The (see text) in the Praecepta: The Medical Fee and its Impact on the Patient.

The brief collection of deontological guidelines entitled Praecepta is one of the most important literary evidence regarding the fee of the ancient physician. This chapter focuses on three passages from the Praecepta, which offer us a wealth of information on this topic. Some technical terms used in the text, such as the term µiσθápiov, show clearly that the author intends both to provide guidelines for the ideal bedside manners and to defend the repute of the physicians from the widespread charge of greed. In some regards, the author of the Praecepta depicts medicine as a 'liberal' art: the good physician disdains monetary gain as the main goal of his service, and aims to safeguard the social status and reputation of the medical profession. On the other hand, the author of the Praecepta enlightens his readers on the bad behaviour of both charlatan physicians and bad-mannered patients.

[Ethical aspirations and the reality of medical practice at the end of the Ancien Regime]. / Aspirations ethiques et réalité de la pratique médicale a la fin de l'Ancien Régime.

At the end of the 18th century, economic survival was difficult for physicians. The medical market was crowded and to build (and seduce) a clientele, they had to pay particular attention to their appearance. Being well dressed and travelling by horse or in a carriage was necessary to demonstrate that they had a good reputation and were a "good" doctor. However, this still did not guarantee financial security for the doctor and his family. In an era when medical fees were only just beginning to be discussed, it was difficult to know how to bill patients and how to get paid. At the same time, the first texts on medical ethics appeared, insisting on modesty, authenticity, delicacy, and sincerity. In this article, by exploring personal archives and printed moral prescriptions, I will suggest that there were tensions between the everyday difficulties of medical practice and the recommendations on medical ethics, tensions that had consequences for the patient-doctor relationship.

Learning from the legal history of billing for medical fees.

INTRODUCTION: When patients pay for care out-of-pocket, physicians must balance their professional obligations to serve with the commercial demands of medical practice. Consumer-directed health care makes this problem newly pressing, but law and ethics have thought for millennia about how doctors should bill patients. HISTORICAL BACKGROUND: At various points in European history, the law restricted doctors' ability to bill for their services, but this legal aversion to commercializing medicine did not take root in the American colonies. Rather, US law has always treated selling medical services the way it treats other sales. Yet doctors acted differently in a crucial way. Driven by the economics of medical practice before the spread of health insurance, doctors charged patients according to what they thought each patient could afford. The use of sliding fee scales persisted until widespread health insurance drove a standardization of fees. CURRENT PRACTICE: Today, encouraged by Medicare rules and managed care discounts, providers use a perverse form of a sliding scale that charges the most to patients who can afford the least. Primary care physicians typically charge uninsured patients one third to one half more than they receive from insurers for basic office or hospital visits, and markups are substantially higher (2 to 2.5 times) for high-tech tests and specialists' invasive procedures. CONCLUSION: Ethical and professional principles might require providers to return to discounting fees for patients in straitened circumstances, but imposing such a duty formally (by law or by ethical code) on doctors would be harder both in principle and in practice than to impose such a duty on hospitals. Still, professional ethics should encourage physicians to give patients in economic trouble at least the benefit of the lowest rate they accept from an established payer.

[Statement of fair retribution in medical oaths]. / Compromiso de retribución justa en los juramentos médicos.

BACKGROUND: to determine if Medical Oaths from different times include the statement of the physician to request from patients a fair retribution for his/her medical services. METHODS: Fifty Medical Oaths found in articles and publications were analyzed. In accordance with their corresponding dates, the Oaths were grouped as ancient /medieval (12), and modern/contemporary (38). RESULTS: Of the fifty, only three specifically included the statement of fair retribution. Two of the three were medieval and belonged to the School of Medicine of Montpellier. The other text was modern (Amato Lusitano's Oath). Four writings showed statements regarding medical assistance to the poor. Eleven pledges indirectly stated that no earnings from other activities and/or relations were obtained. CONCLUSIONS: Ancient oaths emphasize fair retribution, no discrimination in medical assistance based on payment possibilities, and gain of honest earnings. Modern oaths generally do not include these topics and very few mention that the medical profession should not be exercised merely for material purposes. Despite the above, physicians should respect the limits of their obligations and should be committed to assist without discriminating, particularly without taking into consideration their patient's financial possibilities. Therefore their fees should not be excessive for the services rendered.

A history of medical payments: continuity or crisis?

The form and amount of medical payments has been a contentious issue throughout the history of Western medicine. The prices charged by doctors, and the actual payments they receive, have reflected a complex interaction of the social, economic, and political forces impinging upon medical practice. Contemporary concerns about the medical payment system in the U.S. relate, in part, to the unprecedented scale and complexity of the modern system of medical payments. Historical analysis reminds us that medicine and money have always made odd bedfellows. Today's problems may seem intractable, but such problems have been consistent throughout medical history.

Medical fees. Medibank and Medicare.

Because paying the doctor was often a financial burden, many ways were devised to help pay the doctor's bill. This article looks at how private medical insurance began to merge into a government funded medical practice. Recent experiences suggest that payment for general practitioners is about to undergo further change.

Medical fees. Lodge practice.

Paying the doctor often imposed a severe financial burden on patients. Various ways were devised to help patients to access medical care. One such way to pay the doctor was through Friendly Societies. This article looks at the role of these groups in medical practice.

Medical fees. A history of how the doctor was paid in Australia.

Medical fees are an important part of medical practice, yet they have always been a bone of contention. This article is the first in a series of three that will look at the way the doctor was paid. It examines the role of medical fees in early medical practice in Australia.

["Thus it passes from the patient's purse into that of the doctor without causing displeasure" - Samuel Hahnemann and medical fees]. / "Und es sammelte sich ohne Verdruss von Seiten des Kranken in des Arztes Beutel" - Samuel Hahnemann und die Honorarfrag.

In 1834, Hahnemann gave the following advice to his pupil Dr. Karl Julius Aegidi: "We are not allopaths who have high medical fees and can legally demand high sums for evil deeds. We must take what we have earned on the spot, since we are not considered worthy of ordinary justice." In an earlier letter to the same addressee, Hahnemann wrote: "No one enters my house if he does not have with him the money to pay me, unless he is paying me monthly, in advance [...]." There can be no doubt that in Hahnemann's times, fees were the most important component in a physician's income. Dependency on fee income meant that the physician always had to worry about delayed and even avoided payments, and patients' reluctance to pay was notorious. Many doctors lost large parts of their nominal income through bad debts. In some cases, installments were accepted by both parties, to avoid costly legal action, which were usually a last resort. In these circumstances it is hardly surprising to find Hahnemann, the founder of a highly disputed new cure, stressing to his colleagues that for a successful medical practice, cash payments at the time of treatment or in advance were preferable to post-facto bills. Having been ostracized by the medical establishment, Hahnemann showed a remarkable professional awareness of patients' propensity to debt. Long before regular physicians propagated cash payment, Hahnemann derived his income solely from ready-money payments. However, he used a sliding fee structure to allow for the different economic circumstances of his patients, who came from all walks of life. The very poor he treated for free, while members of the rural and urban middle class had to pay considerable fees. In some cases, Hahnemann was able to charge very high fees, and his numerous enemies used this against him.