When the patient is a no-show

If you want to irritate your doctor, the nurse, the medical assistant, the receptionist and pretty much everyone else you deal with at the clinic, it’s easy: Blow off your next appointment. Don’t call ahead of time to cancel or let someone know you’re running late. Just don’t show up. Give yourself bonus points for not calling afterwards either to apologize or reschedule.

Physician clinics, dental practices, optometry centers – you name it, they’ve all struggled with the perpetual issue of no-shows. These days, however, with crowded appointment schedules and clinicians’ time at a premium, it’s becoming a bigger deal than ever. And it should come as no surprise that some area clinics are starting to crack down on patients who don’t show up.

How often do patients fail to keep a scheduled appointment? It’s not clear. Rates appear to vary from one clinic to the next. One study by the Medical Group Management Association put the national average at 5.5 percent. The one sure thing is that health care practitioners seem to almost universally regard no-shows as a problem.

In health care, time is often money. When an appointment slot is booked and the patient doesn’t show up, it’s a lost opportunity to earn revenue. Like it or not, few businesses, including health care practices, can afford to put up with a high rate of no-shows. One academic practice in Milwaukee broke it down into some rather startling numbers:

Between 2000 and 2002, the average no-show rate for our academic practice was 30 percent. We intuitively believed that a disproportionate number of missed appointments were being caused by a small group of patients. In 2002, our practice had 12,100 arrived visits and 4,438 no-shows. No-shows were defined as intended appointments that were not canceled or rescheduled at least two hours before the designated time. Each no-show patient had between one and 18 missed appointments. This accounted for more than 1,300 clinic hours.

It’s not just about the dollars and cents, though. That empty time slot could have been used by another patient who needs to see the doctor. When patients skip an appointment without calling ahead to cancel, physicians and their staff also can perceive it as disrespectful – and it’s the kind of thing that tends to tarnish the relationship.

Clinicians have tried different tactics to discourage no-shows. Some of these strategies are purely preventive: for instance, letters or phone calls to remind patients of an upcoming appointment. More stringent measures might include asking patients to pay a deposit ahead of time, charging patients a no-show fee, or putting them on probation if they miss an appointment without calling first. As a last resort, the habitual no-show offender might be fired from the physician’s practice.

Harsh and unfair? Well, I don’t know.

Measures like these appear to be entirely legal, as long as patients are informed of the policy and what’s expected of them. Enforcement should not be too draconian, advises GoingLegal.com:

The implemented no-show policy should be reasonable to avoid patient complaints and the transfer of good patients to other providers. For example, a policy may state that a patient who arrives more than 30 minutes late shall be assessed the no-show fee. But, if patients are routinely required to wait 30 or minutes or more from the scheduled appointment time, the hypothetical policy is likely unreasonable.

So what about the patient’s side of the story? There are times, after all, when skipping an appointment might be unavoidable. Maybe they had a flat tire on their way to the clinic, or a last-minute household crisis. There might be cases in which someone is too sick to come to an appointment – the story of 85-year-old John Williams of South Carolina, for instance, who missed a 9 a.m. appointment with his physical therapist because he’d fallen and broken his hip.

Or do patients skip appointments because they just don’t care?

Studies have come up with some rather interesting findings. This survey, conducted at the University of Nebraska Medical Center, suggests that some patients “did not feel obligated to keep a scheduled appointment in part because they felt disrespected by the health care system. The effect of this feeling was compounded by participants’ lack of understanding of the scheduling system.”

Other research has suggested that patients who frequently skip appointments tend to be younger, lower-income and have a history of missed appointments and psychosocial problems.

Here’s a surprise, though: Medical practices might be unwittingly contributing to their no-show rate by how they handle their scheduling. That’s one of the conclusions drawn in a study published last year by the American College of Physicians, which found that the logistics of the visit, not the characteristics of the patient, were among the most important factors. When the study’s authors, who are on the faculty at the University of Missouri, analyzed 11,000 scheduled visits, they learned that Medicaid patients scheduled for an appointment after 3 p.m. almost never showed up because that was when public transportation shut down for the day.

Another finding: How the appointment was scheduled seemed to matter:

Schedulers with higher proportions of no-shows were following practice protocol and scheduling the first caller for Monday at 8 a.m., the second for Monday at 8:30, etc. More successful schedulers, however, started the conversation by asking patients, “When would you like to come in?”

Whether the patient had to travel for the appointment also appeared to be a factor:

The study revealed patients who lived five to 10 miles from the practice were very likely to show, while those who lived between 19 and 60 miles were more likely to miss their appointments, but anyone coming from more than 60 miles away almost always showed up.

Other studies have suggested that long waits between the time the appointment is scheduled and the actual date of the appointment tend to increase the likelihood of a no-show.

For what it’s worth, I think it’s disrespectful of patients to fail to show up for an appointment without calling first and cancelling, so their slot can be offered to someone else. I can’t really blame medical clinics for wanting to crack down on this behavior. But before booting the patient to the curb, medical practices ought to ask themselves: What’s the real reason this person is skipping appointments and what can we do that might be helpful? Solving the issue of no-show patients might be more of a two-way street than we think.

3 thoughts on “When the patient is a no-show

  1. I wanted to cite this article that you cited in March 2010: “How often do patients fail to keep a scheduled appointment? It’s not clear. Rates appear to vary from one clinic to the next. One study by the Medical Group Management Association, cited here” The link is no longer available, can you provide a biblographic citation for the MGMA Study? Thank you for your attention to this request.

  2. I think a patient’s history should be factored when a doctor’s office charges a patient a late or no-show fee. One thing not mentioned in this article is that patients sometimes forget their appointment. Especially preventative or well checkups. A patient could have a 95% show-up rate with a doctor. Doctor’s should perhaps reconsider charging late fees to patients who may miss one or two appointments when historically they have a high on-time rate.

  3. I believe patients should be charged a late or no-show fee. They don’t think about the healthcare provider or the interpreter, if one is called, not being able to take care of other patients who may have a real need to be seen because they are waiting for this particular patient to arrive.

    Some patients have real emergencies which prevent them from showing-up at their appointment, but some others just don’t care.

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