Patients and doctors are affected by missed appointments

No-shows are a problem for both doctors and patients.

When a patient misses, or fails to schedule, a follow-up or specialist appointment they are not receiving the care recommended by their doctor.

And for physicians, when a patient no-shows, they’re left with an empty appointment space — which can be fiscally damaging in a predominantly fee-for-service payment system.

The Wall Street Journal cites a study on the issue, which “tracked nearly 7,000 primary-care patients age 65 or older … and discover[ed] that only 71% were ever scheduled for a needed follow-up appointment. Of those, 70% were actually seen at the specialist’s office, meaning that just 50% received the treatment that their primary-care doctor intended them to have.”

Scheduling an appointment with a specialist can be daunting for the older patient, who can be forgetful, anxious about the appointment, or has transportation issues.

These reasons contribute to the fact that missed specialist referrals comprise the biggest source of medical errors.

Computer-based scheduling systems can help, along with automated reminder letters, e-mails or calls. Most small physician practices lack systems to track specialist referrals, which puts them at a disadvantage when compared with large, integrated practices that house both primary care doctors and specialists.

Despite the cost of these systems, they should be strongly considered as we work to modernize our antiquated health IT system.

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  • stargirl65

    We almost always make appointments with specialists before the patient leaves the office. (The only time this is not done is when the specialist’s office is not open, like every Friday and weekdays after 3.) The address, phone number, date, time and reason are on the referral. I am not sure how much more I can do for them besides driving them there and paying for it. How much is my responsibilty and how much it the patient’s responsibility? How much is the system’s responsibility? If you want all of that oversight from the primary care doctor them you are going to have to pay management codes as well as fee for service codes. I barely make ends meet as it is and now you want me to provide babysitting services for the elderly on the side.

    • Primary Doc

      My partner was sued by a patient who developed breast cancer after failing to keep 3 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.

      • http://www.silvercensus.com/ Steffan Lozinak

        I am glad the case was dropped, but seriously, that’s absurd :-/

  • http://www.bryantsstatisticalconsulting.com Tex Bryant

    At a recent conference of the Michigan Medical Group Managers Association one speaker had a solution for this–a little open scheduling. Suppose, for instance, that a primary care physician during a routine office visit notices that her patient has an irregular heart beat. After questioning the patient, she decides that the patient should see a cardiologist soon. So, she has her office staff schedule an appointment. If the cardiologist has some open appointment space, the patient will be seen within 24 hours. If so, the patient will be more likely to show up. Too, the cardiologist will get more referrals as he will be available more often and be more responsive to the needs of the referring physician. Everyone benefits.

  • http://www.medicalisland.net Dr. Lawrence Kindo

    I completely agree with the author that it costs both the patient and the doctor dearly and investing on some advanced, automated reminder systems could be a veritable solution although it might seem more expensive initially. I know such systems would take ages to happen in India but I look forward to it’s implementation soon.

  • http://www.deerghayu.com Garima MD

    I think the physician should take it seriously and when patient shows up, should not forget to ask about what happened and how could the patient be helped by the physician or staff .
    At least patient will know that we care.

  • stargirl65

    Tex,

    I would love for the specialists to see the patient within a reasonable amount of time. It just does not happen. It is often several weeks to months for some specialists. If I call and say I need someone seen emergently, the specialists office says to send them to the ER for care. They are too busy. This even happens for patients they have seen before that call them with problems, get dumped back to me because they are too busy (I do same day appointments). Then when I call because it actually is a specialist problem they have been following, once again referred to the ER. Such a waste.

    • joe

      Stargirl:
      Enough of the specialist bash OK. I can give you many, many stories about managing uncontrolled diabetes, hypertension, infections, etc,etc when the PCP was not “available” or had no reasonable time frame appointments. I have more patient’s in my practice than I can count in whom I have become the defacto PCP because their own PCP has disappeared with their new diagnosis (cancer). PCP vs specialist is not the issue here, it is we ALL do not have the time and the non-medical people who actually run our field don’t get it and frankly don’t wan’t to get it. It is particularly galling when non-medical people like tex become health care “consultants” and make recommendations that clearly show they have never actually worked in the field. They don’t have a clue, but they will happily take money from the system for their “opinion”. No-cardiologist is twiddling his/her thumbs in the office waiting for same day appts. THERE IS NOT TIME. Just like in most PCP clinics I have seen (yours might be an exception), if there are same day appts, they are manned by NP’s for acute issues (which is fine). But even these situations IMO are the minority. Which is why the ER’s/urgent cares become fillted with these patients. Think about it.

      • joe

        PS: One more point to illustrate Tex’s “example”. Those of us in the biz know the majority of no shows are just that….no shows. There is no time to reschedule a new patient at the time another patient no shows. Unless you have an incompetant front office staff, cancellations are filled with more acute patients. I’ve been doing this for over 20 years. You don’t need a healthcare “consultant” to figure out the obvious. And, yes I do have my staff call right before the patient’s appt.

  • http://lockupdoc.com Lockup Doc

    I don’t know how feasible this would be for mainstream medicine, but I know of a large public mental health clinic that has an “intake morning” one day per week. New patients who are motivated to be seen need to get there relatively early (7AM or so) and wait in line for a couple of hours. It’s first-come, first served. If you are one of the early ones, you get your appointment and also get your foot in the door to a clinic where otherwise you would have been on a 6-12 month waiting list. Those who value their treatment are rewarded. Those indifferent to it don’t waste appointment slots that others could have used.

    I wonder if this would work for a small number of initial appointments in some other speciaties? Any thoughts?

  • rezmed09

    No shows are huge problem even when patients are given appts. and reminder calls. The answers from patients range from “I forgot” to “we went shopping” to “I felt sick” (really).

    The solution may be “skin in the game.” Patients often don’t value what they they get for free. The French health care system understands this. Patients should make a deposit for all appointments – $20, which they get back after showing up for the appointment (on time). That would fix a lot of this mess. And for all those out there who are going to scream about the docs being late, sure if the doc is late, the patient can be reimbursed more – but that means cutting your doc visit short after the second time a patient says “oh by the way.”

  • Primary Care Internist

    Maybe every patient should have a primary contact email (for very elderly, a relative). Appt info can be emailed to that contact, then if there’s a no-show situation, at least that email is there as permanent evidence that the effort was made by the PMD.

    Really, I agree with stargirl, why should the primary care doctor be responsible for any more than recommending the specialty consult & giving their info to the patient?

    And “expert witnesses” like that above should be immediately stripped of their license.