The Perennial Problem of No-Show Appointments

— Instead of overbooking, let's focus on why patients aren't showing up

A photo of an empty examination room in a doctor’s office.
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    Fred Pelzman is an associate professor of medicine at Weill Cornell, and has been a practicing internist for nearly 30 years. He is medical director of Weill Cornell Internal Medicine Associates.

If the system we have is so good, then how come it's not working?

No-shows, broken appointments, and late arrivals have been a challenge for medical practices throughout the years. The administration insists it has a system that works; however, that system consistently gives us the same poor results. In a healthcare environment that is so challenged by limited access for our patients, how can we tolerate an unacceptably high broken appointment rate?

All of us practicing medicine say that if I open up our schedule, and you fill it with good appointments, with patients who need to be seen, we will see them all. Most of us even overbook when our appointments are full and patients really need to be seen, such as for an acute sick visit, a last-minute pre-op appointment, or some other urgent issue.

I'd be lying if I said that on an incredibly busy hectic stressful practice day, when someone just doesn't show up, I didn't breathe a little sigh of relief and say, "Now I have a moment to catch my breath, to catch up on charts, to look at my portal messages, to hydrate, to grab a bite, or just use the bathroom." But the administration insists we optimize our schedules, overbook to the no-show rate, build our templates out with 130% capacity, and do everything we can to get patients in.

Wouldn't it make much more sense to work to 100% capacity? It seems that this should be more than enough.

How are we tolerating a 30%, 40%, or even 50% no-show rate for initial visits on our schedules? And across the board, for initial visits and follow-ups, our no-show rate varies between 15% and 40%, depending on the provider and the day.

One problem is that patients scheduled out of the emergency room, or on hospital discharge, often don't want to come see us 2 days after going home when they're still feeling sick. Sometimes, these patients actually have their own primary care provider, but no one bothered to ask them that. Adding them to our schedule prevents other patients from being seen.

And a patient who schedules, then cancels at the last minute and reschedules for the following week, then is a no-show for that appointment, and does this again and again, is preventing not only themselves from getting care, but potentially many other patients as well.

Most industries, including some healthcare settings, take care of this by letting clients know that if they don't show up for their appointment, they'll be charged for the time nonetheless. My dentist's office makes this pretty clear. If you cancel less than 24 hours before your appointment or just don't show up, they'll bill you for the full service. And many of my lawyer friends tell me that if someone doesn't show, or even shows up late, those minutes get billed.

The other day, as I was looking over our schedules for the practice, I noted a line of text that had been typed in the "notes" section of the appointments, which included information patients are supposed to receive, such as an explanation of our late arrival policy, a reminder to bring their insurance card and an updated medication list, and a note about our practice's no-show fee. Wait, what? We have a no-show fee?

We do not. Unlike many private practices, because of a bunch of administrative requirements, we cannot charge a no-show fee for patients who don't show. Therefore, there is no real financial skin in the game for people to keep their appointments.

I'm not suggesting we institute this kind of thing, but it does feel like this leads to less urgency to keep the appointments that are already scheduled. Not showing up doesn't have any negative ramifications -- except for the fact that they are not getting the healthcare they need, and someone else isn't being offered that opportunity as well.

So, if the appointment schedulers are telling patients about a no-show fee, are they deceiving them? My suspicion is are not even telling them this; it's is just some macro templated phrase that they put on every scheduled appointment.

Rather than wasting all this time and energy, wouldn't it be better if we could figure out a way to make sure that everyone's coming who says they are, and everyone who is definitely not coming gets that appointment cleared off the schedule to make it available to someone else who really wants and needs it?

I'm sure there are smart systems out there -- or we could find a way to build some -- that recognize patterns of broken appointments and no-shows, and figure out who we need to reach out to and make sure they're coming. Our administrators assure us that there are portal messages and text messages that can go out, reminding patients about their upcoming appointments and giving them opportunities to cancel or reschedule. If our no-show rate isn't budging, maybe instead of adding more patients onto the schedule, we could put our efforts into really making sure they're coming.

We should be insisting that we have a way to reach our patients to make sure they understand this appointment is valuable and it matters to us that they're coming. Patients need to provide a working phone number that they're willing to answer, and we need caller ID on our end that says, "This is your doctor's office calling," along with a portal message and a text message that they can respond to.

When each day starts, except for some unforeseen emergencies, we should be pretty confident that everyone who we think is coming is actually coming. That way we can push them all the important screening questions and other things needed for a successful appointment. It's time to modernize our systems and insist that our patients also take some responsibility for showing up when they say they will.

I know that some practices, after the first couple of broken appointments, will send patients warning letters and let them know that further broken appointments could lead to them being closed out of the practice. Obviously, none of us really want to do this, but if you've broken three initial visits at our practice, it's time that someone gets you on the phone and says, "I'm sorry; it seems you're wasting everybody's time. If you'd like to join our practice, we'd be willing to see you again in 6 months."

If you've made and broken 10 or 12 follow-up appointments, someone should notice this pattern and figure out the barriers that are keeping you from coming in. If it's an insurance issue, or transportation, or the weather, or anxiety, or fear of what we're going to discover at the visit, or something else we might be able to help you with, let us know. We want you here.

It's all about showing up.