Financing a practice
appropriate assistance you can to any person with an urgent
need for medical care" (Article 18, Canadian Medical
Association Code of Ethics 2004).
This provision, or similar provisions, can be
found in the code of ethics of most medical professional
associations throughout the world. It can, however,
create a dilemma. A physician or other healthcare
practitioner needs to be paid for the services provided -
after all, we need to pay rent and mortgages and feed
ourselves and our families just like anyone else.
However, what should a physician do when a person needs
medical assistance but can't pay?
The concept of
spreading the personal economic risks of injuries and
illnesses is not new. Examples include the clients and patrons
of ancient Rome, the craft guilds in medieval England, and
subsequently the mutual aid systems which developed in Great
Britain in the 19th century which came to be known as Friendly
Societies or Saturday funds. Parishes and workhouses in
medieval times provided a safety net of sorts for the poor and
sick. As industrialization spread throughout Europe, so
did the mutual aid or insurance concept. Many modern
hospitals started out as charitable foundations financed by
public contributions or individual wealthy benefactors.
Masonic lodges in the past would pay a physician from lodge
funds to look after the health of the members.
Some physicians in the past
have in effect run their own insurance schemes.
My father can remember that during his childhood in
England, his family paid the local family physician
sixpence per week (probably roughly equivalent to a dollar) in
return for which they were able to consult with the physician
Participation in many of these
schemes was voluntary which resulted in low
participation which when coupled with poor
administration and low contribution levels, produced
ineffective organizations unable to pay adequate
benefits. In the nineteenth century, compulsory national
health insurance schemes began to be introduced in many
countries, and often took over the management of the
pre-existing charitable hospitals. Private insurance is
also often used to supplement
governmental programs. This has tended to result in an
increase in physician incomes, because generally insurance
plans can afford to pay more than private individuals would
be able to. Currently, physicians in the
US enjoy median incomes around four times that of the
median household income, and this ratio is similar in most
As we pass through peak oil and start
on the downward slope of energy and resource depletion, there
are likely to be severe disruptions in the financial system
which may result in health insurance programs being cut back
or disappearing entirely, and employed physicians laid off.
Physicians may therefore need to consider using any or all of
the above methods in order to ensure they are fairly
compensated. In the case of a family physician serving a
local community, it would be advisable to enter into a
dialogue with the community to see what they are willing to
provide in the way of premises, equipment or funding.
Going forward, physicans will need to be realistic about
what to expect in the way of fees and income.
Whether in private or employed practice, a physician's income
cannot deviate too far from what insurance plans or private
individuals can afford to pay, and as the economy
contracts, physician incomes will have to contract with it,
probably moving closer to the overall median
Other methods of payment worth considering are bartering
physician services directly for other products and services or
joining a Local Exchange Trading System (LETS). Briefly,
the latter is an arrangement whereby a community in effect
prints its own money which can then be used to purchase goods
and services within the local economy. Several of these
systems have been set up worldwide, and they can work well,
but the main drawbacks in practice are that the currency can
only be spent within a very restricted geographical area, it
is difficult to accumulate enough of it to make a large
purchase, for example a house, and the systems are often
dependent on the enthusiasm of one or two key organisers, and
may fail when those organisers burn out.