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The F Word
What four-letter word instills fear and loathing in the hearts of all doctors? The answer: FREE.
By: Wendy Lewis
A patient comes in for a fat reducing treatment. She has done her homework and called around for the best pricing. Although your practice is highly recommended, the fee quoted by your receptionist for that treatment is somewhere at the high middle. However, she likes your office better than the three others she has gone to. “Doctor, I really want to come to you, but XYZ Medspa on the other side of town quoted me $500 less for the same thing…”
You basically have three choices. Tell her to go pound salt (not really, but we know you wish you could say that, and would rather not see it show up on Yelp). Explain that your fee is based on your extensive training and experience, years in practice, superior patient care, and outcomes, yada, yada, yada… Or give her a break and swear her to secrecy (which doesn’t work because patients always talk).
Do you ever do a free treatment and if so, in what situations?
Dr. J Bloom: I offer free treatments in several scenarios. The first being if the patient needs a “touch-up” or maybe some more product to make their treatment perfect. A patient may come back after their swelling resolves from an injectable procedure and if we are both in agreement about an asymmetry or maybe the product resorbed faster than expected, I will touch them up or treat them for no charge, in order to make the patient happy and looking great.
Every “new patient” in our office gets two no-charge underarm laser hair removal treatments, which is included in our “new patient packs.” Because it is a quick and easy treatment for our nurses, it gets patients excited and they are much more likely to have other areas treated while they are there, and continue with future treatments. Our feeling is that offering free “loss leader” treatments makes patients feel valued and excited to do more in our office.
The third case is what I call the “value added” scenario. For example, when I do facelift surgery, during routine post-op visits, patients will get their incisions lasered with a V-Beam PDL to reduce redness and get them looking their best, quicker. We include that service in the price of the facelift as a benefit to them for choosing us.
Dr. Niamtu: The word “free” can excite patients and depress doctors, but in my opinion and experience, sometimes free works for us. I always say that “Loss” is a four-letter word, but “Profit” is not. Medicine and surgery, like all other businesses, must be profitable to survive, which is a basic tenant of business.
The Golden Rule is to treat other people in the same manner as you would want to be treated, and it applies to all things in society, including business and medicine. So, can “free” work in our practices?
In any practice, you can have a patient who is not happy for various reasons. Some factors may be out of our control (biopsychosocial problems of the patient, normal surgical complications), and some may be within our control (rude staff, long wait times, failure to properly set expectations). “Free” can apply to both the problem patient that is unhappy and the best, nicest patient in your practice. Everyone, even wealthy people, appreciate a bargain or discount. If I have been injecting fillers and neuromodulators on a patient for 20 years and have done their facelift, eyelids, and laser and they have sent me numerous patients, it is great to do something free from time to time. Although it may cost me a few hundred dollars, it goes a long way for good will and to say thank you to this awesome patient. They have spent tens of thousands of dollars in my practice over the years and deserve it. I consider this “free” service or discount simply part of our marketing budget, not loss of income.
Although no doctor likes a haggling patient, what we do is expensive and not everyone can afford it. My fees are pretty much what they are, period. But, it was not always like that and many times I discounted procedures because I needed the business or experience. These cases certainly helped me hone my skills and spread my reputation. Even though I may have broken even or in rare cases lost money, they served an important purpose that pays off now. Sometimes I may have lost a facelift, because a patient also wanted eyelids but could not afford both. From a business stand point, I could receive 85 percent of something by discounting or 100 percent of nothing if the patient went somewhere else. Many of these patients were so grateful that they posted positive reviews and sent many friends. It helped them and it helped me.
I still discount or even do a procedure for free, but it is now almost always someone who has a hardship or a pro bono case. The latter is one of the most effective ways to become engrained in your local community.
Dr. B Bloom: I perform complimentary laser treatments for bruising if it occurs post-injection from dermal fillers or neurotoxin treatments I have performed. I will also perform a complimentary laser treatment for any of my Mohs surgery patients who I feel require it to get the best cosmetic result.
Dr. Ortiz: I don’t offer free treatments for patients who would like additional improvement. I try to avoid this situation by properly counseling the patient. The most important aspect of a cosmetic treatment is the consultation. I make it clear that one treatment may not be enough. I recommend a series of treatments to fix a problem. This way, if a problem is not fixed with one treatment, the patient expects to have additional treatments. Alternatively, if the problem is resolved in one treatment, then they are pleasantly surprised. This avoids the expectation that problems can be fixed with one treatment and also the need to offer free treatments. This must be explained at the time of consultation, or patients think that you are covering up for your mistake.
Treatments should not be free. Our time is valuable and a patient should not have the expectation that they deserve free treatments simply because they need additional treatments to correct the problem. If that is the case, then the patient was not adequately educated on the proper treatment course. I use language such as “soften” or “lighten.” I never state that a wrinkle or a spot will disappear. This sets proper expectations and hopefully avoids unhappy patients requesting free treatments.
Dr. Chilukuri: I never discount, but I am happy to give away free products or procedures that work synergistically to help a patient achieve his or her goal. For example, when I perform a nonsurgical lower lid lift, I often start with a combination of neuromodulator and filler. Typically, a patient will not achieve the best result without the neuromodulator, yet he or she will not notice enough of an improvement with the filler alone. In this case, I am happy to add the neuromodulator complimentary. In other cases, I want to improve skin texture along with the filler under the eyes. I may add a complimentary chemical peel after I have addressed the volume loss and dynamic rhytids. Another example would be to introduce the patient to a procedure that may enhance his or her long-term results. In the above example, I would add combined radiofrequency/ultrasound technology (Exilis Ultra) at six to 12 weeks after the lower lid procedure.
Dr. Schwartz: I want to have a drama-free patient experience, so we go out of our way to keep patients satisfied. For example, my philosophy is to charge for a consultation and if the patient signs up for any treatment or surgery within 30 days, we apply the consultation fee to the bill. There are occasions when patients will balk at paying any consultation fee, and we may waive it in select cases. It is unusual for us to do “free” treatments, but if I think they need a little something extra to improve their outcome or make the patient happy, I consider it on a case-by-case basis.
How do you handle patients who have non-invasive treatments and aren’t satisfied with their results?
Dr. J Bloom: With non-invasive body contouring, we make sure that we are very up front with patients at the beginning and counsel them appropriately to reduce the likelihood that they would be unsatisfied. That being said, if patients have not noticed a difference and have spent a good amount of time and money, we offer them additional treatments at our cost. Most patients are okay with paying the disposable fee or a nominal cost to try to improve those areas and they are counseled extensively that they may have a similar result.
Usually the add-on free treatments have no consumables costs. In these cases, the only cost to us is the time of whomever is performing the treatment. Our nurses and nurse aestheticians do laser hair removal, Clear + Brilliant, Coolsculpting, and skincare, which doesn’t change if it is a no-charge treatment or not.
Dr. Niamtu: Giving discounts or free treatments gets sticky with unreasonable patients.
Some common examples are:
• My Botox only lasted eight weeks and with my other doctor it lasted six months.
• I spent $1,500 on fillers and my husband can’t see a difference.
• I did laser resurfacing to look better and I was pink for eight weeks and could not leave my house.
• The facelift you performed did not improve my eyelids.
All of the above have a common denominator in that they involve unrealistic expectations, or the variability of patient treatment and response. Most could have been resolved by proper preoperative conversation and review of expected outcomes. Perhaps my office failed to communicate expectations, payment, or other details of treatment.
You can certainly show the patient the informed consent and point them to the door. This will probably result in a negative review that may stay with you forever and bad PR in the community as well as lost future income.
Some patients will never be happy so you simply have to suck that up, but there may be ways to turn some of them around. The number one way to deal with these patients is for a staff member to simply ask them, “What can we do to make you happy?” Sometimes the answer is surprising and perhaps the patient only wants some explanation, attention, or “love” from the office. Sometimes it may be a partial refund or it may be a total refund.
I hate giving money back as much as the next person, but sometimes what you do now is cheaper than what happens if you don’t. Depending on the situation, I may simply retreat for my cost or for free. If it makes the patient happy, avoids a bad review, and perhaps helps cultivate this patient into a supporter, then it is a necessary part of business. I never refund any monies without a signed legal release where the patient signs off on any liability and promises not to demean our practice in any medium including verbal and online. The release states that no admission of impropriety is expressed and the refund is in the interest of patient relations. I have refunded patients who turned into great supporters. I have also refunded patients and discharged them from the practice. It was worth it.
From time to time, you are going to get taken advantage of and that simply happens in business. Show concern, back up your work, and try to make everyone happy. It pays off in the end.
Dr. B Bloom: For these patients, I review all photos personally with the patient to ensure there is no misunderstanding. The goal with all procedures to set realistic expectations before the procedure. If a patient is dissatisfied but has an appropriate result I may offer an additional complimentary treatment but will require they sign a consent acknowledging that any complimentary services are for further benefit and that no complication or inadequate result has occurred. If I am disappointed with a result I will offer complimentary treatment and it will either be additional treatments or an alternate depending on what will most likely give the best result.
It is easier to offer complimentary treatment if there is no consumable, but if the treatment has a consumable and that is needed to achieve the appropriate result I will do it. I perform these treatments myself, especially if it is for a patient who is already upset.
Dr. Ortiz: With larger treatments, I will offer discounted “touch-ups” if they need a little fine tuning. But, these touch-ups are not free. For example, if the patient is getting a larger resurfacing procedure and needs a spot removed afterwards, I tell them up front that touch-up will be discounted. I don’t nickel and dime my patients. If they are getting multiple procedures on the same day and want a little benign lesion frozen or removed, then I will do that for free. Simply, I will offer a free treatment as a courtesy, but not because a patient feels that they were hoping for more improvement.
Dr. Chilukuri: I truly believe that combination therapy works best for more patients. On the face, this means addressing 3D aging. I utilize a variety of fillers, neuromodulators, technology, and skincare to achieve the most impressive, natural result. Similarly, with body contouring, it is important to address the superficial fat, visceral fat, and skin laxity. I will combine several modalities (Silhouette Procedure with Vanquish ME, Exilis Ultra, Cellutone, and SculpSure) to achieve the most dramatic results. If a patient is not fully satisfied, I will add additional modalities or additional treatment cycles at no cost.
If at all possible, I will offer a treatment that has no consumable if it is the right additional treatment for the patient. For example, I am more inclined to add an additional Exilis Ultra treatment before moving on to an additional SculpSure or CoolSculpting treatment. On the face, if we have a patient with a “heavy brow” following neuromodulator, I will offer Exilis Ultra or Pelleve before considering Ulthera which may not work any better and will definitely have an expensive consumable.
I always take full responsibility for the patient and will perform treatments that I typically do myself. My nurse practitioner and three aestheticians will help me with technology or chemical peels that we may add to improve a patient’s results and subsequent satisfaction. I am criticized for “giving away” procedures, but I always want our patients to be satisfied with the end result.
Dr. Schwartz: I want to have happy patients. So, if I am doing a series of BBL treatments, and the patient doesn’t feel he or she got the results they were hoping for (whether realistic or not), I will usually offer to do another session at no additional charge. If that doesn’t satisfy the patient, then we may suggest something more invasive, like a Sciton Halo treatment. If the treatment is for a patient who is not 100 percent happy, I will always closely manage the patient myself to demonstrate that I do care.
When it comes to injectables, I routinely have patients come back in two to three weeks to check them. If they need a little more neurotoxin to get the best result or a touch up, I will do it at no charge. To be honest, this does not happen often in my practice and it is worth it to me to give them the best possible outcome. I do not want my name on uneven brows or an imperfect result. In New York, that just won’t fly.
In actual fact, some patients will never be happy with anything you do for them, but at least in this way we are doing our best to foster goodwill. Sometimes patients just want to be heard, and it’s not only about the money. I have found in my practice that giving them an audience and showing that you really do care goes a long way to keep patients happy. Everyone likes to get a little something extra, and this strategy has paid off for my practice over time.