Thesis-No-Show Project Bridgette-Noel Final

No-Show Appointments 1

Running Head: WHY ARE PATIENTS NO-SHOW FOR APPOINTMENTS WITH THEIR

PRIMARY CARE PROVIDER

Why Are Patients No-Show for Appointments with Their Primary Care Provider?

Brenda L. Bridgette-Noel, BA (Candidate for MBA)

MGT 6750: Thesis

April 2011

Advisor: Catherine Coleman-Dickson


Table of Contents

Acknowledgements…………………………………………………………………….3

Abstract …………………………………………………………………………………4

Chapters

I. Problem Statement and Need for Research………………………………………5

II. Review of Current Literature……………………………………..........................10

III. Description of the Methodology………………………….…………………. ….23

IV. Findings…………………………………………………….…………………....25

V. Conclusion and Recommendations………………………….…………………...35

Appendices:

Appendix A (Questionnaire)…………………………………………………………….41

Appendix B (Rating Average) ….……………………………………………………….42

Appendix C (Results Charts) …………………………………………………………….45

Appendix D (No-Show Letter) …………………………………………………………...48

Appendix E (Proposal for No-Show Reduction) …………………………………………49

References……………………………………………………………………………….50


Acknowledgements

I would like to acknowledge a number of people for their support and prayers through

this experience.

To my husband for his support and help throughout this process, thank you for being an

unbelievable cheerleader, my foundation, and editor. But mostly, thank you for being a great

listener during this whole process.

To my sister and friend Dorothy – you are my prayer partner and the check and balance

in my life. Thank you for the constant encouragement and the devotion that you have shown.

You have been so patient with me these past few months!

To my sister Allyson, the love that you have shown me was well received. Thank you so

much for always encouraging and supporting me throughout my education and life.

To my Children’s Hospital of Philadelphia (CHOP) family, Sharon Sutherland, MD and

Andrea McGeary, MD-Medical Director, thanks for lending your time to assist with the research

and for providing continual feedback.

Finally, thank you to my Rosemont family, Joan Wilder and Marie Bynum for your on-

going support. To Catherine, my thesis advisor, you have been so helpful and informative,

despite your busy schedule and our short time-line! I appreciate all your help and support.

Thank you.


Abstract

Missed patient visits (no-shows) continue to be a growing problem within the healthcare system

in many urban areas. Medical practices are often looking for ways to reduce the no-show rate by

analyzing patterns relating to missed appointments. The costs of missed appointments are

significant and are gaining attention throughout medical institutions. Emergency Department

overuse is about $38 billion dollars in the United States. The goal is to reduce Emergency Room

utilization by getting patients back to their medical home for continuity of care. A survey,

developed by the author, will be used to investigate some of the reasons why patients’ miss their

scheduled appointment with their primary care provider. Results from the survey will be

presented, followed by a comprehensive review of current literature surrounding interventions

for this wide spread problem. The author will examine the current model of acute and well care

access at The Children’s Hospital of Philadelphia Primary Care Center at Cobbs Creek and

investigate other health care models. The hope is to decrease the no-show rate at the pediatric

primary care practice in West Philadelphia.


Chapter 1: Problem Statement and Need for Research

Throughout the United States, health care providers and staff often struggle with patients

who frequently do not show for appointments. This is a major issue for medical practices in

several urban settings. When patients fail to show up for their primary care (PCP) appointments, it can

lead to a delay in diagnoses and detection of diseases. Missed appointments with a primary care

provider unavoidably increases emergency room utilization, which accelerate the cost of that patient care.

It is now a national initiative to get patients back to their medical home. Many governmental and

insurance companies are all collaborating in trying to find ways to improve continuity of care and at the

same time decrease cost to the health care system. The goal is to practice preventive medicine in the

medical home.

Today, a growing number of people are using hospital emergency departments (EDs)

for non-urgent care for conditions that could have been treated in a primary care office. On a

national scale, 56 percent or roughly 67 million visits are potentially preventable. If this trend is

reduced, it will allow opportunities to improve quality health care and lower the costs within the

health care system. Simplified, the problem is expensive care in the incorrect place at the

incorrect time. In 2005 the annual number of emergency department visits in the United States

increased nearly by 20% from 96.5 million in 1995 to 115.3 million. That increase was seen

over a period of 10 years (www.nehi.net, 2010). This begs the question regarding why patients

present to the ED for non-acute issues rather than to their primary care provider (PCP). Can it be

that many Americans do not have a PCP?

To further understand this wide spread issue, it is imperative to ascertain who uses the

ED for non urgent care and why that choice was made rather than seeing a PCP? A national

survey of emergency departments demonstrated that 56% of all visits were avoidable (Figure 2).

Emergency room abuse continues to grow exponentially with little intervention to changing this

http://www.nehi.net/


pattern of behavior. According to the New England Healthcare Institute (NEHI), the overuse of

U.S. emergency departments (EDs) is responsible for $38 billion in wasteful spending each year

(March 2010). This has emerged as a significant topic of discussion—and debate. The

following graph demonstrates non-urgent visits nationwide are on the rise.

Source: CDC National Hospital Ambulatory Care Survey

In 2007, the NEHI published a seminal report entitled, Waste and Inefficiency in the

Health Care System-Clinical Care: A Comprehensive Analysis in Support of System-Wide

Improvements. “The research found that 30 percent, or nearly 700 billion, of all health care

spending is wasteful, meaning that it could be eliminated without reducing the quality of patient

care.” The study found six major sources of waste such as; unexplained variation of clinical

care, patient medication adherence, misuse of drugs and treatments, emergency department (ED)

overuse, underuse of appropriate medications, and overuse of antibiotics. For the purpose of this

paper, the focus will be on emergency department overuse, which was the fourth largest category

of misuse responsible for up to $38 billion in wasteful spending in the U.S. every year (NEHL

Research Brief, 2010).


Emergency departments are the only place in the U.S health care system where people

have access to a wide range of services at anytime regardless of their ability pay or the severity

of illness. Currently, the ED appears to be functioning somewhat as a primary care office rather

than a place that treats acute illnesses. The nationwide study highlights that patients present to

the ED for basic services such as prescription refills, colds, flu, diaper rash, ringworm, just to

name a few. The high costs of emergency room care impacts patients and insurance carriers and

create a drain on health care dollars. A study performed in Massachusetts showed that

emergency department overuse is high across all insurance payer groups (Figure 2).

Figure 2. Avoidable ED Use in Massachusetts by Insurance PayerGroup, 2005

Source: MADHCFP

The Massachusetts study also demonstrated that avoidable ED use was almost

identical across all age groups, even for patients 65 and older (Figure 3). With that said, ED

overuse encompasses the entire population, despite of age or insurance (NEHL, 2010).


Figure 3. Avoidable ED Use in Massachusetts by Age Group, 2005

Source: MADHCFP

Further studies have shown that the abusers of the emergency departments have

contributed to the growing cost of health care and consumers are paying for that abuse in the

form of higher premiums. Why are the insured and uninsured, coming to the ED in large

numbers? According to Meisel and Pines (2008), the answer is economics. The way in which

health information is shared and incentives aligned, both patients and doctors are driving the

uninsured and insured alike to line up in the ER for medical care. It has been suggested that

many people without a health care background don't have a good way to judge whether

headaches, stomach discomfort, or fever are true medical emergencies. Primary care providers

have little reason to tell someone not to seek ED care, especially if the complaint is potentially

serious. If by chance the doctor advised the patient to wait and not to go to the ED and the

patient’s symptoms worsen the malpractice potential is always there. With that said, many come

to the ED because it’s a one stop shop that is always open.


Emergency department overuse is an area where costs can be reduced significantly if

patients return to their medical home for non-urgent care. Research suggests that many of the

patients that end up in the emergency room for non acute issues tend not to be followed by their

primary care providers, does not have a primary care provider or demonstrate a history of

multiple no-shows. These patients often come from low-income families with government

assisted coverage, uninsured or self-pay (Market Watch, 2010).

No-shows often correlate with access, delays and lack of continuity in care, which leads

to the following concerns. Why do patients choose to go the emergency department for non-

acute care? What are the patterns with those patients that present to the emergency room? This

paper will attempt to address common themes in these patients and examine the factors relating

to missed appointments.


Chapter 2: Review of Current Literature

In order to present a comprehensive background for this research, a review of current

literature pertaining to this topic is structured as follows. First, an overview of the problem, next

the definition of “no-show,” followed by current literature reviews from various medical

institutions, which includes primary care and specialty practices. Finally, barriers, interventions

and opportunities related to this topic will be discussed.

Non-attendance (failure to attend clinic appointments) is a universal problem in the

management of pediatric clinics. In general, non-attendance rates in the United States (US) range

from five to 55%, whereas United Kingdom (UK) figures range from three to 12% (Goldbart, et

al 2009). According to Goldbart et al, “Non-attendance has both social and financial costs.

Social costs include unused resources, such as personnel time, equipment and clinic capacity

(2009).” Primary care providers rely on appointment scheduling to keep their practice operating.

A missed appointment means the providers, nurses, phlebotomists and other support staff

suddenly find themselves with time on their hands that should be filled by sick or well patients.

However, that medical appointment time may never be recovered. This becomes more

problematic when appointment demands are high, especially during the flu and cold season or

when parents are trying to get mandated school forms or sports physical appointments for their

children.

No-shows are referred to as “missed appointments” and “non-attendance,” which will be

used interchangeably throughout this paper. No-show is defined as, “patients who neither kept

nor cancelled their scheduled appointments in advance,” (Goldman et al, 1981). This represents

a persistent problem in many ambulatory medical settings. A missed appointment limits

practices from providing care to patients and their failure to cancel appointments in advance


create substantial inefficiencies for the physician and for the medical institution. When there are

missed appointments there will be missed revenue. There is a price for no-show appointments

and last minute cancellations. In addition to affecting efficiency, failure to manage this area of a

medical practice can result in staggering associated costs. For example, if the average evaluation

and management charge for a patient with Gastro- esophageal Reflux Disease (GERD) is $150

and there are five no-shows each week, the lost revenue could be $39,000 a year or more.

In 2008, Elmendorf Air Force Base experienced 15,521 no-shows of medical

appointments, costing the hospitals in the Anchorage Bowl, Alaska nearly $1.3 million in lost

productivity. The report further showed that there were 4,493 beneficiaries, not on active duty,

they however, diverted to Urgent Care Centers. It is not their preferred method to seek care but

it created an additional expense of more than $500,000, bringing the total cost to nearly $2

million (Sorrells, 2009). To help reduce appointment no-shows at Elmendorf Air Force Base, an

appointment reminder system was established to call patients two days before their

appointments. The system sends a message identifying the patient, date and time of the

appointment. The system gave the patient the opportunity to cancel the appointment, which

freed up the slot for someone else to utilize. The downside to this system is not having correct

patients’ phone numbers for the system to perform reminder calls.

The Sibley Heart Center at Children’s Healthcare of Atlanta, which handles 30,000

outpatient’s appointments at 18 facilities annually, rolled out a new initiative to reduce a 16.7%

same day cancellation and no-show rate. The Market Watch, 2010 research showed that the

types of patients who were least likely to show often came from low-income families either on

state coverage such as Medicaid or uninsured and self-pay. Patients in that study gave the

following reasons for missing their appointments: “We couldn’t find the place, the directions


were bad, I forgot, I could not find parking and I did not have a ride.” Some of the respondents

were unaware that Medicaid provides transportation for their patients (Market Watch, 2010).

Although, patients routinely receive an automated reminder calls 48 hours before the

appointment time, five of the clinics continued to struggle with habitual no-shows. Staff

members decided to take it a step further by making personal calls five to seven days in advance

to families who have missed previous appointments. The caller verified that patients had

directions and a ride to prevent challenges associated with missed appointments. Since the

program is in its early stages, comprehensive data is not yet available. However, the no-show

rate appears to be declining (Market Watch, 2010).

A large national survey of 160 pediatric residency continuity clinics with children of all

ages including adolescents showed an average appointment failure rate of 31%. Failure to keep

clinic appointments is also a major barrier to effective and efficient health care delivery. Among

the myriad of reasons, forgetfulness is cited as number one for appointment noncompliance

among adolescents and adults (AAP, 2010). Several studies have shown that telephone and

mailed reminders are effective in improving clinic attendance among children and adults. One in

particular, was done at an inner city hospital based clinic, which examined the effect of a single

telephone call reminder on appointment compliance among 703 adolescents. The study was

divided into a control and an intervention groups. The intervention group received the

appointment reminder call while the control group did not.

Findings from the study demonstrated that the attendance rate was significantly increased

from 44.1% in the control group to 55.6% in the attempted intervention group. This represented

a 26.1% increased in the attendance rate. The completed intervention analysis, which included

the control and the intervention groups who were contacted successfully by telephone, showed


an increase in the attendance rate. Attendance was significantly increased from 44.1% in the

controls to 65.2% in the group that was contacted successfully by telephone. This represented a

47.8 % increase in attendance. The telephone call reminders were successful in improving

appointment compliance because two thirds of the adolescent patients who received telephone

reminder calls kept their appointments (Bundy et al, 2010). The only other study factor

associated with appointment attendance were patients without insurance, they were clearly less

likely to attend. The result of this study suggests that telephone reminder messages are very

effective in increasing attendance rates in a hospital-based adolescent clinic.

According to a report issued by Courtney Griggs at Fort Sill, 17,000 patients missed their

appointments at Reynolds Army Community Hospital in 2009, which cost the hospital over $1.2

million in lost revenue. The report mentioned that, “When somebody doesn't show up for an

appointment, the doctor is sitting there wasting his time, and then there are calls from other

patients who cannot get an appointment” (2009). Because patients choose not to call to cancel

appointments, it hampers productivity within the medical practice and it prevents other patients

from gaining access to see the doctor. The reporter further asserted that a no-show is not just

one missed appointment but it is two, it is a missed appointment for the person that did not show

up and a missed appointment for the patient that could not get in. Dr. Bruce Lovins, Chief of

Primary Care noted that an office visit cost about $94, multiply that by 17,000 patients and it will

cost about $1.6 million in lost revenue (www.army.mil). It appears that patients and families are

not making the connection that missed appointments are costing the government and tax payers

millions. Although there were no interventions mentioned in this report, the hospitals are

requesting that patients and families call to cancel appointments as a way to reduce no-shows.


In contrast to the study done at the inner city hospital based clinic for 703 adolescent

patients, prior research has been done to ascertain methods used to keep visit rates (show rates)

high among family medicine residency practices in the United States. This investigation was

performed because patients’ failed to keep their scheduled appointments in family medicine

residency practices, which became challenging to manage. Johnson et al researched and

gathered effective management strategies used to achieve low no-show rates. A one-page

questionnaire was mailed out to 448 family medicine residency program directors to provide data

for their residency practice for the following information.

1. The distribution of patients by age and by type of health insurance.2. The average numbers of new and established patients seen, and the average

number of no-shows per half-day,3. The level of satisfaction with the current methods for reducing no-shows and for

managing no-shows4. Assessment of the impact of no-shows on resident education, continuity of patient

care, patient access to care and clinic outcome (Johnson et al, 2007).

Respondents were given the option of supplying actual data and to free text their methods

for reducing and managing no-shows. The management of no-shows was defined as “reducing

the impact of no-shows once they occur” (Johnson, Mold and Pontious, 2007). Of the 448

questionnaires, which were mailed, 141 practices responded with a total of 31.5% response rate.

The study shows that the respective mean and median no-show rates were 17% and 15%.

Practices with higher proportions of new patients (P=.03), Medicare patients (P=.008) and self-

pay patients (P=.001) were more likely to have higher no-show rates, and those with higher

proportion of patients aged 46 to 64 years (P=.002) were more likely to have lower no-show

rates. The no-show rates were not associated with the proportion of pediatric or Medicaid

patients (Johnson, Mold and Pontious, 2007). It appears that respondents were more concerned


about the impact of no-shows on patient care that is both access and continuity of care. Statistics

for the questionnaire variables are shown in Table 1.

Table 1. Descriptive Statistics for Residency Program Practice (n=135)

Variable Mean Median Range

Patients’ health insurance typeMedicaid, %Medicare, %Private insurance, %Self-Pay, %

0.35 (0.19)0.20 (0.10)0.31(0.21)

0.300.20 0.27

0.0 -0.800.01 -0.480.01 -1.00

Patients’ age distribution0-18 years, %19-45 years, %

0.23 (0.11)0.30 (0.11)

0.200.30

0.02-0.600.1-0.75

46-64 years, % 0.27 (0.10) 0.25 0.03-0.6065-79 years, % 0.16 (0.09) 0.15 0.0-0.5580 years +, % 0.06 (0.06) 0.05 0.0-0.50Patients seen per half-dayNew patients, n 1.77 (0.79) 2.0 0-4Established patients, n 7.08 (2.02) 7.0 1-12Total No. of patients, n 8.81 (2.23) 8.0 3.5-15No-shows per half-day, n 1.83 (0.98) 2.0 0.4-5.0No-show rate, % 0.17 (0.07) 0.15 0.03-0.42Administrator satisfaction score *Reducing no-shows 2.79 (1.00) 3 1-5Managing no-shows 2.93 (0.97) 3 1-5Impact of no-shows score +Overall 3.05 (1.20) 3 1-5Resident education 2.76 (1.07) 3 1-5Continuity of care 3.06 (1.11) 3 1-5Access to care 3.31 (1.10) 3 1-5Income 3.09 (1.05) 3 1-5* Where 1= very dissatisfied and 5 = very satisfied. +Where 1= minor impact and 5 = major impact.

The methods used by the rate exemplars fell into six categories: patient education, patient

reminders, sanctions, open access, emphasis on continuity, and scheduling rules (Table 2). All

but two practices attempted to contact all patients within 24 to 48 hours of every appointment to

remind them of the appointment. One practice administrator reported that “when a secretary,

who had been telephoning all of the patients the day before their appointment, decided to stop

doing so (without telling her supervisors), the no-show rate went from 5% to 10% within one

week.” Of the two practices that did not telephone to remind patients, one had a complete open-


access scheduling system. The clinic manager reported, “Our no-show rate, which was 25% two

years ago, went to 9% when we began calling every patient the day before their appointment and

added a walk-in clinic, and to 4% when we converted to an open-access scheduling system”

(Johnson, Mold and Pontious, 2007).

Several of the practices created no-show policies for patients who did not keep

appointments in attempt to curtail this issue. The following are list of interventions taken to

control patients that missed their appointments:

1. Patients were forewarned about the policy upon joining the practice and or when scheduling or being reminded of an appointment.

2. Systems were created to track and document no-shows in the patients’ medical records and scheduling system.

3. Notification to the physician of all no-shows.4. A telephone call to the patient after each no-show.5. Warning letters after each of the first two no-shows.6. A dismissal letter after the third no-show in six months (Johnson, Mold and

Pontious).

According to this report, 90 % of the patients who missed three appointments within six

months were dismissed from the various practices. This may appear to be punitive to the general

public, especially, with young pediatric patients who may not be able to make the decision on

whether to present for an appointment or not. Prior research suggests that in primary care

residency program practices, those more likely to missed scheduled appointments are young

adults, unmarried and non-white patients. They seem to have larger families and less education,

whose language, race or sex is not concordant with that of the clinician, patients who have no

insurance or are on Medicaid, patients new to the practice, patients referred from the emergency

department, patients with acute rather than chronic illnesses, patients scheduled with first-year

residents or medical students, patients with a history of missed appointments and patients with

physician-identified psycho-social problems (Johnson, Mold & Pontious, 2007). Strategies used to

reduce no-show rate are reflected in Tables 2 and 3.


Table 2. Strategies Used by Exemplary Practices to Reduce

No-show Rates (n=11)

Method Practices Using Method

No. (%)

Patient education 10 (9)

On enrollment in practice 7 (64)

When each appointment is made 6 (55)

When reminded of appointment 4 (36)

After each no-show 7 (64)

After repeated no-shows 5 (45)

Patient reminders 9 (82)

Telephone call to all patients 9 (82)

Letter/card to all patients 1 (9)

No. of reminder strategies, median (range) 1 (0-3)

Patient sanctions 9 (82)

Expelled from practice 9 (82)

Required to walk-in (no appointments) 1 (9)

Open-access*

Complete

Partial (lots of work-in slots)

9 (82)

3 (27)

6 (55)

Residents work in small teams 7 (64)

Try to determine cause for no-shows 2 (25)

*Open access defined as no appointments made beyond 1 week ahead; complete open access defined

as no advance appointments; partial open access defined as some advance appointments.

Table 3. Strategies Used by Management Exemplar Practices (n=8)

Method Practices Using Method


No. (%)

Overbooking 5 (63)

Overbook all residents equally 3 (380

Overbook based upon no-show rate 2 (25)

Walk-ins and work-ins 8 (100)

Encourage/allow walk-ins/work-ins 7 (88)

Adjust schedule to demand-see all patients wanting to be seen

2 (25)

*Open access defined as no appointments made beyond 1 week ahead; complete open access defined

as no advance appointments; partial open access defined as some advance appointments.

Furthermore, open- access scheduling has been suggested as a way to improve patient flow

and increase continuity of care and patient satisfaction. An open-access system may better meet

the needs of the patients who frequently missed appointments. Two practices within the study

reported that the no-show rate dropped by 50% after they converted to an open-access scheduling

system (Johnson, Mold and Pontious, 2007). Based on this study it is possible to reduce the no-

show rates in residency practices to below 10% by using combinations of well established

methods consistently. Reducing the impact of no-shows once they occur seems to be best

accomplished by increasing the numbers of walk-in/work-ins patients and overbook the

residents’ schedules equally.

Another study was done to investigate the factors for no-shows in pediatric allergy

patients. In this research, variables such as the effects of age, gender, ethnic origin, waiting time

for an appointment and the timing of the appointment on non-attendance (no-show) were

assessed. Chi-square tests were used to analyze statistically significant differences of categorical

variables. Logistic regression models were used for multivariate analyses. A total of 442 visits in


a 21-month period were included in the study. The overall proportion of non-attendance (no-

show) at the pediatric allergy clinic was 33.0%. Jewish rural patients had 19.4% non-attendance;

Jewish urban patients had 35.6% non-attendance; and Bedouin patients had 57.1% non-

attendance (p < 0.001). Non-attendance was higher in spring and winter (43.5% and 36.7%,

respectively) than in summer and autumn (26.9% and 26.5%, respectively) (p = 0.016). The

research further noted that no-shows were not significantly influenced by gender, age and hour

of the appointment or waiting time for the appointment. A multivariate logistic regression model

demonstrated that the ethnic origin of the patients and the season of the year were significantly

associated with non-attendance. Logistical issues such as when the appointments were scheduled

and time of day were also significant predictors. The study concluded that in children attending

allergy clinics, factors that determine non-attendance include the ethnic origin of the patients and

the season of the year (Dreiher, et al, 2008). The purpose of this study was to identify factors

contributing to no-shows and no interventions were discussed.

A randomized controlled study was performed in an urban primary care clinic at the

Geneva University Hospitals serving a preponderance of vulnerable patients. “The purpose of

that study was to test the effectiveness of a sequential intervention reminding patients of their

upcoming appointment and to identify the profile of patients missing their appointments.”

Patients booked appointments in a primary care or HIV clinic and were sent a reminder 48 hrs

prior to their appointment according to the following sequential intervention: 1). Phone call (land

line and mobile); reminder; 2). If no phone response: A Short Message Service (SMS) reminder;

3). If no available land line or mobile phone number: a postal reminder.

The rate of missed appointment, the cost of the intervention, and the profile of patients

missing their appointment were recorded. Results 2123 patients were included: 1052 in the


intervention group, 1071 in the control group. Only 61.7% patients had a mobile phone recorded

at the clinic. The sequential intervention significantly reduced the rate of missed appointments:

11.4% (n = 122) in the control group and 7.8% (n = 82) in the intervention group (p [less than]

0.005), and allowed to reallocate 28% of cancelled appointments. A satisfaction survey

conducted with 241 patients showed that 93% of them were not bothered by the reminders and

78% considered them to be useful” (Perron, et al, 2010). The study concluded that a simple

reminder system can increase the show rate significantly at medical outpatient practices.

Barriers:

Access to healthcare seemed to be a major barrier; it is defined by the Institute of

Medicine (IOM) as “the timely use of personal health services to achieve the best health

outcomes.” A study done by the CDC revealed that only 18 percent of US children receive all

recommended immunization without delay in the first two years of life (Randolph, 2004). The

challenges surrounding efficient access are an issue most primary care offices faced daily. To

date, interventions addressing children’s access to care have mainly focused on health insurance

and availability of clinicians.

Conversely, health systems are increasingly examining the impact of practice scheduling

systems on access to care for patients. Diwakar and Denton asserted that,” appointment

scheduling systems lie at the intersection of efficiency and timely access to health services.

Timely access is important for realizing good medical outcomes (2008).” It is also an important

determinant of patient satisfaction. Advanced Access, more commonly called ‘Open-Access’

appears to hold promise not only to more timely delivery, but also to more patient-centered and

efficient care in pediatric practices.


There are other barriers related to access to care such as patients’ preferences for time of

day, (often evenings and Saturdays appointment preferred) in addition availability of particular

service provider is important for some patients. Still, the problem of matching supply and

demand is not simple because different patients have different perceptions of the urgency of their

need (Diwakar and Benton, 2008). This expectation can be challenging because of the practice

inability to accommodate such request due to exam room capacity and staffing. Patients’ wait

time within the office is another barrier to care. Evidence also suggests that many no-shows are

related to discomfort experience during the appointment and disrespect caused by long wait time

(Diwakar and Denton, 2008). This may occur because the provider is running behind with

complex or acute patient care.

Many urban disadvantage families do not have access to transportation, making arriving

on time for appointments difficult. Once the appointment is made if the patient is not seen by

their Primary Care Provider (PCP), it can result in an inefficient visit. Because that provider is

unfamiliar with the patient’s history and it could take twice as much time to review the medical

chart. Physicians’ personal life can result in unexpected patient visit cancellations, which are

missed opportunities for care. With that said, not only the patient but the provider can

contribute to missed appointments.

Opportunities:

Open-Access is a primary area for improvement to assist patients with easier scheduling,

which prevents delay in treatment and diagnosis. It takes away the barrier that tends to exist

within the healthcare system (Diwakar and Denton, 2008). In addition, it provides more

flexibility for parents and empowers them to coordinate their child’s care and prevents

emergency room visits.


Another opportunity is to allow for a few walk-ins per day according to challenges that

may exist within the families such as telephone access and language barriers. Some studies have

shown that overbooking is one way to accommodate patients with time constraints, for example,

working parents. The idea of overbooking is to compensate for the expected no-show that the

practice experience.

Recommendations have been made to redesign the scheduling systems to allow medical

practices to offer same-day appointments to all patients regardless of the nature of their problems

(routine or urgent). The guiding principle is, “do today’s work today.” Basically, you are

matching the supply of the clinicians each day to the daily demands for office visits. This model

will reduce wait time for appointments, elimination of “wait list,” and ultimately improve office

efficiency. This appears to be a recipe that may improve continuity of care by matching patients

with their primary care physicians, which will enhance access to care.

Chapter 3: Description of Methodology

The purpose of this paper is to determine why patients are no-shows for their medical

appointments with their primary care providers. Existing research discussed in Chapter 2, as well


as additional journal articles, leads the researcher to believe that the problem is not specific to

just primary but various specialties. Several barriers were identified as well as opportunities to

improve patients’ show rate at the researcher’s pediatric primary care practice in West

Philadelphia. However, to verify this hypothesis data needed to be collected through a survey

administered.

Research Approach

A survey was created to gather information needed to analyze the myriad of reasons why

patients are no-shows for their medical appointments. The survey consisted of three questions;

the first was multiple choices while questions 2 and 3 were open ended. Additional research was

done to ascertain internal triggers that may increase the no-show rate. The responses were then

analyzed and tabulated.

Data Collection Methodology

A survey was produced and distributed to 1200 pediatric patients. The survey was

distributed amongst four primary care centers within the city of Philadelphia. Phone interviews

were conducted as well as a paper version were created and randomly distributed within the four

primary care centers. Although 1200 patients were requested to complete the survey, and 1,024

responded, which resulted in an 85% return rate. An electronic survey tool such as “Survey

Monkey” was not chosen because the majority of the respondents do not own computers and or

reluctant to give their email addresses. This caused the researcher to look for alternative ways to

reach the sample audience to ensure an acceptable return rate. Appendix B includes a copy of

the survey that was utilized with the rating and percentage.


For this thesis, information was gathered by using published information such as Health

Care Journals, insurance carriers’ websites and The Children’s Hospital of Philadelphia (CHOP),

Data Collection Department. Children and adolescent were all included in the study because the

four primary care practices provide care for patients from age 0-21 years. In terms of

demographics the practices are located in urban areas. Internal and external variables potentially

associated with no-shows, such as payer plans (insurance), visit types (sick, return, well and new

patient) and time of day (appointment) will be measured, shown in Appendix C. Emergency

Room visits from CHOP will be reviewed from February 2010 to January 2011 for the four

primary care centers. The information will be given in a graphical and narrative form.

Quantitative methods will be used to identify patterns with the data collected. The results of the

survey will be discussed in Chapter 4.

Chapter 4: Findings

The author’s research was conducted to ascertain the various reasons for no-shows in a

physician’s office. Chapters 1-3 of this thesis presented the purpose and the objectives of the


study, provided a review of current and relevant literature relating to no-shows and examined the

methodology by which the research survey was developed and conducted. In reviewing

pertinent literature and discussing the no-show issue which seemed problematic for most

practices, it became clear that there is no single solution. Although, you cannot eliminate no-

shows completely, you can reduce their frequency. The reason and the rates for no-show vary

greatly among primary and specialty care offices. However, the financial impact of no-shows

can be challenging to manage and may affect the bottom line. Barriers were discussed as well

as opportunities to keep patients in their medical home and avoid over utilization of the

Emergency Room for non-acute symptoms. In Chapter 3, the methodology used to collect data

for this study was illustrated. The chapter outlined the survey that was administered to the

respondents in order to verify the author’s hypothesis.

Results of the survey

In this section, respondents’ answers to each question of the survey will be addressed, and

significant findings will be presented. The results in their entirety can be found in Appendix B

(illustrating total response by questions and percentage), and Appendix C (displaying pie chart

results by internal and external variables). As discussed in Chapter 3, the response choice for

question one was multiple choice, while questions two and three were open ended, which sought

to explore the qualitative in-depth opinion of the respondents.

The first question addressed the reasons why patients did not show-up for their

appointments. 38% mentioned appointment time, 17% mentioned transportation, 16% stated

insurance/co-pay concerns, 12% stated that the child was feeling better, 11% stated other-patient

related challenges, while 5% stated other-office related challenges were connected to their


missed appointments. A few examples of the 5% that stated office related challenges were,

‘appointment too far out, office error, office closed, and parent not aware of the appointment.’

This suggests that appointment times given to patients are not convenient for them and the

offices may need to delve further to gain a better understanding of ‘time of day.’ The issue of

lack of transportation appears to be more of an external issue relating to the patient rather than

internal to the office. However, further inquiries are required to learn of the available resources

for disadvantage patients.

Although insurance and co-payment are issues for some patients the government has

provided programs such as ‘Children’s Health Insurance Program’ (CHIP), so children in the

United States have the opportunity to be insured. It is a matter of educating and pointing

families to the available resources. It became imperative for the author to dig deeper to

understand what responses fell into the ‘other’ category because 16% made that choice. Upon

further investigation it became apparent that the responses noted below had to be separated into

two categories such as ‘other-patient related’ and ‘other- office related’ in order to comprehend

the feedback provided.

Some of the responses in the “other” category are as follows: dissatisfied with front desk service, did not like the doctor, appointment too far out, appointment made and parent not aware, family emergency, personal, loss of job, school, parent sick could not bring child to the appointment, scheduled with the wrong doctor, out of town, custody issues, office error, late for appointment and weather.


Question two of the 1,024 completed surveys, addressed the reason that prevented the

patients from calling to cancel their appointment. The responses are as follows: 32% stated that

they forgot/no reason given, 21% called/arrived after the appointment time, 2% noted that the

office was closed, 8% stated that their telephone were disconnected and 19% went to the ED.

The ED data is quite significant because further evidence showed that over 13,000 patients went

to the Emergency Department (CHOP, Data Collection Department) during the period of May

2010 to February 2011. Although, financial information was not available, it is important to

capture the data based on operational impact or cause and effect analysis. 5% stated that they

were not aware of the appointment; another 5% noted that it was a scheduling error while 6%

mentioned that telephone access to the office was an issue. Interestingly, the highest percentile

reflected the occasions when the patients forgot or no reason was given. This emerged as an

opportunity for improvement.


Question three was open-ended, because it was designed to solicit feedback on what the

office could do to help patients keep their future appointments. The responses of the 1,024

surveyed are as follows: 39% stated that a reminder call, email and letter will be helpful while

34% mentioned that better appointment availability can improve their show rate. 2% stated that

the site was not convenient while 25% took responsibility for missing their appointment. This

particular feedback was interesting because it did not lead to an action plan for the office.

Therefore, it can be concluded from Question three that a reminder call, mail notification and/or

appointment availability are areas that could be enhanced as ways to improve the show rate.


The next section addressed internal and external variables that may be associated

with the no-show rate such as type of visit, time of day, and payer plan (insurance). The author

researched and reviewed nine months of data from May 2010 to February 2011 from the

Children’s Hospital of Philadelphia (CHOP), Data Collection Department. The objective of this

section is to gain a better understanding of the challenges that patients and families could face,

which may perhaps prohibit their ability to receive care.

No-show data for all four primary care centers were a bit challenging to analyze because

the practices visit types varied based on need and preference. In an effort to achieve accurate

and meaningful data, the researcher looked for commonalities within each visit type and created

one standardized template across the practices. The results are as follows: Of the 601 patients

that were scheduled with the PL1 (Residents and Interns), 37% no-showed. Some of these

patients believe that because the residents and interns are in training, they are not qualified to

handle their care. While this is just a perception, it does play a vital role in the show rate.

Of the 1,796 new patients that were scheduled, 29% no-showed and of the 9,091 follow-

up (return) visits, 27% no-showed. Of the 4,309 non-physician visits, 25% did not show. 1,796

new patients may not seem to be a large number; however, every new patient visit equals 30

minutes of a physician’s time, while in essence two return patients (15 minutes per visit) could

have been seen in that time slot. With that said, the average cost of a new patient visit is $350.


To strengthen this point, 1,796 new patients that no-showed cost the four primary care practices

$628,600, which is a significant number that affects the bottom line of any operation. Of the

27,113 well-child visits (equivalent to a physical or well baby care) 24% no-showed and of the

2,173 office procedures scheduled 22% failed to show for their appointment.

Special attention must be given to ‘Sick’ and ‘After Hours’ (visits scheduled after the

office is closed) visit types since these visit types appear to be the triggers which lead patients

and families to the Emergency Room (data collected from CHOP). Of the 27,970 sick patients

that were scheduled 15% no-showed while 3,726 afterhours visits demonstrated a 19% no-show

rate. Both visit types reflected a total of 34%. Although, the patient population may appear to

be diminutive within each visit type, it is still significant because of wasted resources and the

financial consequences associated with this phenomenon.

Visit Types NS Visits Sched Visits Total Visits Total %AFTER HOURS 894 3,726 4,620 19%NEW PATIENT VISIT 747 1,796 2,543 29%NEWBORN 187 2,196 2,383 8%NON PHYSICIAN VISIT 1,419 4,309 5,728 25%OFFICE PROCEDURE 615 2,173 2,788 22%PL1 353 601 954 37%SICK 4,897 27,970 32,867 15%WELL CHILD VISIT 8,429 27,113 35,542 24%


Total 20,826 78,975 99,801 21%

The next section addresses the time of day that practices received the highest no-shows.

Scheduled appointments will be compared with the no-show visits for hourly blocks. The

purpose of this section is to determine, which time frame is more convenient for patients.

According to the data, of the 11,293 patients that were scheduled at 2pm, 3,434 missed their

appointments, which gave a total of 23%. Additionally, at 9am 12,770 were scheduled and 3,614

missed their appointments, which gave a total of 22%. However, at 8am, 10am, and 1pm 21%

missed their scheduled appointments, which is a significant percentage for any pediatric practice

that may have a long waiting-list of patients waiting to get an appointment with their

pediatrician. The data further showed that patients and families preferred the 4pm through 7pm

time frame, which demonstrated the lowest no-shows that ranged from 16% to 19%.


Appt Time NS Visits Sched Visits Total Visits Total %7.00 0 2 2 0%8.00 829 3,132 3,961 21%9.00 3,614 12,770 16,384 22%10.00 3,308 12,741 16,049 21%11.00 1,298 5,259 6,557 20%12.00 689 2,715 3,404 20%13.00 3,716 13,751 17,467 21%14.00 3,434 11,293 14,727 23%15.00 2,298 8,440 10,738 21%16.00 422 2,254 2,676 16%17.00 883 3,801 4,684 19%18.00 861 3,677 4,538 19%19.00 233 1,212 1,445 16%Total 21,585 81,047 102,632 21%

In this section we will address the no-shows by the various payer plans. Scheduled

appointments will be compared with the number of no-show visits for the numerous insurance

mixes. The purpose of this section is to determine if a specific insurance plan influence the no-

show rate. According to the data, of the 41,109 Keystone Mercy patients that were scheduled,

9,136 no-showed, which gave a total of 18% while 12, 642 Americhoice patients that were

scheduled, 2,687 missed their appointment giving a total of 18%. The data is quite significant

because both plans are Medicaid based, that is, funded by the government. One may conclude

that because the insurance plans are free, the patients and families may undervalue the

importance of the visits and just not show up. Furthermore, patients may not be aware that their

absence affects the practice operationally and financially.

Medical Assistance Plan of Pennsylvania (MAPA,) is also Medicaid based and is funded

by the government. Of the 773 patients that were scheduled, 133 no-showed; this reflects 15%.

Although, the number of patients scheduled versus the number that no-showed was not huge, the

impact was very similar in nature. Tricare is a military based insurance. Of the 216 patients that


were scheduled, 36 no-showed, giving a total of 14%. The commercial plans such as Keystone

East, Personal Choice, Aetna and Cigna ranged from 10% to 11% on average. Coincidentally,

practices with large Medicaid patients realized a high no-show rate compared with the above

commercial plans.

Payer NS Visits Sched Visits

Total Visits

Total %

Aetna 571 5,119 5,690 10%Americhoice 2,687 12,642 15,329 18%Blue Plan 257 2,128 2,385 11%Keystone East

1,149 9,762 10,911 11%

Keystone Mercy

9,136 41,109 50,245 18%

MAPA 133 773 906 15%Personal Choice

542 5,064 5,606 10%

Commerical Other

102 1,027 1,129 9%

Charity Care 20 176 196 10%TriCare 36 216 252 14%Cigna 54 461 515 10%Totals 14,687 78,477 93,164 16%

Additionally, Emergency Room visits based on payer plan for the four primary care

centers at the Children’s Hospital of Philadelphia are addressed. Data was drawn from February

2010 to January 2011 to determine how many patients from the four primary care centers went to

the Emergency Room broken down by insurance type. The objective was to confirm whether

insurance plans influence ER visits. As indicated in Chapter one and two, patients presented to

the ER for non-acute concerns, even though, they should seek care from their medical home


(PCP). Of the 14,678 patients that visited the ER, 7,353 were Keystone Mercy members while

2,533 were United Community Health

Plan (formerly Americhoice) and

1,300 were Medical Assistant of PA

(MAPA). The above mentioned plans

are products of Medicaid, which are

state funded. Although, no financial

data was available, the findings lead to

the assumption that because the plans

are free patients and families tend to demonstrate misuse and do not place importance on it’s

worth or connect the cost associated with the process.

Payer Name: 4 PCC Patient ER Visits

Aetna Better Health 137Aetna HMO 400Aetna POS 283AmeriHealth Administrators 17Blue Cross Other 19 Cigna 62Commercial Other 15Highmark Blue Cross/ Blue Shld 91Keystone HP East HMO 1003Keystone Mercy Health Plan 7353Medical Assistance PA 1300Personal Choice PPO 543TriCare 34UHC Community PA (Americhoice) 2533United Health Care 70Blue Shield Other 79Keystone East POS 139Total 13378


It is safe to conclude that there are many predictors of no-shows. The findings

established in this chapter confirmed that patients’ access to care, education surrounding the

ramification of missed appointments, telephone and or mail appointment reminders are few

recommendations that can decrease the no-show rates. Although, there is no single easy fix to

this complex problem, implementing a variety of measures can decrease the no-show rate and

boost revenue.

Chapter 5: Recommendations and Conclusions

This study strengthens the growing body of evidence demonstrating that no-show results

are significant in the pediatric population as well as general medicine. From the research

conducted and the analysis performed on the survey results, it can be determined that patients

and families missed their appointments for a myriad of reasons. Although, evidence pointed to

internal and external variables, missed appointments can ultimately affect patient care and the

bottom line of any medical practice. In general, the above stated- results provide practical

support for the foundation of the hypothesis proposed in this research.

As discussed in Chapter One and Two, missed appointments with the primary care

provider increases Emergency Department (ED) utilization, which escalates the cost of that


patients’ care. The use of the hospital ED for non-urgent care when primary care might be more

appropriate has been identified as one of the causes contributing to increasing Medicaid costs.

The study also showed that patients turn to the ED for basic health care needs. When patients

fail to keep their appointments, it can lead to a delay in diagnosis and detection of diseases,

which eventually affects outcomes. Primary care providers serve as the gatekeepers to patients

care and missed appointments limit the physician’s ability to provide continuity of care.

Recommendations

The survey data unearthed some remarkable findings that seem to prove several

phenomena. As indicated in the study, at times the appointment times given were not

convenient and 38% of the patients preferred 4pm through 7pm. Based on this finding, one

would think that adding more time slots in the afternoon and evening sessions would be the

answer, but that can prove to be challenging and costly. Incidentally, if office hours were

extended, it may not prove to be an appropriate option from an operational standpoint. It is more

prudent to overbook the earlier appointment times where patients are more likely to miss their

appointments such as the 8am to 1pm block. Overbooking the schedule to cover no-shows is

relatively easy to implement but more difficult to advertise. Provider and support staff buy-in

are critical to the success of this course of action. One can take a conservative approach by

overbooking some portions of the schedule as an introduction, expand later if successful, and

evaluate for impact. This suggestion may not reduce no-shows but can replace revenue and

increase productivity. Additionally, transportation was also a challenge for patients and families

although, transportation is external to the practice and further research showed that the State of

Pennsylvania provides transportation for patients with Medical Assistant plans. The goal would


be to place signage in key areas in the primary care center to showcase the information on the

initial telephone greeting (if an automated system exists). While confirming appointments, the

caller will verify whether the patient needs transportation and provide that information as well.

Secondly, patients should be reminded by telephone 48hrs prior to their appointment.

Studies have shown that patients tend to forget if the reminder call is made before 48hrs.

Depending on the nature of the practice (specialty care), post card reminders can be helpful. For

those patients that are habitual no-shows (offices can determine very quickly) letters should be

sent as indicators of the amount of appointments that were missed and the importance of keeping

their appointments. Patients should be linked with a social worker or office nurse if that is an

option to address no-show behavior and the effect it has on their care.

Thirdly, establish a cancellation option on the telephone menu so that patients can call to

cancel the appointment. Best practice indicates that medical practices with call-center

capabilities can add a cancelation line to an interactive voice-response system. When the caller

chooses the ‘cancel appointment’ option, the system automatically removes that appointment and

frees up the space for another. A less expensive method is to implement a voice mail system so

that the caller can leave a message indicating the cancellation. However, the concern with this

workflow is that someone has to check the voicemail on a regular basis (round the clock), which

can be a barrier if the practice is short-staffed.

Fourthly, signs can be posted in key areas of the office reminding patients and families to

call to cancel appointments if they are unable to make it, so that appointment time can be offered

to another patient. A message can be recorded on the initial telephone greeting when callers are

waiting (messaging on hold) to speak with the office. The message can read, “We know that

things come up and sometimes you can’t keep a scheduled appointment. When that happens,


please let us know as soon as possible so we can offer your appointment to another patient.”

Call our cancel line at 27/7 at 215-123-1212.

Fifthly, redesign the scheduling system to an open-access model; this is the first step for

improving access to care because it directly impacts the practice by determining appointment

availability, practice efficiency, and wait time. An open-access model allows medical practices

to offer same-day appointments to all patients regardless of their problems (urgent or routine).

The guiding principle is, to “do today’s work today” (Randolph, 2004). This is done by

matching the supply of the providers each day to the daily demands for visits. Appointment

demand is predictable, that is, winter months are labeled as the sick season, and therefore, sicker

visits are needed during that time frame. Although, many pediatric offices offer same-day

appointments for acute care, open-access expands same-day access to include routine and

preventive care (Bundy et al., 2005). With that said, continuity of care is improved by matching

patients with their primary care physician and the overall improvement of physician and patients’

satisfaction. For successful implementation provider and support staff must work together

collaboratively. This model may not work for academic practices that provide resident and

medical student education, based on the outlined program criteria. In other words, the number of

patients per resident session is set. Part of their training is to assess the patient first and then

present findings to the attending physician, which can generate a significant wait time.

Additionally, demand and supply (capacity) need to be balanced. If not, the daily demand can

out weight the office capacity, which can lead to stressful days, incurred overtime, and the

reduction of the quality of service.

Finally, create a no-show report that lists upcoming appointments of patients with

histories of no-shows. Medical practices can implement preventive measures, such as reminder


calls, post cards/letters, cancellation line, signage in the office, no-show communication on

automated telephone system, open access (if applicable) and overbooking appointment slots to

compensate for the lost revenue.

Conclusion

Based on this study, last minute cancellations and no-shows are very disruptive for a

clinical practice. Most patients do not make the connection of how a missed appointment affects

continuity of their care and the bottom line. It is important that the practice educate patients and

families that the appointment times are reserved specifically for them. In addition, private

practice’s income is directly linked to how many patients a provider sees per day. Insurance

companies do not pay for missed appointments, and it is easy to see why no-shows are one of the

costliest and stressful issues for medical practices.

This study demonstrated that there is no simple solution to preventing no-shows. Maybe

a more realistic goal is to reduce the overall rate to a relatively low level. But there are many

methods that one can embrace to prevent no-shows from governing the practice as recommended

above. In the author’s primary care center in West Philadelphia a 30% no-show rate was

historically seen. Although, a definition was given in previous a chapter for ‘no-show,’ it is

imperative that the author redefine the meaning of a no-show to tailor to the office needs.

According to The Children’s Hospital of Philadelphia, Primary Care Center at Cobbs Creek, any

patient that does not give the office at least a minimum of four hours’ notification that they are

not coming to their scheduled visit is define as a no-show. The author adopted the following

recommendations:

1. Appointment reminder calls within 48hrs.


2. Created a cancellation message on automated telephone system requesting that patients

arrive on time or cancel well in advance.

3. Overbooked the schedule during the 8am to 11am time frame.

4. Developed posters and flyers to educate patients and families on the impact of no-shows.

5. Included no-show information to “message on hold” and initial telephone greeting.

6. Created a no-show letter, waiting on approval to implement. With that said, the practice

has already seen a 10% increase in the show rate (Appendix D).

The other three primary care offices have also embraced some of the above

recommendations and they too have realized a 7% to 9% increase in their show rate. Finally, the

author is confident that the findings presented here will add to the growing body of knowledge

that will be used to assess the effectiveness and benefits to patients receiving optimum care by

their primary care provider. By utilizing some of the methods outlined in this paper, practices

can control the loss of income by managing no-shows, which will improve overall patient and

staff satisfaction.


Appendix A: Questionnaire

Dear Patients,

We are surveying patients that were recently unable to make their appointments in an effort to help better serve our families with our appointment availability. Please take a couple of minutes to answer a few questions.

Primary Care Centers: Please circle your practice, (Cobbs Creek), (South Philadelphia), (University City) and (Market Street).

1. Was your missed appointment related to any of the following? a) Appointment time. b) Transportation. c) Insurance or co-pay concerns. d) Child is feeling better. e) Other- please explain_________________________________


2. What are the reasons that prevented you from calling to cancel the appointment?

3. How can our center help your family maintain (keep) your appointments in the future?

Appendix B: Total Response and Percentage

Question 1. What was your missed appointment related to any of the following?

Category Phone Face to Face Total Responses Total %

Appointment Time 240 150 390 38%Transportation 129 48 177 17%Insurance/ co-pay concerns 100 60 160 16%Child is feeling better 83 44 127 12%Other - Pt Related 65 50 115 11%Other - Office Related 30 25 55 5%

Total by Category 647 377Total Responses - Q1 1024


Question 2. What were the reasons that prevented you from calling to cancel the appointment?

Category Phone Face to Face Total Responses Total %

Pt Forgot/No Reason Given 180 148 328 32%Called/Arrived after appointment time 130 90 220 21%Office Closed 10 6 16 2%Pt Phone Disconnected 55 32 87 8%Went to ED 122 75 197 19%Not aware of Appt 35 20 55 5%Scheduling Error 30 25 55 5%Telephone Access to Office 46 20 66 6%



Question 3. How can our center help your family keep your appointments in the future?

Category Phone Face to Face Total Responses

Total %

Need a Reminder (email, letter, phone) 210 190 400 39%Site not convenient 10 9 19 2%Patient took responsibility for missing appointment

140 115 255 25%

Better appointment availability 190 160 350 34%


Total Patient Response 3072


Appendix C: Other Variables by Total Number and Percentage.


NS Visits Sched Visits Total Visits Total %AFTER HOURS 894 3,726 4,620 19%FOLLOW UP 3,285 9,091 12,376 27%NEW PATIENT VISIT 747 1,796 2,543 29%NEWBORN 187 2,196 2,383 8%NON PHYSICIAN VISIT 1,419 4,309 5,728 25%OFFICE PROCEDURE 615 2,173 2,788 22%PL1 353 601 954 37%SICK 4,897 27,970 32,867 15%WELL CHILD VISIT 8,429 27,113 35,542 24%Total 20,826 78,975 99,801 21%


NS Visits Sched Visits Total Visits Total %7.00 0 2 2 0%8.00 829 3,132 3,961 21%9.00 3,614 12,770 16,384 22%10.00 3,308 12,741 16,049 21%11.00 1,298 5,259 6,557 20%12.00 689 2,715 3,404 20%13.00 3,716 13,751 17,467 21%14.00 3,434 11,293 14,727 23%15.00 2,298 8,440 10,738 21%


16.00 422 2,254 2,676 16%17.00 883 3,801 4,684 19%18.00 861 3,677 4,538 19%19.00 233 1,212 1,445 16%Total 21,585 81,047 102,632 21%


NS Visits Sched Visits Total Visits Total %Aetna 571 5,119 5,690 10%Americhoice 2,687 12,642 15,329 18%Blue Plan 257 2,128 2,385 11%Keystone East 1,149 9,762 10,911 11%Keystone Mercy 9,136 41,109 50,245 18%MAPA 133 773 906 15%Personal Choice 542 5,064 5,606 10%Commercial Other 102 1,027 1,129 9%Charity Care 20 176 196 10%TriCare 36 216 252 14%Cigna 54 461 515 10%Totals 14,687 78,477 93,164 16%

Appendix D: No Show Letter

(Practice address and logo)

Dear Patient,

We had an appointment reserved for you today and were concerned when you did not show or call within 24 hours to cancel the appointment. Our policy is to call patients two days prior to their appointment to remind them of the date and time. We perform these calls as a courtesy to our patients and to all allow us the opportunity to rebook the time slot should the appointment not be necessary. Recognizing that everyone’s time is valuable and that appointment time is limited, we ask that you provide 24 hours notice if you are unable to keep your appointments. Please call us at your earliest convenience to reschedule your appointment as your primary care provider felt it was important to see you.


Thanks you for your anticipated cooperation.

The scheduling staff (Practice name)

Appendix E: Proposal for No-Show Reduction

Reduce overall PCC no-show rate by 7%, which adds 7,000 visits across all four sites

Currently our net lost revenue is $2,100,328

With a 7% reduction we can potentially increase net revenue by $541,550 for FY12


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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380684/pdf/amjph00522-0025.pdf

Thesis-No-Show Project Bridgette-Noel Final

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