A large multi-state specialty practice with more than 150 locations ran 1.42 million outbound patient touches over the course of a year. Those touches produced 200,730 booked appointments and $40.1 million in revenue impact. The practice did not pay for the 1.42 million touches. It paid per appointment that actually landed on the schedule.
That last sentence is the whole argument. Hold onto it, because almost nothing else in health technology is priced that way, and I think that is about to change.

The Number That Should Change How You Read a Pricing Sheet

Start with what the $40.1 million is actually made of, because the composition matters more than the headline. Of that total, $33.1 million was pure recovery: 165,578 appointments that would have leaked out through cancellations, no-shows, and unfilled slots, recaptured by proactive AI outreach. The remaining $7.0 million was net-new revenue, 35,152 appointments from patients who were not on the schedule at all, surfaced by closing care gaps and reactivating lapsed patients. Cancel-fill alone converted 85,051 at-risk slots into $17.0 million in booked appointments.
These are not projected. They are booked appointments confirmed by the EHR. And the practice paid per booked appointment, which means its spend scaled exactly with the value it received, and not a dollar before. That is a fundamentally different transaction than the one most health tech still runs.

Why Most Health Tech Is Still Priced on Activity

Walk through almost any healthcare software contract and you find the same logic underneath it. The vendor gets paid for activity. Seats provisioned, calls placed, messages sent, reports generated. The invoice arrives whether or not a single patient reached the schedule.
This made sense in an earlier era, when software was a tool a team picked up and the value lived in the team using it. But it quietly hands all of the risk to the buyer. The practice pays up front, commits to a term, and then spends the next twelve months trying to prove internally that the spend was worth it. The vendor has already been paid for the activity, regardless of the outcome.
That is the part that should bother every operator. You are buying effort and hoping for results. The dashboard fills with numbers that feel like progress, calls attempted, texts delivered, tickets closed, and none of them connect cleanly to revenue. So when a COO or an operating partner asks "what does this cost?" they are rarely asking for a number. They are asking the more honest question underneath it: what am I on the hook for if this does not work? Activity pricing has only one truthful answer. You are on the hook for all of it.

The Objection Every Operator Should Raise

Here is where a sharp buyer pushes back, and they should. If you pay a vendor per booked appointment, aren't you just paying them to book appointments, good, bad, or pointless? Doesn't that incentivize double-booking, marginal visits, and tolerating no-shows? Value-based contracting in healthcare has a long and unflattering history of exactly these perverse incentives, so the skepticism is earned.
The answer is that the unit you pay on has to be the unit you actually want, and it has to be verified by a system you control, not self-reported by the vendor. In the case above, the appointments were confirmed by the practice's EHR, not counted by us. The outreach was governed by EHR-integrated campaign rules that match a specific patient to a specific outreach at a specific time, which is the opposite of spray-and-book. And the economics only work for both sides when the appointments are real: a no-show helps no one, which is why no-show rebooking is itself one of the paid outcomes rather than a loophole.
The discipline that protects the buyer is the same discipline that protects the model. If the metric you pay on can be gamed, you picked the wrong metric. A booked, EHR-confirmed, kept appointment is very hard to fake, and very easy to tie to revenue. That is why it works as the unit of exchange.

Why Risk-Sharing Wins in a Consolidating Market

I want to be careful not to overclaim. Plenty of activity-priced and subscription-priced software has built durable, valuable businesses, and will keep doing so. What is changing is not that activity pricing was always wrong. It is the conditions the market now operates in.
Private equity is consolidating specialty practices at a steady clip, and consolidation brings financial discipline. Operating partners read every line item across the portfolio against the P&L. They are not moved by activity dashboards, and they have very little patience for spend they cannot tie to revenue. Put a CFO-ready model in front of that kind of buyer, projected recovery, cost reduction, and a clear return, and the activity-priced vendor in the next meeting has nothing comparable to put on the table. They are selling effort to a room that only buys outcomes.
The same logic shows up on the inbound side. One top-20 national dermatology practice was converting just 51% of its inbound referrals, leaving roughly 3,400 already-referred patients a month off the schedule, around $6 million a year walking out the door. Not a marketing failure, a follow-through failure. A pay-for-performance vendor that gets paid only when those referrals convert is staring at the same number the operator is staring at, from the same side of the table.
That alignment is the real point. After three exits and twenty-five years in this industry, the pattern I keep coming back to is that markets do not turn when the messaging gets better. They turn when the proof accumulates. Pay-for-performance does not generate that proof on its own, the outcomes data does, but it is the clearest signal a vendor can send that it believes its own numbers: it agrees to be paid in them.
The operators who insist on that structure are going to spend less and capture more, because they stop paying for activity that may or may not convert and start paying only for the chair that got filled. That is a better deal for the practice. It happens to be a better business for the vendor too. Aligned incentives usually are.

Rick Scorzetti is Chief Commercial Officer at Parakeet Health, an AI-powered patient access platform for large specialty practices. Over 25 years in healthcare technology, he has helped build three companies to exit across life sciences, health tech, and patient experience. Connect with him on LinkedIn.