Study's solution to no-shows: overbooking

Examining a long-used travel industry practice, researchers found overbooking could be an efficient way to deal with the extra time created by patient no-shows.

By — Posted Feb. 4, 2008

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Just as airlines routinely overbook flights to ensure all seats on the planes are filled, some physicians could overbook their schedules to ensure that all the time slots in their schedules are filled, according to a recent study.

Two University of Colorado researchers published a study that shows how overbooking patients could increase practice productivity and reduce idle time caused when patients don't keep appointments. In January, the study won the 2007 Best Paper Award from Decision Sciences, an academic journal about operations management and decision-making within organizations.

The researchers developed a computerized simulation tool that runs analyses based on specific attributes of the practice, such as size, patient demographics and average length of appointments, to help determine when to overbook, and by how many patients, or if it's even feasible.

In many ways, practices already do this through "squeezing in" patients, said researchers Linda LaGanga, PhD, and Steve Lawrence, PhD.

"I think everyone's first reaction to overbooking in heath care is, 'That's got to be awful,' and we thought that, too," said Dr. Lawrence, an associate professor of operations management at the University of Colorado at Boulder Leeds School of Business. He is an adviser to Dr. LaGanga, who conducted the research for her dissertation as a PhD candidate and is now an instructor at Leeds. "But we knew it happened, so we wanted to see when benefits exceed the costs."

The Colorado research is one of the latest of many studies looking at how practices can maximize their efficiency by dealing with their no-show problems, beyond a sign threatening a $25 charge for a missed appointment. Other research has focused on finding ways to reduce no-shows, rather than the Colorado assumption that they will happen. One researcher said the risk of overbooking is that if patients do show, wait times will increase.

"In airlines when you overbook, you bump customers, and they are the ones who pay the price for overbooking. The rest of the plane goes fine. The problem in health care is if you overbook, it will cause delays for other patients and that needs to be considered," said Suresh Chand, PhD, a Purdue University management professor. He, along with Herbert Moskowitz, PhD, also a Purdue management professor, completed a two-year study in 2006 on improving practice efficiencies, determining that a mix of open-access and appointment scheduling was the best way to maximize practice efficiency and account for no-shows.

Dr. Lawrence agreed 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.

Value of waiting

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. The computer simulation she created through her research is not available for general use, although she is considering developing a Web site where it can be accessed.

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, for example, 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, the researchers said.

Health care consultant Cynthia Ethier, with Weymouth, Mass.-based Beacon Partners, said she has clients who have tried overbooking. "To be honest with you ... I'm not sure they have such great patient satisfaction," she said. Many serve a large indigent or Medicaid population and place a higher value on productivity, she said.

Dr. Lawrence said although these clinics shouldn't ignore patient satisfaction, the mentality is much different than in a cash-based specialty clinic where patients pay out of pocket and have higher expectations.

A misconception of overbooking is that it means double-booking, Dr. LaGanga said. But overbooking could be as simple as shortening the time between visits or increasing the number of visits for a particular time of day.

While the computerized simulations are too complicated to do by hand, a simple solution is to shorten the time between appointments relative to the average rate of no-shows, Dr. Lawrence said.

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. That's really the goal, Dr. Lawrence said -- to increase capacity so fewer patients are turned away.

Ethier said many practices she deals with have found that new patients are more likely not to show up, or to arrive late, so practices will strategically double-book in a way that won't put the physician behind schedule if both patients show up. For example, when a new patient is given a 45-minute time slot for initial evaluation, it's not uncommon for a follow-up appointment for an existing patient to be scheduled for the first 15 minutes of the new patient's time slot.

Factoring in the behavior of patients and using a probability model as opposed to a simulation model, based on averages, is a safer way to make predictions, said Dr. Moskowitz, who used probability models in his research with Dr. Chand.

"It's not the averages that kill you. It's the variations on the averages," Dr. Moskowitz said. Probabilities based on experience and human characteristics are much more reliable, he added.

Dr. LaGanga acknowledges that overbooking should in no way eliminate the goal of reducing no-shows. The fewer the no-shows, the less uncertainly involved in running simulations, she said.

Dave Gans, vice president of practice management resources for the Medical Group Management Assn., said in some practices open access could be the solution, but overbooking should not be ruled out in others.

He said if a clinic is running with a 20% no-show rate, even after efforts to reduce that rate, "it makes sense to overbook."

But even practices that determine an extra wait won't send patients packing shouldn't take the patients' time for granted. "Patients have an opportunity to make a choice, too," Gans said.

So will physicians, like airlines, soon start offering $100 and a free round-trip ticket to anyone willing to give up their seat in the exam room?

Not out of the question, Dr. LaGanga said, though she figures any incentives will be more modest, such as gift cards.

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Effects of overbooking

Two University of Colorado researchers 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.

Patient arrival patternEffect
Spaced throughout the dayNo effect on physician. No patients waiting.
Bunched early in the dayPhysician runs behind early in the day but catches up, preventing overtime. Patient wait times extend throughout the day but are eliminated toward the end of the day.
Last appointment of the day is latePhysician stays on schedule until the late arrival, which creates idle time that turns into overtime by the end of the day. No patients waiting.
Bunched latePhysician experiences idle time midday and experiences overtim. Patients experience waits late in the day.
More patients arrive than predictedPhysician runs behind schedule and stays behind for the entire day. Patients experience waits throughout the day.

Note: study assumes the expected number of patients arrive except as noted (last scenario)

Source: "Clinic Overbooking to Improve Patient Access and Increase Provider Productivity," Decision Sciences, May 2007

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Risks of overbooking

University of Colorado researchers 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.

Patient wait time
No-show rateAppointments per day
10%5 min.6 min.7 min.8 min.16 min.
20%11 min.12 min.17 min.18 min.22 min.
30%11 min.16 min.18 min.20 min.25 min.
40%14 min.16 min.20 min.25 min.30 min.
50%14 min.19 min.20 min.30 min.35 min.
Physician overtime
No-show rateAppointments per day
10%8 min.12 min.15 min.16 min.29 min.
20%16 min.18 min.30 min.30 min.38 min.
30%15 min.29 min.33 min.35 min.41 min.
40%18 min.29 min.39 min.45 min.46 min.
50%18 min.33 min.43 min.49 min.55 min.

Source: "Clinic Overbooking to Improve Patient Access and Increase Provider Productivity," Decision Sciences, May 2007

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