Part 25

The Secretary of the Treasury’s order of April 19, 1921 transferred the functions of the District Supervisor’s Office to the then Bureau of War Risk Insurance, and the Act of August 9, 1921 transferred by law the activities of these offices to the U. S. Veterans’ Bureau, but left unhampered the jurisdiction and authority of the U. S. Public Health Service concerning matters of hospitalization.

Without the work of the facilities afforded by the U. S. Public Health Service it would indeed be impossible for the U. S. Veterans’ Bureau to function and discharge its obligations relative to the hospitalization, medical care, and treatment of disabled ex-service men and women. Co-ordination of their work has led to the fullest cooperation on the part of every agency, to the end that the disabled ex-service man is receiving the best treatment which a grateful government can provide. You have, of course, before you all the data and information relative to the extent of the work carried on by the U. S. Public Health Service as it relates to the beneficiaries of the U. S. Veterans’ Bureau.

The relation of this Bureau to the War and Navy Departments is fundamental, for the reason that before any person can be accorded the benefits provided for under the act creating the U. S. Veterans’ Bureau, a record must be obtained from the War or Navy Department showing the military or naval record of the person seeking benefits either for compensation, insurance, vocational training, or medical care and treatment. Something over 900,000 requests have been made to date on the War and Navy Departments requesting a transcript of the military or naval record of the person while in the active service and there has been no diminution in the number of reports requested daily, in that our average number of requests each day is about 1,000. The matter of furnishing adequately the transcript of record of an ex-service man or woman, showing whether or not they received any medical treatment while in the active service is indeed a most difficult problem. It must be remembered cases are now arising where a given individual has been discharged from the military or naval service for a period of approximately three years, and that in all probability they did not receive medical care or treatment while in the service, but their health has become impaired subsequent to their discharge from the service. Quite true they might have had some slight attack of influenza while in the service or some other disability, but did not report for medical care and treatment.

The most of these individuals believe that the War or the Navy Department should have had a record of such indisposition on their part, and that, in turn, it is up to the U. S. Veterans’ Bureau to secure such a record upon which to predicate the service origin of a given disability. Certainly not in the history of this government has the military and naval establishments been called upon to complete and compile the records of statistics and facts comparable to that resulting from the late war, and while there have been many mistakes made both on the part of the U. S. Veterans’ Bureau in requesting the information and on the part of the War and Navy Departments in submitting information, the great bulk of work has been performed in a most satisfactory manner, and great benefits have been accorded to those applying for the same under the beneficent laws passed by our Congress.

On January 1st, 1922 there had been filed with the U. S. Veterans’ Bureau 81400 claims for compensation. In each and every claim filed it was necessary to request the War or Navy Department for the military or naval record of the person applying for compensation benefits, and in many instances it was necessary to make duplicate requests because of inadequate identification given or of additional evidence which the claimant submitted which would make it possible for the War or Navy Department to make a more exhaustive search of their records. To show the promptness with which reports have been received from the War and Navy Departments for no claim is either allowed or disallowed without a report from the War or Navy Department—out of the 814,000 claims filed, 51% have been allowed, 41% have been disallowed, and 8% are pending awaiting information either from the War or Navy Departments or from the claimant himself.

Also to December 15th, 1921, 486,884 former service men had requested vocational training. It was necessary for the Rehabilitation Division of the Federal Board for Vocational Education, (now a part of the U. S. Veterans’ Bureau), to request the military or naval record from the War or Navy Department, and out of that number 299,000 had been declared eligible for training; 135,000 had been declared ineligible for training; and 51,000 cases were pending to determine their rights to vocational training. These figures also represent a tremendous work required of the War and Navy Departments in that the records of each man must be obtained before final disposition was made of the case.

When viewed from the stupendous task, the results accomplished are indeed commendable.

The great assistance of the War and Navy Departments should also not be overlooked when it is remembered that at the date of the signing of the Armistice there were approximately $40,000,000,000 worth of insurance in force which had been written through the service of the War and Navy Departments in providing insurance officers to make contact with every man who was a member of the military or naval forces.

The War and navy Departments have always been of tremendous assistance in the matter of hospitalization of ex-service men and women. On December 1st, there were 1,410 beds occupied in Army Hospitals, and 2,032 beds occupied in Naval Hospitals. Certainly then from this resumé of facts the contact with the War and Navy Departments is most vital.

The contact of the U. S. Veterans’ Bureau with the Post Office Department is apparent. It need only be mentioned that to date the U.S. Veterans’ Bureau, representing the consolidated agencies since their organization have received approximately 90,000,000 incoming pieces of mail, and have dispatched approximately 105,000,000 pieces of mail, and the daily average receipt of incoming mail in the Bureau, even under decentralization, is approximately 41,000 pieces of mail per day and the outgoing pieces of mail from the Central Office of the Veterans’ Bureau is approximately 58,000 pieces of mail per day.

The Veterans’ Bureau as you have been informed relative to the care of ex-service men of foreign allied countries and of American soldiers residing in allied countries has a vital contact with the State Department in addressing their communications to the various foreign countries and in the utilization of the various U. S. Consuls.

The Department of Justice has charge of all suits filed against the U. S. Veterans’ Bureau where suit is brought on an insurance contract. The department of Justice also handles all prosecutions where irregularities are found under the act creating the U. S. Veterans’ Bureau.

Under the Interior Department you know of the use made of the St. Elizabeth’s Hospital and of hospitals under the jurisdiction of the Commissioners of Indian Affairs.

The contact is also quite vital with the Department of the Interior in obtaining various information from the Pension Bureau as a person may be filing an application for compensation and also an application for a pension.

The Department of Agriculture has been of very great assistance to the Bureau in rendering advice relative to the training of disabled ex-service men with a vocational handicap who desire to take up agricultural pursuits, and at the present time the Department of Agriculture is rendering most valuable service in mapping out agricultural courses for the first Vocational School of the Government located at Chillicothe, Ohio.

Many disabled ex-service men taking vocational training have been assisted by the Department of Commerce in mapping out their careers for work incident to that of the Department of Commerce.

The Department of Labor has been of very great assistance in aiding the Bureau to find employment objectives for disabled ex-service men undergoing training or who have been rehabilitated by the U. S. Veterans’ Bureau.

This will give you a general view of the relation of the U. S. Veterans’ Bureau to the Executive Departments of the government. The U. S. Veterans’ Bureau naturally must have a close contact with the Congress. Congress continually calls upon the Bureau for data and information which can only be obtained from the other Executive Departments of the government but which immediately relate to the work of the U. S. Veterans’ Bureau.

Inasmuch as you Gentlemen are essentially interested in hospital administration, I should like to speak briefly on the question of hospital records, and what data the Bureau is required to have when it is called before Congress relative to Appropriations. As you know, Congress makes one appropriation to the U. S. Veterans’ Bureau for Medical and Hospitals Services. Sums from this appropriation are in turn allotted to the U.S. Public Health Service, the War and the Navy Departments, the Interior Department, and the National Homes for Disabled Volunteer’ Soldiers. When the U. S. Veterans’ Bureau is called before Congress for every appropriation it must show specifically how the money has been allotted, for what purposes it has been allotted, and the result accomplished.

It has become imperative for the U. S. Veterans’ Bureau to have available comprehensive records concerning all hospitals in which there are being treated its beneficiaries. It is not sufficient that these records be only those concerning the admission and discharge of patients and the physical examination report in each instance, but equally fundamental data concerning the results of treatment, periodical turn-over of patients, the hospitals’ administration, and of equal importance, but from a different angle, the cost of operation with the resulting per diem cost per patient.

A considerable part of the records on patients, their flow in and out of hospitals and similar data are available or can be made available, the value of these data so derived, of course, will be proportionate to the accuracy or thoroughness with which the records of admission and discharge are prepared and transmitted. The report of admission and discharge of patients and the report of physical examination are at present the only reports common to all Government Hospitals. The necessity for the prompt rendering of accurate admission and discharge reports and physical examination reports in all instances is apparent. Such reports are of very great importance to the U. S. Veterans’ Bureau, for upon them is determined the medical rating of the hospitalized beneficiaries and any delay or omission in the rendering of records of this character reflects upon the administration of the U. S. Veterans’ Bureau.

In regard to the individual hospital operation costs, until very recently the U. S. Veterans’ Bureau has been operating in the dark on unit costs. It is demanded that the U. S. Veterans’ Bureau have complete knowledge of the cost of operating all government hospitals, not merely as a gross item, but classified by purpose of expenditure and by department of hospital for which spent. The reason for this point is made two-fold—First, that the Bureau before it can allot money to the several services for hospital expense, must be in a position to know for what purpose the money should be disbursed; and second, because the Congress of the United States is holding the Bureau accountable for all moneys appropriated to it and unless this Bureau can tell Congress in detail this money has been spent, or is to be disbursed, our hospitalization program will be jeopardized until such information can be secured.

The per diem rates for hospitals of the several services vary materially so far as our estimates are concerned. The degree to which such a variation in rates is only an apparent variation due to the different bases upon which they are calculated is not at present ascertainable, but it should be. Not only should this Bureau know what it costs for its own patients at any one institution, but it should know the per diem cost over a given period for all the patients hospitalized there. The cost to this Bureau affects not only our appropriation; the cost to the service operating the hospital, including this Bureau’s share, but it affects the U. S. Treasury. If the cost of maintenance of certain hospitals is excessive, it would be poor business not to evacuate that hospital, if other conditions made it practicable, or if impracticable to attempt to reduce its operating cost.

Recently the U. S. Public Health Service inaugurated a system of cost accounting by individual hospitals. With the perfection of this procedure the U. S. Veterans’ Bureau will be in a position to talk intelligently about operating costs with these hospitals whether by departments of hospitals, purposes of disbursement, such as salaries, repairs, etc., or by unit costs.

The U. S. Veterans’ Bureau looks forward to the time when similar data are available and regularly submitted by the War Department, the Navy Department and the National Homes for Volunteer Disabled Soldiers, not merely as reimbursements due certain appropriations, but by actual disbursements of detailed purpose of not only for this Bureau’s share, but for total operations.

The U. S. Veterans’ Bureau also maintains contact with the various miscellaneous Departments and institutions of the government. Time will not permit of going into any details or of mentioning these contacts.

The U. S. Veterans’ Bureau when viewed from its huge task of running an insurance company with over three and one-half billions of insurance in force, of making payments on 149,000 insurance claims each month, making payment on 204,000 compensation claims each month, with approximately 29,000 ex-service men and women undergoing hospitalization, and having caused to be made over 1,000,000 medical examinations and responsible for 104,000 disabled ex-service men undergoing vocational training, representing a task which calls for the closest cooperation and assistance from every department of the government and only by having the closest cooperation possible will the government, through the U. S. Veterans’ Bureau, be able to discharge its obligations to the host of disabled ex-service men and women of this country.

The Bureau has always enjoyed the fullest cooperation from the various departments of the government and knows that the same cooperation will be extended with unstinted measure in the future, to the end that every pledge will be redeemed concerning the care and treatment of the defenders of this Republic, and to the end that this administration will go down in history as an administration that did not forget its sick and wounded soldiers, and brought peace and contentment to every fireside where assistance on the part of the government was requested and was due.”

COLONEL JAMES A. MATTISON, N. H. D. V. S, gave the following discussion of “Economy of Administration in U. S. Veterans’ Hospitals”:

“The subject is so broad that we can only consider certain phases of it within the time allotted for this paper. We all recognize that there are certain fundamental essentials which must of necessity be provided in every hospital regardless of the number of patients cared for. This necessarily means that overhead expenses of an institution hospitalizing small numbers of patients will be out of proportion to those of a hospital caring for a large number.

The general business management, the purchasing of supplies and equipment, the conservation and dispensing of the same, the elimination of waste, etc,. will be considered only casually for the purpose of emphasizing the importance of adhering as closely to strict business methods as is done in the case of every successful business man, whether he be a hospital executive, a merchant, or a man in any other line of business.

In this connection, it might be said that a mistake which is made in many government institutions, and one which is not made by the most successful business men, is to attempt to start on economy at a place where one can least afford to economize, that is in the pay and allowances of the personnel immediately responsible for the management of the institution, the responsible heads of departments, etc. In other words, we are not always willing to pay for brains, a price commensurate with the business responsibility involved. Again when we have been fortunate enough to secure the right man the right place, we do not always recognize his value by paying him a price commensurate with the value of his work. Furthermore, when we have made the mistake of getting the wrong man, who in reality is receiving a greater compensation than his services are worth, and one who, in reality, is a very expensive employee, we oftentimes make the mistake of not recognizing inefficiency and promptly correcting it,

In case there is any decided handicap along the lines of inefficiency in the responsible personnel in the administrative, utility, service or professional departments, it should be promptly corrected, as it is to those in such petitions to whom we constantly look to be on the alert in recognizing the short comings of all subordinate personnel.

In visiting our own or other hospitals we promptly recognize the presence or absence of evidence of the proper vigilance or efficiency in every department. In case of a tour of inspection of one of these institutions there should be found spurting steam valves, leaking water faucets, extravagant use of electric lights, overheated buildings, garbage and swill tanks running over with waste food supplies, evidence of lack of organization and co-operation on the part of the personnel, professional or otherwise, we should immediately recognize the fact that there was inefficiency existing in the personnel of such an institution, and as a result of this, a decided lack of economical and efficient administration. Finding such conditions in other departments, we should expect to find unsatisfactory conditions when the patient population was reached. We should expect to find histories poorly written or not written at all, patients waiting over-time for special examinations or special treatments, lack of accurate laboratory and X-ray records, etc. The matter of such inefficiency and consequent poor administration on the part of the personnel in any institution would naturally lead to great dissatisfaction on the part of the patients of such an institution and to the greatest lack of economy on the part of the administration, of the hospital.

In connection with the professional department proper, again the attainment of the most satisfactory results from the standpoint, both of economy and efficiency, is dependent upon the capacity and co-operation of the responsible personnel. There has been much discussion in regard to the number of professional personnel doctors, nurses, attendants, etc., and on this subject there has been apparently wide differences of opinion. However, these differences have been based upon differences of viewpoints of what the actual conditions to be met were.

A definite agreement has been reached in regard to the required personnel, nurses, doctors, attendants, social service, workers, etc., to each two hundred patients in a hospital caring for all acute patients, whether they be major surgical, acute active neuro-psychiatric, active tuberculosis, or other type of acute condition requiring active, constructive treatment.

As a matter of fact, however, we all know that in none of our Veterans’ Hospitals, especially the larger ones of 500 to 1000 or more beds, are all the patients or even a majority of them represented by this type of patients, on the contrary we have a large group of convalescent patients who require professionally very much less attention from the standpoint of active constructive treatment, dietetic attention, etc., and hence require vastly less personnel, and the expense of their maintenance in the hospital will be very greatly reduced from that of the acute type. Again, we have another group which represents the semi-domiciliary type, many of whom require very slight constructive treatment, and yet they belong to a type of patients who are capable of being finally rehabilitated and restored to an earning status in life. This group requires still less care than the former, and naturally less personnel and proportionately less per capita cost to the institution caring for them. Lastly, we pass to a purely domiciliary group who are to a large measure permanently disabled and are, therefore, many of them, to be permanent charges oh the Veterans’ Hospitals. The great majority of the latter group will require little or no special treatment, but will require only general care and maintenance. In this group we are dealing with a type who will represent the minimum per capita cost.

As time goes on we shall realize, especially in our larger hospitals, that the above condition will exist to a larger and larger measure and the necessity of a very close checking system and a very careful classification of the patients along the lines indicated above will be a matter of the very highest importance.

This does not mean that as long as special treatment along any line is needed that each patient will not have such expert examinations, care and treatment as his condition calls for. Quite the contrary, the most careful and competent examinations should be directed by hospital units composed of the most competent staff of men including surgical; medical; ear, nose and throat; X-ray., etc., at such intervals as the condition of the patient calls for. It will be by this system alone that we are to keep a check on the progress toward recovery of each individual patient and prevent an undue accumulation of a domiciliary group. By proper cooperation of such a group with the rehabilitation section, many men may be selected as suitable persons for rehabilitation in the vocational schools. The importance of this we all realize as there is a certain percentage of patients who will be quite content with their state as long as they are receiving complete maintenance and a liberal compensation of from $80 to $150 per month and no cares and no responsibilities to assume in life. That is we should be constantly on the alert to prevent making permanent residents or charges of any man who can be restored to an earning status in life.

Contrast, if you please, with the conditions in our hospitals the patient in private hospital, who is paying from $10 to $50 per day for private nursing, hospital accommodations, etc., and a correspondingly high rate for special professional services, and who in addition to this is losing heavily because of his absence from his personal business. In the latter case there is a much greater incentive for getting well, a greater incentive for requesting that special nurses and other expenses be cut off at the earliest moment it is found that they are no longer needed and for the additional request that they be discharged from the hospital as early as possible after the maximum benefits from hospitalization have been received. In the one case, the private patient is paying freely a large sum of money to get well. In the other case, the patients of our Veterans’ hospitals in many cases are paid liberally for being sick.