No Refund Without Receipt

"As medicine goes, so goes dentistry." Most dentists believe this old saying to be true. Medicine introduced us to insurance, group practices and managed care, among other enlightened things. As a result, for better or worse, we've come to look to it for guidance in accepting new protocols. Dentistry's main claim to pioneering was when OSHA and "60 Minutes" singled us out as potential generators of a host of bad things. For this assumption, medicine willingly relinquished the lead.

Normally, though, it's kind of like playing "crack the whip" when we were kids. Whether perched on roller skates or ice skates, or just being a dentist, the position at the tail end of the activity is not the most stable place to be. While we owe a certain amount of gratitude to our fellow health professionals for pioneering third-party participation in our affairs, the latest inspiration to spring from the fertile minds of a certain medical faction is perhaps more than we countenanced.

We speak of PR, not the abbreviation for public relations or product recall, but for Patient Refund. Money-back guarantees are such a proven strategy in business that proponents of this concept argue that medicine's transformation into a bona fide business qualifies it for the same consideration.

Lord have mercy on us all! Who are these people questioning the sacred concept that the doctor gets paid no matter what? Well, Pogo was right, we have met the enemy and he is us. At the head of the "crack the whip" line is one of the nation's top fertility clinics, which began offering patients a partial refund if they didn't get pregnant. This is money we're talking about refunding, not eggs or sperm. Some urology groups are giving refunds to men whose vasectomy reversals didn't pan out. We assume that a refund for a vasectomy that didn't work in the first place would be more than just an apologetic, "Sorry, Dad."

Kaiser Permanente's Northern California Region is offering up to $25 of co-payment to members if they're not satisfied with their doctor visit.

Patient: "I'm not satisfied with my doctor visit."

Kaiser: "Whoa! Why not?"

Patient: "He kept me waiting two hours."

Kaiser: "That all?"

Patient: "No. He didn't even say he was sorry."

Kaiser: "We're sorry."

Patient: "Too late, I want my $25. Now."

Our ancient contention that "We're dealing with human tissue here, so no guarantee is given or implied" may be in for some modification if this contingency fee thing catches on. A patient says three months after his prophy, "Hey, my tartar has come back."

Us: "Well, this is human tissue we're dealing with here, you know."

Patient: "So?"

Us: "Righto, just so you know. Here's your refund."

It has long been our policy with full denture cases that at the first sign of dissatisfaction, a full refund is given immediately. This prevents being shotgun-married to a predictably doomed partnership destined for a nasty divorce later on. The expansion of this anti-ulcer/nervous breakdown policy to all other disciplines of dentistry, however, is a sobering notion.

Dr. Geoffrey Sher, executive director of the Pacific Fertility Center, a proponent of the contingency fee idea, says, "The message we are sending people is very simple: We are so confident we can deliver, we can share the risk with you." Of course the risk he's talking about involves pregnancy, a pretty much black-and-white issue. You're either pregnant or you're not. Doesn't work that way with bridges, for example. At least for the doctor, there are about 10 criteria for a successful effort, with lots of uncertainty and gray areas. The patient may have only one criteria -- he either likes it or he doesn't.

Dr. Drew Altman, president of the Kaiser Family Foundation of Menlo Park, Calif., says, "I'm very much afraid of this. I hope it doesn't spread. I mean, what are we going to do next, offer consumers a set of free steak knives or pots and pans for their business?" We know what he means; we've already offered them unlimited use of the magazines and restrooms. Where will it all stop?

Critics view the trend as "over-the-top commercialism." Dr. Robert M. Tenery Jr., a Dallas ophthalmologist and member of the AMA's Council on Ethics and Judicial Affairs, states, "Doctors do the very best they can, and what happens after that is beyond their control." Not so sure is medical ethicist David Thomasma of Chicago's Loyola University. He says if medical professionals are serious about providing quality health care, they should be equally serious about providing a refund for not meeting expectations.

Dr. Sher adds, "I am completely willing to crusade this issue. I believe it's better for the patients. And I'm not alone. The minute the guard is dropped a little, others will come out of the shadows."

By "others" I have a sinking feeling he might be including the dental profession, those of us on the tail end of the whip. Are we going to have to post signs stating hypocritically, "Refunds cheerfully given"? Or "No refunds without a sales receipt"? Maybe "This office guarantees its work. If you are dissatisfied for any reason, return your filling in its original container and your decay will be refunded in full, no questions asked." I am reminded of that old Broadway hit, "Stop the World, I Want to Get Off!"

Who are these people questioning the sacred concept that the doctor gets paid no matter what?

We've already offered patients unlimited use of the magazines and restrooms. Where will it all stop?