Should Patients Get a Money-Back Guarantee?

Alicia Ault

July 25, 2016

It sounds like a pitch from one of those late-night infomercials: satisfaction guaranteed or your money back! But it's no joke. It is a promise from one of the nation's pioneering health systems, Geisinger.

So far, the Danville, Pennsylvania-based nonprofit integrated health services organization has refunded at least $100,000 to some 100 patients who were unhappy with the service or care they received. The refunds have covered a gamut of complaints — from long waits in the emergency department to unappetizing hospital meals to disagreements with physicians over care plans.

A refund is a radical idea in healthcare, so radical that a handful of major health plans preferred not to comment on Geisinger's program or conceded, off-the-record, to a faintness of heart due to legal and other concerns.

"It's basically kind of a nutty idea," said Daniel Callahan, cofounder and president emeritus of the Hastings Center, a nonpartisan bioethics research institute. "It has the potential for being a pretty messy business all around," he told Medscape Medical News.

Geisinger Chief Executive Officer David T. Feinberg, MD, said that when he first began discussing the refund notion with peers, they were dubious. Almost 9 months into the program, called ProvenExperience, "They think we're nuts, still," Dr Feinberg told Medscape Medical News.

He is undaunted. "Our industry is ripe for disruption," said Dr Feinberg, adding that Geisinger is "confident [the refund] will be disruptive." He wants to upend a system that he views as too provider centered. He notes that, just as in retail, healthcare consumers have increasingly more choice. And those consumers are shouldering more costs, giving them a reason to be choosier about where they spend their dollars, said Dr Feinberg.

To him, that boils down to creating a model in which the customer is always satisfied. Dr Feinberg often cites Starbucks as an inspiration. If you don't like your latte, the barista will make it again, no questions asked. Starbucks, however, is not in the business of giving customers money back.

Dr Feinberg is certain Gesinger won't be opening its wallet too often. "It's not going to cost us a lot of money," he said. "When you give a warranty or guarantee, you can either do it because you're really good and you're not going to have to give anything back, or you have a really bad product."

In Geisinger's case, the money-back guarantee is a show of confidence, said Dr Feinberg.

It also shows the community that Geisinger is serious, Trissa Torres, MD, MSPH, FACPM, senior vice president at the Institute for Healthcare Improvement (IHI), told Medscape Medical News. The refund "sends a very public signal about really putting patients at the center of care," she said.

And, she notes, healthcare has borrowed from the business world before —adopting quality improvement methods from the auto industry, for instance. Although "there are things we can learn from the for-profit business world," Dr Torres said, "they are different." Good healthcare "is not all about the money, it's about the health outcomes," she said.

Real-time Response

Starbucks remakes a latte on the spot. A physician can't reperform a surgery the same day, but staff can try to make up for mistakes immediately — by handing out vouchers for transportation or meals, for instance, said Greg F. Burke, MD, Geisinger's chief patient experience officer, who is also a practicing internist at the health system.

Patients also get their money back quickly after a complaint has been filed and evaluated. ProvenExperience was tested, minimally, by patients undergoing spinal surgery. If for any reason the surgery patients weren't pleased, they could log onto an app specially built for the program. Once there, they'd log a complaint and select, from a sliding scale of $1 to the amount of their copay, how much of the copay they wanted to have refunded. The request was processed in 3 to 5 business days.

In November 2015, Dr Feinberg announced that ProvenExperience would be expanded to cover anyone and anything having to do with Geisinger, which spans 30,000 employees (including 1600 employed physicians), 12 hospitals, two research centers, and a health plan that serves 510,000 members. The Geisinger system serves three million residents of Pennsylvania and southern New Jersey.

The refund only applies to copays and deductibles, however.

So far, the top complaints have been for the following:

  • long waits, especially in the emergency department

  • lack of communication with the care team

  • not being happy with the care plan (they wanted something else than what was administered)

  • care environment (noise)

  • concerns about food (delivery time and taste)

  • financial issues, including charges and copays

Patients almost never ask for a full refund, which is keeping costs low, said Dr Feinberg. "It's not unusual to see a refund request of $150," he said.

Geisinger verifies that the patient actually spent the money before issuing a refund. It appears on the patient's bill as a "patient experience adjustment," said Dr Feinberg.

A Touchy Area for Physicians

In many cases, patients complain about physicians by name — and those physicians will hear about it directly from Geisinger. That's not particularly new at the health system, since patients already rate their physicians by awarding them one to five stars, which are posted on the physician's bio page.

The ProvenExperience comments — positive or negative ― are an added layer of feedback, Dr Burke told Medscape Medical News. The comments can be made anonymously, or the patient can identify himself or herself.

Geisinger physicians have received training in how to deliver patient-centered service, and they have been given scripts on how to introduce the idea that patients can ask for a refund.

But the whole process "wasn’t really vetted" with Geisinger staff or physicians before Dr Feinberg announced the rollout, said Dr Burke, who ended up presenting the refund program to a number of Geisinger's physician groups.

"Many of them got the basic premise of this being the right thing to do from an ethical standpoint," Dr Burke said. But physicians had numerous concerns, including whether the refund would turn medicine into a commodity.

The most common worry was that patients would take advantage of physicians. Dr Burke found that notion somewhat distasteful. Physicians ask patients to trust them, he said. "It would be the height of hypocrisy to say back to patients that we don't trust you," said Dr Burke. "If they say they had a bad experience, they had a bad experience."

Since ProvenExperience started, "it's like we've turned the faucet on," said Dr Burke, noting that Geisinger has had a flood of complaints. That means going back to the physicians, or nurses, or pharmacists, or maintenance staff, or greeters, or reception, discussing the complaint with them, and figuring out a way to do better.

In one recent instance, a family complained about a surgeon's poor communication skills. They said the surgeon was not available for follow-up and that they did not feel respected. Dr Burke brought the family together with the surgeon, and they spent an hour hashing things out. Later, Dr Burke met with the surgeon's superior to discuss his history with patients and ended up suggesting counseling for the surgeon.

The refund requests can be mindboggling. Dr Burke said he had had a request for a refund for a service provided 22 years ago. One patient wanted a refund before a procedure was performed, and another wanted money back because the doctor yawned during the visit.

That's the messy end of the guarantee, said Callahan, of the Hastings Center. Some patients "are going to be cranky people no matter what you do for them," he said. And, he cautioned, "you can be sure, knowing human nature, that some people probably would try to take advantage" of the refund offer.

The challenge is to determine which complaints "are threats to health vs threats to somebody's delicate psyche," said Callahan.

Dr Burke acknowledges the challenge. He said he works closely with Geisinger's patient advocates and risk management staff to determine which complaints can be addressed through a refund and which fall into the medicolegal bucket.

Opening the Door to Litigation?

Geisinger's chief sees the money-back guarantee program as an antidote to litigious patients.

"We're not admitting that we made an error," said Dr Feinberg. "What we're saying is, we understand your perception, and we apologize." Patients are appreciative — and less likely to pursue the matter further, he said.

"When the patient doesn't feel they were listened to, they go the litigation route," agreed Priscilla Keith, counsel for Community Health Network Inc, in Indianapolis, Indiana. She said that when patients feel like they've been heard, "it benefits all parties," and it also tends to increase satisfaction scores.

Taking the time to listen and responding quickly or positively "builds a trust," Keith told Medscape Medical News.

"The more confidence and trust, and the better experience the patient has with the provider and the organization, the less likely they are to sue," agreed Dr Torres of the IHI.

Will Proven Experience Drive Change?

Just having a refund won't necessarily improve the quality of care or patient satisfaction, said Dr Torres.

The key will be "how they take this information [from the patients] and use it to drive system change, to drive improvements that would be realized by any patient that comes along," she said.

Geisinger is doing just that, said Dr Burke ― measuring and tracking the complaints, feeding information back to staff, from housekeepers to nursing assistants, physicians to cafeteria workers ― and working to truly have a more patient-centered system.

Callahan said it will be interesting to see whether, in a few years, Geisinger's patients are more satisfied and whether the staff has changed its behavior in a measurable way. For now, it's not clear whether the refund is experimental or a long-term commitment, he said. Geisinger's administrators "may not know themselves," said Callahan.

So far, no other health systems have followed in Geisginer's footsteps. "I'm not surprised," said Dr Torres. Bottom-line pressures mean "that any financial risk is really difficult to take," she said. "But if Geisinger is able to demonstrate how they benefited, others may come along and adopt it," she said.

Dr Feinberg envisions only success. "Maybe in a few years everyone else will be doing it and it's normal," he said.

Dr Feinberg and Dr Burke are employees of Geisinger Health System. Dr Callahan and Dr Torres have disclosed no relevant financial relationships.

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