Should Health Systems Adopt a Money-Back Guarantee? At least one health organization, Geisinger Health System, is taking the lead in launching a money-back guarantee for unhappy patients in the form of rebates. Patient complaints that are backed by the guarantee are not necessarily tied directly to patient care. Rather, they are more service-oriented. Are these rebates a good idea for healthcare? Will other health clinics and doctors follow Geisinger's lead? If people once considered physicians to be God-like, Should Dissatisfied Patients Get Their Money Back? ethicist Art Caplan, PhD, explored this topic, asking whether patient rebates are a good idea. He cited Geisinger Health System's recent decision to offer money-back guarantees when patients are not happy with a healthcare provider's service. Such rebates would not be connected to the quality of care that patients had received, but rather to such amenities as office wait times and level of communication with staff members. Although Caplan applauded efforts to measure patient satisfaction, he also asked whether programs such as Geisinger's divert patients to focus more on the frosting (eg, service amenities) than on the cake (ie, whether they received good medical care). Caplan's commentary generated a torrent of critical comments from practicing physicians and other healthcare providers. One family doctor says that such practices are ushering in an era of "Neverland medicine." "If we allow gimmicks...to be the norm, it will surely put an end to medicine as we know it," he writes, asking: "Do we want our profession to be a 30-minute infomercial, or one based on science and founded on the principles of caring, but also on reality?" Other Professions Don't Give Rebates A psychiatrist wonders why should physicians be required to offer rebates when most companies in other fields don't have to do so. "Do home builders do this, or mechanics?" he asks. He also distinguishes between the words "patient" and "customer" ("They're not customers," he notes, "and we are not selling turnips or screws"). State medical boards and malpractice suits are avenues for patient complaints, he writes, as are the proliferating number of online consumer rating sites. "There are a hundred professional review sites where narcissistic, antisocial, and borderline patients (not to mention competing professionals and stalkers) may vent their unhappiness," he states. Like several other commentators, the psychiatrist proposes a system in which difficult patients could be charged more for the extra work they require from their healthcare providers. "If a patient sees us once and we bill once, but the patient calls us between visits, leaves forms for us to fill out, calls again, messages us, drops in unscheduled, makes a scene in the waiting room, brings hundreds of pages of documents for our review, and harasses us and our staff, then we should be able to charge them whatever amount of time and trouble they caused us...." He ends with the fiery statement, "The day the money-back guarantee arrives will be the day I start selling turnips." Rebates Equal Burnout An emergency department doctor finds the idea to be "well-meaning but horrible," and believes that it will increase physician burnout. "Clearly," she writes, "this was designed by someone who has never set foot in the trenches and seen doctors and nurses verbally and even physically abused by patients and their families for things that were completely out of our control." Citing studies that have linked patient satisfaction with increased mortality and morbidity, she adds, "Unlike virtually every other specialty, we do not have the right to refuse service to drunks, drug addicts, and patients with personality disorders and psychiatric disorders... Throw in refunds if they are not happy because they didn't receive narcotics or antibiotics?" An ophthalmologist emphasizes the fact that excellent care may not always be palatable to the patient. "Sometimes doing what is right, saying the truth, and good care involve saying things and doing things that may not create 'satisfaction.' Shooting for satisfaction can result in doing some pretty stupid things, such as overtreatment with narcotics [and] mollifying patients with temporary fixes that only delay a satisfactory treatment...." Furthermore, he adds, offering refunds can be construed as admission of malpractice and other error. In the end, he says, the market will decide. "The patient may go elsewhere if something doesn't click, and a physician may discharge a patient for similar reasons. This is the essence of capitalism and competition." An emergency department doctor agrees, outlining some possible scenarios for his workplace. "You're welcome for saving your life. Oh, you didn't want to live and therefore you're dissatisfied and don't want to pay?" he writes, as well as "You're welcome for the antibiotics I just gave you for your abscessed tooth. Oh, you didn't want antibiotics, you wanted OxyContin®?" One family physician notes the importance of distinguishing between satisfaction and quality metrics, writing, "Quality is not cost or satisfaction. It is based solely on the outcomes data that we hold critical to the practice of medicine." Is a Patient Merely a Customer? A pediatrician agrees that "Patients are not customers. They are individuals with a health problem seeking help to get well. Teaching them and providing them with the tools to manage their health or disease process is the physician's role. Confusing that with the retail experience is a disservice to both parties. It ignores the therapeutic relationship that is a part of the healing process. And it ignores the reality of medicine. People are not merchandise, and their health does not have a warranty." An internist predicts that Geisinger will regret adopting this system. "Most patients will have difficulty differentiating their dissatisfaction. To them, there is not much difference between 'I hated your food' and 'I hated the doctor,' and 'I didn't like the advice the doctor gave me....' I am a firm believer in efficiency and in not keeping people waiting for no good reason, always being courteous, always taking the time to explain our care plan, shared decision-making, and other aspects of care that respect the patient and show good manners. However, the money-back guarantee goes too far." Apologizing for a Dysfunctional Healthcare System Writes a psychiatrist, "This seems like a slippery slope.... I have occasionally not charged a patient for their appointment when I have been running excessively late. But my focus is on treating all of my patients with respect and compassion, not on how to make it up to them if I don't, or am working in a dysfunctional system that makes it impossible to do so, as is so often the case these days." Several comments focus on the fact that offering rebates will only result in a minority of people generating most of the complaints. A few commenters also concede that physicians should aim to improve service. One gastroenterologist writes, "As healthcare-givers, we should be aware of what constitutes a quality service, and when we fall short of that, take preemptive measures and communicate this to clients—for instance, when a clinic is running late, we could prewarn everyone that we are running late..." Many readers suspect that the idea came from a nonphysician manager or "bean counter." As one retired family doctor writes, "The patient-centered home is being turned into the patient-centered day care, in which the aggravating nonessentials are assuming precedence.... I am aghast and only happier and happier to be retired!" she says. Such practices essentially reduce professionals to mere service providers, despite years of difficult training and hard work. Says a urologist, "I did not work up to 126 hours per week in residency and do one in two urology calls for 24 years to the point of sleep deprivation in order to become obsequious. If my clinic is running late, maybe I could offer to wash and wax my patients' cars?" Clearly, this topic is sensitive, as physicians chafe at some of the mandates of value-based medicine. As more practices turn to the concierge or cash-only business model, patients' perceived level of service promises to become increasingly important in the future. Such metrics as quality of communication and length of wait in the office can easily be monitored and improved. However, as the professionals who are actually treating patients remind us all, these perceptions should always be subordinate to excellence of care and outcome. As one registered nurse commented, "The concept of satisfaction is a subjective measurement and does not reflect reality. Healthcare service is not a latte, and medicine is not black and white.... Even with patient-centered care, you can't satisfy everyone with an optimal budget." Source
