Are No-Shows Harming Your Practice? Here's Help

Neil Chesanow


September 15, 2016

No-Shows: New Ways to Tackle a Persistent Problem

Getting patients to keep their appointments is a persistent problem, but many practices are experimenting with new technologies to increase the odds that patients show up on time (or at all), a recent Medscape article reported.

Over the years, practices have tried numerous strategies—mailed appointment reminders, personal and automated phone calls, fees for missed appointments, overbooking, or some combination of these—to remind patients of their upcoming appointments and encourage them to cancel those they don't plan to keep.

But none of these methods is foolproof. Charging patients for missed appointments certainly gets patients' attention, for example, but the practice remains controversial, the article noted. Melissa Stratman, CEO of Coleman Associates, a Boulder, Colorado-based consulting firm, worries that this type of action drives a wedge between patients and their doctors.

Not all practices are willing to impose no-show fees, and reminder phone calls only work up to a point. But practices are increasingly looking to technology to provide more effective solutions.

One of these strategies is texting appointment reminders. David Kaelber, MD, medical informatics officer at MetroHealth, an integrated public health system in Cleveland, Ohio, believes that texting makes it simple and convenient for a patient to cancel an appointment. "When you get a text, you're much more likely to act on it," he says. Texting has helped some practices reduce their no-show rate by 10%-20%.

Recognizing the correlation between scheduling and show rates, some practices are trying online scheduling, the article notes. The further out patients book appointments, the more likely they are to cancel or fail to show, according to research by athenahealth. (Personal communication: April Marks, athenahealth; November 16, 2015) The cancellation rate for appointments scheduled more than 20 days in advance hovers around 40%, but it drops to 11% for appointments scheduled the same day.

Smart scheduling—made possible by software that analyzes a patient's appointment history to determine the likelihood that he or she will appear, and overbooking that time slot if the probability is low—has worked well for some practices. For those with websites, electronic self-scheduling, in which patients are given the opportunity to book their own appointments based on available time slots, also increases the odds that they will show up.

The topic of reducing no-shows sparked a lively debate among Medscape readers. For many, charging patients for missed appointments, even at the risk of harming the doctor-patient relationship, is worth the gamble; the prospect of having to pay for a service you don't receive is powerful motivation to appear.

"We have a strict and enforced cancellation and no-show policy," a general practitioner explained, speaking for many commenters. "Patients are made well aware of this on day ONE. Repeat offenders are terminated from the practice."

"A quick letter with a bill for the missed-appointment fee has been helpful for us," an ophthalmologist wrote. "The letter stresses that if the patient calls and sets up another appointment—and then actually shows up—I will waive the $50 fee. (Nobody would care if the fee were only $25.) I give ample leeway—3 visits at least—before I dismiss patients who are repeat no-shows."

"Why not charge a new patient before the appointment, as new patients can be the worst no-show offenders?" suggested a pain management specialist. "This sets the tone of the nascent doctor-patient relationship."

At least one ob/gyn has already thought of that. "Canceling late is just as bad as a no-show," he observed. "Like hotels, the best solution by far is a $50 credit deposit, which is lost if a patient cancels less than 24 hours before an appointment. But the fact that I have to tell my colleagues about something so simple and obvious furthers my concern for anyone outside of private medicine really caring at all about what happens to us."

"A local dermatologist has a first come/first served policy," a psychiatrist observed. "He opens the doors at 7 AM and closes them when he has met his quota for the day. He has a thriving practice, and patients show up early to be seen ASAP."

For other commenters, no-shows reflect the fact that many patients don't value their appointments with the doctor the way they should.

"A fair number of patients don't even show up for specialist appointments," a family physician pointed out. "That's a real pity. Patients don't understand how much goes into the preparation for an appointment: calling insurance, getting permissions, sending information, etc. I think it's a general 'Who cares?' attitude on the patients' part. Respect on their part would help. Most would call their hairdresser if they weren't going to make it for an appointment—but doctor visits aren't considered as important."

"Follow-up appointments for my geriatric patients or patients with chronic illnesses take a lot of prep work," an internist agreed. "Like many primary care physicians, I spend hours the night before visits preparing the labs/radiology, reviewing specialist notes, and preparing the outline of my note to be prepared for the visit. When these patients reschedule, it wastes all of that work and messes everything up. I don't think patient self-scheduling will help with this at all," he adds. "It seems more of a solution for acute visits."

"You can't have a 'patient-driven' system when the patient isn't really a customer in the sense that they are not the ones paying for the service," a psychiatrist opined. "It's been my experience that the lower the copay, the more likely it will be that the patient will not show up."

But other doctors said they understood the situation from the patient's perspective.

"There is another side to this issue," an emergency physician maintained. "When patients sit and wait for an excessive length of time for a scheduled appointment, but then the physician charges a no-show fee if the patient can't make the appointment or is late, it does not convey a positive message about the physician."


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.