Medical Ethics Corner: Lattes & Health Care

health-care-coffeeBy: Dr. Brent Schillinger, Guest Contributor

If you’re not satisfied with your medical care at the Pennsylvania based Geisinger Health System you now have a recourse not often found in traditional medical practice. You can ask for a refund.  And thanks to technology you can conduct the entire transaction through an app on your smartphone and the money will come back to you in three to five business days.

This novel step in the world of medical practice is perhaps the latest consequence of the corporatization of medicine and the transition of patients into consumers.  In fact in numerous published articles, Geisinger CEO Dr. David Feinberg repeatedly suggests that delivering medical care is not very different from buying a coffee at Starbucks.  “If you don’t like the cappuccino, they don’t sip it and say, ‘We made it right, we’re not giving you a new one,’” was Feinberg’s quip in a recent edition of Healthcare IT News in defense of his refund policy, which started as a pilot in November of 2015 and now is in full swing.

This concept of promising to patients (or shall we just say consumers of healthcare) a money back guarantee does not sit well with most seasoned physicians.  It raises a number of philosophical issues as well as a host of ethical and legal scenarios that are in conflict with the traditional practice of medicine.

As physicians we are obligated to do the right thing.  We can only guarantee to do our best.  We cannot make guarantees about events and processes that are completely out of our control.  We charge for our professional opinion.  We charge for our services.  Opinion and services are separate from results.  We don’t charge for results.  Imagine a “consumer” coming into your office and directly asking to have his or her gall bladder removed and asserting that “doc if you don’t do a good job I want my money back.”  Or how about a seriously ill patient discharged after a three-week course in the ICU for sepsis and multi-organ failure, “No problem, we want you to be happy with every part of your ICU experience. If the food wasn’t what you expected we will refund your money, no questions asked.”

If you take a closer look at how the Geisinger policy actually works, in fact they do not guarantee to give back all the money they have collected, only your co-pays and/or deductible.  In other words whatever dollars the insurance has paid, that they will retain.  Any healthcare attorney will tell you this sounds a lot like insurance fraud.  A full refund would involve sending all monies back to the insurance company as well as.  Gesinger I presume has some clever way of listing this refund as a patient courtesy adjustment, which doesn’t necessarily make the transaction kosher.  This would never pass muster in the world of private physician practice.  Medicare in particular would threaten to sanction you immediately especially if you were publicly advertising this money-back guarantee.

Perhaps we have the federal government to thank for the motivation behind this novel approach.  Under the Affordable Care Act, payments will be increasingly tied to the quality of services rather than quantity of service.  Geisinger wants to give the perception of higher quality by guaranteeing patient satisfaction.  We all know you can make the room pretty but we must question does the patient really know whether they received the best quality appropriate care?

Healthcare delivery is not the same as retail sales.  I would suggest that refunds are totally inappropriate when it comes to medical decisions or opinions.  In spite of my distaste for this novel approach, the idea seems to be catching on.  Officials at Geisinger are calling the program a big success.  The University of Utah Healthcare system is seriously considering a similar scheme.  The online newsletter from Advisory Board (an organization that consults globally with healthcare organizations to improve their bottom lines) takes it a step further suggesting that a “Starbucks style loyalty program can be used to incentivize patient loyalty.”  Interestingly enough Advisory Board cites JAMA as their literary research reference.

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