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INTRODUCTION
Patient no-shows. Ask any office manager, practice administrator, operations director, call center manager, or COO to name what keeps them up at night and they’ll save the greatest grief for no-shows. That’s why we are dedicating an entire guide to patient no-shows. If you are just joining us, make sure to check out The Definitive Guides to Appointment Types and Cancellations, they both interplay nicely with this guide.

I’m here to tell you patient no-shows do happen, they are not your biggest problem, and you can lower your patient no-show rate.

The average practice has a no-show rate from 5-10% with clinics having ones from 20-30% according to literature. However, the rate varies tremendously depending on specialty (primary care will have higher no-shows than a neurologist), geography, appointment type, and time of year (ex. Physicals needed for kids for sports in September will have lower no-show rates than physicals in March without any inherent need).
WHAT CAUSES NO-SHOWS
There are a number of reasons patents no-show however after analyzing data from thousands of no-show appointments, we found the most common reasons patients no show are:
Poor Patient Access 
There is a saying in sales, time kills all deals. The saying applies to appointments too. The further out you book a patient, specifically a new patient, the more likely they are to no-show. Patients are more likely to forget, have a scheduling conflict, or go to another doctor who can see them sooner.

Athenahealth did a fantastic study and found that, “An analysis of 4.2 million appointments scheduled in 2016 by 13,000 providers found that shorter appointment lead times can be critical to getting new patients in the door”. Specifically, athenahealth found that
“On average, a new patient who waits more than a month for a first appointment is more than twice as likely to cancel and not reschedule as a new patient who is scheduled within a week.”

Patient Population 
Socioeconomic levels also play a role in no-shows. These are correlations, not causations. The most common reasons patients no-show in lower socioeconomic areas include:
  • Can’t take off work/responsibilities – many of us are fortunate to have salaried jobs, but if you are being paid by the hour, then a doctor’s appointment becomes a much more obvious economic calculation. A couple of hours spent in getting to the appointment, seeing the provider and getting back can equal groceries for the week.
  • Lack of Transportation – for the same reason, many can’t find transportation to get to their appointment. If you don’t have a car and aren’t in a city, public transportation (if it exists) can take 3x longer! NIH did a phenomenal study worth reading but overall they found that patients with better access to transportation utilized healthcare more frequently. As a result, many states have started subsidizing transportation costs for these patients. Offices should look into these programs or subsidize ride sharing when possible.
  • High Cost of Healthcare – Healthcare is expensive. An economic decision often has to be made. If a co-pay is $50 (assuming one has insurance) plus 2 hours missed of work, that can be upwards of $80 for a benefit that is not always immediately available.
Bad Patients
There are those who will continuously no-show. They just don’t value your time
Lack of Patient Appointment Reminders 
The patients were never reminded, BUT they expected to be reminder. As a result they didn’t keep track on their own appointments.

DIRECT SCHEDULING AND NO-SHOWS
We often hear of practices who assume providing direct scheduling will result in better patient access and thus, a reduction in no-shows. However, we cannot find any credible studies that indicate that direct scheduling improves patient access, what we have surmised is that direct scheduling changes the how patients access care however, it does not increase their frequency to access care.

New patients no-show at a higher rate than established patients New patients do not yet have a reason to be attached to a specific office. They haven’t experienced the warmth of the staff, the care of the nurses, and the insightfulness of the physicians. To a new patient, an office is still just a name on a page. This is not unique to healthcare, it’s a concept well studied in behavioral economics called the Endowment Effect.

The Endowment Effect: People pay more/value more something they already possess, like a relationship with a doctor. Without that relationship, the value isn’t as high. It’s why you see so many businesses like Warby Parker or Casper mattresses offer free returns within the first 30-60 days of having their product. They know that once they get the products in your hands you will value it more and be very unlikely to return them.

New patient no-shows are more painful financially
New patients do not just have a higher initial appointment value. They also have a higher lifetime value. Once a patient is in the practice they will keep coming back year after year. So, when they no-show they represent a much greater loss in revenue.

Direct Scheduling
The easier it is for patients to direct schedule, the higher the no-show rate will be. Many practices are turning to direct scheduling in an effort to improve patient access. It changes the way patients access the schedule, but doesn’t always improve it. Often times it’s actually faster to book on the phone, hence why implementing online scheduling actually INCREASES the number of phone calls to a call center by 24%. It should be decreasing it! Literature is very poor as to the actual usage of online scheduling, it’s an incredibly hard stat to find.

However, if an appointment becomes very easy to book online, then a patient can book online everywhere very easily. Patients can often make multiple appointments for multiple providers and no-show all but one. Direct scheduling software does not preclude this.

In addition, the difficulty in creating an appointment, actually leads to fewer no-shows. Now, don’t go nuts here, but “switching costs” can help explain the concept. Switching costs states the more expensive it is to move to a competitor, the less likely a customer is to move. So if a patient has to work a bit harder, ie an appointment is more expensive to make in terms of time, the patient is likely to go elsewhere.
TWO MISCONCEPTIONS ABOUT NO-SHOWS
More Reminders
No-shows will happen, always. You will never rid yourselves of them. Automated reminders can be helpful, but studies have found that manual reminders are even more powerful. The answer is not more reminders. Too many reminders risk angering patients. When that happens, patients unsubscribe and the reminders are useless.

They are a bigger issue than cancellations
For 90% of practices this is not true. Cancellation rates tend to be 20%, no-shows tend to be 5-10%. Based on extensive analysis of customers before they use QueueDr, we find about a 25% staff fill rate on cancellations. That means 15% of appointment slots are unfilled because of cancellations, only 5-10% because of no-shows. Pull your data and let that guide you.

No-shows do however, garner an emotional reaction from the office and thus we are more likely to remember them.


4 EFFECTIVE WAYS TO DECREASE NO-SHOWS
Everyone wants to decrease no-shows and there are a million articles on how to do so. We will try and offer some unique solutions to the problem

Improve Patient Access
    1. OnDemand Schedule Management – something we’ve written about frequently and practice daily, it should be your first step.

    2. Open Access - another way to improve patient access to decrease no-shows is through open access scheduling. Leave 30% of the schedule open daily for new patient appointments.

Ban Bad Patients
If they no-show 4 or more times, they are out. Keep a list of these patients on hand. This isn’t always an option for practices, but if there are other practices in the area that a patient can go to, recommend that they do so.

Encourage Cancellations: Ask Patients Who Don’t Need to be seen to cancel. We are stealing this brilliant idea from a customer of ours. Encourage established patients who don’t need to see the doctor to cancel their appointments! That way you have slots open up with enough to time fill them.

Relationship Development 
Create processes and procedures that enable the entire staff to create a relationship with the patient, not just the physician. The last time I called the doctor’s office I said I wanted an appointment. The response from the scheduler was not, “awesome, we’d love to have you”, or even “sounds great, let me help you”. It was “what’s your birthdate?” Needless to say I did not feel like a value customer of this practice. Here are some other ways you can encourage relationship development throughout the entire patient lifecycle.

    1. Know the patient’s name – Have front office staff print the daily schedule and have it in front of them so they can greet patients by name instead of greeting them with “put your name down on the list please”.

    2. Greet the patient by name– Have front office staff print the daily schedule and have it in front of them so they can greet patients by name instead of greeting them with “put your name down on the list please”. Similarly thank them for coming when they leave

    3. Enable your staff to go the extra mile and make sure they are comfortable. Train staff on how you expect patients to be treated but also give them the power to make a positive impact on someone's day.

Very small touches by front office staff can make a big difference in patient loyalty. Improved patient loyalty means fewer no-shows!


CHARGING FOR NO-SHOWS
Anecdotally it seems about half of the practices we’ve talked with say that they charge for no-shows (note: that doesn’t mean they actually do). You shouldn’t say you charge a no-show fee, nor actually institute one. Instead we recommend a repeat violator rule that bans the repeat no-showers after four no-shows.

Please Note the absolute number of appts are irrelevant, it’s the percentages that matter. We choose round numbers to make this a little more graspable.
The key takeaway is that by instituting a no-show charge and demanding a credit card you lose enough new patients that you end up losing revenue even when accounting for the addition of revenue from no-show charges. If only 1 in 5 new patients balk at giving you their credit card and refuse to book with you because of it, you will lose money. That’s because the average lifetime value of a new patient isn’t just the value of their appointment, like it is with established patient appointment. It is value of all their future appointments.
CONCLUSION
No-shows are not the big bad wolf that they are made to be. Practices focus on them because it’s very frustrating when someone tells you they will do something and doesn’t and also because a no-show cannot be filled. That doesn’t mean that practices should not try and decrease them. We’ve listed 4 effective ways to decrease no-shows above. All of them don’t just prevent no-shows, but also help other areas of the practice. We completely understand the emotional anger that staff go through when a patient no-shows. In fact, we feel the exact same way when someone no-shows a QueueDr demo! In those times its hard not to act irrationally. That’s why we preach looking at the data and taking practice actions that prevent no-shows in the first place. We hope this helps and if you have any out-there ways of preventing no-shows we’d love to hear them and add them to the guide!
If you liked this definitive guide,
try our Definitive Guide to Waitlists