Opinion | No-Shows Have Got to Go!

Is 120% ever the answer?

At a recent administrative team meeting, with about 100 people on Zoom, senior members of the administration started talking about ways to improve access. Clearly, access is a problem, and making sure patients get access to the right care at the right time is something we need to prioritize and optimize.

Getting our patients into care is key, making sure appropriate follow-up is made, making sure that patients have access to the specialists and subspecialists they need when we need them to be seen, making sure they can get all the tests, imaging, screening, and preventive medicine that all of us deserve and should have access to.

Overbooking Is Not the Answer

Apparently, there has been a large initiative across our institution, like many others, looking at the problems with access, and counting up the hours of available clinical full-time employees seeing patients, and comparing this to the number of patients scheduled to see them, and those that actually show up. And one of the solutions that someone in administration (not a clinician) has suggested is that to account for a high no-show rate, we should just overbook everybody.

Even on Zoom, I could hear a collective sigh going through the minds of the clinicians on the call. No-show rates, including same-day cancellations when there’s no time to squeeze someone else in, have always been a major problem for most practices. When we all come in in the morning and see a full complement of patients on the schedule, but then a number of them don’t show up, there are often mixed emotions among the clinicians — although clearly administrators don’t feel the same way.

Sometimes the clinician sees this situation as a break in their busy day, a relief from their last clinical session when they squeezed in two or three additional patients, a chance to catch up on some phone calls, or work on some of the notes of the patients they have already seen through that session, or just take a break, get a cup of coffee, use the bathroom. Breathe. But these patients that don’t show up are in fact missed opportunities for healthcare, and we would also rather they didn’t happen.

None of the doctors I’ve worked with over these past few decades have ever complained about seeing the patients that were scheduled to see them, even a full and slightly overbooked schedule. But if you schedule up to a no-show rate, you’re almost guaranteed to create more headaches and problems than you solve.

When everyone shows, doctors are going to be even more rushed, more pressed for time, feeling more overwhelmed. Care will almost certainly suffer, as what we in primary care really need is the time to sit and talk to our patients, to address their concerns, to deal with their multiple acute and chronic issues, to help get them to the best state of mental health and physical health that we can. And patients will not really like it much either.

Sure, it may make it just a little bit easier to get an appointment when they call up, but in fact the wait is probably going to be a lot longer when they arrive and they are told that their doctor has three patients scheduled at 10:00, and they are number four. So instead of trying to overbook schedules, which most of us usually do anyway when a patient calls up and needs to be seen, maybe we could just do everything humanly possible to ensure that everybody gets there for the appointments that are already scheduled.

Skin in the Game

Once again, that old line about every system being perfectly designed to get the results it produces comes into play here as well. The administration insists that everything they’re doing to try and call and confirm that patients are coming — text messages, portal messages, phone calls, robot calls, and postcards in the mail — is working. But if it’s leading to a high no-show rate, then something needs to change.

Right now, when a patient calls up our practice at 11:30 and says they don’t think they’re going to be able to make it for their 11:00 appointment that day, the system calls it a “Patient Cancellation.” Unfortunately, this is actually — and should be called for the purposes of bookkeeping and data monitoring — a “Broken Appointment,” and this information needs to be collected, and can ultimately be valuable in terms of scheduling patients for further future follow-up visits.

Patients also need to have some skin in the game. They need to know that there is a cost to them just not showing up.

Recent analysis of the data our practice collects has shown an unacceptably high no-show rate for certain types of visits, especially new patient appointments and hospital discharge follow-up appointments. Just the other day, one of our residents was seeing a new patient on their schedule, and reviewing their chart in advance of their appointment we saw that they had been admitted to the cardiac ICU at our hospital after a major stroke and multiple other complications.

When the patient finally arrived for their visit, checking in 30 minutes late for their new patient appointment, we were able to discover that the patient already had a primary care provider, had already seen them once since going home from the hospital, and had seen their outside local cardiologist as well, despite not being able to get a timely appointment with our own cardiologists who took care of them during their hospitalization. But when it was time to go home, no one had bothered to ask if the patient had doctors already taking care of them.

In speaking with the patient and their family, we learned that they had no interest in continuing to come to our clinic to receive primary care, because they were perfectly happy with their local primary care doctor who had been taking care of them for many years. Just because you send someone home from our hospital doesn’t mean they need a primary care appointment within a week with us. You need to ask the right questions.

And when we schedule patients for new patient appointments, we need to make sure they have working phone numbers, accurate emails, correct emergency contact information, and be willing to be enrolled in the patient portal. If for some reason they can’t be enrolled in the portal, we need to have a group of people work to figure out what their barriers are. It’s not enough to say that people don’t have access to broadband or cell phones or computers; we have to help them overcome these barriers to healthcare that clearly create more inequities.

The Pre-Visit Phone Call

I would love to see our institution put in a mandatory phone call at least 48 hours before appointments, making sure that patients still wanted to keep these appointments, had transportation arranged, knew where they were going to be going, had filled out all their appropriate health forms, had updated their insurance information, and anything else that would help them (and us) make the visit go smoother.

Some of these widgets that send texts to patients asking them to say “Yes” or “No” to confirm whether they’re coming to an appointment or not are not a bad way to augment things. But because we’re still seeing such a high no-show rate, clearly this can’t be enough.

And when we do call, I wish the telecom team could change the caller ID to say something other than “bland generic hospital name.” Perhaps we could get it to say “This is Dr. Pelzman’s office calling to make sure you’re still interested and able to come in to your appointment on Wednesday, so please pick up the phone — we’re not after you about an unpaid bill, we promise. We just want to be able to take good care of you.”

I bet that would go a long way to making sure people come to their scheduled appointments. And it would avoid the psychological and physical burden on patients and harm to providers of simply overbooking to the no-show rate.

I’m 120% sure.

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