How can we reduce the no-show rate in primary care?

At a quality and patient safety meeting recently, one of the departments was presenting their annual report on all they have done, reviewing progress that has been made around several quality and patient safety initiatives.

One of their project centered on efforts to decrease an incredibly high no-show rate.

Coupled with their desire to avoid overbooking appointments, the problem has compromised patient access, both for their own established patients and for new patients seeking care there.

As the clinician who is leading the initiative reviewed the efforts they have made, including more electronic reminders, telephone calls in advance of appointments to confirm that patients are coming, and care managers working with patients on transportation barriers, he dropped in, almost without slowing down, a $30 no-show fee that their practice had instituted.

Suddenly, everyone in the room woke up.

Wait, can we do that?

Everyone started buzzing and talking about this, hopelessly distracting from the rest of the presentation.

No one was really that interested in the rest of their efforts to decrease medication errors and improve care coordination and collaboration.

You could see all the eyes light up around the room at the prospect of sudden windfall, a pile of cash, magically collected from patients who didn’t show up for their appointments.

It turns out that this particular department is a specialty where the providers take very few insurance plans, with the bulk of their patients being self-pay, and the rest mostly commercial insurers with whom they’ve negotiated individual deals around this issue.

When pressed by other members of the group, this clinician did acknowledge that it is really just a veiled threat, not something that they were actually going to end up charging patients. In fact, they’d collected absolutely nothing from any patient.

So even for their practice, if after a while patients realize that no one is really going to go after them for the 30 bucks, will it end up helping their no-show rate? More than likely, those who’ve historically not shown up for appointments will continue to do so at the same rate at which they did before there was this potential monetary downside.

It’s like what they teach you in Parenting 101 classes. If you keep saying to young children that if you don’t clear your dishes we’re just going to leave them on the table, but then you never leave them on the table — and if you don’t eat your vegetables you’re not going to get dessert, but the children keep leaving their green beans untouched and dessert is delivered nonetheless — the children are never going to change their behaviors.

For most of the practices at our institution, we are unable to charge no-show fees for our patients, and most of us really have no interest in doing so.

It feels sort of punitive, and although there is certainly something to having some skin in the game, some cost to not showing up, most of us feel that it’s better to try and find a way to make the patient understand what that cost is, rather than have it become a thing all about the money.

Perhaps when we make appointments, we can find ways to communicate how important it is for the patient’s health, and for their (and others) ability to access their providers, that they keep these appointments.

“We’re giving you an appointment with Dr. Smith for next Wednesday at 9 a.m., and it’s really important that you keep that appointment to make sure your medical conditions are properly taken care of. If you can’t keep the appointment, please make sure you let us know in advance, because if that appointment goes unused, not only are you not receiving the healthcare you need, but some other patient who really needs to be seen will not be able to get into the practice.”

I’m not saying that’s going to work for everybody, but it’s possible that if you remind patients that they’re tying up a valuable resource, something that’s actually incredibly important to them, as well as potentially important to someone else, then maybe we can make some progress.

Many of my friends in private practice have late cancellation and no-show fees, and I certainly know lots of people in lots of other professions who, if you don’t show up for a scheduled professional visit, they certainly reserve the right, after informing you in advance, of charging you for the time that you have caused them to not have available to deliver the services they offer.

But here at our academic medical center, serving a vast population of complex patients in a resource-poor environment, we need to find a way to strike a balance between thinking of this as a commercial venture, where we still do need to pay the bills (and keep the lights turned on and make sure there are plenty of supplies and vaccines on hand) while sticking to our desire to be here for our patients, to prove that we’re not in this for the money, that it’s all about getting our patients the care they need when they need it.

Perhaps as we continue to develop a more patient-centered care model, and we begin to move away from the fee-for-service environment, we can fold this into some new model of payment.

Some proposed ideas have been based on the per-member per-month model, such that a practice will be paid a certain amount to provide all the care, for all the health needs, for a population of patients.

Perhaps as we refine and redesign the accountable care organization, this can be taken into the mix to help calculate the final cost of taking care of our patients, across all the services they need.

And maybe we can ultimately get so granular that we can break this down to a diagnosis-by-diagnosis cost accounting system.

Diagnosed with hypertension? This is how much we figure it’s going to cost to take care of you.

Chronic low back pain? In our experience, this is what we as an institution need to take care of you, from office visits, to physical therapy, to injections, to surgery, to imaging, to visit with multiple specialists.

Roll it all into one, and get buy-in from all of the people taking care of patients.

This could conceivably be similar to what surgeons do, where there’s a bundled payment that includes all of their pre-op visits, all of the surgery, and all of the post-op care.

Regardless of what model we end up choosing, there’s got to be a better way than to nickel-and-dime each visit, getting a fee for this patient when they show up, and that patient when they don’t.

Maybe we can even use this to tip our country ever closer to a model where cost isn’t even a major consideration in the care we need to get our patients, that everyone can receive the care they need to manage all of their health conditions, throughout their life no matter what they face.

We’ve just got to get them to show up.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

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