I never reached the status of the George Clooney character in the recent movie, 'Up in the Air,' but I fly enough to have advanced frequent flyer status, know that you don't get behind a family with a stroller in the security line, you never check bags, and you don't fly through O'Hare on the Wednesday before Thanksgiving.

A recent flight brought an encounter with one of the airlines 'fees' that seem to crop up now at every turn.Do these people hire creativity consultants to come up with new ways to charge us a little here, or a lot there?And do they think we can't add, that we really don't count the baggage fee or the price of the peanuts into the cost of our trip?

That got me thinking about the problems with their business model.

Simply, the operating costs of the airlines are higher than their revenue, thus the industry has been beset by losses for years.Cost cuts prove difficult given the high fixed and capital costs combined with labor costs that are protected by collective bargaining.Volatile fuel prices make it near impossible.

The answer? Well, raise prices, of course.

However, the market has proven as resistant to price hikes as my dog is to giving up her tennis ball.Discount carriers such as Southwest keep a lot of downward pressure on prices.

So what do you do?

Fees.Lots and lots of little fees. Bag check fees, on board snack fees, ticket change fees, headphone fees, fees for seats with marginally more leg room, fees for early boarding, fees to not have a screaming baby on your flight.OK, I made that last one up, but here's betting a lot of people might consider that one.

While I understand their financial reality, it is interesting to contemplate the effect of the fees on airlines relationship with their customers.It is not good.

Economic theory says the idea of fees makes sense.There is a cost to handle checked bags, so shouldn't those who check bags bear that cost?Burying that in the general price of the ticket penalizes people who just carry on.This logic holds with all of the other fees.There is a cost to change the ticket, a cost to provide the snacks, a cost even for providing the extra leg room.  Some would say this is exactly the way to price this service.

But customers, who complain about the service already, feel nickeled and dimed to death.They are not thinking about how their behavior drives incremental cost for the airlines.They wonder, given what they paid for the ticket, why they have to pay more to change their ticket?

Many argue this is the new reality of flying, so get used to it.Industry economics make this a necessity, and since almost every airline does it, there is no real downside in terms of customer relations.After all, where are the passengers going to go?

On a related note, I saw an interesting sign at the front desk of a practice I was visiting a few weeks ago.Actually, there were several signs.As someone in the revenue cycle management business, I was happy to see that co-pays and open balances were due at the time of service.But other signs, new signs, indicated there would be a rebilling fee if a second statement had to be sent, a fee would be added if you gave an invalid insurance card, a fee for appointments that were missed or not rescheduled in time, and a fee if you wanted to read a current magazine.Just kidding again on that one.

And the parallels to the airline industry flooded my mind immediately.

The economics are upside down and cost cutting is not going to save the day.There is no discount Southwest Airlines with low, low prices, or maybe there is with emerging retail clinics.But regardless, the buying power of the government and five gigantic payers mean that prices haven't moved up in a decade.In some cases, they have plummeted.

Physicians, particularly small practices, trying to find a way to make it all work begin to scrutinize costs and look at what drives their need for staff, the biggest cost item of the bunch.And logically they come to consider the alternative of fees.We have to charge for certain things that drive extra work.

Like the airlines, many physicians will lament the impact of not only fees, but also higher co-pays and deductibles on their relationships with their patients.They'll admit it is changing things for the worse, that it is all becoming more business and less personal.

But they have a right to make a fair living for the care they provide, right?If forced to choose between a little less patient satisfaction with the experience and a continual downshift in lifestyle, the fee approach might not seem so bad.

Part of the point here is to simply raise the issues about the fee strategy for physician practices.Many have already or will consider it.It can add revenue, but does come with a cost, even if intangible.

But there is a bigger point that I want to make as well.To do that, let's go back to the airlines.

If your business model is so flawed that most companies in the industry have lost money for most of the past decade, will charging for the second checked bag really solve the problem?

Many practices are like Southwest, routinely doing just fine in spite of market challenges.Good for you.

But more and more will have to face the reality that charging to copy charts is not going to fix what ails them.Overhead is too high, you are paying for too much space, you don't have enough patient volume, your physicians are just not producing enough, you're in the wrong part of town and your payer mix stinks, your billing and collections process leaks cash like a sieve, and you have so much manual processing that you have too many employees.You are not going to fix those problems by charging to copy a chart.If you want to survive, you have to do the hard work of fixing your business model.

Then you can afford to give everyone a bag of peanuts as a nice customer service gesture.