Research: No-Shows Cost Health Care System Billions

Things had gotten so bad at the Bronx veterans hospital that doctors were, in effect, begging their patients to show up as scheduled.

Three years ago, the James J. Peters VA Medical Center began a "Don't Be A No-Show" campaign, reminding veterans of the importance of keeping appointments.

The campaign explained the detrimental effect on everyone -- not just surgeons and clinical staff, but also fellow veterans -- when a patient skips an appointment without canceling.

"It means one less patient will see the doctor and it means someone waiting for an appointment was bumped to another day needlessly," said Bronx VA spokesman James E. Connell III. "It's not good for the patient, and it's an inefficient use of clinical resources."

Such inefficiency, by one account, costs the U.S. health-care system more than $150 billion a year. And while it's easy to point the finger at the chronic no-shows, a growing body of research suggests clinics themselves are as much to blame because of scheduling and other issues.

The problem is particularly acute at urban hospitals and smaller specialty clinics with low patient volume. While pediatric clinics might see a no-show rate of below 5 percent, urban family clinics often see no-show rates between 10 and 20 percent.

And certain outpatient and surgical clinics -- think colonoscopies, endoscopies, pulmonary tests and other procedures that require special prep or diets by the patient -- have even higher rates. In a given week, a 50 percent no-show rate -- while quite high -- isn't unheard of at some specialty clinics.

"It's really a flip of a coin whether they show up or not," said Patricia Alafaireet, director of applied health informatics at the University of Missouri.

Built into the cost of care

That sort of uncertainty might kill off a restaurant, a hair salon, an auto mechanic and pretty much any other appointment-based business model.

Within medicine, it's all part of the game -- and built into the cost of care for the rest of us. Those who skip regular appointments often end up needing more costly emergency care down the road.

"It differs very widely by practice type," said Kevin Bennett, associate professor at the Department of Family and Preventive Medicine at the University of South Carolina School of Medicine.

The family medicine practice where he works -- which is somewhat like a primary care practice, except that as a teaching institution it has regular faculty as well as residents who rotate through infrequently -- has a no-show rate that fluctuates from month to month, even from year to year, as is the case with many clinics.

"We'd gotten it down to 10 percent" a few years ago, Mr. Bennett said. Now, it's up to 15 percent. "In a bad month, it creeps closer to 20."

That jump, he said, demonstrates the culpability of the clinic in creating -- or at least, not fully managing -- the no-show problem. After all, it's not as if the practice's patient population started forgetting its medical appointments at higher rates for no good reason.

Instead, in the case of the family medicine practice, a switch to a new electronic medical record system -- complete with a new appointment system -- drove up the rates. "We're getting operationally back up to speed," Mr. Bennett said, after a 12- to 15-month "loss of productivity."

Why does a booking system matter so much? Lots of experts point to poor scheduling as a top culprit in creating no-shows. Some clinics, for example, book appointments on a rolling basis, one open slot after another.

But if you book a patient for an 8:30 a.m. Monday appointment without checking the patient's preferences, there's a good chance that appointment will be skipped. And if you schedule a patient's follow-up appointment for six months down the road or with an unfamiliar physician (which happens often at teaching institutions with young doctors), expect a similar result.

Life's complications often prevent a patient from showing up in the first place, said Ms. Alafaireet, of the University of Missouri.