From a financial standpoint, missed appointments and “no-shows” have always been a significant problem for healthcare practitioners. It has been estimated that, prior to the COVID-19 pandemic of 2020, the cost of missed patient appointments was more than $150 billion annually. Of course, the “cost” goes far beyond the financial aspects. Missed appointments are often related to critical follow-up for chronic disease management or preventive screenings. If these patients later experience an illness, injury or loss, they may hold the healthcare provider responsible and assert a malpractice claim.
According to some surveys, prior to March 2020, patient no-show rates ranged anywhere from 5% to 50% depending on the type of healthcare practice and location. Since the onset of COVID-19, SVMIC policyholders have reported that the number of missed appointments and no-shows have escalated and therefore increased the risks to patient safety.
The primary causes identified for missed appointments and no-shows are the same now as they were prior to the pandemic, but they have been significantly exacerbated. To reduce the number of missed appointments and no-shows, it is important to first examine the primary causes to understand how and why they occur.
COST: Higher deductibles and out-of-pocket costs combined with confusion about preventive care coverage means that some missed patient appointments are simply in response to financial strain. As we all know from the continuous stories in the news, the pandemic has increased that financial strain by causing large-scale unemployment, loss of insurance, and a shift in priorities.
FEAR: Many people generally dread going to the doctor under normal circumstances. They are afraid of bad news or that the doctor will lecture them about unhealthy behaviors or not following medical advice. They also dislike spending time in a waiting area exposed to other patients, increasing their risk of contracting something. Again, the risk of exposure to COVID-19 has only increased these fears.
TIME: Work and family commitments often take precedence over personal health particularly with regards to regular office visits and preventive care. The pandemic has created additional childcare issues and home-schooling requirements for many parents.
DEMOGRAPHICS: Disadvantaged populations often have more difficulty keeping appointments due to income, language, or age barriers. Patients who are elderly may no longer drive, and patients who have lost their jobs may not have reliable transportation. Despite their circumstances, they may be reluctant to use public transportation particularly in the current environment. Patients in rural areas may not even have access to public transportation. The challenges presented by these and other demographic conditions may have become more pronounced because of the COVID-19 crisis.
WHAT CAN BE DONE?
First, let’s look at the factors identified above. With respect to cost, providers are encouraged to work with patients who have a financial hardship caused or affected by the pandemic. Everyone understands that a medical practice is a business, and these businesses have suffered too during the pandemic. But, to the extent possible, helping patients during this difficult time by making alternative pay arrangements, such as payment plans, will hopefully increase patient safety, decrease potential claims, and establish a long-term physician-patient relationships that will extend beyond the COVID-19 pandemic.
Alleviating a patient’s fear can be done in a multitude of ways, but it typically starts through better communication and education. Many practices are using targeted emails, website information, and patient portals to notify their existing and prospective patients of the steps the practice is taking to ensure patient safety and reduce the risk of COVID-19 transmission during in-person visits. These steps often include contactless registration and having patients wait in their car until they can be placed in an examination room. Practices are also adopting telehealth to provide patients with an alternative to in-person visits.
Some practices have addressed the time problem by implementing protocols allowing only one patient to be scheduled in the office per time slot. Again, telehealth is an alternative that would allow patients to keep their appointments, especially routine and follow-up visits, while also maintaining their family and work obligations.
Demographics may be the most difficult obstacle for a practice to overcome. But, again, through communication and education as well as telehealth, some of these obstacles can be overcome.
Regardless of the reasons or the circumstances (pandemic or no pandemic), when medical practices are challenged with missed appointments during which follow-up care or treatment was to be provided, it is important that the practice have a procedure to ensure that no-shows and cancellations are communicated to the treating provider, and any actions taken are documented in the medical record.
Depending on the patient’s diagnosis and/or reason for the appointment, the treating provider may instruct an assigned staff member to follow-up missed appointments either verbally or by way of a “missed appointment letter.” Generally, the efforts required to contact the patient are commensurate with the severity of the patient’s medical condition and potential consequences of missed treatment.
When notifying the treating provider of a missed appointment, staff should include the reason for the visit. Depending on the patient’s diagnosis and/or reason for the appointment, the treating provider may instruct that the patient be contacted and informed of the need for the appointment to be rescheduled and kept. Instructions should include the time frame (e.g., “call patient to reschedule, should be seen within 7-10 days”).
If a patient is at minimal risk (e.g. a well checkup), no action may be required or a single phone call or letter outlining the consequences of failure to receive needed treatment in a timely manner may be sufficient.
For patients at moderate risk, such as those who need ongoing monitoring or treatment, a more concerted effort may be required. Usually two documented phone calls and a certified letter outlining the consequences of failure to receive needed treatment in a timely manner should be adequate.
If the missed appointment is for the purpose of notifying the patient of abnormal test results requiring further treatment, failure to follow-up on a missed appointment could lead to a delay in diagnosis if the patient is not notified and treatment does not ensue. Generally, the reasonableness of the follow-up effort will depend on the clinical importance of the test results, the severity of the patient’s medical condition, and the risk associated with failing to notify the patient of the results.
All efforts to educate the patient and complete the follow-up should always be documented in the medical record. If letters are sent, they should be in clear, reader-friendly language at a fourth-grade reading level in order to be understandable and in compliance with Limited-English Proficiency Guidelines. If the letter is returned undeliverable, verify that the address on the letter corresponds with the address given by the patient, and if a new address is provided by the post office, resend the letter to the new address and note this in the medical record. If a letter is returned because delivery was refused by the patient, resend the letter to the same address using first class regular mail.
As with all patient communication, staff should document the date and time of the call or place a copy of the missed appointment letter in the patient’s medical record.
If a patient repeatedly does not return to the office after appropriate contact attempts have been made and documented, the treating provider may, as a last resort, take steps to discharge the patient from the medical practice. HOWEVER, during the COVID-19 crisis, it is strongly recommended that you consult an SVMIC Claims Attorney to discuss the circumstances prior to discharging the patient. Call 800-342-2239 or email us at ContactSVMIC@svmic.com for assistance.
Jeffrey A. Woods is the Director of Risk Education in the Risk Education and Evaluation Services Department at SVMIC. Jeff received his Bachelor of Science degree from the University of Tennessee Martin and his Juris Doctorate degree from the University of Tennessee Knoxville. Following graduation, he practiced law in Knoxville for almost 15 years, advising physicians and healthcare providers and defending them in malpractice claims. He is licensed to practice in Tennessee and all Federal courts, including the United States Supreme Court. He is a member of the Tennessee Bar Association.
Jeff joined SVMIC in 2003 and was a Senior Claims Attorney until 2015 when he transferred to his current position.
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