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and the award amounts to $50 in each case, there will be $100 per month that we know that we will need. We will know that we have got to pay that in all the succeeding months of the year. It means not only the death awards but it means money that must be paid on account of personal injuries. Suppose a man breaks his leg in January, and we know that we must pay him for six months. That is not a guess.

The CHAIRMAN. You are not basing this on existing cases, but prospective cases ?

Mr. VERRILL. It also covers actual cases that have come on the roll from the first of July to January 1, and which must be carried for the balance of the year?

Mr. BYRNs. You mean by that the obligation resting on the com. mission at this time?

Mr. VERRILL. Yes, sir.

Mr. BYRNES. Are you paying this $10,000 per month now, or do you estimate that you will have to pay it, based upon past experience?

Mr. VERRILL. A part of it we know about. The cases come in month by month and they are a cumulative force. If a case comes in July, we would have to make the payments for six months, or half the year; if it came in August, we would have to make the payments for five months, and so on. The average that we have here represents quite a number of regular compensation cases that have to be paid. We know that they have to be paid every month.

The CHAIRMAN. How long does it take to adjudicate one of these cases?

Mr. VERRILL. Usually about three or four months to adjudicate a death case.

The CHAIRMAN. So that if you do not get this $600,000, or all of it

Mr. VERRILL (interposing). We are estimating on the cases that will be adjudicated before the end of the fiscal year, and upon which payments will have to be made. We are not estimating upon anything that we will not be called upon to pay before the 1st of July. Whenever a case is adjudicated it carries back compensation.

The CHAIRMAN. If a case came in to-day it would not be adjudicated before the 1st of next July?

Mr. VERRILL. We would adjudicate it as soon as we could. Some of them would take longer than others. Some of them we might adjudicate and pay within a month of the death. That depends upon the delay we may meet with. The average time is about three months in death cases.

The CHAIRMAN. You can not control this expenditure?

Mr. VERRILL. No, sir; and we would not consider the delay of the work a legitimate means of control.

The CHAIRMAN. We would not want you to do that.

Mr. VERRILL. I have mentioned medical bills, and I will say that we have been backward in settling medical bills. So far as this involves medical expenses, the average stated is not a fair figure. As you gentlemen know, to a considerable extent the Public Health Service facilities have been transferred to the Veterans' Bureau, and they are no longer available to us in the same degree as in the past. While we got that service free, we must now pay for service else

where, and that will cause a considerable increase which I would not be able to estimate accurately and for which no estimate is made in the figures given the committee.

NUMBER OF EMPLOYEES IN COMMISSION-SALARIES

The CHAIRMAN. How many people have you on your pay roll? Mr. V'ERRILL. About 75.

The CHAIRMAX. What is the annual rate of expenditure for the compensation of such employees? Mr. V'ERRILL. It is $124,910. The CHAIRMAX. What is the highest rate of pay? Mr. V'ERRILL. The salaries of the commissioners, at $1,000, and then we have an attorney at $1,000.

EMPLOYMENT OF DOCTORS.

The CHAIRMAN. How many doctors have you employed ?

Mr. V'ERRILL. We do not pay the salaries of any doctors. We have doctors detailed to us from the Public Health Service who handle the medical administrative work.

The CHAIRMAX. What about those doctors who pass upon the injured persons who are applying for compensation?

Mr. VERRILL. Our law requires us to use Government doctors wherever it is practicable. We use the Public Health Service doctors wherever it is possible.

The CHAIRMAN. To what extent has that been found to be praeticable?

Mr. V'ERRILL. We use the Public Health Service doctors wherever we can find them. In the Navy Department we use the naval surgeons. We use them in the navy yards and naval establishments.

The CHAIRMAN. What do you do in the case of civilian employees!

Mr. V'ERRILL. That is what I mean-civilian employees. The Army doctors are available to us in Army establishments where such doctors are on duty.

The CHAIRMAN. How many doctors have you used from the Public Health Service and from the Army and Navy?

Mr. VERRILL. At the navy yards we use the doctors who are on duty there.

The medical facilities of the Public Health Service in October, 1921, included 42 general hospitals, 13 tuberculosis hospitals, and 10 hospitals for neuro psychiatric cases. On the staffs of these hospitals were 946 full-time medica! officers and 246 consulting specialists. There were also employed a nursing staff of 1,622 and approximately 10,000 technical and miscellaneous employer In addition, there were 21 out-patient offices and 82 dispensaries in various sections of the country.

During the six months ended June 30, 1921, the l'nited States Public Health. Service treated in hospitals 5,233 injured Government employees entitled to are under the provisions of the compensation act. To these cases there were siren 62,087 days of hospital relief.

The number of injured employees treated during this period at dispensaries was 19,0.57. These received in all 56,778 dispensary treatments. The dispensary treatments consisted in part of examinations, frequently by specialists, anul included laboratory and X-ray examinations. In many instances the dispensary service consisted of baking and massage of injured parts with the corresponding physiotherapeutic attention. No charge against the compensation commission is paid for any of this service.

The CHAIRMAX. How many do you employ outside of those Army, Navy, and Public Health Service doctors?

Mr. VERRILL. We do not employ any on salaries, but we pay them according to the service they render.

FEES OF DOCTORS. The CHAIRMAN. What do you pay them? Mr. VERRILL. The usual fees. The CHAIRMAX. What are the usual fees? Mr. VERRILL. That depends upon the locality and the class of work. The CHAIRMAN. Tell us what is the usual fee. Mr. VERRILL. I would say that the ordinary fee would be $2 for an office visit and $3 for a house or hospital visit.

The C'HAIRMAX. What about the examinations they make ? Mr. VERRILL. That would depend upon the nature of the case and the nature of the examination made. Under ordinary circumstances $5 would be the fee for a special examination, although sometimes it is $3. For special or extensive examinations, with special reports, it might run higher than that.

The CHAIRMAN. Have you a limit for medical fees beyond which . you will not go?

Mr. VERRILL. Not exactly. If we find that a doctor overcharges us, we drop him.

The CHAIRMAN. Why not fix a limit to the fee and never go beyond it?

Mr. VERRILL. It has not been found to be practicable to fix a maximum fee, but we have to pay according to the service rendered.

The CHAIRMAN. Why do you not fix a maximum and minimum fee to be paid doctors for making examinations?

Mr. VERRILL. I would not know how to do that. We might have to send a man to a specialist for examination or for a series of examinations requiring several visits or several days, and we would pay him according to the service rendered.

The CHAIRMAN. Who fixes the amount that is charged ?

Mr. VERRILL. We have a division in the office that handles that. If the charge is above the ordinary routine charge and is not fully and satisfactorily explained, it is allowed only for the usual rate or referred to the commission.

The CHAIRMAN. It seems to me that we ought to be able to get the exact charge that should be allowed in any given class of cases.

Mr. VERRILL. The charges for surgical operations, for example, would depend largely upon the difficulty of the cases. For such an operation as hernia, for instance, we might pay $50 in one locality and we might have to pay $100 in another locality.

The CHAIRMAN. Do you allow the doctors to dictate the charges, or do you fix a limit beyond which they can not go?

Mr. VERRILL. The fee is supposed to be the customary fee in the locality.

The CHAIRMAX. I think that in the public service we should have a limit to fees. That is done in all other services, and why should it not be done in this? For example, a doctor for examining a veteran of the Civil War receives $3, and until a year or two ago he did not receive that much, but was paid $2. I think the Veterans' Bureau

went wild on their fees, but we took it up with them and I think

they are getting it down within a reasonable limit now. You have · no regulation covering that?

Mr. VERRILL. No, sir; we have no rigid limit. If we find a doctor who, in our judgment, is overcharging us, we send him no more cases.

The CHAIRMAN. Suppose you submit for the record a typical bill showing the highest amount you pay for medical services.

Mr. VERRILL. The highest bill would represent a difficult surgical case.

The CHAIRMAN. We want to know about it. This is public money, and the committee wants to know just how it is expended. We think that you people should have some system by which you can let us know just what you are expending for these sort of services.

Mr. VERRILL. I would like to furnish the statement, but I want to be sure that I furnish what you want.

The CHAIRMAN. We want to be sure that we are not paying excessive fees for these services. We have found that when they are allowed to make charges of this kind without any supervision the charges are excessive, and we do not want that done. We find that doctors are not at all scrupulous about their charges. Mr. VERRILL. We know that there are some such cases.

The CHAIRMAN. You think there is no escape from giving you the entire $600,000 for the rest of this year?

Mr. VERRILL. That is my opinion; yes, sir. I feel very confident that that is absolutely correct.

(The statement follows:) Under the practice of the commission the usual charge for an office visit is $2; for home or hospital visit, $3. Any bill submitted for a charge in excess of this rate, unless accompanied by details showing the reason or by a statement of the reason, calls for an inquiry from the commission in explanation of the charge. Nearly always a satisfactory explanation is furnished; if not, the bill is allowed at these rates. Of course, an additional allowance is frequently made when the visit calls for an additional travel allowance because of distance or when it is shown that incidental to the examination one or more X rays had to be taken, or that blood tests had to be made involving perhaps laboratory fees, or that treatment had to be given beyond what might be incidental to an ordinary examination or visit. It is consistently the practice of the commission to require detailed itemization or explanation of blls so that the evidence of the reasonableness of the charge may always be available in the record. It is also the pract ce to require explanation if the number of visits is greater than seems reasonable from the record. In cases of infection the number of visits would necessarily be much greater than for the same kind of an injury without infection. With medical operations a similar policy is followed, itemization and detailed explanation being required. In multiple fractures, compound fractures, or infected fractures the fee which would be customary and reasonable in a simple case would not be fair or reasonable, and service for such a fee could not be expected. The medical bills are subject to careful study and scrutiny to see that a high grade of service is being secured and that no unreasonable or fancy rates are paid. Inferior service at cut rates would not be likely to result in economy. It might readily result in multiplieci visits and treatments, in unreasonably prolonged disability, and in permanent partial disabilities of an unnecessarily high degree

Following are three typical cases of serious injury showing any unusual medical and hospital expenses paid on account of each :

Case 66187, electrician, 25 years of age. Ladder slipped, resulting in fall on switch and high-tension wires, causing electrical burns, some first and some thiril degree: infected, face, right arm, chest, left arm, left hand sloughed off, amputation ends radius and ulnar 3 inches; 3 inches humerus removed right

arm, lower third; badly infected right elbow. Physician's bill-cleansed daily. used di-chloramine-T, and Chlorocosane, with parresine spray and pa rrasined mesh gauze; also used dilute listerine daily, January 1 to April 20, 1920, inclusive, with two dressings on January 21; 112 dressings, at $5 each, $560. Hospital bill-October 31, 1919, to April 20, 1920, inclusive, 172 days, at $3 per day, $516. For period October 31 to December 31, 1919, physician's bill of $63, not itemized, not yet settled because of failure of presentation on account of death of physician. Photographs of injured employee, $14. Artificial limb with movable fingers, $200. The employee, on April 21, 1920, being able to get about, was transferred to a Government hospital, where he was retained until recovered. The final result was a total loss of the left hand and loss of about 50 per cent of the function of the right hand. The burns of the face and neck, due to especially good treatment, left no serious or noticeable disfigurement.

Case 11648, auto driver, age 23; electrical burns both thighs and buttocks, back, hands, and right foot. Burns were deep, with infection. Very careful daily dressings were necessary for a long time. During this period the life of the employee was in great danger, and for a long time recovery was exceedingly doubtful. One physician--September 11, first visit and dressing, $10; September 12 to December 12, visits and dressings, once daily, at $2.50, $227.50. Second physician-September 11 to December 12. 75 visits and dressings, at $2.50, $187.50. When these bills were received by the commission the physicians rendering them were advised that in accordance with the practice of the commission at that time only $2 would be allowed for each hospital visit and dressing, that rate being considered reasonable unless some valid reason could be shown for a greater allowance in a special case. The physicians, in reply, submitted evidence, with photographs, in regard to the unusual and exceedingly serious character of the injuries. The daily dressings for which charge was made were not simple dressings that would have been required in the case of an ordinary injury or burn. For a long time it was necessary to remove particles of the charred tissue or infected tissue under morphine, a service which might more properly have been classed as an operation rather than a dressing. It was shown that due to the extensive area and depth of the burns it often required from two to three hours to do the dressings. It may be stated that skin grafting was required of about 150 square inches. These bills were accordingly paid at the full rate for which rendered, as given above. The employee in this case was later transferred to another hospital where he could be under the care of the surgeons of the Public Health Service and of an able specialist attached to the staff of the Public Health Service. Hospital treatment was required to be continued for more than a year, and the wounds did not entirely heal for considerably more than two years.

Case 31602. Millwright, age 37; fracture of the neck of the femur. This employee was cared for in a private hospital for a long time, no Government hospital being available. After the first adjustment of the fracture, the surgeon being unsuccessful in obtaining union, two bone-graft operations were performed. These, however, were without successful result. About two years after the accident the employee was sent to the Mayo Clinic in the hope that a sue(essful operation would be possible. A bill for examination at the Jayo ('linic, including general physical examination, urinalysis, blood count, Wassermann test, eye examination, and X rays, was paid to the amount of $50. The opinion of the surgeons at the Mayo Clinic was unfavorable to operation, but it was suggested that perhaps one of two well-known surgeons in New York and Boston who had been notably Successful in this particular type of case might be willing to recommend operation with hope of success. After first consulting the doctors by letter, the employee was accordingly sent for examination, first. to Dr. B., in Boston, and afterwards to Dr. A., in New York, following out the suggestion of the Mayo Clinic. Dr. B. examined the employee on two successive days, having special X rays taken, and was paid $25 for the examination. Dr. A, made a similar examination and held out some hope of improvement, if he was permitted to operate. The employee, however, after considering carefully all that he had been told by these various specialists with regard to the probability of improvement from operation, declined operation and returned to his home. The several exam nations by specialists in this case were considered. fully warranted, because of the fact that the employee had been totally disabled for nearly three years and was likely to be totally disabled for perhaps another year and fully 50 per cent disabled for the remainder of his life.

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