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MANAGED CARE May 1997. ©1997 Stezzi Communications

The roots of modern managed care go back to prepaid health plans of the 19th century, but many of the concepts we use today were embraced in ancient times. The Babylonians had a system with many parallels to the present one.

Hammurabi's Managed Health Care – Circa 1700 B.C.

By Allen D. Spiegel, Ph.D.

AT THE DAWN OF CIVILIZATION, about 4,000 years ago, nomadic Semite tribes developed a managed health care system. Using cuneiform, a hieroglyphic writing, they inscribed the concepts on clay tablets and chiseled them into stone between the 17th and 21st centuries B.C.

Adapting the existing edicts, King Hammurabi of Babylon incorporated these managed care precepts in the Codex Hammurabi, a huge stone stele erected about 1700 B.C.:

Rates set for general surgery, eye surgery, setting fractures, curing diseased muscles and other specific health care services. Fees set according to a sliding scale based on ability to pay. Owners to pay for health care for their slaves. Objective outcome measurement standards to assure quality of care. Outcomes information management to include data collection and evaluation. Consumer and patient's rights to be publicized, explained and made known to all.

Not only that, but marketing and advertising activities promoted adoption of the plan.

In the Codex prologue, Hammurabi characterized his compilation of judicial decisions: "These are the just verdicts that Hammurabi, the experienced King, has imposed in order to establish firm discipline and good governance in his country." Judgments followed the traditional and harsh "eye for an eye, tooth for a tooth" punishments of the Semite tribes. As we will see, physicians were well rewarded, but when they failed, the penalties were considerable.

Codex Hammurabi clearly indicated that physicians merited public esteem and were to be rewarded with adequate fees, carefully prescribed and regulated by law.

Defining population coverage

Everybody under Babylonian rule was covered by the Codex's managed health care system, but not all received equal treatment. Distinctions existed among the three social classes: awelum (upper class), mushkenum (middle class) and wardum (slaves). A Medicaid-type coverage for slaves required their owners to pay for health care services. Of the 282 edicts, 15 mentioned physicians, veterinarians, barbers or wet nurses.

Establishment of a fee schedule

Regardless of social class, access to medical care was unrestricted. There was no capitation and no level of uncompensated care. Codex Hammurabi established uniform fees for service with a sliding scale based on ability to pay and seriousness of the procedure, something like diagnosis-related groups in present-day hospitals. Awelum paid most, mushkenum less. The wardum's owner paid least.

To understand the fees, consider comparative economics: A free craftsman earned 5 to 8 grains of silver per day, taking about one year to earn 10 to 14 shekels (one shekel equaled 180 grains of silver). A wooden door cost one to two shekels; earthenware jars were sold for from one-fourth to two-thirds of a shekel; a wooden tray for carrying on the head went for one-half shekel; and a middle class dwelling rented for about five shekels a year.

Here are sections of the code and the fees prescribed:

§206 If a man strikes a freeman in an affray and inflicts a wound on him, that man may swear, "Surely I did not strike him willingly," and he shall pay the surgeon.

§215-217 If a surgeon has made a deep incision in the body of a gentleman with a lancet of bronze and saves the man's life or has opened a carbuncle in the eye of a man with a lancet of bronze and saves the eye, he shall take 10 shekels of silver. If the patient is a freeman, he shall take 5 shekels of silver. If the patient is a slave, the master of the slave shall give 2 shekels of silver to the surgeon.

§221-223 If a physician set a broken bone for a man or cure his diseased bowels, the patient shall pay five shekels of silver to the physician. If he be a freeman, he shall give three shekels of silver. If it be a man's slave, the owner of the slave shall give two shekels of silver to the physician.

§224 If a veterinary physician operate on an ox or an ass for a severe wound and save its life, the owner shall give to the physician 30 grains of silver.

Credentialing providers

Priests administered magico-religious medicine with three types of healers: Baru (diviner), Ashipu (exorcist) and Azu (physician). Another category consisted of doctors of an ox or an ass (veterinarians). Gallabu (barbers) branded slaves, performed plastic surgery removing markings, and did dental surgery. A Baru, essentially an internal medicine specialist, practiced hepatoscopy, believing that the liver was the seat of the soul and center of vitality. Diagnoses were made by consulting a concisely coded model of a sheep's liver.

But while a patient could consult any willing provider, some providers risked the penalty of death or dismemberment mandated in Hammurabi's Codex.

Azum were educated in priestly temple schools and students learned from the clay tablets and practical experience. An Azu diagnosed ailments by listening to the patient's accounts, not by physical examination.

Pharmaceutical benefits

There was no extra charge for medications. More than 250 medicinal plants, 120 mineral substances and 180 other drugs were combined with alcoholic beverages, bouillon, fats, honey, milk in various forms, oils, wax and parts and products of animals. Medications were ground, strained and filtered for ointments or plasters to spread on a piece of thin leather to apply. Narcotics came from hemp, mandragora, opium and solium temulentum. Prescriptions specified enemas, laxatives, lotions, ointments, pessaries, pills, poultices, powders, salves and suppositories. A patient's prescription could be "enveloped in the aroma of burning feathers and liberally dosed with dog dung and pig's gall."

Specialty referrals, consultations and denial of care

There was no limitation on referrals or consultations. Kings and aristocrats secured the services of renowned physicians, lent the doctors to their allies and sent them "to visit the courtesans whom they loved." Baru, Ashipu and Azu readily exchanged treatment regimens. Denial of care is not mentioned, although one clay tablet text warned medical students "not to touch a patient who is likely to die."

A Baru or Ashipu was not accountable because gods, demons or evil spirits caused treatment outcomes. But an Azu could be held accountable.

An Azu prescribed drugs and medications, performed surgery, set fractures, palliated visible sores and treated snakebites. Medical instruments included bronze lancets, metal tubes to blow remedies into bodily orifices, tubes to be used as catheters and spatulas. When an Azu used a "bronze lancet" or other means to heal a patient, he was accountable for direct human error or aggression. If a patient died or was seriously injured, the outcome was easily observed and the "eye for an eye" penalty imposed. But significantly and mercifully, judges omitted any references to the Codex in their recorded decisions and were guided by tradition, public opinion and common sense.

Quality, outcomes and penalties

Quality-of-care edicts in Hammurabi's Codex left no margin for error: Health care providers had to be flawless or lucky:

§194 If a man gives his child to a nurse and the child die in her hands, but the nurse unbeknown to the father and mother nurse another child, then they shall convict her of having nursed another child without the knowledge of the father and mother and her breasts shall be cut off. (A wet nurse was paid about 3 shekels)

§218 If a physician operate on a man for a severe wound with a bronze lancet and cause the man's death, or open an abscess in the eye of a man with a bronze lancet and destroy the man's eye, they shall cut off his fingers.

§219-220 If a physician operate on the slave of a freeman for a severe wound with a bronze lancet and cause his death, he shall restore a slave of equal value. If he open an abscess in his eye with a bronze lancet, and destroy his eye, he shall pay silver to the extent of one-half his price (average prices for male slaves ranged from 16-30 shekels).

§226 If a barber has excised a slave's mark without the knowledge of his owner so that he cannot be traced, they shall cut off that barber's forehand.

§227 If a man has constrained the barber and he excises the slave's mark so that he cannot be traced, they shall put that man to death and shall hang him at his own door. The barber may swear, "Surely I excised it unwittingly," and then go free.

Penalties included burning, drowning, hanging, impalement on a stake, bodily mutilation and monetary fines. But quality-of-care penalties were adjusted by social class with the opportunity to escape death or mutilation by paying a monetary fine. Practice standards were written on the clay tablets and recorded by the temple schools. Outcome measurements were specifically identified in the Codex, as were the severe corrective actions for improving the practice of medicine. How much more total can "total quality management" be than to cut off the hands of the offending health care provider?

Medical records

Thousands of clay tablets recorded descriptions of ailments, including abscesses, colic, gallbladder trouble, rectal prolapse and venereal disease. Forty tablets interpreted dreams and described prevention of nightmares. Medical care data documented ailments, causes, treatments and therapy outcomes. A clay tablet chart systematically and routinely entered the physician's name and relevant data.

Deselection of providers

Hammurabi's Codex specified the harshest form of deselection possible. If the physician erred through omission or commission, his fingers or hands were cut off, immediately stopping his practice. This severe punishment for negligence supposedly weeded out physicians incapable of delivering adequate care. In addition, it prevented these physicians from practicing in a different locality. Obviously, such a penalty discouraged a physician surplus.

Patient rights and satisfaction

Codex Hammurabi anticipated communication problems such as "gag rules" and "patient protection laws." Providers were commanded to follow the edicts on the stele to assure patients of their rights. A huge stele was erected on the grounds of the major temple in Babylon for everybody to read. Clay tablets duplicated the Codex and were distributed throughout the nation. Hammurabi, who had a rather high opinion of himself, specifically advised all those seeking justice that the Codex would tell them what to expect:

"Let the oppressed man who has a cause come before my statute called 'King of Justice' and then have the inscription on my monument read out and hear my precious words, that my monument may make clear his cause to him. Let him see the law which applies to him, and let his heart be set at ease!

Codex Hammurabi strictly enforced compliance through severe penalties. If they were not satisfied, patients could seek justice from a legal system. However, there is no evidence of either prosecution or defense lawyers in Babylonia.

Patient disenrollment

While there was no managed care organization from which to disenroll, Babylonians could move up or down the social class ladder and thereby change their level of health care.

Marketing and advertising the Codex

In the Codex introduction, Hammurabi lavishly applied the ancient advertising and political rule that if you say something loud enough, often enough and in grandiose language, people will believe it.

With 16 lines of blessings and 282 lines of calamitous curses for noncompliers, Hammurabi invoked the gods and repeatedly glorified his benevolent actions undertaken for the benefit of his subjects:

"Anum and Illil ... called me by name Hammurabi ... to make justice to appear in the land, to destroy the evil and wicked that the strong might not oppress the weak.... My words are choice, my deeds have no rival; only for the unwise are they vain, and for the profoundly wise they are worthy of all praise."

He proclaimed himself "a god amongst kings, imbued with knowledge and wisdom."

But despite all of the high-powered hyperbole, history views Hammurabi as a leader who cared for his people and had great military, managerial and diplomatic skills.

Lessons from antiquity?

In the fervent rush to employ managed care, our society may in some ways be re-entering the realm of an ancient medical care system. Aggrieved health care consumers may welcome a move toward harsh penalties in the name of justice and/or simply for revenge, though it isn't necessarily the providers who would suffer.

In the late 1980s, Babylonian clay tablet cookbooks from 1700 B.C. resurfaced to reveal what one observer called "a cuisine of striking richness, refinement, sophistication and artistry."

It isn't far-fetched to suggest that, with appropriate language changes, the prologue and epilogue of Codex Hammurabi present lofty moral and ethical goals that managed care organizations might emulate:

"...to cause justice to prevail in the land, to destroy the wicked and the evil, to prevent the strong from oppressing the weak ... to further the welfare of the people ... I brought health to the land; I made the populace to rest in security; I permitted no one to molest them ... I restrained them that the strong might not oppress the weak, and that they should give justice to the orphan and the widow.... "

Allen D. Spiegel, Ph.D., M.P.H., is a professor of preventive medicine and community health at the College of Medicine, State University of New York, Health Science Center at Brooklyn, N.Y. With Florence Kavaler, M.D., he is co-author of Risk Management in Health Care Institutions: A Strategic Approach (Jones and Bartlett, Sudbury, Mass., 1997).

Just who was Hammurabi?

Babylonia, Mesopotamia, Iraq: They're all the same place, more or less, the area between the Tigris and Euphrates rivers known as the "cradle of civilization."

A great military commander, Hammurabi consolidated small states in the vicinity after ascending to the throne on the death of his father, Sinmuballit, in 1792 B.C.

Rightly or wrongly, he is more widely known for Codex Hammurabi, or Hammurabi's Code, a collection of 282 judicial decisions from the latter part of his reign that is the largest such collection that has survived from the period.

The stela (column) on which it was inscribed was discovered in 1901 and given to the Louvre, where it remains today.

Outcomes-based Fee Schedule

This chart outlines fees and penalties for successful and unsuccessful procedures. There are no fees for unsuccessful bone setting and sinew mending because outcomes are usually not fatal; operations can be repeated until the result is satisfactory. Omission of fees for mushkenum (the middle class) indicate that the scribe failed to copy a section containing a penalty. Awelum were the upper class; wardum were slaves.

Seal of a Babylonian Azu with reverence to the gods, a self-portrait and depictions of bronze knives, cups and needles. Translation: O Edinmagi, servant of the god Girra, who helps mothers in childhood, Ur-Lugaledina the physician is your servant. (From A. Leix. Medicine and the Intellectual Life of Babylonia. Ciba Symposia 1940; 2:663 - 674.)

Clay model of a sheep's liver used for divination. Each of the designated individual fields has explanatory text with specific diagnoses. (From A. Leix. Medicine and the Intellectual Life of Babylonia. Ciba Symposia 1940; 2:663 - 674.)