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PAYMENT BY PREMIUM VERSUS

PAYMENT BY FEE

Some little time ago a letter appeared in one of our weekly journals in which the writer, a medical man in a Midland town, related the remarkable circumstance that he and his partner had not had occasion to visit a single patient in four days, although they “enjoyed' a clientèle of nearly 4000 persons. Recollection of this letter has times and oft afforded me much solace, when for days at a time no patient has called for my services. In a country practice with a little less than half that clientèle, such periods of enforced idleness often occur in the course of the year, and I cannot think that these experiences are uncommon in other practices, town or country.

I know, of course, that the general sickness rate has been declining for years, but it seemed to me that in my own district the decline was moving at an abnormal pace. Accordingly in November I proceeded to investigate, and found that the income I derive from private practice, as distinguished from contract practice, has been actually stationary in amount for twelve years. Further search discovered the fact that the population that I can regard as my own clientèle has increased by about three hundred in that time. Obviously, then, my income from private practice must diminish unless the increase of population continues. In other country districts, and in towns, conditions must be more or less similar, though increase of population is generally met by increase of doctors. With a stationary population income could only be augmented by gatherings from the flocks of other shep. berds. An attempt to increase fees would probably defeat its object, and a 'speeding up' in the way of making more visits per case must not be thought of.

It will, I think, be admitted that there is now going on a general steady decrease in the amount of work that falls to the general practitioner (consultants are out of my ken, but one does hear whispers that there is consternation even in Harley Street) and a constant decline of the income derivable therefrom. The causes of this lessened and lessening sickliness in the body of the public are before our eyes. The agencies at work in the community all tending to ward off illness, to nip it in the bud, and, without our assistance, even to cure it when developed, are very numerous. I think most of them are to be found in the following list : Medical officers of health, school medical officers, midwives, druggists, patent medicines, hospitals, nursing homes, isolation hospitals, village and district nurses, sanatoriums, holidays, cycling and motoring, games of all sorts, simple living, vegetarianism (?), ambulance, nursing and health lectures, medical advice in the lay Press, popular medical books, bonesetters, increased facilities for travel. Nearly all these agencies are of recent birth or introduction, and there can be no possible doubt that their combined effect in reducing the need to call in the doctor must be in the aggregate enormous.

To contemplate the above list must be perfectly appalling for the doctor who lives by fees and whose very existence is at stake. Moreover, most of these agencies have not been working during a whole generation—they haven't got into their stride yet. Their effect is only just beginning to manifest itself. The list, too, is growing every year. The business of doctor, as hitherto worked on the time-honoured and undoubtedly dignified method of pay for services rendered, is all too obviously a business that is wasting daily under our very noses, and apparently it would pass the wit of man to devise a remedy for the rot that is eating at our vitals. We not only have made, and do make, no resistance to the spread of most of these influences, but to those most potent to harm us we actually lend our aid. We provide from our ranks medical officers of health and school medical officers, who promptly go over to the enemy and exert all the knowledge and power they possess to prevent from coming to us the supplies that sustain us. We actually provide the enemy with weapons, such a's midwives and nurses, ambulance, nursing and health lectures, with which to sap our food supply. How long can we last out? The ring round us is getting stronger and closer, and if relief comes not, the end cannot be far off. Relief from outside is not to be hoped for--the only chance for the beleaguered garrison is to cast away its old wornout weapons and to adopt a new and effective arm.

The system on which we have relied for work and sustenance is, under the actual condition of things, falling short of our needs. Payment by fee as a source of income is failing, because there are fewer sick people to provide the fees. The more sick people there are the more fees we get; we thrive best when the people are dropping with faintness. Though we do not knock the man down, yet finding him down we demand money for helping him up and putting him on his feet again. In any other sphere of life this kind of action would be considered immoral. (Even scout-boys are taught that it is immoral to receive pay for deeds of help and kindness.) True that in his distress the sufferer often promises to pay and does not : and true that in many cases the fallen man can only afford to reward us with a small cash fee' paid at the time we give the lift. Wrong as it seems and is, considered in an ethical sense, it is an action we are all committing day after day. Now and again a bitter jibe is burled at us by a passer-by, but secure in our sense of uprightness and proper dealing, it has never occurred to us that our conduct has been anything but perfectly dignified and proper, humane and altruistic.

Let us now examine this system at close quarters. We ask for fees for work done. The amount of the fees ought to.be exactly proportionate to work done. But we find the fee varying in the same practice from half-a-crown up to a guinea, or from sispence up to five shillings, without relation to the work done. The fee is generally supposed to bear some connexion with the pecuniary means of the patient, but if we compare the halfcrown from the pocket of the labourer with the half-guinea we extract from the merchant rejoicing in an income of 10001. a year, we discover that the poor man pays a day's wage, and the wellto-do man a fifth part of his daily income for the service rendered. So it is manifest that the fee has but the vaguest relation to the income of the patient. Inquiry will also show that it has the least possible relation to rent; and even if it had a close relation to rent, rent has but an indefinite association with income; so that, for instance, it is not possible to charge a uniform fee down a long row of houses. A uniform fee over a layer of patients we imagine to be on the same pecuniary level would press heavily on the man with a family and but lightly scratch the bachelor. The fee, then, varies within the widest limits, and has no definite relation either to the income or the rent of the person paying it.

Let us now probe for the meaning of 'work done' or 'service rendered.' This work done' we at once perceive has a value that varies as wildly as the weather. At one visit it may be a life-saving service that we render, at the next we may merely have to provide material for a trivial chat. Moreover the value to the patient of the 'work done,' when considered in a medical sense, has the utmost diversity. It is not customary, apart from operations, to consider' work done in a medical sense at all in measuring the fee charged. 'Work done' resolves itself into 'visits' or 'consultations, and as such is gaily entered in our books. (It is rather ludicrous to think that 'cash' practices should flourish both at the bottom and the top of the profession !) We charge for the 'visit,' the value of which, it is evident, is in constant and variable. But we can see that even when we lump all the service we render into 'a visit’ we are yet dealing with a thing of multifarious intent. A dozen factors need to be considered in estimating the value of ‘a visit,' apart from the service rendered to the patient which itself changes infinitely, as we have just observed. There are the time of day or night at which the visit is made, the distance travelled, the weather, state of roads and contour of country. A journey six miles out in one direction in fine weather would involve the consumption of a trifling amount of energy, while a call four miles off into the hills in the opposite direction on a rough night in January might be absolutely exhausting. But fees are not governed by considerations of weather, of actual physical labour expended or of the nature of the case. The fee for the visit is the same whether the case be one of pneumonia or gumboil. It has no evident connexion either with the amount or value of the service rendered to the patient, and seems to bear no relation to the physical or psychical energy consumed in rendering the service.

Then, again, how is it possible to gauge the worth of the visit as made by the newly fledged practitioner and the physician of high degrees and experience? It may be they are partners in the same practice, and charge the same fee. The medical man who 'insists on a small cash payment' at the East End may have at the same time gone through the same strenuous examinations, and be in every way as capable and experienced as his confrère at the West End who is paid a guinea for a service which in a medical sense is much less important and efficacious. It is apparent, then, that the value of the visit, the service rendered, the work done, in its relation to the fee charged, is perfectly nebulous and intangible, and that there is no standard of value, nor in the nature of things can there be. The amount of the fee is a sum fixed at the will of the doctor performing the service, and in actual practice is really governed and determined by the capacity and readiness to pay of the person served. Peradventure, the estimate is found to exceed the expectation of the person served, and the demand has either to be reduced or dignity saved by entering the debt in the ledger for future collection.

Having made our 'visit ’and at last arrived at the exact figure of the fee to be charged for the 'work performed,' the consideration now before us is, naturally, when shall the next visit be made? One doctor will be of a sanguine disposition, and always eager to see hopeful signs. Another, it may chance, is the unfortunate possessor of a bilious and melancholy temperament, and rather inclined to take a gloomy view of things in general, and his cases in particular. For reasons psychological we may safely predict that the sanguine visitor will not get through as many visits per year as the bilious gentleman. The caustic Nineteenth Century

reviewer tells us that most doctors make as many visits as they think the patient can pay for, but though this is not the first nor the hundredth time the accusation has been cast at the profession -I merely quote to show that the system of fees does lay us open to this kind of attack-it cannot be denied that dread of making more visits than the case requires does operate with most of us, though obviously the more case-hardened would feel indifference to public opinion. Doubtless a reputation so acquired would work its own downfall. But it is a fact that one hears accusations of this nature made against individual medical men:

That temperament alone does affect the number of visits doctors pay to their patients is demonstrated in midwifery practice, in which there can be no question of making fees.' One doctor will visit every day for a fortnight, and another will call three times in what he considers the regulation seven days. In this class of practice it is usual to charge a fixed fee, which a prospective patient can ascertain months before she needs the service, so that the number of 'subsequent' visits makes no difference to the fee charged.

Enough has now been said to exhibit the uncertainty, the instability, the variability, the unsteadiness of the basis on which stands our system of payment for work done. It is a system that crushes the poor, weighs heavily on the middling-to-do, and may embarrass even the rich. It has been claimed that it is the only method of payment that consorts with the dignity of a noble profession,' though I think it must be conceded that the lower the fee the thinner the dignity. I grant that it is the only system possible in consulting and operating work, although the want of uniform proportion between service rendered and fee charged must often be glaringly evident both to the charger and the charged. It has often come into my mind that in taking the amount of a day's wages from a servant-girl or a day-labourer I have been doing something that as a member of a humane calling I ought not to have done. One must live! Yes. The service was worth it! Yes. But the thought nevertheless leaves me uneasy. How much happier we doctors would be if we had not to charge for our services; if we could discard from our minds all the thoughts that accompany a commercial transaction! Such a state of bliss can never be ours, however, so long as society rests on its present foundation. If all our dealings with our patients could be promptly settled for cash as soon as transacted, how nearly perfectly happy should we not be! Such beatitude is not for us. We are panting under the weight of a system which is crushing the breath out of us, which is overwhelming us with the load of bad debts that cling to it like limpets to

1. The Insurance Bill, the Doctors and National Policy,' by Harry Roberts, July 1911.

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