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Coping With the No-Shows

Coping With the No-Shows
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Fred N. Pelzman, MD

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine. Pelzman’s Picks is a compilation of links to blogs, articles, tweets, journal studies, opinion pieces, and news briefs related to primary care that caught his eye.

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Fred N. Pelzman, MD (click to view)

Fred N. Pelzman, MD

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine. Pelzman’s Picks is a compilation of links to blogs, articles, tweets, journal studies, opinion pieces, and news briefs related to primary care that caught his eye.

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5,941. Are you kidding me?

Disturbed by a rising no-show rate in our residents’ practices, we ran the numbers the other day. Looking back over the past year, we discovered something remarkable, and worrisome, about patients scheduling appointments in our practice.

Surprisingly, that number, 5941, represents those patients who have made and no-showed (i.e., broken) three to 10 appointments in our practice during the year.

When we include those that have broken only 1 or 2 appointments, the number goes well over 10,000.

What is disturbing is what this represents. This is 10,000 lost opportunities for those patients who didn’t come in to be seen and get care, as well as missed opportunities where we had to tell 10,000 other people that there was no availability on the schedule because those appointments were locked up.

If you think about it, that represents several practitioners sitting around essentially doing nothing for an entire year. Or thinking about it another way, if those slots were available we could have three other practitioners taking care of patients full-time for a whole year, providing an awful lot of necessary care.

A Warning Letter

One of the decisions we’ve made after reviewing this, is for those who have broken a large number of appointments, we will offer their providers the opportunity to send a warning letter. It seems reasonable if someone has broken, just not showing up, 10 appointments in our practice over a year, that it’s worth letting them know that they are preventing us from caring for them — as well as others who desperately need to be seen — from getting the care they need.

Each provider is different. Some have a different level of tolerance for no-show appointments. I know some providers who, if you break two appointments with them, will send a letter warning you that you may be kicked out of their practice. Some feel much more lenient with their established patients, and are more understanding of no-shows for those that they’ve cared for over many years. Some providers will give an initial visit one or at most two chances, and after that they tell them not to bother making an appointment with them.

Clearly, the whole process of access to appointments, scheduling, show rates, and all the rest, is complicated, and there are many factors that go into why patients make appointments, keep appointments, or no-show for appointments. But how do we optimize this, how do we make sure that patients are not blocking off our schedules and then letting it sit there unused?

Let’s be honest. When we have a packed day, our schedule crammed with overbooked patients, and suddenly someone doesn’t show up, that brief opening in your day can seem like a breath of fresh air. A small pause, or at least a moment where you can catch up a little bit.

But it does come at a cost. What did the patient need that day? Were they sick, and was there something we really needed to attend to?

We can’t chase them all down, call them up and make sure that they’re okay, rescheduling to see make sure we see them the next day.

The Downsides of Open Access

Different models of advanced access and open access can certainly be seen as advantageous for patients; we want them to be able to be seen, to come in when they want to be seen, but for those wasted appointments that are clogging up the system, we need to restructure and tighten up the process.

One of the newer pieces of functionality in our patient portal that is about to go online is the ability for patients to schedule themselves, to actually directly put themselves right onto your schedule into an available appointment slot. Some see this as exciting, the wave of the future, true open access, but some see it as worrisome, that patients may make appointments that they may not need or even really plan to keep.

It reminds me of smartphone apps where people can make reservations at restaurants, with very little sense of responsibility. Theoretically you could make 20 reservations for dinner Friday night, keep none of them, and it’s no skin off your teeth. The restaurant wants you to make a reservation at their place, but they certainly don’t want you not showing up.

In the olden days, you actually had to call the restaurant to make a reservation and speak to the maître d’, and there was somehow some shame in not showing up for that reservation. In fact, many places would take a credit card and hold it for you, and use that to make sure you kept your reservation.

You feared not showing up and then dared try to make another reservation. Missed a dinner reservation last week? Table by the bathroom.

To Overbook or Not to Overbook?

One of my psychiatrist friends tells me that they never overbook psychiatric appointments, and yet at the same time they worry mightily about their no-show rate. Understandably, it would be hard to see two complex psychiatric patients during a single time slot, when everybody wants to feel that the full attention of the therapist is focused on them during those 45 minutes.

We primary care providers, on the other hand, will almost always overbook our schedules, squeezing someone in for a blood pressure check, a minor illness, a single issue, using two rooms to run back and forth between patients — while someone is getting an EKG we’ll check in on the other one, while someone is undressing we’ll go take a look at that rash, maximizing our efficiency to keep things moving.

But the worry is always that if you overbook to your no-show rate, that is if you know your no-show rate is going to be 40% this week among all your providers and you book your practice at 140%, then there are certainly going to be days when everyone shows up. And that can get crazy, leading to provider burnout, and patient dissatisfaction.

The addition of a new telephone electronic reminder system seems to be chipping away a little bit at our no-show rate. The system calls patients (for whom we have an active telephone number) reminding them of their appointment 48 hours in advance, giving them the option to confirm that they are keeping the appointment, or selecting an option that allows them to tell the practice they will not be keeping it. This created availability has been extremely helpful in getting us a bunch of same-day or next-day appointments for patients who want to be seen urgently.

It does seem fair in the big picture, however, that if you’ve made multiple appointments to see one of our providers as a new patient, and just don’t have the courtesy to call and cancel, you just don’t show up, that at a certain point we can send you a gentle reminder letter that this is preventing us from caring for you and preventing many of our other patients from being seen in a timely fashion. And after that, it certainly seems like it’s time for you to get your care elsewhere.

It’s true, if someone has broken 10 appointments with us in a year, it is worth us trying to figure out why they aren’t coming, what we can do to help them get into care, do they need help with transportation, insurance, finding a provider who better matches their personality and health needs?

But at the same time, these 10,000 no-show appointments represent lost care opportunities, as well as lost income for the practice, and lost learning opportunities for our physicians in training.

Make and keep an appointment, and we will get you all the care you need. Table for two, by the window with a view, is ready and waiting for you.

 

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine. Pelzman’s Picks is a compilation of links to blogs, articles, tweets, journal studies, opinion pieces, and news briefs related to primary care that caught his eye.

1 Comment

  1. My son wanted to make an appt with a rhematolotist. He has had this pain that comes and goes . His father who is a physician has suggested many times that he needs to see a specialist about this. So my son has an internist and he had to ask for a referral, but by the ridiculous rules we live with these days, the doctor said he hadn’t seen him in quite some time and wanted to see him first. My son inadvertantly missed the appointment. He didn’t mean to even though seeing his doc and then getting a referral meant two separate apps. for would have to put out more copay not to mention how difficult it is for him to get away from his He busy schedule as post-doc and it just slipped his mind. Two doctor visits might take more of his time then just getting the referal to see the one specialist. There was no warning, he got a bill from the internist’s office for not showing up. And I’m guessing unless my son pays up, or we his parents cover for him (he is almost 40!) the unpaid bill will go to collections. I have urged him to call the doctor’s office and actually try to explain the situation with the doctor not the secretary who most likely issued the bill. He is wrong for missing the appointment, no doubt. He isn’t one of those patients who miss lots of appointment, in fact he is not one who makes a habbit of seeing a doctor on a routine basis. So far that has not called that I know of and he may pay the bill.eventually, but it isn’t like he has a lot of extra $$ hanging around. He still has not seen a rhematologist and there are days he is miserable but then for no reason the pain goes away.

    Reply

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