The underpinnings of modern medical coding and billing find their roots deep within the long history of medicine. Our contemporary reimbursement systems, complex as they may sometimes appear, mirror a lineage that stretches back to the medieval era—a time when the philosophies underlying medical care were as much about societal ethics as they were about healing.
Medical care was different back then.
During the Middle Ages (around 450 A.D. to 1450 A.D.), physicians practiced medicine within a framework profoundly influenced by ancient Greek and Roman medical theories. The teachings of Galen, who postulated that human health was governed by the balance of four humors, dominated medical thought. When an imbalance occurred—say, an excess of the sanguine humor—a physician might resort to blood-letting as treatment. While such a remedy appears archaic at first glance, in today’s context, it parallels modern interventions in acute heart failure; after all, removing excess fluid from the bloodstream is a critical component of treating a congested system.
Payment for medical care was different, too.
What makes medieval medical care particularly fascinating is its multi-tiered payment system. In this era, the interaction between physician and patient was not solely about clinical decisions. It was also an intimate negotiation influenced largely by the patient’s social and economic standing. Educated physicians who tended to the upper echelons of society—merchants, nobility, and even royalty—could scarcely charge a fixed fee for their services. Instead, they adhered to the Roman tradition of accepting “honoraria,” essentially payments that were voluntary and reflective of the patient’s means. These constraints did not apply to all practitioners; barber-surgeons and less formally educated healers often operated under very different rules.
Medieval society’s ethical commitments further shaped payment practices. Influenced by ancient Greek and Roman ideals, there was an inherent duty among physicians to care for the poor. This altruistic commitment wasn’t a modern invention but stemmed from a tradition where monks and clergy, driven by Christian imperatives, rendered service to those unable to pay. When the practice of medicine began extending beyond the Church’s exclusive domain, the spirit of charity persisted. Even as physicians began to experiment with fee structures, there was an underlying recognition that effective care must remain accessible to all, regardless of wealth.
Tiered payments
One compelling historical account comes from the writings of the medieval French surgeon Henri de Mondeville. His observations reveal a sliding scale of fees:
- The poorest received treatment without any charge—an early form of charity care.
- Those of modest means might compensate with in-kind payments, such as fowls or ducks.
- Friends and relatives of physicians offered token gratitude rather than fixed money.
- For some wealthier classes, whose fees were less reliable, physicians were incentivized to provide quick, efficient care—a precursor to modern prospective payment systems like the diagnostic-related groups (DRGs).
- For some of the very wealthiest, physicians were kept on retainer.
Some things never change – or not that much.
In many ways, these medieval practices echo today’s complexities. We see parallels in the fee-for-service arrangements and even in modern concierge medicine, where a retainer fee system finds its roots in the medieval model of annual retainers to ensure ongoing health care. History offers us a mirror in which to examine our modern systems and appreciate the deep, interwoven relationship between ethical care offerings and financial realities.
The evolution of payment models—from honoraria to itemized billing—demonstrates that while the tools and technologies of medicine have undergone radical changes, the fundamental challenge of reconciling care with compensation remains timeless.
