Sixty is the number of patients left on our schedules at the end of the day on Monday this week, people who never showed up, what we call no-show appointments. This number does not include those patients who did reach our practice to reschedule (these are counted separately), but simply those who never made it in for their scheduled appointments.

While we are a very busy practice, and this is not an enormous percentage overall for that particular day, what struck me was how many missed opportunities for us to provide care this likely represented.

Not only were those 60 patients not seen, but there must be a certain number of other patients who were told that appointment slots were not available for them to be seen, and their care had to be pushed off to another day.

Analyzing no shows

At the end of the day, each provider is expected to look back at their schedule and review patients who didn’t show up, and ensure that safe follow-up occurs. Was this a “scary” follow-up, someone who had critically high blood pressure, worrisome imaging, worsening renal function, or an abnormal biopsy, for whom we made an urgent short-term follow-up appointment? Or was it simply a patient who had scheduled an annual physical, and then didn’t show up?

We worry more about those sicker patients, but even the annual visits that no-show for their appointments come at a cost of health, and of health care. Perhaps they rescheduled and get their annual physical another day, but perhaps someone who really needed to be seen didn’t get in to be seen simply because of that placeholder, that appointment that was never used.

This morning at our practice’s Continuity and Access task force meeting, we battled with our no-show rate, our continuity indices, the challenges of getting our phones answered, the ability for urgent patients to be scheduled, the lack of infrastructure to provide truly adequate evaluation and triage before patients are scheduled, and we struggled to think about the best ways to create a perfect system of access.

One of my partners told the story of his journey to get an appointment at a new practice downtown where they use online scheduling, even for first time patients — a high tech option that allowed him, with the click of his mouse, to pick the day he wanted to be seen, the time, to pre-fill out his initial visit questionnaire, and to confirm his insurance and get pre-authorized for the visit.

He then received an email reminder the day before the appointment, offering him one last opportunity to cancel or reschedule.

But that technology will have to wait, for now for us it’s just the phones.

The unanswered phone … again

As you heard from me in this column several times, getting our phones answered remains a significant hurdle for our practice, and very frequently patients tell us they didn’t cancel an appointment because they couldn’t get through. We cannot be punitive about missed appointments if they cannot get through to let us know they aren’t going to make it in.

The administration keeps coming up with new plans to try and get the overflow phones answered, be that a rollover system that tries to find the next available telephone person who is available, or a system to shunt callers who wait on hold more than a certain number of minutes to an outside agency, who would then answer our phone, take a message, and email us.

Looking at this from the patient side, it matters that you can get in to be seen when you want to be seen. Despite what we all think about the importance of continuity, there are times when you just need to see somebody, when you’re sick, when you need an appointment. All the different machinations and combinations of overflow schedules, access teams, urgent-care dedicated providers, that we build into the system, can only begin to scratch the surface of getting our patients in to see us, which is of necessity the first step in getting them the health care they need.

So how can we fix this?

Overbooking schedules makes people anxious, people live in fear of the day where they have 100 percent show rate of a schedule they booked to a 30 percent no-show rate.

Interim care, urgent care, and any PCP-discordant care are all suboptimal, both from a provider standpoint and from a patient satisfaction standpoint. Almost always these types of visits lead to redundant testing and overtreating.

One of the challenges remains that patients who no-show for appointments have no skin in the game, there doesn’t seem to be much of a cost to them to schedule an appointment and then just not come.

A friend recently told me he went to a doctor’s appointment, and a large sign in the waiting area said, “If you are more than 15 minutes late for your appointment you may be rescheduled.” They also advised patients that that missed appointment would be charged to make up for the lost revenue for the practice, some sort of administrative penalty fee. Obviously this is not something that can be charged to an insurance company, since there is no office visit against which that charge could be filed.

It is possible that charging patients a fee for no-show appointments could reduce the rate at which they occur, and make patients less likely to schedule an appointment for which there is a chance they might not keep it. But it also puts restrictions on patients, and makes them feel they can’t make an appointment if there’s any chance they might not be able to keep it, and therefore get charged. Seems somehow to go against all we believe about our primary desire to get our patients in, to get them seen, to get them to health care.

The open access solution

Having done modified open access in my own practice here for the past 15 years, I can tell you that patients love the fact that if I’m in practice the day they want to be seen, unless I have a hard stop on my day (usually a meeting I need to be at), that we will fit them into my schedule.

The hardest part of changing to open access was convincing patients when they left one appointment that they didn’t need to schedule a follow-up 3, 6, or 12 months from now, that it was OK, just call me when they were ready, and they would be added to my schedule.

I have quite a few patients who continue to have little faith in this system, and insist on leaving the office clutching an appointment card with their next scheduled appointment to see me. Somehow this provide some security, some peace of mind, and probably helps them overcome a fear they’ve learned from other practices where they are told that the doctor’s next appointment is three months from now when they call up and want, or need, to be seen.

Open access isn’t for everybody, and it is an incredible challenge in a large practice, where people have multiple different schedules, different templates, different ideas about how they want to stack their patients on this day or that, and the rapidly changing schedules of residents adds to the intricacies and chaos of trying to get everybody in.

But no matter how we do it, seeing those 60 empty appointments, which doesn’t even begin to count the number of patients who called up and got through and actually canceled their appointments, makes me think that we certainly have the capacity to see more, to do more, to get all our patients into the care they need.

Our task force meeting ended with the administrators and schedulers along with some of the residents and faculty, breaking up into a smaller group to try and rethink how we handle the demand for appointments, overflow patients, urgent and same-day appointments, interim care versus continuity care, and I’m hopeful that we will come up with more ideas to help streamline and improve this process.

Yesterday, one of my patients was 3 hours late to her appointment because the transportation that picked her up got stuck in traffic on the bridge from Brooklyn. The last thing we want to do is bill her for this missed visit, not see her, and have her suffer the consequences of missed care.

I was long gone, at a meeting in the hospital.

But one of my partners saw her, so she did not become an empty spot on the schedule, one of those missed opportunities for care.

She showed up, and so did we.

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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