We quote from a 2008 paper by Ty Ulmer and Cathy Troxler of University of Florida's Community Health Scholars program:
The rates of missed appointments documented in the literature vary greatly. One national study in 1999, which surveyed 468 family practice residency programs in the U.S., obtained a 60 percent response rate. This study, possibly the most comprehensive one available, found that over a third of those practices surveyed had a no-show [defined as "patients who neither kept nor cancelled scheduled appointments"] rate of over 21 percent.
Another study found that both no-shows and cancelled appointments together amounted to 31.1 percent of all appointments made and 32.2 percent of the total time that is scheduled in a given workday. Another study with relatively similar results found that 25 percent of appointments scheduled resulted in missed appointments.
There are a variety of demographic and lifestyle characteristics that are associated with nonattendance. These include the patient's age, the referral source, illness, linguistic capacity, and marital status. Other structural barriers include a lack of transportation, lack of a telephone, being a single mother, long wait times, low socio-economic status, and use of Medicaid.
But, there's more, of course. Patients might not appear for a follow-up visit they deem to be unnecessary and simply an additional billing mechanism. Patients who faithfully kept their earlier appointments might resent that they were forced to wait for an hour or more beyond their scheduled appointment time. As such, they concluded that the office in question was quite overbooked, and a no-show would be...no problem.
Since health care is either "free" or substantially paid by a third party in most cases, the patient does not appreciate the value of it. Indeed, we have often said in this column that the most important thing in America about health care is that we shouldn't have to pay for it. Such issues as actual quality of outcomes pale in comparison.
Medical practice management guru Elizabeth Woodcock offers these observations:
The loss of the revenue associated with the visit is obvious, but what may not be as apparent are the many hidden costs. With a missed appointment, all the time and effort spent confirming insurance coverage, previewing the patient's chart, readying the exam room, and other tasks, are all lost. Additional resources, moreover, must be spent after patients miss their appointments. In sum, every missed appointment costs your practice big bucks—$100 to more than $500, depending on your specialty and setting.
Prevention is the best medicine. [In addition to the normal reminders], enhance your chances for a successful outcome by texting patients to remind them about their visits two hours in advance of their appointment.
She also recommends that cancellation notifications by the patient should be encouraged, and an easy mechanism to do so should be instituted. Overbooking, she argues, should be considered if your no-show rate goes above five percent.
Blogs frequented by doctors offer plenty of juicy comments and anecdotes on the matter of missed appointments, including lively debates over the wisdom of charging patients for such an offense. As most providers know, effective October 1, 2007, CMS allows them to charge Medicare beneficiaries (not Medicare itself) for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge non-Medicare patients for missed appointments.
I have to share one posting with you, the content of which seems dubious...
My partner was sued by a patient who developed breast cancer after failing to keep three referrals to a breast specialist for evaluation of an abnormal mammogram. The expert witness (an MD) said that the standard of care would have been for my partner to provide transportation and accompany the patient (a Ph.D. in her forties) to the specialist's office. After three years and over $400,000 in defensive legal fees, the case was dropped with no settlement.
Regarding SMS (text messaging) as a way to remind patients of their upcoming appointments, a number of studies indicate that this is an excellent approach. In one report, 41% of respondents indicated that they would prefer a text reminder, compared to only 1.3% who wanted a phone call. Likewise, Kaiser Permanente implemented SMS reminders in a one-month pilot project, resulting in 1,837 fewer no-shows.
While a number of such services are available to practitioners, the folks at Los Angeles-based Screenpush International Inc. are about to release Notifly, an automated appointment reminder platform. [http://screenpush.com]
I recently caught up with Joshua Otten, Managing Partner, who detailed some of the new product's advantages.
Current products are usually a small part of a much bigger and more complex and expensive platform, and many customers do not really want or need all the other tools that are included. Cost per reminder on current products ranges from 12.5 cents to 50 cents per reminder. Notifly will be significantly less expensive, as low as 2 to 4 cents per reminder.
We also wanted to reduce user error. In a number of current programs, many fields have to filled out, slowing down adoption, as well as making it complicated for the end user. In Notifly, we make it simple: You answer two questions, and the system does the rest.
Adaptive learning in the software, and our knowledge of peak response times assures that the SMS is sent out at the optimum time.
Since the most frequently cited reason for missed appointments is that the patient simply forgot, and most people seem to prefer SMS reminders, this looks like an idea whose time has definitely come.
Michael D. Shaw
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