Pay clinicians by the hour, not the script

Of all the operational choices a clinical business makes, the most consequential one is rarely discussed publicly: how the clinicians get paid.

There are roughly two ways to do it in Australian telehealth:

1. Per-script. The clinician’s pay scales directly with their throughput. More appointments, more scripts written, more money. This is the model that built the boom of low-cost telehealth in 2020–2023.
2. Per-consult with time minimums. The clinician is paid for their time, not their output. They are paid the same whether they decline to prescribe or write the script.

We chose the second model. It costs us materially more per consult than the first model would. We’re public about it because the implications go beyond economics.

What the incentives actually look like

Imagine a clinician 30 minutes into a 6-hour shift, with a patient on the other end of the consult asking for a script. The clinical case for prescribing is somewhere between “borderline” and “reasonable but I’d want more information.” The clinician has three options:

• Prescribe. Fast. Patient is happy. Income units accumulated.
• Decline. Slower. Patient may be unhappy. No income unit. Possibly a complaint.
• Order tests / book a follow-up. Slower still. Less revenue per hour. Possibly fewer total patients seen this shift.

Under a per-script model, every one of those decisions has a financial gradient. Under a per-hour model, the gradient is flat. The clinician is paid the same regardless of what they do clinically. The only signal they’re responding to is whether they think it’s right.

That’s the entire point.

The cases this affects

We’ve written before about why we decline to prescribe in a meaningful share of consults across our programs. The clinical reasons (untreated comorbidity, contraindications, patient goals that don’t match what the treatment does) are constant across the industry, but the rate at which they get acted on varies hugely depending on how clinicians are paid.

It’s the same dynamic across the medication landscape:

• A patient presenting where the indication is borderline and a careful workup is needed.
• A patient asking for a repeat where the diagnosis has shifted.
• A patient wanting a procedural intervention where consent and counselling shouldn’t be rushed.

In each case, the clinically right thing takes longer than the prescription. If pay scales with prescription, the clinician carries the cost of doing the right thing personally. That’s a cruel system to put clinicians inside.

What we ARE optimising for

We’re often asked what we measure if not prescription rate. The honest answer:

• Clinical outcomes at defined intervals across each program (e.g. continuation rates at 6 and 12 months, blood pressure control rates, condition-specific symptom scores).
• Complaint rate per 10,000 consults. We watch this monthly.
• Patient continuity (whether patients return for a planned second appointment, which we’ve found to be the strongest single predictor of outcome).
• Clinician retention. Burnout is a clinical-safety issue. A burned-out clinician is a worse clinician.

These metrics don’t go up when a clinician writes more scripts. They go up when a clinician makes good decisions over time.

The cost we accept

The honest trade-off: a per-hour model produces lower revenue per clinician hour than a per-script model. Across a year, that’s hundreds of thousands of dollars we don’t earn. We’ve concluded it’s a fair price for a clinical model we’re comfortable with.

Some patients are unhappy that we sometimes decline to prescribe what they expected. Many more come back two years later, often after a worse outcome elsewhere, and say “I wish I’d listened the first time.” Both feedback streams matter. Neither would change our payment model.

The signal patients should look for

If you’re choosing between two online clinics, the question to ask, directly, is: “How are your clinicians paid?”

If the answer is “per script,” that’s information about how clinical decisions are likely to go inside that business. If the answer is “per hour” or “per consult,” that’s a different signal. Neither is automatically right or wrong for every business. But it’s the signal worth asking about.