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INTRODUCTION TO THE DEFINITIVE GUIDE TO PATIENT CANCELLATIONS

Patient cancellations are the persona non-grata of the schedule, often ignored for their more popular sibling, “no-shows”. Finding best practices for patient cancellations is hard and often a copy and paste from best practices on no-shows. Practice management systems ignore patient cancellations too. Pulling a no-show report is quite easy, but have you ever tried to pull a report on the percentage of patient cancellations filled? Still, many practices realize cancellations are a problem, but because the data isn’t readily available do not realize how large a problem they are nor what to do about them. That’s why we wanted to share the knowledge we’ve gained analyzing over 170,000 cancelled appointments for practices across the US.

THREE TYPES OF CANCELLATIONS

There are three types of cancellations: Cancellations, no-shows, and bumps. We will be treating them as three separate types of patient fails.

Patient Cancellations

A patient cancellation is when a patient gives notice ANY TIME before the appointment that they won’t make it.

Patient No-Shows

A no-show is when a patient does not show up for the appointment AND does not give notice. Some practices use the term no-show to describe a cancelled appointment with under 24 hours’ notice, we will not be using that. We recommend reading The Definitive Guide to Patient No-Shows for a deep dive in preventing no-shows.

Provider Cancellations aka Bumps

A bump is when a doctor cancels on a patient. Traditionally doctors cancel on patients for emergencies. You will see a high rate of bumped appointments in surgery practices since doctors must rush to the OR for emergency surgery and in OB/GYNs where doctors will rush into the hospital to deliver babies. Provider cancellations/bumps are more rare than patient cancellations, but they are very disruptive. As a result, we recommend The Definitive Guide to Provider Cancellations/Bumps. for best practices on dealing with them.

DRIVERS OF PATIENT CANCELLATIONS

Top Patient Cancellation Reasons
While patients cancel for many reasons, the probability of a patient canceling for any reason increases dramatically the longer the time between when an appointment is scheduled and when the appointment takes place. Here are the main reasons patients cancel:

Personal reasons

A time that worked for someone’s schedule a week ago, doesn’t work now. Some sub-reasons here include; transportation, lack of childcare, work obligations.

Financial reasons
Healthcare is expensive. When a patient booked an appointment, their budget could fit another appointment, but when the appointment was coming closer they realized they couldn’t.

Window shopping
Some people book appointments with multiple providers trying to find the shortest wait. They then cancel the other appointments once they find the appointment that best fits their schedule.

HOW MANY PATIENT CANCELLATIONS SHOULD A PROVIDER HAVE A DAY?

What is a normal number of patient cancellations?

There has been extensive research on cancellations, but it has been done using small sample sizes since data is hard to come by. A great example of an healthcare company utilizing the valuable data they have in an interesting manner is this FiveThirtyEight article by athenahealth employees analyzing whether the 2016 US Presidential election stressed people out enough to seek medical attention (it did not).

Because data is siloed, many practices are unsure what is considered a “normal” number of cancellations.

Here are the most important factors that dictate how many patient cancellations a practice has:

Patient quantity

The more patients a provider sees a day the more opportunities there are for patients to cancel.

Specialty

Certain specialties see more patients and have higher cancellation rates.

Orthopaedics (30-40 patients/day)

Dermatology (40+ patients/day)

Primary Care (20-30 patients/day)

Pediatrics (20-30 patients/day)

Patient mix

Certain demographics of patients are more likely to cancel appointments.

Seasonality

A practice will likely have fewer patient cancellations in December and July when many providers (and patients) are on vacation. Also, certain specialties will have busier periods like flu season for internal medicine and allergy season for allergists, which will increase the number of cancellations but not necessarily the cancellation rate.

Time of day

After analyzing thousands of cancellations, we saw the majority of cancellations happen before noon. When are patients most likely to cancel appointments? Find the answer here!

Patient Appointment Reminders

Health systems' data often show higher patient no-show rates than patient cancellation rates. This is not because patients no-show at a higher rate, but because of their appointment reminders. Automated appointment reminders (read more here about other important criteria for appointment reminders here) cancel appointments in the EHR when a patient cancels the appointment via the appointment reminder. However, most appointment reminder systems require front office staff to manually cancel appointments. IN that case, staff cancel the appointments hours or days after the patient really cancelled them. They are incorrectly marked as patient no-shows when they were cancellations!

A DEEPER DIVE INTO PATIENT CANCELLATIONS

Day of the Week and Patient Cancellations

Mondays have the most patient cancellations

23 % of appointments are cancelled on Monday. Most offices are closed on the weekends, so demand to cancel on Monday represents those who wanted to cancel on Saturday and Sunday as well.

Patients are most likely to cancel Wednesday appointments

21% of appointments scheduled on Wednesdays are cancelled, followed very closely by Thursdays.

Month of the year

No month stands out as having a very high number of cancellations but December, June and July stand out for having a lower number of cancellations. The reason is that both patients and and providers are more likely to be on vacation, so there are fewer appointments.

WHAT APPOINTMENT TYPES ARE PATIENTS CANCELLING?

We assigned the cancellations categories to breakdown which appointment type is the most cancelled. Office visits, for example, represent non-acute, non-follow-up appointment types for established patients in a practice. Office visits, for example, represent non-acute, non-follow-up appointment types for established patients in a practice. Annual visits represent well-visits, physicals, annual exams. We've gotten a lot of questions about medical appointment types and how to organize them after writing this guide, so we wrote a whole guide dedicated to appointment types, enjoy!

Patient Cancellations by Appointment Type

Follow-ups

Follow-ups were the most common type of appointment cancelled. Nearly 45% of the cancellations were follow-up appointments. This makes sense because follow-ups are the most common appointment type.Your health system might call them rechecks or established patient appointment types.

New Patient

20% of the patient cancellations were new patient appointments. That's particularly problematic since getting a new patient in is vital for a health systems success. We cover patient access and new patients in The Definitive Guide to Patient Access.

Office Visits

15% of the appointments were office visits, the other catch-all appointment type.

Annual Visit

14% were annual visits or physicals. Primary care sees a larger volume of appointments than specialties, hence their position on this list.

Procedure

Procedures represent 5% of the patient cancellations. While they make up a low volume, procedures represent a very high revenue loss.

GEOGRAPHICAL IMPACT ON PATIENT CANCELLATION RATE

Certain specialties in certain geographical areas have lower cancellation rates than others. A major determining factor has to do with geographic demand and scarcity for a certain specialty.

For example, 19.2% of Americans live in rural areas, but only 11.4% of physicians practice in rural areas* The AAMC (Association of American Medical Colleges) published a study in 2012 detailing specialty shortages in certain states. This is despite the efforts of the federal government to alleviate these supply deficiencies.

Replaceability

While higher demand caused by a lack of supply (vs. too much demand) can result in lower cancellation rates, high demand alone is not enough to lead to lower cancellation rates. There is another factor, “replaceability”. Replaceability is the ability for a patient to find another doctor in the same specialty. Replaceability explains the link between improving patient access and lowering patient cancellation rates.

If there is a high demand for a specialty AND high replaceability (lots of doctors in that specialty) that will lead to higher cancellation rates since the high demand will create long patient wait times and patients have the ability to find another doctor.

However, if there is high demand for a specialty and low replaceability, then it will lead to low cancellation rates.

HOW MANY PATIENT CANCELLATIONS DO PRACTICES FILL ON THEIR OWN?

The average practice fills 15% of their cancelled appointments. However, it's quite difficult for individual practices to measure this themselves.As a result, most practices don't realize the size of the problem. Many practices run weekly reports on patient cancellations but cannot pull reporting on how many of those cancellations are filled.

How to calculate your health system's cancellation fill rate

Depending on what practice management system your health system uses, you may be able to pull the requisite data. This is a data intensive calculation, but if you do this via Excel and save your equations, you can repeat this process easily after the first time

1. Pull all a month's appointments, created and cancelled, and when they were created and cancelled.

2. The staff filled a cancellation if:

1. The first appointment, at a given time and date, has been cancelled by the patient.

2. A second appointment exists, for which the patient showed up, has the same same provider, beginning appointment time and date, and appointment location. Finally, the staff created this appointment AFTER the first appointment.

Note: Data requires the second condition in case a slot is double booked.

PULL PATIENT CANCELLATION FILL RATE DATA

Here is a comprehensive list of the data to pull and how to evaluate it to help you understand the impact cancellations are having on your organization.

Pull all appointments (whether cancelled or not) for the last month including the following fields:

1. Provider

2. Appointment time and dates

3. Appointment location

4. When the appointment was created

5. Appointment status

6. Cancellation reason

Exclude the following appointment records

1. Bumped/provider cancelled appointments

2. No-showed appointments

3. Appointments cancelled and filled by the same patients since they are usually staff correcting their mistakes.

Review the appointments left

If a cancelled appointment has an appointment where the patient arrived and matches all of the criteria listed below, the appointment was filled:

1. Provider

2. Appointment time and date

3. Appointment location

4. Appointment creation date/time is greater than cancelled date/time

Note: We do not require the appointment type to be the same for an appointment to count as filled. You can calculate the cancellation revenue loss by looking at the revenue lost from cancellations unfilled AND for cancellations that were filled but with a lower value appointment type.

WHAT QUEUEDR FOUND

Staff Cancellation Fill Rate of 15%

The average provider’s staff fills about 15% percent of cancelled appointments. We saw some deviations depending on the factors below.

Lead time

Staff fill rates for cancelled appointments, that are cancelled within 24 hours of the appointment, can be 50% lower than further out cancellations. The staff has more time to find a patient, while patients have more time to adjust their schedules to accommodate a doctor’s availability.

Health System demand and replaceability

Health systems with higher demand and low replaceability have higher fill rates because there are more patients who want to fill that cancellation!

The number of schedulers

A health system with a higher ratio of schedulers to patient cancellation will have a higher fill rate. However, the added overhead is usually not cost-efficient, particularly if there are alternatives.

Scheduler determination

For small practices, every single scheduler matters. Some schedulers snd practice managers we've interviewed display Herculean effort, working nights and weekends to ensure all schedules are full and everyone shows up. This only occurs in very small practices. If you have one of these schedulers, double their pay.

BEST PRACTICES FOR FILLING PATIENT CANCELLATIONS

Keeping Your Health System's Schedule Full

Have a process in place to fill your cancellations. See The Definitive Guide to Healthcare Automation for a helpful case study. This process should:

1. Be clear and concise

2. Assign responsibilities to specific people

3. Continuously measured

Processes that work but come at a cost

Here are three common processes we've seen from health systems and their drawbacks:

1. Have patients call-in

This is the most common process. Patients are told explicitly to call the office each morning to ask if there are any openings for the day. There are some major downsides to this system including:

Reliability

Relying on patients to make a concerted effort to call every morning is putting too much work on patients.

Increase in call volume and backlog

With health system margins at record lows, adding more staff is not an option. Furthermore, this process creates a poor patient experience. Patients are forced to put in extra work instead of the health system bearing that burden.

2. Open Scheduling

Open scheduling leaves part of every day open for patients calling in for same day appointments. This requires a lot of staff training and work and is often used in pediatric groups where they see many acute/sick visits. However, there are additional limitations

Financial inefficiency

This process places higher value on sick visits then potentially more valuable and urgent appointment types.

Fairness

Patients who are booked out months could end up being treated worse than a patient who just happened to call in at the right time.

Disorganization

Many health systems have experimented with open scheduling. Over time, providers push back, instructing their staff to follow their preferences. For example, a provider might only want to see 3 new patients on a Friday afternoon. Within 6 months, the open schedule becomes much more rigid.

3. Double Booking
Health systems who think a patient is going to cancel or no-show, double-book that appointment time. When the analysis is wrong and the patient does show up, patients face a long patient wait time. Long patient wait times represent one of the biggest threats to an excellent patient experience. Part of that is that most waiting rooms leave something to be desired. Here are 5 ways to make your waiting room awesome!

TACTICS THAT DON'T WORK FOR FILLING PATIENT CANCELLATIONS

While many health systems have tried these tactics, they often create more staff work while not improving patient access.

Waitlists

Based on interviews with customers, we've found that 90% of practices don’t use the waitlist, but almost all of them wish they did. It’s time to give up here. Waitlists require far too much extra work and training. Many practice management systems do not have them at all. There is no consistency in the process. The fact that 90% of practices don’t use the waitlist should tell us something! Read more about this in The Definitive Guide to Waitlists

Charging patients

Charging patients for last minute cancellations, creates many obstacles. For starters, you need a credit card which is intimidating for patients. Second, your staff needs a way of charging them. Third, they need to actually charge them! Most offices use the threat of charging, but never implement it. We cover the practice in depth and the math behind why it doesn't work in The Definitive Guide to No-Shows.

CONCLUSION

Cancellations are a real problem that often goes ignored because it cannot be quantified. Often, cancellation rates are 4-5x greater than no-show rates but medical organizations don't always recognize them as a problem. Follow the numbers, create a new process and use technology wherever possible to improve your patient access.

The Definitive Guide to Patient Cancellations

Think a waitlist will help fill those cancellations?

Check out The Definitive Guide to Waitlists

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INTRODUCTION TO THE DEFINITIVE GUIDE TO PATIENT CANCELLATIONS