Short order medical care

I have been away on vacation this week, spending time in the cool mountains. It has been a pleasure to hike through the woods taking in beautiful vistas and listening to the music of mountain streams.
We have a cabin the woods equipped with all the comforts of home including a kitchen where we prepare some of our meals. However, vacation is not vacation if it did not include dining out as well. We are isolated but are within a 30 minute drive of multiple small quaint towns, each of which has multiple dining options.

Last night we exercised the option to indulge at a local Italian restaurant. It was really hopping with a full parking lot, a full bar of waiting patrons, and people spilling out into the parking lot. The wait staff was really hustling, clearing tables and seating customers as fast as possible. In watching this complex ballet of activity, it occurred to me what this reminded me of; my office. The parallels were striking. Most people had called ahead and had reservations (an appointment). The restaurant had a basic idea of the nature of their problem (they were hungry). In contrast to my office, the restaurant has an explicit and  defined menu of options and it is pretty much agreed upon that the customer selects from those menu options. We have a list of options which are opaque to my customers which I select to bill for after the fact. The more the patient has ordered, the more the items are discounted. This has all sorts of implications in terms of incentives to consume.

In each case there is a frantic pace to get people in an out. In both cases, the rooms (in MD offices) and tables (in restaurants) are where revenue is generated.  As long as we are financially locked into the short order model of ambulatory care, we will be stuck with the short order health care delivery system. The restaurant industry has certain advantages. The restaurant model has take out, a concept that perhaps the health care industry can create.  The restaurant industry has long recognized that they deliver both what clients need and what they want. People need food but they can want much more. Their needs can be satisfied by the most basic foods but their wants can be virtually infinite and the restaurant industry responds to this by offering a mix of offerings, ranging from the most basic fast food to the most indulgent (and pricey) experiences.

Retail medicine is responding, albeit slowly. Regulatory barriers and legacy payment arrangements have served as brakes on real innovation. Acute ambulatory clinics have moved to a menu driven service model. Patients seem to accept that if it is not on the menu, they will not ask for it. There will always be a few people, like those who want to order a hamburger at Taco Bell, who will be indignant. Concierge practices try to make explicit the difference between what patients need and what they want. These efforts are in their infancy. There is much more to come and the pressures to develop models which create clear distinctions between needs and wants will become acute as the payment from insurance (both public and private) will become more and more focused on paying only for needs, not wants.

We should be view this as both as threat and an opportunity to escape the medical short order delivery model.