If patients are no-shows, doctors should ask why

A little sleuthing could go a long way toward alleviating an ongoing problem for many medical practices — the no-show patient.

Cancellations disrupt the practice’s patient flow, waste physicians’ time and hurt the bottom line, prompting some doctors to charge a no-show fee, or even terminate relationships with chronic offenders.

But did any staff member ask the patient why he or she canceled at the last minute or failed to show at all? Tracking cancellations and following up with a five-minute phone call to the absent patient could provide valuable information about the patient and the practice itself, which can help physicians bring the missing patient back into the office, improve the practice and minimize overall cancellations in the future with little cost or time spent. Finding out the “why” behind no-shows is likely to be more important as physicians’ pay increasingly gets tied to quality.

“When physicians are paid by volume, there’s no reason to follow no-shows as long as you can fill the slot. If physicians are paid for quality, the formula changes. It may be worth it to get the patient back. That’s a good thing about being paid for quality,” said Gaspere (Gus) Geraci, MD, vice president of physician leadership in quality and value with the Pennsylvania Medical Society.

Little time, big results

The first step is to track cancellations, either through office personnel or by using automated technology, then have an office manager or other administrator call each patient on that list to determine the reason. Ask for specifics, not generalities. If they said they had to cancel, ask for the precise reason and use that data to determine any trends. For example, most missed appointments are likely to take place on Fridays, said Billie Blair, PhD, president and CEO of The Change Strategists, a management consulting firm with offices in Los Angeles and Round Rock, Texas. She said practices might want to schedule fewer appointments that day.

Kenneth Hertz, principal with MGMA Health Care Consulting Group, said the office staffer shouldn’t have to make more than three or four calls per day. He said doctors need to let the office manager know this is important and that they want to be kept abreast of results.

Pradeep Vangala, MD, an Orlando, Fla., internist, said he began tracking no-show patients successfully with automated technology after reminder phone calls made one and three days before an appointment didn’t work on some patients. The program sends an automated message to those who missed appointments. The message uses an office worker’s voice, and asks patients to press certain buttons on their phone relating to their reason for cancellation. For instance, one button is for illness and one is for money issues.

Doctors can enter into the conversation later if there’s a major medical issue, or if the problem lies with office practices.

“If the doctor talks to the patient and works things out, that sends a very strong message to the patient that the doctor cares, and that gets around to neighbors and friends,” Hertz said.

While it’s up to each physician to determine whether he or she will charge for no-shows, Dr. Geraci said there needs to be a fair policy that takes into account true emergencies. Hertz suggested limiting the fee to chronic offenders.

Turning around no-show excuses

One of the main reasons for missed appointments is that patients simply forget, Dr. Geraci said.

“Calling them gives you a chance to reschedule,” he said. If the appointment was made far in advance, the office needs to call or text a reminder to the patient closer to the date. According to a 2012 report, “Performance and Practices of Successful Medical Groups,” by the Medical Group Management Assn. based on 2011 data, 41.3% of 348 practices included in the survey phoned patients in advance of appointments. Dr. Vangala said he asks patients for their preferred method of communication — house or cell phone, text or email. “If the patient never checks their house phone, it’s no use calling it,” he said.

If the patient isn’t feeling well, a nurse practitioner or physician can talk to the patient over the phone to discuss the problem. “You may determine the patient needs to go to the hospital in an ambulance, or the doctor can even make a house call,” Dr. Geraci said.

Blair said that if the physician knows the patient’s medical history, medications can be prescribed over the phone and video arrangements can be made, if possible, so doctor and patient still can see each other, and the patient is still charged.

Follow-up calls are especially important for patients with chronic illnesses. “If the patient is a no-show and the doctor doesn’t follow up, and something happens to the patient, the practice has a big problem,” Hertz said.

Some patients skip appointments because they don’t have the money for a co-pay or they have a balance due. Dr. Geraci said the practice could waive the co-pay, although it’s not something it would want to do routinely. Blair suggested setting up credit arrangements with the patient, and Hertz recommended handling each situation on its own.

“If the patient is on a fixed income and gets their check on the 15th of the month and their appointment is on the 12th and they’re down to their last $15 with a $30 co-pay, there is a problem. Ask the patient if it would be helpful to change the appointment date,” Hertz said.

Some patients cite failures in the practice itself, whether it’s a surly office employee or inability to see the doctor when they need to the most. Hertz said a patient may have been able to get a same-day appointment at another practice when they were feeling ill after being told they’d have to wait several days to see their regular doctor.

“The patient often wants to be seen in a timely fashion. The receptionist may not understand the importance. She may say they can’t get you in for three days, and if the pain persists you should go to the ER. Without follow-up calls, this may not even get past the front desk to the doctor, so the problem may never get fixed,” Hertz said.

Blair said some no-shows actually may no longer be your patient, having left the practice for whatever reason. “You won’t know this until you do some investigating. It gives you an opportunity to look at staff and restructure, if necessary,” she said.

Some patients skip appointments because they didn’t do something physicians asked them to do at their last visit, like take a test or fill a prescription, and don’t want to tell the doctor, Dr. Geraci said. Dr. Vangala said if he notices a patient didn’t have a mammogram, he asks how he can help the patient make an appointment. He also uses technology to track people who don’t come in for an annual physical, which he said is technically a no-show. “The office calls these patients and talks to them about the importance of preventive health and the need for the physical,” he said.

”By making calls, you can weed out the patients you want to keep and the ones who are lost causes. You can eventually identify a patient who just doesn’t care. On the positive side, patients recognize you care that they missed an appointment. It could be financially worthwhile to keep them or get them back,” Dr. Geraci said.