Health Care: How to Reduce No-Show, Cancellation, and Noncompliance in Outpatient Appointment

Frequent ‘No Shows’, failure to attend scheduled appointments, not only deprives other patients’ chance of having timely and needy medical care but also increases the risk of medical non-compliance and poor outcomes. Patients who schedule clinic appointments and fail to keep it have a negative impact on patient care, productivity, and learning opportunities.

It is probable that a doctor runs late for an appointment due to other patients coming late for their scheduled visits, or due to an unusually complex visit that requires extra time, which may lead to more waiting time. But, patients who miss appointments, classified into two groups: those who might be ‘excused’ because of their difficult life circumstances; and those who were simply reckless about keeping appointments, are blameworthy because they reduce the chance of others waiting for professional attention. Hence, it is necessary to understand the situation necessitating ‘no compliance’ both from the patient’s and hospitals’ perspectives and enforce policy decisions to reduce such incidence.

Literature reviews reveal that “on an average 42% of appointments become no-shows,” and are a common occurrence in primary care, but little is known about the reasons or the consequences of missing an appointment. (Lacy et al). ‘Younger patients, men, patients with lower socioeconomic status, those with traditional medical assistance or no insurance, and patients who are divorced or widowed, as well as new patients are more likely to miss appointments. Moore et al (2001) cite that the primary reason for failure to appear includes “forgetfulness, lack of transportation, feeling better, lack of sense of urgency for the appointment, lengthy amount of time between scheduling an appointment, and short notice of the appointment.”

However, one study that investigated patient issues found that the participants felt disrespected, which was compounded by their lack of understanding of the scheduling system. It is also found that most of those who failed to adhere to their appointment were unaware of the financial impact of a failed appointment and perceived their absence as a positive event for the clinician and staff.

Investigations by Moore et al (2001) to measure time and money lost from failed appointments, at a family practice center (FPC) in a metropolitan area of South Carolina, estimate that “the daily loss would total $1,412.03 or 14.2% of anticipated revenue” and the projected losses across 250 working days per year would be $353,008,” from failed appointments. Moreover, failure to attend appointments increases others’ waiting time and leads to the under-utilization of equipment and manpower. In addition, delay in the presentation will precipitate chronic conditions and avoidable ill health.

For every patient obtaining outpatient treatment, it is crucial to continue consultation with the clinician for ascertaining progress in treatment, deciding laboratory investigations, and discontinuing treatment. When a patient fails to show up for consultations, he or she is eliminating the chance of others who are awaiting their turn for consultation and are also inflicting harm on themselves by noncompliance to necessary follow-up medical care. It is probable that due to unforeseen contingencies one may not be able to adhere to individual commitments, but a willful absence is clear wastage of resources and impediment to an individual’s health.

Studies found that patients who did not attend an outpatient appointment after discharge were more likely to be rehospitalized in the same year or have a relapse, sometimes with serious symptoms that may endanger themselves. “Lack of insight, positive symptoms, younger age, male gender, substance abuse, unemployment, and low social functioning are cited as factors associated with nonadherence.” (Compton et al).

Involuntary legal status at discharge or leaving against medical advice was the strongest predictor of outpatient nonadherence. Fear of hospitalization is considered as another major factor promoting avoidance of outpatient treatment among some patients. Organizational factors acted as barriers for patients, preventing them from attending an appointment or canceling one, and communication issues at all levels were seen as a problem by all groups of participants. (Martin, Perfect and Mantle).

Basic steps to reduce no-show and cancellation rates are:

  • Call the patient once or twice before the appointment as a reminder
  • Call patients who miss appointments to let them know they have missed
  • Have the practitioner call the patient personally to discuss concerns over the effects of missing an appointment
  • Penalize the patient with a charge for a no-show

A study of strategies adopted by Kingstowne Family Practice (PLLC), Alexandria will reveal that penalizing patient with a charge for a no-show is irrational. Kingstowne Family Practice (PLLC), obtains undertaking from the patient or the responsible party to adhere to the NO SHOW POLICY of the hospital. A specific clause stating that “In consideration of those patients needing same-day appointments I agree to the No Show Policy and its stipulated fees” is incorporated in its registration form.

It boasts that though most patient registration office requires at least 24-hour notice for appointment cancellation in advance, taking into account unusual circumstances that may influence a patient’s no show, this office fixed the cancellation notice time to at least 3 hours. Cancellation messages to be left on the answering machine are date and time-stamped. If a cancellation occurs less than three hours from the appointment time it will be considered ‘NO SHOW”. For the first ‘No Show” the patient will receive a warning letter. The second time there will be a $50 charge for a regular visit, and a $100 charge for a one-hour physical appointment that is missed.

After the third time, these fees will increase to $75 and $150 respectively, if these recur within one year. All ‘no show’ fees are required to be paid at the beginning of subsequent visit, before the patient is seen by the doctor. Four ‘No Shows’, within one year, will result in the patient receiving termination letter from the practice. It is essential to maintain patient adherence to clinician’s instructions and present themselves for further investigations. But, taking stringent first step to penalize, instead of streamlining admission and follow up procedure is not justifiable. It is also essential to take lenient approach with persons who are on the way to recovery, since discontinuation of medical care will exacerbate his condition.

Most popular and effective intervention to reduce no-shows, among other things, has been reminder calls or mailings, providing transportation, new-patient education, scheduling changes, and incentives or disincentives (Lacy et al). It is suggested that “Interventions to improve continuity of care between the outpatient and inpatient settings may have an impact on adherence to follow-up care.” (Compton et al). Patient motivation is considered as the most effective method to reduce no-shows. A text messaging reminder service, which allows staff to send a text message to out patient registrants several days before their appointment to remind them to attend, is found to reduce number of missed appointments. (Case Study – Hull & East Yorkshire Women and Children’s Hospital).

For eliminating difficulty obtaining timely appointment, “‘open access’ (OA)(also known as ‘same-day scheduling’ or advanced access) is proposed as a solution to practice-level barriers by shortening wait times for appointments and improving practice efficiency.” (Bundy et al, 82). “OA is an alternative scheduling system based on the principle that patient demand for appointment is predictable. Therefore, practices can match appointment capacity to anticipated demand, and patients can be offered same-day appointment with their primary care physician” (Bundy et al, 82) reports that OA may decrease appointment no-shows, improve continuity of care, and increase both patient and staff satisfaction.

Example

It may be noted that the problem for noncompliance may not lie with the patient, and penalizing the patient in such a situation and removing him or her from the patient roster will not improve the clinic’s no-show and cancellation rate. According to Glinn, a practicing therapist with Future Rehab, LLC of Bakersfield, CA, who has extensively studied no-show and cancellation, the three primary factors that make patients to seek practices rate it in ‘Triple As’, namely: ability of the staff, access for the patients, and atmosphere of the clinic. If a clinic’s non-arrival rate borders on or exceeds 10%, it signals a problem, and should be addressed.

Sets of data to be analyzed to determine no shows and cancellations are: average weekly combined no-show and cancellation rate; average weekly no-show rate; average weekly cancellation rate; and average weekly percentage of no-shows and cancellations that reschedule and then arrive for the rescheduled appointments.

Though the problems leading to no-show may be internal and there are certain limitations on imposing fee for no-show, practices often penalize the patients. Since insurers will not pay fee for missed appointments and Medicaid forbids clinicians from charging its patients for missed appointments it will be difficult to collect the fee directly from the patient. It is suggested that calling a patient within 15 minutes of the missed appointment, ensuring probable time of appearance for consultation, leaving messages at any phone numbers in the patient’s record, sending an email, and reminding fine for no-show are better alternative to charging fee for no-show.

From the experience of Sandra Lloyd, outpatient clinic manager for the Institute for Rehabilitation and Research in Houston, two-call reminder process prior to appointment is found to give positive results, because it gives patients additional notice and reminders about their approaching appointments. Above all patient-practitioner relationship is a critical factor for adhering to appointment. Providing some staff on flex time to call patient’s home and talking with caregiver or family member of the patient, rather than just the patient, gives more opportunity to work out any scheduling or transportation problems prior to the actual day of the appointment.

It is experienced that motivation of the staff and offering incentives to the front-desk and therapy staff could reduce cancellation rates. If staffs are not motivated they will be more interested in their own schedules than patients’ schedule. Glinn explains that “a practice that aggressively tracks its no-shows and cancellations and then addresses the internal problems that contribute to the high rates can see its weekly average fall to as low as 3% to 4%.

Drawing on staff input to develop creative ways to make practice more accessible, able, and attractive to the patient can result in improvements. Active involvement of staff members in scheduling, and seeking their opinions in management decisions, as well as rewards for helping rates falling below set target can be ‘as simple as recognition for a job well done to gifts and bonuses’. Recognizing staff members who encourage patient arrivals and fostering a sense of partnership between front-desk staff, clinicians, and their patients will boost appointment adherence.

Works Cited

Lacy, Naomi L et al. Why We Don’t Come: Patient Perceptions on No-Shows. Annals of Family Medicine. 2004. Web.

Moore, Charity G, Wilson-Witherspoon, Patricia, and Probst, Janice C. Time and Money: Effects of No-Shows at a Family Practice Residency Clinic. Family Medicine, 33(7): 522-7. 2001. Web.

Martin, Chris, Perfect, Tracey and Mantle, Greg. Non-Attendance in Primary Care: The Views of Patients and Practices on its Causes, Impact and Solutions. Family Practice. 2005. Web.

Compton, Michael T et al. Predictors of Missed First Appointments at Community Metal Health Centers after Psychiatric Hospitalization. Psychiatric Services. 2006. Web.

Case Study – Hull & East Yorkshire Women and Children’s Hospital. Kingston Communications. 2008. Web.

Bundy, David G. Open Access in Primary Care: Results of a North Carolina Pilot Project. Pediatrics Official Journal of the American Academy of Pediatrics. American Academy of Pediatrics. Web.