When Patients Don’t Show Up

For decades, no-show patients have proven to be a costly problem for physicians. In fact, missed appointments lead to a staggering $150 billion impact on the US healthcare system annually.

The reasons patients opt out of appointments are as individual as the patient and include concerns about healthcare costs, long wait times, and a lack of transportation, said Michael Nilsson, a software developer and founder of AddEvent, a calendar technology platform that healthcare professionals use to reduce missed appointment rates.

“Perhaps the most frustrating or perplexing reason patients skip appointments is forgetfulness or apathy,” Nilsson told Medscape Medical News.

And while sending multiple reminder emails, texts, and phone calls can sometimes mitigate missed appointments, no single communication device is entirely effective.

Just ask Bernadette Anderson, MD, MPH, a family physician in Columbus, Ohio, who says juggling schedules when patients don’t show up is a regular occurrence, a financial loss, and a big stressor for her and her staff.

“Every time a patient is a no-show, it’s a $200 hit,” she said. “We aren’t able to put another appointment in that person’s slot, and this creates a substantial burden for us.”

Anderson routinely treats multiple members of a family, which leads to even more complications.

“We set aside several back-to-back slots for those families,” Anderson said. “If that family has historically skipped appointments, I will double book them with other patients. This means all the patients in that time slot are sitting in the waiting room even longer — if everyone shows up.”

Getting no-show patients back on the schedule can also be challenging.

“What this means is that I have to use my staff’s limited resources to try to rebook appointments and get these patients back to the office,” she said.

Anderson added that this back-and-forth not only is deleterious to the patient’s health but also can start to put a strain on the patient/physician relationship.

“You start to wonder if a patient is serious about his or her health,” she said. “It makes me wonder, ‘Do you want my guidance and/or is this a good fit for both of us?’”

Gather Relevant Data

If no-shows are a challenge in your office, quantify how big of a problem they are. One way to do so is to gather revenue per visit (RPV) data, suggested Peter A. Wishnie, DPM, who ran a private podiatry practice in Piscataway, New Jersey, for 34 years before retiring.

“The percentage of kept appointments every single week is an important statistic,” said Wishnie, who coaches healthcare practitioners on becoming better business owners. “By contrast, if your RPV is $160 on average and 20 of your patients don’t show up, you’re losing $3200 that day alone.”

Additionally, if your RPV remained the same for 5 days of the work week, you stand to lose $64,000 a month or $768,000 annually, Wishnie added.

“Doctors tend to go with the flow,” he said. “Patients come and go, but most physicians have no clue what their RPV is.” However, having statistics on hand can help you identify the issue and start adjusting.

Don’t Lose Patients During Follow-Ups

Let’s say your show-up rate is decent, but you’ve noticed that after a preliminary appointment, your patients aren’t complying with your suggestion that they return to your office for a follow-up appointment, whether that’s in 2 weeks or 2 months.

“Your patient may not be so happy about coming back, especially if they have high copays or high deductibles,” Wishnie said. “This is where it’s very important for doctors to tell patients why they need to come back and what happens if they don’t.”

For example, use phrasing like, “I know you might feel better, but I need to see you again to make sure we take care of XYZ so this doesn’t happen again,” he added.

“By explaining the health reasons — and quantifying those reasons — you can possibly avoid a no-show,” Wishnie said.

Get Your Front Desk Onboard

When a new patient calls to make an appointment, Paul Rosenberg, MD, a board-certified plastic surgeon in private practice in Fort Lee, New Jersey, and head plastic surgeon at the New Jersey Gynecomastia Center, trains his staff to get to know them a little bit — to try to reach out to them on a human level.

“We don’t lead with ‘what kind of insurance do you have,’” he said. We try to address the pain and find a connection.”

Then, after that initial appointment, it might help to have your front desk staff at the ready with a script for discussing next steps.

“It’s the job of the front desk to ask, ‘How was everything today’ and to help the patient understand why they might need a follow-up appointment,’” Wishnie said. “If the patient still doesn’t understand, it’s at that moment where the nurse or doctor should come up front and explain it to them.”

Then, should a patient cancel that appointment, train your staff to say, “let’s reschedule that” vs “would you like to reschedule that,” Wishnie added.

“Make sure your front desk team reinforces the new appointment day three times so that the patient is clear on when they need to come back.”

Try Different Forms of Reminder Messaging

While text message reminders from your office may annoy some patients, texts have proven to be especially effective in keeping patients on schedule. One older study found that text message reminders reduced no-show rates by 38%.

In addition, Nilsson said that integrating add-to-calendar links in patient confirmation and reminder emails resulted in a 7% increase in patients showing up for appointments.

“The reality is, patients are inundated with digital messages, and while confirmation emails and reminders are great, getting the appointment in a patient’s iPhone or digital calendar is even better.”

When All Else Fails, Consider a Missed Appointment Fee Policy

It may not be ideal, but the only way to handle repeat missed appointment offenders may be to charge them for missing appointments. These fees can cost patients up to $100 or more.

“Many healthcare providers have begun implementing no-show fees to disincentivize missed appointments and make up for lost revenue,” Nilsson said.

For Anderson, it’s critical to communicate with patients and, first, allow for one missed appointment before charging them for the lost time.

“I don’t confront a patient about it the first time,” she said. “The second time, I send out a bill with a fee for their no-shows. After the third time, we discuss it, and that’s when my patients realize I’m serious. I say — nicely — that if this keeps happening, I might need to discharge them from my practice.”

Ultimately, one thing that makes a difference in appointment-keeping is the relationship a patient has with a doctor and where they are in their treatment, said Rosenberg.

“When an established patient is coming for a pre-op or follow-up appointment, the rate of missed appointments is zero,” Rosenberg said.

Lambeth Hochwald is a New York City–based journalist who covers health, relationships, trends, and issues of importance to women. She’s also a longtime professor at NYU’s Arthur L. Carter Journalism Institute.