The Efficient Ophthalmologist

Getting a Handle on Reducing ‘No-shows’

Under normal circumstances, I like to present an issue or topic, and then answer or solve relevant questions or problems germane to the issue. In this case, however, I am discussing a problem for which I must admit the answer is still quite elusive. In our practice, the no-show (NS) and same-day-of-appointment cancellation rate averages 13-15%, and this costs the practice over $100,000 per provider a year in lost revenue.

Predicting No-shows

Similar to most practices, we study this trend very carefully in order to make accurate and relevant predictions about the creation of appropriate patient templates, collection of anticipated revenues, and to better understand why patients demonstrate such behavior.

While in denial mode, we blame the weather — both bad and good. We rationalize that clinic days close to holidays, tax day and post-weekend celebrators (i.e., Monday, which is the day workers call in sick most commonly) account for some of this trend. In reality, however, this situation occurs equally randomly on any day of the week, amidst many days with similar weather patterns. Just as curiously, on the biggest NS days, kept appointments can be nearly 100%, making it rather difficult to overbook the template in order to compensate for an anticipated NS/same-day cancellation rate. Overselling seats, similar to the airlines, often bites a practice on days when attendance is high, leading to longer than usual wait times and a stressed staff who serve as the front line to patient complaints.

Because our practice also serves Medicaid patients, we calculated the percentage of the NS/same-day cancellation in this demographic to determine if the problem is disproportionately higher in this population. Though it is indeed higher, it is by no means the most significant indicator of our 13-15% NS/same-day cancellation statistic.

The Reminder Call ‘Solution’

Some time back, we converted to an automated, computer-generated phone system to remind patients of their upcoming appointments. It asks them or the responsible party to press a number to confirm the appointment, or call the office to reschedule.

I argued that having lost the personal touch of a staff member calling the home, patients felt less obligated to keep their appointments. So, primarily to school myself, we did a three-month study comparing the NS/same-day cancellation rates between my patients whom a staff member called and my partners' patients our automated system called. And, as you might imagine, though the attendance rate of those called personally was slightly higher, it was not significantly so.

We did learn, however, that the request to “press the number on their telephone keypad” if they planned to keep their appointments came at the end of the automated message. Many people (my family included, by the way), once they hear the purpose of the automated call, hang up before hearing the prompt to respond. So, our messages must be short, and the request to confirm made near the beginning of the call.

We then looked at the percentage of patients who did not keep their appointments but had responded they would be there when prompted by a staff member or the automated system, and compared that to those whom the system never reached successfully. Again, there was little difference. In other words, even patients who confirmed their appointments days before still have a significant NS/same-day cancellation rate.

Tweaking the Reminders

Next, we experimented with the timing of the reminder calls. We called two days, three days and one week before the appointment. Patients we did not reach would each be called at least two more times.

We even paid an employee overtime to take home the list of patients who did not answer during the day so she could call them in the evening, assuming that some were at work during the day where we did not wish to trouble them with a call from their doctor's office. At least, we thought, if they needed to reschedule, we could still open the slot to a patient calling in for a new appointment. Silly us.

We then had the clever idea that certainly a disproportionate number of NS/same-day cancellations were attributable to those patients for whom we had no working or current phone number. And while this may be true, it is a relatively small number against the total percentage, though we have removed those patients from the template in order to fill the slot. If they showed up — bonus; although not for the patients who have to wait a little longer.

No-shows Have Excuses

Whew. Exhausting to write about, let alone trying to solve the problem. We are now doing a study in which we call the no-shows or same-day cancellations, respectfully asking why they were unable to keep their appointment. The reasons patients do not show up are as you would expect: sudden illness, no transportation, etc.

Thankfully, once we reach them, most certainly do reschedule. This is little consolation relative to the amount of staff time spent tracking them down, the template slots which could have been assigned to patients who actually show up, the idle physician and staff time, or the lost weekly revenue.

A Penalty Fee May Be Next

No-shows and same-day cancellations are a significant problem in most practices. Busier practitioners may be unaware due to a high daily volume, and an appreciation for the opportunity to catch up when behind in their clinic as a result of several no-shows.

Is the failure to call or reschedule a trend reflective of an increasingly lazy, less accountable society? Certainly people make the activities a priority that are most important to them. For example, very few people no-show or cancel on the day of their assigned surgery date (thankfully).

In any event, as a business, our bottom line suffers, and though prevalent in other fields of medicine, charging the patient a penalty fee of $25-$50 for missed appointments or those canceled less that 24 hours from the scheduled time is unpalatable in ophthalmology. However, as healthcare reform squeezes us yet further, this form of patient behavior modification may become a necessity. OM

Steven M. Silverstein, MD, FACS, is a cornea-trained comprehensive ophthalmologist in practice at Silverstein Eye Centers in Kansas City, Mo. He invites comments. His e-mail is ssilverstein@silversteineyecenters.com.