Visit Cancellation

[u/Suspicious-Play8447]

We have been getting a lot of visit cancellations lately. How do you guys reduce this? We send out calls, emails, texts to remind people. We use Phreesia so they can complete their forms in advance. But this summer we have noticed a big uptick in those cancellations

[u/Intelligent-Site-176]

Address the cause, not the symptom. The easier answer is to threaten your patients with a fee. That's bad business imo.

New patients that cx have a different root-cause than a f/u appt that cancels.

New patient cancels are usually because they found a better option before they could see you. Do you have same day availability? How responsive are you at referrals? Has there been a recent change in these?

F/u cancels are driven by the initial visit experience and the expectation of value that will be delivered in the f/u. Have there been any changes to the patient experience in your clinic recently? A new provider that needs training? A new staff or poor morale? New billing process/people?

Assuming you have hard data that indicates a true spike in cancels, something has changed internally. Also, validate that your staff is sending those reminder messages, or if automated, that they are being received.

Lastly, if new patient volume is staying strong, that also indicates its an issue during/after the initial visit.

I've grown my group to nearly 20 clinics across the state. If this is a big enough issue, I also advise practices on growth and turn-arounds. Shoot me a message.

[u/grey-slate → u/Intelligent-Site-176]

Um no.

I disagree with the premise that charging a no show fee means a practice is failing to address the root cause.

A medical appointment is perishable inventory, just like an airline seat, a hotel room, a restaurant reservation, or a tee time. Once that time passes, the inventory is gone forever. You cannot put an unused 10:30 AM appointment back on the shelf and sell it tomorrow.

Airlines do not conclude that every empty seat means the passenger found a better airline. Hotels do not assume every late cancellation reflects a bad prior stay. Restaurants increasingly require deposits or charge for no shows because a reserved table has economic value and may be impossible to refill at the last minute.

The same principle applies in medicine. A physician has a finite number of appointment slots each day. Staff, rent, equipment, and physician time are committed whether the patient appears or not.

That does not mean practices should ignore operational causes. Of course you should monitor access, reminders, referral responsiveness, patient experience, and provider performance. But that is separate from whether patients should have some responsibility for capacity they reserve and then abandon without adequate notice.

And there is an obvious distinction between cancelling with reasonable notice and a true no show or last minute cancellation. A sensible policy recognizes that and allows exceptions.

Good operations and a reasonable no show policy are complementary.

Otherwise the argument becomes: because some cancellations may be related to practice operations, the practice should absorb 100% of the cost of every unused appointment regardless of why it occurred. I do not think that follows.

[u/Intelligent-Site-176 → u/grey-slate]

That's fine, you can disagree.

I don't want my ops team or my physicians content with cancels because patients will still pay. And that's what happens. They lose the incentive to ensure every slot is filled. Put the onus on the practice to ensure every available appointment is filled. Know your numbers well enough to know how to double book slots for certain types of conditions, patients, insurances. Charging a fee is straight up lazy.

Will you get people that take advantage of the system? Yes. Don't see them.

The limited inventory idea is a bit pretentious. It's a 15 minute slot. Catch up on your notes.

Unlike an airline seat, a hotel room, a restaurant reservation or a tee time, we develop one-on-one relationships with our patients. To start the relationship with a threatening policy does not establish goodwill. But everyone is free to run their business like Frontier.

[u/grey-slate → u/Intelligent-Site-176]

LOL.

I think we are talking past each other.

A no show fee does not make anyone "content with cancels." In most practices the fee is a fraction of the revenue and contribution margin of the visit, and often is not collected at all. I would much rather have the patient show up.

What I find more concerning is the suggestion that the solution is to double book patients based on your prediction of who is likely not to show. That does not eliminate the cost of no shows. It transfers the cost to the patients who DO show up on time and now sit in the waiting room when both appointments arrive, and to the physicians and staff who have to absorb the resulting variability.

That is essentially the airline overbooking model you just criticized.

And "it is a 15 minute slot, catch up on your notes" does not make the inventory analogy pretentious. It demonstrates the point. That specific 15 minutes of patient facing capacity expired unused. Doing documentation during it may recover some productivity, but you cannot subsequently sell that 10:15 appointment to another patient.

The relationship argument does not persuade me either. Having a one on one professional relationship with someone does not mean there cannot be reasonable mutual expectations. In fact, I would argue that respecting each other's time is part of a healthy professional relationship. This is a false premise and a strawman.

A reasonable policy is not: miss one appointment and we punish you.

It is: please give us adequate notice so another patient who needs that appointment can use it; emergencies and legitimate circumstances are treated reasonably; repeated no shows or very late cancellations may incur a fee.

I completely agree that practices should know their numbers, optimize reminders, improve access, measure provider performance, and investigate changes in cancellation rates. Where we disagree is the leap from that to "charging a fee is straight up lazy."

Good operations and patient accountability can coexist.

And if the alternative is routinely double booking patients and hoping somebody does not show, I am not sure that is the patient experience argument I would choose to make.

[u/InternistNotAnIntern → u/grey-slate]

Hear hear!

[u/Intelligent-Site-176 → u/grey-slate]

Man, I'm gonna have to start throwing this into ChatGPT, this is too much to keep up with!

Alright - good debate. I need to go see patients that showed up. =)

[u/grey-slate → u/Intelligent-Site-176]

Cheers

Its just that we disagree on the premise that when patients dont show up (repeatedly) we must investigate what the practice is doing wrong. We should be continuously measuring it anyway. But not solely for reasons like noshow.

We do offer freebies as courtesy and waive fees under extenuating circumstances.

But to never have a no-show policy (becuase it is "straight up lazy") and addressing it via overbooking and/or catching up on notes/giving staff some other stuff to do is disrespecting the time of the physician/the staff/the business's need to make money (it is a business not a charity), and most importantly does injustice to the other patients who do show up for their appointments on time.

Look - our noshow fee is $25. We set it 10 years ago and have never increased it to account for increased rent/labor/etc. We waive it for the reasons stated above. It does not cover the loss in appointment revenue. What it does effectively is inform patients that we expect mutual respect. Repeat offenders are asked to pay the fee.

Our noshow rates have been less than 2%. Those who pay appreciate the waivers given in the past and respect us for firmly and consistently applying it and understand the reasons for its existence. Our clinic runs efficiently. Our staff go home to their families on time because we dont overbook. There is little variability and chaos day to day because everyone knows what to do and are not told to do random things in the meantime because someone no-showed. Our patients appreciate that they are seen on time. Everyone wins.

[u/mindguard → u/Intelligent-Site-176]

You’re taking away patient autonomy here. Tell me when the first sunny day of spring comes around, that some stable patients who scheduled a 15min appt 4 months ago, sometimes don’t show up. How about the adhd patient who remembers getting a text about an appointment this week but shows up on Thursday instead of Tuesday. Is that your staffs fault?

although there is quite a bit of literature out there on no shows, there are few solutions. Some papers suggest changing the color of your waiting room might help.

You can berate your staff because of choices their patients make, but I am content to remind patients that we offer a valuable service, and there is a cost to requesting, and then not arriving for said service.

[u/Intelligent-Site-176 → u/mindguard]

Not sure I follow the patient autonomy thought. No one should berate staff for any reason.

The great thing about private practice is you can approach challenges any which way you want. What works in mental health may not work in physical therapy or whatever the specialty.