320 Years of History
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In the general prologue of The Canterbury Tales, Geoffrey Chaucer describes physicians as having a “special love for gold.” Since well before Chaucer’s time, the issue of physician remuneration has been discussed, with the debate continuing today. The earliest evidence of this issue is in the Code of Hammurabi from around 1750 BC. Hippocrates, Plato, and Galen discussed remuneration, and it was an issue in Jewish and Islamic culture too. During the last few centuries, issues around physician remuneration have continued to be discussed.
Probably the oldest extant primary source of medical fees is the code of Hammurabi. Written about 2000 B.C., the code is a set of laws decreed by King Hammurabi of Babylon. There are several references to physicians, including how they should be paid for their services. For example, sections 215-217 of the code read:
In medieval Europe, some physicians were employed by royalty and attended to the health of the royal court and perhaps some of its subjects, others were paid by the church to treat the sick of the parish and the poor. Some city states such as Venice employed physicians to give free treatment to the poor, treat the rich at reduced rates and advise the state on medical-legal and public health matters.
There are many sources from America which record how physicians were paid and whether fees were regulated or not. One example is the regulation of fees in Boston starting in 1780. It was the Boston Medical Society which developed the fee bill in order to stop physicians from undercutting each other. The fees on the fee bills were minimums so physicians could charge more, but no less. In addition, patients only wanted to pay for services if it included treatment such as a drug or a procedure. The fee bill however stipulated that charges be made for all visits. Because the physicians were controlling the fees, they made sure that they were always very well compensated, their general policy being to increase fees in good economic times but not to lower them in hard economic times. Between 1795 and 1806 the cost of living changed very little but the fees increased by 50-60%.
In Boston, we see an example where the physicians controlled their own remuneration and thus sometimes charged quite high amounts for their services. In South Carolina in 1844, we have an example of quite the opposite. The St. Peter’s parish, like the whole state, was very poor so the local officials decided to set a fee bill to curb the “exorbitant, oppressive” physician fees which “unjustly absorbs so large a portion of [the farmers] hard earned incomes.”
If we compare the fees in Boston and South Carolina, we can see the vast difference in fees when physicians or the community set them. In Boston in 1806, a regular single visit was $1.50, normal obstetrical delivery was $12.00, treating gonorrhea was $10.00 and the fee for amputating a leg was set at $40.00. In South Carolina, almost three decades later in 1844, a regular single visit was no charge, normal obstetrical delivery was $3.00, treating gonorrhea was $2.00 and the fee for amputating a leg was set at $5.00.
The advancing settlement of America westward necessitated innovative solutions for physician remuneration due to low populations and poor patients. For example, a physician only agreed to move to Tucson, Arizona in 1871 after twenty-five families agreed to pay him $100 a year for his services. The frontier medical practice also required novel ways of payment such as poultry, cattle, tobacco, fruit, vegetables, wood and clothes. Barter was also a common payment method in Australia.
The very first physicians were military and naval surgeons and so would have been paid as salaried practitioners. As free settlers came though, “civilian” physicians would need to be paid and payment with goods and services would have been acceptable because the early Australian physician would have few places to spend his money. By the middle of the nineteenth century there are examples of fee regulation in Australia. The Port Philip Medical Association set fees for three different classes of patient with different fees for different classes. The 1st class patients (i.e. rich patients) had to pay two to five times as much as 3rd class (i.e. poor patients) for the same treatment.
From the very earliest of recorded history in the code of Hammurabi to the present day, we can find records of physician remuneration. It was an important matter of debate in medical texts as well as non-medical writings from Aristophanes’ and Sophocles’ plays as mentioned above to Moliere’s “Le Malade imaginare” and George Bernard Shaw’s “The Doctor’s Dilemma”. For the subject to be found throughout recorded history -- medical and nonmedical -- the issue must have been important, as it is today. Perhaps, some ideas to help us fix our current problems can be found in the past.
Additional Reference:
Probably the oldest extant primary source of medical fees is the code of Hammurabi. Written about 2000 B.C., the code is a set of laws decreed by King Hammurabi of Babylon. There are several references to physicians, including how they should be paid for their services. For example, sections 215-217 of the code read:
In medieval Europe, some physicians were employed by royalty and attended to the health of the royal court and perhaps some of its subjects, others were paid by the church to treat the sick of the parish and the poor. Some city states such as Venice employed physicians to give free treatment to the poor, treat the rich at reduced rates and advise the state on medical-legal and public health matters.
There are many sources from America which record how physicians were paid and whether fees were regulated or not. One example is the regulation of fees in Boston starting in 1780. It was the Boston Medical Society which developed the fee bill in order to stop physicians from undercutting each other. The fees on the fee bills were minimums so physicians could charge more, but no less. In addition, patients only wanted to pay for services if it included treatment such as a drug or a procedure. The fee bill however stipulated that charges be made for all visits. Because the physicians were controlling the fees, they made sure that they were always very well compensated, their general policy being to increase fees in good economic times but not to lower them in hard economic times. Between 1795 and 1806 the cost of living changed very little but the fees increased by 50-60%.
In Boston, we see an example where the physicians controlled their own remuneration and thus sometimes charged quite high amounts for their services. In South Carolina in 1844, we have an example of quite the opposite. The St. Peter’s parish, like the whole state, was very poor so the local officials decided to set a fee bill to curb the “exorbitant, oppressive” physician fees which “unjustly absorbs so large a portion of [the farmers] hard earned incomes.”
If we compare the fees in Boston and South Carolina, we can see the vast difference in fees when physicians or the community set them. In Boston in 1806, a regular single visit was $1.50, normal obstetrical delivery was $12.00, treating gonorrhea was $10.00 and the fee for amputating a leg was set at $40.00. In South Carolina, almost three decades later in 1844, a regular single visit was no charge, normal obstetrical delivery was $3.00, treating gonorrhea was $2.00 and the fee for amputating a leg was set at $5.00.
The advancing settlement of America westward necessitated innovative solutions for physician remuneration due to low populations and poor patients. For example, a physician only agreed to move to Tucson, Arizona in 1871 after twenty-five families agreed to pay him $100 a year for his services. The frontier medical practice also required novel ways of payment such as poultry, cattle, tobacco, fruit, vegetables, wood and clothes. Barter was also a common payment method in Australia.
The very first physicians were military and naval surgeons and so would have been paid as salaried practitioners. As free settlers came though, “civilian” physicians would need to be paid and payment with goods and services would have been acceptable because the early Australian physician would have few places to spend his money. By the middle of the nineteenth century there are examples of fee regulation in Australia. The Port Philip Medical Association set fees for three different classes of patient with different fees for different classes. The 1st class patients (i.e. rich patients) had to pay two to five times as much as 3rd class (i.e. poor patients) for the same treatment.
From the very earliest of recorded history in the code of Hammurabi to the present day, we can find records of physician remuneration. It was an important matter of debate in medical texts as well as non-medical writings from Aristophanes’ and Sophocles’ plays as mentioned above to Moliere’s “Le Malade imaginare” and George Bernard Shaw’s “The Doctor’s Dilemma”. For the subject to be found throughout recorded history -- medical and nonmedical -- the issue must have been important, as it is today. Perhaps, some ideas to help us fix our current problems can be found in the past.
Additional Reference:
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