The No-Show Epidemic

Think about the way your favorite companies set your expectations and deliver on them. Look to Amazon for free two-day shipping and easy returns. Look to Lyft for frictionless booking and immediate cancellation--even if the requested driver is already on their way. The nature of interactions in health care is becoming similar. Reframing the transactional norms is undoubtedly playing a part in patients skipping on their appointments: if a last-minute Lyft cancellation is okay, why not the same for an appointment? But as a practice you know that the economics are vastly different, and not in your favor. Kim Decker, chief of the Martin Army Community Hospital Healthcare Management Division, commented, “An appointment missed by you is an appointment missed by two.”

No-shows are an epidemic, consuming as much as 14% of a practice’s revenue. They impact multiple parties: those who no-show, those waiting for an appointment to open up, and the practice, itself. But to say no-shows are solely a reflection of contemporary consumer habits is untrue. There are several reasons for high no-show rates, and certain types of patients may be more inclined to exhibit this behavior. Here’s what we know and what that means for you:

Booking in Advance

In our research we find that over 12% of appointments that are scheduled 30+ days in advance result in a no-show. Instead of providing patients with the ability to make their next appointment for six months from now; offer online, self-scheduling options and an automated reminder three weeks prior that they’re due to come in. Avoiding such long-term booking can also be valuable in ensuring you have reserved capacity for some same-day appointments. Giving the patient more power to schedule, cancel and reschedule via their preferred method of communication is an effective way to improve attendance.

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Transit

On average, patients in the United States travel thirty minutes to their specialists, and rural patients fare even worse. The burdens of long commutes, and limited transport options in low-income communities, have largely been overlooked, but that’s quickly changing. Hitch Health and Lyft tested the value of ride partnerships with clinical facilities and found that no-show rates in downtown Minneapolis decreased by 27%. Further, CareMore tested patient satisfaction with provision of free Lyft rides as well as their punctuality to the appointment: those who rode with Lyft were almost 20% more likely to be on time, and 98% were satisfied with aspects of the experience riding in a free Lyft to their appointment. Providing this option at your practice - even if it’s simply to allow scheduling and not to pay for it - may vastly increase patient access and improve patient experience.

Unproductive Fees

Missed appointments and unfilled slots are a financial drain, and, as a reaction, providers institute fees to discourage last-minute cancellation and no-shows. However, many practices have found that those patients who accrue a cancellation fee upon no-showing, will never return to that practice. And while a $20-50 fine does provide some consolation for the slot that goes unfilled, you would need to charge the patient a whopping $150-200 to adequately compensate the practice for the appointment.

If your practice is toying with the idea of implementing a late cancellation/no-show fee, consider a system in which it is waived upon the patient’s next visit, or doesn’t apply to a new patient. Allowing a patient without a history of no-showing to erase a temporary account charge by rescheduling (and being on time to their next visit) is a productive way to promote cancelling in advance.

Long Hold Times

One of the most frequently reported reasons for missing appointments among patients of one New York FQHC was being unable to reschedule or cancel on the phone. Running into long hold times or failing to reach an access center representative prevented patients from being able to cancel in advance. Ensuring your call center has the tools it needs to manage a heavy call volume - including the ability to cancel via text or online - is imperative in being able to try and fill those cancellations with appointments.

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But while these trends can be predicted to some degree, some patients might benefit from additional outreach. We know putting in extra effort to engage every individual isn’t feasible; so here are some patient cohorts that tend to no-show more, and why:

  • New patients: they have not yet established any sense of loyalty to the practice: there is no patient-physician relationship to nurture. Send personalized reminders to engage these individuals instantly, before they even come for their first appointment.

  • Younger, working age patients (< 50 years): it’s harder to keep appointments while balancing the demands of a full-time job. Send out that two or three week appointment heads-up that we mentioned earlier and consider offering extended hours once or twice a week.

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  • Sick patients: hospital follow-ups are a type of appointment that’s commonly skipped, but not deliberately. Accommodating sick patients and preventing the circular nature of illness and no-shows might mean: spending more resources on nurses who can call patients to check-in, on having pharmacists on staff to do medical reconciliation while the patient is already in, or sending case workers for home visits.

  • Medicaid patients and patients with higher co-pays: affordability is certainly a concern, here, and the reality is that your toolkit of preventative measures is limited. The best thing you can do here is to educate your patients about the effects of no-showing. You can also engage in what we call intelligent double-booking: double book appointments where patients are likely to no-show - but not all appointments.

Ultimately, reducing no-shows will take work on your side and it is undoubtedly a worthwhile effort. Higher no-show rates amount to longer wait times for other patients, poor health outcomes, reduced care quality, and poor patient experience. Make it known to your patients that cancelling in advance is appreciated, and if a patient skips three or more appointments, it might be time to let them go. Try to discern patterns and test interventions, such as implementing new protocols for new patients and upgrading your patient access tech stack (see, for example, DASH). And when in doubt, look at patient history to predict attendance and consider double-booking.

Wondering what the end state looks like? The Henry J. Austin Health Center utilized DASH’s no-show prediction tool to confidently double-book and ultimately reach capacity. Click here to read a case study. You’ll be glad you did something about the no-shows; plan for some time to celebrate when you do.

References

  1. “Estimating the Cost of No-Shows and Evaluating the Effects of Mitigation Strategies” Retrieved March 27, 2019. https://journals.sagepub.com/doi/abs/10.1177/0272989X13478194?journalCode=mdma

  2. “Patient Education, Scheduling Fixes Shrink Patient No-Show Rates” Retrieved March 27, 2019. https://patientengagementhit.com/news/patient-education-scheduling-fixes-shrink-patient-no-show-rates

  3. “Prevalence, predictors and economic consequences of no-shows” Retrieved March 27, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4714455/