A money-back guarantee for hospital care

A goal of the program is to identify flaws in the health care system's processes.

Where: Geisinger Health System in Danville, Pa.

The issue: Improving satisfaction among patients discontent with their hospital stay.


In August 2015, a patient who had undergone spinal surgery at Geisinger Health System complained that he wasn't given an adequate explanation of his $1,000 insurance copayment for a recent surgery, said Jonathan Slotkin, MD, director of spinal surgery for Geisinger's Neurosciences Institute.

Initially, the patient simply wanted to convey his situation to Geisinger president and CEO David Feinberg, MD, MBA, who then instructed that he be refunded the $1,000. But by the time Dr. Slotkin met with his patient, the man said he didn't want any money back; he didn't care as much about the money as improving the situation for future patients. “I said, ‘We feel we should've done better. You should take the money back,’” Dr. Slotkin recounted. “By the time he left, he was going to take back $500 in a refund.”

This situation led Drs. Feinberg and Slotkin to think about doing this on a larger scale. “We were talking about that patient, and then the idea came out of that conversation about building an app to facilitate refunds and making it a formal program,” said Dr. Slotkin, who is also medical director of Geisinger in Motion, which develops mobile device technology as part of the health system's Division of Applied Research and Clinical Informatics.

How it works

The result, launched as a pilot in November 2015, is an app that allowed for the refunding of copayments on a sliding scale to patients undergoing bariatric or spinal surgery. It was initially offered to about a dozen patients, whom were chosen because they have larger copays: about $2,000 for bariatric surgery and $1,000 for spinal surgery. “We wanted the copayment to be large because we wanted the program to move the needle,” Dr. Slotkin said. “If we were talking about refunding a $5 copay for a visit, we didn't think that was going to wake up the institution and its associates to the importance of the project.”

The goal of the program is not only to satisfy patients by refunding their costs when they are displeased with their experience but also to identify flaws in the health system's care processes. “The key piece is the feedback we get from patients. We call anybody that uses this program to ask for a refund to ask where we went wrong. Then, we engage the service areas or disciplines where that issue took place, and we work to make it not happen again,” said Dr. Slotkin.


The pilot resulted in 1 bariatric surgery patient and 1 spinal surgery patient asking for full copayment refunds, Dr. Slotkin said. An additional spinal surgery patient asked for a partial refund of $150.

The bariatric surgery patient reported concerns about the environment of care, specifically construction noise, Dr. Slotkin said. The patient also mentioned a painful IV she felt wasn't addressed quickly enough, as well as some displeasure with the financial structuring of the copayment itself.

The patient who requested a partial refund cited food items that did not come quickly enough and the fact that Geisinger's finance office requested a partial down payment before the surgery. “For that patient, that $150 is symbolic. They're sending a message to the system that the overwhelming part of what they had done went well, but then the following issues were not great,” Dr. Slotkin said.

Since the program's launch, Geisinger's patient experience team has received more than 55 calls from patients inquiring about or asking for refunds. Because these patients were not part of the pilot, those requests were handled on a case-by-case basis, Dr. Slotkin said.

The refund program is focused on patients' subjective sense of their experience, and Geisinger was willing to give a refund to anyone in the pilot who asked for one, he said.

Program leaders aren't worried about whether patients will be dishonest. “What we felt was that our patients put their trust in us, so we should put our trust in our patients. We did not suspect there would be widespread misuse or dishonesty, and we have not seen that there's been. We felt that the loyalty it would engender in people would far outweigh any dishonesty,” Dr. Slotkin said.


For clinicians, having a patient ask for a refund could cause them to feel that they've done something wrong. “I personally ran into that being the guinea pig in the pilot,” said Dr. Slotkin. When a patient complains through the refund program, the physician is made aware, “but this is not a punitive program by any means, and very rarely do patients complain about their doctor or the care provided [to] them,” he said. Most times, dissatisfaction is related to incidentals such as lunch being delivered late or billing issues.

Others on the hospital staff are still leery of the program, he added. “Some providers, administrators, and staff members believe that this type of program is a financial mistake or risky, and what folks need to learn is that if we succeed in starting to extinguish these negative events and in growing more loyalty in our patients and their family members, then the benefits of that are going to far outweigh the small percentage on the margin of folks that are asking for refunds or partial refunds,” Dr. Slotkin said.

There is no concern at this point about how much money the refund program will cost, he said. Plans are to continue to evaluate the effects of the program as it moves forward. “And quite honestly, this is a great opportunity for Geisinger to see ProvenExperience [the refund program] as a ‘secret shopper’ program, allowing us to witness how the entire continuum of care affects the patient experience,” Dr. Slotkin said.

Technical challenges to the program include appropriately dispensing refunds and correcting the related systemic issues. “You need to have a process for making the refund occur quickly and reliably because the only thing worse than whatever went wrong in the patient's service is then also not even getting the refund correct,” Dr. Slotkin said. “And we need to make sure that we're building reliable backend processes to prevent whatever it is the patient points out from happening again because, if we keep duplicating the same mistakes, then this type of program is worthless.”

Next steps

Geisinger has rolled out the program to all areas of the health system and will soon make the app available to all inpatients and outpatients, not just bariatric and spinal surgery inpatients, Dr. Slotkin said. The goal is for the program to apply to every patient's copayment, coinsurance, and deductible, and the app has been changed to reflect this broader scope, he said. “Any of the patient's personal financial responsibility will be on the line anytime a patient interacts with the system,” Dr. Slotkin said. “And that's our skin in the game to commit all 30,000 Geisinger employees to excellent patient experience.”