A Cure for Doctors' Bills

The medical profession sees the writing on the wall.
IV

While it is impossible to state just what the annual dues would be, it is certain that they would be very much lower than doctors’ bills for any serious illness under present conditions. Four factors would operate to this end.

First, each member would, in effect, be paying his doctors’ bills by the installment plan. Instead of being presented with a bill of $1500 in one year, he would pay, let us say, $150 a year for ten years.

Second, it would cost less for each doctor to operate as part of a medical guild than if he were practising as an individual, because of the division of the overhead. By the same token, it would cost less for the whole or any part of the guild to function than it would for all the doctors or any portion of them were they practising separately. Hence the guild could charge less for its services.

Third, the periodical medical examinations should effect a marked reduction in the amount of illness of those who would belong to the guild. It is a fair guess that the hours of medical service for guild members would be from 10 to 20 per cent less than for non-members who do not submit themselves to regular examination. In such diseases as tuberculosis and cancer, especially, the cost of cure is reduced by early discovery and treatment.

Fourth, the medical profession would be placed under new and powerful motives to keep people well. Each member of the guild would pay his dues whether in good health or bad, and the guild doctor’s income would remain the same. The better the member’s health, therefore, the greater the doctor’s income per hour of service rendered.

It is amazing that in a profession in which the interests of the practitioner and the public seem, superficially at least, exactly opposite, so little suspicion exists that the doctor acts for his own interest rather than the patient’s. Disease is the doctor’s means of livelihood, yet he is always laboring to put it out of existence. This would remain true if the medical profession were organized in guilds, but the doctors would also feel new motives to encourage and practise preventive medicine, and would be in a better position to promote it.

It is to be presumed that the guild doctor, recognizing the advantage of good health among his patients, will exert himself to promote a positive health programme among them. He would naturally be more interested than the private practitioner in the correction of dangerous ways of living before they lead to actual ill health. Many preventive measures beside regular examinations would be included in the programme of a medical guild: vaccination against smallpox, immunization against diphtheria and other diseases, as well as instruction about diet, exercise, ventilation, and sanitation in the home. In other words, the guild doctor would carry on a well-organized offensive against disease and ill health rather than find himself always on the defense after their attack is well under way.

It is not at all beyond reason to suppose that the annual dues of a member of a well-run medical guild would be less than 10 per cent of the cost of any major illness in the present medical chaos. Recent studies by the Metropolitan Life Insurance Company show that families of workingmen spend on an average $140 a year for medical care. A six months’ study of 8000 families, including 17,000 individuals, showed that while 6 per cent reported no expenditure, a large share of the outlay fell on a small proportion of the families. Two thirds of the total was spent by one fifth of the families. One per cent spent $1000 or more for the year covered.

In applying this sample of human experience to the problem of guild rates, two reservations should be noted. First, the people concerned were wage workers, not salaried and professional folk, and hence probably demanded less in the way of comfort and attention than would middle-class members of a guild. Also, they probably did not call in the doctor at all unless it was absolutely necessary.

The figure of $140, therefore, is probably lower than the annual premium which would be required to meet the needs of the salaried and professional class.

But, even assuming that the average cost of medical care to the middle-class family is as high as $200 a year, a guild could probably guarantee complete medical and hospital services for $150 for each family or from $30 to $50 for each person.

There is every reason to believe that the general public would see the advantages of such an organization as the proposed medical guild. Who would not prefer to spend even $150 each year rather than to be faced suddenly with a bill of $1500 to $3000 for a major illness in his family? Who would not prefer to be regularly examined and advised by his doctor as part of a general service for a limited annual fee rather than to be treated only when sickness occurs and at unpredictable expense?

V

As a layman, I have stressed the advantages of the medical guild to the public. But consider now the advantages to the doctors themselves.

What is their greatest source of financial anxiety? I wager that nine out of ten will say: ‘Uncertainty of income.’ Not to know in advance how many patients he will have next year is undoubtedly the doctor’s nightmare. What is the least agreeable part of their dealings with their patients? I wager most of them will reply: ‘Adjusting my fees to my guess at the size of their incomes.’ Charging ‘what the traffic will bear’ has long since become both immoral and foolish in the world of commerce and trade, yet the practice survives in medicine to plague both doctors and patients.

Imagine a grocer who charged his wealthy customers two dollars a box for a breakfast food, gave it away to the poor, and asked anywhere from fifty cents to one dollar of his white-collar customers according to his estimate of what they might be earning at the time. The rich customer would feel imposed upon; the poor would dislike being objects of charity—especially if their receiving a free box of cereal gave the grocer a right to expose their family finances to students of economics; and the middle class would always be in a state of dissatisfaction either bent upon deceiving the grocer or suspecting that they were being mulcted. The tact that a more intimate and professional relationship exists between doctor and patient does not excuse the continuance of the present unethical and irritating system of fees.

The medical-guild plan offers the practical possibility of bringing the ‘fixed price’ principle into medicine. While some people will always have to be given medical care, as they are given food and lodging, by charity and public institutions, all but those on the poverty line could afford to pay dues to a medical guild—especially if the dues were graded in accordance with the degree of extra comforts provided to its members. The guild doctor would never have to concern himself with the income of his patients.

Nor would the guild doctor ever have to worry about the amount of his own income next year. It would be fixed and guaranteed in advance—by the dues already in the treasury. Probably the question of staff compensation could best be solved by a fixed-minimum-income plan, perhaps providing also for a division of profits should any accrue. It goes almost without saying that the cost of operation should include payment of an income that is adequate and substantially in advance of prevailing levels in private practice. The economies of operation should allow this—and still permit lower charges to the public.

Another advantage to the doctor might be noted, even though it is comparatively unimportant: more effective office administration. The doctor who practises as an individual has always the bother of running his own books, of billing and collecting, or of hiring someone to do his paper work and then keeping constant check on the purely clerical aspect of his business. He is also bothered with case records and their proper filing. In a medical guild all these matters would be done for him, and by people probably far better qualified than he.

Finally, it becomes increasingly apparent as the months go by that the guild plan would have an advantage for the medical profession as a whole. Never has there been such acute public dissatisfaction with the organization of medical service. The high costs of medical care are not only the subject of countless articles in the public prints, but are even being discussed in the inner circles of the profession. The whole problem is under a five-year survey by the Committee on the Costs of Medical Care headed by the Secretary of the Interior, Dr. Wilbur, and composed of doctors, economists, and publicists.

The medical profession itself has now seen the writing on the wall. Something must be done. In Europe the drift is toward state medicine. In this country, too, there is a definite set of opinion in that direction. At the annual meeting of the American Medical Association held in Detroit in June, the retiring president of the association told the house of delegates that socialization of medicine, along lines now suggested in England, was inevitable, unless the American physicians themselves established medical centres to enable the poor and the ‘white-collar classes’ to cope with the mounting cost of living.

‘Medicine,’ he said, ‘is being besieged on every side by forces that are constantly growing stronger and stronger, and unless some defensive effort is made to break the siege, the profession must eventually capitulate, become socialized, and become employees of the State.’

Most American doctors look upon any such solution with dismay. The medical journals are full of protestations against the threatened loss of the doctor’s professional independence. State medicine is their special bête noire. Industrial medicine is another. This danger was discussed at the annual meeting of the New Jersey Medical Society, also held in June, and the assembled physicians were called upon to resist absorption by the ‘industrial machine.’ The New York Medical Week, official organ of the New York County Medical Society, echoes the same fears and pleads for ‘independence.’ ‘The hireling of a corporation retains his place only at the pleasure and secondarily to the financial interests of his employers.’

The final argument for the medical guild is professional independence. The medical guild avoids control of the profession by either the State or the ‘industrial machine.’ It makes possible a desirable reduction in the cost of medical care to the public—and under more efficient management than the State, at least, is likely to offer. And to the doctors it offers the ultimate advantage of continued control of their own destiny and the destiny of their profession.

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