ZDoggMD on Fee-for-Service: Why Volume-Based Medicine Is Destroying the Profession

Fee-for-service medicine is the water physicians swim in, so invisible it often goes unquestioned. ZDoggMD — Dr. Zubin Damania — has questioned it directly, forcefully, and for years. His argument: the volume-based payment model is one of the foundational structural problems in American healthcare, and it's making physicians miserable while delivering worse care.

What Fee-for-Service Actually Does

In a fee-for-service system, physicians and healthcare systems get paid for each service delivered — each visit, each procedure, each test ordered. More services, more revenue. The financial incentive is volume.

ZDoggMD's critique, drawn directly from his Health 3.0 framework : this creates an incentive to do things to patients rather than for them. It rewards quantity of encounters over quality of outcomes. It penalizes time spent — talking with a patient for 40 minutes about lifestyle changes that would eliminate their need for three medications isn't more reimbursable than three separate prescription renewals.

In Health 1.0 terms, the model created the solo-practice physician who was autonomous but also operating under financial pressures that incentivized overtreatment. In Health 2.0, the same incentive structure got applied at scale by corporate health systems — maximizing throughput, compressing visit times, measuring physician productivity in RVUs (relative value units) generated per hour.

How This Becomes a Burnout Problem

When your value to the organization is measured in RVUs per hour, time becomes the enemy of care quality. Every minute spent on anything other than billable service is a minute of lost productivity. The physician who takes an extra 10 minutes to have a difficult conversation with a patient about prognosis — that physician is, in RVU terms, underperforming.

This creates moral injury at the structural level. You know what good care looks like. Good care is slower. Good care involves listening, not just documenting. Good care sometimes means ordering fewer tests and spending more time explaining. But the system rewards the opposite, and every physician working in a production-oriented practice feels this conflict daily.

ZDoggMD argues that until the fundamental payment model shifts from volume to value — paying for outcomes rather than services — the moral injury built into physician practice cannot be fully addressed. The structural incentive is wrong, and all the wellness programs in the world won't fix a wrong incentive structure.

What Physicians Can Do Right Now

System-level payment reform is slow. Physicians can't wait for Congress to fix fee-for-service while their careers erode. The options available now:

  • Direct primary care — removes insurance as intermediary, eliminates the fee-for-service billing cycle for primary care, creates space for longer appointments and actual relationship-based medicine
  • Concierge medicine — retainer-based model with smaller panels and more time per patient; same logic as DPC with different market positioning
  • Negotiate for non-RVU time — some employed physicians have successfully negotiated for administrative time, teaching time, or patient communication time that doesn't show up as RVUs
  • Reduce the documentation overhead — in a volume-based practice, the time you don't spend charting is time you get back; ambient AI documentation that handles notes in real time is the fastest available lever on this

    • ZDoggMD's Health 3.0 manifesto:

    Take Back the Time the System Steals

    You can't change fee-for-service today. You can eliminate midnight documentation today. NoPajamaTime: notes done during the encounter, before the patient leaves.