Physician compensation, past and presentBMJ 2003; 327 doi: https://doi.org/10.1136/bmjusa.03050004 (Published 19 November 2003) Cite this as: BMJ 2003;327:E224
From BMJ USA 2003;May:276
Since earliest times, wise men have experimented with various methods of compensating physicians. Fee for service is the oldest documented model. The Code of Hammurabi (1792 - 1750 BC) specified physicians' fees: “If a doctor has healed a freeman's bone or has restored diseased flesh,… the patient shall give the doctor five shekels of silver.” The Mesopotamian rulers set the amount to be paid for each procedure, just as the Canadian government does today.
In 2000 BC, Egyptian physicians were salaried, employed by the army or the temple. They would not charge for services, only for the medication they dispensed. Their contracts resemble those of contemporary military and industrial-based physicians in the United States.
Ancient Chinese physicians were members of the upper class and were philanthropists, receiving no pay. Some worked on a retainer, serving special interest groups such as the court or wealthy families, foreshadowing today's sports team physicians.
In India, the laws of Manu (200 BC - AD 200) stipulated that charges reflect income; the sliding fee scale is not a recent invention. The successful doctor could claim the patient's property in case of non-payment.
In Greece, Hippocrates advised that patients should pay in advance, experimenting with prepaid medical plans circa 400 BC. Hippocrates also emphasized that doctors could justify their bills only by participating in continuing medical education. Greek physicians were upper-class citizens and did not treat the poor or slaves. Plato explained the Greek tier system: Slaves were treated by physicians' assistants; rich people, by doctors. Today, medical students run free storefront clinics and specialists run “boutique” offices for the wealthy.
In Europe during the Middle Ages, doctors and patients agreed on a fee, and the doctor made a deposit. If the patient died, the doctor was not paid but got the deposit back. If a procedure was unsuccessful, the doctor paid a fine, and only if all were happy did the doctor get the deposit and payment. Punishment for lack of success could be severe. Queen Austrechild (? - AD 568) had her doctors beheaded for their failure to cure her.
Doctors in the Middle Ages objected to regulated fees for the rich. Doctor Guglielmo da Saliceto of Italy complained, “It would not be a bad thing to ask the highest possible fees for medical treatment, giving the examination of excrement and urine as a reason.” During this time there existed an installment system to pay for surgery; surgeons would receive a lifelong annuity if the patient could not pay for an operation in a lump sum.
The monasteries, which dispensed care in the Middle Ages, were motivated by Christian charity and dependent on donations. The hospices provided unequal care, with some treating all who came as worthy of the best care, and others, as the Council of Clermont declared, “promising health for filthy lucre.” The American Medical Association code of ethics states, “Each physician has an obligation to share in providing care to indigent patients.” Present day physicians fail in this effort, as did the monastic Christian healers.
Are there lessons to glean from the past about the future of health care?