Nsttute .for. Research on Papers Doctors, Politics, and Pay Disputes in Advanced Industrial Countries: an Es Say Review and a Research Note

This paper comprises an essay review of Eckstein's classic work aQd a research report on investigations of payment disputes which the authc> rs conducted in England, Sweden, and the United States, 1965-68. The firs t section discusses difficulties in Eckstein's research, particularly methodological problems that arise from the failure to use comparative data to test his hypotheses about the influence of the BMA on health policy. Secondly, this paper seeks to account for why governments pay doctors as they do. It evaluates the hypothesis that, among western industrial countries, widely known physician preferences on method of pay determine subsequent policy, whatever the bargaining arrangements and distinctive national political setting. Two bodies of data are used: primary studies of payment method decision in Sweden, England, and the United States, and secondary information on methods of payment employed throughout Western Europe compiled by Glaser. Both bodies of data proved consistent with our factual hypothesis. The explanation offered stresses the structural imbalance between the political resources of physicians and governments on questions of payment method. This account has policy implications quite different from those stressing the impact of bargaining forms and settings in payment method decisions; it implies that governments should not concentrate on changing methods of pay to reform health policy, but should use other policy instruments to accomplish reform goals. Doctors, Politics, and Pay Disputes in Advanced Industrial Countries: An Essay Review and a Rese~ch Note Studies of medical politics usually emphasize one of the following types of inquiries: a) analyzing the internal politics of medical organizations, as with Oliver Garceau's classic study of the American Medical Association;l b) describing and explaining the roles individual physicians play in the political life of the community as voters, officials, or citizen participants in civic life;2 or, c) assess.ing the impact of medical groups and organizations on ,public policy, particularly health policy.3 Harry Eckstein's widely known study of the BMA is primarily a study of the third type, a discussion of the channels of influence, the tactics, and the effectiveness of the British Medical Association in shaping public policy to their ends. This paper comprises an essay review of the Eckstein work and a research report on medical payment disputes which the authors conducted in England, Sweden, and the United States, 1965-68. The research report tentatively suggests ways to correct the difficulties we identify in the Eckstein research, particularly problems that arise from Eckstein's failure to use comparative data to test his hypotheses explaining the influence of the BMA on health policy. Our larger concern, of which this study is a part, is an investigation of the outcomes of conflicts over the methods by which doctors ought to be paid in western industrial countries. England, Sweden, and the United States provide the primary comparative data, but we fortunately have extensive secondary evidence on other countries from the recently published work by William Glaser, Doctors Pay, (Baltimore: Johns Hopkins Press, 1970). The first section discusses the Eckstein