An occasional bump in patient flow in a practice is to be expected. But how can doctors of optometry handle patients who repeatedly fail to show up for their appointments and don't call to cancel?
There are several strategies doctors can take to address the issue, including appointment reminders by mail, email and text; cancellation fees; pre-appointing; or overbooking.
The issue is explored in a newly posted AOA Ethics Forum case study, "Approaches for Medicaid Patient No-Shows," by Robert Moses, O.D., along with a poll, where doctors can weigh in on the issue. According to a study by the Illinois College of Optometry, which Dr. Moses cites, the no-show rate in their clinics is 24.8%. "Missed appointments increase concerns about delayed or aborted care and potentially serious consequences for patients," he writes. "Financial loss, staffing concerns and equipment investment impact providers by this unpredictability." It's not a conversation doctors enjoy having. And they will go the extra mile to work with patients.
Two doctors, two approaches
As patients seamlessly flow through his office, Nathan Otte, O.D., who practices in Seymour, Indiana, talks to them about their eyes and how to keep their vision healthy. Every once in a while, though, that flow is disrupted. "It is easy to think about the production value lost in an appointment slot with patients who miss their exams, but we always try to keep the perspective of the patient in mind," Dr. Otte says. "We give them the benefit of the doubt that something happened to prevent them from making the appointment. If it is an important medical follow-up, we will actively try to reach the patient to reschedule. Otherwise, we will wait for them to call us.
"Our EHR system keeps an appointment history log, so if we identify a patient who may have multiple no-shows, we will first offer a slot that isn't our highest demand," Dr. Otte says. "We may also double book that patient with medical or contact lens follow-up, and if both patients come at the same time, we are able to see them without backing up our schedule for appointments later in the day. We've found this to be a successful way to accommodate our patients without disrupting the flow of the schedule or impacting revenue."
"Our goal is to pre-book every patient before they leave our office for their next exam," says Shalu Pal, O.D., who practices in Toronto, Canada. "We want to find a place in our future schedule for each patient so that we can properly monitor their eyes. Pre-booking has dramatically reduced the tracking down and back and forth calls with our busy patients. Our reminder and recall system consists of calling and emailing patients to confirm their appointments. "
For instance, patients needing to be seen in six months are contacted one month prior to their visit. If her office does not receive a confirmation back, it will call again two weeks before the appointment and then make a final two-day reminder/confirmation call. "If we have not heard from a patient, we do not remove them from the schedule but will double book that time slot," Pal says. "If both patients arrive simultaneously, we manage both."
Upon confirmation, she says, patients are reminded of her 24-hour cancellation policy without being charged a cancellation fee. "If someone confirmed and they don't show up on time, we call within 10 minutes to find out where they are. For most loyal patients, first-time offenders and new patients, we remind them of our 24-hour cancellation policy and typically waive the fee as a sign of good faith. If someone has no-showed twice after confirming or cancels twice at the last minute, we will charge them the cancellation fee and require them to pre-pay for their exam if we are going to book another appointment."
Every situation is different, Pal adds. "It is a judgement call on whether a patient is in need of our patience or if they are taking advantage of our kindness" she says. "We do our best to be on time and we do ask for the same in return."
Tips for dealing with no-shows
Practice management consultants agree that doctors should consider all perspectives, including that of patients, before settling on a strategy. Here are their tips:
1. Focus on customer service
"Most optometric practices do not have enough patient demand and should remain very customer service-oriented in order to promote word-of-mouth referrals. I do not recommend no-show fees for optometrists because it creates too much bad will with patients," says Neil Gailmard, O.D., MBA, chief optometric officer of the Independent Doctors of Optometric Care (IDOC) and CEO of Gailmard Eye Center in Munster, Indiana.
"Very active confirmation of all appointments two days in advance greatly reduces no-shows. Appointment confirmation can be much easier with the use of an electronic communication company, but that system will not reach everyone and staff must call patients who are not reached via email or text. Overbooking or double-booking can be effective for patients who repeatedly no-show, but these should be fairly rare. Overbooking can create stress on doctors and staff if all patients do show up and can create service issues."
2. Communication is key
Especially electronic communication, says Steve Vargo, O.D., MBA, vice president of optometric consulting at Prima Eye Group. "While human interaction is preferred in many situations, society has become more tech savvy, and most patients are not put off by electronic reminders," says Dr. Vargo, noting that patients should identify the best way to reach them. "If you do not receive a confirmation by a certain number of days prior to the scheduled exam, you could open the exam slot to other patients. With no-show fees, you risk ill-will and negative word-of-mouth if a patient had a valid reason for missing the appointment."
Dr. Vargo has a better idea: "It should be incumbent on the optometrist and staff to stress the need for regular care," he says. "When patients better understand the need for a regular exam and eye health checkup, they will be more likely to keep their appointment.
3. Show value to patients
Gilan Cockrell, O.D., CEO of the Williams Group, advises that doctors consider how they can make patient visits less stressful. He calls it showing value to the patients. The check-in process can be streamlined. Trust can be built with the doctors and staff using positive reinforcement—affirming patients when they arrive on time and doctors being on time themselves. "If you create an environment of trust and respect, most people are going to do what they can to get there," Dr. Cockrell adds.
His office also keeps a list of people at the reception desk for when the schedule suddenly and unexpectedly opens up. For those patients who have flexible schedules, they are happy to move their appointments up.
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