For basic acute medical care and Pre-R, it’s just the wrong force vector diagram.
Every pay structure comes with hidden forces, also called incentives and disincentives, which nudge our behaviors. For doctors paid hourly (like me in the ER), a good shift is a mellow yet steady shift, with few yet interesting patients. “Fee for service” forces are significantly different and you can guess what happens… lots of services! Keep the patients coming and keep the services flowing. I’ll admit that I’ve never tried this model, but I often hear it called the “you eat what you kill” model. No thanks. To illustrate, if I’m paid for every ultrasound I order, and the machine is sitting idle, and my ultrasonographer friend is paid per scan, most certainly more ultrasounds will be ordered. Hospital managers wrestle with these decisions as managers do in every service industry. Combinations of hourly and fee for service models exist as well.
Concierge medicine is yet another business model with its own incentives and disincentives. Many doctors have chosen this path rejecting both hourly and fee for service. Memberships are sold to a select group of patients who are likely tired of waiting for appointments, and who have the financial means to join. With membership, patients know they can reach their doctors or a member of the group at any hour to receive guidance and care. It seems brilliant, but leaves out the less fortunate. In the limit, if every doc goes to the concierge model, many patients will simply no longer have access to primary care physicians.
As with fitness, auto, yacht and wine clubs, the best scenario for any membership model program is to sell many memberships, which never get used. This may seem unsavory for a medical practice, but on the flip side, it creates a strong incentive for illness prevention. So it makes great sense for people with diabetes, hypertension, heart disease to join concierge medicine practices if available. Unfortunately, a practice filled with such patients is like a gym with all machines occupied – cramped.
For acute, basic medical care, Pre-R has instead chosen the Roto Rooter meets Mother Teresa hybrid model. You call us to help unplug your drain, and we’ll treat you so well so you’ll want to help us unplug other peoples’ drains. I’m enjoying it immensely already. All forces in alignment!