Mike On Healthcare

Physician Practice Patient No-Shows:

• How many can you expect?
• How can you prevent them?
• How can you reduce their frequency?

The average no-show rate for physician practices can range from as low as none to as high as 60 percent of all appointments.  Most practices experience an average of 5 to 7 percent. (Woodcock 2007, 178)

Practices in which physicians rotate between different sites tend to have a higher rate of no-shows.  Patients may get confused as to which site to visit.  The less loyalty patients have to a physician, the more likely they will be no-shows. (Woodcock 2007, 179)

Practices that schedule appointments too far in advance may find that patients make alternate plans for the scheduled time-frame.  Patients given appointments well into the future may decide to locate other physicians who can see them sooner, start to feel better, or simply forget.

Some MGMA scenarios and best practices (Woodcock 2007, 179-180):

No shows aren’t just an administrative problem.  Their causes may be deeply rooted in emotions and attitudes about your practice.  Consider these comments and what’s really behind the emotion expressed:

• “You’re so busy, you won’t miss me.”  Warn practice staff not to express relief at a no-show or cancellation, even on their busiest day.  Patients will get the message that their absence is actually welcomed.
• “I hope I can remember this appointment.”  Patients tend to lose those little appointment cards.  If your patients are forgetting about their appointments, don’t schedule them more than three months in advance.  Instead, call the patients six weeks ahead of time to schedule.
• “I feel wonderful; is there any reason for me to come in to be seen?”  Remind patients, especially those with chronic illnesses, that routine preventive visits are important to their care, even when there are no symptoms to report.
• “I’ll just hear bad news.”  Handle the emotional side of medical care by addressing patients’ fears head on.  For patients you’re concerned about or for the services most patients find fearful, ask a nurse to make contact two or three days before the appointment to give last-minute support.
• I tried to cancel, but I couldn’t get through.”  Set up a 24-hour/seven day-a-week cancellation voice mail and email address so patients can cancel or ask for scheduled changes at any time.  Make sure someone is held accountable to monitor all such messages and to contact patients to reschedule within one working day of their communication.
• “You’re the one who moved my appointment.”  Avoid cancelling clinics without ample notice, and offer alternative access to patients whose appointments have been moved.

Being knowledgeable about the emotional side of no-shows will help prevent at least some of them – and improve the care delivered to your patients.

Managing the Frequency of No-Shows

Here are ideas from MGMA resources and the healthcare industry to reduce patient no-shows (Baginski 2010):

• Track the reasons each patient gives for a no-show. Trends in excuses can help point to solutions. For example, are they covered by a certain insurance carrier, seen by the same physician or on a certain day of the week?
• Call your patients to reschedule their missed appointments. In this economy, you can’t afford to wait for patients to call you back.
• Set automated reminder phone calls the day before an appointment.
• Or, even better, have staff make routine reminder calls the day before an appointment. Research from the American Journal of Medicine shows this is more effective than automated phone systems – but certainly more time consuming.
• Send postcards/mailers a few weeks in advance to remind patients of their appointments.
• Develop a call list of patients who are able to come in for short-notice appointments. When a no-show happens, these patients may be able to fill the empty spot.
• Allow patients to prepay for their next appointment, giving them an incentive to return.
• Send “Sorry we missed you!” appointment letters (with or without fees) to patients.
• Place a nominal charge on your patient’s bill that will clear when the patient shows up for the appointment. If they do not show, the patient will pay the charge.
• Reward patients who show up on time with discounts on their bill.
• Limit appointments per patient to one per week.
• Explore ways to text appointment reminders to interested patients. Kaiser Permanente recently implemented SMS and its pilot program showed a .73 percent improvement in no-shows, saving $150 per appointment.
• Provide the option to send your patients an e-mail appointment reminder.
• Update/confirm contact information when a patient makes an appointment. This will help you track down patients who don’t show.
• Print future appointments on a business card to give to the patient before they leave your office. “I couldn’t read the handwriting” excuses won’t fly with this method.
• Have patients repeat the date and time of their next appointments, whether they’re in your office or on the phone.
• Discharge patients who accumulate a set amount (your choice) of no-shows in a year.
• Charge for same-day cancellations (which can be just as bad as no-shows), unless it’s an emergency.
• For patients who use public transportation, remind them to schedule their appointment according to the transportation schedule.
• Schedule repeat offenders during a time that has less of an effect to the overall schedule.
• Consider overbooking when appropriate. Overbooking doesn’t have to mean double booking. It could be shortening time between visits or adding more visits to a certain time of day. But beware – longer wait times and lack of understanding about scheduling can leave patients feeling disrespected, according to an Annals of Family Medicine research article.
• Always thank patients who cancel and reschedule well in advance of your no-show policy. A little goodwill can go a long way.
• Schedule accurately so patients don’t have long wait times, which may lead them to believe that the practice doesn’t value their time, convincing them to not value yours.
• Compare the number of patients handled by each of your doctors and their clinical staff.  Consider reassigning the load so patients are evenly distributed and seen by the provider they visit with the most.
• Evaluate your practice management system to see if it can supplement or automate any tracking or patient reminder tools you’re currently using.
• Hold a gift card drawing for all patients who show up on time in a given month.
• Clearly explain, and have new patients sign, a written no-show policy.
• Elizabeth Woodcock, MBA, FACMPE, CPC, in the book Mastering Patient Flow, offers the following suggestions to reduce the number of no-shows:
  • Develop strong relationships with patients to increase their commitment to your practice. Suggestions include sending birthday or holiday cards and assigning nurses to specific patients to work and follow up with.
  • Schedule appointments within a reasonable time of the patient’s call. The longer the lapse, the greater the chance of a no-show.
  • Switch to open or advanced access scheduling to provide appointments the same day a patient is looking for an appointment.

Overbooking Appointments as a Possible Solution

The challenge of balancing the interests of patients with those of the physician is increased when patients fail to show up for scheduled appointments.  Overbooking appointments mitigates the lost productivity caused by no-shows but increases patient wait time and physician overtime.  Basically, when patients fail to show up for their scheduled appointments, physician productivity and efficient clinic capacity are reduced (Cayirili 2003).  To mitigate this loss, healthcare clinicians have experimented with a number alternative appointment scheduling policies. Some clinics overbook appointments by double-booking patients into common appointment times and relying on no-shows to allow the schedule to catch up (Chung 2002).  Others have experimented with “wave scheduling” policies that build extra appointments into a schedule to boost better productivity and leave the other appointment slots empty (Silver 1975).  This combination allows a schedule to catch up after backlogging occurs, thus reducing patient wait time and reducing the need for clinic overtime.  Practitioners have reported success in managing appointment schedules with these and other similar approaches, but their accounts have been anecdotal and do not analyze or describe how scheduling performance relates to no-shows or other system characteristics (Chesanow 1996) (Chung 2002) (Baum 2001).

In 2007, two University of Colorado researchers (Linda R. LaGanga and corresponding author Stephen R. Laurence) won a 2007 Best Paper Award from Decision Sciences for proposing overbooking as a solution for the loss of productivity for physician clinics when patients fail to show up (LaGanga and Lawrence 2007).  In their paper, the authors propose to build upon and extend the double-booking, block scheduling, and wave-scheduling devised by practicing clinicians to develop and measure the performance of a number of scheduling rules based on these policies.  The authors suggest that physician practices adjust traditional appointment scheduling performance measures to capture the dynamics of overbooked appointment scheduling systems, determine their effectiveness when overbooking is used to compensate for the lost productivity of no-shows, and provide recommendations for improving performance in overbooked appointment scheduling systems.  LaGanga’s and Laurence’s analysis is potentially useful for schedulers and providers to identify and evaluate operational policy changes that will boost clinic productivity and improve patient services.

Dr. LaGanga, who is also director of quality systems and operational excellence at the Mental Health Center of Denver, a state-contracted facility, said the model allows users to place a value on wait time and productivity.

For small private practices where the percentage of no-shows is low, the value placed on limiting wait times likely will be greater than for a busy practice that serves mostly managed care members or a specialty practice where the competition is minimal. So, in general, the practices for which benefits of overbooking outweigh the risks likely will be large, busy practices that have a high percentage of no-shows.

A misconception of overbooking is that it means double-booking. But overbooking could be as simple as shortening the time between visits or increasing the number of visits for a particular time of day. For example, if the average no-show rate is 30%, and the average time allotted per visit is 15 minutes, a practice could reduce that 15 minutes by 30% and allow only 10.5 minutes per appointment, resulting in more appointment slots (LaGanga and Lawrence 2007).

Effects of Overbooking

LaGranda and Laurence created computer simulations to see how overbooking might affect patient wait times and physician overtime. This illustration uses a 50% no-show rate because, the researchers said, although unusually high, it’s easy to illustrate how overbooking relative to the no-show rate would impact the daily schedule. In this case, the clinic would book 10 appointments in five appointment slots, assuming only half would show up (LaGanga and Lawrence 2007):

Risks of Overbooking

The researchers further developed simulation models to determine the impact overbooking would have on clinics, depending on clinic size. Size is measured by the number of appointments per day. This model shows the impact overbooking would have on patient wait times, assuming all patients show up, instead of no-shows continuing at their usual rate. This model assumes appointments are 15 minutes long, but it can be adjusted for any appointment length (LaGanga and Lawrence 2007):

Dr. Lawrence stated that “the real cost is if you do overbooking, there will be patient waits and overtime to be sure.” But he argues that overbooking could still be beneficial for some practices. The dilemma is determining when it might work or when the stakes are too high (LaGanga and Lawrence 2007).

References
Baginski, Caren. MGMA In Practice blog . July 9, 2010. http://blog.mgma.com/blog/bid/34426/30-ways-to-reduce-patient-no-shows (accessed November 25, 2011).

Baum, Neil H. “Control your scheduling to ensure patient satisfaction.” Urology Times 29, no. 3 (2001): 38-43.

Cayirili, Tugba. “Outpatient scheduling in health care: a review of literature.” Production and Operations Management 12, no. 4 (2003): 519-549.

Chesanow, Neil. “Can’t stay on schedule? Here’s a solution.” Medical Economics 73, no. 21 (1996): 174-180.

Chung, M. K. “Tuning up your patient schedule.” Family Practice Management (41-48) 9, no. 1 (2002).

LaGanga, Linda R., and Stephen R. Lawrence. “Clinit Overbooking to Improve Patient Access and Increase Provider Productivity.” Decision Sciences 38, no. 2 (May 2007): 251-276.

Silver, M. “Scheduling: Least developed art.” Family Practice News 5, no. 32 (1975): 34.

Woodcock, Elizabeth W. Mastering Patient Flow: Using Lean Thinking to Improve Your Practice Operations. Engelwood: MGMA, 2007.