Sunday, August 18, 2019

Should Doctors Offer a Money Back Guarantee?

It may seem odd that a gastroenterologist patronizes fast food establishments several times each week.  I’m in one right now as I write this.  I eschew the food items –though French fries will forever tempt me – and opt for a large sized beverage.  In truth, I am not primarily there for a thirst quenching experience, but more to ‘rent a table’ so I can bury myself in some reading.  Indeed, many thousands of New York Times issues have been devoured at these tables.  I saw a sign posted on the wall here that I had not seen before.

Sorry, No Refunds

Refunds?  How often can this happen in a place like this?  We all know that food items in these institutions are remarkably consistent, which is one of benefits that customers enjoy.  Your Big Mac or Whopper will taste the same in Pittsburgh as it does in Peoria.  I questioned the server on this new development and she explained that increasingly customers were demanding refunds for contrived reasons in an effort to bilk the restaurant.  At some point, the restaurant decided to put an end to this practice. 

Refund Free Zone!

I wonder how my patients would react to being greeted by such a sign in my office?  Of course, physicians do not offer refunds or a money back guarantee for our services, as other industries boast.  Nearly every infomercial includes the tag, “and if you don’t agree that these _____  are the best you’ve ever used, simply return it for a full refund – no questions asked!”  Not so in the medical profession.   We are paid regardless of the outcome or your satisfaction.  It is true that physician reimbursement policy is evolving away from fee-for-service (FFS) toward a value-based system.  In other words, physicians won’t be paid separately for every medical service we provide you, but for the overall ‘value’ we provide, which is a somewhat amorphous concept.  FFS clearly incentivizes the medical profession to overtreat patients because we are paid more for doing more, even if such care may not be truly necessary.   It remains to be seen if the value-based payment approach will protect patients and be fair to physicians. I have my doubts.

Many professionals are paid regardless of how their clients fare.  It you lose your case in court, your lawyer will still be paid.  If a judge is overruled on appeal, his wages aren’t reduced.  If your investment underperforms, your financial planner doesn’t return his fee to you.  Tradesmen, on the other hand, make a commitment to satisfy us as a condition for getting paid.  If we hire a plumber to unclog a sink, for example, he understands that if he doesn’t deliver, then we won’t either. 

What if all of us were paid on results rather than on time expended?  Would this lead to higher quality goods and services?  Could it really apply to the medical profession?  If a patient comes to see me with abdominal pain, which often defies explanation even after a thorough medical evaluation, is it fair that I wouldn’t be paid if the patient’s pain persists?

None of this applies to Whistleblower readers.  These posts are free so don't ask me for refund.  


  1. Erik Nuveen, MD, DMDAugust 25, 2019 at 3:39 AM

    In the field of Cosmetic Surgery, we have been essentially forced to offer a guarantee of satisfaction for our entire careers. It has been an interesting journey indeed! Any patient who does not receive ideal outcomes has grounds for requesting a refund, without exception. All patient know that if we do not provide said refund, we will be sued and we will lose far greater than the value of the refund in defending ourselves and in reputation destruction that is so endemic to the anonymous public on-line. The idea of arguing, debating a refund request or discussing it with a patient is long since dead and not an option in today’s society. Some might call it daylight robbery. There are some patients that are very well versed at googling “How to get your money back from a plastic surgeon” and they follow the outline to a T. As the physician, the only options we have at this point are to try very hard to identify the grifter before they strike or go back to reconstructive surgery altogether.

  2. Frederick M Pevow, MDAugust 26, 2019 at 8:47 PM

    One of my funniest experiences was with a patient's father who called himself, Dr. Money.
    Little Money had chronic serous otitis media with significant hearing loss and obstructive tonsil and adenoid hypertrophy. The admitting clerk wanted to know if she should give Dr.Money a professional discount but I think Dr. Money was a doctor of bulldozer repair and was quite pleasant but different. He had a pet lion that roared and caused complaints from neighbors. He insisted on some type of guarantee so I offered 90 days on parts and 30 days on labor. He was quite pleased and Little Money had uneventful surgery with a return of normal hearing and better school grades. I roar everytime I think of Dr. Money.

  3. I've often said, that if alternative cancer treatments are prohibited, then approved conventional cancer therapy should come with a money-back guarantee.
    When Duke got in trouble for fraud in their cancer research under Dr. Potti they claimed that none of the patients in their study were harmed, even though they all died, because they received the standard of care in cancer treatment. Bizarre indeed! So, if death is the expected outcome, then it seems unconscionable to prohibit alternatives.

  4. Before I retired from my practice, I always offered a money back guarantee if the patient or parent of a child patient was unhappy with my care. When teaching students, residents, and fellows, I exhorted them to avoid taking money from dissatisfied patients. I offered the refunds to the payor, be it an insurance company, governmental payor, responsible party, or the payor of the co-pay and did not keep any portion of the fee. This served me very well. No payor ever complained about receiving the refund but a number of patients returned the refund to me after thinking about their dissatisfaction and deciding they were wrong. The results were that relatively few patients took advantage of the offer, many continued their care with me, and those few who accepted the refunds were free to seek care elsewhere without financial penalty or hardship. Also, there were no malpractice actions ever filed and only two records requests from plaintiffs’ attorneys without further action in over forty years of practice.

  5. I like Dr. JBN's idea a lot. As the attorneys point out, 'It is always about the money'. The only downside I can see, is if it becomes like cosmetic surgery, as Dr. Nuveen indicated. At that point, I guess it will be like the farmer who won the lottery, and when interviewed about what he was going to do with all that money, replied, "Well now I can continue to farm until the money runs out"

  6. This raises tricky issues. If surgeons, for example, are only paid (or paid more) for favorable outcomes, then we can expect that they will avoid riskier cases. Who wins here?

  7. Which is Exactly what will happen when CMS starts bundling level 2-4 visits into one code. Zero incentive to take complex cases.

  8. I had thought, Greg, that CMS was putting this plan on hold, but you might know better.