostic facilities prolonged the period of examination and evaluation prior to treatment. In addition, overflow of patients from tuberculosis facilities raised the average length of patient stay in general-care units. T o w a r d the end of the 1940s the Department of Hospitals engaged in a concerted drive to expand ancillary services and eliminate diagnostic bottlenecks. Crowding was also eased by the adoption of more rigorous criteria for the admission of patients. T h e average period of initial evaluation therefore declined. Duration of stay was shortened in 1949 by the establishment of homecare programs and more effectively in 1952 by the initiation of a campaign to transfer patients to proprietary nursing homes and public-home infirmaries when definitive hospital care was completed. Finally, the composition of patients changed, as the proportion of obstetrical patients, who remain in the hospital only a few days, increased and as several municipal hospitals—new ones as well as existing ones that were relocated from Welfare Island to populated neighborhoods—became active institutions with more rapid turnover of patients. Rate of Bed Turnover. T h e rate of turnover of general-care beds—a measure of the over-all effectiveness with which hospital beds are used—increased five times as rapidly in the 1940s as in the 1950s. T h e large increase in the first period reflects the confluence of two tendencies: increased occupancy and shortened patient stay. In the second interval the reduction in stay was partly offset by a decline in rate of occupancy. Proprietary hospitals had a large increase in the rate of bed turnover d u r i n g the period 1940-58, voluntary hospitals a mod-

PATTERNS OF HOSPITAL USE

45

erate increase, and municipal hospitals only a slight increase. T h e entire gain in the proprietary system was confined to the 1940s. I n the voluntary system a moderate gain occurred in the 1940s and a small one in the 1950s. In the municipal system the decline in rate of occupancy from a very high level served to offset a reduction in patient stay. DISTRIBUTION BY T Y P E O F

ACCOMMODATION

Reference has been made to the association between patients' pay status and type of hospital accommodation—private, semiprivate, and ward. For example, all public-charge patients are in the ward, whereas most insured patients are semiprivate. Both private and semiprivate patients in the hospital receive care from their own physicians; the difference between them is that the former occupies a single-bed room while the latter occupies a multiple-bed room (usually containing two or four beds). If the n u m b e r of beds in the multiple-bed room is large, say eight, the accommodation may be designated as private ward, a subclass u n d e r semiprivate. What is usually called the ward service is, more precisely, the general ward. More and more this designation has come to mean provision of medical care by one of the organized clinical departments of the hospital and the absence of a private physician rather than a large n u m b e r of beds in the patient's room. In newly built or modernized hospitals designed for the flexible use of facilities, there are few, if any, patients' rooms with more than four beds: rooms with two, three, or four beds may be used interchangeably for semiprivate and ward patients, as needed. All general-care patients in proprietary hospitals are either private or semiprivate, and all patients in municipal hospitals are general ward patients. ( T h e single exception in the municipal system is Sydenham Hospital, which was allowed to maintain its private and semiprivate services when acquired by the City of New York in 1949.) Voluntary hospitals have both private (including semiprivate) and ward patients. Private and Ward Services of Voluntary Hospitals. Most voluntary hospitals have all three types of accommodation. It is, therefore, necessary to distribute the facilities and services of the

BACKGROUND

46

voluntary system by type of accommodation as a prerequisite to preparing such a distribution for all hospitals. T a b l e 2.7 divides beds, discharges, and patient days in voluntary hospitals between private (including semiprivate) and ward services. Private and semiprivate patients are combined because (1) for many purposes, including the teaching role of hospitals, the important distinction is between them, on the one hand, and ward patients, on the other; (2) they must ultimately be combined in any analysis that includes proprietary hospitals in New York City, since most of the latter do not report separate statistics for private and semiprivate patients; and (3) the presentation and analysis of data are facilitated. Table

2.7. G E N E R A L - C A R E F A C I L I T I E S AND S E R V I C E S IN V O L U N T A R Y H O S P I T A L S BY T Y P E O F A C C O M M O D A T I O N , N E W Y O R K C I T Y , 1940, 1950, A N D 1958 1940

Facility or Service Bed complement All accommodations Private and semiprivate Ward Discharges All accommodations Private and semiprivate Ward Patient days All accommodations Private and semiprivate Ward

1950

1958

Number*

Percent

Number*

Percent

Number*

Percent

19,005 8,001 11,004

100.0 42.1 57.8

19,180 9,958 9,222

100.0 52.0 48.0

21£20 13,004 8,216

100.0 61.3 38.7

422 168 254

100.0 39.8 60.2

520 309 211

100.0 59.5 40.5

612 422 190

100.0 69.0 31.0

5,070 1,918 3,152

100.0 37.8 62.2

5,411 2,942 2,469

100.0 54.4 45.6

6,102 3,851 2,251

100.0 63.1 36.9

• In thousands, except for beds.

SOURCE: See T a b l e 2.5.

Between 1940 and 1958 general-care ward beds in voluntary hospitals declined by 2,800, whereas the n u m b e r of private and semiprivate beds increased by 5,000. T h e increase in private and semiprivate beds in voluntary hospitals was achieved in part by expanding plant by 2,200 beds and in part by transferring ward facilities to semiprivate use (with or without physical conversion). Private beds declined by 400 between 1940 and 1958, and private ward beds (classified under semiprivate) declined by 800.* Only semiprivate beds increased—by 6,200.

P A T T E R N S OF H O S P I T A L USE

47

T h e ward service of voluntary hospitals declined in discharges and patient days as well as in beds. At the same time, total general-care discharges and patient days in the voluntary system increased, so that the gains of the private (including semiprivate) service must have exceeded the losses of the ward service. T h e relative importance of the ward has, therefore, declined. T h e greatest decline has occurred in the proportion of ward to total discharges and the smallest in the proportion of ward to total beds, with the proportion of ward to total patient days in between. These shifts signify certain changes in the measures of hospital use, and these can be examined directly. Table

2.8. C O M P U T E D M E A S U R E S O F H O S P I T A L U S E I N G E N E R A L C A R E F A C I L I T I E S O F V O L U N T A R Y H O S P I T A L S BY T Y P E OF A C C O M M O D A T I O N , N E W YORK CITY, 1940, 1950, A N D 1958

Measure

of Hospital

Use

R a t e of occupancy (percent) All a c c o m m o d a t i o n s Private and semiprivate Ward L e n g t h of stay (days) All a c c o m m o d a t i o n s Private and semiprivate Ward A n n u a l rate of bed turnover (ratio) All a c c o m m o d a t i o n s Private and semiprivate Ward

1940

mo

1958

73.0 65.7 78.5

77.4 81.0 73.5

78.8 81.1 75.0

12.0 11.4 12.5

10.4 9.5 11.7

10.0 9.1 11.8

22.1 21.0 23.0

27.1 31.0 22.9

28.8 32.5 23.1

SOURCE: T a b l e 2.7.

Whereas the rate of bed turnover in the private (including semiprivate) service rose strikingly in the 1940s and modestly in the 1950s, it remained unchanged in the ward in both periods. In the 1940s a reduction in average length of patient stay in the ward was offset by a decline in rate of occupancy, and in the 1950s a slight improvement in occupancy was offset by a small prolongation of stay. It will be recalled that the rate of bed turnover in municipal hospitals behaved in similar fashion, although the timing of the changes in rate of occupancy and length of stay differed. Computing Rates of Occupancy in Two Types of Accommodation. Since World War II the rate of occupancy in the private (including semiprivate) service of voluntary hospitals has consis-

48

BACKGROUND

tently exceeded t h a t in the ward. T h e rate of occupancy in the s e m i p r i v a t e service a l o n e is, however, higher t h a n shown in the table, a n d t h a t in the p r i v a t e service is m u c h lower. I n 1958 the rates of occupancy in the private, semiprivate, a n d w a r d generalcare services were, respectively, 68, 85, a n d 75 percent. M a n y v o l u n t a r y hospitals r e p o r t a rate of occupancy in the h i g h 80s or 90s for t h e i r semiprivate service, a n d in the 60s or low 70s f o r their ward. At first glance it would seem that such hospitals m u s t have large n u m b e r s of vacant ward beds. I n fact, this is t r u e only in hospitals in which semiprivate a n d ward facilities are segregated a n d n o t used interchangeably. It is n o t t r u e in a hospital w h e r e a p a t i e n t applying for a semiprivate b e d is adm i t t e d to the ward in t h e absence of a vacant semiprivate bed. A l t h o u g h physically located in the ward, such a patient, who is u n d e r the care of his o w n physician, is classified as semiprivate. U n d e r this p r o c e d u r e the rate of occupancy of the semiprivate service is overstated a n d that of the ward u n d e r s t a t e d . T h e s i t u a t i o n described above is particularly c o m m o n in hospitals w h i c h r e p o r t services for private ward patients b u t do n o t designate any private ward beds. In 1957 a special analysis of t h e H o s p i t a l C o u n c i l ' s inventory data f o u n d that 82,000 private ward p a t i e n t days (equivalent to an average daily census of 224) were r e p o r t e d by six v o l u n t a r y hospitals that r e p o r t e d n o private w a r d beds. T h e s e hospitals c o m p u t e d rates of occupancy of 54 p e r c e n t in the w a r d a n d of 101 percent in semiprivate accommodations. W h e n the physical location of patients was taken into account, the result was a rise in ward rate of occupancy to 75 percent a n d a r e d u c t i o n in semiprivate occupancy to 80 percent. For hospitals t h a t use t h e i r beds flexibly for b o t h semiprivate a n d ward p a t i e n t s t h e r e are n o firm bases on which to c o m p u t e the rate of occupancy of each type of a c c o m m o d a t i o n . R e p o r t e d rates of occupancy s h o u l d be viewed with c a u t i o n . It may be sensible to c o m p u t e a r a t e of occupancy for all m u l t i p l e - b e d rooms c o m b i n e d , r a t h e r t h a n separately for semiprivate a n d ward accommodations. Trends in Private and Ward Services. It is n o w possible to analyze trends in private (including semiprivate) a n d w a r d facilities and services f o r general-care patients in all hospitals, before e x a m i n i n g the respective roles of the three hospital systems.

49

P A T T E R N S O F H O S P I T A L USE Table

2.9. G E N E R A L - C A R E F A C I L I T I E S A N D S E R V I C E S IN A L L HOSPITALS BY T Y P E OF A C C O M M O D A T I O N , N E W Y O R K C I T Y , 1940, 1950, A N D 1958 1940

Facility or Service Bed complement All accommodations Private and semiprivate Ward Discharges All accommodations Private and semiprivate Ward Patient days All accommodations Private and semiprivate Ward

1950

1958

Number•

Percent

Number•

Percent

Number•

Percent

3 2 ¿42 11,300 21,242

100.0 34.7 65.3

32J84 13,619 18,965

100.0 41.8 58.2

35,670 17,270 18,400

100.0 48.4 51.6

707 243 464

100.0 34.4 65.6

870 452 418

100.0 52.0 48.0

993 589 404

100.0 59.4 40.6

9J87 2,597 6,790

100.0 27.7 72.3

9,785 3,895 5,890

100.0 39.8 60.2

10,217 5,006 5,211

100.0 49.0 51.0

• In thousands, except for beds. SOURCE: See T a b l e 2.5.

In each item—beds, discharges, and patient days—the ward service has declined, and the private (including semiprivate) service has gained by an even greater amount. T h e proportion of ward to total general-care facilities and services has, therefore, declined. Notwithstanding, general-care ward patients, who constitute two fifths of all discharges in New York City, still receive more than one half of patient days. Some of the factors underlying this relatively high use of the ward in New York City are explored in Chapter 4. Since the proportion of ward to total has declined much faster for discharges than for beds, the rate of bed turnover in ward facilities has lagged behind that in the private (including semiprivate) service. Indeed, the computed measures show no change for the former, compared with a large increase for the latter. Rate of Bed Accommodation

Turnover

1940

1958

Difference

Private and semiprivate

21.5

34.1

+ 12.5

Ward

21.8

21.7

-

0.1

Trends in Private Service by Hospital Ownership. T a b l e 2.10 shows the respective roles of the three hospital systems in caring

50

BACKGROUND

for p r i v a t e ( i n c l u d i n g semiprivate) patients in 1940, 1950, a n d 1958. T h e role of m u n i c i p a l hospitals is negligible, b e i n g l i m i t e d to S y d e n h a m H o s p i t a l . Table

2.10. P R I V A T E ( I N C L U D I N G S E M I P R I V A T E ) G E N E R A L - C A R E F A C I L I T I E S A N D SERVICES BY H O S P I T A L O W N E R S H I P , N E W Y O R K C I T Y , 1940, 1950, A N D 1958

1940 Facility or Number* Percent Service Bed c o m p l e m e n t All hospitals 11J00 100.0 Voluntary 8,001 70.8 Municipal 0 0 Proprietary 3,299 29.2 Discharges All hospitals 243 100.0 Voluntary 168 69.2 Municipal 0 0 Proprietary 75 30.8 Patient days All hospitals 100.0 2,597 Voluntary 73.8 1,918 Municipal 0 0 Proprietary 679 26.2

1958

1950 Number•

Percent

Number*

Percent

13,619 9,958 73 3,588

100.0 73.1 0.5 26.4

17 ¿270 13,004 61 4,205

100.0 75.4 0.3 24.3

452 309 2 141

100.0 68.5 0.4 31.1

589 422 2 165

100.0 71.6 0.3 28.1

3,895 2,942 16 937

100.0 75.6 0.4 24.0

5,006 3,851 16 1,139

100.0 76.9 0.3 22.8

• In thousands, except for beds.

SOURCE: See T a b l e 2.5.

V o l u n t a r y hospitals have h a d a rising share of private (inc l u d i n g semiprivate) beds, discharges, and patient days. A l t h o u g h p r o p r i e t a r y hospitals have experienced sizable growth in n u m e r ical terms, t h e i r rate of expansion has been below that of the private service of v o l u n t a r y hospitals. P r o p r i e t a r y hospitals have a higher p r o p o r t i o n of discharges than of p a t i e n t days. T h i s is consistent with their below-average p a t i e n t stay. As previously shown, length of stay in p r o p r i e t a r y hospitals is 7 days, c o m p a r e d with 9 days in the private ( i n c l u d i n g semiprivate) service of v o l u n t a r y hospitals. R a t e of occupancy in p r o p r i e t a r y hospitals is 74 percent, compared with a r e p o r t e d rate of 81 percent in the private ( i n c l u d i n g semiprivate) service of v o l u n t a r y hospitals. Trends in Ward Service by Hospital Ownership. T a b l e 2.11 shows the roles of v o l u n t a r y a n d m u n i c i p a l hospitals in caring for ward patients in 1940, 1950, a n d 1958.

51

P A T T E R N S OF H O S P I T A L USE Table

2.11. W A R D GENERAL-CARE FACILITIES A N D SERVICES BY H O S P I T A L O W N E R S H I P , N E W YORK CITY, 1940, 1950, A N D 1958

1940 Facility or Number• Percent Service Bed complement All hospitals 21242 100.0 Voluntary 11,004 51.8 Municipal 10,238 48.2 Discharges All hospitals 464 100.0 Voluntary 254 54.6 Municipal 210 45.4 Patient days All hospitals 6,790 100.0 Voluntary 46.5 3,152 Municipal 3,638 53.5

1958

1950 Number•

Percent

Number*

Percent

18J)65 9,222 9,743

100.0 48.6 51.6

18,400 8,216 10,184

100.0 44.6 55.4

418 211 207

100.0 50.4 49.6

404 190 214

100.0 47.1 52.9

5,890 2,469 3,421

100.0 42.0 58.0

5211 2,251 2,960

100.0 43.2 56.8

• In thousands, except for beds. See Table 2.5.

SOURCE:

T h e ward service in voluntary hospitals has definitely declined, whatever the criterion. In municipal hospitals ward beds and ward discharges have each increased slightly, whereas patient days have declined appreciably. As a result, the share of voluntary hospitals in the general-care ward service has declined and that of municipal hospitals increased. In 1940 municipal hospitals had more than one half of all ward patient days, b u t less than one half of beds and of discharges; by 1950 they also had more than one half of ward beds; and by 1958 they had, in addition, more than one half of all ward discharges. Between 1940 and 1958 the proportions of ward beds, discharges, and patient days held by each system converged. As a result, the differences between the two hospital systems in ward rate of occupancy, length of stay, and rate of bed turnover have narrowed. 1940 Hospital (Computed

Use measure)

Rate of occupancy (percent) Length of stay (days) Turnover rate (ratio)

Voluntary Ward 78.5 12.5 23.0

Municipal 97.4 17.3 20.5

1958 Difference + 18.9 + 4.8 - 2.5

Voluntary Municipal Ward 75.0 11.8 23.1

79.8 13.8 21.1

Difference + 4.8 + 2.0 -2.0

BACKGROUND

52

It may be that o n e of the factors leading to convergence is the increased p r o p o r t i o n of public-charge patients in the wards of voluntary hospitals (see C h a p t e r 14). Services for Ambulatory

Patients and in the

Home

T r a d i t i o n a l l y , a short-term voluntary or municipal hospital in N e w York City has operated an outpatient d e p a r t m e n t for the sick poor. A m o r e recent development—a postwar p h e n o m e n o n in its present size—is the emergency d e p a r t m e n t , which f r e q u e n t l y started in the o u t p a t i e n t d e p a r t m e n t and in some instances still cannot be separated f r o m it. Organized home-care programs radiating f r o m hospitals have old antecedents b u t in New York City they represent a postwar revival and growth. Also discussed in this section are the emergency a m b u l a n c e service and, more briefly, services to private a m b u l a t o r y patients, including those f u r n i s h e d by diagnostic clinics in hospitals. OUTPATIENT DEPARTMENT

T h e n u m b e r of visits to o u t p a t i e n t d e p a r t m e n t s of voluntary and m u n i c i p a l hospitals in N e w York City has fluctuated considerably. Data for selected years are shown in T a b l e 2.12. T h e volume of o u t p a t i e n t d e p a r t m e n t visits in both hospital systems in 1958 was almost the same as in 1930 or 1950 b u t substantially below that in 1940—at t h e end of a decade of depression. Compared with m o r e recent years, the volume of visits in 1958 was the same as in 1951 b u t 400,000 higher than in 1955. Table 2.12. O U T P A T I E N T D E P A R T M E N T VISITS BY H O S P I T A L OWNERSHIP, NEW YORK CITY, 1925-58 Number Year 1925 1930 1940 1950 1958

Total 3,596 5,623 7,720 5,577 5,446

(in Thousands)

Voluntary 2,798 4,275 4,805 3,436 2,801

Municipal 798 1,348 2,915 2,141 2,644

Percent Voluntary 77.8 76.0 62.2 61.6 51.4

Municipal 22.2 24.0 37.8 38.4 48.6

SOURCE: For 1925, 1930, and 1940-United Hospital Fund of New York, Out-Patient Service Statistics Relating to Hospitals and Independent Dispensaries in New York City (New York, 1926-41); for 1950 and 1958-Hospital Council of Greater New York, annual inventory.

P A T T E R N S OF HOSPITAL USE

53

In voluntary hospitals the volume of visits in 1958 was the same as in 1925 but well below the volume in the intervening years shown in the table. Conversely, the 1958 volume of visits in municipal hospitals was four times that in 1925, double that in 1930, and only 10 percent below that in 1940. All of the increase in total visits between 1955 and 1958 occurred in municipal hospitals. T h e postwar tendency toward more visits in municipal hospitals and fewer visits in voluntary hospitals was arrested in 1959, when the effects of the new payment policy by government first became felt. In September, 1958, the City of New York undertook to pay voluntary hospitals $5 per outpatient department visit by recipients of public assistance, provided certain criteria were met. At the same time, the State of New York agreed to reimburse the City $2.50 per visit by recipients of public assistance in municipal and voluntary hospitals. Visits in outpatient departments of voluntary hospitals have declined from three fourths of the total in 1930 to five eighths in 1940 and 1950 and to approximately one half in 1958. Future trends in outpatient department services will depend on a n u m b e r of factors. One is the growth of health insurance for medical services outside the hospital. It is perhaps surprising in the face of both rising per capita income and health insurance enrollment in New York City that the volume of outpatient department visits rose in the second half of the 1950s. T h i s was accompanied by an even more rapid increase in emergency department visits (see below). T h e r e have been no compensatory declines in similar or possibly substitute services. Visits by ambulatory patients in Department of Health clinics and independent dispensaries u n d e r voluntary control amounted to 2.5 million in 1958, the same as in 1950. Here, too, the tendency in recent years has been for the volume of services in governmental clinics to increase and in voluntary clinics to decline. It is fair to note that d u r i n g the postwar period the n u m b e r of clinic visits for dental care, for which there is little voluntary health insurance coverage, has increased faster than for any other type of service. Between 1947 and 1956 visits to dental clinics of

54

BACKGROUND

hospitals, Health Department, and independent dispensaries rose by more than 400,000. D u r i n g this period there was also a large increase in visits to pediatric clinics—more than 300,000. T h e largest single reduction—more than 400,000 visits—occurred in syphilis clinics, as a result of changes in medical practice. 9 Examination of changes in the n u m b e r of visits to the outpatient department and emergency department of hospitals operting both services fails to reveal a shift f r o m the former to the latter. T h e relationship between the two types of service is complex, and u n d e r certain conditions one department may be expected to gain simultaneously with the other. U n d e r other conditions one gains at the expense of the other. 1 0 Analysis of data for individual voluntary hospitals shows that there is an inverse relationship between changes in average income per visit and in n u m b e r of visits to outpatient departments. In general, the larger the increase in income, the larger is the reduction in volume of visits. In specific instances, however, increases in outpatient department charges, if unaccompanied by other steps, may serve to raise the proportion of free visits, rather than to reduce the total volume. T h e greatest reductions in outpatient department load have occurred in clinics in which rigid adherence to district lines or to formal eligibility criteria was introduced or became more firmly enforced. T h e decline in outpatient visits in voluntary hospitals is consistent with the decline in their ward services. In 1940, when voluntary hospitals had 55 percent of all general-care ward patients, they had 62 percent of all outpatient department visits. In 1950, the voluntary hospitals' proportions were 50 and 62 percent, respectively, and by 1958, 47 and 51 percent, respectively. However, in individual hospitals there is no u n i f o r m relationship between the volumes of the two services. As reported by one survey, the proportion of ward patients referred by, or originating in, the outpatient department varies greatly, from 15 percent in one hospital to 65 percent or more in another. 1 1 Some of the variation has to do with differences in the diagnostic composition of referred patients, but much of it is not yet understood. Municipal hospitals in New York City do not charge for outpatient department services. For several years a proposal has been

PATTERNS OF HOSPITAL USE

55

pending to charge outpatients one dollar a visit, with suitable adjustment downward for persons who cannot afford the fee. T h e major stated objective of the proposal is to reduce overcrowding in the outpatient departments of municipal hospitals and thereby permit available physicians' time to be concentrated on fewer patients. T h i s is expected to improve the quality of care. In support of the proposal it is argued that persons who do not require the services of a physician should not be encouraged to come to the outpatient department, add to its crowded condition, and consume scarce services. It is also pointed out that inpatients who can afford it are required to pay, so that there is no reason why the same r e q u i r e m e n t should not in principle apply to ambulatory patients. An arrangement to reduce or waive the fee for those unable to pay would provide protection against denial of needed services. 12 In opposition it has been argued that a charge may operate indiscriminately, effecting a reduction in visits by patients who need the services of a physician as well as by patients who do not. It is also observed that certain patients, particularly among the aged, do not like a means test and prefer to forego necessary medical care rather than submit to one. Similarly, it has been argued that other groups of dependents, such as children and pregnant women, may be deprived of needed services if a charge is levied. Finally, it has been suggested that direct efforts to improve the quality of care—an objective that enlists general support —may prove to be more fruitful. EMERGENCY

DEPARTMENT

T h e year 1948 is the first for which data on hospital emergency departments could be obtained for both voluntary and municipal hospitals. Because the volume of services rendered by proprietary hospitals is so small—10,500 visits in 1958—it has not been compiled routinely and is omitted from T a b l e 2.13. Considerable variation exists among hospitals in the role assigned to the emergency department and in the manner of counting its services. O n e large teaching hospital in New York City still does not report any emergency department visits b u t assigns them all to the outpatient department. Although detailed comparisons

56 Table

BACKGROUND 2.13. E M E R G E N C Y D E P A R T M E N T V I S I T S BY H O S P I T A L O W N E R S H I P , N E W Y O R K CITY, 1948, 1950, A N D 1958 Number

Year

Total

1948 1950 1958

880 1,052 1,811

(in Thousands)

Voluntary

Municipal

Percent Voluntary

Municipal

539 341 61.3 38.7 579 473 55.0 45.0 842 969 46.5 53.5 SOURCE: For 1948—New York State Department of Social Welfare, unpublished information, and United Hospital Fund of New York, unpublished information; for 1950 and 1958—Hospital Council of Greater New York, annual inventory.

may b e unwise w i t h o u t t h o r o u g h study of the programs involved, t h e r e is n o d o u b t that the s h a r p u p w a r d t r e n d in the r e p o r t e d figures on visits to hospital emergency d e p a r t m e n t s is real. W i t h i n a decade the v o l u m e of emergency d e p a r t m e n t visits in N e w York City has d o u b l e d . T h e a n n u a l rate of increase for the decade was 7 percent, b u t in the most recent f o u r years it averaged 10 percent. Emergency d e p a r t m e n t visits increased in b o t h hospital systems. Between 1948 a n d 1958 they increased by m o r e than one half in voluntary hospitals and increased m o r e t h a n threefold in m u n i c i p a l hospitals. As a result, the m u n i c i p a l system's share of the total has increased f r o m 39 to 54 percent, exceeding 50 percent for the first time in 1957. T h e increase in emergency d e p a r t m e n t visits is a significant d e v e l o p m e n t in the use of hospitals after W o r l d W a r II. I n d e e d , the rate of expansion in other parts of the c o u n t r y has f r e q u e n t l y exceeded that in N e w York City. In an analysis of available data, the Hospital Council f o u n d that trends in injuries, changes in the use of the emergency a m b u l a n c e service, shifts of patients f r o m the o u t p a t i e n t d e p a r t m e n t , and increases in the n u m b e r of visits paid for by Blue Cross cannot account for m o r e than a small fraction of the increase in emergency d e p a r t m e n t visits in N e w York City. 1 3 O t h e r factors have been offered in explanation, i n c l u d i n g the relative unavailability of physicians at certain hours of the day a n d on certain days of the week, increasing acceptance of the hospital as a c o m m u n i t y health center, and changes in the ethnic composition of the city's population. It would be worth while to ascertain the relative i m p o r t a n c e of these factors in N e w York

57

PATTERNS OF HOSPITAL USE

City, as well as of others that m i g h t emerge in the course of study. T h e factors responsible for the increased use of hospital emergency d e p a r t m e n t s influence the characteristics of patients served a n d their needs for services. These, in t u r n , are the p r o p e r bases for staffing a n d e q u i p p i n g hospital emergency d e p a r t m e n t s . SERVICES FOR PRIVATE A M B U L A T O R Y

PATIENTS

T h e Hospital Council's hospital inventory for the year 1958 shows 222,000 visits by private a m b u l a t o r y patients to the 37 voluntary hospitals that r e p o r t e d such visits. Projected to the 62 voluntary hospitals that report offering services to private amb u l a t o r y patients, the resulting estimate is 350,000 to 425,000 visits by 200,000 persons. In addition to being incomplete, the r e p o r t e d figures are p r o b a b l y n o t very reliable, in view of the evident lack of u n i f o r m criteria a m o n g hospitals in a n s w e r i n g this question. T h e U n i t e d Hospital F u n d reports an increase of 30 percent between 1955 and 1959 in the n u m b e r of private a m b u l a t o r y patients cared for in its m e m b e r hospitals. A large p a r t of the increase may be a t t r i b u t e d to more complete reporting. Most of the services r e p o r t e d are diagnostic x-ray and laboratory tests. In its a n n u a l inventory the Hospital Council also i n q u i r e s a b o u t special diagnostic centers offering a medical e x a m i n a t i o n and complete evaluation. U n d e r this p r o g r a m physicians on the a t t e n d i n g staff make use of the hospital's diagnostic tools a n d e q u i p m e n t . 1 4 At the end of 1958, six voluntary hospitals r e p o r t e d diagnostic centers. T h e year 1958 m a r k e d the closing of the p i o n e e r diagnostic center in New York City, namely, the M o u n t Sinai Hospital's consultation service for persons of m o d e r a t e means, w h i c h was established in 1931. T h i s service accepted patients only on referral by physicians and assured their r e t u r n to the latter f o r treatment. T h e reason for closing the clinic was insufficient d e m a n d for this service by physicians, relative to that for other hospital services. A m o n g the factors advanced as accounting for the insufficient d e m a n d were the following: the growth of u n i o n h e a l t h centers and their concentration on diagnostic services (see Chapter 1); the provision of similar services by some of the centers

58

BACKGROUND

affiliated with the Health Insurance Plan of Greater New York; and the rise in M o u n t Sinai's flat fee from $35 to $80 in the course of a decade. It was observed at the time that the Hospital's cancer detection clinic, which does not require the patient's referral by a physician, was gaining in popularity while the diagnostic clinic was losing. 18 Also noteworthy is termination of community service d u r i n g 1959 at the diagnostic clinic operated by the Department of Health. Eight municipal general hospitals have diagnostic clinics. These do not admit patients referred by physicians b u t serve in effect as coordinating mechanisms for screening and evaluating patients already accepted by the outpatient department. EMERGENCY AMBULANCE SERVICE

T h e emergency ambulance service may be viewed as a transportation service, first-aid medical service, and means of distributing inpatients among participating hospitals. It is obviously important in the first two roles, but its third role also deserves attention. T h e ability of a hospital to redirect and transfer to another hospital patients brought by its own ambulance permits the former to be selective in admitting patients and leads to some of the prevailing differences among hospitals and hospital systems in patient composition. T a b l e 2.14 shows the n u m b e r of emergency ambulance service calls in voluntary and municipal hospitals since 1930. Proprietary hospitals do not participate in this service, which is operated in municipal hospitals or subsidized by the City of New York in voluntary hospitals. Table

2.14. E M E R G E N C Y A M B U L A N C E C A L L S BY H O S P I T A L O W N E R S H I P , N E W YORK CITY, 1930, 1940, 1950, A N D 1958 Xumber

Year 1930 1940 1950 1958

Total 193 494 344 346

(in Thousands)

Voluntary 109 293 178 143

Percent

Municipal

Voluntary

84 201 166 203

New York City Department of Hospitals, Number Ambulance Calls (New York, 1931-59; mimeographed).

SOURCE:

56.5 59.3 51.8 41.3

Municipal 43.5 40.7 48.2 58.7

and Disposition

of

PATTERNS OF HOSPITAL USE

59

T h e total n u m b e r of emergency ambulance calls in 1958 was the same as in 1950, but the municipal system's share increased during the eight-year interval, whereas that of the voluntary system declined. T h e rise in the proportion of calls made by municipal hospitals is even greater if 1940 is taken as the base year. Although the n u m b e r of calls in municipal hospitals was the same in 1958 as in 1940, there had been a sharp decline during World War II and an almost uninterrupted rise afterward. In voluntary hospitals the n u m b e r of calls declined by one half between 1940 and 1958, as a sharp drop during World W a r II was followed first by a small rise and then by another decline. Today 26 of 71 voluntary general hospitals in New York City operate an emergency ambulance service, while 14 of 15 municipal general hospitals do so. During the 1950s eight voluntary hospitals, all in Brooklyn, relinquished their emergency ambulance service whereas only two new voluntary hospitals, one in the Bronx and one in Queens, established it. Since the assigned emergency ambulance zones in the aggregate cover the total area of New York City, without overlap and without gaps, hospitals that continue the service have had to assume responsibility for additional territory and sometimes for changed territory. T h e fact that an ambulance district radiates from a hospital that agrees to participate in the service means that, regardless of the initial plan, after some hospitals join and others abandon the service, districts are inevitably unequal in size and different in shape. Underlying the decisions by some voluntary hospitals to abandon the emergency ambulance service were a n u m b e r of factors, long r u n and immediate. Chief among the long-run factors was recognition that the emergency ambulance service is properly a transportation service, not a medical service. 18 Some hospitals also believed that the emergency ambulance service is a liability to a hospital's public relations; this adverse effect became aggravated with the removal of physicians from routine ambulance duty. An immediate factor was the large financial loss incurred prior to the sizable increase in the City's payment per ambulance in 1953. Only hospitals that participate in the emergency ambulance service ordinarily care for patients picked u p by ambulance. T h e r e are two circumstances under which a hospital that does not

BACKGROUND

60

participate may receive a m b u l a n c e

patients:

(1) b y s p e c i a l

ar-

r a n g e m e n t w i t h a p a r t i c i p a t i n g h o s p i t a l f o r t h e r e f e r r a l of c e r t a i n types o f p a t i e n t , u s u a l l y to c o m p l e t e its t e a c h i n g p r o g r a m ;

and

(2) at t h e r e q u e s t of t h e i n d i v i d u a l p a t i e n t . T h e r e s u l t is that m a n y v o l u n t a r y h o s p i t a l s , i n c l u d i n g s e v e r a l of t h e m a j o r t e a c h i n g centers, d o not care for emergency a m b u l a n c e patients. W h e r e a s m u n i c i p a l hospitals keep most of their

ambulance

patients who require hospital admission, voluntary hospital ambul a n c e s t a k e m a n y of t h e i r p a t i e n t s to o t h e r h o s p i t a l s , e s p e c i a l l y to m u n i c i p a l h o s p i t a l s . P a t i e n t s a r e m o r e likely to b e r e d i r e c t e d to ano t h e r h o s p i t a l a t n i g h t t h a n d u r i n g the d a y , i n d i c a t i n g that s o m e h o s p i t a l s a r e n o t s o well p r e p a r e d to c a r e f o r e m e r g e n c y i n p a t i e n t s a t n i g h t . R e d i r e c t i o n of p a t i e n t s to o t h e r h o s p i t a l s is in c o m p l i ance with a m b u l a n c e rules and regulations.17 A d e c a d e a g o the H o s p i t a l C o u n c i l d i s c u s s e d t h e p r a c t i c e s of v o l u n t a r y h o s p i t a l s in r e d i r e c t i n g a m b u l a n c e p a t i e n t s in

these

words: Part of this movement [of patients] is accounted for by the policy of voluntary teaching hospitals to select for admission certain types of cases. T h e low reimbursement rate traditionally p a i d by the City to the voluntary hospitals for the care of p u b l i c charges has undoubtedly contributed to this tendency. T h e most i m p o r t a n t factor, however, is the fact that the voluntary hospitals with emergency a m b u l a n c e service have only one third the ward capacity of the m u n i c i p a l hospitals in which to a c c o m m o d a t e a m b u l a n c e patients. 1 8 T o d a y t h e c o r r e s p o n d i n g r a t i o is o n e f o u r t h , a l t h o u g h v o l u n t a r y h o s p i t a l a m b u l a n c e s r e s p o n d to m o r e t h a n two fifths of all calls. A s e m e r g e n c y d e p a r t m e n t s of h o s p i t a l s c o n t i n u e to e x p a n d , it may b e c o m e m o r e practicable for hospitals that d o not participate in the e m e r g e n c y a m b u l a n c e s e r v i c e to j o i n in c a r i n g f o r p a t i e n t s p i c k e d u p b y a m b u l a n c e . It m a y b e d e s i r a b l e to c o n s i d e r d e l i n e a t ing a m b u l a n c e districts a r o u n d receiving hospitals rather

than

a r o u n d the s m a l l e r n u m b e r of h o s p i t a l s t h a t o p e r a t e a m b u l a n c e s . ORGANIZED H O M E

CARE

I n 1947 M o n t e f i o r e H o s p i t a l i n s t i t u t e d its p r o g r a m of h o m e care, b y w h i c h t h e h o s p i t a l o r g a n i z a t i o n m a k e s a v a i l a b l e c e r t a i n h o s p i t a l p e r s o n n e l , f a c i l i t i e s , a n d s e r v i c e s to the p a t i e n t at h o m e .

61

P A T T E R N S OF H O S P I T A L USE

In many instances the result is care that is more appropriate to the patient's needs than can be provided in the hospital, as well as cheaper care. T h e attitude of the patient and his family toward home care is an important factor in the program's success. Among voluntary hospitals in New York City home care has failed to secure a large measure of acceptance. Only four such programs are reported, two of which are small ones financed by a special fund for cancer patients and one is primarily designed for teaching medical students. In 1949 the New York City Department of Hospitals established home care in its hospitals, in order to provide more appropriate care to the sick poor and, more urgently, to help relieve severe overcrowding of beds. Today every municipal general hospital b u t one and both municipal hospitals for the chronically ill have home care programs. Since the Hospital Council's comprehensive study of home care was completed in 1956,19 two programs operated by municipal tuberculosis hospitals have been terminated. O n e ceased when the parent hospital closed. In the other the conclusion was reached that under modern methods of treatment a tuberculosis patient who has been discharged from the hospital can travel to an outpatient department or clinic for f u r t h e r medical care. T h e year 1949 was the first in which both hospital systems operated organized home-care programs. T h e volume of services rendered, as expressed in patient days, has been stable in recent years. Table

2.15. P A T I E N T DAYS R E P O R T E D F O R P A T I E N T S O N H O M E CARE BY H O S P I T A L O W N E R S H I P , N E W YORK CITY, 1949, 1950, A N D 1958 Number

(in

Year

Total

Voluntary

1949 1950 1958

216 531 817

27 34 43

Thousands) Municipal 189 497 775

Percent Voluntary 12.5 6.4 5.3

Municipal 87.5 93.6 94.7

SOURCE: H o s p i t a l C o u n c i l of G r e a t e r New York, a n n u a l inventory.

Comparison of Cost. Average daily census on home care increased from 590 in 1949 to 1,450 in 1950 and 2,240 in 1958. Although it cannot be assumed that all these patients would oc-

62

BACKGROUND

cupy hospital beds in the absence of a home-care program, some would. In New York City the saving in hospital beds attributable to home care has been estimated at roughly one fourth of the n u m b e r of patients on home care, 20 after allowance for the retransfer of patients from home to hospital for medical reasons. For the year 1958 a saving of 660 beds is thus indicated, on the assumption that a rate of occupancy of 85 percent could have been attained. In New York City most of the saving—95 percent—is achieved in municipal hospitals. Higher estimates of bed saving have been made. If as many as three fourths of the patients on home care were to be hospitalized in the absence of a home-care program, 2 1 the saving in New York City would a m o u n t to 2,000 beds. In comparing the cost of caring for a patient on home care and in the hospital, the estimate of bed saving is important from the standpoint of both capital expenditures and operating expenditures. Existing knowledge is insufficient to permit a choice between the two extreme fractions cited above. It is recognized, however, that a valid comparison of cost would take account of the additional expenditures incurred by the patient's family due to his presence at home. D u r i n g interviews with hospital administrators the staff of the Hospital Council learned that some voluntary hospitals consider lack of money as the chief obstacle to establishing a home-care program. Even if this program were accepted as an economical device from the community's standpoint, it would still entail expenditures to the individual hospital for which there are no obvious sources of income. Broadening of Program. Several administrators also reported difficulty in finding in their hospitals a sufficient n u m b e r of patients likely to benefit from home care. T h e y are more pessimistic than the findings of surveys cited in the Hospital Council's study of home care 22 or the findings of more recent studies by Associated Hospital Service of New York (AHS). 23 Currently in negotiation between A H S and some of its member hospitals is a program of early hospital discharge of Blue Cross subscribers, with subsequent visits to patients' homes by Visiting Nurse Service. A H S will pay the bill. A pilot project

PATTERNS OF HOSPITAL USE

65

found that this program could save m o n e y for B l u e Cross, and r e c e n t State legislation authorized its i n c o r p o r a t i o n as a benefit in subscribers' contracts. S i n c e most A H S subscribers are private or semiprivate patients and all existing home-care programs in New Y o r k City are for ward patients, the new p r o g r a m represents a significant d e p a r t u r e

from

traditional

practice.

It may be

ex-

pected that patients will b e younger than in existing home-care programs, that a significant p r o p o r t i o n of them will b e short-term, convalescent patients, and that the individual private physician will m a k e some of the decisions that have h i t h e r t o b e e n made by the h o m e - c a r e team. T h e organization of home-care services will, therefore, r e q u i r e a d a p t a t i o n to the needs of a new g r o u p of patients. Elsewhere some home-care programs have successfully served private and s e m i p r i v a t e patients. 2 4 It c a n n o t be assumed that hospitals have the necessary personnel r e q u i r e d to staff an organized home-care program.

The

Hospital C o u n c i l ' s study of programs f o u n d great variation

in

staffing a n d in f r e q u e n c y of h o m e visits by physicians, nurses, social workers, and physical therapists. T h e range of variation was wide even a m o n g hospitals in the m u n i c i p a l system. It may be that an e x t r a m u r a l p r o g r a m is m o r e v u l n e r a b l e to r e d u c t i o n in staff and d e t e r i o r a t i o n in quality of care than a p r o g r a m operated within the confines of a hospital. All of the e x i s t i n g home-care programs in N e w Y o r k

City,

voluntary and m u n i c i p a l , care for patients discharged f r o m the hospital. H o m e care can b e provided to persons prior to, o r without, their admission to the hospital, if they are properly evaluated. O n e voluntary hospital for long-term patients in N e w Y o r k City has recently u n d e r t a k e n to d e m o n s t r a t e this on a pilot basis, with provision for research a n d evaluation. Services

in Non-General-Care

Facilities

T h e data in T a b l e 2.4 pertain to all hospital facilities in N e w York City u n d e r voluntary, m u n i c i p a l , and proprietary ownership. Hospitals u n d e r federal and state ownership are e x c l u d e d . Although certain n u r s i n g - h o m e facilities are i n c l u d e d in the data, most are o m i t t e d . W h e n the data on general care facilities and services ( T a b l e 2.5) are s u b t r a c t e d f r o m the c o r r e s p o n d i n g

figures

BACKGROUND

64

in T a b l e 2.4, the differences represent figures for non-generalcare facilities ( T a b l e 2.16). T h e s e include facilities for patients with tuberculosis a n d m e n t a l illness and also for p a t i e n t s in reh a b i l i t a t i o n a n d in receipt of long-term care. T h e last is f u r t h e r s u b d i v i d e d b e t w e e n beds in hospitals for the chronically ill a n d n u r s i n g - h o m e beds. T h e data in T a b l e 2.4 include only those n u r s i n g - h o m e u n i t s that are integral parts of hospitals which a d m i t persons directly f r o m the c o m m u n i t y . Excluded, therefore, are n u r s i n g - h o m e facilities that are located separately, at homes for the aged, or at instit u t i o n s that offer hospital services only to their own inpatients. T h e e x c l u d e d facilities a n d their services are discussed in the last section of this chapter. Table

2.16. D I S T R I B U T I O N OF FACILITIES A N D SERVICES FOR N O N GENERAL-CARE P A T I E N T S BY H O S P I T A L O W N E R SHIP, N E W YORK CITY, 1940, 1950, A N D 1958

Facility or Service Bed complement All hospitals Voluntary Municipal Proprietary Discharges All hospitals Voluntary Municipal Proprietary Patient days All hospitals Voluntary Municipal Proprietary

1940 Number*

1958

1950 Percent

Number*

Percent

Number*

Percent

8,618 3,012 5,371 235

100.0 34.9 62.4 2.7

10^09 3,379 6,919 611

100.0 31.0 63.4 5.6

13,002 3,663 8,814 525

100.0 28.2 67.8 4.0

49 5 43 1

100.0 10.2 87.8 2.0

51 5 42 4

100.0 9.8 82.4 7.8

58 10 43 5

100.0 17.3 74.1 8.6

3,250 1,046 2,147 57

100.0 32.2 66.0 1.8

3,958 1,114 2,658 186

100.0 28.1 67.2 4.7

4219 1,248 2,820 151

100.0 29.6 66.8 3.6

• In thousands, except for beds. See Table 2.5.

SOURCE:

I n 1958 m u n i c i p a l hospitals r e p o r t e d two thirds of the beds a n d p a t i e n t days in non-general-care facilities, and v o l u n t a r y hospitals r e p o r t e d most of the r e m a i n i n g one third. T h e same year m u n i c i p a l hospitals r e p o r t e d three fourths of all discharges f r o m these facilities, a m a r k e d decline f r o m their share in 1940 and 1950. Since m u n i c i p a l hospitals have r e t a i n e d a constant propor-

P A T T E R N S OF H O S P I T A L

USE

65

tion of patient days, they must have experienced a prolongation of patient stay relative to voluntary and proprietary hospitals. Part of the prolongation is attributable to the development of public-home infirmary units in the municipal system. So far totals have been distributed by hospital ownership. It is helpful also to view the role of non-general-care facilities within each ownership group. T a b l e 2.17, therefore, shows the amounts in T a b l e 2.16 as percentages of the corresponding amounts in T a b l e 2.4. Table

2.17. P R O P O R T I O N O F F A C I L I T I E S A N D S E R V I C E S F O R NON-GENERAL CARE P A T I E N T S T O T O T A L BY H O S P I T A L O W N E R S H I P , N E W Y O R K C I T Y , 1940, 1950, A N D 1958

Facility or Service Bed complement All hospitals Voluntary Municipal Proprietary Discharges All hospitals Voluntary Municipal Proprietary Patient days All hospitals Voluntary Municipal Proprietary

Percent

of

Total

1940

1950

1958

20.6 13.7 34.4 6.7

25.1 15.0 41.3 14.6

26.7 14.8 46.3 11.1

6.5 1.2 17.0 1.3

5.5 1.0 16.8 2.8

5.5 1.6 16.6 2.9

25.7 17.1 37.1 7.9

28.8 17.1 43.6 16.5

29.3 17.0 48.6 11.7

SOURCE: T a b l e s 2.4 a n d 2.16.

Because non-general-care patients include a large n u m b e r of long-stay patients, they account for a much higher proportion of total patient days than of discharges—29 percent compared with 6 percent. In the municipal system the proportion of patient days by non-general-care patients has been rising and approached one half in 1958. In the voluntary system this proportion has remained constant, at 17 percent. In the proprietary system, it has fluctuated a great deal—between 8 and 16 percent—primarily because of changing arrangements in the care of patients with tuberculosis.

BACKGROUND

66

T h e proportions shown for beds are close to the corresponding proportions for patient days, but always lower. T h i s means that non-general-care facilities tend to operate at higher rates of occupancy than general-care facilities. Between 1940 and 1958 the entire increase in beds in the municipal system was assigned to non-general-care facilities. By Table

2.18. D I S T R I B U T I O N B E T W E E N G E N E R A L C A R E A N D O T H E R C A R E OF I N C R E A S E IN B E D C O M P L E M E N T , BY H O S P I T A L O W N E R S H I P , N E W Y O R K CITY, 1940-58 Percent

Number Hospital Ownership All hospitals Voluntary Municipal Proprietary

Total 7,512 2,866 3,450 1,196

General Care 3,128 2,215 7 906

Other 4 ¿84 651 3,443 290

General Care

Other

41.6 77.3 0.2 75.8

58.4 22.7 99.8 24.2

SOURCE: T a b l e s 2.5 a n d 2.16.

contrast, in the other two hospital systems between three fourths and four fifths of the increase in total beds was devoted to generalcare facilities and between one fifth and one fourth to nongeneral-care facilities. T h i s contrast is even more striking for patient days than for beds. In voluntary and proprietary hospitals non-general-care Table

2.19. D I S T R I B U T I O N B E T W E E N G E N E R A L C A R E A N D O T H E R C A R E OF I N C R E A S E IN P A T I E N T DAYS, BY H O S P I T A L O W N E R S H I P , N E W Y O R K CITY, 1940-58 Number

Hospital Ownership All hospitals Voluntary Municipal Proprietary SOURCE: T a b l e s 2 . 5 a n d

Total 1,799 1,234 11 554

(in Thousands)

Percent

General Care

Other

General Care

Other

830 1,032 -662 460

969 202 673 94

46.1 83.7 -6,019.0 83.0

53.9 16.3 6,119.0 17.0

2.16.

facilities accounted for one sixth of the increase in total patient days between 1940 and 1958. In municipal hospitals total patient days remained virtually unchanged, so that the increase in nongeneral-care facilities offset a substantial decline in general care.

67

P A T T E R N S OF H O S P I T A L USE

T h e non-general-care facilities of hospitals comprise a heterogeneous g r o u p . T a b l e 2.20 shows the d i s t r i b u t i o n of beds a n d services by type of program. As usual, the percentage d i s t r i b u t i o n Table

2.20. D I S T R I B U T I O N OF NON-GENERAL-CARE BEDS A N D SERVICES BY TYPE OF PROGRAM, N E W YORK CITY, 1958 Discharges

Beds Type of Program Total Psychiatry Tuberculosis Physical medicine and rehabilitation Hospital for chronically ill Nursing home or public-home infirmary

A'umber* 13,002 2,111 4,622

Patient

100.0 16.2 35.6

Number• 58 37 10

Percent 100.0 63.8 17.3

725

5.6

2

3,641

28.0

1,903

14.6

Percent

Number•

Days

4219 730 1,364

Percent 100.0 17.3 32.4

3.4

177

4.2

7

12.1

1,286

30.4

2

3.4

662

15.7

• In thousands, e x c e p t for beds. SOURCE: H o s p i t a l C o u n c i l of G r e a t e r New York, a n n u a l inventory.

of patient days is similar to that of beds, and the d i s t r i b u t i o n of discharges differs f r o m the other two. Only in physical m e d i c i n e and r e h a b i l i t a t i o n is the p r o p o r t i o n of discharges close to the p r o p o r t i o n of patient days. In psychiatry and in n u r s i n g - h o m e facilities the two percentages display the widest divergence, with the f o r m e r having the m u c h higher p r o p o r t i o n of discharges and the latter the higher p r o p o r t i o n of patient days. T h e s e relationships m e a n that a m o n g non-general-care patients psychiatric patients have t h e shortest d u r a t i o n of stay and nursing-home patients the longest. T r e n d s and developments will next be considered by type of program, as follows: (1) psychiatric facilities; (2) tuberculosis facilities; (3) long-term facilities—(a) rehabilitation, (b) hospitals for chronically ill, (c) n u r s i n g homes serving as integral parts of hospitals, (d) other types of n u r s i n g homes. Before this is done, it is a p p r o p r i a t e to i n t r o d u c e a brief analysis for one year of the dist r i b u t i o n of non-general-care facilities by type of a c c o m m o d a t i o n . In 1955 almost 94 percent of all such beds were assigned to the ward service a n d only 6 percent to private a n d semiprivate

BACKGROUND

68

services. In the municipal system all non-general-care beds were classified as ward, whereas in the proprietary system all such beds were classified as private or semiprivate, except for the tuberculosis unit in one hospital, which was used u n d e r a special arrangem e n t with the City of New York. In the voluntary system the proportion of ward beds to total varied by program, ranging from a low of 64 percent in psychiatry, to 80 percent in hospital beds for chronically ill, 94 percent in tuberculosis, and 100 percent in physical medicine and rehabilitation; 83 percent of the non-general-care beds in voluntary hospitals were assigned to the ward. In part the high proportion of ward care reflects the manner in which these programs are paid for, b u t in part it also reflects decisions to provide physicians' services through the clinical departments of hospitals rather than through the private physicians of patients. Psychiatric

Services

In this country most hospital services to psychiatric inpatients are furnished in state hospitals. In recent years the patient census in these hospitals has declined. Reversal of the long-term upward trend in 1955 came about because a speeding-up in the rate and n u m b e r of discharges overtook the continuing increase in the rate and n u m b e r of admissions. 25 At the same time psychiatric facilities and services in community general hospitals have increased in the U n i t e d States. Beds set aside for psychiatric patients increased from 10,600 in 1954 to 14,400 in 1958 and admissions increased from 202,400 to 257,300, respectively. T h e latter figure was substantially higher than the n u m b e r of admissions to public mental hospitals, 210,000. 26 Psychiatric facilities in general hospitals play a more important role in hospital admissions than in patient days. This means that their average patient stay is shorter than in state mental hospitals. In New York City in 1958 psychiatric units of general hospitals reported 32,000 admissions and 530,000 patient days. In 1957 New York City residents were responsible for 12,000 admis-

69

P A T T E R N S OF H O S P I T A L USE

sions to state m e n t a l hospitals a n d 15.8 m i l l i o n p a t i e n t days. Alt h o u g h the state hospitals r e p o r t e d only 27 percent of the combined admissions, they r e p o r t e d 97 percent of the c o m b i n e d patient days. T a b l e 2.21 shows the data on all psychiatric facilities in N e w York City u n d e r v o l u n t a r y , m u n i c i p a l , a n d p r o p r i e t a r y ownership. E x c l u d e d are state hospitals a n d psychiatric facilities in federal hospitals. Both beds a n d p a t i e n t days d o u b l e d in v o l u m e Table

2.21. D I S T R I B U T I O N OF FACILITIES A N D SERVICES FOR P S Y C H I A T R I C I N P A T I E N T S BY H O S P I T A L O W N E R S H I P , N E W YORK CITY, 1940, 1950, A N D 1958

Facility or Service Bed complement All hospitals Voluntary Municipal Proprietary Discharges All hospitals Voluntary Municipal Proprietary Patient days All hospitals Voluntary Municipal Proprietary

1950

1940

1958

Number*

Percent

Number•

Percent

1,028 88 705 235

100.0 8.6 68.5 22.9

1,561 308 979 274

100.0 19.7 62.7 17.6

2,111 485 1,338 288

100.0 23.0 63.4 13.6

34 33 1

100.0 t 97.1 2.9

35 1 31 3

100.0 2.8 88.6 8.6

37 2 31 4

100.0 5.6 83.9 10.5

360 25 278 57

100.0 7.0 77.2 15.8

583 95 402 86

100.0 16.3 69.0 14.7

730 161 495 74

100.0 22.0 67.9 10.1

\

Number*

Percent

• In thousands, except for beds. + Less than 500. SOURCE: See Table 2.5.

between 1940 a n d 1958, whereas discharges increased less t h a n 10 percent. M o r e t h a n two thirds of the increase in p a t i e n t days took place in the first interval, b e t w e e n 1940 a n d 1950, whereas the increase in beds was evenly d i v i d e d b e t w e e n the two intervals. N e w York City's m u n i c i p a l hospitals c o n t i n u e to play a prep o n d e r a n t role in c a r i n g for psychiatric i n p a t i e n t s in the comm u n i t y . T h e i r relative i m p o r t a n c e is declining, however, a n d that of voluntary hospitals is rising. U n l i k e general-care facilities, psychiatric facilities r e p o r t the

70

BACKGROUND

shortest d u r a t i o n of patient stay in m u n i c i p a l hospitals a n d t h e longest stay in voluntary hospitals. T h e c o m p u t e d data for 1958 follow: Average Length of Patient Stay (Days) All hospitals Voluntary Municipal Proprietary

19.9 78.0 16.0 19.2

W h e n separate psychiatric hospitals are e l i m i n a t e d f r o m the comparison, length of stay in psychiatric u n i t s of general hospitals is 52.2 days in the voluntary system a n d 14.8 days in t h e m u n i c i p a l system. T h i s difference reflects the fact that psychiatric units in m u n i c i p a l hospitals are heavily o r i e n t e d toward diagnostic a n d screening services, whereas psychiatric u n i t s in v o l u n t a r y hospitals tend to emphasize t r e a t m e n t for a short t e r m ^ u p to three months. I n the 1940s there was a modest increase in the n u m b e r of visits to psychiatric clinics of hospitals, a n d in the 1950s the increase was large. D u r i n g the same p e r i o d visits to psychiatric clinics of i n d e p e n d e n t dispensaries u n d e r v o l u n t a r y o w n e r s h i p declined f r o m 51,000 in 1940 to 30,000 in 1950 a n d 300 in 1958. Psychiatric services in family and o t h e r social service agencies are omitted f r o m these counts. Table

2.22. V I S I T S T O P S Y C H I A T R I C C L I N I C S O F O U T P A T I E N T D E P A R T M E N T S BY H O S P I T A L O W N E R S H I P , N E W YORK CITY, 1940, 1950, A N D 1958 Number

Year

Total

1940 1950 1958

48 68 178

(in Thousands)

Voluntary 22 28 63

Percent

Municipal 26 40 115

Voluntary 45.8 41.2 35.4

Municipal 54.2 58.8 64.6

SOURGK: United Hospital Fund of New York, Outpatient Service Statistics Relating to Hospitals and Independent Dispensaries in Mew York City (New York, 1911-59), and unpublished information.

Visits to psychiatric clinics of v o l u n t a r y hospitals increased slightly in the 1940s and more than d o u b l e d in the 1950s, b u t in each decade their rate of increase was lower t h a n in m u n i c i p a l hospitals. In the latter, visits increased o n e half in the 1940s and

PATTERNS OF HOSPITAL USE

71

almost tripled again in the 1950s. As a result, the m u n i c i p a l hospitals' p r o p o r t i o n of psychiatric visits to o u t p a t i e n t d e p a r t m e n t s rose f r o m 54 to 65 percent. A l t h o u g h trends for inpatients a n d for o u t p a t i e n t s have r u n in opposite directions—with v o l u n t a r y hospitals r e p o r t i n g an increasing p r o p o r t i o n of the f o r m e r a n d a dec l i n i n g p r o p o r t i o n of the latter—the share of voluntary hospitals in o u t p a t i e n t services is still well above that for i n p a t i e n t services, 35 percent c o m p a r e d with 22 percent. ( T h e latter figure is the voluntary hospitals' share of patient days; their share of discharges is only 6 percent, because of a relatively longer patient stay.) A significant factor in the expansion of services in psychiatric clinics of hospitals has b e e n financial s u p p o r t received t h r o u g h the N e w York City C o m m u n i t y Mental H e a l t h Board, whose b u d g e t is a u g m e n t e d by State funds. In the voluntary system contracts with individual hospitals subsidize expansion of services. I n effect, the City pays 50 p e r c e n t of expeditures for psychiatric clinics as long as services are increased, provided that the a m o u n t paid does n o t exceed the increase in e x p e n d i t u r e s occasioned by the expansion of services. In its Master Plan the Hospital Council stated that " t h e care of psychiatric p a t i e n t s should be an i m p o r t a n t f u n c t i o n of general hospitals." 27 Subsequently, the Hospital Council elaborated: T h e additional psychiatric units in general hospitals will provide needed care promptly when the patient is most likely to benefit from it. In the units of the voluntary hospitals psychiatrists will be able to care for their private patients. T h e organization of a psychiatric staff in a general hospital will also serve to extend knowledge of the emotional factors of illness to other services of the hospital. 28 Despite an initial reluctance by voluntary hospitals to establish psychiatric units, a c o n j u n c t u r e of circumstances, i n c l u d i n g the development of t r a n q u i l i z e r drugs and increased financial s u p p o r t f r o m g o v e r n m e n t , have recently enabled t h e m to move in the desired direction. Since 1954 the n u m b e r of patients in psychiatric units of v o l u n t a r y general hospitals in N e w York City has doubled. I n 1958 seven voluntary general hospitals in N e w York City had psychiatric units, and a n o t h e r five, w i t h o u t designated beds, were listed as a d m i t t i n g psychiatric patients in emergencies, for treatment, or both. 2 9 Of those with psychiatric u n i t s six are

BACKGROUND

72

located in Manhattan and one in the B r o n x . An additional psychiatric unit opened in the B r o n x in 1959. I n the municipal system two newly built general hospitals have established psychiatric units in recent years. Plans have been initiated to establish psychiatric facilities in a fifth and a sixth municipal hospital, with the simultaneous aim of reducing the size of, and eliminating overcrowding in, the psychiatric service at Bellevue Hospital Center. If these additional facilities materialize, there will be psychiatric units in three municipal general hospitals in Manhattan and in one each in the B r o n x , Brooklyn, and Queens. Tuberculosis

Facilities

I n the summer of 1953 the upward trend in tuberculosis patients in hospitals in New Y o r k City was reversed for the first time. Since then there has been an uninterrupted decline. T h e downturn was sharp, apparently reflecting the introduction in 1952 of a new set of drugs. T h e hydrozides of nicotinic acid, used separately or in c o m b i n a t i o n with other drugs, have resulted in a substantial reduction in patient stay. T a b l e 2.23 gives data on tuberculosis patients in hospitals in New York City in 1940, 1950, and 1958. Between 1940 and 1950 there was a sizable decline in tuberculosis beds in voluntary hospitals. T h i s reflects mostly the inability of one hospital to continue under voluntary ownership and its sale to the City of New York. T h e increase in municipal hospital beds between 1940 and 1950 reflects the City's acquisition of this hospital and also the opening of a tuberculosis facility in Queens. In addition, to meet the demand for beds, tuberculosis units in existing hospitals were expanded to the utmost and beds for acute c o m m u n i c a b l e diseases were diverted to tuberculosis patients. T o t a l tuberculosis facilities were further augmented in 1949 when a proprietary hospital agreed to assign several hundred beds to this purpose, under a special arrangement with the Department of Hospitals. Between 1950 and 1958 tuberculosis beds declined in each hospital system, as did discharges. Most striking is the decline in patient days (and, equivalently, average daily census).

PATTERNS

Table

OF H O S P I T A L

73

USE

2.23. D I S T R I B U T I O N O F F A C I L I T I E S A N D S E R V I C E S F O R P A T I E N T S W I T H T U B E R C U L O S I S BY H O S P I T A L OWNERSHIP, NEW YORK CITY, 1940, 1950, A N D 1958

Facility or Service

1940 Percent

Number*

Percent

Number*

Percent

4,754 1,588 3,166 0

100.0 33.4 66.6 0

5,506 962 4,207 337

100.0 17.4 76.5 6.1

4,622 700 3,685 237

100.0 15.1 79.8 5.1

11 3 8 0

100.0 27.3 72.7 0

11 1 9 1

100.0 9.1 81.8 9.1

10 1 8 I

100.0 10.0 80.0 10.0

1901

100.0 30.2 69.8 0

2,010 333 1,577 100

100.0 16.6 78.4 5.0

1J64 240 1,047 77

100.0 17.6 76.8 5.6

Number

Bed complement All hospitals Voluntary Municipal Proprietary Discharges All hospitals Voluntary Municipal Proprietary Patient days All hospitals Voluntary Municipal Proprietary

1958

1950

*

574 1,327 0

• In thousands, except for beds. SOURCE: See T a b l e 2.5.

It should be noted that the total n u m b e r of tuberculosis inpatients reported by hospitals is consistently lower than the number reported by the T u b e r c u l o s i s Register, a perpetual inventory of persons with active tuberculosis. A comparison of the estimated n u m b e r of persons in tuberculosis facilities at the end of 1950 and 1958, as reported by hospitals and by the Register, follows: Source of Data

1950

1958

Hospitals Register

5,860 6,714

3,427 4,378

Difference

+

854

+

951

Decline 1950-58 - 2,433 -2,336 -

97

T h e two sources report approximately the same size of decline in tuberculosis patients between 1950 and 1958—2,350 to 2,450. T h e n u m b e r reported by the Register at a given time is, however, 850 to 950 higher. T h e direction of the difference is surprising, since logically the Register should deal with the smaller n u m b e r of patients: (1) it lists active tuberculosis cases only, whereas a hospital unit may be caring for some arrested cases; and (2) it lists tuberculosis cases only, whereas a hospital

74

BACKGROUND

u n i t may also be caring for patients with n o n t u b e r c u l o u s conditions of the chest. A f t e r analysis of data a n d consultation with experts, it was c o n c l u d e d that for the p u r p o s e of tracing the use of tuberculosis hospitals a n d units over time the data f r o m hospitals are p r o b a b l y m o r e reliable than those f r o m the Register. T h e relative i m p o r t a n c e of voluntary hospitals in tuberculosis care has declined: f r o m one third in 1940 to 15 percent in 1958, as measured by beds; and f r o m 27 to 10 percent, as m e a s u r e d by discharges. Conversely, the relative i m p o r t a n c e of m u n i c i p a l hospitals has increased. T h i s trend remains substantially u n c h a n g e d w h e n hospitals located outside the city that serve primarily N e w York City residents are included in the data. In 1950 t h e r e were almost 900 such beds. T h e n u m b e r was well in excess of 1,000, if beds in State hospitals used by N e w York City residents, t h o u g h n o t specifically allocated to them, are also counted. T h e c o m p l e t e data o n tuberculosis facilities a n d services for residents of N e w York City, i n c l u d i n g those located outside the city are shown in T a b l e 2.24; these show larger volumes of services than in T a b l e 2.23 above, and raise the relative i m p o r t a n c e of v o l u n t a r y hospitals in past years. Since the year 1958 is not affected, the result is to c o n t i n u e the decline in the relative i m p o r t a n c e of v o l u n t a r y hospitals into the 1950s. By 1958 the net decline f r o m peak in all hospitals serving N e w York City residents was of the o r d e r of 2,150 beds, or 31 percent. T h e decline in patient days f r o m peak was 1,080,000 or 43 percent (see T a b l e 2.24). T h e rate of occupancy in tuberculosis facilities declined f r o m 96 percent in 1952 to 81 percent in 1958. I n municipal hospitals the decline was f r o m 99 to 78 percent, p a v i n g the way for a sizable reduction in bed c o m p l e m e n t in 1959. In the m o d e r n t r e a t m e n t of tuberculosis it is feasible to p e r f o r m a smaller part of the total care in the hospital than formerly. 3 0 Visits to tuberculosis clinics of hospitals show an increase f r o m 80,000 in 1950 to 108,000 in 1958, with the share of m u n i c i p a l hospitals rising f r o m 72 to 86 percent. M o r e striking is the relative gain of D e p a r t m e n t of H e a l t h clinics, which cared for 70 percent of all clinic cases with active tuberculosis in 1958, comp a r e d with 50 percent in 1950. 31

75

P A T T E R N S OF H O S P I T A L U S E Table

2.24. D I S T R I B U T I O N OF F A C I L I T I E S A N D SERVICES F O R P A T I E N T S W I T H T U B E R C U L O S I S BY H O S P I T A L O W N E R S H I P , N E W YORK C I T Y A N D E N V I R O N S , 1940, 1950, A N D 1958

Facility or Service Bed complement All hospitals Voluntary Municipal Proprietary Discharges All hospitals Voluntary Municipal Proprietary Patient days All hospitals Voluntary Municipal Proprietary

1940

1950

1958

Number*

Percent

Number*

+ Percent

5J79 2,013 3.566 0

100.0 36.0 64.0 0

6 J SI 1,417 4,627 337

100.0 22.2 72.5 5.3

4,622 700 3,685 237

100.0 15.1 79.8 5.1

11^25 2,959 8,966 0

100.0 24.8 75.2 0

11,732 1,898 9,388 446

100.0 16.2 80.0 3.8

9,735 1,371 7,943 421

100.0 14.1 81.6 4.3

2,180 712 1,468 0

100.0 32.7 67.3 0

2^86 461 1,725 100

100.0 20.1 75.5 4.4

1J64 240 1,047 77

100.0 17.6 76.8 5.6

Number*

Percent

• In thousands, except for beds. t Between 1950 and 1952 beds increased by 400, discharges by 850, and patient days by 160,000. NOTE: Approximately 200 New York City residents in state hospitals, with 43,000 patient days, are not included in this table. SOURCE: See T a b l e 2.5.

T h e r e is considerable overlap in role between tuberculosis clinics operated by hospitals and chest clinics operated by the D e p a r t m e n t of H e a l t h . O n e difference is that hospital o u t p a t i e n t d e p a r t m e n t s focus m o r e on the follow-up of discharged inpatients, while D e p a r t m e n t of H e a l t h clinics focus m o r e on the care of newly diagnosed patients and on supervising patients' families. A l t h o u g h the tuberculosis patient load is declining, eradication of the disease is n o t yet in sight. 32 T h e r e remains a n e e d for sound p l a n n i n g to provide a d e q u a t e facilities for the care of tuberculosis patients. A p p r o p r i a t e roles for general hospitals, particularly teaching hospitals, and provision for a reasonable geographic d i s t r i b u t i o n of facilities are dealt with elsewhere (see C h a p t e r 11). R e p o r t i n g early in 1959, the C o m m i t t e e on the T u b e r c u l o s i s Survey expressed satisfaction with the length of patient stay in tuberculosis hospitals a n d units in New York City a n d c o n c l u d e d

BACKGROUND

76

t h a t t h e e x i s t i n g s u p p l y o f b e d s was a m p l e . T r u e , 5 p e r c e n t o f all n e w l y r e p o r t e d a c t i v e eases of t u b e r c u l o s i s fail to a c c e p t h o s p i t a l i z a t i o n (even t h o u g h it is f u l l y p a i d for by g o v e r n m e n t in Y o r k S t a t e ) , b u t this p r o p o r t i o n is p r o b a b l y n o t r e d u c i b l e . O f s p e c i a l c o n c e r n is p r o v i s i o n of c a r e f o r l o n g - t e r m

New

33

patients

w i t h t u b e r c u l o s i s , w h o f r e q u e n t l y h a v e associated m e d i c a l c o n d i t i o n s . T h e y r e q u i r e well o r g a n i z e d p r o g r a m s , w i t h a d e q u a t e personnel and equipment. M a n a g e m e n t of t u b e r c u l o s i s p a t i e n t s is dispersed a m o n g vario u s types of facility, a n d c a r e of t h e i n d i v i d u a l p a t i e n t m a y

be

f r a g m e n t e d . W i t h total t r e a t m e n t of a p a t i e n t s e l d o m l a s t i n g less t h a n t w o years a n d s u b s e q u e n t s u p e r v i s i o n t a k i n g m u c h

longer,

e x t r a effort a n d i n g e n u i t y m u s t b e e x e r t e d to c o o r d i n a t e s e r v i c e s for a mobile population.34 Facilities

for Long-Term

Patients

As p r e v i o u s l y listed, f a c i l i t i e s f o r l o n g - t e r m p a t i e n t s c o m p r i s e units for rehabilitation; hospital beds for the chronically ill; a n d n u r s i n g - h o m e o r i n f i r m a r y beds. I n this r e p o r t t h e last g r o u p is d i v i d e d i n t o f a c i l i t i e s a t t a c h e d to h o s p i t a l s ( a n d i n c l u d e d in t h e d a t a p r e s e n t e d in this c h a p t e r ) a n d those t h a t are n o t . REHABILITATION

FACILITIES

Since W o r l d W a r II the public and the medical

profession

h a v e b e c o m e a w a r e o f t h e p o t e n t i a l c o n t r i b u t i o n of r e h a b i l i t a t i o n services to t h e w e l f a r e of all types of p a t i e n t , w h e t h e r on t h e way to f u l l r e c o v e r y o r u n d e r g o i n g a d j u s t m e n t to a p e r m a n e n t i m p a i r m e n t . S i n c e a r e g i m e n of i n t e n s i v e r e h a b i l i t a t i o n b e g i n s e a r l y in t h e p a t i e n t ' s h o s p i t a l stay, it s h o u l d b e i n s t i t u t e d in t h e g e n e r a l h o s p i t a l w h i l e t h e p a t i e n t is r e c e i v i n g m e d i c a l o r s u r g i c a l c a r e . In the c o m m u n i t y general hospital the rehabilitation service is essentially a c l i n i c a l d e p a r t m e n t u n d e r t h e d i r e c t i o n of t h e c h i e f o f p h y s i c a l m e d i c i n e , a n d as such it s e l d o m r e q u i r e s a s p e c i a l a s s i g n m e n t of b e d s for t h e p a t i e n t s it serves. T o b e d i s t i n g u i s h e d f r o m t h e d e p a r t m e n t of physical m e d i c i n e o f a g e n e r a l

hospital

is t h e so-called r e h a b i l i t a t i o n facility o r c e n t e r . U n d e r t h e definit i o n e m p l o y e d b y t h e H i l l - B u r t o n p r o g r a m , a r e h a b i l i t a t i o n facility is e x p e c t e d to p r o v i d e i n t e g r a t e d d i a g n o s t i c e v a l u a t i o n

and

t r e a t m e n t services, i n c l u d i n g m e d i c a l , p s y c h i a t r i c , s o c i a l , a n d vo-

P A T T E R N S OF HOSPITAL

77

USE

c a t i o n a l . T h e s e services are provided through the team a p p r o a c h , and

this calls for t h e participation

of m a n y different

medical

specialists and a u x i l i a r y personnel. A r e h a b i l i t a t i o n facility m a y serve b o t h inpatients and a m b u l a t o r y patients, d e p e n d i n g o n the a v a i l a b i l i t y of beds. U n d e r the H i l l - B u r t o n p r o g r a m grants f o r b e d s are treated separately f r o m grants for the r e h a b i l i t a t i o n facility itself. A n inventory of r e h a b i l i t a t i o n facilities and services c o n d u c t e d in 1 9 5 5 by the State H i l l - B u r t o n agency, then called t h e N e w York

State J o i n t

Hospital

Survey and

Planning

Commission,

listed 25 hospitals in N e w Y o r k City, 19 voluntary and 6 m u n i c i pal. T e n hospitals—5 voluntary and 5 municipal—assigned

beds

to r e h a b i l i t a t i o n patients. Most voluntary hospitals that a d m i t t e d a n d cared for r e h a b i l i t a t i o n inpatients did n o t assign a specific n u m b e r of beds to the service. T h e r e were, in a d d i t i o n , 5 reh a b i l i t a t i o n facilities outside hospitals, all u n d e r v o l u n t a r y ownership, with four for o u t p a t i e n t s only and o n e for i n p a t i e n t s only. E v e r y hospital r e p o r t e d that it served o u t p a t i e n t s as well as inpatients. T h e Hospital C o u n c i l ' s a n n u a l inventory r e p o r t e d 107 beds for patients in r e h a b i l i t a t i o n in 1950, all in m u n i c i p a l hospitals, b u t did n o t report any service statistics for t h e m . F o r t h e year 1 9 5 8 , 14 hospitals—5 voluntary and 9 m u n i c i p a l — r e p o r t e d

data

o n beds, discharges, and p a t i e n t days. Table

Facility

2.25. D I S T R I B U T I O N O F R E H A B I L I T A T I O N F A C I L I T I E S A N D SERVICES F O R I N P A T I E N T S BY H O S P I T A L O W N E R S H I P , N E W Y O R K C I T Y , 1958 or

Service

Bed c o m p l e m e n t All hospitals Voluntary Municipal Discharges All hospitals Voluntary Municipal Patient days All hospitals Voluntary Municipal

Number•

Percent

725 222 503

100.0 30.6 69.4

2 1 1

100.0 50.0 50.0

177 36 141

100.0 20.4 79.6

• In thousands, except for beds. SOURCE: Hospital Council of Greater New York, annual inventory.

78

BACKGROUND

T h e m u n i c i p a l system reports f o u r fifths of the p a t i e n t days received by rehabilitation patients. In fact this is an understatem e n t , for in one m u n i c i p a l hospital with 240 beds assigned to r e h a b i l i t a t i o n , discharges a n d p a t i e n t days are n o t separated f r o m services to o t h e r long-term patients. H O S P I T A L FACILITIES FOR T H E CHRONICALLY ILL

Hospital facilities for the chronically ill are i n t e n d e d for longt e r m patients in need of active medical or surgical care. C o u n t i n g these facilities is not a simple matter, since it is sometimes difficult to separate a n d distinguish t h e m f r o m general-care facilities, on the one h a n d , and nursing-home or infirmary facilities, on the o t h e r hand. Specifically, the N e w York State Plan for a d m i n i s t e r i n g the H i l l - B u r t o n p r o g r a m draws certain distinctions between hospital a n d nursing-home care of the chronically ill. T h e hospital for the chronically ill is defined as "a place for the p a t i e n t n e e d i n g active around-the-clock medical and professional n u r s i n g care and observation. Hospital care is necessary when difficult diagnostic procedures are indicated, when the severity of illness r e q u i r e s constant medical observation, and when highly skilled n u r s i n g techn i q u e s must be a p p l i e d . " 35 T h e role of the n u r s i n g h o m e is outlined below. Hospital facilities for the chronically ill, as c o u n t e d in this r e p o r t , are a residual g r o u p . For the year 1940 they i n c l u d e all beds other than those designated for general care, psychiatry, and tuberculosis. For 1950 rehabilitation beds are also d e d u c t e d , t h o u g h their services are not r e p o r t e d separately. By 1958 nursingh o m e and infirmary beds are separated and deducted. Because of the f r e q u e n c y with which facilities for long-term patients may be reclassified f r o m one category to a n o t h e r , as well as differences a m o n g authorities in classifying a given facility and the high degree of u n c e r t a i n t y that s u r r o u n d s the classification of certain facilities, the data on hospital facilities for the chronically ill and their services must be i n t e r p r e t e d with caution. Subject to these reservations, data on hospital facilities for the chronically ill are presented in T a b l e 2.26 for the years 1940, 1950, and 1958.

P A T T E R N S OF H O S P I T A L USE Table

79

2.26. D I S T R I B U T I O N O F H O S P I T A L F A C I L I T I E S A N D S E R V I C E S F O R C H R O N I C A L L Y I L L BY H O S P I T A L O W N E R S H I P , N E W Y O R K C I T Y , 1940, 1950, A N D 1958

Facility or Service Bed complement All hospitals Voluntary Municipal Discharges All hospitals Voluntary Municipal Patient days All hospitals Voluntary Municipal

1958

1950

1940 Number

* Percent

Number

• Percent

Number

* Percent

2,836 1,336 1,500

100.0 47.1 52.9

3,7 35 2,109 1,626

100.0 56.4 43.6

3,641 1,741 1,900

100.0 47.8 52.2

4 2 2

100.0 50.0 50.0

5 3 2

100.0 60.0 40.0

7 5 2

100.0 71.4 28.6

989 447 542

100.0 45.3 54.7

1,365 686 679

100.0 50.3 49.7

1,286 630 656

100.0 49.0 51.0

* In thousands, exept for beds. SOURCE: See T a b l e 2.5.

In this field the two hospital systems play approximately equal roles in beds and patient days b u t not in discharges. O n e hospital reports m o r e than one half of all discharges f r o m the v o l u n t a r y system, though it has only 15 percent of the beds. P e r h a p s all or part of this facility should be considered for reclassification to general care, as a result of c o n t i n u i n g changes in the types of patient cared for. It should be recognized, of course, that general care u n i t s of hospitals treat some long-term patients, and properly so. T o limit their role to caring for the acutely ill would be to d e p r i v e the long-term patients of the benefits of medical progress. At times of diagnostic evaluation, surgery, or exacerbations of illness, longterm patients do not differ f r o m acutely ill patients in the degree or types of active care r e q u i r e d . Indeed, in certain areas, such as physical therapy or radiation therapy, long-term patients m a y req u i r e m o r e personnel and m o r e complex facilities t h a n short-term patients. N o r is it likely that other institutions can p r o v i d e as a d e q u a t e a level of care for these long-term patients as can the general-care hospital. Existing i n f o r m a t i o n on the use of general-care hospitals in New York City by long-stay patients is scanty. It is insufficient to support any conclusions regarding the propriety of such use.

80

BACKGROUND

N U R S I N G - H O M E F A C I L I T I E S IN H O S P I T A L S

T h e r e are o t h e r long-term patients w h o do not n e e d active hospital care b u t need skilled n u r s i n g care a n d related services in an institution, u n d e r medical direction. Such a facility, as described by the H i l l - B u r t o n Act, is a n u r s i n g h o m e that a d m i t s p a t i e n t s solely because they are sick b u t offers t h e m a home-like a t m o s p h e r e and security d u r i n g their prolonged stay. I t is n o t a custodial institution or b o a r d i n g home. 3 * Data on nursing-home facilities that are integral parts of hospitals are presented for the year 1958 in T a b l e 2.27. It is possible t h a t the facilities so classified today p e r f o r m e d the same f u n c t i o n in 1950 or even in 1940, when they were classified as hospital beds f o r the chronically ill. Over the years classification of facilities has b e c o m e m o r e refined because of two parallel developments: (1) increasing complexity of medical care and, therefore, increasing specialization of personnel a n d facilities p r o v i d i n g the care; and (2) increasing availability of f u n d s f r o m a variety of sources, which eventually calls for a finer a d j u s t m e n t of rates of p a y m e n t to services r e n d e r e d . Of p a r t i c u l a r i m p o r t a n c e in the financial r e a l m are a m e n d m e n t s to the p u b l i c assistance provisions of the Social Security Act, because these have raised Federal participation in s u p p o r t of long-term patients in institutions. In some parts of the c o u n t r y voluntary health insurance plans offer subscribers limited benefits for care in n u r s i n g homes. Table Facility

2.27. D I S T R I B U T I O N O F N U R S I N G - H O M E B E D S I N H O S P I T A L S BY O W N E R S H I P , N E W Y O R K C I T Y , 1958 or

Service

Bed complement All hospitals Voluntary Municipal Discharges All hospitals Voluntary Municipal P a t i e n t days All hospitals Voluntary Municipal

Number*

Percent

1J03 515 1,388

100.0 27.1 72.9

2 1 1

100.0 50.0 50.0

662 181 481

100.0 27.3 72.7

• I n thousands, exept for beds. SOURCE: Hospital Council of G r e a t e r New York, a n n u a l inventory.

P A T T E R N S OF HOSPITAL USE

81

M u n i c i p a l hospitals c o n t r i b u t e almost three fourths of the beds and patient days in these facilities. As will be seen in the next section, this p r o p o r t i o n may be misleading, since only a small segment of nursing-home facilities are c o u n t e d here. Indeed, m u n i c i p a l facilities of this type, officially designated as public-home infirmaries, have not e x p a n d e d as p r o j e c t e d . O n e reason is that some of the facilities that were b u i l t could n o t be staffed. A n o t h e r i m p o r t a n t reason is the opposition of the medical staffs of university hospitals to establishing a n d o p e r a t i n g such units. T h e recent decision by Bellevue Hospital C e n t e r to staff a public-home infirmary when the new plant is c o m p l e t e d marks a significant break with this policy. OTHER NURSING-HOME

FACILITIES

O u t s i d e the hospital f o u r categories of nursing-home facilities are recognized in N e w York City: the incorporated n u r s i n g h o m e u n d e r v o l u n t a r y ownership; the infirmary of a h o m e for the aged, also u n d e r voluntary ownership; the infirmary of a p u b l i c home; a n d the p r o p r i e t a r y n u r s i n g home. For lack of data it is not possible to p r e p a r e a table for nursing-home facilities outside hospitals that would go back to 1940 or even to 1950. For the year 1958, however, the data are complete a n d mesh with those developed for hospitals. N o t shown in this table are nonhospital facilities for shorterterm patients. In 1958 there were 250 beds in convalescent homes in N e w York City, which reported almost 3,000 discharges a n d 73,000 p a t i e n t days. O u t s i d e the city there are certain convalescent h o m e s that serve primarily residents of N e w York City. T h e s e h a d 1,050 beds in 1957, 37 after a generation in which convalescent homes had closed or reduced their capacity. 3 8 P r o p r i e t a r y n u r s i n g homes play a m a j o r role in the care of long-term patients. T h i s is a relatively new p h e n o m e n o n , with their significant expansion d a t i n g back to the early 1950s. I n 1950, for example, there were 2,400 beds in p r o p r i e t a r y n u r s i n g homes a n d in 1952, 3,090, b u t in 1955, 5,400, a n d in 1958, 9,160. T h e role of infirmaries of homes for the aged has also increased in recent years, b u t at a slow rate. Some additional infirmary facilities were created by converting facilities for domicili-

BACKGROUND

82 Table

2.28. D I S T R I B U T I O N OF N U R S I N G - H O M E F A C I L I T I E S O U T S I D E H O S P I T A L S A N D T H E I R SERVICES BY O W N E R S H I P , N E W Y O R K CITY, 1958 Facility

or

Service

B e d capacity A l l facilities Voluntary Nursing homes Infirmaries, homes for aged Municipal Proprietary Discharges All facilities Voluntary Nursing homes Infirmaries, homes for aged Municipal Proprietary Patient days All facilities Voluntary Nursing homes Infirmaries, homes for aged Municipal Proprietary

Number•

Percent

14J52 4,528 1,062 3,466 468 9,156

100.0 32.0 7.5 24.5 3.3 64.7

12 6 1 5

100.0 50.0 8.3 41.7

t 6

t 50.0

4,083 1,373 284 1,089 184 2,526

100.0 33.6 6.9 26.7 4.5 61.9

• In thousands, except for beds, t Less than 500. SOURCE: Adapted from New York State Joint Hospital Survey and Planning Commission, Hospitals and Related Facilities in New York State (Albany, N. Y., 1960; typewritten).

ary patients, a n d others were newly built. In the latter effort, the H i l l - B u r t o n p r o g r a m has f u r n i s h e d some assistance. T h e separate voluntary n u r s i n g homes have increased their capacity 50 percent since 1950, when the n u m b e r of beds was 710. T h e r e has been n o formal change in the capacity of the infirmary section of the p u b l i c h o m e on Staten Island. However, the City H o m e on W e l f a r e Island, with some facilities of this type, was closed in 1953. T h e f o u r categories of n u r s i n g homes share these characteristics: almost all of their patients need long-term care, a n d the m a j o r i t y are aged (65 years and over) a n d in receipt of O l d Age Assistance. T h e r e are differences a m o n g the facilities, however, in the way in which patients are admitted, so that some differences arise in the degree a n d types of illness of patients a n d in their

P A T T E R N S OF H O S P I T A L USE

85 39

cultural and social characteristics. These are described at length in another report. 40 It is interesting that public-charge patients constitute a majority of patients in proprietary nursing homes. By contrast, proprietary general hospitals have no public charges. A striking finding from Table 2.29 is that in 1958 the n u m b e r of beds in nursing homes outside hospitals exceeded the total n u m b e r of beds in hospitals for non-general-care patients (Table 2.16). If psychiatric and tuberculosis facilities are eliminated from the comparison, the relative importance of nursing-home facilities outside hospitals in caring for long-term patients is increased substantially. Table

2.29. D I S T R I B U T I O N OF FACILITIES A N D SERVICES F O R L O N G T E R M CARE BY O W N E R S H I P A N D BY L O C A T I O N W I T H RESPECT T O HOSPITALS, N E W YORK CITY, 1958 Number*

Facility or Service Bed capacity Total Voluntary Municipal Proprietary Discharges Total Voluntary Municipal Proprietary Patient days Total Voluntary Municipal Proprietary

Percent Outside Hospitals

20,421 7,006 4,259 9,156

6269 2,478 3,791 0

14,152 4,528 468 9,156

30.7 35.4 11.0 0

69.3 64.6 89.0 100.0

23 IB 4 6

11 7 4 0

12 6 t 6

47.8 53.8 100.0 0

52.2 46.2 t 100.0

6J08 2,220 1,462 2,526

2,125 847 1,278 0

4,083 1,373 184 2,526

34.2 38.2 87.4 0

65.8 61.8 12.6 100.0

Total

In Hospitals

Outside Hospitals

In Hospitals

* In thousands, except for beds, t Less than 500. SOURCE: Tables 2.25-2.28.

( T h e bed figures in T a b l e 2.29 represent capacity, rather than complement, because only the former were available for nursing homes outside hospitals. In this instance there is, however, no difference between bed capacity and bed complement for longterm facilities in hospitals.)

BACKGROUND

84

Over-all n u r s i n g h o m e facilities outside hospitals represent 70 p e r c e n t of all facilities for long-term care. T h e y report m o r e t h a n one half of all discharges a n d two thirds of all patient days. I n the p r o p r i e t a r y system all facilities for long-term care are located a p a r t f r o m hospitals a n d have n o ties with them. I n the m u n i c i p a l system the large m a j o r i t y of facilities are in hospitals a n d the o u t s i d e u n i t is affiliated with a hospital for medical staffing. I n the v o l u n t a r y system the m a j o r i t y of facilities are outside hospitals, b u t some have ties of varying intensity with hospitals. T h e p e r c e n t a g e d i s t r i b u t i o n by ownership is given in T a b l e 2.30. W h e n facilities for long-term care outside hospitals are taken Table

2.30. P E R C E N T A G E D I S T R I B U T I O N OF T O T A L FACILITIES A N D SERVICES F O R L O N G - T E R M CARE BY O W N E R SHIP, N E W Y O R K CITY, 1958

Ownership Total Voluntary Municipal Proprietary SOURCE: Table 2.29.

Bed Capacity 100.0 34.3 20.9 44.8

Discharges 100.0 56.5 17.4 26.1

Patient Days 100.0 35.8 23.5 40.7

into account, it is the p r o p r i e t a r y system that looms largest and the m u n i c i p a l system smallest by far. T h e s e findings are the very opposite of those derived f r o m s t u d y i n g only long term facilities in hospitals. Summary 1. T h i s c h a p t e r describes changes in the respective roles of voluntary, m u n i c i p a l , a n d p r o p r i e t a r y hospitals in N e w York City in p r o v i d i n g services to inpatients and to a m b u l a t o r y patients. It was possible to trace back total beds to the year 1920 a n d total services to 1930. Almost every series on individual programs begins n o t later t h a n 1940. 2. At the e n d of 1958 t h e r e were 151 hospitals with a capacity of almost 50,000 beds. D u r i n g calendar year 1958 they cared for 1,050,000 i n p a t i e n t s and r e p o r t e d 14.4 million patient days. T h e y also r e p o r t e d 0.8 m i l l i o n p a t i e n t days on h o m e care, 5.4 million visits to o u t p a t i e n t d e p a r t m e n t s , 1.8 million visits to emergency d e p a r t m e n t s , a n d r o u g h l y 0.4 million visits by private a m b u l a t o r y

P A T T E R N S OF HOSPITAL USE

85

patients. Finally, they responded to 350,000 emergency ambulance calls. 3. Excluded from the above are the following: (a) Federal hospitals in New York City, chiefly Veterans Administration hospitals. In 1958 the latter had 3,600 beds, and 85 percent of their occupants were residents of the city. (b) State hospitals. T h e four institutions in New York City had 10,700 beds, and 98 percent of their occupants were from New York City. However, these hospitals accommodated only 22 percent of the city's residents in the state mental hospital system. T h e remaining 78 percent were cared for in hospitals located in neighboring counties in New York State. (c) Nursing home facilities for long-term patients outside hospitals. These aggregated 14,200 beds in 1958, compared with fewer than 2,000 nursing-home beds that were integral parts of hospitals. (d) Convalescent home facilities for shorter-term patients. T h e n u m b e r of beds located in New York City was only 250, b u t the n u m b e r of beds in the suburbs that served the city's residents amounted to 1,050. 4. A comparison between New York City's short-term hospitals and the nation's in 1958 shows the following: (a) T h e admission rate to hospitals of the resident population was 125 per 1,000 in both instances. (b) Average length of stay was higher by one third in New York City. Consequently, hospital use per person per year was higher by one third. (c) Outpatient departments of hospitals were used 3.5 times as often in New York City. (id) Emergency departments of hospitals were used 2.3 times as often in New York City. (e) Municipal hospitals play a larger role here in every item that is compared, and voluntary hospitals a smaller one. Proprietary hospitals are relatively more important in New York City in inpatient care and less important in services for ambulatory patients. 5. T h e r e are two aspects to the summary of trends in facilities and services: the direction of the total and changes in the relative importance of the two major hospital systems.

86

BACKGROUND

6. T o t a l bed complement in hospitals increased from 30,200 in 1920 to 36,600 in 1930, 41,200 in 1940, 43,500 in 1950, and 48,700 in 1958. T h e largest increase occurred in the 1950s and the smallest in the 1940s. Patient days show a smaller increase in the 1950s than in the 1940s or 1930s. T h e increase in discharges in the 1950s was the same as in the 1940s and larger than in the 1930s. 7. Beginning in 1940 the share of voluntary hospitals has increased in total discharges and patient days b u t decreased in beds. T h e share of municipal hospitals has changed in the opposite direction for each item. Proprietary hospitals registered both numerical and relative gains in the care of inpatients; they play scarcely any part in caring for ambulatory patients. 8. In 1958 general care beds constituted 73 percent of all hospital beds, b u t their discharges constituted 94 percent of all hospital discharges. O n the whole, general care facilities and services increased in both the 1940s and 1950s. T h e share of voluntary hospitals continued to rise and that of municipal hospitals declined. Proprietary hospitals also reported a larger share of beds, discharges, and patient days. 9. T h e three computed measures of hospital use behaved differently: (a) Rate of occupancy in general care facilities rose in the 1940s and declined in the 1950s. (b) Length of stay declined by two days in the 1940s and by one day in the 1950s. (c) Rate of bed turnover rose sharply in the 1940s and only slightly in the 1950s. 10. T h e r e has been an absolute, as well as a relative, decline in the ward service and an increase, both absolute and relative, in the private (especially semiprivate) service. Even so, the ward still reported 41 percent of all general care discharges in 1958 and 51 percent of all general care patient days. 11. T h e share of municipal hospitals in the ward service has steadily increased and that of voluntary hospitals decreased. In 1940 the former had more than one half of all general-care patient days, but less than one half of beds or discharges; by 1950 they also had more than one half of all ward beds; and by 1958, they had, in addition, more than one half of all ward discharges. Proprietary hospitals do not maintain a ward service.

PATTERNS OF HOSPITAL USE

87

12. In the private (including semiprivate) service the share of voluntary hospitals has increased and that of proprietary hospitals declined. T h e municipal system plays a negligible part. 13. Visits to outpatient departments of hospitals increased during the depression of the 1930s and declined during World W a r II and subsequently. T h e r e was little change in total volume during the 1950s. 14. T h e share of voluntary hospital outpatient departments has steadily declined. T h e i r volume of visits has continued to fall, while that of municipal hospitals rose in the 1950s, after a drop in the 1940s. By 1958 the share of municipal hospitals was almost one half. 15. Between 1948 and 1958 visits to emergency departments of hospitals more than doubled. Volume of service increased in each hospital system, b u t at a much more rapid rate in municipal than in voluntary hospitals. T h e former reported more than one half of all emergency department visits for the first time in 1957. 16. Available data on services to private ambulatory patients are incomplete and not reliable. T h e n u m b e r of visits to voluntary hospitals in 1958 is estimated between 350,000 and 425,000. A reported increase between 1955 and 1958 may be more apparent than real. 17. Diagnostic centers in hospitals have not expanded as anticipated. T h e year 1958 marked the closing of the pioneer consultation service in New York City for persons of moderate means. 18. T h e total n u m b e r of calls answered by the emergency ambulance service in 1958 was the same as in 1950 but smaller than in 1940. T h e volume of services rendered by voluntary hospitals continued to decline, whereas that rendered by municipal hospitals rebounded from the sharp wartime drop. As a result, the share of voluntary hospitals declined from 59 percent in 1940 to 41 percent in 1958. 19. Home-care patient days rose rapidly between 1949 and 1950 and for several years thereafter. By 1955 a plateau was reached, with all b u t one municipal general hospital operating an organized home-care program and only four voluntary hospitals doing so. Among the latter two are very small, and one is primarily intended for teaching. Ninety-five percent of the average daily census on home care is reported by municipal hospitals.

88

BACKGROUND

20. Facilities a n d services in hospitals for non-general-care patients have also increased since 1940. T h r e e f o u r t h s of the increase has occurred in the m u n i c i p a l system. By 1958, almost o n e half of all p a t i e n t days in m u n i c i p a l hospitals were for nongeneral-care patients, c o m p a r e d with one sixth in voluntary hospitals a n d one eighth in p r o p r i e t a r y hospitals. 21. Both beds a n d patient days in psychiatric services of volu n t a r y , m u n i c i p a l , a n d proprietary hospitals have d o u b l e d since 1940, while discharges have increased b u t slightly. A l t h o u g h the m u n i c i p a l system r e m a i n s p r e d o m i n a n t , the share of v o l u n t a r y hospitals has increased. 22. Visits to psychiatric clinics of hospitals have e x p a n d e d even m o r e rapidly. H e r e , u n l i k e the i n p a t i e n t service, the share of v o l u n t a r y hospitals has b e e n contracting. 23. T u b e r c u l o s i s facilities and services e x p a n d e d t h r o u g h the s u m m e r of 1953, a n d then a long-term decline set in. Both m a j o r hospital systems have reduced facilities a n d services for inpatients, with v o l u n t a r y hospitals proceeding at the faster rate. T h e share of m u n i c i p a l hospitals is f o u r fifths of the total. 24. O u t p a t i e n t services are of rising i m p o r t a n c e in tuberculosis care. T h e chest clinics of the D e p a r t m e n t of H e a l t h play a p r o m i n e n t role. 25. M a n y hospitals with a rehabilitation d e p a r t m e n t do not assign any beds to it. In 1958 14 hospitals r e p o r t e d such assignments, which aggregated 725 beds. Most of the beds a n d services were in m u n i c i p a l hospitals, and the r e m a i n d e r in voluntary hospitals. 26. Hospital facilities for the chronically ill, as c o u n t e d for this study, failed to increase in the 1950s. T h e share of each m a j o r system is close to one half of the total. All n u m b e r s s h o u l d be i n t e r p r e t e d with caution, however, because of difficulties in classifying and reclassifying facilities for long-term patients. 27. N u r s i n g - h o m e types of facility in hospitals have e x p a n d e d less rapidly t h a n anticipated. M u n i c i p a l hospitals have almost three f o u r t h s of all such beds. 28. N u r s i n g - h o m e types of facility outside hospitals have expanded rapidly. I n c l u d e d are separate n u r s i n g homes, infirmaries of homes for the aged, and an infirmary of a p u b l i c home. I n 1958

PATTERNS OF HOSPITAL USE

89

p r o p r i e t a r y n u r s i n g homes reported 65 p e r c e n t of these beds a n d 62 percent of the patient days, compared with 32 a n d 34 percent, respectively, for the voluntary system a n d only 3 a n d 4 percent, respectively, for the m u n i c i p a l system. 29. If all facilities for long-term patients are c o m b i n e d , they a m o u n t to 20,400 beds in 1958, 70 percent of t h e m outside hospitals and 30 percent inside. T h e y r e p o r t e d only 23,000 discharges b u t 6.2 million patient days. 30. Of the total n u m b e r of patient days r e p o r t e d by long-term facilities in New York City the p r o p r i e t a r y system c o n t r i b u t e d two fifths, the voluntary system one t h i r d , a n d the m u n i c i p a l system less than one f o u r t h . 31. A m o n g a n u m b e r of substantive a n d technical p r o b l e m s discussed are the following: (a) Rates of occupancy by type of hospital a c c o m m o d a t i o n private, semiprivate, and ward—cannot be i n t e r p r e t e d u n e q u i vocally. (b) T h e rate of bed turnover is shown to be related mathematically to the two traditional c o m p u t e d measures of hospital use—rate of occupancy a n d length of stay. (c) Changes in the o u t p a t i e n t d e p a r t m e n t v o l u m e of visits are analyzed in relation to changes in charges a n d income. P o t e n t i a l effects on quality of care are cited. (d) F u t u r e tendencies in hospital home-care p r o g r a m s are explored as Blue Cross extends benefits to this area a n d one hospital establishes a pilot p r o g r a m for patients w h o have n o t recently been in a hospital. Factors e n t e r i n g into a p r o p e r c o m p a r i s o n of cost between h o m e care a n d hospital care are e n u m e r a t e d . (e) P r o b l e m s raised by the present organization of the emergency a m b u l a n c e service are considered in r e l a t i o n to the expanding role of the hospital emergency d e p a r t m e n t . Appendix

2.A

E S T I M A T I N G NUMBERS O F BEDS, DISCHARGES, AND P A T I E N T DAYS FOR 1940 In general, the data on beds and services for inpatients in 1940 are based on the published data of the United Hospital Fund, 4 1 as adjusted.

BACKGROUND

90

Special problems were posed by the need to convert figures on patients treated into figures on discharges, that is, to estimate and subtract the number of patients in the hospital at the beginning of the year. T h e s e were handled by reference to relationships between the number of patients in a given type of accommodation in a given hospital at the beginning of the year and on the average during the year (average daily census), when both figures were available from the Hospital Council's annual inventory. T o obtain more complete counts than those published, several adjustments were made. HOSPITAL SYSTEM

TOTALS

Voluntary Hospitals. T h e psychiatric unit at New York Hospital was added from data in the Hospital Council's files. Doctors Hospital and T h e Hospital of the Rockefeller Institute were also added from data furnished by the hospitals. Proprietary Hospitals. T w o psychiatric hospitals licensed by the New York State Department of Mental Hygiene were added, which are not included in United Hospital Fund counts. T h e data were taken from the "Hospital Service" issue of the Journal of the American Medical Association.42 Municipal Hospitals. None. T Y P E O F CARE

Tuberculosis. Data were obtained from the annual compilation published by New York Tuberculosis and Health Association. 43 Psychiatry. Data were obtained as follows: (a) Voluntary hospitals. T h e New York Hospital unit, as above. (b) Municipal hospitals. From the Annual Report of the New York City Department of Hospitals. 4 4 (c) Proprietary hospitals. T w o hospitals, as above, plus one hospital included in the United Hospital Fund count. 4 5 Chronically III. Figures were calculated as follows: (a) Voluntary hospitals. T o t a l less tuberculosis (above) less psychiatry (above) and less general care (below). (b) Municipal hospitals. United Hospital Fund, as given. (c) Proprietary hospitals. T a k e n as zero. General Care. Data were obtained as follows: (a) Voluntary hospitals. General-care hospitals, as reported by United Hospital Fund, plus Doctors and Rockefeller Hospitals (as above) less tuberculosis in general hospitals. 40 (b) Municipal hospitals. General-care hospitals (including acute communicable diseases) less tuberculosis in general-care hospitals 4 7 and less psychiatry. 48

PATTERNS OF HOSPITAL USE (c) Proprietary hospitals. chiatric hospital. 4 9

Appendix

91

U n i t e d Hospital F u n d total less one psy-

2.B

DERIVATION OF RELATIONSHIP AMONG RATE OF BED T U R N O V E R , R A T E OF OCCUPANCY, A N D L E N G T H O F P A T I E N T STAY T h e three terms are defined as follows: „ ,, Admissions or Discharges (in a year) R a t e of bed turnover = —;—2—i 1 i Beds „ , Average Daily Census 0 R a t e of occupancy = Beds Length of stay =

Patient Days Admissions or Discharges

T h e s e relationships hold true: Beds = Average Daily Census .'. Beds =

R a t e of Occupancy

PatientDays 365 x R a t e of Occupancy

. . . . t^- 1 PatientDays Admissions or Discharges = ^ i — — 0 L e n g t h of Stay Substitute: „ 1 . Patient Days R a t e ofr bed turnover = = — — L e n g t h of Stay

P a t i e n t Days —— ¡r-^—365 x R a t e of Occupancy

P a t i e n t Days L e n g t h of Stay

365 x R a t e of Occupancy P a t i e n t Days

ggg

R a t e of Occupancy L e n g t h of Stay

3

CHARACTERISTICS OF PATIENTS IN SHORT-TERM HOSPITALS

It is i m p o r t a n t to compare the three o w n e r s h i p groups (voluntary, m u n i c i p a l , and proprietary) and the two types of hospital service (private a n d ward) with respect to the characteristics of p a t i e n t s in short-term hospitals. Such i n f o r m a t i o n is a prerequisite to realistic p l a n n i n g for a m o r e coordinated n e t w o r k of hospital facilities a n d services. I n view of the differences in mission assumed by the t h r e e hospital systems, it is n o t surprising that t h e i r patients differ in pay status (insured, p u b l i c charge, a n d so forth). O t h e r characteristics of persons, such as age, ethnic status, or residence, are associated with pay status b u t may play an i n d e p e n d e n t role in d i s t r i b u t i n g patients by hospital ownership and by accommodation. T h i s c h a p t e r discusses the following characteristics of p a t i e n t s in short-term hospitals in N e w York City: (1) pay status; (2) residence—in the city or outside; (3) ethnic status—Puerto Rican, nonwhite, or n o n - P u e r t o Rican white; (4) age; (5) length of stay; (6) diagnostic category; (7) need of hospital care. For the purposes of this report the most i m p o r t a n t comparisons are between the wards of voluntary and m u n i c i p a l hospitals. Pay

Status

Differences in pay status of patients are m u c h greater a m o n g the three hospital systems t h a n between the ward services of voluntary and m u n i c i p a l hospitals. T h e latter are sizable, however. T o facilitate c o m p u t a t i o n and to simplify presentation of data, all patients in m u n i c i p a l hospitals are treated in this c h a p t e r as if they were in the ward. T h i s is not actually so, b u t the only

PATIENTS IN S H O R T T E R M HOSPITALS

93

private (including semiprivate) service (at Sydenham Hospital) is of modest size, serving fewer than 2,000 patients a year with 16,000 patient days. T a b l e 3.1 shows rates per 100 discharges and per 100 patient day for three categories of pay status. An A H S patient is paid for in full or in part by Associated Hospital Service of New York. A public charge in a voluntary hospital is someone for whom government assumes financial responsibility in full or in part. T h e concept of a public charge in a municipal hospital poses some difficulty; it was handled in this context by classifying as public charges all patients, except those with Blue Cross or Workmen's Compensation coverage and those who pay full rates. Public-charge patient days in municipal hospitals were computed from the ratio of tax funds to total income. Public assistance recipients in hospitals, included among public-charge patients, are easily defined but pose some difficulty in counting (see Appendix 3.A). Altogether, 44 percent of the patients discharged from generalcare hospitals in New York City in 1957 were Blue Cross subscribers and 27 percent were public charges. However, government paid for more patient days than Blue Cross, 39 percent compared to 37 percent. One fifth of the patient days paid for by government were for the indigent (recipients of public assistance) and four fifths were for the medically indigent (persons who normally pay their way but cannot afford to pay for hospital care). Proprietary hospitals do not care for public charges, whether indigent or medically indigent, and neither does the private (including semiprivate) service of voluntary hospitals. Comparison of the two ward services shows that voluntary hospitals have 2.5 times as many Blue Cross subscribers per 100 patients as municipal hospitals. T h e r e is a further difference between the Blue Cross subscribers in the two ward services, in that 42 percent of all AHS days in municipal hospitals are discount days compared with 30 percent in voluntary hospital wards. (A discount day is one for which AHS pays 50 percent of the full benefit and the subscriber pays 50 percent of regular charges.) Municipal hospitals have approximately twice as many public charges and public assistance recipients per 100 patients as the

94 Table

BACKGROUND 3.1. R A T E PER 100 DISCHARGES A N D R A T E PER 100 P A T I E N T DAYS A C C O R D I N G T O PAY S T A T U S OF P A T I E N T S IN GENERAL-CARE HOSPITALS, BY H O S P I T A L O W N E R SHIP A N D TYPE OF A C C O M M O D A T I O N , N E W YORK CITY, 1957 Voluntary

Pay Status Discharges Associated Hospital Service subscribers Public charges Public-assistance recipients Patient days Associated Hospital Service subscribers Public charges Public-assistance recipients

Private and Sem iprivate

Ward

51 14

67 0

23 44

9 85

64 0

4

0

11.5

20

0

47 20

65 0

20 50

8 91

62 0

0

11

17

0

All AccommoAll Hospitals dations

44 27 6.5

37 39 8

4.5

Municipal

Proprie tary

SOURCES: United Hospital Fund of New York, Central T a b u l a t i n g Service Bureau, unpublished tabulations for all subscribing hospitals in New York City; Appendix 3.A; and T a b l e 17.4.

wards of voluntary hospitals. In both ward services public assistance recipients are responsible for a higher proportion of discharges than of patient days. T h i s means that their hospital stay is shorter than that of other ward patients, largely because maternity patients with a relatively short stay constitute a high proportion of hospitalized persons receiving assistance under the program of Aid to Dependent Children. T h e proportions of public charges and of Blue Cross subscribers in the wards of voluntary hospitals have been rising. In 1947 public charges received 31 percent of all ward days in voluntary general hospitals in New York City and Blue Cross subscribers, 9 percent; the corresponding figures in 1957 were 50 and 20 percent, respectively. T h e proportion of Blue Cross subscribers in municipal hospitals has increased to 9 percent from 3.5 percent in 1950. T h e question arises whether the difference between the wards of the two hospital systems in the proportion of public assistance recipients is a true one or a reflection of the difference in the

PATIENTS

IX S H O R T - T E R M

95

HOSPITALS

ethnic composition of patients. For one group of public-assistance recipients the difference appears to be a true one. A higher proportion of Old Age Assistance recipients than of any other group of public-assistance recipients 1 receives care in municipal hospitals, despite the fact that the proportion of Puerto Ricans and nonwhites—who tend to concentrate in municipal hospitals—is lower among recipients of Old Age Assistance than among recipients of any other category of public assistance. 2 Nonresidents

Closely associated with pay status is the patient's general area of residence. Hospitals in New York City are not likely to have many nonresident public charges or public-assistance recipients, because other local units of government will not pay for their care here. Conversely, patients able to pay for their care are free to travel to the hospital of their (or their physician's) choice. T a b l e 3.2 shows the percentage of nonresident discharges in the three hospital systems in New York City in 1933 and 1957, including a breakdown between the private (including semiprivate) and ward services for voluntary hospitals. Between 1933 and 1957 the proportion of nonresident discharges in New York City hospitals doubled. T h i s came about not because the proportion of nonresident patients increased in each hospital system and type of accommodation, b u t rather because those hospitals and types of accommodation that have always had a sizable proportion of nonresident patients increased in relative importance. Table 3.2. PROPORTION (PERCENT) OF NONRESIDENTS AMONG DISCHARGES FROM VOLUNTARY, MUNICIPAL, AND PROPRIETARY GENERAL-CARE HOSPITALS, NEW YORK CITY, 1933 AND 1957 Hospital Ownership All hospitals Voluntary Private and semiprivate Ward Municipal Proprietary

App.

19)3 4.5 6 12 4 1 n.a.

1957 9 11 15 4 1 7

SOURCES: Neva R . Deardorff a n d Marta Fraenkel, Hospital Discharge Study (2 vols.; New York, 1942); Hospital Discharge Study, u n p u b l i s h e d summary books in custody of Hospital Council of G r e a t e r New York; a n d A p p e n d i x 3.B.

BACKGROUND

96

T a b l e 3.3 shows h o w n o n r e s i d e n t p a t i e n t s w e r e d i s t r i b u t e d in 1957. Almost t h r e e f o u r t h s of all n o n r e s i d e n t s w e r e d i s c h a r g e d f r o m v o l u n t a r y hospitals a n d a n o t h e r o n e f o u r t h f r o m p r o p r i e t a r y hospitals. Of the small n u m b e r discharged f r o m m u n i c i p a l hospitals, almost o n e t h i r d w e r e a c c i d e n t cases. 3 Table

3.3. D I S T R I B U T I O N BY H O S P I T A L O W N E R S H I P OF N O N RESIDENT DISCHARGES FROM GENERAL-CARE H O S P I T A L S , N E W Y O R K CITY, 1957

Hospital

Ownership

All hospitals Voluntary Private and semiprivate Ward Municipal Proprietary

Number

Percent

91,000 67,000 59,000 8,000 2,000 22,000

100.0 73.6 64.8 8.8 2.2 24.2

SOURCE: See T a b l e 3.2.

N i n e t e n t h s of all n o n r e s i d e n t s w e r e d i s c h a r e d f r o m p r i v a t e ( i n c l u d i n g s e m i p r i v a t e ) a c c o m m o d a t i o n s . T h e p r o p o r t i o n of private p a t i e n t s a m o n g N e w York City residents is, t h e r e f o r e , lower t h a n a m o n g all p a t i e n t s hospitalized in N e w Y o r k City. T h e e t h n i c c o m p o s i t i o n of n o n r e s i d e n t p a t i e n t s may b e inferr e d f r o m t h e data o n live b i r t h s . I n the p e r i o d S e p t e m b e r - N o v e m ber, 1956, P u e r t o R i c a n a n d n o n w h i t e s c o n s t i t u t e d only 2 p e r c e n t of all live b i r t h s to n o n r e s i d e n t s in hospitals in N e w York City. 4 T h e r e is s o m e i n d i c a t i o n in t h e b i r t h statistics t h a t t h e n u m b e r of s u b u r b a n residents receiving care in N e w York City hospitals m a y b e d e c l i n i n g . 5 T h i s is associated w i t h the e x p a n s i o n of hospitals in the s u b u r b s . Ethnic

Status

C o m p l e t e , or nearly c o m p l e t e , i n f o r m a t i o n o n t h e e t h n i c status of p a t i e n t s in hospitals in N e w York City b e c a m e available f o r the first t i m e f r o m the H o s p i t a l Discharge S t u d y of 1933. At that t i m e N e g r o e s c o n s t i t u t e d 14 p e r c e n t of t h e p a t i e n t s discharged f r o m m u n i c i p a l general hospitals a n d 3 p e r c e n t of the p a t i e n t s discharged f r o m v o l u n t a r y general hospitals—less t h a n 0.5 p e r c e n t of those discharged f r o m p r i v a t e a n d s e m i p r i v a t e services a n d 4 p e r c e n t of those discharged f r o m the w a r d . 6 N e g r o e s t h e n

P A T I E N T S IN S H O R T - T E R M

HOSPITALS

97

constituted approximately 5 percent of the population of New York City. 7 Proprietary hospitals did not participate in the Hospital Discharge Study. For them there is no information on the ethnic composition of patients until the year 1951. For the period between 1933 and 1951 there are no data on the ethnic composition of patients in voluntary hospitals. T h e r e is, however, an intervening estimate for municipal hospitals: in 1946 nonwhites constituted 31 percent of all discharges from municipal general care hospitals. 8 THE YEAR 1 9 5 1

For 1951 a sample of persons hospitalized in New York City has been tabulated by hospital ownership and by ethnic status. T h e data were obtained in the course of a household survey conducted in 1952 by a special committee of the Health Insurance Plan of Greater New York (HIP) and were made available to the Hospital Council. Table

3.4. D I S T R I B U T I O N BY H O S P I T A L O W N E R S H I P OF P U E R T O RICAN, N O N W H I T E , A N D O T H E R W H I T E RESIDENT A D M I S S I O N S , N E W Y O R K CITY, 1951

Hospital Ownership N u m b e r in sample (all hospitals) Percent Voluntary Municipal Proprietary

Total 882

Puerto

Rican 33

Nonwhite 114

Other

White

735

58.0 23.8 18.2

30.4 57.5 12.1

22.8 76.3 0.9

64.6 14.2 21.2

100.0

100.0

100.0

100.0

SOURCE: Punch cards from Household Survey conducted by Health Insurance Plan of Greater New York.

T h e complete sample of hospitalized residents of New York City amounted to 939. Included are 2 percent who were admitted to Federal and State hospitals and 4 percent who were admitted to hospitals outside the city. T h e latter equals almost 40 percent of the n u m b e r of nonresidents hospitalized in New York City. T a b l e 3.4 shows that in 1951 three fourths of the nonwhites admitted to hospitals in New York City received care in municipal

98

BACKGROUND

hospitals a n d the r e m a i n d e r in v o l u n t a r y hospitals. P u e r t o Ricans received m o r e t h a n one half of their care in m u n i c i p a l hospitals a n d most of the r e m a i n d e r in v o l u n t a r y hospitals. (In view of the size of the sample, the d i s t r i b u t i o n of P u e r t o R i c a n p a t i e n t s by hospital o w n e r s h i p m a y n o t b e reliable.) N o n - P u e r t o Rican whites received two thirds of t h e i r care in v o l u n t a r y hospitals and a n o t h e r one fifth in p r o p r i e t a r y hospitals. W h a t was the e t h n i c composition of resident p a t i e n t s in each hospital system in 1951? T o answer this q u e s t i o n percentages are d i s t r i b u t e d by e t h n i c g r o u p . Table

3.5. D I S T R I B U T I O N BY E T H N I C S T A T U S O F R E S I D E N T A D M I S S I O N S T O V O L U N T A R Y , M U N I C I P A L , A N D PROP R I E T A R Y H O S P I T A L S , N E W Y O R K C I T Y , 1951 Total

Hospital Ownership

Number in Sample Percent

All hospitals Voluntary Municipal Proprietary

882 511 210 161

100.0 100.0 100.0 100.0

Percent Puerto 3.7 2.0 9.1 2.5

Rican Nonwhite 12.9 5.1 41.4 0.6

Other

White

83.4 92.9 49.5 96.9

SOURCE: S e e T a b l e 3.4.

P u e r t o R i c a n p a t i e n t s c o n s t i t u t e d almost o n e t e n t h of the admissions to m u n i c i p a l hospitals a n d only 2 p e r c e n t of the admissions to v o l u n t a r y hospitals. N o n w h i t e s were m o r e t h a n two fifths of the admissions to m u n i c i p a l hospitals a n d 5 p e r c e n t of the admissions to v o l u n t a r y hospitals. In c o m b i n a t i o n , P u e r t o Rican and n o n w h i t e patients are shown to have c o n s t i t u t e d in 1951 m o r e t h a n one half of the admissions to m u n i c i p a l hospitals; this may b e an o v e r s t a t e m e n t of the t r u e facts (see A p p e n d i x 3.C). An obvious s h o r t c o m i n g of the above d a t a on hospital admissions, a p a r t f r o m the size of sample, is the lack of a breakdown b e t w e e n private ( i n c l u d i n g semiprivate) a n d w a r d patients in voluntary hospitals. T H E YEAR 1 9 5 7

T h i s deficiency is r e m e d i e d in the estimates d e v e l o p e d for the year 1957. Admissions to general-care hospitals were distributed

PATIENTS IN S H O R T T E R M

99

HOSPITALS

by e t h n i c status a n d by hospital o w n e r s h i p a n d type of accommod a t i o n on the basis of d a t a and according to procedures described in A p p e n d i x 3.C. Table

3.6. D I S T R I B U T I O N O F P U E R T O R I C A N , N O N W H I T E , A N D O T H E R W H I T E A D M I S S I O N S T O G E N E R A L - C A R E HOSP I T A L S BY H O S P I T A L O W N E R S H I P A N D T Y P E OF A C C O M M O D A T I O N , N E W Y O R K C I T Y , 1957 Puerto

Total

Rican

Hospital Ownership All hospitals Voluntary Private and

Number 962,400 584,100

Percent 100.0 CO.7

Number 78,100 34,600

Percent 100.0 44.3

semiprivate Ward Municipal Proprietary

392,600 191,500 208,900 169,400

40.8 19.9 21.7 17.6

5,900 28,700 41,800 1,700

7.6 36.7 53.5 2.2

Nonwhite NumPerber cent 132,000 100.0 48,200 36.5 11,800 36,400 79,500 4,300

8.9 27.6 60.2 3.3

Other

White

Number 752,300 501,300

Percent 100.0 66.7

374,900 126,400 87,600 163,400

49.9 16.8 11.6 21.7

SOURCE: See A p p e n d i x 3.C.

I n c o m p a r i s o n with 1951, v o l u n t a r y hospitals played a larger role in 1957 for each e t h n i c g r o u p , whereas the role of m u n i c i p a l hospitals was smaller. I n p a r t this is a t r u e difference, a n d in part it reflects the inclusion of n o n r e s i d e n t s in the 1957 data; nonresidents c o n s t i t u t e a significant p r o p o r t i o n of patients in v o l u n t a r y hospitals a n d a negligible one in m u n i c i p a l hospitals. T h e differences b e t w e e n 1951 a n d 1957 shown for p r o p r i e t a r y hospitals are probably n o t real b u t reflect the influence of large s a m p l i n g variation in the 1951 data. M u n i c i p a l hospitals r e p o r t e d 22 p e r c e n t of all admissions in 1957. T h e i r relative i m p o r t a n c e to the e t h n i c g r o u p s varied f r o m 12 p e r c e n t for n o n - P u e r t o Rican w h i t e patients to m o r e t h a n 50 percent f o r P u e r t o Ricans and 60 percent for n o n w h i t e s . Conversely, p r o p r i e t a r y hospitals, with 18 percent of all admissions, accounted for 22 p e r c e n t of n o n - P u e r t o R i c a n w h i t e patients and for only 2 or 3 p e r c e n t of P u e r t o R i c a n and n o n w h i t e patients. V o l u n t a r y hospitals were of substantial i m p o r t a n c e to each e t h n i c group, r a n g i n g f r o m as m a n y as two thirds of n o n - P u e r t o R i c a n white admissions to just over o n e t h i r d of n o n w h i t e admissions. T h e b r e a k d o w n in 1957 b e t w e e n the private ( i n c l u d i n g semi-

BACKGROUND

100

private) and ward services in voluntary hospitals is new. Five sixths of Puerto Rican admissions to voluntary hospitals were ward patients, as were three fourths of nonwhite admissions. By contrast, only one fourth of n o n - P u e r t o Rican white admissions to voluntary hospitals were ward patients. Admissions to the wards of voluntary hospitals were almost equal in n u m b e r to admissions to municipal hospitals. T h e two ward systems were not, however, equally important to the three ethnic groups. Municipal hospitals cared for almost 70 percent of nonwhite ward patients, 60 percent of Puerto Rican ward patients, and 40 percent of n o n - P u e r t o Rican white ward patients. Patients in the wards of both hospital systems comprise the following proportions of all patients in the three ethnic groups: Puerto Rican, 90 percent; nonwhite, 88 percent; other white, 28 percent. In summary, the proportion of Puerto Rican patients receiving care in wards is approximately the same as for nonwhites but three times as high as for n o n - P u e r t o Rican whites. Among ward patients a majority of n o n - P u e r t o Rican whites (60 percent) use voluntary hospitals, and a majority of Puerto Ricans and of nonwhites (60 percent or more) use municipal hospitals. T h e proportion of ward patients using municipal hospitals is higher for nonwhites than for Puerto Ricans. What was the ethnic composition of patients admitted to each hospital system in 1957 and to each type of accommodation? Table 3.7. D I S T R I B U T I O N BY E T H N I C STATUS OF ADMISSIONS T O VOLUNTARY, MUNICIPAL, AND PROPRIETARY GENERALCARE HOSPITALS, NEW YORK CITY, 1957 Total Hospital Ownership Number Percent All hospitals 962,400 100.0 Voluntary 584,100 100.0 Private and semiprivate 392,600 100.0 Ward 191,500 100.0 Municipal 208,900 100.0 Proprietary 169,400 100.0 SOURCE: Table 3.6.

Percent Puerto Rican Nonwhite 8.0 14.0 6.0 8.0 1.5 15.0 20.0 1.0

3.0 19.0 38.0 2.5

Other White 78.0 86.0 95.5 66.0 42.0 96.5

P A T I E N T S IN S H O R T - T E R M

HOSPITALS

101

P r o p r i e t a r y hospitals had relatively few P u e r t o Rican a n d nonw h i t e patients in 1957. T o g e t h e r P u e r t o Rican and n o n w h i t e patients c o n s t i t u t e d almost three fifths of the admissions to m u n i c i p a l general-care hospitals and 14 percent of the admissions to voluntary generalcare hospitals. In the latter system P u e r t o Rican and n o n w h i t e patients constituted fewer than 5 percent of private ( i n c l u d i n g semiprivate) admissions and 34 percent of ward admissions. S u p p l e m e n t a r y data for one g r o u p of voluntary general hospitals indicate that a m o n g public-charge patients, the c o m b i n e d p r o p o r t i o n of P u e r t o Ricans and nonwhites to total is 40 percent. 9 T h i s is a somewhat higher figure t h a n for all ward patients in v o l u n t a r y hospitals b u t m u c h lower than for the patients in municipal hospitals—58 percent. USE

OF

HOSPITALS

BY

NONWHITES

N o n w h i t e s constituted 38 percent of the discharges f r o m m u n i cipal hospitals in 1957, compared with 14 percent in 1933. T h i s marks an increase of 170 percent. T h e i r rate of increase in volu n t a r y hospitals was a p p r o x i m a t e l y the same—from 3 p e r c e n t of the total in 1933 to 8 percent in 1957. T h e i r rate of increase in the wards of voluntary hospitals was m u c h greater—from 4 p e r c e n t of the total to 19 percent. Still, in 1957 the p r o p o r t i o n of nonwhite patients was only one half as large in the wards of v o l u n t a r y hospitals as in m u n i c i p a l hospitals. T a b l e 3.7 also shows that in 1957 nonwhites comprised 14 percent of all admissions to short-term hospitals in N e w York City. T h i s is higher than their p r o p o r t i o n in the p o p u l a t i o n in 1957—12 percent. A high b i r t h rate accounts for a significant fraction, perhaps one half, of the relative excess in hospital admissions. It has been suggested that some fraction of the excess may represent readmissions owing to adverse socioeconomic circumstances. 1 0 T h e conclusion that nonwhites in N e w York City tend to use more hospital care than o t h e r groups in the p o p u l a t i o n is c o n f i r m e d by earlier studies on hospital admissions or discharges. In 1951, for example, as shown by T a b l e 3.5, nonwhites constituted 13 percent of all resident admissions to voluntary, m u n i c i p a l , a n d

102

BACKGROUND

proprietary hospitals in the city. If other hospitals in a n d o u t of the city are also considered, nonwhites constituted 12.5 percent of all admissions by N e w Y o r k City residents. T h e y constituted 9.5 percent of the city's p o p u l a t i o n in 1950. 1 1 In 1935-36 the N a t i o n a l H e a l t h Survey m e a s u r e d m o r b i d i t y a n d the use of medical a n d hospital services by p o p u l a t i o n g r o u p s . N e g r o e s in N e w Y o r k City were f o u n d to use 20 percent m o r e hospital care than whites. 1 2 In 1933 nonwhites constituted 5 percent of the p o p u l a t i o n of N e w Y o r k City a n d a c c o u n t e d for 8 percent of the discharges f r o m voluntary a n d m u n i c i p a l general hospitals. 1 3 H a d proprietary hospitals b e e n included, the p r o p o r t i o n of nonwhite discharges w o u l d have b e e n u n d e r 8 percent b u t p r o b a b l y no less than 7 percent. I N F L U E N C E O F E T H N I C S T A T U S IN D I S T R I B U T I N G

PATIENTS

Differences in ethnic c o m p o s i t i o n of patients stem in part from patients' differences in i n c o m e a n d in health insurance enrollment, as discussed in C h a p t e r 1. T h e q u e s t i o n arises whether ethnic status also exerts an influence of its own in the d i s t r i b u t i o n of patients a m o n g hospital systems and between types of accomm o d a t i o n . Several studies shed light on this question. F o r e x a m p l e , o n e study of obstetrical care in N e w York City f o u n d that P u e r t o R i c a n s a n d nonwhites m a k e less use of private physicians than d o " o t h e r w h i t e " patients. In 1955, 83 percent of n o n - P u e r t o R i c a n white live births were attended by private physicians, c o m p a r e d with only 11 percent for nonwhite births a n d 5 percent for P u e r t o R i c a n births. Moreover, a m u c h higher proportion of " o t h e r w h i t e " births with fathers in a low occupational status (laborers a n d others) had a private physician than did P u e r t o R i c a n a n d n o n w h i t e births with fathers in a high occupational status (professional, m a n a g e r i a l , a n d technical). 1 4 It is possible to isolate the ethnic factor to s o m e degree by holding income constant. T h i s can be d o n e by studying the distribution a m o n g hospitals a n d between a c c o m m o d a t i o n s of persons a d m i t t e d to hospitals from low-income p u b l i c housing projects, in which tenants' i n c o m e is u n i f o r m l y low. F o r a g r o u p of h o u s i n g projects in the northern half of Man-

103

PATIENTS IN SHORT-TERM HOSPITALS

h a t t a n these were the findings regarding the use of wards in the two hospital systems:

Ethnic Status

Puerto Rican Nonwhite Other white

Proportion (Percent) Ward to Total Admissions

90 90 85

Proportion (Percent) Municipal to All Ward Admissions

40 72 42

T h e r e was a small difference a m o n g the three e t h n i c groups in the e x t e n t to which they used ward accommodations.

There

was, however, a large difference b e t w e e n nonwhites and the others in the e x t e n t to which they used m u n i c i p a l hospitals. i n a similar study of hospital admissions f r o m a poor neighb o r h o o d in which b o t h voluntary and m u n i c i p a l hospitals are accessible, the Hospital C o u n c i l f o u n d that the p r o p o r t i o n

of

patients with B l u e Cross insurance using the ward was a b o u t twice as high as in the city as a whole. 1 5 F u r t h e r m o r e ,

public

h o u s i n g tenants with B l u e Cross insurance who use the ward are m u c h m o r e likely to go to a voluntary hospital than to a municipal hospital. T h e ratio was of the o r d e r of three to one. 1 0 A study of patients in a g r o u p of n i n e voluntary general hospitals found wide variations a m o n g the three e t h n i c groups in the p r o p o r t i o n of patients with B l u e Cross insurance who use the ward. A m o n g n o n - P u e r t o R i c a n white patients with B l u e Cross 10 to 15 percent use the ward; a m o n g nonwhites the proportion exceeds 50 p e r c e n t ; and a m o n g P u e r t o R i c a n s , it reaches 7 0 percent.17 T h e tendency for n o n w h i t e patients to m a k e greater use of m u n i c i p a l hospitals than their white n e i g h b o r s is n o t new. Analysis of u n p u b l i s h e d data for 1933 yields the same result. A t that time the tendency was perhaps even stronger than today. 1 8 T h e r e is o n e f u r t h e r aspect of the use of m u n i c i p a l hospitals that merits a t t e n t i o n . Because they are disproportionately used by nonwhites, w h o are a relatively y o u n g e r p o p u l a t i o n ,

municipal

hospitals would b e e x p e c t e d to have a h i g h e r p r o p o r t i o n of nonwhite discharges in the y o u n g e r ages than in the older ages. T h i s effect is a c c e n t u a t e d by the tendency of white patients in m u n i c ipal hospitals to c o n c e n t r a t e in the o l d e r ages. I n c o n s e q u e n c e ,

BACKGROUND

104

age class 15—44 in m u n i c i p a l general hospitals c o n t a i n s m o r e n o n w h i t e t h a n w h i t e discharges, b u t age class 65 a n d o v e r cont a i n s six times as m a n y w h i t e discharges as n o n w h i t e . 1 9 Age

Composition

A g e d persons (65 years a n d over) stay l o n g e r in t h e h o s p i t a l t h a n o t h e r p a t i e n t s . T h e y are m o r e likely to suffer f r o m m e d i c a l c o n d i t i o n s that r e q u i r e p r o l o n g e d t r e a t m e n t a n d to b e w i t h o u t a s u i t a b l e h o m e . T h e y m a y pose a discharge p r o b l e m w h e n definitive care in t h e hospital is c o m p l e t e d . I n c o n s e q u e n c e of t h e i r l o n g e r stay t h e aged c o n s t i t u t e a h i g h e r p r o p o r t i o n of t h e p a t i e n t census of a hospital o n a given day t h a n of the p a t i e n t s a d m i t t e d to, o r discharged f r o m , t h e hospital d u r i n g a t i m e i n t e r v a l . T h e t w o ways of l o o k i n g at t h e age c o m p o s i t i o n of p a t i e n t s a r e u s e f u l f o r d i f f e r e n t purposes, b u t they s h o u l d b e clearly d i s t i n g u i s h e d . I n this r e p o r t t h e o n e will b e d e s i g n a t e d "one-day p a t i e n t census" a n d t h e o t h e r , "discharges o r admissions." DATA FOR EARLIER YEARS

D i s t r i b u t i o n s of discharges by age class are a v a i l a b l e f o r t h e year 1933 f o r v o l u n t a r y a n d m u n i c i p a l hospitals b u t n o t f o r prop r i e t a r y hospitals. T h e 1933 data reflect t h e p a t t e r n of hospitalizat i o n at t h e d e p t h of t h e depression. L i t t l e w o u l d b e g a i n e d today f r o m a d e t a i l e d c o m p a r i s o n of the age c o m p o s i t i o n of p a t i e n t s in m u n i c i p a l a n d v o l u n t a r y hospitals at that t i m e . T h e 1933 d i s t r i b u tions of discharges by age class are t h e r e f o r e p r e s e n t e d in A p p e n d i x 3.D (see T a b l e 3.18). It was possible to d e v e l o p d i s t r i b u t i o n s of hospital a d m i s s i o n s by age f o r all t h r e e hospital systems for t h e year 1951. T h e data are t a k e n f r o m t a b u l a t i o n s of p u n c h cards f u r n i s h e d by H I P . Because of certain l i m i t a t i o n s i n h e r e n t in h o u s e h o l d surveys (mostly, omission of the hospitalization e x p e r i e n c e of p e r s o n s w h o d i e d d u r i n g the survey period), t h e d i s t r i b u t i o n s a r e clearly deficient in t h e o l d e r ages. Accordingly, these d a t a are p r e s e n t e d f o r t h e record in A p p e n d i x 3.D (see T a b l e 3.19). D i s t r i b u t i o n s of a one-day p a t i e n t census by age a r e available f o r the fall of 1953. H o s p i t a l s w e r e r e q u e s t e d to s u b m i t a n age d i s t r i b u t i o n of p a t i e n t s as of a given d a t e to t h e A m e r i c a n M e d i c a l

P A T I E N T S IN S H O R T T E R M HOSPITALS

105

Association, 20 which furnished the Hospital Council with the machine tabulations for all hospitals in New York City that completed the questionnaire. Table

3.8. P E R C E N T A G E D I S T R I B U T I O N BY A G E G R O U P O F O N E DAY P A T I E N T CENSUS IN V O L U N T A R Y , MUNICIPAL, A N D PROPRIETARY GENERAL-CARE HOSPITALS, N E W Y O R K C I T Y , 1953

Age Group (Years)

Voluntary

0-14 15-44 45-64 65 and over

Municipal

Proprietary

11.1 36.1 33.0 19.8

12.8 29.7 29.1 28.4

6.6 45.2 36.4 11.8

100.0

100.0

100.0

SOURCE: American Medical Association, unpublished data for New York City hospitals collected through special questionnaire. See Frank G. Dickinson, Age and Sex Distribution of Hospital Patients (Bulletin 97; Chicago, Bureau of Medical Economic Research, American Medical Association, 1955).

In 1953 municipal hospitals had the highest proportion of aged patients and proprietary hospitals had the lowest, with voluntary hospitals in the intermediate position. Municipal hospitals also had the highest proportion of children, and proprietary hospitals again had the lowest proportion. In age class 15-44 proprietary hospitals had the highest proportion by far. T h i s was in large part attributable to their high proportion of obstetrical patients at that time. In the 1953 survey voluntary hospitals were not asked to distinguish between private and ward services. It is, therefore, not possible to compare the age composition of patients in municipal hospitals with that in wards of voluntary hospitals. DATA FOR RECENT YEARS

For 1957 and 1958 it was possible to develop selected distributions by age class of a one-day patient census and of admissions (or discharges). Private and ward patients in voluntary hospitals are presented separately. 1. Admissions to voluntary general hospitals for the year 1958 and discharges from municipal hospitals for 1957. T h e r e is no comparable distribution for proprietary hospitals. 2. One-day patient census in voluntary, municipal, and pro-

BACKGROUND

106

prietary hospitals in 1958. T h e s e are estimates developed separately for each hospital system, as described in Appendix 3.D. (Appendix 3.D also contains Tables 3.20 and 3.21, with selected distributions of patients by age class for intervening years.) Discharges from, or Admissions to, Hospitals. T a b l e 3.9 shows admissions to voluntary hospitals in 1958 and discharges from municipal hospitals in 1957. Voluntary hospitals had a lower proTable

3.9. PERCENTAGE D I S T R I B U T I O N BY AGE GROUP OF ADMISSIONS T O VOLUNTARY GENERAL HOSPITALS BY TYPE OF ACCOMMODATION, AND OF DISCHARGES FROM MUNICIPAL GENERAL HOSPITALS, NEW YORK CITY, 1958 AND 1957 Admissions,

Age Group (Years) 0-14' 15-44* 45-64

65 and over

Voluntary Hospitals, 1958

Total 14.9 44.4 27.4 13.8

Private 3.7 40.1 37.1 19.1

Semiprivate 12.9 45.5 29.6 12.0

100.0

100.0

100.0

Private and Semiprivate 11.9 44.7 30.5 12.9

General Ward 22.5 43.8 19.7 14.0

100.0

100.0

Discharges, Municipal Hospitals, 1957 15.7 48.3 17.9 18.1

100.0

• I n voluntary hospitals the age breakdown is 0-12 and 15-44. SOURCES: United Hospital F u n d of New York, Central T a b u l a t i n g Service Bureau, u n p u b l i s h e d tabulations for 33 subscriping general hospitals in New York City, 1958; and Hospital Morbidity R e p o r t i n g , J o i n t Project of the New York City Dep a r t m e n t s of H e a l t h a n d Hospitals, Bulletins, 1-11, special reports, and tabulations, p r e p a r e d by Marta Fraenkel (New York, 1957-58; mimeographed).

portion of aged and of children than municipal hospitals. T h e semiprivate service is chiefly responsible for the former and the private service for the latter. T h e proportion of aged patients in municipal hospitals was higher than in the wards of voluntary hospitals b u t lower t h a n in the private service of voluntary hospitals. It is now possible to compare trends in the population of New York City and in each hospital system with respect to the aged. Between 1933 and 1957 the proportion of aged in the population rose from approximately 4.5 percent (3.8 percent in 1930 and 5.6 percent in 1940) to 9 percent, that is, it doubled. During this period the proportion of aged to total discharges or admissions rose from 5 percent to 13 percent in voluntary general hospitals and from 6.5 percent to 18 percent in municipal general hospitals.

P A T I E N T S IN S H O R T - T E R M H O S P I T A L S

107

It is concluded that (1) the proportion of aged among hospital patients rose faster than in the population at large and (2) that the proportion of aged patients rose at the same rate in each hospital system. One-Day Patient Census. T a b l e 3.10 shows for the year 1958 the estimated age composition of a one-day patient census in each hospital system and type of accommodation. A more detailed breakdown of age class 65 and over is presented in another report. 21 Table

3.10. D I S T R I B U T I O N OF AGE G R O U P S IN ONE-DAY P A T I E N T CENSUS IN G E N E R A L - C A R E H O S P I T A L S BY H O S P I T A L O W N E R S H I P A N D T Y P E OF A C C O M M O D A T I O N , N E W YORK CITY, 1958 Ail Ages

Hospital NumOwnership ber All hospitals 29,215 Voluntary 17,098 Private and semiprivate 10,353 Ward 6,745 Municipal 8,930 Proprietary 3,247 SOURCE: See Appendix

0-14

Age Group

{Years)

15-44

45-64

65 and

over

Per- Num- Per- Num- Per- Num- Per- NumPercent ber cent ber cent ber cent ber cent 100.0 2,948 100.0 9,444 100.0 9,873 100.0 7,010 100.0 58.3 1,682 57.1 5,562 58.9 6,049 61.3 3,805 54.3

35.3 23.0 30.5 11.2 3.D.

570 1,112 1,072 194

19.3 3,471 37.8 2,091 36.3 2,680 6.6 1,202

36.8 4,093 22.1 1,956 28.4 2,589 12.7 1,235

41.5 2,219 19.8 1,586 26.2 2,589 12.5 616

31.7 22.6 36.9 8.8

In every age class voluntary hospitals had a majority of the patients, ranging from 54 percent in age class 65 and over to 61 percent in age class 45-64. Among ward patients municipal hospitals had a majority in three of the four age classes, children being the exception. If patients in each age class are classified by type of accommodation, the highest proportion of ward patients is among children, not among the aged, as one might expect. Age Class 0-14 years 15-44 45-64 65 and over All ages

Proportion (Percent) Ward to Total Patients 74.0 50.5 46.0 59.5 53.5

BACKGROUND

108

O n e reason for the high proportion of ward patients among children is that most pediatric facilities in voluntary hospitals are classified as ward accommodations. H o w were the patients in each hospital system and type of accommodation distributed by age? M u n i c i p a l hospitals had a Table

3.11. D I S T R I B U T I O N BY AGE G R O U P OF ONE-DAY P A T I E N T CENSUS IN V O L U N T A R Y , MUNICIPAL, AND P R O P R I E T A R Y G E N E R A L - C A R E HOSPITALS, N E W Y O R K CITY, 1958 Percent in Age Group

All Ages Hospital Ownership Number All hospitals 29,275 Voluntary 17,098 Private and semiprivate 10,353 Ward 6,745 Municipal 8,930 Proprietary 3,247

Percent 100.0 100.0 100.0 100.0 100.0 100.0

0-14 10.0 9.8 5.5 16.5 12.0 6.0

(Years)

15-44

45-64

65 and over

323 32.5 33.5 31.0 30.0 38.0

33.7 35.4 39.5 29.0 29.0 37.0

24.0 22.3 21.5 23.5 29.0 19.0

SOURCE: T a b l e 3 . 1 0 .

higher proportion of aged and of children than did proprietary or voluntary hospitals. Proprietary hospitals had the lowest proportion of aged and, along with the private (including semiprivate) service of voluntary hospitals, had

the

lowest proportion

of

children. It should be added that public-charge patients in voluntary hospitals have a higher proportion of aged than the other ward patients in voluntary hospitals b u t a lower proportion than patients in municipal hospitals. Table 3.12. P E R C E N T A G E D I S T R I B U T I O N BY AGE G R O U P OF ONE DAY P A T I E N T CENSUS IN WARDS OF V O L U N T A R Y AND M U N I C I P A L G E N E R A L CARE HOSPITALS, N E W Y O R K CITY, 1958 Voluntary Hospital Age Group (Years) 0-14 15-44 45-64 65 and over

Wards

Other than Public Charges 17.3 31.1 31.6 20.0

Public Charges 15.9 30.7 27.5 25.9

Municipal Hospitals 12.0 30.0 29.0 29.0

100.0

100.0

100.0

SOURCES: See Appendix 3.D and T a b l e 3.11.

P A T I E N T S IN S H O R T - T E R M

109

HOSPITALS

It was possible to estimate the n u m b e r and p r o p o r t i o n of aged a m o n g patients in r e c e i p t of p u b l i c assistance in each hospital system (see A p p e n d i x 3.A). T h e proportions are shown

below

both for discharges and for patient days: Proportion (Percent) Public-Assistance in General-Care Category

Voluntary

Discharges Patient days

14 30

I n each hospital

system

the proportion

of Aged among Recipients Hospitals Municipal 19 44

of aged

discharges

a m o n g public-assistance recipients is a p p r o x i m a t e l y the same as the proportion of aged a m o n g all ward discharges ( T a b l e

3.9).

However, the p r o p o r t i o n of all patient days used by the aged is m u c h h i g h e r for public-assistance recipients than for ward patients (see T a b l e 3.11). It follows that the average d u r a t i o n of hospital stay of aged persons on p u b l i c assistance is m u c h longer than that of o t h e r aged patients in the ward. Length

of Patient

Stay

O n e well-known difference a m o n g patients in voluntary, municipal, and proprietary hospitals is in the average length of patient stay. S i m i l a r , b u t smaller, differences also o b t a i n

between

private ( i n c l u d i n g semiprivate) and ward patients in voluntary hospitals. In 1958 the average length of stay of general-care patients in New York City hospitals was as follows: Voluntary hospitals, all services Private and semiprivate service Ward service Municipal hospitals Proprietary hospitals All hospitals

Days 10.0 9.1 11.8 13.8 6.9 10.3

T h e average length of stay of public-charge patients in voluntary hospitals was 13.2 days—1.4 days m o r e than that of all patients in voluntary hospital wards. T h i s difference, which reflects differences between p u b l i c charges and o t h e r ward patients in almost every clinical service, has b e e n constant for f o u r years. 2 2 A t the same time the difference in average length of stay between public-

110

BACKGROUND

charge patients in voluntary and municipal hospitals has been steadily narrowing. It has long been accepted that the diagnosic composition of patients (the proportion of patients admitted for tonsillectomy or obstetrics, on the one hand, and neurology or orthopedic surgery, on the other hand) is an important cause of differences among hospitals in average length of patient stay. Also important are the socioeconomic circumstances of the patient and his family, for these bear on the availability of a home to which the patient can be discharged and on the likelihood of the patient's having received a prior diagnostic evaluation, so that he is ready for treatm e n t u p o n admission. Recently data have appeared that show persistent differences among local hospital systems in the average length of stay of patients with the same diagnostic condition. 2 3 T h e implications of these findings are not clear, in the absence of information regarding possible differences among the hospital systems' patients in the complexity of their diagnostic problems and in the presence of associated medical conditions. Only this year have data appeared that point to differences among the regions of this country in average length of stay of patients with identical diagnostic condition and with membership in the same medical care plan. 24 Such geographic differences in patient stay apparently reflect differences in medical practice, about which relatively little can be said with assurance at this time. Differences in average length of patient stay typically reflect consistent differences in the distribution of discharged patients by length of stay. For municipal hospitals distributions of patients by length of stay have been available for several years, as a result of the work of the Hospital Morbidity Reporting Project. Distributions for all three hospital system are available only for the year 1951 and are presented in T a b l e 3.13. These distributions suffer from the usual limitations of the household survey in reporting hospital use. Seventeen percent of the patients discharged from municipal hospitals remained 21 days or longer; 12 percent of the patients in voluntary hospitals and 2 percent of the patients in proprietary hospitals stayed as long. Similarly, seven tenths of the patients dis-

P A T I E N T S IN S H O R T - T E R M HOSPITALS Table

111

3.13. D I S T R I B U T I O N BY L E N G T H OF STAY OF DISCHARGES FROM VOLUNTARY, MUNICIPAL, AND P R O P R I E T A R Y HOSPITALS, NEW YORK CITY, 1951

Length of Stay Number in sample (all discharges) Percent 1 - 2 days 5 - 6 days 7-13 days 14-20 days 21 days or more Average (mean) number of days

Total 856

Voluntary

Municipal

Proprietary

500

199

157

14.0 30.3 34.8 9.5 11.4

13.6 27.6 37.0 9.6 12.2

12.0 31.7 27.2 12.0 17.1

17.8 37.0 37.6 5.7 1.9

100.0

100.0

100.0

100.0

11.0

10.8

14.0

6.5

SOURCE: P u n c h cards from Household Survey conducted by Health Insurance Plan of Greater New York.

charged from municipal hospitals left within 13 days; this compares with almost eight tenths for voluntary hospitals and more than nine tenths for proprietary hospitals. A distribution of patient days by the length of stay of discharged patients shows that long-stay patients, who constitute a small proportion of all patients, account for a large proportion of total patient days. Table

3.14. D I S T R I B U T I O N BY L E N G T H OF STAY OF P A T I E N T DAYS O F DISCHARGED P A T I E N T S , VOLUNTARY, MUNICIPAL, AND P R O P R I E T A R Y HOSPITALS, NEW YORK CITY, 1951

Length of Stay Number of days in sample (all discharges) Percent 1 - 2 days 3 - 6 days 7-13 days 14-20 days 21 days or more SOURCE:

Total

Voluntary

Municipal

Proprietary

9,434

5,442

2,940

1,052

1.6 13.3 28.2 14.6 42.3

1.5 12.5 30.4 15.0 40.6

1.1 10.6 16.8 13.9 57.6

3.3 25.4 48.2 14.6 8.5

100.0

100.0

100.0

100.0

See Table J.13.

It is sometimes useful to separate the total stay of long-stay patients into two parts: the number of days incurred prior to a specified length of stay and the number of days incurred after that.

112

BACKGROUND

In the above d i s t r i b u t i o n s patients who stayed 21 days or longer constituted 11 percent of all discharges a n d a c c o u n t e d for 42 percent of all p a t i e n t days—21 percent p r i o r to the twenty-first day a n d 21 percent afterward. T h i s distinction is i m p o r t a n t in evalua t i n g the possibilities of r e d u c i n g hospital use, since a saving at the terminal end of a patient's stay is p e r h a p s m o r e likely t h a n the e l i m i n a t i o n of his e n t i r e hospital stay. (See also comparisons of hospital admission rate a n d length of stay in N e w York City a n d U n i t e d States in C h a p t e r 2.) F o r the year 1957 distributions of discharged patients by length of stay are available for patients in receipt of O l d Age Table

3.15. P E R C E N T A G E D I S T R I B U T I O N B Y L E N G T H O F S T A Y O F O L D AGE ASSISTANCE RECIPIENTS, G E N E R A L CARE VOLUNTARY AND MUNICIPAL HOSPITALS, N E W Y O R K C I T Y , 1957

Length of Stay (Days)

Voluntary

Municipal

All discharges 0-14 15-19 20-29 30-59 60-89 9 0 a n d over

100.0 48.1 12.4 14.9 16.6 4.4 3.6

100.0 44.0 9.3 13.7 20.4 6.6 6.0

SOURCE: Sadie Zuchovitz a n d William K a u f m a n , Hospital Utilization by Recipients in the Public Assistance Programs in New York City, 1957 (Special Research a n d Statistical R e p o r t s No. 15; Albany, N. Y., New York State D e p a r t m e n t of Social W e l f a r e , I960).

Assistance. I n voluntary hospitals one f o u r t h of all discharged Old Age Assistance recipients stayed 30 days or longer; in m u n i c i p a l hospitals one t h i r d did so. Selected

Diagnostic

Categories

Detailed and c u r r e n t i n f o r m a t i o n on the diagnostic composition of patients is available only for m u n i c i p a l hospitals. For all hospital systems in N e w York City i n f o r m a t i o n is available for the year 1954 for selected diagnostic categories; these data were f u r n i s h e d the Hospital Council by the A m e r i c a n Medical Association (AMA). U n f o r t u n a t e l y , the q u e s t i o n n a i r e d i d n o t ask voluntary hospitals to distinguish between p a t i e n t s on private (including semiprivate) service a n d those on w a r d service.

PATIENTS IN SHORT-TERM HOSPITALS

113

Variations in the response rate may affect the reliability of the data. However, a comparison of the AMA data with those reported by the Hospital Morbidity Reporting Project for the municipal hospitals in the year 1956 shows no material differences, except for obstetrics. It is known that in recent years the n u m b e r and proportion of obstetrical patients have increased in municipal hospitals and declined in proprietary hospitals. In the instructions to hospitals the diagnostic categories were defined in terms of the codes of the Standard Nomenclature of Diseases and Operations and the International Statistical Classification of Diseases, Injuries and Causes of Death. For each patient only the primary diagnosis (the final diagnostic statement of the condition for which the patient was admitted to the hospital) was requested. 2 5 T a b l e 3.16 summarizes the data submitted to the American Medical Association by hospitals in New York City, expressing the n u m b e r of discharges in each diagnostic category as a rate per 100 total discharges. Table

3.16. R A T E P E R 100 D I S C H A R G E D P A T I E N T S F O R S E L E C T E D D I A G N O S T I C C A T E G O R I E S IN V O L U N T A R Y , M U N I C I PAL, A N D P R O P R I E T A R Y G E N E R A L C A R E H O S P I T A L S , N E W Y O R K C I T Y , 1954 Diagnostic

Category

T o n s i l l e c t o m i e s ( i n c l u d i n g tonsils and adenoids) Appendectomies M a l i g n a n t n e o p l a s t i c disease Cardiac disease Fractures Obstetrical ( e x c l u d i n g Caesarean section)

Voluntary 5.5 2.5 5 5 3 20

Municipal 1.5 0.7 6 10 6 17

Proprietary 8 4.5 2.5 4 2 23

SOURCE: American Medical Association, unpublished data for New York City hospitals collected through special questionnaire. See Frank G. Dickinson a n d James R a y m o n d , Some Categories of Patients Treated by Physicians in Hospitals (Bulletin 102; Chicago, Bureau of Medical Economic Research, American Medical Association, 1956).

T h e smallest differences among the three hospital systems are in the proportion of obstetrical patients to total. These have been f u r t h e r reduced in the interim, as previously noted. T h e largest differences occur in tonsillectomies and in appendectomies. T h e rate in proprietary hospitals exceeds that in municipal hospitals five or six times. Smaller differences—ratios of two or three to one

BACKGROUND

114

—occur in c a r d i a c disease, m a l i g n a n t n e o p l a s t i c disease, a n d fractures. H e r e m u n i c i p a l h o s p i t a l s have the highest rates a n d prop r i e t a r y h o s p i t a l s t h e lowest. D a t a c o m p u t e d f r o m a r e c e n t p u b l i c a t i o n by Associated Hosp i t a l Service of N e w Y o r k also show a s u b s t a n t i a l d i f f e r e n c e bet w e e n v o l u n t a r y a n d p r o p r i e t a r y hospitals in N e w York C i t y in t h e p r o p o r t i o n of t o n s i l l e c t o m i e s to total p a t i e n t s p a i d f o r by AHS—2.5 c o m p a r e d w i t h 6 p e r 100. 28 B o t h rates are l o w e r t h a n those r e p o r t e d in 1954 f o r all h o s p i t a l p a t i e n t s , regardless of pay status. How Many Patients

Do Not Belong

in the

Hospital?

O n v a r i o u s occasions e s t i m a t e s have b e e n given of t h e n u m b e r of p a t i e n t s in t h e w a r d s of v o l u n t a r y hospitals a n d in m u n i c i p a l h o s p i t a l s in N e w Y o r k C i t y w h o d o n o t r e q u i r e t h e services of a h o s p i t a l a n d c o u l d , t h e r e f o r e , b e discharged to a n o t h e r type of facility. U s u a l l y s u c h e s t i m a t e s are n o t m a d e s i m u l t a n e o u s l y f o r b o t h systems b y t h e s a m e p e r s o n o r t e a m a p p l y i n g u n i f o r m criteria. T h e H o s p i t a l S u r v e y f o r N e w York, w h i c h was c o n d u c t e d in t h e m i d d l e 1930s, d i d e x a m i n e p a t i e n t s in b o t h hospital systems at t h e same t i m e , b u t t h e s a m p l e was exceedingly small—admissions to selected services in f o u r hospitals in the single m o n t h of Nov e m b e r , 1935. O n t h e basis of f o r m s c o m p l e t e d by the m e d i c a l staff of each h o s p i t a l , w h i c h a r e n o w in possession of t h e H o s p i t a l C o u n c i l , it was c o n c l u d e d t h a t 17 p e r c e n t of t h e w a r d p a t i e n t s in v o l u n t a r y h o s p i t a l s a n d 6 p e r c e n t of p a t i e n t s in m u n i c i p a l hospitals h a d b e e n u n n e c e s s a r i l y hospitalized f r o m a m e d i c a l standp o i n t . W h e n h o m e c o n d i t i o n s w e r e also t a k e n i n t o a c c o u n t , it was c o n c l u d e d t h a t 5 a n d 3 p e r c e n t , respectively, of the admissions h a d b e e n unnecessary. 2 7 I n A p r i l , 1946, t h e N e w York City D e p a r t m e n t of H o s p i t a l s surveyed its p a t i e n t load at t h e r e q u e s t of the H o s p i t a l C o u n c i l . It f o u n d t h a t 22.5 p e r c e n t of t h e p a t i e n t s in its g e n e r a l hospitals a n d 20 p e r c e n t of t h e p a t i e n t s in all m u n i c i p a l hospitals were c h r o n i c a l l y ill. T h e r e p o r t o n this survey does n o t f u r n i s h t h e c r i t e r i a e m p l o y e d to classify p a t i e n t s as chronically ill, b u t a brief discussion in t h e H o s p i t a l C o u n c i l ' s Bulletin at t h a t t i m e indicates t h a t these w e r e p a t i e n t s with l o n g - t e r m illnesses w h o oc-

PATIENTS IN S H O R T T E R M HOSPITALS

115

c u p i e d acute beds for lack of a p p r o p r i a t e s u b s t i t u t e facilities. T h e Bulletin adds, w i t h o u t amplification, that previous studies had shown that 20 percent of the general-care beds in voluntary hospitals were occupied by chronically ill patients. 2 8 I n March, 1954, the special staff of the Hospital Council's home-care study f o u n d that 20 p e r c e n t of the patients in the ward of a large voluntary hospital were eligible for h o m e care f r o m a medical s t a n d p o i n t . T h e final r e p o r t on this study also cites ano t h e r survey, and this o b t a i n e d the same results in the ward of a n o t h e r large voluntary hospital in N e w York City with similar admission policies. T h e Hospital C o u n c i l staff also d e t e r m i n e d that two thirds of the medically eligible patients were socially eligible for h o m e care, so that 13 p e r c e n t of all ward patients m i g h t be expected to be suitable candidates for such a program. 2 9 I n 1955 a survey of patients in m u n i c i p a l hospitals c o n c l u d e d that 19 percent of the one-day p a t i e n t census d i d n o t r e q u i r e hospital care. T w o thirds of the almost 2,000 patients so classified were in the D e p a r t m e n t ' s long-term hospitals ( G o l d w a t e r Memorial and Bird S. Coler), a n d a n o t h e r 12 p e r c e n t were in Metropolitan and City Hospitals, t h e n still located on W e l f a r e Island and m u c h less active t h a n today. T h e o t h e r 13 active m u n i c i p a l general hospitals accounted for the r e m a i n i n g 20 p e r c e n t of the patients in the system w h o n o longer r e q u i r e d hospital care. 3 0 By 1955 a n u m b e r of measures h a d been i n s t i t u t e d designed to red u c e the n u m b e r patients in m u n i c i p a l hospitals w h o could profit f r o m other facilities a n d p r o g r a m s (see C h a p t e r 2). T h e i m p o r t a n t question of the use of the hospital by patients w h o do not r e q u i r e hospital services is difficult to resolve. F r o m t h e b e g i n n i n g voluntary health i n s u r a n c e in this c o u n t r y has emphasized coverage of the costs of hospital care. It is likely t h a t this emphasis may have c o n t r i b u t e d to the use of hospitals by private patients for purposes that are p e r h a p s n o t essential. Absence of financial reasons to leave the hospital may unnecessarily p r o l o n g the stay of public-charge patients. T h i s p r o b l e m calls for constant attention at the medical a n d a d m i n i s t r a t i v e levels. T o d e t e r m i n e w h o does a n d w h o does not b e l o n g in the hospital, it is necessary to consider the existence of a p p r o p r i a t e s u b s t i t u t e facilities a n d programs of a d e q u a t e quality, a n d also t h e i r cost in

BACKGROUND

116

personnel, m o n e y , and organization. F u r t h e r m o r e , potential savings in hospital beds c a n n o t be estimated reliably on the basis of an evaluation of patients on a single day b u t rather should take into a c c o u n t the trend of discharges in the i m m e d i a t e period thereafter. T h e r e c e n t survey of tuberculosis patients in hospitals in New Y o r k City did c o n d u c t such a follow-up, with the result that the estimate of the n u m b e r of patients in the hospital classified as unnecessarily hospitalized was substantially reduced. 3 1 T h e r e is good reason why surveys performed at various times and for various purposes yield different conclusions. T h e

past

surveys are of value, however, in providing useful leads for future research in this area. A survey of patients in hospitals to determ i n e which ones b e l o n g there and which do not and, a m o n g the latter, which r e q u i r e substitute facilities and which do not, is a necessary step in any a t t e m p t to develop a long-range plan for facilities for the care of the sick in N e w Y o r k City. Summary

and

Discussion

T h e following trends in p a t i e n t composition are described: 1. T h e p r o p o r t i o n s of B l u e Cross and public-charge patients and patient days have increased in each hospital system since the late 1940s. 2. T h e p r o p o r t i o n of n o n r e s i d e n t patients in N e w Y o r k City hospitals a p p r o x i m a t e l y d o u b l e d between 1933 and 1957. A downturn may now b e u n d e r way. I t is roughly estimated that the n u m b e r of residents of N e w Y o r k City who seek care outside is 4 0 percent of the n u m b e r of nonresidents cared for in hospitals in N e w Y o r k City (all

figures

are exclusive of Federal and State

hospitals). 3. B e t w e e n 1933 and 1957 the p r o p o r t i o n of n o n w h i t e patients increased at the same rate in b o t h hospital systems b u t at a faster rate in the wards of voluntary hospitals. However, the proportion of n o n w h i t e to total ward patients in voluntary hospitals is only one half that in m u n i c i p a l hospitals. 4. Since 1933 the p r o p o r t i o n of aged (65 and over) has increased faster in hospitals than in the population at large b u t at a p p r o x i m a t e l y the same rate in voluntary and m u n i c i p a l hospitals.

P A T I E N T S IN S H O R T - T E R M

HOSPITALS

117

Apart from the comparisons between patients in voluntary hospital wards and municipal hospitals that are shown in T a b l e 3.17, the following findings pertaining to hospital use in New York City are important: 1. In 1957, 44 percent of the patients discharged from generalcare hospitals in New York City were Blue Cross subscribers and 27 percent were public charges. However, government paid for more patient days than Blue Cross. One fifth of the patient days paid for by government were for the indigent and four fifths were for the medically indigent. 2. T h e same proportion of Puerto Rican patients as of nonwhite patients received care in the ward—90 percent. T h i s was three times as high as the proportion of all n o n - P u e r t o Rican white patients who receive care in the ward. Among ward patients a majority of n o n - P u e r t o Rican whites (60 percent) use voluntary hospitals and a majority of Puerto Ricans and of nonwhites (60 percent of more) use municipal hospitals. A higher proportion of nonwhite ward patients than of Puerto Rican ward patients use municipal hospitals. 3. When income is held constant—in order f u r t h e r to isolate the ethnic factor—the three ethnic groups have approximately the same proportion of ward patients (perhaps slightly lower for the n o n - P u e r t o Rican whites). T h e r e is, however, a large difference between nonwhites, on the one hand, and Puerto Ricans and n o n Puerto Rican whites, on the other hand, in the use of wards in municipal hospitals. 4. Within the municipal hospital system the proportion of nonwhite patients is much higher in the younger ages than in the older. In age class 15-44 the n u m b e r s of nonwhite and white discharges are approximately equal. In age class 65 and over white discharges exceed nonwhites by six to one. 5. T h e 1957 estimates confirm findings in earlier studies that in New York City nonwhites use more hospital care than other groups in the population. 6. Long-stay patients (here defined as 21 days and over) comprise 11 percent of all discharges and use 42 percent of all patient days. If the total stay of these patients is divided into two segments

BACKGROUND

118

(before and after 21 days), the first part of the stay accounts for 21 percent of all patient days and the second part for the remaining 21 percent. T a b l e 3.17 brings together the salient comparisons between patients in the wards of voluntary hospitals and in municipal hospitals. For all the characteristics of patients listed in this table, the Table

3.17. RATE PER 100 DISCHARGES OR PER 100 IN ONE-DAY PATIENT CENSUS FOR SELECTED P A T I E N T CHARACTERISTICS IN WARDS OF VOLUNTARY AND MUNICIPAL GENERAL-CARE HOSPITALS, NEW YORK CITY, 1957 OR 1958 Patient

Characteristic

Voluntary Hospital Wards

Pay status (discharges) Associated Hospital Service subscribers Public charges Public-assistance recipients Ethnic status (discharges) Puerto Ricans Nonwhites Other Whites Nonresidents (discharges) Aged (one-day census) All ward patients Public charges Public-assistance recipients Length of stay (discharges) Old Age Assistance recipients, 30 days or more

Municipal Hospitals

23 44 11.5

9 85 20

15 19 66

20 38 42

4

1

23.5 26 30

29 29 44

25

33

differences between the two ward services are large, or at least substantial. It was not possible to make a direct comparison between the patients in the two ward services by various lengths of stay and by diagnostic category, because these items were not reported separately for the private and ward services of voluntary hospitals. However, available data on average length of patient stay and on the distribution of Old Age Assistance recipients by days of stay suggest that the municipal hospital wards are likely to have a higher proportion of long-term patients than the voluntary hospital wards. T h e discussion of patients no longer in need of hospital care yields no conclusions on their current n u m b e r or proportion in

PATIENTS IN SHORT-TERM HOSPITALS

119

e i t h e r h o s p i t a l s y s t e m . T h i s is a n i m p o r t a n t p r o b l e m t h a t calls f o r continuing attention. T h e finding t h a t t h e r e a r e c e r t a i n s t r i k i n g d i f f e r e n c e s i n pat i e n t c o m p o s i t i o n b e t w e e n t h e t w o w a r d services has s i g n i f i c a n t i m p l i c a t i o n s f o r p l a n n i n g . A w a r d b e d i n o n e s y s t e m is n o t i n t e r c h a n g e a b l e w i t h a w a r d b e d in the o t h e r system. W h a t e v e r the reasons may b e for the existing differences—historical, traditional, c u l t u r a l , g e o g r a p h i c , a d m i n i s t r a t i v e , o r s o m e c o m b i n a t i o n of t w o o r m o r e — m u n i c i p a l h o s p i t a l s h a v e l a r g e r p r o p o r t i o n s of p o o r patients, old patients, patients f r o m m i n o r i t y groups, a n d long-stay p a t i e n t s t h a n t h e w a r d s of v o l u n t a r y h o s p i t a l s . A n y a t t e m p t to c o o r d i n a t e t h e s e r v i c e s r e n d e r e d by t h e t w o h o s p i t a l s y s t e m s m u s t rest o n t h e p r e m i s e of a n e q u i t a b l e , p e r h a p s r a n d o m ( t h a t is, a r r i v e d at b y c h a n c e , w i t h o u t s e l e c t i o n ) , d i s t r i b u t i o n of p a t i e n t s between t h e m . T h i s means that individual hospitals may have to f o r e g o s o m e of t h e i r a u t o n o m y i n s e l e c t i n g — a n d r e j e c t i n g — p a t i e n t s f o r a d m i s s i o n . I n t u r n , t h e a b i l i t y of h o s p i t a l s to b e c o m e less s e l e c t i v e w i l l d e p e n d , t o s o m e d e g r e e , o n t h e a v a i l a b i l i t y of app r o p r i a t e related facilities to receive patients discharged f r o m the h o s p i t a l a f t e r t h e i r d e f i n i t i v e t r e a t m e n t is c o m p l e t e d . T h e w i l l i n g ness a n d a b i l i t y of v o l u n t a r y h o s p i t a l s t o b e c o m e less s e l e c t i v e m a y h i n g e o n t h e a d e q u a c y of p a y m e n t f o r t h e c a r e of p u b l i c charges.

Appendix

3.A

E S T I M A T I N G T H E N U M B E R O F PUBLIC-ASSISTANCE R E C I P I E N T S IN V O L U N T A R Y AND M U N I C I P A L GENERAL-CARE HOSPITALS AND T H E PROP O R T I O N OF AGED AMONG T H E M , N E W Y O R K C I T Y , 1957 U n t i l certain research studies b e c a m e available in 1960 f r o m the N e w York State D e p a r t m e n t of Social W e l f a r e , there was n o direct i n f o r m a t i o n o n the hospitalization of public-assistance recipients in N e w York City. F i n a n c i a l i n f o r m a t i o n developed in this r e p o r t for o t h e r p u r p o s e s seemed to be the only basis for c a l c u l a t i n g p a t i e n t days used by public-assistance recipients. D a t a on p a t i e n t s were u n a t t a i n a b l e for v o l u n t a r y hospitals a n d looked u n c e r t a i n for m u n i c i p a l hospitals.

120

BACKGROUND

W h e n t h e n e w d a t a f r o m t h e State D e p a r t m e n t of Social W e l f a r e b e c a m e a v a i l a b l e , t h e e s t i m a t e s of p a t i e n t days h a d a l r e a d y b e e n comp l e t e d . T h e two sets of d a t a were r e a s o n a b l y close. It was d e c i d e d to p r e s e n t t h e e s t i m a t e d d a t a f o r two reasons: (1) they i n c l u d e d recipi e n t s of h o m e relief, w h e r e a s t h e n e w d a t a d i d n o t ; (2) they p e r t a i n e d to a single c a l e n d a r year, w h e r e a s t h e n e w d a t a reflected t h e total h o s p i t a l stay of d i s c h a r g e d p a t i e n t s , h o w e v e r long. T h e n e w d a t a were, h o w e v e r , a u n i q u e s o u r c e of i n f o r m a t i o n o n discharges f r o m v o l u n t a r y h o s p i t a l s f o r t h e f o u r F e d e r a l categories of public-assistance recipients. TOTAL

NUMBER

OF

PUBLIC-ASSISTANCE

RECIPIENTS

T h e a m o u n t of m o n e y s p e n t by g o v e r n m e n t in v o l u n t a r y a n d m u n i c i p a l h o s p i t a l s f o r t h e care of t h e i n d i g e n t ( r e c i p i e n t s of p u b l i c assistance) is c a l c u l a t e d in C h a p t e r 16 of this r e p o r t . T h e financial figures serve as a s t a r t i n g p o i n t f o r e s t i m a t i n g t h e n u m b e r of p a t i e n t days, as follows: Patient Days: Voluntary Hospitals. P a y m e n t s f o r t h e i n d i g e n t were r e l a t e d to total gross p a y m e n t s by g o v e r n m e n t f o r t h e care of inpatients. T h e q u o t i e n t is t h e p r o p o r t i o n of i n d i g e n t p a t i e n t days to total p u b l i c - c h a r g e p a t i e n t days. T h i s p r o p o r t i o n was a p p l i e d to o n e half of all w a r d days, b e c a u s e in 1957 p u b l i c - c h a r g e days c o n s t i t u t e d o n e half of total p a t i e n t days in t h e w a r d . Patient Days: Municipal Hospitals. H e r e r e c e i p t s f o r t h e care of t h e i n d i g e n t were d i v i d e d by 93 p e r c e n t to reflect t h e fact t h a t reimb u r s e m e n t f r o m t h e State of N e w York fell s h o r t of c o m p u t e d p a t i e n t day cost by 7 p e r c e n t . T h e d e n o m i n a t o r f o r c a l c u l a t i n g t h e r a t i o of i n d i g e n t to total p a t i e n t days was o b t a i n e d by e l i m i n a t i n g t h e cost of m e n t a l h y g i e n e clinics f r o m gross i n p a t i e n t cost, as p u b l i s h e d in t h e A n n u a l Cost S t a t e m e n t of t h e N e w York City D e p a r t m e n t of Hospitals. Patients: Municipal Hospitals. T h e p r o p o r t i o n of p u b l i c assistance recipients to total p a t i e n t s is taken f r o m t h e d a t a c o m p i l e d by t h e Division of Collections of t h e D e p a r t m e n t s of H o s p i t a l s o n t h e potential r e i m b u r s e m e n t s t a t u s of p a t i e n t s . Patients: Voluntary Hospitals. D a t a r e c e n t l y b e c a m e a v a i l a b l e f r o m the N e w York State D e p a r t m e n t of Social W e l f a r e f o r r e c i p i e n t s of O l d Age Assistance, Aid to t h e B l i n d , A i d t o t h e T o t a l l y a n d Perm a n e n t l y Disabled, a n d A i d to D e p e n d e n t C h i l d r e n . 3 2 A n a d j u s t m e n t was i n t r o d u c e d f o r r e c i p i e n t s of H o m e R e l i e f . NUMBER

AND P R O P O R T I O N

OF

AGED

Patients. All r e c i p i e n t s of O l d Age Assistance a r e 65 a n d over. All recipients of A i d to t h e Disabled, H o m e R e l i e f ( i n c l u d i n g V e t e r a n s

PATIENTS IN SHORT TERM HOSPITALS

121

Relief), a n d Aid to D e p e n d e n t C h i l d r e n are u n d e r 65. A m o n g all recipients of A i d to t h e B l i n d in New York. State 43 percent were 65 or over in 195 7. 33 D a t a o n t h e p r o p o r t i o n of aged a m o n g p a t i e n t s in N e w York City hospitals in receipt of Aid to the B l i n d recently b e c a m e a v a i l a b l e f r o m the State D e p a r t m e n t of Social W e l f a r e . Patient Days. I n each h o s p i t a l system a r a t i o was c o m p u t e d of t h e s u m of e x p e n d i t u r e s in behalf of recipients of O l d Age Assistance p l u s 50 p e r c e n t of e x p e n d i t u r e s in behalf of recipients of Aid to the B l i n d to total e x p e n d i t u r e s for p u b l i c assistance recipients. T h e basic d a t a h e r e e m p l o y e d r e p r e s e n t claims s u b m i t t e d to the State by the D e p a r t m e n t of W e l f a r e of t h e City.

Appendix

3.B

E S T I M A T I N G NONRESIDENTS IN GENERAL-CARE H O S P I T A L S BY O W N E R S H I P A N D BY TYPE OF ACCOMMODATION, N E W Y O R K C I T Y , 1957 T h e p r o p o r t i o n of n o n r e s i d e n t s in N e w York City hospitals was estimated t h r o u g h scatter d i a g r a m s d r a w n separately for each h o s p i t a l system. Over a p e r i o d of m o r e t h a n five years the H o s p i t a l C o u n c i l of G r e a t e r N e w York a c c u m u l a t e d d a t a on the p r o p o r t i o n of nonresidents to total p a t i e n t s a d m i t t e d to 63 v o l u n t a r y , m u n i c i p a l , a n d p r o p r i e t a r y hospitals. B e g i n n i n g in 1956 the N e w York City D e p a r t m e n t of H e a l t h has p r e p a r e d several special t a b u l a t i o n s of b i r t h s a n d deaths in hospitals by a r e a of residence. For each h o s p i t a l t h e p r o p o r t i o n of n o n r e s i d e n t admissions was plotted against its p r o p o r t i o n of n o n r e s i d e n t deaths. A line of best fit was t h e n d r a w n . T h e p r o p o r t i o n of n o n r e s i d e n t admissions for each hospital system was r e a d off t h e vertical axis to correspond to the system's p r o p o r t i o n of n o n r e s i d e n t deaths. W i t h i n t h e v o l u n t a r y system the p r o p o r t i o n of n o n r e s i d e n t patients a d m i t t e d to t h e p r i v a t e ( i n c l u d i n g semiprivate) a n d w a r d services was o b t a i n e d directly f r o m the H o s p i t a l Council's admission surveys. T h e results yielded by the scatter d i a g r a m s were checked t h r o u g h the f o l l o w i n g m e a n s : 1. C o m p a r i s o n w i t h the findings of the H o s p i t a l Discharge Study. T h e increase in t h e p r o p o r t i o n of n o n r e s i d e n t admissions b e t w e e n 1933 a n d 1957 in each type of a c c o m m o d a t i o n was m u c h smaller t h a n in the v o l u n t a r y h o s p i t a l system as a whole.

BACKGROUND

122

2. For a number of voluntary hospitals, the Hospital Council had admission data for intermediate years, such as 1945. In these hospitals the trend in the proportion of nonresident admissions was consistently upward in each time interval, both in the private service and in the hospital as a whole. 3. Data on births in New York City to residents of Nassau County showed large increases through the year 1955. Since then a small decline has set in. 4. In 1956 the proportion of nonresident births in hospitals in New York City was 8 percent. Analysis by the Hospital Council shows that maternity patients tend to travel shorter distances to the hospital than do other diagnostic categories of general-care patients in the same accommodation. T h e proportion of nonresidents may be expected to be higher for all general hospital patients than for births (or for maternity patients). 5. Recently certain data have become available that seem consistent with the estimates presented in this chapter. (a) Voluntary Hospitals. In the nine general hospitals affiliated with Federation of Jewish Philanthropies nonresident patients constituted 10 percent of all patients in 1959—13 percent in the private (including semiprivate) service and 5 percent in the ward. 3 4 (b) Municipal Hospitals. In fiscal year 1958-59 nonresidents accounted for almost 1 percent of the discharges from municipal general hospitals. 35

Appendix

3.C

E S T I M A T I N G T H E D I S T R I B U T I O N BY E T H N I C S T A T U S O F ADMISSIONS T O G E N E R A L - C A R E HOSPITALS, NEW YORK CITY, 1951 AND 1957 Estimates of admissions to general-care hospitals by hospital ownership and by ethnic status are presented in the text for two years, 1951 and 1957. Certain differences between the two sets of estimates should be noted. 1. T h e data for 1951 pertain only to the city's residents. T h e data for 1957 pertain to all patients admitted to, or discharged from, voluntary, municipal, and proprietary hospitals in New York City. A large proportion of nonresident patients in New York City hospitals consists of non-Puerto Rican whites. 2. T h e data for 1951 are based on a household survey, whereas those for 1957 are based on hospital records. A household survey lacks information on persons who died in the hospital during the survey

PATIENTS IN SHORT-TERM HOSPITALS

123

period. Since deaths in hospitals occur in disproportionate n u m b e r s a m o n g older age groups, it is the n o n - P u e r t o Rican white p o p u l a t i o n that is chiefly affected. 3. T h e data for 1951 are for admissions to all hospitals whereas the data for 1957 are only for general-care or short-term hospitals. However, long-term hospitals account for a small fraction of all hospital admissions. 4. T h e data for 1951 are based on a sample, with known variance. T h e data for 1957 pertain to all hospital admissions or discharges. T h e method of estimating the 1957 distribution, described below, is subject to some degree of error, whose m a g n i t u d e is u n k n o w n . 5. T h e data for 1951 are available only by hospital ownership group. T h e d a t a for 1957 are also available by type of accommodation. T h i s significant i m p r o v e m e n t in detail was m a d e possible by the division of admissions to voluntary hospitals into private (including semiprivate) a n d ward. ESTIMATES

FOR

THE

YEAR

1951

T h e data for 1951 derive from tabulations of p u n c h cards that were furnished by the H e a l t h Insurance Plan of Greater New York. T h e s e cards are i n t e n d e d to reflect the hospitalization experience of a representative sample of the population of New York City in a single year. O n e a d j u s t m e n t has been m a d e in the original data: patients admitted to hospitals in New York City with ownership u n k n o w n were combined with patients a d m i t t e d to municipal hospitals. T h i s was justified by the obvious understatement of the relative importance of the municipal hospital system in the sample, in comparison with the known distribution of all discharges from New York City hospitals in 1951, as reported by hospitals. O n e result of the a d j u s t m e n t was to reduce the p r o p o r t i o n of nonwhites in municipal hospitals, b r i n g i n g it closer to the p r o p o r t i o n reported for the year 1952 by the exploratory project in Hospital M o r b i d i t y Reporting; 3 8 even so, it was still too high. ESTIMATES FOR T H E YEAR

1957

T h e estimates for the year 1957 were m a d e in two steps: 1. For the general care hospitals in each hospital ownership g r o u p a percentage d i s t r i b u t i o n of patients by ethnic status was developed. 2. T h e percentages were applied to the corresponding n u m b e r of discharges reported by each hospital system and type of accommodation in 1957. T h e data employed to estimate the ethnic composition of patients in each hospital system were chiefly the following: (1) surveys of

124

BACKGROUND

samples of patients admitted to individual hospitals in New York City, performed by the staff of the Hospital Council in recent years for 63 hospitals, of which 27 yielded information on ethnic composition; (2) a one-day patient census in 1959 in nine general hospitals affiliated with Federation of Jewish Philanthropies, which was compiled by the staff of the subcommittee on hospitals and health agencies; (3) special tabulations prepared for the Hospital Council by the Department of Health showing both ethnic status of the patient and identity of the hospital for live births occurring during threemonth intervals in 1956 and 1959 and deaths occurring during threemonth intervals in 1956 and 1958; and (4) discharges from municipal hospitals, reported by the Hospital Morbidity Reporting Project, operated jointly by the Department of Health and the Department of Hospitals of the City of New York. T h e precise technique of estimating the ethnic composition of patients for the three hospital systems varied in accordance with the availability of data. Municipal Hospitals. T h e Hospital Morbidity Reporting Project furnished a breakdown between white and nonwhite discharges for 1957, 1956, and also for 1952. T h e problem was to estimate the number and proportion of Puerto Rican patients. A threefold breakdown of admissions by ethnic status was available for seven municipal hospitals through the Hospital Council's own admission surveys. (It is recognized that the data on Puerto Ricans are not always complete or accurate.) For these seven hospitals the proportion of Puerto Rican to total admissions was plotted on a scatter diagram against the proportion of Puerto Rican live births to total and separately against the proportion of Puerto Rican deaths to total. In each instance a line of best fit was drawn, and the proportion of Puerto Rican admissions to municipal general-care hospitals was read off the vertical axis for the corresponding value of the proportion of Puerto Rican live births or of Puerto Rican deaths in the system. An adjustment was then made in the proportion of nonwhite discharges reported by the Hospital Morbidity Reporting Project, on the assumption that 10 percent of all Puerto Rican patients are nonwhite. Voluntary Hospitals. For these hospitals a threefold distribution of patients (one-day census) by ethnic status became available only for general hospitals affiliated with Federation of Jewish Philanthropies. It could not be assumed that these hospitals were representative of all voluntary hospitals. Accordingly, it was decided to plot on a scatter diagram the proportion of Puerto Rican admissions against the proportion of Puerto Rican births and separately against the proportion of Puerto Rican deaths for those hospitals for which ethnic information on admissions

PATIENTS IN SHORT-TERM HOSPITALS

125

or p a t i e n t s was available; the same was d o n e for n o n w h i t e s . For t h e b r e a k d o w n between p r i v a t e a n d w a r d services in v o l u n t a r y hospitals only the i n f o r m a t i o n on b i r t h s in 1959 was u s e f u l . O n e check, a p p l i e d to t h e results o b t a i n e d f r o m t h e scatter d i a g r a m s was consistency between the e s t i m a t e d p r o p o r t i o n s of P u e r t o R i c a n a n d of n o n w h i t e admissions to each type of a c c o m m o d a t i o n w i t h t h e p r o p o r t i o n of P u e r t o R i c a n a n d of n o n w h i t e admissions to the hosp i t a l system as a whole. C o m p a r i s o n w i t h t h e findings of t h e Federation one-day census was also h e l p f u l . Proprietary Hospitals. For lack of a sufficient n u m b e r of hospitals for which the H o s p i t a l C o u n c i l h a d e t h n i c i n f o r m a t i o n o n admissions, the t e c h n i q u e of the scatter d i a g r a m was n o t suitable. T h e m e t h o d finally e m p l o y e d was t h a t of analogy. F o r all t h r e e hospital systems e t h n i c i n f o r m a t i o n was a v a i l a b l e for live b i r t h s a n d for deaths. For v o l u n t a r y a n d m u n i c i p a l hospitals estimates of the e t h n i c composition of p a t i e n t s h a d b e e n d e v e l o p e d . T h e p r o p o r t i o n of P u e r t o R i c a n admissions a n d of n o n w h i t e admissions to p r o p r i e t a r y hospitals was the missing t e r m in a p r o p o r t i o n in w h i c h the o t h e r t h r e e terms were k n o w n (for e x a m p l e , P u e r t o R i c a n to total b i r t h s in p r o p r i e t a r y hospitals a n d P u e r t o R i c a n to total admissions a n d P u e r t o R i c a n to total births in t h e p r i v a t e service of v o l u n t a r y hospitals).

Appendix

3.D

ESTIMATING T H E DISTRIBUTION OF BY A G E , G E N E R A L C A R E H O S P I T A L S , N E W Y O R K C I T Y , 1958

PATIENTS

A n u m b e r of separate d i s t r i b u t i o n s by age were a v a i l a b l e for discharges a n d for a one-day p a t i e n t census. All were u s e f u l in d e v e l o p i n g the estimated d i s t r i b u t i o n by age of a one-day census for t h e year 1958 (this is e q u i v a l e n t to a d i s t r i b u t i o n of p a t i e n t days by age). AVAILABLE

DATA A N D

SOURCES

For convenience the a v a i l a b l e d a t a o n t h e age c o m p o s i t i o n of p a t i e n t s in N e w York City h o s p i t a l s are listed by year of occurrence. Sources are given, the quality of t h e d a t a is assessed, a n d p e r t i n e n t tables are presented. 1933. Discharges f r o m all m u n i c i p a l h o s p i t a l s a n d most v o l u n t a r y hospitals. P r o p r i e t a r y hospitals d i d n o t p a r t i c i p a t e in the H o s p i t a l Discharge Study. T h e result was a c o m p l e t e c o u n t of p a t i e n t s discharged f r o m the p a r t i c i p a t i n g hospitals, p e r f o r m e d by a professional staff assisted by W o r k s Progress A d m i n i s t r a t i o n ( W P A ) workers. T h e results were p u b l i s h e d in two volumes. 3 7

BACKGROUND

126

T h e distributions of hospital discharges by age in the year 1933 are of historical interest. T h e y are therefore presented in T a b l e 3.18 for general hospitals. Table

3.18. D I S T R I B U T I O N BY A G E G R O U P O F D I S C H A R G E S F R O M V O L U N T A R Y A N D MUNICIPAL GENERAL HOSPITALS, N E W Y O R K C I T Y , 1933

Age Group

(Years)

Voluntary

N u m b e r (all ages) Percent 0-14 15-44 45-64 65 and over

Municipal

254,956

182,835

23.3 55.5 16.5 4.7

16.2 56.3 21.0 6.5

100.0 SOURCE: Neva R. Deardorff and Marta Fraenkel, Hospital New York, 1942), Appendix IX.

100.0 Discharge Study

(2 vols.;

1951. Admissions to voluntary, m u n i c i p a l , a n d proprietary hospitals in New York City, based on interviews of a sample of households conducted by the H e a l t h I n s u r a n c e Plan of G r e a t e r New York (HIP). T h e p u n c h cards c o n t a i n i n g the hospitalization experience were f u r n i s h e d to the H o s p i t a l Council. T h e n o t e o n the ethnic status of patients describes the a d j u s t m e n t m a d e in the d a t a for m u n i c i p a l hospitals. Hospitalization data by age o b t a i n e d f r o m a household survey suffer f r o m certain limitations, since the deaths missed by the survey occur disproportionately a m o n g aged persons. By comparison with the data for 1933, given above, or with the d a t a for m u n i c i p a l hospitals for 1952, given below, the p r o p o r t i o n of aged patients in the H I P d a t a is far too low. T h e d a t a for 1951 are presented for the record, since they are not elsewhere available. Table

3.19. D I S T R I B U T I O N BY A G E G R O U P O F R E S I D E N T ADMISSIONS T O VOLUNTARY, MUNICIPAL, A N D P R O P R I E T A R Y H O S P I T A L S , N E W Y O R K C I T Y , 1951

Age Group

(Years)

N u m b e r in sample (all ages) Percent 0-14 15-44 45-64 65 and over

Total

Voluntary

Municipal

Proprietary

861

500

203

158

17.6 58.0 17.3 7.1

15.6 58.2 17.6 8.6

24.6 55.7 14.3 5.4

14.6 60.7 20.3 4.4

100.0

100.0

100.0

100.0

SOURCE: Punch cards from Household Survey conducted by Health Insurance Plan of Greater New York.

PATIENTS IN SHORT-TERM HOSPITALS

127

1952. All discharges f r o m m u n i c i p a l h o s p i t a l s for six m o n t h s , May t h r o u g h O c t o b e r , 1952. T h i s was an e x p l o r a t o r y study in hospital m o r b i d i t y r e p o r t i n g in w h i c h p a r t i c i p a t i o n by v o l u n t a r y hospitals was also a t t e m p t e d b u t d i d not succeed. T h i s study was p u b l i s h e d . 3 8 Selected d a t a are p r e s e n t e d below for c o m p a r a t i v e p u r p o s e s (see year 1957). 1953. A one-day census of p a t i e n t s in v o l u n t a r y , m u n i c i p a l , a n d p r o p r i e t a r y hospitals. T h e d a t a for N e w York City are derived f r o m m a c h i n e record t a b u l a t i o n s f u r n i s h e d to the H o s p i t a l C o u n c i l by t h e A m e r i c a n M e d i c a l Association, w h i c h collected t h e i n f o r m a t i o n nation-wide. T h e l i m i t a t i o n s of the d a t a h a v e to d o w i t h a n u n e v e n ness in response rates by d i f f e r e n t h o s p i t a l g r o u p s . E d i t i n g of r e t u r n s at the n a t i o n a l level may also c o n s t i t u t e a weakness. T h e findings of this survey for general-care hospitals in N e w York City are p r e s e n t e d in T a b l e 3.8. 1955. A one-day census of o n e fifth of all p a t i e n t s in m u n i c i p a l hospitals. E x c l u d e d f r o m the o r i g i n a l study were p a t i e n t s in obstetrical units, p r e m a t u r e i n f a n t units, a n d tuberculosis u n i t s of g e n e r a l hospitals. T h e s e exclusions are consistent w i t h t h e p u r p o s e s of t h e study. Certain a d j u s t m e n t s were m a d e in the o r i g i n a l d a t a in o r d e r to develop a c o m p l e t e age d i s t r i b u t i o n of patients. T h e place of obstetrical p a t i e n t s a n d of p r e m a t u r e i n f a n t s in the age d i s t r i b u t i o n is obvious. For tuberculosis p a t i e n t s the age d i s t r i b u t i o n for the t h r e e general hospitals involved was t a k e n f r o m the T u b e r c u l o s i s H o s p i t a l Survey of 1958. 30 T a b l e 3.20 p r e s e n t s t h e o r i g i n a l d i s t r i b u t i o n of p a t i e n t s by age a n d the m o r e c o m p l e t e d i s t r i b u t i o n as a d j u s t e d . Table 3.20. DISTRIBUTION BY AGE GROUP OF ONE-DAY PATIENT CENSUS IN MUNICIPAL GENERAL HOSPITALS, NEW YORK CITY, 1955 Original

Number in sample (all ages) Percent 0-14 15-44 45-64 65 and over

Data

1,479

Adjusted

Data

1,761

13.4 21.2 29.2 36.2

13.4 27.0 27.2 32.4

100.0

100.0

SOURCE: H o w a r d M. Rusk, J o h n E. Silson, Joseph Novey, a n d Michael M. Dasco, Hospital Patient Survey (New York, 1956), p. 26; a n d a d j u s t m e n t s .

1956. Discharges f r o m m u n i c i p a l hospitals only. T h e source is the H o s p i t a l M o r b i d i t y R e p o r t i n g P r o j e c t (see year 1957 for data).

BACKGROUND

128

1957: Municipal Hospitals. T o t a l discharges from m u n i c i p a l hospitals. T h e source is the same as for 1956. T a b l e 3.21 presents the age composition of patients discharged from all municipal hospitals in 1952, 1956, and 1957. Table 3.21. D I S T R I B U T I O N BY AGE GROUP OF DISCHARGES FROM A L L MUNICIPAL HOSPITALS, NEW YORK CITY, 1952, 1956, AND 1957 Age Group (Years)

1952

Number (all ages) Percent 0-14 15-44 45-64 65 and over

121,952

1956

235,047

1957

242,528

15.1 48.6 20.1 16.2

14.2 47.7 20.0 18.1

13.7 48.4 19.7 18.2

100.0

100.0

100.0

SOURCES: M a r t a I r a e n k e l a n d Carl L. E r h a r d t , Morbidity in the Municipal Hospitals of New York City (New York, 1955); a n d H o s p i t a l Morbidity R e p o r t i n g , J o i n t Project of the New York City D e p a r t m e n t s of H e a l t h a n d Hospitals, Bulletins, 1-11, special reports, and tabulations, p r e p a r e d by M a r t a Fraenkel (New York, 1957-58; mimeographed).

1957: Voluntary Hospitals. Admissions to voluntary general hospitals. T h i s is a complete count for a sample of 28 hospitals in New York City that subscribed to the Central T a b u l a t i n g Service B u r e a u of the U n i t e d Hospital Fund. T h e d a t a were especially tabulated for the Hospital Council. T h e sample seems to be representative of all voluntary general hospitals in New York City, except for the underrepresentation of large hospitals (500 beds or more). Since better data became available for 1958, those for 1957 are not presented. 1958: Voluntary Hospitals. (1) Admissions. A complete count for a sample of 33 hospitals, as described for 1957 above. T h e large hospitals were better represented in this sample. T h e data are presented in T a b l e 3.9. (2) One-Day Patient Census. A one-day patient census was conducted in 12 hospitals by Associated Hospital Service, which furnished the final tabulation for the g r o u p as a whole to the Hospital Council. 1958: Municipal Hospitals. A one-day patient census conducted by the Department of Hospitals for the Office of the City Administrator. Patients were counted as 65 and over or under 65. 1958: Proprietary Hospitals. A one-day patient census. T h i s is a complete count prepared in the summer of 1958 by the Department of Hospitals for the Office of the City Administrator. T h e distribution of patients age 45 and over conforms to the class intervals employed in this chapter, but age class under 45 was not broken down.

PATIENTS IN SHORTTERM HOSPITALS

129

1959. A one-day patient census. T h i s was performed in 9 voluntary general hospitals affiliated with Federation of Jewish Philanthropies. T h e survey was performed by the staff of the subcommittee on hospitals and health agencies of Federation's Study Committee. E S T I M A T E O F ONE-DAY P A T I E N T CENSUS,

1958

Estimates were prepared separately for each of the three hospital systems and by type of accommodation. In every instance a percentage distribution by age was applied to patient days (this is equivalent to a one-day patient census, which may be defined as patient days divided by 365) in general-care hospitals, as classified by the United Hospital Fund. Under this classification psychiatric and tuberculosis units of municipal hospital centers are excluded. One adjustment to the data for proprietary hospitals was made in order to eliminate a psychiatric hospital (see Chapter 2). T h e percentage distributions by age were developed as follows: Voluntary Hospitals. T h e 1958 one-day patient census prepared by Associated Hospital Service and the 1959 one-day patient census prepared by Federation of Jewish Philanthropies were combined. T w o hospitals were deleted to avoid duplication. Municipal Hospitals. T h e count of patients 65 years old and over was taken directly from the report issued by the Department of Hospitals. T h e distribution of patients below age 65 was determined in relation to the available distributions of patients in 1953 and 1955 (Tables 3.8 and 3.20) and in relation to the trend in discharges between 1952 and 1957 (Table 3.21). Proprietary Hospitals. T h e distribution for ages 45 and over was taken from the report of the one-day patient census furnished by the Office of the City Administrator. Age class under 45 was split into two classes on the basis of the one-day patient census in 1953, with due allowance for the decline in the number and relative importance of obstetrical patients.

4

USE OF WARD SERVICE BY H E A L T H INSURANCE SUBSCRIBERS

Health insurance increases the ability of subscribers to pay for hospital care. O n e of the results anticipated from the expansion of voluntary health insurance enrollment was a reduction in the use of the ward service. T h i s result has been achieved only partially. F o r New York City estimates of health insurance enrollment are available for two separate years, 1952 and 1958. D u r i n g the six-year interval the proportion of the city's residents with some insurance for the cost of hospital care increased from 56 1 to 71 p e r c e n t 2 (see Chapter 1); at the same time the proportion of general-care patients in the city's hospitals receiving care in the ward declined from 45 to 41 percent. 3 Comparison States as a

between Whole

New

York

City and

the

United

In New York City the proportion of patients in the ward is considerably higher than in the nation, although the two have approximately the same proportion of population enrolled under hospital-care insurance—70 percent. I n the year 1953, for which data are available both for New York City and the U n i t e d States, the proportion of ward patients in the former was 45 percent, compared with 33 percent in the latter. 4 T h e figure for New York City is for general-care patients discharged from its voluntary, municipal, and proprietary hospitals. F o r New York City's residents discharged from short-term (general-care) hospitals the proportion of ward patients is somewhat higher. T h e r e are two reasons for this. O n e is largely statistical, namely, that most beds in psychiatric, tuberculosis, and long-term facilities in voluntary general-care hospitals are allocated to ward

131

USE OF W A R D SERVICE

patients (see Chapter 2), as are all such facilities in municipal hospitals. T h e other is that New York City's hospitals care for a considerable n u m b e r of nonresident general-care patients (more than 90,000), 90 percent of whom are in the private (including semiprivate) service (see Chapter 3). As a result, the proportion of ward patients among the city's residents in 1958 was 45 percent. Furthermore, the rate of decline in the proportion of ward patients in the 1950s was lower than indicated by the above figures. In the past decade two new Veterans Administration hospitals were built in New York City. T h e three hospitals in this system report that approximately 85 percent of their patients come from the city (see Chapter 2). T h a t the local Veterans Administration hospitals play a relatively larger role in hospitalizing veterans than the Veterans Administration hospital system as a whole is evidenced by the fact that the former care for 60 percent of all veterans hospitalized in New York City for non-service-connected medical and surgical conditions, whereas the latter care for 45 percent of the corresponding total. 6 AHS

Patients

in

Wards

Many patients in the wards of local hospitals have hospital-care insurance. For reasons stated elsewhere (see Chapter 17), it is not possible to obtain complete data on hospitalized patients with commercial insurance. T h e statistical analysis in this chapter will, therefore, focus on patients with Blue Cross (Associated Hospital Service, that is, AHS) membership. In dealing with A H S patients in the ward it is necessary to exercise care with the data. T h e A H S concept of ward is somewhat broader than that employed by hospitals in this area. In hospital statistics a ward patient is one who does not have—and does not pay—a private physician but is u n d e r the care of a clinical department of the hospital (see Chapter 2). A H S adds to this category the patient who has—and pays—a private physician b u t occupies a bed in a room with more than six beds. Unless otherwise specified, it is the hospitals' definition of a ward patient that is followed in this book. T h e hospitals report that one eighth of all A H S patients in New York City occupy the ward. T h e voluntary hospitals report

132

BACKGROUND

Table 4.1. P R O P O R T I O N OF AHS PATIENTS IN WARD, VOLUNT A R Y AND MUNICIPAL GENERAL-CARE HOSPITALS, NEW YORK CITY, 1958 -r„t„< Hospital Ownership All hospitals Voluntary Municipal Proprietary

AHS Patients (in Thousands) 4543 326.9 19.3 108.7

AHS Patients in ÌVard Number (in Thousands) 55.2 37.2 18.0 0

Percent of Total AHS 12.1 11.4 93.4 0

SOURCE: T o t a l patients: T a b l e s 17.8, 17.9, and 17.10. Ward patients: voluntary hospitals—United Hospital Fund of New York, Central T a b u l a t i n g Service Bureau, unpublished tabulations for 33 subscribing general hospitals in New York City, 1958; municipal hospitals—Associated Hospital Service of New York.

that m o r e than 11 p e r c e n t of all A H S patients occupied ward a c c o m m o d a t i o n s in 1958; a c c o r d i n g to its own definition,

AHS

reports that almost 17 p e r c e n t of all A H S patients in U n i t e d Hospital F u n d m e m b e r general hospitals occupied the ward that year. T h e difference of 5 p e r c e n t a g e points is a t t r i b u t a b l e to patients with t h e i r own physician in r o o m s with m o r e than six beds. T h i s table also shows that there are twice as m a n y A H S patients in the wards of v o l u n t a r y hospitals as in m u n i c i p a l hospitals. Since over-all there are fewer ward patients in voluntary general-care hospitals than in m u n i c i p a l hospitals, it follows that A H S subscribers cared for in the ward are m o r e than twice as likely to be in voluntary hospitals than in m u n i c i p a l hospitals (see also C h a p t e r 3). Possible

Explanatory

Factors

E X T E N T O F I N S U R A N C E AGAINST DOCTOR

BILLS

O n e reason usually advanced for the fact that an insured person receives care in the ward is lack of insurance against doctor bills. T o d a y , however, 63 percent of the population of New York City have some kind of medical-care insurance, 6 only 8 percentage points fewer than have hospital-care insurance. A l t h o u g h questions may b e raised r e g a r d i n g the completeness and adequacy of benefits provided by the several types of medical-care insurance, the difference b e t w e e n the n u m b e r s of persons holding hospitalcare and medical-care insurance has u n d o u b t e d l y narrowed in the

USE OF WARD SERVICE

133

past decade, both here and in the nation. T h i s is particularly true of insurance against surgeons' (including obstetricians') bills. During the period 1952-58, whereas the proportion of ward patients in New York City declined by 4 percentage points, the proportion of residents with medical-care insurance rose by an estimated 25 percentage points. Moreover, even a m o n g subscribers to the Health Insurance Plan of Greater New York (HIP), who have complete protection against doctor bills (with the possible exception of the anesthesiologist's), a certain n u m b e r are to be found in hospital wards. O n e study found that 4 percent of H I P subscribers hospitalized in 1955 (who also had membership in A H S ) were admitted to municipal hospitals. 7 Finally, data from three large voluntary teaching hospitals in New York City indicate that perhaps one fourth of their A H S patients in the wards are also known to carry B l u e Shield insurance. T h i s figure is probably higher than in the typical community voluntary general hospital. It would appear that, although lack of insurance against doctor bills may deter a patient from taking a semiprivate bed, the presence of such insurance does not guarantee that he will. Also at play are other influences, which may be grouped under three headings: the physician-patient relationship; financial considerations; and a miscellaneous category, comprising organizational factors on the one hand and sociocultural factors on the other. Some factors can be classified under more than one heading. PHYSICIAN-PATIENT

RELATIONSHIP

During field interviews conducted in the course of this study with physicians, hospital administrators, and social workers, a number of reasons were advanced why insured patients obtain care in the ward. Some of these bear on the relationship between the patient and his physician and between the physician and hospitals. 1. T h e patient may have a physician who lacks a staff appointment at a hospital with the privilege of admitting private patients. T h i s is true of many Negro physicians. It has been suggested in a report on hospital care in another city that perhaps one factor

134

BACKGROUND

in the relatively high use of w a r d beds by N e g r o patients is lack of staff a p p o i n t m e n t s for t h e i r physicians. 8 2. A physician w h o wishes to f u r t h e r the teaching p r o g r a m of his hospital may p r e f e r to r e f e r a p a t i e n t to its ward service r a t h e r t h a n to a n o t h e r physician. 3. A person w i t h o u t a family physician may rely on a neighb o r i n g hospital to r e f e r h i m to a physician, when needed. I n 1951 a h o u s e h o l d survey f o u n d that m o r e than one fifth of the families in N e w York City d i d n o t have a family physician. 9 A l t h o u g h every hospital will, u p o n request, f u r n i s h a list of physicians to w h o m the p a t i e n t may t u r n , some hospitals will not take the initiative. H e r e , too, an i m p o r t a n t reason would be the hospital's desire to increase the n u m b e r of w a r d patients available for teaching. T h i s factor is likely to be of some i m p o r t a n c e as long as the ward service r e m a i n s the focal p o i n t of medical e d u c a t i o n programs in hospitals (see C h a p t e r 6). 4. Because they n e e d p a t i e n t s for w h o m the chief resident of a clinical service can assume c o m p l e t e responsibility, certain large teaching hospitals a d m i t to their ward patients w i t h o u t a private physician w h o have b o t h Blue Cross and Blue Shield insurance. It has been suggested that medical fees collected f r o m insurance plans are a logical source of s u p p l e m e n t a r y financial s u p p o r t for g r a d u a t e medical e d u c a t i o n . B l u e Shield does not share this view a n d has stopped paying bills for services r e n d e r e d by residents in some hospitals. 5. T r a d i t i o n a l l y , a person w h o receives his medical care in the o u t p a t i e n t d e p a r t m e n t of a v o l u n t a r y hospital receives his inpatient care in its ward. Such a person may jeopardize his status in the clinic by a c c e p t i n g a semiprivate a c c o m m o d a t i o n . Since the emphasis in v o l u n t a r y h e a l t h insurance policies is on protection against the costs of hospitalization, it is possible for a person who is insured against the cost of illness in the hospital not to be insured against the cost of illness outside. If so, he may wish to attend the o u t p a t i e n t d e p a r t m e n t , in order to avoid the cost of private medical care, i n c l u d i n g physicians' services a n d drugs. It it k n o w n that the cost of medical care on an a m b u l a t o r y basis can loom large to the i n d i v i d u a l a n d his family. 1 0

USE OF W A R D

SERVICE

185

T h e last reason also involves finances, which received frequent mention in the interviews. FINANCIAL

CONSIDERATIONS

Under the heading of finances are grouped those factors that would entail out-of-pocket expenses by the patient at the time of illness. 1. T h e patient with hospital-care insurance may lack, insurance against doctor bills. Although insured for surgery, he may be admitted to the hospital for a medical condition. 2. T h e patient may carry Blue Shield insurance. If his income exceeds the ceiling for full-service benefits, he would be subject to an additional fee, unpredictable in a m o u n t . (Depending on the type of contract held, the income ceiling of the local Blue Shield Plan is $4,000 or $6,000 per family.) In surgery there is also a bill to be paid for anesthesia when it is not administered by a hospital employee. 3. If the patient's prognosis indicates a long hospital stay, full AHS benefits will r u n out. D u r i n g the discount period a semiprivate patient is expected to pay one half of the hospital's regular charges. T h e relative importance of this is suggested by the fact that in the member general hospitals of the United Hospital Fund the proportion of discount to patient days is more than twice as high for AHS ward patients as for A H S semiprivate patients. 4. Even for a short illness, expenditures may sometimes be anticipated in a semiprivate accommodation that do not occur in the ward. An example is the cost of private-duty nursing, currently more than $50 a day. For the ward patient the hospital assigns a special-duty nurse if needed and usually pays her or, under certain programs, obtains assistance from the City. Also to be considered are the cost of blood and radiotherapy, both of which are excluded from benefits u n d e r the existing A H S contract. Some voluntary hospital administrators consider it a responsibility of the hospital to protect the patient against assuming excessive financial burdens. 5. Services rendered by and through medical social workers are generally more readily available to ward patients than to semi-

BACKGROUND

136

private patients. It is easier to a r r a n g e for w a r d patients such services as housekeeping, taxis, convalescent care, or prostheses, if n e e d e d after discharge f r o m the hospital. 6. M a t e r n i t y patients with A H S receive a cash benefit of $80, b u t this does n o t come close to m e e t i n g the hospital bill. T h o s e w h o cannot pay the difference may seek care in the ward. However, the difficulty with this e x p l a n a t i o n is that A H S m a t e r n i t y patients have behaved differently f r o m all m a t e r n i t y patients. W h e r e a s the p r o p o r t i o n of ward patients a m o n g A H S m a t e r n i t y patients has declined almost to the same e x t e n t as a m o n g A H S n o n m a t e r n i t y patients, the p r o p o r t i o n of w a r d p a t i e n t s a m o n g all m a t e r n i t y patients in the city has increased. 1 1 T h e last t r e n d contrasts, of course, with that for all n o n m a t e r n i t y general-care patients. T h e comparative data are as follows:

Category

of

Admission

A H S maternity A H S nonmaternity All maternity All general-care patients

Terminal Years 1951-59 1951-59 1952-58 1952-58

Change in Proportion {Percent) of Ward to Total From

To

Difference

23 24 33 45

15 17 38 41

-8 -7 +5 -4

An i m p o r t a n t factor in the increase in the p r o p o r t i o n of ward maternity patients is the rising share of b i r t h s c o n t r i b u t e d by Negroes and P u e r t o Ricans. W i t h relatively low average income, they have a higher b i r t h rate t h a n t h e rest of t h e population. 1 2 At this p o i n t the financial factors b e g i n to m e r g e with the social or cultural. SOCIAL AND ORGANIZATIONAL FACTORS

1. T h e r e are groups, particularly a m o n g the new arrivals in the city, who have no tradition of b e i n g cared for in the hospital by their own physicians. O n e labor u n i o n , almost half of whose m e m b e r s are N e g r o or Spanish-speaking, purchases A H S coverage for all dependents. In 1958, 56 percent of the d e p e n d e n t s hospitalized were accommodated in the ward—16 p e r c e n t in m u n i c i p a l hospitals and 40 percent in v o l u n t a r y hospitals. 1 3 Similarly, whereas 10 to 15 percent of all white p a t i e n t s with A H S in one g r o u p of voluntary general hospitals were in the ward, the com-

USE OF W A R D SERVICE

137

parable figure for Negro patients was more than 50 percent, and for P u e r t o Rican patients, 70 percent 1 4 (see Chapter 3). 2. Some persons have a marked and conscious preference for the ward service of a particular hospital, voluntary or municipal. T h e y know the hospital and trust it and do not like to be referred elsewhere. T h i s is one of the problems encountered by the pilot project at one of the municipal hospitals (Metropolitan) that aims to find and refer insured patients to neighboring voluntary hospitals. 3. Some persons do not know they are insured. Others know but do not know what benefits are provided by their policies. It is conceivable that increasing reliance on employer payment of health insurance premiums, when not accompanied by adequate education of employees, may serve to extend the area of ignorance. 4. A patient with insurance or other means to pay for his hospital care may find himself in a municipal hospital in an emergency. An emergency patient who can pay is less likely to occupy a ward bed in a voluntary hospital, because he can be transferred to the more appropriate accommodation during his hospital stay. Just what proportion of total admissions to municipal hospitals consists of emergency patients is a moot question. T h e figures cited range all the way from 10 to 90 percent of all admissions; the correct figure cannot be ascertained without study. It is reasonable to speculate that the true figure is closer to the middle of the range than to either extreme. T h e true figure may be higher today than formerly, because municipal hospitals are providing an increasing share of the city's emergency services, as measured in ambulance calls and in emergency department visits (see Chapter 2). 5. A patient with insurance or other means to pay for hospital care may find himself in a municipal hospital for still another legitimate set of reasons. T h e municipal hospital system may have a unique facility, as exemplified by a unit for patients with cerebral palsy. 6. Finally, particularly in winter, there may be a shortage of semiprivate beds in the community, so that insured persons in need of hospitalization must accept ward accommodations. Although this reason is frequently cited, its effect is believed to be

BACKGROUND

138

limited, particularly when the patient is admitted to a voluntary hospital. If patients who are potentially semiprivate go to the ward when semiprivate accommodations are overcrowded b u t do not do so during periods of normal or low semiprivate occupancy, it would be reasonable to expect a high semiprivate census in the summer months and a low ward census. In fact, the semiprivate patient census is high when the ward patient census is high and both are low at the same time. T h e d r o p in census from peak to trough is greater for semiprivate accommodations than for ward accommodations. T h i s is not to say that there is no shortage of semiprivate beds in the community. But if there is, it will not express itself through a high ward census, because patients with their own physicians who occupy a ward bed, whether temporarily or permanently, are classified and reported by hospitals as semiprivate patients (see Chapter 2). Discussion

and Implications

of

Analysis

As the Hospital Council stated in its annual report of 1958— 59: "Corrective measures designed to b r i n g about a shift of patients from ward to semiprivate accommodations more nearly comparable to the growth in hospital insurance must be as varied as are the factors that have brought a b o u t the existing situation." 15 Among the preliminary suggestions made at the time were that efforts should be made to educate policy holders about the provisions of their policies; expand insurance for physicians' services and broaden hospital care insurance benefits; influence a larger proportion of patients to seek semiprivate accommodations; and educate the public to rely on a family physician in preference to an outpatient clinic, as this might also lead to an increased use of semiprivate accommodations. On the basis of the discussion in this chapter additional steps are indicated. One is provision of hospital staff appointments with private patient privileges for more practicing physicians (see Chapter 5). Another is expansion of medical teaching in private (including semiprivate) accommodations, with the cooperation of patients and their physicians (see Chapter 6). T h e Hospital Council believes that the proportion of vard

USE OF W A R D SERVICE

139 16

patients in N e w York City hospitals should be reduced. One model that deserves f u r t h e r investigation is the pattern of hospital use in one of the five boroughs of New York City, namely, R i c h m o n d (Staten Island). In 1955, when the Hospital Council studied the hospitalization needs of Staten Island, the p r o p o r t i o n of ward admissions in the voluntary and proprietary general hospitals of this b o r o u g h was 20 percent—less than one half of the city-wide figure of 42 percent that year. 17 By 1958 the p r o p o r t i o n for Staten Island was 17 percent and for the city 41 percent. Since Staten Island is largely self-sufficient in providing hospital care to its residents, 1 8 the 17 percent figure applies to the residents, as well as to the hospitals, of the borough. A small u n d e r s t a t e m e n t of the t r u e p r o p o r t i o n of ward patients results from the presence on the Island of the U n i t e d States Public H e a l t h Service Hospital, which renders some services to local residents. Absence of a m u n i c i p a l general hospital on Staten Island may c o n t r i b u t e to the relatively low proportion of ward patients. O t h e r influences in the same direction are the low p r o p o r t i o n of P u e r t o Rican a n d n o n w h i t e population, who for reasons of income, health insurance status, and other factors tend to be heavy users of ward service. Concentration on Staten Island of employees of the City with m e m b e r s h i p in H I P f u r t h e r reduces the d e m a n d for ward accommodations. Certain characteristics of the local hospitals and medical profession probably c o n t r i b u t e to the prevailing emphasis on semiprivate care. N o n e of the three voluntary hospitals on the Island is a m a j o r teaching center with a d e m a n d for large n u m b e r s of ward patients for teaching. N o n e is supported by substantial p h i l a n t h r o p i c c o n t r i b u t i o n s or earnings on investments. As to the physicians, a relatively larger proportion than elsewhere in the city are in general practice, earning correspondingly lower fees. A large majority of the total (with few specific exceptions) have one or more hospital staff a p p o i n t m e n t s with private patient privileges, through which they earn part of their income. Summary 1. Between 1952 and 1958 the proportion of New York City's p o p u l a t i o n with hospital-care insurance rose f r o m 56 to 71 per-

140

BACKGROUND

cent, whereas the proportion of ward general care patients in local hospitals declined from 45 to 41 percent. 2. T h e proportion of New York City residents receiving care in the ward is 45 percent, substantially higher than in the nation as a whole. 3. Twelve percent of all A H S patients are in wards, as reported by hospitals. T h e proportion reported by AHS is higher, because it encompasses not only patients without a private physician b u t also patients with a private physician in a room with more than six beds. 4. O n e reason that persons with A H S insurance receive care in the ward is lack of medical-care insurance. T h i s factor is, however, of declining importance. It is reported that 63 percent of the residents of New York City have some type of insurance against the cost of doctor bills. 5. Factors favoring the use of ward accommodations by persons with hospital-care insurance, as advanced in field interviews, are enumerated and discussed. Broadly, these fall in three groups: physician-patient relationship; financial; and other, including social and organizational. Available information is introduced to appraise the relative weight of the several factors. 6. T h e implications of the analysis are that corrective measures must be as varied as the factors that have brought about the existing situation. 7. It is suggested that the experience of Richmond (Staten Island) might be examined as a possible model for reducing the proportion of ward patients in New York City.

Part II. PERSONNEL, PLANT, AND ORGANIZATION

5

ATTENDING STAFF

Hospital care is rendered by people: it takes physicians, nurses, and others, making use of various facilities and equipment, to give care to patients. It is reasonable to think that well-trained, experienced personnel, working with superior facilities and equipment, are capable of providing better care than personnel with lower qualifications, working with inferior facilities and equipment. It is also reasonable to think that more effective organization can both increase the volume of services produced by a given combination of people and plant and improve the quality of care rendered. This capability may not invariably be translated into performance (see Chapter 10). T h i s and subsequent chapters in Part II deal, in order, with physicians as attending staffs of hospitals, physicians as interns and residents, nurses, physical plant, and hospital organization and management. These are followed by chapters on quality of care and on hospital coordination. Significance

of Staff

Appointments

T H E ATTENDING STAFF O F A H O S P I T A L

In New York City the term attending staff has traditionally referred to physicians in practice who contribute their services in hospital wards and outpatient departments. In return, they receive an opportunity to keep abreast of new clinical knowledge and enjoy the privilege of admitting patients to private and semiprivate accommodations. Patients in the general ward are considered the responsibility of the particular clinical department rather than of an individual physician, and attending physicians

144

PERSONNEL, P L A N T , AND ORGANIZATION

caring for them neither submit a bill nor receive payment from the hospital (see Chapter 4). T h e r e is no doctor fee to patients in the outpatient department either, but there is an increasing tendency for some hospitals, especially the municipal, to pay physicians for serving there. Since the end of W o r l d W a r I I a n u m b e r of nonuniversity voluntary hospitals in New Y o r k City have instituted a system of full-time directors of clinical service, under which incumbents spend all their time in the hospital and earn their income in a variety of ways (see Chapter 9). University hospitals have had full-time physicians on their staffs for a generation or two. T h e attending staffs of hospitals are largely drawn from physicians in practice in the c o m m u n i t y . Physicians in training (interns and residents) and retired physicians are excluded. Physicians in related fields (industry, insurance, and administration) may or may not seek hospital staff appointments. W h e t h e r it is appropriate to exclude certain categories of practicing physicians from access to hospital staffs is a moot question in actuality, if not in theory. RESPONSIBILITY OF HOSPITAL TO T H E

COMMUNITY

T h e Hospital Council of G r e a t e r New York addressed itself to this problem at length in its report Hospital Staff Appoint1 ments of Physicians in New York City. Its position can be stated briefly. T h e central question is whether hospitals should aim to appoint to their attending staffs a cross section of the medical practitioners in the community or limit their staffs to full specialists or diplomates certified by specialty boards. (A full specialist is one who reports that he limits his practice to a single field of medicine. A diplomate is one who has passed certain examinations posed by a board of specialists in his field, having qualified for admission to the examination by training and experience). T h e issue is not whether a m e m b e r of a hospital's attending staff should perform only the diagnostic and treatment procedures for which he is qualified; this goes without saying. T h e issue is whether to appoint to the staff only the best qualified physicians in the community or to afford every practicing physician an opportunity to

145

A T T E N D I N G STAFF

learn and grow, meanwhile carefully supervising what he does and limiting his activity in the hospital to what he is equipped to do. In a country like England a sharp line is drawn between physicians who practice in the hospital and physicians who practice in the community. In New York City no such line exists, although some hospitals take pride in having only full specialists on their staffs. T h e Hospital Council believes that hospitals are the best place for transmitting to the practicing physician information on medical advances. If the physician is to have a systematic opportunity to keep abreast of developments in medical knowledge and to improve his performance, he must have access to the organized staff of a hospital. Most physician services are rendered outside the hospital. A physician who cannot qualify to work in the hospital, where supervision is available, is not qualified to practice outside the hospital, where supervision does not exist. It is the obligation of hospitals to the nonhospitalized public to reach out to the community and to afford to every physician who practices there an opportunity to join a hospital's staff and participate in its work within the limits set by his experience and competence. Hospitals do not discharge this obligation by appointing only the best qualified physicians to their staffs. Physicians

and Staff Appointments

T R E N D IN N U M B E R O F P H Y S I C I A N S ,

in New

York

City

1950-58

T h e American Medical Association reports that between 1950 and 1958 the total n u m b e r of physicians in New York City declined from 19,700 to 18,700, or by 1,000. T h e decline in the number of physicians in private practice was even greater, 1,300. T h e reduction of 336 in the group in temporary service with the federal government is a result of a change in classification in the Medical Directory. T o d a y the same physicians would be charged to the federal service, not to the areas of their permanent residence. Another difference between the 1950 and 1958 counts is that the former excludes one recent class of graduates from

146

PERSONNEL, PLANT, A N D ORGANIZATION

Table 5.1. NUMBER OF PHYSICIANS BY TYPE OF PRACTICE, NEW YORK CITY, 1950 A N D 1958 Type of Practice Total physicians In private practice In hospital (in training or institutional service) In practice in related fields Retired or not in practice Temporarily with federal government

1950 19,695 15,412

1958 18,696 14,115

3,222 341 384 336

3,597 567 417 0

Change - 999 - 1,297 + + + -

375 226 33 336

SOURCE: American Medical Association, Directory D e p a r t m e n t , Survey of Number of Physicians in the United States by County, Dependencies and Canada, March I, 1950 (Chicago, 1950), pp. 77-78; a n d its Physician-Population Counts in the United States by County, 1958 (Chicago, 1958), p p . 64-65.

U n i t e d States a n d C a n a d i a n medical schools, whereas the latter excludes two. T o m a k e the c o u n t s of physicians in the two years c o m p a r a b l e , the following a d j u s t m e n t s are necessary: 1. 1950, total reported Less: temporarily with federal government Adjusted, 1950 2. 1958, total reported Plus: 1957 graduates from United States and Canadian medical schools in voluntary and municipal hospitals, New York City (see Chapter 6) Adjusted, 1958 3. Change 1950 to 1958, adjusted basis

19,695 336 19,359 18,696

550 19,246 - 113

Between 1950 a n d 1958 the total n u m b e r of physicians in New York City is shown to have d e c l i n e d by a p p r o x i m a t e l y 100, r a t h e r than by 1,000. T h e several a d j u s t m e n t s d o n o t affect the size of the decline in the n u m b e r of physicians in p r i v a t e practice, which r e m a i n s at 1,300 (see A p p e n d i x 5.A). T h e decline in the n u m b e r of physicians in private practice, who are by far the p r e d o m i n a n t source of physicians seeking a n d h o l d i n g hospital staff a p p o i n t m e n t s , is consistent with the cessation of g r o w t h in the city's p o p u l a t i o n d u r i n g this p e r i o d and with the increase in p o p u l a t i o n in n e i g h b o r i n g s u b u r b a n counties. In part, it may also reflect the fact that physicians' incomes in N e w York City are relatively low. I n 1949 the average net income of practicing physicians in N e w York City was reported

A T T E N D I N G STAFF

147

by the U n i t e d States D e p a r t m e n t of C o m m e r c e to be lowest a m o n g the 32 largest cities in the c o u n t r y . It was t h e n 25 percent below the national average, c o m p a r e d with 11 p e r c e n t in 1941. 2 It is interesting that N e w York City ranks second or t h i r d f r o m the t o p a m o n g 20 large cities in the level of certain selected specialists' fees, as m e a s u r e d by the U n i t e d States B u r e a u of L a b o r Statistics. 3 H e l p i n g to reconcile a t e n d e n c y toward low average physicians' income a n d high fees are the high ratio of physicians to p o p u l a t i o n a n d the large p r o p o r t i o n of ward to total hospital patients, for whose care physicians receive n o p a y m e n t . T R E N D IN PHYSICIANS' A P P O I N T M E N T S IN T W O H O S P I T A L SYSTEMS,

1948-58

For this study an analysis was m a d e of the staff a p p o i n t m e n t s of a 10 percent s a m p l e of physicians listed in the Medical Directory of New York State, as of 1958. I n so far as possible the classification of physicians by type of practice was m a d e c o m p a r a b l e with that developed f o r the year 1948 for all physicians in N e w York City. As the Directory does n o t list courtesy staff a p p o i n t m e n t s in voluntary hospitals or any a p p o i n t m e n t s in p r o p r i e t a r y hospitals, these were e l i m i n a t e d f r o m the 1948 data. T h e figures for b o t h years p e r t a i n to physicians with r e g u l a r staff appointm e n t s in voluntary a n d m u n i c i p a l hospitals. Table

5.2. PHYSICIANS W I T H R E G U L A R STAFF A P P O I N T M E N T S I N V O L U N T A R Y OR MUNICIPAL HOSPITALS, OR B O T H , N E W YORK CITY, 1948 A N D 1958

Hospital Ownership Total physicians with regular staff appointments a. In voluntary hospitals only b. In municipal hospitals only c. In voluntary and municipal hospitals Total in voluntary hospitals (a + c) Total in municipal hospitals (b + c)

1948

1958

Change

10,600 5,990 1,890 2,720 8,710 4,610

10,890 5,610 1,520 3,760 9,370 5,280

+ 290 - 380 - 370 + 1,040 + 660 + 670

SOURCE: Hospital Council of Greater N e w York, Hospital Staff Appointments of Physicians in New York City ( N e w York, 1951), pp. 30-31; and study of staff appointments, 1958.

T a b l e 5.2 shows that (1) a l t h o u g h the n u m b e r s of physicians with staff a p p o i n t m e n t s in v o l u n t a r y hospitals only a n d in m u n i c i pal hospitals only declined, the n u m b e r of physicians w i t h ap-

PERSONNEL, PLANT, AND ORGANIZATION

148

p o i n t m e n t s in b o t h systems increased; (2) as a result, each hospital system h a d an increase in its a t t e n d i n g staff. T h e n u m e r i c a l increase was the same in b o t h hospital groups, b u t the relative increase was twice as great in m u n i c i p a l hospitals as in v o l u n t a r y hospitals—15 p e r c e n t c o m p a r e d w i t h 7.5 percent. Attending

Staffs of Municipal

Hospitals

H o w d o these statistical findings accord with what is k n o w n of the difficulties e n c o u n t e r e d by hospitals in N e w York City in a t t r a c t i n g physicians to t h e i r a t t e n d i n g staffs? I n m a n y interviews it was r e p o r t e d that in c e r t a i n specialties, such as pediatrics, most hospitals in M a n h a t t a n , Brooklyn, a n d the Bronx, v o l u n t a r y or m u n i c i p a l , have difficulty in r e c r u i t i n g new staff m e m b e r s . At all m u n i c i p a l hospitals it is increasingly necessary to pay physicians for a t t e n d a n c e in the o u t p a t i e n t d e p a r t m e n t . At m u n i c i p a l hospitals w i t h o u t university affiliation, the c o m m o n r e p o r t was of difficulty in r e c r u i t i n g in every specialty. T h e i r a t t e n d i n g staffs are d e c l i n i n g by a t t r i t i o n , for lack of replacements at the b o t t o m step of the p r o m o t i o n l a d d e r . If n o t h i n g is d o n e to i m p r o v e rec r u i t m e n t , the r a t e of decline is likely to accelerate. T h e r e m a i n d e r of this c h a p t e r concentrates on the staffing situation in m u n i c i p a l hospitals, with particular emphasis on hospitals w i t h o u t university affiliation. It will be f o u n d that t h e available d a t a b e a r o u t the c o m m o n report. Presentation of data is followed by a discussion of the factors that m i g h t account for p r e v a i l i n g trends, c o n c l u d i n g with an a t t e m p t to assess their implications f o r the f u t u r e . TRENDS A N D C O M P A R I S O N S

Appointments in Municipal Hospitals. T o ascertain in which m u n i c i p a l hospitals the increase in the total n u m b e r of a t t e n d i n g physicians took place, a c o m p a r i s o n was m a d e between the numb e r of staff a p p o i n t m e n t s in the system in 1948 and in 1958. Such a comparison differs f r o m a comparison of physicians holding a p p o i n t m e n t s (shown in T a b l e 5.2) in two ways: (1) physicians with offices outside the city w h o are on the staffs of the hospitals are included, a n d (2) physicians w h o hold a p p o i n t m e n t s in two or m o r e m u n i c i p a l hospitals are c o u n t e d m o r e than once.

A T T E N D I N G STAFF

149

Exclusive of consultants' positions, the number of appointments increased from 5,270 in 1948 to 6,450 in 1958. Most of this increase is accounted for by university hospitals and by the opening of new hospitals. Of the municipal general hospitals without university affiliation, 9 out of 11 suffered reductions in size of staff. T h e two hospitals with increases in staff occupy new buildings. Duplicate Appointments. A physician who holds appointments in two or more hospitals may favor one over the other. If so, the burden of possible neglect associated with duplicate staff appointments is likely to fall more heavily on a municipal hospital than on a voluntary. One reason is that, whereas 71 percent of the physicians in municipal hospitals are also on the staffs of voluntary hospitals and must be responsive to their demands, only 40 percent of the physicians in voluntary hospitals also serve in municipal hospitals and must respond to their demands. Another reason is that the voluntary hospital is in a better position to induce attendance through its control over beds for physicians' private (including semiprivate) patients. T h e r e has been an increase in the number of physicians with duplicate appointments within the municipal hospital system. It is estimated that in 1948 the number of attending appointments in the municipal hospital system exceeded the number of physicians holding them by 500; in 1958 the correspoding figure was 1,000. T h e rules of the Department of Hospitals that formerly tended to reduce the number of duplicate appointments between municipal general hospitals at ranks higher than clinical assistant have been relaxed. T h e Commissioner of Hospitals has the authority to approve duplicate staff appointments between any two hospitals and at any rank for a medical specialist in a field in which recruitment is difficult. Data on staff appointments do not convey anything about trends in frequency of attendance by physicians at the hospital nor about the length of their visits. Meaningful data pertaining to these items are not available. Caliber of Physicians. T h e very extent to which the attending staffs of the two hospital systems overlap, as shown in T a b l e 5.2, raises the question whether there can be much of a difference in their caliber. At first impression the answer seems to be negative.

150

P E R S O N N E L , P L A N T , A N D O R G A N I Z A T ION

T h e following data for 1958 c o m p a r e the p r o p o r t i o n of a t t e n d i n g staff in each hospital system w h o are d i p l o m a t e s , full specialists, or graduates f r o m American ( U n i t e d States a n d C a n a d i a n ) m e d i cal schools. Proportion (Percent) to Total Attending Staff Voluntary Hospitals

Status of Physician Diplomate of specialty board Full specialist Graduate of American medical school

48.2 69.9 72.5

Municipal Hospitals 46.5 68.6 68.5

Differences between the two g r o u p s of hospitals in p o r t i o n of physicians with given status are very small. Larger differences appear, however, w h e n the same son is m a d e a m o n g three categories of physician: those p o i n t m e n t s in one system or in the o t h e r a n d those with m e n t s in both.

the procompariw i t h apappoint-

Proportion (Percent) to Total Attending Staff

Status of Physician Diplomate Full specialist Graduate of American medical school

Both Voluntary and Municipal Hospitals 56.9 77.9 75.3

Voluntary Hospitals Only 42.0 64.2 70.4

Municipal Hospitals Only 20.4 45.1 51.4

Physicians with m u n i c i p a l hospital a p p o i n t m e n t s only have the lowest p r o p o r t i o n of diplomates, f u l l specialists, a n d graduates of A m e r i c a n medical schools. T h e reason is t h a t almost t h r e e fourths of t h e m are at non-medical-school hospitals. By contrast, of the physicians with a p p o i n t m e n t s in b o t h systems, only one half are associated with non-medical-school m u n i c i p a l hospitals. Hospitals in First and Third Teaching Classes. T h e data on staff a p p o i n t m e n t s p e r m i t certain comparisons b e t w e e n the two hospital systems for c o r r e s p o n d i n g t e a c h i n g classes of hospital. Class I teaching hospitals are defined for this p u r p o s e as comprising those with a medical school affiliation for u n d e r g r a d u a t e teaching and approved residency t r a i n i n g p r o g r a m s in m o r e than 10 specialties; Class II teaching hospitals are d e f i n e d as h a v i n g the

ATTENDING

151

STAFF

same type of medical school affiliation and approved residencies in 6 or more specialties but fewer than 10; and Class I I I teaching hospitals are all hospitals not classified as Class I or Class I I . It turned out that the number of Class II teaching hospitals in the municipal system was too small to permit valid comparisons with Class II teaching hospitals in the voluntary system. T h e comparisons that follow are therefore limited to Class I and Class I I I teaching hospitals. 1. Diplomate Status. What proportion of staff appointments is held by certified diplomates? Proportion (Percent) of to Total Attending

Hospital Teaching Class Class I Class I I I

Voluntary Hospitals 65.5 43.4

Diplomates Staff

Municipal Hospitals 64.2 S7.0

Difference + 1.5 +6.4

T h e proportion of staff appointments held by diplomates is considerably lower in Class I I I hospitals than in Class I. T h e difference between the two systems in Class I teaching hospitals is small. In Class I I I it is considerably greater. 2. Full Specialists. A similar comparison was made of the proportion of staff appointments held by full specialists. Proportion Hospital

to

Teaching Class Class I Class III

Voluntary Hospitals 80.0 64.7

(Percent) of Full Specialists Total Attending Staff Municipal Hospitab 82.9 59.4

Difference -2.9 +5.3

T h e proportion of appointments held by full specialists is again much lower in Class I I I hospitals than in Class I. W i t h i n Class I the proportion of full specialists is higher in municipal hospitals. W i t h i n Class I I I voluntary hospitals have the higher proportion. 3. Age.

The

Medical

Directory

of New

York

State does not

report the age of physicians. It does report the year of graduation from medical school, and this can serve as an index of age. T h e following data show, in each teaching class of hospitals, the proportion of appointments held by physicians who have been gradu-

152

PERSONNEL, PLANT, AND

ORGANIZATION

ated f r o m medical school since 1941, the year this c o u n t r y e n t e r e d W o r l d war II. Proportion t0

Hospital Teaching Class Class I Class III

Voluntary Hospitals 34.1 26.3

(Percent) of Graduates since 1941 Total Attending Staff Municipal Hospitals 33.6 21.0

Difference +0.5 +5.3

T h e findings h e r e are similar to those for d i p l o m a t e status. T h e y indicate that (1) Class I hospitals are b e t t e r able to attract y o u n g physicians to the a t t t e n d i n g staff t h a n are Class I I I hospitals; a n d (2) w i t h i n Class I I I , m u n i c i p a l hospitals are at a considerable disadvantage. I n s u m m a r y , Class I t e a c h i n g hospitals consistently display a m o r e favorable position t h a n Class I I I in attracting physicians to the a t t e n d i n g staff. I n Class I teaching hospitals the difference between the two systems is small a n d may favor either one. I n Class I I I teaching hospitals t h e difference is considerable, a n d it is consistently u n f a v o r a b l e to t h e m u n i c i p a l system. Relative Attractiveness. A n a t t e m p t was m a d e to e x a m i n e the relative attractiveness of staff a p p o i n t m e n t s in v o l u n t a r y and m u n i c i p a l hospitals. T h i s was d o n e by correlating for each physician w i t h a p p o i n t m e n t s in b o t h systems the teaching class of the v o l u n t a r y hospital a n d of the m u n i c i p a l hospital with which he is affiliated. E x c l u d e d f r o m t h e analysis were consultants' appointm e n t s and a t t e n d i n g a p p o i n t m e n t s in closely associated v o l u n t a r y a n d m u n i c i p a l hospitals. T h e n u m b e r of physicians associated with Class II m u n i c i p a l hospitals is again too small to p e r m i t analysis. For the others, Table

5.3. CROSS-CLASSIFICATION BY T E A C H I N G CLASS OF HOSP I T A L OF S T A F F A P P O I N T M E N T S H E L D BY PHYSICIANS A F F I L I A T E D W I T H B O T H H O S P I T A L SYSTEMS, N E W YORK CITY, 1958

Municipal

Hospital

Teaching Class Total appointments Class I Class II Class III SOURCE:

Voluntary Total 4280 1,860 260 2,160

Hospital

Classi 830 450 60 320

Teaching Class II 770 380 70 320

Class

Class III 2,680 1,030 130 1,520 Hospital Council of Greater New York, study of staff appointments, 1958.

ATTENDING

STAFF

153

despite variation, there is a tendency for a physician to accept a p p o i n t m e n t in a voluntary hospital of lower teaching class t h a n that of his m u n i c i p a l a p p o i n t m e n t . T h i s is conveyed by the fact that while 55 p e r c e n t (1,030 of 1,860) of all a p p o i n t m e n t s in Class I m u n i c i p a l hospitals are associated with Class I I I v o l u n t a r y hospitals, 39 p e r c e n t (320 of 830) of all a p p o i n t m e n t s in Class I v o l u n t a r y hospitals are associated with a p p o i n t m e n t s in Class I I I m u n i c i p a l hospitals. T h e ranks held by physicians in the two systems were also compared. A h i g h e r rank in a given teaching class of hospital in o n e system t h a n in the o t h e r may be taken as an indication of a lower degree of attractiveness, and conversely for a lower r a n k . Table

5.4. C O M P A R I S O N B E T W E E N R A N K S H E L D I N V O L U N T A R Y A N D MUNICIPAL HOSPITALS OF SPECIFIED T E A C H I N G C L A S S BY P H Y S I C I A N S W I T H A P P O I N T M E N T S I N B O T H S Y S T E M S , N E W Y O R K C I T Y , 1958

Teaching Hospital of

Class of Appointment

M u n i c i p a l , Class I a n d : V o l u n t a r y , Class I V o l u n t a r y , Class III M u n i c i p a l , Class III a n d : V o l u n t a r y , Class I V o l u n t a r y , Class III

Physician's Municipal

Rank in Hospital

Total Physicians

Higher

Equal

Lower

450 1,030

160 190

190 400

100 440

320 1,520

270 460

30 600

20 460

SOURCE: H o s p i t a l Council of G r e a t e r New York, s t u d y of start a p p o i n t m e n t s , 1958.

Physicians with a p p o i n t m e n t s in Class I I I teaching hospitals in both systems have a p p r o x i m a t e l y the same r a n k in each, with just as m a n y having the h i g h e r r a n k in o n e as in the other. Physicians with a p p o i n t m e n t s in Class I m u n i c i p a l hospitals a n d Class I I I voluntary hospitals are m o r e likely to have the same or lower r a n k in the f o r m e r than the same or h i g h e r r a n k (the odds are 10 to 7). Similarly, as may be expected, physicians with a p p o i n t m e n t s in Class I voluntary hospitals a n d Class I I I m u n i c i p a l hospitals are m o r e likely to have the same or lower r a n k in the f o r m e r t h a n the same or h i g h e r r a n k (6 to 1). Physicians with a p p o i n t m e n t s in Class I teaching hospitals in b o t h systems are m o r e likely to have the same o r higher r a n k in the m u n i c i p a l hospital t h a n in the voluntary (6 to 5). A l t h o u g h n o n e of these comparisons yields a large difference

PERSONNEL, PLANT, AND ORGANIZATION

154

between the two hospital systems, each points in the same direction, namely, toward a relatively lower attractiveness on the p a r t of Class III municipal hospitals. T h e nature of the d i f f e r e n c e s small and always in the same direction—is consistent with the reports encountered in interviews that this is a period of mounting difficulty for these hospitals. T R E N D IN P A Y M E N T O F P H Y S I C I A N S FOR A T T E N D A N C E IN

OUTPATIENT

DEPARTMENT

T h e foregoing conclusion receives support from another set of facts, namely, the rapid increase in the n u m b e r of paid outpatient department sessions in municipal hospitals. Between 1955 and 1958 the n u m b e r of paid sessions (including those for anesthesiologists, psychiatrists, and physicians in public-home infirmaries) doubled, with the result that today more than one half of all outpatient department sessions in municipal hospitals are paid for, mostly at $15 per session. In voluntary hospitals such payment is rare. Payment to physicians for service in the outpatient departments of municipal hospitals began in the mid 1930s. It was then limited to certain clinics, such as tuberculosis, venereal disease, and refraction. As the range of clinics in which payment could be made was expanded, limitations on the rank of the physician who might be paid were slowly removed. Today a physician of any rank may receive payment for working in the outpatient department, and many physicians of senior rank request payment as a means of qualifying for old age benefits under the Social Security Act. Substantial differences exist among municipal hospitals in the proportion of all outpatient department sessions paid for, ranging from approximately 20 percent to 90 percent or higher. In general, there is a tendency for nonuniversity hospitals to pay for a higher proportion of sessions than university hospitals. Although the n u m b e r of physicians with appointments in municipal hospitals has increased, they are apparently not so available as formerly to render free care in the outpatient department. Aggravating the situation is the expansion in the volume of visits, which has increased the demand for physicians' services.

ATTENDING STAFF EXPLANATORY

155

FACTORS

T h e r e was a time, not more than a generation ago, when staff appointments to the wards of municipal hospitals in New York City were highly sought after by young physicians. Here one could develop proficiency in medicine and maintain it over the years, keeping abreast of advances in medical knowledge. Today, municipal hospitals without medical school affiliation seem to have lost their attraction for young physicians. How has the change come about? In interviews with physicians and hospital administrators a number of reasons were advanced. These are presented in order of increasing importance. Departmental Rule. T h e rule of the Department of Hospitals that a staff member above the rank of clinical assistant can hold only one general hospital appointment, unless authorized to the contrary by the Commissioner, tends to militate against municipal hospitals without medical school affiliation. When a physician must choose between an appointment in a university affiliated general hospital and an unaffiliated one, he is likely to take the former. Decline in Attraction of Teaching. With the advent and expansion of house staff who were graduated from foreign medical schools, the morale of the attending staff who supervise graduate education has been impaired. For some attending physicians, it was reported, a municipal hospital without medical school affiliation no longer offers a stimulating environment for teaching. Decline of House Staff as Source of Attending Staff. With the rising proportion of foreign exchange students on the house staff, most of the alumni return to their countries of origin and do not become potential recruits to the attending staff. T h i s point is independent of the question whether these men would be considered qualified to receive such appointments. Moreover, a present member of the attending staff would consider that he has lost the prospect of receiving referrals from the men he has trained when they enter practice. Relative Scarity of Certain Specialists in the City. Throughout the city hospitals report difficulty in recruiting pediatricians and

156

PERSONNEL, PLANT, AND ORGANIZATION

obstetricians to their attending staffs. It was also frequently mentioned that it was difficult to attract specialists in ophthalmology and otolaryngology. Oftentimes similar difficulties were reported by neighboring voluntary and municipal hospitals and by both nonuniversity and university hospitals. T h e r e is, however, a difference in degree. Decline in Number of Physicians in Practice. As previously shown, there has been a significant decline in the number of physicians in private practice in New York City. In two of the boroughs, the Bronx and Brooklyn, the rate of decline is above the city-wide average. Economic Pressures and Incentives. At the time they complete their training, the majority of physicians today have families and must earn a living (see Chapter 6). T h e y cannot afford to give their time to a municipal hospital without compensation in money or private patient privileges. T h e i r families also put a heavy demand on their leisure time, so that they cannot spend as much time at hospitals as their predecessors did. Moreover, there exist opportunities for earning money, such as service at Veterans Administration hospitals and outpatient clinics, in union health centers and industrial concerns, and in insurance companies. Office practice is more lucrative than it was a generation ago, with the average number of physicians' services per person per year estimated to have doubled since 1929. 4 Finally, for contributing his services in the ward or outpatient department of a voluntary hospital, the physician gains an opportunity to earn a good part of his livelihood. He receives no such return when he makes a similar contribution in a municipal hospital. T h e net result is that even when the physician is on the attending staff of a hospital, he visits less often. It was further reported that, whereas in the past a physician would come to the hospital and spend two or three hours at a time on the ward, today "he comes and runs." Transformation of Training from Apprenticeship to Residency. Thirty or so years ago attendance in hospital wards was the only way a physician could acquire proficiency in a field on the basis of which he would qualify as a specialist. This was

A T T E N D I N G STAFF

157

particularly true in surgery. In local hospitals promotion from the staff of the outpatient department to that of the inpatient service was a significant step in a man's career. P r o m o t i o n was not readily forthcoming and had to be earned. T o d a y a physician qualifies as a specialist through residency training. T h e young physician in practice has less to gain than his predecessor from an appointment in the ward of a municipal hospital, because he is already fairly proficient by the time he enters practice. Moreover, the opportunity to gain in proficiency is not so great as in the past, because the specialty boards expect the senior residents to assume full responsibility for the care of patients. Another consequence of the transformation of medical training is that as graduate training has become longer and more formal, it calls for larger resources in men and materials. T h e s e the City of New York has failed to provide to its hospitals. In an affiliated municipal hospital this lack, is not so apparent, because the medical school affords considerable supplementation in personnel, salaries, and equipment. As a result, the nonaffiliated hospitals are without important support and leadership in the effort to raise standards of care and education. A

BALANCED

VIEW

Nevertheless, the fact is that senior m e n on the attending staff do remain at municipal hospitals without medical school affiliation to perform the necessary work, and that some younger men, apparently in insufficient numbers, do j o i n them. W h e n the question is asked why they do so, in view of all the adverse factors enumerated above, the answer frequently given is that physicians enjoy the association with the hospital and the prestige. T h e r e may be, in addition, a small financial return from service in the outpatient department. T h e s e favorable factors do not seem to be of great weight, in comparison with the adverse factors. W h a t is a balanced view of the current status of the attending staff in municipal hospitals without medical school affiliation? I n the course of interviews several physicians suggested that municipal hospitals without medical school affiliation may be better off today than they were twenty or thirty years ago. T o d a y the special-

PERSONNEL, PLANT, AND ORGANIZATION

158

ist m e m b e r s of the a t t e n d i n g staff are well trained and are not, as formerly, a c q u i r i n g proficiency by practicing on ward patients. T h e i m p o r t a n t q u e s t i o n is w h e t h e r enough well-trained m e n are b e i n g r e c r u i t e d i n t o the system to replace the m e n leaving it t h r o u g h resignation and r e t i r e m e n t . A l m o s t every hospital in N e w Y o r k City has difficulty in attracting

certain

medical

specialists,

such

as pediatricians

and

obstetricians, who follow the y o u n g middle-class population to the suburbs. I t is true, nevertheless, that m u n i c i p a l hospitals w i t h o u t medical school affiliation seem to have difficulty across the board in r e p l a c i n g senior m e n with new appointees at the b o t t o m of the p r o m o t i o n ladder. M a n y m e m b e r s of the senior a t t e n d i n g staff find it necessary to work l o n g e r and harder than their predecessors did. S o m e are, m o r e o v e r , w o r k i n g beyond their strength. Possibilities are nearly exhausted f o r r e d u c i n g the size of a t t e n d i n g staff by consolidating two m e d i c a l or surgical services in a hospital into o n e or for increasing a v a i l a b l e m a n p o w e r by l e n g t h e n i n g

the

a n n u a l p e r i o d of service of a t t e n d i n g staff m e m b e r s . O n e physician-administrator summarized the possibilities for attracting physicians to the a t t e n d i n g staffs of m u n i c i p a l hospitals as follows: it is easier for hospitals with a medical school affiliation than for hospitals w i t h o u t such affiliation; it is easier for hospitals with new buildings, facilities, and e q u i p m e n t than for hospitals with obsolete buildings, facilities, and e q u i p m e n t ; it is easier for hospitals with good n u r s i n g service than for hospitals with poor nursing service o r similar frustrations—at least to retain the attending staff that they have; it is easier for hospitals with adequate parking areas and accessible to expressways than for hospitals without these conveniences. A b o v e all, in his o p i n i o n , the d e t e r m i n i n g factor is the interest, loyalty, zeal, and leadership of the chief of service. T h e evidence suggests that the gradual, probably accelerating, attrition

of a t t e n d i n g staff at some of the

non-medical-school

m u n i c i p a l hospitals is the greatest single threat to t h e i r ability to c o n t i n u e to provide care of adequate quality. Drastic steps may be r e q u i r e d to arrest and reverse recent trends. It will not b e simple to find a solution to this problem, if the factors involved are as varied and as deep-seated as stated

A T T E N D I N G STAFF

159

above. Any effort at solution must, of course, take into account other aspects of the problem, including the pattern of financing hospital care in New York City. Alternative approaches are discussed elsewhere (see Chapters 9, 11, and 21). Summary 1. Every physician in practice should have the opportunity to join the attending staff of a hospital and to participate in its work within the limits set by his experience and competence. Hospitals do not fulfill this obligation to the community by appointing to their staffs only the best qualified physicians. 2. Between 1950 and 1958 the n u m b e r of physicians in private practice in New York City declined by 1,300, or 8 percent. T h i s decline is consistent with the cessation of population growth in the city and the relatively low average income earned by its practitioners. 3. Between 1948 and 1958 the number of physicians with staff appointments increased in each hospital system. T h i s increase has come about through an increase in the number of physicians who have appointments in both hospital systems, more than offsetting the decline in the number of physicians with appointments in one system only. 4. T h e entire increase in staff appointments in the municipal system has occurred in hospitals with medical school affiliation or with new physical plant. Among municipal general hospitals without medical school affiliation 9 of 11 have had decreases in size of staff; the two with increases occupy new buildings. 5. A comparison was made of the caliber of physicians in the two hospital systems, as expressed in the proportion of diplomates, full specialists, and graduates from American medical schools. Appreciable differences were found among physicians with voluntary hospital appointments only, municipal hospital appointments only, and appointments in both systems. T h i s is important, because the physicians with appointments in municipal hospitals only tend to be concentrated in non-medical-school hospitals. 6. Similar comparisons were made between the staffs of Class I and Class I I I teaching hospitals in the two systems. T h e teaching class of a hospital, defined in the text, is determined by the scope

PERSONNEL, PLANT, A N D ORGANIZATION

160

of its teaching program. T h e data show that a t t e n d i n g staffs in Class I hospitals had higher qualifications t h a n staffs in Class III hospitals; a n d that w i t h i n Class I I I hospitals the staffs of v o l u n t a r y hospitals had the higher qualifications. T h e latter have also b e e n m o r e successful in r e c r u i t i n g y o u n g physicians to their a t t e n d i n g staffs. 7. A l t h o u g h most of these differences are small, all p o i n t in the same direction. T h e y are consistent w i t h t h e view t h a t this is a t i m e of m o u n t i n g difficulty for m u n i c i p a l hospitals w i t h o u t medical school affiliation. 8. T o d a y m o r e than one half of all o u t p a t i e n t d e p a r t m e n t sessions in m u n i c i p a l hospitals are paid for. Non-medical-school hospitals tend to pay for a larger p r o p o r t i o n of t h e i r sessions than medical school hospitals. I n b o t h the t r e n d is u p w a r d . 9. In the course of interviews a n u m b e r of e x p l a n a t i o n s were advanced for the fact that m u n i c i p a l hospitals w i t h o u t medical school affiliation have lost their attractiveness for y o u n g physicians. A m o n g the i m p o r t a n t factors are: the decline in the n u m b e r of physicians in practice in t h e city, which is a c c e n t u a t e d in certain specialties; economic pressures a n d incentives that d r a w physicians elsewhere; a n d the t r a n s f o r m a t i o n of g r a d u a t e medical t r a i n i n g f r o m apprenticeship to residency, which has r e d u c e d the y o u n g practitioner's d e p e n d e n c e on m u n i c i p a l hospitals. 10. M u n i c i p a l hospitals w i t h o u t medical school affiliation are n o t r e c r u i t i n g e n o u g h y o u n g m e n to replace the o l d e r m e n leaving t h r o u g h resignation a n d r e t i r e m e n t . T h e a t t r i t i o n of t h e attending staffs at some of these hospitals poses t h e greatest single threat to their ability to c o n t i n u e to provide care of a d e q u a t e quality.

Appendix

5.A

T R E N D IN N U M B E R OF LICENSED PHYSICIANS AND OF T H O S E IN PRIVATE P R A C T I C E IN N E W YORK CITY Despite, and perhaps because of, the plethora of data on physicians in New York City, it proved difficult to determine whether the number of private practitioners had remained constant or declined during the 1950s. It was not until data were obtained from the Directory Depart-

161

ATTENDING STAFF

m e n t of the A m e r i c a n Medical Association that a firm c o n c l u s i o n c o u l d be reached. (It s h o u l d be n o t e d t h a t these differ f r o m t h e d a t a in the p u b l i s h e d Directory of the American Medical Association, because of a difference in timing.) TOTAL

NUMBER

The Medical Directory of New York State 5 presents a t a b l e in its p r e f a c e o n the n u m b e r of licensed physicians listed in each b o r o u g h in N e w York City. B e t w e e n 1948 a n d 1958 the total f o r t h e city fluctuated as follows: Date June 1, 1948 November 15, 1950 March 1, 1953 December 1, 1954 October 1, 1956 September 15, 1958

Number 17,554 17,761 17,591 17,864 17,712 17,756

A v a i l a b l e d a t a f r o m o t h e r sources show the following n u m b e r s of physicians in N e w York City in 1950: Directory Department, AMA 8 Special study by AMA 7 (computed) U.S. Public Health Service and Census»

19,695 17,920 19,188

O n e factor t h a t h e l p s to e x p l a i n the differences a m o n g all these figures is the e x t e n t to w h i c h resident physicians are i n c l u d e d . T h i s d e p e n d s , at least in p a r t , o n t h e provisions of the State licensure law a p p l i c a b l e to residents, w h i c h c h a n g e f r o m time to time (see C h a p t e r 6).

I t is also n o t e w o r t h y t h a t the lowest of all the figures, t h a t of the Medical Directory of New York State, c o n t a i n s a large n u m b e r of d u p l i c a t e listings for physicians w i t h offices in two or m o r e b o r o u g h s . O n t h e basis of a 10 p e r c e n t s a m p l e the e x t e n t of d u p l i c a t i o n is estim a t e d at 870 f o r p r i v a t e p r a c t i t i o n e r s a n d at a larger n u m b e r f o r all physicians. IN

PRIVATE

PRACTICE

T h e H o s p i t a l C o u n c i l h a d p e r f o r m e d a study of h o s p i t a l staff a p p o i n t m e n t s for physicians in 1948 9 a n d wished to p e r f o r m a s i m i l a r o n e for 1958. T h e f o r m e r was a total c o u n t of physicians; t h e l a t t e r , it was decided, w o u l d b e a 10 percent s a m p l e of the physicians listed in the Medical Directory of New York State. The American Medical Directory w o u l d p r o v i d e s u p p l e m e n t a r y i n f o r m a t i o n o n t h e physicians, as n e e d e d . 1 0 T h e p o i n t of d e p a r t u r e of a study of hospital staff a p p o i n t m e n t s is t h e n u m b e r of physicians in practice (mostly private practice). O n

PERSONNEL, PLANT, AND ORGANIZATION

162

the basis of t h e p u b l i s h e d d a t a for 1948 11 a n d the s a m p l e survey for 1958, t h e c h a n g e in t h e d i s t r i b u t i o n of physicians a p p e a r e d to be as follows: Change

Total Not in practice In practice

1948 17,703 2,853 14,850

1958 17,690 2,320 15,370

1948-58 - 13 - 533 +520

T h e s e figures were n o t consistent with w h a t is k n o w n f r o m o t h e r sources a b o u t t r e n d s in the n u m b e r of physicians n o t in practice. T h e r e was reason to suspect t h e completeness of the c o u n t for this g r o u p . Nevertheless, t h e r e was n o basis for d e t e r m i n i n g t h e t r u e direction of t r e n d in the n u m b e r of physicians in practice u n t i l the u n p u b l i s h e d d a t a f r o m t h e Directory D e p a r t m e n t of t h e A m e r i c a n M e d i c a l Association b e c a m e available. T h e y c o u n t a p e r s o n only once, at the address of his choice. T h e c o m p l e x i t y of t h e task of e s t i m a t i n g t h e t r u e t r e n d is illust r a t e d by t h e finding t h a t b e t w e e n 1950 a n d 1958 t h e n u m b e r of private p r a c t i t i o n e r s d e c l i n e d by 1,300, a l t h o u g h the total n u m b e r of licensed physicians m a y have declined by only 110 (see page 146).

g

INTERNS AND RESIDENTS

Interns and residents have become important members of the staff of the modern hospital. In New York City 64 voluntary hospitals, 18 municipal hospitals, and 1 proprietary hospital have approved training programs for interns (newly graduated physicians in their first year of full-time hospital experience) or residents (physicians in the second and subsequent years of training in a specialized field of medicine) or both. T h e presence of interns and residents helps a hospital provide medical services around the clock, and maintain an educational environment, both of which increase patients' prospects of receiving care of high quality (see Chapter 10). T h e twin objectives of rendering service to patients through young physicians and of educating the latter are closely linked. One program may attach too much weight to the hospital's present service requirements to the neglect of the young physicians' education; whereas another may attach too much weight to medical education and research to the detriment of patient care. An authority recently stated: " T o o much service may mean too little education. But too much emphasis on research and education may also result in a type of patient care which is impersonal and lacking in understanding of the real needs of the patient." 1 T h e two extremes should be avoided. Although the primary objective of intern and residency training is to educate the young physician, 2 rendering service to patients is an "inevitable, proper and necessary" element of such education. 3 W o r k i n g under the supervision of experienced physicians, the young physician is expected to assume progressively increasing responsibility in patient care.

164

PERSONNEL, PLANT, AND ORGANIZATION

Every hospital should aim for an educational atmosphere. A hospital that cannot be approved for intern or residency trai ning or, if approved, is unable to recruit trainees with appropriate educational background, can still foster a good teaching p r o g r a m for its attending staff.'* It is important for the practicing physician to keep abreast of advances in medical knowledge, and the best way —perhaps the only practical way—for him to do this is by participating in the work of an active hospital staff. Statement

of

Problem

T h e Hospital Council's Master Plan for Hospitals and Related Facilities for New York City states that there are three m a j o r factors to be considered in p l a n n i n g hospital facilities and services: care of patients, medical education, and medical research. 6 T h e first two are emphasized. T h e n u m b e r of hospital beds in a community should be determined by the needs of the population for care; the distribution of beds among individual hospitals is determined by (1) the geographic distribution of the population and (2) the need to concentrate in one place sufficient n u m b e r s of patients for training residents in the various medical specialties. A major consideration in setting the m i n i m u m size of new general hospitals in New York City at 200 beds was the desire to have every general hospital offer residency training in at least the four basic medical fields—internal medicine, general surgery, obstetrics, and pediatrics. Large hospitals, drawing on larger population groups, would in addition offer training in other specialties.6 Looking ahead, the Master Plan anticipated that private patients, as well as ward patients, would come to be employed for teaching. In residency training, particularly in the surgical specialties at the senior level, teaching with private patients poses certain problems that require continuing attention. In any event, as long as ward patients exist in sizable numbers, they should serve as the core of medical education programs. T h e Master Plan, published in 1947, was developed at a time of apparently inexhaustible demand by young physicians for house staff positions in hospitals. It was believed that for every hospital

I N T E R N S AND RESIDENTS

165

in New York City to offer residency training would improve the quality of care given to patients and maintain the preeminent position of local hospitals in graduate medical education in this country. T h e reform of undergraduate medical education in the United States had borne fruit, so that few applicants for internships and residencies were graduates of unapproved medical schools. Experience before World W a r I I in training graduates of foreign medical schools had been limited largely to graduates of schools in Western Europe, many of them American citizens who had gone abroad for their medical education. Immediately after the war residency training in this country expanded rapidly, and there was reason to expect the trend to continue, in line with the acceleration of specialization in medical practice. Hitherto, there had been few vacant house staff positions. T h e r e were no grounds for anticipating that additional house staff positions in New York City hospitals would go unfilled. Accordingly, the Master Plan's recommendations on graduate training in hospitals were received in a favorable climate. A recent review by the Hospital Council shows that in the decade 1947-57 the number of hospitals in New York City with approved residency training programs in all four basic medical specialties doubled, increasing from 17 to 35. T h i s occurred during a period when the total number of general hospitals with 200 beds or more increased by 10 percent, from 57 to 63. Among voluntary hospitals alone the record was even more favorable: the number with residency training programs in all four basic fields tripled between 1947 and 1957, increasing from 8 to 24, while the n u m b e r with 200 beds or more increased only by 2, from 43 to 45. T h e number of voluntary hospitals with residency training in three basic fields also increased during this period, while the number of hospitals with two or fewer programs declined, the last most dramatically. A closer view of postwar developments in residency training in New York City shows, however, that not every hospital with expanded training programs has been able to recruit graduates of American (United States and Canadian) medical schools for its residency positions. O f the 16 voluntary hospitals that attained

166

PERSONNEL, PLANT, AND ORGANIZATION

approval for residency training in all four basic fields d u r i n g the period 1947-57, only 2 reported recently that graduates of American medical schools constituted 70 percent or more of all their residents. T w o more hospitals reported that such graduates constituted between 50 and 70 percent of their residents. O n the other hand, 2 hospitals reported that all of their residents were graduates of foreign medical schools, and in 5 hospitals foreign graduates constituted more than 80 percent of all residents. I n many hospitals in New York City—and throughout the country—recruitment of house staff for approved training programs has become a struggle, recurring annually and often with disappointing outcome. Early in the 1950s there was a high rate of vacancies in intern and residency positions. Recently relatively few positions in local hospitals have gone unfilled. However, many hospitals have large n u m b e r s of house staff who attended medical school abroad; these physicians frequently lack the qualifications of graduates of American medical schools, with resultant problems in the provision of medical care of adequate quality. ( T h e i r additional impact on the attending staff was discussed in Chapter 5.) I m m i n e n t is a period of decline in the n u m b e r of eligible candidates for house staff positions; this will accentuate the difficulties in recruitment facing some hospitals. How the present situation in New York City came about can best be understood against the background of developments in graduate medical education in the country, examined both for the similarities and differences that obtain between this city and the United States as a whole. Detailed findings for New York City then follow, with major emphasis on a comparison between the voluntary and municipal hospital systems. Finally, alternative proposals for action are discussed. Developments

in the

Nation

T h e first hospitals in this country were established to care for the sick poor. From the beginning it was recognized that they needed the services of physicians around the clock and that their wards provided an unexcelled opportunity for training young physicians. T h r o u g h o u t the first century of house staff history in this country the n u m b e r of physicians involved was small. Most

I N T E R N S A N D RESIDENTS

167

physicians went directly into practice, whereas only a few attained the coveted position of hospital attending through prolonged training on the house staff. 7 P R E - W O R L D W A R II P H A S E

T h e expansion of house staff training has occurred since 1900.8 In its modern form and extent, however, it is of fairly recent origin. One medical educator gives 1935 as the beginning of the present pattern of graduate medical education in this country. 9 In 1914, for the first time, a state (Pennsylvania) required the hospital internship as a prerequisite for licensure. 10 It was also in 1914 that the first complete listing of internships in this country was issued. Thereafter, increasing numbers of physicians took an internship as a means of acquiring assurance and skill in clinical medicine, though some did not. (By 1935 fewer than 1 percent of the physicians who had been graduated from New York City's medical schools between 1919 and 1931 lacked an internship.) 11 In 1920 there were enough internship positions to provide one for every graduate of United States medical schools, had every internship been of one year's duration. T h e balance between the total n u m b e r of internship positions and the annual n u m b e r of graduates of United States medical schools remained close and precarious until 1926, when a sizable excess of the former (750) occurred for the first time. 12 By World W a r II the excess had risen to 2,900, but 2,000 of the positions were held by second-year interns. 1 3 Expansion of residency training came later. Formerly, a physician became a specialist by cultivating a special interest or skill in his practice and then limiting himself to it; by apprenticeship to such a specialist; or, less often, by training in Europe. T h e n came the postgraduate schools of medicine and the hospitals' residency training programs. 14 In 1926 the first complete listing of approved residency training programs showed 1,780 residency positions, a n u m b e r equal to 36 percent of the internship positions offered that year (4,950). 10 T h e formation of certifying and examining boards in the specialties, which contributed greatly to the establishment of residency training as the chosen route to specialization, reached a peak in the 1930s. In that decade 12 of the 19 speciality boards now in existence were established, 9 in the

PERSONNEL, PLANT, A N D ORGANIZATION

168

three-year period 1934-37.16 By 1940 there were 4,880 residency positions, or 60 percent of the n u m b e r of internship positions (8,180). 17 THE

POSTWAR

PHASE

W o r l d W a r II and its aftermath brought a rapid transformation in graduate medical education in this country. T h e r e were two simultaneous developments in intern training: (1) the total n u m b e r of positions continued to increase, rising by 52 percent between 1940 and 1958 (from 8,180 to 12,469) 18 and (2) the number with a two-year term declined from 25 percent of the total in 1940 to 10 percent in 1949 19 and to less than 1 percent in 1958. T h e Korean W a r brought the virtual abandonment of the twoyear internship. 2 0 Although the n u m b e r of graduates of American medical schools continued to increase, it was far from sufficient to fill all positions. Vacancies continued to increase, until they were stabilized by the influx of foreign-educated physicians. T h e armed forces gave considerable stimulus to residency training when they took account of a physician's diplomate status in classifying and assigning him. After World W a r II many discharged physicians sought residencies for refresher training or in preparation for a specialist's career. In 1945, for the first time, the n u m b e r of residency positions offered exceeded the n u m b e r of internships, 8,930 to 8,430. By 1949 the n u m b e r of residency positions had doubled to 18,670; and by 1955 tripled to 26,520. In 1958 their n u m b e r reached 31,800. 21 T h e n u m b e r of residency positions was now 250 percent of the n u m b e r of intern positions, compared with 60 percent in 1940 and 106 percent in 1945. T h e n u m b e r of interns and residents holding positions in approved programs in this country can be presented beginning in 1930. Between 1930 and 1958 the n u m b e r of interns in this country nearly doubled, whereas the n u m b e r of residents increased eighteen fold. In 1930 there were one fourth as many residents as interns; in 1940, one half; and in 1958, the ratio was better than two and one half to one. In the single decade of the 1940s the ratio of residents to interns was reversed from one half to two. (Indeed, the shift in ratios was even sharper in the fiveyear period 1945-50; b u t 1945 was an abnormal year and should

INTERNS AND Table

169

RESIDENTS

6.1. I N T E R N S A N D R E S I D E N T S I N PROGRAMS, U N I T E D STATES,

Year

Total

1930 1940 1945 1950 1957 1958

7,000 11,453 8,364 21,416 35,174 37,110

Interns

APPROVED TRAINING 1930-58

Residents

5,500 7,553 6,300 6,821 10,198 10,352

1,500 3,900 2,064 14,595 24,976 26,758

Residents per 100 Interns 27 52 33 214 245 258

SOURCE: 1930, 1940, 1950, a n d 1957-Frank Bane (for the Surgeon General's Consulta n t G r o u p on Medical Education), Physicians for a Growing America (Washington, D C., 1959), p. 9; 1945-U.S. Public H e a l t h Service, Division of Public Health Methods, Health Manpower Source Book, Section 9 (Washington, D.C., 1959), p. 25, and letter from Frank G. Dickinson, then with American Medical Association, to H e r b e r t E. Klarman, March 27, 1951; and 1958—American Medical Association, Council on Medical Education and Hospitals, Directory of Approved Internships and Residencies, 1960, reprinted f r o m Journal of American Medical Association, CLXXIV, No. 6 (October 8, 1960), p. 583.

not serve as a base.) Although the n u m b e r of interns in approved training programs has continued to increase, the n u m b e r of residents is increasing at a faster rate and the ratio of residents to interns continues to rise. T h i s indicates prolongation of medical training. FACTORS IN EXPANSION O F HOUSE STAFF

T h e n u m b e r of hospitals in this country with approved training programs and the average n u m b e r of physicians per hospital house staff have both increased. Among the factors contributing to the higher demand by hospitals for house staff are the following: 1. Reduction in the average length of patients' stay in hospitals. As a result, a higher proportion of house staff time than formerly is devoted to patients' initial examinations u p o n admission. T h i s calls for a larger house staff at a given time to maintain a given degree of thoroughness of examination. 2. Increased activity in caring for ambulatory patients, especially in the emergency departments of hospitals in large cities. 3. Continuing proliferation of medical specialties and subspecialties, accompanied by the desire of hospitals to cover as many services as possible with residents. 4. T h e requirement by most specialty boards that a year's

170

PERSONNEL, PLANT, A N D ORGANIZATION

training in internal medicine and general surgery, the m o t h e r specialties, precede and augment training in the medical and surgical subspecialities. 22 5. Increasing reliance by attending staff on interns and resid e n t s to r e n d e r m e d i c a l services to h o s p i t a l i z e d p a t i e n t s , which releases the former to provide more services outside the hospital. 28 6. T h e tendency for more hospitals to assign house staff to the private service. Twenty-five years ago this serivce was regarded as providing b u t a "meager" educational experience to the young physician. 24 In the middle 1940s it was reported that residencies in private pavilions had improved. 2 6 Today, assignment to the private service is an important supplement to assignment on the ward, if not a substitute for it. 7. An increase in the proportion of interns and residents who are married and have children, so that many are not so readily available as formerly for round-the-clock duty seven days a week. (A survey of the graduates of United States medical schools in 1959 shows that 63 percent of the male graduates were married; and of the married students, 24 percent had two or more children. 2 6 In 1959-60, 71 percent of all residents were married.) 2 7 8. An increase in the n u m b e r of fellows, many of whom do substantially the same kind of work as residents but follow a nineto-five o'clock schedule. T h e postwar expansion in graduate training in medicine has been made possible by (1) an increase in the n u m b e r of physicians graduated from American medical schools; (2) prolongation of the average duration of graduate medical education; and (3) an influx of physicians from abroad seeking hospital training in this country. T h e n u m b e r of graduates from American medical schools increased from 5,100 in 1940 to 6,135 in 1951 and 6,860 in 1958.28 For the period 1940-58 the increase was approximately 35 percent. W i t h an increasing n u m b e r and proportion of physicians in this country engaged in specialty practice, the average duration of graduate medical education for graduates of American medical schools has lengthened from an estimated two years in 1940 to 3.25 years in 1956 (see Appendix 6.A). A recent study estimates

I N T E R N S AND RESIDENTS

171

the average duration of graduate medical education in 1958 at 3.5 years. 29 For the period 1 9 4 0 - 5 8 the average duration of graduate medical education was lengthened by 75 percent. T h e increase in the n u m b e r of foreign-educated physicians serving as house staff in this country has taken on spectacular dimensions, particularly in the 1950s. I n Appendix 6.A it is estimated that there were 2,500 of these physicians in 1951, 8,900 in fiscal year 1956, and at least 12,500 in fiscal year 1959. In less than a decade the n u m b e r of foreign-educated physicians serving as house staff increased by 10,000. T h e principal factor is the exchange visitors program, which was authorized by the United States Information and Educational Exchange Act of 1948 and became effective in July, 1949. T H E P R O B L E M OF T H E FOREIGN-EDUCATED

PHYSICIAN

D u r i n g the period 1 9 4 5 - 5 0 the rate at which new intern and residency positions were created in approved hospital training programs in this country exceeded the rate of increase in the number of candidates. T h e result was a rise in the n u m b e r of vacant positions. T h e subsequent influx of large numbers of physicians educated abroad (attending medical schools outside the United States and Canada) has succeeded in curtailing the number of vacant positions but not in eliminating them. Vacancies in this country reached a peak in the year 1952—2,900 in intern positions and 5,425 in residency positions. In 1958 vacant positions were still numerous—2,120 and 5,060, respectively—despite substantial increases in the n u m b e r of interns and residents. Relative to the total n u m b e r of house staff positions, vacancies fluctuated from 11 percent in 1949 (the first year for which complete data are available) to 25 percent in 1952 and to 16 percent in 1958 3 0 (see following section for comparison with New York City). It is possible for numerous vacancies to exist, because no attempt is made to balance the n u m b e r of intern or residency positions offered with the n u m b e r of candidates. I n passing on an individual program, the Council on Medical Education and Hospitals of the American Medical Association is concerned only with its educational potential (see final section of this chapter). Interns and residents, however, also render medical services to patients.

172

PERSONNEL, PLANT, AND ORGANIZATION

Although some graduates of foreign medical schools are well trained and capable, others have deficiencies in English or in the basic medical sciences or in clinical contact with patients. One American student of medical education abroad has summarized the p r o b l e m as follows. A vast n u m b e r of students admitted to foreign medical schools lack knowledge of the basic sciences—a necessary foundation for medical education. In addition, the tradition in most foreign countries, with a few notable exceptions, of admitting to medical school all persons capable of passing from secondary school results in large classes. T h e s e preclude teaching in small groups, intimate interchange between student and teacher, and practical laboratory instruction. Finally, the organization of hospital services in other countries may serve to minimize or even eliminate contact between medical students and patients, much less assumption by the former of clinical responsibility. 3 1 Medical and hospital authorities in this country have been concerned about the medical service problems resulting from the increase in the n u m b e r of foreign-educated physicians on house staffs. After experimenting with a list of approved foreign medical schools, which could not be kept current, a decision was rcached in 1956 to establish the Educational Council for Foreign Medical Graduates ( E C F M G ) which would evaluate every graduate of a foreign medical school (except Canadian and the University of Puerto Rico) who applied for an internship or residency in the United States. T h e evaluation consists principally of an examination in medicine, modeled after the National Board examinations, and a screening for comprehension of English. T h e organization was established in 1957, and the tests were inaugurated in the spring of 1958 and given twice a year thereafter. By December, 1960, 41 percent of the candidates had passed with a standard certificate (grade of 75 or higher) and 25 percent had obtained a temporary certificate (grade of 70-74) that entitled them to receive training in this country for two years. 3 2 B e g i n n i n g J a n u a r y 1, 1961, hospitals in this country have been requested not to appoint or retain as interns or residents physicians without a state license who lack a certificate from E C F M G . In the immediate future the number of exchange visitors serving as house staff in approved training

173

INTERNS AND RESIDENTS

programs in this c o u n t r y is likely to decline; the p r o b a b l e size of the decline is discussed in the final section of the chapter. Comparison between United States

New York City and the

T h e long term t r e n d in training physicians in hospitals in N e w York City resembles that in the U n i t e d States b u t is n o t identical with it. Similarities lie chiefly in the expansion in residency training a n d in the influx of large n u m b e r s of physicians educated abroad. A m a j o r difference between the two geographic areas is that twenty-five years ago graduate medical education in N e w York City was considerably advanced over most o t h e r parts of the country. T h e intervening years have witnessed some catching u p by the latter a n d a lag in the rate of expansion of house staff t r a i n i n g in New York City compared with that in the nation. T h e lag in the i n t e r n s h i p is particularly noteworthy. T a b l e 6.2 shows the increase in interns a n d residents in approved programs in all hospitals in New York City and the U n i t e d States between 1935 and fiscal year 1959. ( T h e data for the U n i t e d States in 1935 show the n u m b e r of i n t e r n s h i p a n d residency positions, rather than the n u m b e r of persons filling them, because the latter could n o t be ascertained. T h e error resulting f r o m this substitution is believed to be small, since relatively few positions were then vacant.) T h e 1959 data for N e w York City are based on a special house staff q u e s t i o n n a i r e by the Hospital Council to which every hospital with an approved program responded. N e w York City had the same n u m b e r of hospitals approved for i n t e r n s h i p t r a i n i n g in 1935 a n d in 1959 and approximately the same n u m b e r of interns—60 hospitals a n d 1,230-1,240 interns. ( T h e hospitals involved were n o t identical. T h r e e programs were discontinued before or d u r i n g the war a n d at least six a f t e r the war, 3 3 so that a m i n i m u m of n i n e new ones were established.) In the U n i t e d States the n u m b e r of hospitals with approved internships increased f r o m 697 34 to 853, 36 a n d the n u m b e r of interns increased by o n e half. N e w York City's p r o p o r t i o n of all interns in this country declined from 18 percent in 1935 to 12 percent in fiscal year 1959.

PERSONNEL,

174 Table

6.2.

PLANT,

AND

ORGANIZATION

I N T E R N S A N D R E S I D E N T S IN A P P R O V E D T R A I N I N G P R O G R A M S IN N E W YORK CITY A N D U N I T E D S T A T E S , 1935 A N D F I S C A L 1959 Change

Place Interns and Residents N e w York City U n i t e d States Interns N e w York City U n i t e d States Residents N e w York City U n i t e d States

Number

1935

1959

1,759 9,599

4,990 37,110

+ 3,231 + 27,511

1,239 6,759

1,226 10,352

+

520 2,840

3,764 26,758

+ 3,244 + 23,918

13 3,593

Percent + 185 + 287 +

1 53

+ 625 + 845

SOURCF: 1935—American M e d i c a l Association, Medical Education in the United States and Canada, 19S-I-35, r e p r i n t e d f r o m Journal of American Medical Association, CV, No. 9 ( A u g u s t 31, 1935), p p . 699, 709, a n d A p p e n d i x 6.B; a n d 1 9 5 9 - A m e r i c a n M e d i c a l Association, C o u n c i l o n M e d i c a l E d u c a t i o n a n d Hospitals, Directory of Approved Internships and Residencies, I960, r e p r i n t e d f r o m Journal of American Medical Association, C L X X I V , N o . 6 ( O c t o b e r 8, 1960), p. 583, a n d H o s p i t a l C o u n c i l of G r e a t e r N e w York, q u e s t i o n n a i r e survey of house staff in h o s p i t a l s in N e w York. City, A p r i l 20, 1959.

T h e n u m b e r of hospitals in New York City with approved residencies increased f r o m 53 in 1935 to 88 in 1959, and the n u m b e r of residents increased m o r e than sevenfold. In the c o u n t r y as a whole the n u m b e r of hospitals with approved programs increased f r o m 3 9 2 36 to 1,2 6 5, 37 a n d the n u m b e r of residents increased nine and one half times. N e w York City's p r o p o r t i o n of the nation's residents in a p p r o v e d programs declined f r o m 18 percent in 1935 to 14 percent in fiscal year 1959. W h i l e the n u m b e r of physicians serving as house staff in New York City almost tripled between 1935 and 1959, it increased almost f o u r f o l d in the U n i t e d States. New York City's share of house staff t r a i n i n g in this c o u n t r y is, therefore, smaller today t h a n it was a g e n e r a t i o n ago, 13 percent compared with 18 percent. A second difference between New York City and the nation, which has u n d o u b t e d l y influenced local t h i n k i n g a b o u t solutions to c u r r e n t problems, is the m u c h larger role that the two-year internship formerly played here. In the classic study of internships in N e w York City in the m i d d l e 1930s it was f o u n d that in 40 of 50 hospitals with r o t a t i n g internships (then accounting for 72 percent of all internships) the length of t r a i n i n g was two years or longer. It was one and one half years in 3 hospitals, and in only 7

INTERNS A N D RESIDENTS

175

hospitals was it one year. 3 8 At that t i m e the two-year i n t e r n s h i p was the direct r o u t e to medical practice for m a n y local physicians, w h o subsequently a c q u i r e d f u r t h e r a n d specialized skill in clinical m e d i c i n e as v o l u n t e e r m e m b e r s of the a t t e n d i n g staffs of hospitals 39 (see C h a p t e r 5). By 1941, at the b e g i n n i n g of W o r l d W a r II, a p p r o x i m a t e l y two thirds of all internships in N e w York City were for two years; 4 0 this compares with one f o u r t h , as previously n o t e d , for the U n i t e d States. Since the two-year i n t e r n s h i p is equally rare today in N e w York City a n d in the nation, its decline has been m u c h faster here. A t h i r d difference between N e w York City a n d the n a t i o n is the f o r m e r ' s m u c h larger p r o p o r t i o n of house staff g r a d u a t e d f r o m foreign medical schools. In N e w York City almost one half of all physicians serving as house staff in a p p r o v e d p r o g r a m s in 1959 were graduates of foreign medical schools; the c o r r e s p o n d i n g prop o r t i o n for the U n i t e d States is estimated at o n e t h i r d . Also pointing to a sizable difference between N e w York City a n d the U n i t e d States in this respect is the fact that the f o r m e r has 6 of the 10 hospitals in the c o u n t r y with 50 or m o r e foreign exchange visitors on the house staff. 41 It was possible to develop detailed estimates for fiscal year 1956 of the composition of house staff in the U n i t e d States by location of medical school of g r a d u a t i o n a n d by citizenship status (see A p p e n d i x 6.A). T a b l e 6.3, for fiscal year 1959, shows n u m e r i c a l data for N e w York City and an a p p r o x i m a t e percentage distribution, as derived in A p p e n d i x 6.A, for the U n i t e d States. It s h o u l d be noted that citizenship status is shown only for graduates of foreign schools. T h e n u m b e r of noncitizens a m o n g graduates of American schools is believed to be small. T h e r e are wide differences between N e w York City a n d the nation in the relative i m p o r t a n c e of t e m p o r a r y visitors with exchange visas a n d of U n i t e d States citizens w h o a t t e n d e d medical school a b r o a d . T h e p r o p o r t i o n of house staff in N e w York City hospitals educated a b r o a d has increased f r o m 7.5 percent in 193 5 42 to 48 percent in 1959. T h e corresponding figure for the U n i t e d States in 1935 is n o t k n o w n ; on the plausible a s s u m p t i o n t h a t it was certainly n o h i g h e r t h a n in New York City, the difference b e t w e e n the two areas has widened in the past twenty-five years.

176 Table

PERSONNEL,

PLANT, AND

ORGANIZATION

6.3. D I S T R I B U T I O N O F H O U S E S T A F F I N A P P R O V E D T R A I N I N G P R O G R A M S BY L O C A T I O N O F M E D I C A L S C H O O L O F G R A D U A T I O N A N D BY C I T I Z E N S H I P S T A T U S , N E W YORK CITY A N D U N I T E D STATES, F I S C A L Y E A R 1959 Location an

of j

School

Citizenship

Status

New

York City

United

States

Number

Percent

Percent

4$90 2,602 2,388 526 376 1,486

100.0 52.1 47.9 10.6 7.5 29.8

J 00 66 34 3 10 21

Total G r a d u a t e s of A m e r i c a n s c h o o l s G r a d u a t e s of f o r e i g n s c h o o l s U n i t e d States citizens Permanent immigrants T e m p o r a r y visitors

SOURCE: Hospital Council of Greater N e w York, questionnaire survey of house staff in hospitals in New York City, April 20, 1959, and Appendix 6.A.

T h e fifth difference, which may be associated with the proportion of house staff educated abroad, is the lower rate of vacant positions in N e w York City. T h e rate of vacancy in i n t e r n s h i p or residency programs in a hospital or g r o u p of hospitals c a n n o t be c o m p u t e d precisely, because of complications i n t r o d u c e d by several factors. A m o n g t h e m are (1) interchangeability between i n t e r n s h i p a n d j u n i o r residency positions, d e p e n d i n g on the availability of suitable candidates; (2) variation in counting, or excluding, fellows, whose duties may closely resemble those of residents or differ substantially f r o m t h e m ; (3) differences between the n u m b e r of positions listed for a p r o g r a m and the n u m b e r budgeted, with certain positions c o n t i n u e d to be carried for f u t u r e contingencies; and (4) discrepancies between the n u m b e r of positions vacant and the n u m b e r of house staff r e p o r t e d as still needed. 4 3 In a d d i t i o n , the n u m b e r of vacancies may increase d u r i n g the academic year as physicians leave and are not replaced. It is clear, nevertheless, that in 1959 the rate of vacancy in approved training programs in N e w York City was of the o r d e r of 5 + percent, or one t h i r d of the nation-wide rate of 16 percent. Rates (percent) of vacancy in internships and in residencies were as follows: New

York

City

44

United

States

Internship

7

17

Residency

5

16

45

I N T E R N S AND RESIDENTS

177

In the voluntary hospital system in New York City the majority of vacancies occur in hospitals affiliated with medical schools. Apparently some hospitals have vacancies because they do not choose to fill them with the candidates who are available. A sixth difference between New Y o r k City and the United States is in the proportion of house staff concentrated in affiliated hospitals. I n New York City the relative importance of hospitals associated with medical schools has declined in the past generation. Nevertheless, these hospitals still provide a larger share of house staff training in New York City than they do in the country as a whole (see T a b l e s 6.4 and 6.5, below). An affiliated hospital may be classified as a m a j o r or minor teaching hospital. A m a j o r teaching hospital, as defined by the American Medical Association, is one that is a m a j o r unit of a medical school's teaching program and is so designated. A m i n o r teaching hospital is one that is used to a limited extent in a medical school's teaching program. A striking difference between New York City and the United States in the training of interns is the much greater importance in the former of m i n o r teaching hospitals. Table

6.4. D I S T R I B U T I O N O F I N T E R N S I N A P P R O V E D T R A I N I N G P R O G R A M S BY M E D I C A L S C H O O L A F F I L I A T I O N S T A T U S O F H O S P I T A L S , N E W Y O R K C I T Y , 1936 A N D F I S C A L 1959, A N D U N I T E D S T A T E S , F I S C A L 1958

Affiliation Status of Hospital Number Percent M a j o r teaching M i n o r teaching Unaffiliated

New

1936 1,369 100.0 35.7 26.5 37.8

York

City Fiscal 1959

1,226 100.0 36.7 20.0 43.3

U n i t e d

Fiscal

States

1958

10,198 100.0 37.3 6.8 55.9

SOURCE: Jean Alonzo Curran (for the Committee on the Study of Hospital Internships and Residencies), Internships and Residencies in New York City, 1934-1937; Their Place in Medical Education (New York, 1938), pp. 18, 24; Hospital Council of Greater New York, questionnaire survey of house staff in hospitals in New York City, April 20, 1959; and American Medical Association, Council on Medical Education and Hospitals, Directory of Approved Internships and Residencies, 1958, reprinted from Journal of American Medical Association, C L X V I I I , No. 5 (October 4, 1958), p. 523.

Nation-wide data on the distribution of residents by the affiliation status of hospitals recently became available for the first

PERSONNEL, PLANT, A N D

178

ORGANIZATION

time. T h e s e do not distinguish between m a j o r a n d m i n o r teaching hospitals. Table

6.5. D I S T R I B U T I O N O F R E S I D E N T S IN A P P R O V E D T R A I N I N G P R O G R A M S BY M E D I C A L S C H O O L A F F I L I A T I O N S T A T U S O F H O S P I T A L S , N E W YORK. C I T Y , 1936 A N D F I S C A L 1959, A N D U N I T E D S T A T E S , FISCAL 1960 New

Affiliation Status of Hospital

1936

Number Percent M a j o r teaching Minor teaching Unaffiliated

545 100.0 48.4 34.2 17.4

York

United

Fiscal 1959

Fiscal

3,764 100.0 43.6 29.1 27.3

Stat " 1960

27,531 100.0 60.5

'

39.7

SOURCE: J e a n Alonzo Curran (for the Committee on the Study of Hospital Internships and Residencies, Internships and Residencies in New York City, 1934-1937, Their Place in Medical Education (New York, 1938), pp. 18, 24; Hospital Council of Greater New York, questionnaire survey of house staff in hospitals in New York City, April 20, 1959; and American Medical Association, Council on Medical Education and Hospitals, Directory of Approved Internships and Residencies, 1960, reprinted f r o m Journal of American Medical Association, CLXXIV, No. 6 (October 8, 1960), p. 548.

Residency training is concentrated in medical school affiliated hospitals to a greater extent than intern training. Otherwise, b o t h the t r e n d in New York City and the contrast with the c o u n t r y as a whole are similar to those shown for interns. Usually affiliated hospitals attract higher p r o p o r t i o n s of graduates of A m e r i c a n medical schools than do unaffiliated hospitals. 4 6 A situation in which New York City has both a h i g h e r p r o p o r t i o n of foreign-educated physicians than the U n i t e d States and a higher p r o p o r t i o n of house staff in affiliated hospitals offers s o m e t h i n g of a paradox, which cannot be explained with existing knowledge. It may be that medical school affiliation has a different significance here f r o m elsewhere; or that the p r o p o r t i o n of foreign-educated physicians in unaffiliated hospitals is m u c h higher in N e w York City t h a n in o t h e r parts of the country; or that the p r o p o r t i o n of foreign-educated physicians is higher here in each class of hospitals. Comparison

between

Voluntary

and

Municipal

Hospitals

Between 1935 and 1959 the n u m b e r of interns a n d residents in a p p r o v e d t r a i n i n g programs in New York City increased almost

I N T E R N S AND

179

RESIDENTS

threefold (Table 6.2). T h e rate of increase in voluntary and municipal hospitals was somewhat lower, two and one half times, as the n u m b e r of interns and residents in federal and state hospitals in New York City increased almost ninefold (from 60 to 525). Proprietary hospitals in New York City play a negligible role in graduate medical education; currently two such hospitals are approved for a single residency each, one in pathology and one in psychiatry. T h r o u g h the cooperation of New York City Headquarters of the Selective Service System the Hospital Council was able to compile data on the size of house staff in voluntary and municipal hospitals in 1951 and 1955. These supplement the data for 1935 and 1959. TRENDS, 1 9 3 5 - 5 9

T a b l e 6.6 shows the n u m b e r of physicians in approved training programs in the two major hospital systems for selected years. Table

6.6. H O U S E S T A F F IN A P P R O V E D T R A I N I N G P R O G R A M S IN V O L U N T A R Y A N D M U N I C I P A L H O S P I T A L S , N E W Y O R K CITY, 1935, 1951, 1955, A N D 1959

Year Number 1935 1951 1955 1959 Percent increase 1935-59 1935-51 1951-59 1951-55 1955-59

All Hospitals

Voluntary Hospitals

Municipal Hospitals

1,700 2,929 3,873 4,465

920 1,776 2,180 2,510

780 1,153 1,693 1,955

163 72 52 32 15

173 93 41 23 15

151 48 69 47 15

1935—Appendix 6.B; 1951 and 1955—Hospital Council of Greater New York, tabulations from reports on house staff filed with New York City headquarters of Selective Service System; and 1959—Hospital Council of Greater New York, questionnaire survey of house staff in hospitals in New York City, April 20, 1959. SOURCE:

T h e distribution of house staff by hospital system in 1935 was estimated from several sources, as shown in Appendix 6.B. T h e size of house staff increased in each of the intervals shown. During the sixteen-year span 1935-51 the increase amounted to almost three fourths of the 1935 total, and in the eight-year span

180

PERSONNEL, PLANT, A N D

ORGANIZATION

1951-59 it amounted to one half of the 1951 total. In the 1950s the rate of increase in the first half of the decade was twice that in the second half. For the period 1935-59 the two hospital systems had the same rates of increase, b u t they differ in the timing of the increases. Between 1935 and 1951 the size of house staff almost doubled in voluntary hospitals, while it increased only one half in municipal hospitals. Between 1951 and 1959 the size of house staff increased by seven tenths in municipal hospitals and by four tenths in voluntary hospitals. In the 1950s the entire difference in rate of increase was confined to the first half of the decade. Interns. Figures for total house staff reflect changes in the number of interns and of residents. Changes in the two categories did not follow the same pattern. T a b l e 6.7 shows the n u m b e r of interns in the two m a j o r hospital systems in selected years. During the period 1935-59 the Table

6.7. I N T E R N S I N A P P R O V E D T R A I N I N G P R O G R A M S IN V O L U N T A R Y A N D MUNICIPAL HOSPITALS, N E W Y O R K C I T Y , 1935, 1951, 1955, A N D 1959

Year

All Hospitals

Number 1935 1951 1955 1959 Percent change 1935-59 1935-51 1951-59 1951-55 1955-59 SOURCE: 1935—Appendix 6.B; tabulations from reports on Selective Service System; and naire survey of house staff in

Voluntary Hospitals

Municipal Hospitals

1,205 870 998 1,182

615 463 547 683

590 407 451 499

- 2 -28 + 36 + 15 + 18

+ 11 -25 + 48 + 18 + 25

- 15 -31 + 22 + 11 + 11

1951 and 1955-Hospital Council of Greater New York, house staff filed with New York City headquarters of 1959—Hospital Council of Greater New York, questionhospitals in New York City, April 20, 1959.

n u m b e r of interns in the two major hospital systems actually declined. A substantial reduction occurred between 1935 and 1951, which was not offset by the increase between 1951 and 1959. T h e general pattern, first decline then recovery, held true in

INTERNS AND

181

RESIDENTS

both hospital systems. However, voluntary hospitals had the smaller decline and the greater recovery. Residents. Large increases in the n u m b e r of residents occurred in each hospital system. Between 1935 and 1959 the n u m b e r of Table

6.8. R E S I D E N T S I N A P P R O V E D T R A I N I N G P R O G R A M S IN V O L U N T A R Y A N D MUNICIPAL HOSPITALS, N E W Y O R K C I T Y , 1935, 1951, 1955, A N D 1959

Year Number 1935 1951 1955 1959 Percent increase 1935-59 1935-51 1951-59 1951-55 1955-59

All Hospitals

Voluntary Hospitals

Municipal Hospitals

495 2,059 2,875 3,283

305 1,313 1,633 1,827

190 746 1,242 1,456

563 316 60 40 14

500 331 39 24 12

665 293 95 67 17

SOURCE: See T a b l e 6.7.

residents in voluntary and municipal hospitals increased more than six and one half times. T h e rate of increase was much greater from 1935 to 1951 than from 1951 to 1959; and it was greater in the first half of the 1950s than in the second half. Each hospital system followed the general pattern. Voluntary hospitals had, however, the higher rate of increase in the earlier period and the lower rate in the later period and in each of its segments. T h i s contrast between the two hospital systems in the 1950s is surprising, since the n u m b e r of approved residency training programs in municipal hospitals has declined since 1948, whereas the n u m b e r in voluntary hospitals has increased almost 80 percent (from 188 to 336). T h e difference in the latter system between an increase of approximately 40 percent in residents and an increase of 80 percent in residency programs is one measure of the growth of specialty and subspecialty training programs in New York City hospitals. T h e principal source of the increase in residents in New York City in the 1940s must have been the expansion of American med-

182

PERSONNEL, PLANT, AND ORGANIZATION

ical schools, a c c o m p a n i e d by extension of the length of g r a d u a t e medical training. I n the 1950s the principal, t h o u g h n o t exclusive, source of a d d i t i o n a l residents (as well as of interns) was graduates of foreign medical schools seeking house staff a p p o i n t m e n t s in this country. T R E N D IN ROLE O F F O R E I G N - E D U C A T E D PHYSICIANS,

1951-59

U n i t e d States P u b l i c H e a l t h Service hospitals accept only graduates of U n i t e d States a n d C a n a d i a n medical schools. Veterans Adm i n i s t r a t i o n hospitals follow t h e same p a t t e r n , except t h a t they also accept graduates of foreign medical schools w h o are U n i t e d States citizens. 4 7 I n the three Veterans A d m i n i s t r a t i o n hospitals in N e w York. City o n e f o u r t h of the house staff, all of t h e m residents, are U n i t e d States citizens w h o a t t e n d e d medical school a b r o a d a n d three f o u r t h s are graduates of A m e r i c a n medical schools. I n 1959 the p r o p o r t i o n of house staff in voluntary and m u n i c i p a l hospitals g r a d u a t e d f r o m foreign medical schools was 51 p e r c e n t ( T a b l e 6.15), c o m p a r e d with 48 p e r c e n t in all hospitals, i n c l u d i n g federal ( T a b l e 6.3). For years o t h e r t h a n 1959 house staff c a n n o t be d i v i d e d into graduates of A m e r i c a n a n d foreign schools. Since the d a t a for the years 1951 a n d 1955 originate in reports filed with the Selective Service System, physicians are classified as A m e r i c a n citizens or aliens. T h e f o r m e r g r o u p includes U n i t e d States citizens educated abroad, whereas the latter includes graduates of C a n a d i a n medical schools. T h e n u m b e r of graduates of C a n a d i a n medical schools in approved t r a i n i n g p r o g r a m s in voluntary and m u n i c i p a l hospitals in New York City is small—less t h a n 2 percent of total house staff —and can be disregarded in an analysis of trends. T h e increase in the n u m b e r of aliens represents, therefore, a m i n i m u m estimate of the increase in foreign-educated physicians, so long as the n u m b e r of U n i t e d States citizens e d u c a t e d a b r o a d does n o t decline. Numerical Changes in Total House Staff. T a b l e 6.9 shows data on house staff classified by citizenship status w i t h i n each hospital system for the years 1951 a n d 1959. Between 1951 a n d 1959 the n u m b e r of U n i t e d States citizens rose one seventh (14 percent), while the n u m b e r of aliens rose

183

I N T E R N S AND R E S I D E N T S Table

6.9. HOUSE STAFF IN A P P R O V E D T R A I N I N G P R O G R A M S BY C I T I Z E N S H I P S T A T U S IN V O L U N T A R Y AND M U N I C I P A L HOSPITALS, N E W YORK CITY, 1951, 1955, AND 1959

Citizenship Status All hospitals United States citizens Aliens Voluntary hospitals United States citizens Aliens Municipal hospitals United States citizens Aliens

1951 2$29 2,233 696 1,776 1,343 433 1,153 890 263

1955 3,873 2,408 1,465 2,180 1,383 797 1,693 1,025 668

1959 4,465 2,539 1,926 2,510 1,570 940 1?55 969 986

SOURCE: 1951 and 1955—Hospital Council of Greater New York, tabulations from reports on house staff filed with New York City h e a d q u a r t e r s of Selective Service System; and 1959—Hospital Council of Greater New York, questionnaire survey of house staff in hospitals in New York City, April 20, 1959.

two and three quarter times. T a b l e 6.10 shows the

numerical

c h a n g e s in each h o s p i t a l s y s t e m d u r i n g t h e p e r i o d 1 9 5 1 - 5 9 a n d d u r i n g each four-year s e g m e n t . T h e n u m b e r of a l i e n s a d d e d to h o u s e staff in the 1950s a m o u n t e d t o f o u r t i m e s t h e n u m b e r of U n i t e d States c i t i z e n s a d d e d ^ 1 , 2 3 0 c o m p a r e d w i t h 306. F o r b o t h c i t i z e n s a n d a l i e n s a p p r o x i m a t e l y t h r e e fifths of t h e i n c r e a s e took p l a c e in the first half of the d e c a d e a n d t w o fifths in t h e s e c o n d half. T h e increase in U n i t e d States c i t i z e n s was d i v i d e d as f o l l o w s : t h r e e f o u r t h s a c c r u e d t o v o l u n t a r y h o s p i t a l s a n d o n e f o u r t h to m u Table

6.10. CHANGES IN HOUSE STAFF IN A P P R O V E D T R A I N I N G PROGRAMS BY C I T I Z E N S H I P S T A T U S IN V O L U N T A R Y AND M U N I C I P A L HOSPITALS, N E W YORK CITY, 1951-59, 1951-55, AND 1955-59

Citizenship Status All hospitals United States citizens Aliens Voluntary hospitals United States citizens Aliens Municipal hospitals United States citizens Aliens SOURCE: T a b l e 6.9.

1951-59 + 1J36 + 306 + 1,230 + 734 + 227 + 507 + 802 + 79 + 723

1951-55 + 944 + 175 + 769 + 404 + 40 + 364 + 540 + 135 + 405

1955-59 + 592 + 131 + 461 + 330 + 187 + 143 + 262 - 56 + 318

184

PERSONNEL, PLANT, AND

ORGANIZATION

nicipal. In the first half of the decade b o t h hospital systems rep o r t e d increases; in the second half v o l u n t a r y hospitals gained m o r e t h a n in t h e first half, while m u n i c i p a l hospitals lost. T h e increase in aliens was d i s t r i b u t e d differently, with two fifths a c c r u i n g to v o l u n t a r y hospitals a n d t h r e e fifths to m u n i c i p a l . In t h e first half of the decade m u n i c i p a l hospitals received 53 percent of the total increase a n d in the second half 68 percent. Changes in Proportion of Alien Physicians. A l t h o u g h m u n i c ipal hospitals gained a m a j o r i t y of the a d d i t i o n a l aliens, v o l u n t a r y hospitals also gained m o r e aliens t h a n U n i t e d States citizens in the 1950s. T h e p r o p o r t i o n of alien physicians increased, therefore, in each hospital system. In 1951 the m u n i c i p a l system had a slightly Table

6.11. P E R C E N T A G E O F A L I E N P H Y S I C I A N S I N A P P R O V E D T R A I N I N G P R O G R A M S IN V O L U N T A R Y A N D MUNICIPAL HOSPITALS, N E W YORK CITY, 1951, 1955, A N D 1959

Year 1951 1955 1959

All Hospitals 23.8 37.9 43.1

Voluntary Hospitals 24.4 36.5 37.5

Municipal Hospitals 22.8 39.2 50.3

sourcf: Table 6.9.

lower p r o p o r t i o n of alien physicians than the voluntary; in each system the p r o p o r t i o n was one f o u r t h or less. In 1955 the difference b e t w e e n the two systems was still small—less t h a n t h r e e percentage points—but the m u n i c i p a l system had the h i g h e r proportion of aliens. By 1959 the difference b e t w e e n the two systems had widened to 13 percentage points, as the p r o p o r t i o n of aliens in m u n i c i p a l hospitals rose m a r k e d l y while that in v o l u n t a r y hospitals scarcely changed. Separate Data on Interns and Residents. I n the 1950s the number of interns increased by 220 in v o l u n t a r y hospitals a n d by 90 in m u n i c i p a l hospitals. T h e n u m b e r of residents also increased in each system, b u t by a smaller n u m b e r in v o l u n t a r y hospitals than in m u n i c i p a l s 10 c o m p a r e d with 710. T h e latter reflects the establishment of the B r o n x M u n i c i p a l Hospital C e n t e r , which had 182 residents (and 34 interns) in 1959. T h e data on house staff in approved programs in N e w York.

185

I N T E R N S AND R E S I D E N T S

City hospitals in the years 1951, 1955, and 1959, by citizenship status, are shown for interns in T a b l e 6.22 and for residents in T a b l e 6.23. In two respects the trends in interns and in residents are similar: (1) the n u m b e r of alien physicians in each physician category increased in each hospital system between 1951 and 1959; and (2) between 1955 and 1959 the n u m b e r of U n i t e d States citizens in each category increased in voluntary hospitals and declined in municipal hospitals. T h e difference in trend between interns and residents was this: between 1951 and 1955 the n u m b e r of U.S. citizens serving as residents increased in each hospital system, whereas the n u m b e r serving as interns remained constant (voluntary system) or declined (municipal system). T h e changes in n u m b e r s are reflected in shifts in the proportion of alien physicians. In 1951 voluntary hospitals had the higher Table 6.12. P E R C E N T A G E OF A L I E N PHYSICIANS A M O N G I N T E R N S AND R E S I D E N T S IN APPROVED T R A I N I N G P R O G R A M S IN V O L U N T A R Y AND M U N I C I P A L H O S P I T A L S , NEW YORK CITY, 1951, 1955, AND 1959 Year

All Hospitals

Interns 1951 1955 1959 Residents 1951 1955 1959 SOURCE: T a b l e s 6 . 2 2 a n d

Voluntary Hospitals

Municipal Hospitals

24.1 35.5 40.8

29.8 40.4 37.5

17.7 29.5 45.6

23.6 38.7 44.0

22.5 35.3 37.4

25.6 43.0 52.2

6.23.

proportion of alien physicians a m o n g interns and municipal hospitals had the higher proportion a m o n g residents. In 1955 the proportion of alien physicians was higher than in 1951 for interns and for residents in each hospital system; but the relationships described for 1951 still prevailed. By 1959 municipal hospitals had the higher proportion of alien physicians in each category. COMPOSITION OF HOUSE STAFF,

1959

For the year 1959 alien physicians can be divided into graduates of Canadian medical schools, temporary visitors on exchange

PERSONNEL, PLANT, A N D O R G A N I Z A T I O N

186

visas, and permanent immigrants; and United States citizens can be further divided into graduates of United States and foreign medical schools. T h e data on house staff in the two hospital systems can then be regrouped in the manner of T a b l e 6.3. T a b l e 6.13 shows the numerical and percentage distributions of interns and of residents in voluntary and municipal hospitals in 1959 by location of medical school of graduation and, for graduates of foreign medical schools, by citizenship status. Tables 6.20 and 6.21 below show the distribution of each physician category (graduates of American medical schools, United States citizens educated abroad, and so forth) among hospitals, classified by ownership and by degree of affiliation with a medical school. In 1959 foreign-educated physicians constituted 51 percent Table

6.13. D I S T R I B U T I O N O F I N T E R N S A N D R E S I D E N T S I N A P P R O V E D T R A I N I N G P R O G R A M S BY L O C A T I O N O F M E D I C A L S C H O O L O F G R A D U A T I O N A N D BY C I T I Z E N S H I P S T A T U S F O R G R A D U A T E S OF F O R E I G N S C H O O L S IN V O L U N T A R Y A N D M U N I C I P A L H O S P I T A L S , N E W YORK CITY, 1959 Location

of School and Citizenship Status Interns and Residents American medical schools Foreign medical schools American citizens P e r m a n e n t immigrants T e m p o r a r y visitors Interns American medical schools Foreign medical schools American citizens P e r m a n e n t immigrants T e m p o r a r y visitors Residents American medical schools Foreign medical schools American citizens P e r m a n e n t immigrants T e m p o r a r y visitors

All Hospitals

Voluntary Hospitals

Municipal Hospitals

NumPerPerNumPerNu mber cent cent ber cent ber 4,465 100.0 1,955 100.0 2,510 100.0 49.0 765 39.1 2,187 1,422 56.7 2,278 51.0 1,190 1,088 43.3 60.9 241 437 9.8 196 7.8 12.4 369 130 239 8.3 5.2 12.2 1,472 32.9 30.3 710 36.3 762 1,182 100.0 653 100.0 499 100.0 571 48.3 52.3 214 357 42.9 611 51.7 326 285 47.7 57.1 136 11.5 72 10.5 64 12.8 95 8.0 55 40 8.0 8.1 380 32.2 199 29.1 181 36.3 1,456 3 ¿283 100.0 100.0 1,827 100.0 1,616 49.2 1,065 58.3 551 37.8 1,667 50.8 762 905 62.2 41.7 301 9.2 124 6.8 177 12.2 274 8.3 4.1 75 199 13.7 1,092 33.3 563 30.8 529 36.3 SOURCE: Hospital Council of Greater New York, questionnaire su rvey of house staff in hospitals in New York. City, April 20, 1959.

I N T E R N S AND

187

RESIDENTS

of the house staff in the two major hospital systems, whereas alien physicians constituted 43 percent (Table 6.11). T h e difference of 8 percentage points is accounted for by United States citizens educated abroad offset in part by graduates of Canadian medical schools. United States citizens educated abroad constituted 12 percent of house staff in municipal hospitals and 8 percent in voluntary hospitals. Temporary visitors on exchange visas constituted the largest group of physicians educated abroad—one third of total house staff and almost two thirds of house staff educated abroad. T h e relative importance of temporary visitors in the two hospital systems can be expressed in two ways: Proportion Temporary Total Home Stafj Voluntary hospitals Municipal hospitals

30 36

(Percent) of Visitors to Foreign-Educated. House Staff 70 60

T h e greatest difference between the two hospital systems is in the proportion of permanent immigrants—5 percent in voluntary hospitals and 12 percent in municipal. T h e entire difference is attributable to residents, owing to certain provisions of the New York State licensure law (discussed later in this chapter). Affiliation Status and Success in Recruiting Interns. Analysis of the composition of house staff in terms of hospital ownership alone obscures the influence of other facts on recruitment of graduates of American medical schools. T a b l e 6.14 shows the degree of success in attracting interns attained by voluntary and municipal hospitals in each medical school affiliation class. A hospital is either very successful or unsuccessful in attracting interns from American medical schools. While 7 hospitals reported that all of their interns were graduates of American medical schools, 32 had no such interns. T w o sets of facts may explain the concentration of hospitals at the extreme ends of the distribution. (1) Most hospitals have a single intern training program, the rotating internship, in which the intern in typically assigned to the four major clinical services during the year. This program either does or does not attract

PERSONNEL, PLANT, AND O R G A N I Z A T I O N

188

O O O O — t^ 00

a c

bo C

^ o o o

U,

<

T > 0 ""tCMID> 0 0lO Çl\00 — < 00 00

OH

O ^ VD h 3 Q2 CQ< CO s o se h

N 0\

QQZ Z fi ü.

h U >n O< j Z< £— H -t^ WM Oi ®S 7 Pi D h «5 M -f SSl Ü J " 3 >A N . Cl o 2S 2

-"S *i-Co 3 o> c oo om r— o— o• • 3 o u < c m O S ->5 ÜS —; a; cm ¿• s Zs4J ~M "S * S ® "a •Ü c

£ < = > »firtrt Vj V. o Cl t^ 00d e s c X5 \ 00t ra o0 ci s >• T