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When revenue is a no-show When revenue is a no-showProviders work to reduce skipped appointments, which can hit the bottom line By Melanie Evans

Missed medical appointments disrupt schedules, potentially leaving doctors and nurses with gaps in the workday. But beyond the hassles, they can leave providers with a financial gap as well.

http://www.modernhealthcare.com/apps/pbcsi.dll/storyimage/CH/20121103/MAGAZINE/311039954/AR/0/Surgeon-no-shows.jpg Missed medical appointments disrupt schedules, potentially leaving doctors and nurses with gaps during the workday. But beyond the hassles, they can leave providers with a financial gap as well.

Surgeons faced with a patient who does not show for a consultation may lose revenue, perhaps $500 per visit, but the greater financial hit could be the surgery that never occurs, says David Kaplan, vice chairman of administration and finance for the department of surgery at the Mount Sinai Medical Center, New York, which includes 1,029-bed Mount Sinai Hospital.

Not every surgery consultation will lead to an operation, but doctors could lose out on a surgery when patients miss critical consultation appointments. And hospitals potentially lose revenue from a missed admission, he says.

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Strategies that can improve the likelihood patients will keep their appointments help to reduce those missed opportunities, Kaplan says. "You never know when and where and which patients" will lead to an operation, he says.

Efforts at Mount Sinai and elsewhere to limit the cost and disruption from missed appointments have prompted providers to experiment with methods to communicate more readily with patients and make scheduling -- or rescheduling -- an appointment much easier.

Mount Sinai made significant gains six years ago when it began to schedule reminder calls. Its rate of patients who did not keep their appointments, or the "no-show" rate, dropped from about 8% to 5%, Kaplan says. Patients may appreciate the attention to detail and consideration of a reminder call and that can bolster the likelihood they will show up as planned, Kaplan says. (The hospital's automated call service, which is used to give patients appointment reminders, also proved useful in the aftermath of superstorm Sandy last week that caused flooding and power outages in New York. Mount Sinai alerted patients to appointment cancellations.)

In general, patients who receive reminder calls are more likely to keep an appointment, according to a study of more than 10,000 patients published in 2010 by the American Journal of Medicine. Nearly one-quarter, or 23%, of those who did not get a call skipped an appointment, compared with 13% to 17% of those who received calls three days ahead of their visit.

Nine months ago, Mount Sinai launched a scheduling website that allows patients to book and cancel online to make it easier to seek -- or move -- an appointment, he says.

Salt Lake City-based Intermountain Medical Group schedules roughly 2.8 million appointments per year, says Cindy Beebe, patient access manager for the subsidiary of 21-hospital Intermountain Healthcare.

Of those, about 131,600 patients skip out on their appointments with the medical group, which employs 1,153 doctors who work throughout the health system's hospitals and clinics. And about 1 in 4 appointments were canceled during an analysis of a three-month period this year, she says. Half of them rescheduled, but of the cancellations, the rate of reschedules could be higher because of limits on how the system tracks appointments.

Beebe says she did not have a figure for the number of appointments left unfilled by patients from cancellations or patients who do not show up. Walk-ins fill some openings. Others can be filled by patients with a scheduled appointment, but who place their name on a waiting list for an earlier opening, if an opportunity occurs.

To reduce the chance patients will not show up, the medical group uses personal and automated phone calls that can be staggered throughout the day to catch people when they might be available, Beebe says.

Intermountain may soon communicate with patients by e-mail, text messages and phone and allow patients to automatically schedule and cancel appointments online. Beebe says the medical group has previously considered those options, but until this year was unable to find technology that could embed the choices within Intermountain's existing online patient portal.

Patients may request an appointment online currently, but that request must be manually checked against Intermountain's scheduling system and then confirmed, she says.

More convenient scheduling options could improve the rate at which patients keep their appointments, she says. For example, mothers awake in the middle of the night with a newborn would no longer have to wait for clinics to open to schedule appointments and make sure the dates and times are confirmed.

The medical group is also considering development of a smartphone app for patients to download up-to-date information about wait times at urgent-care clinics, Beebe says.

Three community health centers operated by three-hospital Baystate Health in Springfield, Mass., started to text appointment reminders to patients about nine months ago, but it's unclear yet what effect it may have on the clinics' rate of no-shows, says John Koomson, the health centers' director.

But stronger connections between patients, doctors, nurses and other staff after the clinic overhauled its operations three years ago appear to have led to fewer missed appointments, he says. The no-show rate now hovers between 25% and 30%, compared with 40%.

The clinics, which serve about 30,000 patients and schedule about 122,000 annual patient visits, primarily serve patients on Medicaid or Medicare, he says. Many face economic challenges that can make it difficult to keep appointments, such as limited transportation.

Helping to build those stronger ties, changes to the clinic's practice introduced patients to a team of clinical staff to give patients a number of familiar faces who will provide their care. Patients typically see the same providers on subsequent visits, he says. "It's almost like private practice."

Baystate's clinics have also started to overschedule patients, booking 11 or a dozen patients for eight or nine available slots to address the high no-show rate, which contributes to the clinics' losses, though not as much as the lack of payment for care-coordination services and the low reimbursement rates from Medicaid and Medicare, Koomson says.

"You're paying the cost of the doctor and there is no revenue," he says. "It's a waste of capacity."

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