Pediatric Neurology 52 (2015) 198e201
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Original Article
The Estimated Cost of “No-Shows” in an Academic Pediatric Neurology Clinic Lindsay M. Guzek BS, Shelley D. Gentry ASM, Meredith R. Golomb MD, MSc * Division of Child Neurology, Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
abstract OBJECTIVE: Missed appointments (“no-shows”) represent an important source of lost revenue for academic medical
centers. The goal of this study was to examine the costs of “no-shows” at an academic pediatric neurology outpatient clinic. METHODS: This was a retrospective cohort study of patients who missed appointments at an academic pediatric neurology outpatient clinic during 1 academic year. Revenue lost was estimated based on average reimbursement for different insurance types and visit types. RESULTS: The yearly “no-show” rate was 26%. Yearly revenue lost from missed appointments was $257,724.57, and monthly losses ranged from $15,652.33 in October 2013 to $27,042.44 in January 2014. CONCLUSIONS: The yearly revenue lost from missed appointments at the academic pediatric neurology clinic represents funds that could have been used to improve patient access and care. Further work is needed to develop strategies to decrease the no-show rate to decrease lost revenue and improve patient care and access. Keywords: no-show, missed appointment, cost, finance, health care, academic medical center
Pediatr Neurol 2015; 52: 198-201 Ó 2015 Elsevier Inc. All rights reserved.
Introduction
Pediatric neurology is a small subspecialty that is in short supply; the supply of pediatric neurologists is estimated to be at least 20% less than demand,1 and this shortfall is expected to get worse as more senior pediatric neurologists retire. Many of the largest practice groups are based in academic medical centers (AMCs). Academic pediatric neurologists face increasing pressure to be more clinically productive.
L.M.G. was responsible for drafting the article, design and completion of study, interpretation of data. S.G. was responsible for retrieving data and calculations. M. R.G. was responsible for design and concept of study, interpretation of data, and revising the article and was the study supervisor. This study received no funding and there are no conflicts of interest. The authors report no disclosures.
Article History: Received August 18, 2014; Accepted in final form October 21, 2014 * Communications should be addressed to: Dr. Golomb; Division of Child Neurology; Department of Neurology; Indiana University School of Medicine; 705 Riley Hospital Dr. RI 1340; Indianapolis; Indiana 46202. E-mail address: [email protected] 0887-8994/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2014.10.020
Missed appointments (also known as “no-shows”) decrease clinical productivity. Although, there have been studies on the reasons patients provide for no-shows2-4 and patient demographics3,5,6 associated with no-shows, there are few studies that focus primarily on analyzing the financial strain missed appointments put on health-care systems and subspecialties such as pediatric neurology. AMCs are especially vulnerable to economic threat because of increased costs associated with training physicians and decreased revenue associated with serving a high percentage of Medicaid patients. In the United States, training physicians in residency and fellowship costs $16 billion annually, most of that money coming from the teaching hospitals themselves.7 In addition, AMCs take care of 26% of all Medicaid hospitalizations, but account for only 5% of hospitals.7 The added cost of missed appointments puts increasing pressure on an AMC. The survival and health of AMCs are important for the continued care of a vulnerable patient population, the training of future physicians, and continued advancement in the treatment of complex diseases. The pediatric neurology outpatient clinics at Riley Hospital for Children are associated with Indiana University
L.M. Guzek et al. / Pediatric Neurology 52 (2015) 198e201
199
School of Medicine and are part of a large AMC. This group is the largest provider of pediatric neurology care and the only provider of pediatric neurology fellowship training in Indiana, with 12 pediatric neurologists and two nurse practitioners. All of the pediatric neurology faculty participate in teaching, and several participate in research. The Riley pediatric neurology clinics have faced ongoing issues with “no-shows,” with no-show rates of generally 20% to 30%. The goal of this study was to estimate the economic impact of missed appointments on the pediatric neurology clinic, one of the many specialty clinics at Riley Hospital. Methods Participants and design A retrospective cohort study was performed of all patients who missed appointments in the outpatient pediatric neurology clinics at the Riley Outpatient Center (ROC) location downtown at Riley Hospital for Children in Indianapolis, Indiana, and its primary satellite clinic, (Riley North) during the medical academic year from July 1, 2013 to June 30, 2014. Data on two smaller, part-time satellite clinics with three or fewer total half-day clinics a week were not included. A missed appointment or “no-show” was defined as an appointment where the patient and family simply did not show up, or an appointment that was not canceled at least 24 hours in advance. All patient families received reminder phone calls both 3 and 2 days before the visit; the first call was by a staff member, the second was an automated call. Patient families had the opportunity to cancel during each of those calls, and if they did cancel, that was not counted as a “no-show.”
Data analysis There were six missed visit types to assess: new Medicaid, follow-up Medicaid, new private insurance, follow-up private insurance, botulinum injection Medicaid, and botulinum injection private insurance. Botulinum toxin injections are used to treat spasticity in children with cerebral palsy and are billed as procedures. Average billing and reimbursement data for each visit type were estimated by the clinic’s financial staff based on average coding for these patients in our clinic, available data, and financial staff’s experience, as reimbursement varies among insurance companies. Patients with self-pay and combination insurance were treated as patients with private insurance based on recommendations from the financial staff. Data on the number of scheduled patients and the number of no-shows for each site were retrieved from the electronic record. Number of each type of visit and number of visits from each type of payer were stored in several different data sets; so, the proportions of the six missed visit types for each month were estimated by detailed record review of 1 week of data from that month.
Ethics This study was approved by the Indiana University Institutional Review Board.
FIGURE 1. No-show rates by month at the Riley Outpatient Center, Riley North, and average combined no-show rate. (The color version of this figure is available in the online edition.)
The average reimbursement for a follow-up patient was $49.16 from Medicaid and $112.85 from private insurance. The average reimbursement for a botulinum injection visit was $151.00 from Medicaid and $210.00 from private insurance.
Clinic volume
A total of 10,831 visits were scheduled during the academic year studied: 7808 were scheduled at the primary site, the Riley Outpatient Center location downtown (ROC); and 3026 were scheduled at the primary satellite clinic, Riley North.
No-show rates
The yearly no-show rate for both sites was 26% and ranged from 21% in April 2014 to 39% in January 2014. At the ROC, the no-show rate ranged from 21% in November 2013 to 39% in January 2014. There were 2130 missed appointments (27% yearly no-show rate). At the Riley North satellite clinic, the no-show rate ranged from 14% in April 2014 to 40% in January 2014. There were 668 missed appointments (22% yearly no-show rate) at the satellite clinic. Of note, Indiana had record-breaking cold temperatures in January 2014. (See Fig 1 for variation in monthly no-show rates.)
Results
Estimated revenues lost for each month and for the year
Estimated billing and reimbursement per visit
The yearly billing loss for both sites was $788,733.58, and the total reimbursement (payment) loss was $257,724.57. The yearly reimbursement loss was $189,700.99 at the ROC and $68,023.58 at Riley North. The monthly reimbursement loss from missed appointments at both sites ranged from $15,652.33 in October 2013 to $27,042.44 in January 2014. (See Fig 2 for variation in monthly losses.) The average loss per no-show was $101.83 at the ROC and $89.06 at Riley North.
The average new patient visit was billed at $411.00. The average follow-up patient visit was billed at $231.40. The average botulinum injection visit for spasticity involved injections in two limbs and was billed at $625.00. Billing did not depend on insurance status. The average reimbursement for a new patient was $126.56 from Medicaid and $219.40 from private insurance.
200
L.M. Guzek et al. / Pediatric Neurology 52 (2015) 198e201
FIGURE 2. Revenue lost by month at the Riley Outpatient Center, Riley North, and combined loss from both clinics. (The color version of this figure is available in the online edition.)
Discussion
Missed appointments in this pediatric neurology group were an important source of financial loss. Academic pediatric neurology groups face particular challenges because they serve a large number of Medicaid patients; are often referred the most complicated patients; and need to supervise pediatric neurologists-in-training. However, academic pediatric neurology groups must monitor and improve their financial health to continue serving these missions. The amount of revenue lost because of missed appointments has been studied in other specialties and clinic settings. For one family medicine residency clinic with a 31.1% no-show rate, the clinic’s yearly income was reduced between 3% and 14% because of missed appointments.8 This family medicine clinic was able to replace more than half of their no-shows with walk-in appointments. This would be challenging to do in most academic pediatric subspecialty clinics at Riley Hospital where the patient population may be drawn from all over Indiana. In an outpatient adult endoscopy clinic with an 18% no-show rate, the daily monetary loss was 16.4% of the total potential revenue.9 An endoscopy clinic has substantial differences from a pediatric neurology clinic. While the endoscopy clinic is procedure based, few of the neurology appointments include procedures. There has been little work on financial losses because of missed appointments in neurology. Avitzur10 described an administrator who analyzed the cost of noshows in his 13-physician private adult neurology practice in 2001, and found the practice lost more than $131,000 a year from missed appointments. The patient population in this previous study is different from the population in the present study because it includes adult patients and is a private practice, making the findings difficult to apply to academic pediatric neurology clinics. In the present study, the yearly reimbursement loss because of missed appointments in this pediatric neurology clinic with a 26% no-show rate was $257,724.57 during the July 2013 to June 2014 academic year. This number was based on estimated reimbursements. Billing losses were $788,733.58. These monetary losses represent lost opportunities to improve patient access and care, or to expand other parts of
an AMC’s missions, including education. This number includes losses from only one subspecialty clinic. There are more than two dozen outpatient clinics at Riley Hospital, and all have no-shows that contribute to economic losses. These clinics could provide more care for more patients if they could retrieve at least a portion of the losses. Several strategies have been studied to address missed appointments and the associated costs. One of the most common strategies used to target the no-show rate is a telephone or text-message reminder, but there are mixed results on the effectiveness of this strategy. While Sawyer and colleagues.4 observed a 12% decrease in the number of no-shows in an adolescent clinic with the implementation of telephone reminders, Satiani et al.11 did not observe a decrease in the number of missed appointments at a vascular laboratory clinic. Overbooking is another potential solution used by some clinics to lessen the costs of missed appointments. Berg et al.9 found that booking an additional nine patients a day in an endoscopy suite decreased the economic loss. However, overbooking comes with risks. If all patients show up on a given day, patients are likely to have an increased waiting time, which increases the risk of future no-shows. Long waiting times is one of the reasons patients miss appointments.12 The Riley pediatric neurology clinic has tried mail reminders, automated phone call reminders, and phone call reminders from clinic support staff, with no substantial decrease in no-show rate. Some causes of no-shows, such as the record-breaking cold in Indiana during January 2014, would be difficult to predict and address. Predicting no-show patterns, then using targeted overbooking, could improve clinic flow. Daggy et al.13 developed a model to predict a patient’s no-show probability and used that information to determine when to overbook in a Veterans’ Administration hospital. Pediatric neurology and other subspecialty clinics could use a similar approach to attempt to decrease their no-show rate and improve their financial performance without decreasing patient satisfaction. There are several other reported approaches to decreasing no-shows that do not appear to be good options for our clinic. Some practices have reported decreased noshow rates with no-show fees, but Medicaid and some other insurances do not permit providers to charge them.14 Almost 70% of the individuals seen in our clinic have Medicaid health coverage, and our group has had concerns about charging no-show fees to some patients and not others. Implementing an advanced access schedule that allows patients to obtain appointments within a day or two has been observed to be helpful in decreasing the no-show rate in some centers15 but not in others.16 We have had concerns about whether an advanced access model would work in a pediatric subspecialty environment with high referral volume and a large catchment area. Heptulla et al.17 tried the advanced access model in a pediatric endocrinology clinic and found that although it did decrease patient wait time for appointments and increased patient and family satisfaction, it did not significantly decrease no-show rates. There are several limitations to this study. This study only looked at the direct costs from missed appointments, the amount of payment that the clinic would have received
L.M. Guzek et al. / Pediatric Neurology 52 (2015) 198e201
had the patients shown up. The true costs of missed appointments are believed to be much higher. Scheduling appointments, getting patients ready for an appointment even before they walk into the hospital, and corresponding with referring doctors all cost time and money. In addition, only 1 week a month was used to look at the patient composition that made up the no-show population. These data were then applied to the rest of the month. This study also does not take into account less immediately quantifiable losses from no-shows. These include decreased patient access, longer waiting times for appointments, possible negative effects on patients’ care and on patient satisfaction, and inefficient use of staff and other clinical resources. Missed appointments hurt the economic health of academic pediatric neurology clinics. Further work is needed to analyze the economic effects of applying strategies to decrease the no-show rate in this setting. A good first step could include using predictive modeling to informatively schedule and overbook patients for a period of time and analyzing the effects it has on no-show rate and costs. In order for a health-care system to take care of patients, it must first take care of itself. On airplanes, parents are instructed to put on their own oxygen masks before putting them on their children. Similar to oxygen for a passenger, revenue is critical for health-care groups’ survival. Pediatric neurology is a small subspecialty with few procedures and low reimbursement rates. Pediatric neurologists need to find new strategies to solve their financial issues if they are going to continue providing care well into the future.
3.
4.
5.
6.
7. 8.
9.
10. 11. 12.
13. 14.
15.
References 16. 1. Subspecialties CoP. Pediatric Neurology. 2014; http://www.pedsubs. org/subdes/Neurology.cfm. 2. Collins J, Santamaria N, Clayton L. Why outpatients fail to attend their scheduled appointments: a prospective comparison of
17.
201
differences between attenders and non-attenders. Aust Health Rev. 2003;26:52-63. Al-Faris EA, Abdulghani HM, Mahdi AH, Salih MA, Al-Kordi AG. Compliance with appointments and medications in a pediatric neurology clinic at a University Hospital in Riyadh, Saudi Arabia. Saudi Med J. 2002;23:969-974. Sawyer SM, Zalan A, Bond LM. Telephone reminders improve adolescent clinic attendance: a randomized controlled trial. J Paediatr Child Health. 2002;38:79-83. Lamberth EF, Rothstein EP, Hipp TJ, et al. Rates of missed appointments among pediatric patients in a private practice: Medicaid compared with private insurance. Arch Pediatr Adolesc Med. 2002; 156:86-87. Yoon EY, Davis MM, Van Cleave J, Maheshwari S, Cabana MD. Factors associated with non-attendance at pediatric subspecialty asthma clinics. J Asthma. 2005;42:555-559. Grover A, Slavin PL, Willson P. The economics of academic medical centers. N Engl J Med. 2014;370:2360-2362. Moore CG, Wilson-Witherspoon P, Probst JC. Time and money: effects of no-shows at a family practice residency clinic. Fam Med. 2001;33:522-527. Berg BP, Murr M, Chermak D, et al. Estimating the cost of no-shows and evaluating the effects of mitigation strategies. Med Decis Making. 2013;33:976-985. Avitzur O. Practice strategies to reduce no-shows. Neurol Today. 2003;3:22-27. Satiani B, Miller S, Patel D. No-show rates in the vascular laboratory: analysis and possible solutions. J Vasc Surg. 2009;50:701-702. Lacy NL, Paulman A, Reuter MD, Lovejoy B. Why we don’t come: patient perceptions on no-shows. Ann Famy Med. 2004;2: 541-545. Daggy J, Lawley M, Willis D, et al. Using no-show modeling to improve clinic performance. Health Informatics J. 2010;16:246-259. Torrieri M. Combating Patient No-Shows at Your Medical Practice. Psychiatric Times. http://www.physicianspractice.com/login?referrer¼ http%3A//www.physicianspractice.com%2Fcombating-patient-noshows-your-medical-practice. 2014. Murray M, Tantau C. Same-day appointments: exploding the access paradigm. Fam Pract Manag. 2000;7:45-50. Bennett KJ, Baxley EG. The effect of a carve-out advanced access scheduling system on no-show rates. Fam Med. 2009;41:51-56. Heptulla RA, Choi SJ, Belamarich PF. A quality improvement intervention to increase access to pediatric subspecialty practice. Pediatrics. 2013;131:e585-590.
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Original Article
The Estimated Cost of “No-Shows” in an Academic Pediatric Neurology Clinic Lindsay M. Guzek BS, Shelley D. Gentry ASM, Meredith R. Golomb MD, MSc * Division of Child Neurology, Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
abstract OBJECTIVE: Missed appointments (“no-shows”) represent an important source of lost revenue for academic medical
centers. The goal of this study was to examine the costs of “no-shows” at an academic pediatric neurology outpatient clinic. METHODS: This was a retrospective cohort study of patients who missed appointments at an academic pediatric neurology outpatient clinic during 1 academic year. Revenue lost was estimated based on average reimbursement for different insurance types and visit types. RESULTS: The yearly “no-show” rate was 26%. Yearly revenue lost from missed appointments was $257,724.57, and monthly losses ranged from $15,652.33 in October 2013 to $27,042.44 in January 2014. CONCLUSIONS: The yearly revenue lost from missed appointments at the academic pediatric neurology clinic represents funds that could have been used to improve patient access and care. Further work is needed to develop strategies to decrease the no-show rate to decrease lost revenue and improve patient care and access. Keywords: no-show, missed appointment, cost, finance, health care, academic medical center
Pediatr Neurol 2015; 52: 198-201 Ó 2015 Elsevier Inc. All rights reserved.
Introduction
Pediatric neurology is a small subspecialty that is in short supply; the supply of pediatric neurologists is estimated to be at least 20% less than demand,1 and this shortfall is expected to get worse as more senior pediatric neurologists retire. Many of the largest practice groups are based in academic medical centers (AMCs). Academic pediatric neurologists face increasing pressure to be more clinically productive.
L.M.G. was responsible for drafting the article, design and completion of study, interpretation of data. S.G. was responsible for retrieving data and calculations. M. R.G. was responsible for design and concept of study, interpretation of data, and revising the article and was the study supervisor. This study received no funding and there are no conflicts of interest. The authors report no disclosures.
Article History: Received August 18, 2014; Accepted in final form October 21, 2014 * Communications should be addressed to: Dr. Golomb; Division of Child Neurology; Department of Neurology; Indiana University School of Medicine; 705 Riley Hospital Dr. RI 1340; Indianapolis; Indiana 46202. E-mail address: [email protected] 0887-8994/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2014.10.020
Missed appointments (also known as “no-shows”) decrease clinical productivity. Although, there have been studies on the reasons patients provide for no-shows2-4 and patient demographics3,5,6 associated with no-shows, there are few studies that focus primarily on analyzing the financial strain missed appointments put on health-care systems and subspecialties such as pediatric neurology. AMCs are especially vulnerable to economic threat because of increased costs associated with training physicians and decreased revenue associated with serving a high percentage of Medicaid patients. In the United States, training physicians in residency and fellowship costs $16 billion annually, most of that money coming from the teaching hospitals themselves.7 In addition, AMCs take care of 26% of all Medicaid hospitalizations, but account for only 5% of hospitals.7 The added cost of missed appointments puts increasing pressure on an AMC. The survival and health of AMCs are important for the continued care of a vulnerable patient population, the training of future physicians, and continued advancement in the treatment of complex diseases. The pediatric neurology outpatient clinics at Riley Hospital for Children are associated with Indiana University
L.M. Guzek et al. / Pediatric Neurology 52 (2015) 198e201
199
School of Medicine and are part of a large AMC. This group is the largest provider of pediatric neurology care and the only provider of pediatric neurology fellowship training in Indiana, with 12 pediatric neurologists and two nurse practitioners. All of the pediatric neurology faculty participate in teaching, and several participate in research. The Riley pediatric neurology clinics have faced ongoing issues with “no-shows,” with no-show rates of generally 20% to 30%. The goal of this study was to estimate the economic impact of missed appointments on the pediatric neurology clinic, one of the many specialty clinics at Riley Hospital. Methods Participants and design A retrospective cohort study was performed of all patients who missed appointments in the outpatient pediatric neurology clinics at the Riley Outpatient Center (ROC) location downtown at Riley Hospital for Children in Indianapolis, Indiana, and its primary satellite clinic, (Riley North) during the medical academic year from July 1, 2013 to June 30, 2014. Data on two smaller, part-time satellite clinics with three or fewer total half-day clinics a week were not included. A missed appointment or “no-show” was defined as an appointment where the patient and family simply did not show up, or an appointment that was not canceled at least 24 hours in advance. All patient families received reminder phone calls both 3 and 2 days before the visit; the first call was by a staff member, the second was an automated call. Patient families had the opportunity to cancel during each of those calls, and if they did cancel, that was not counted as a “no-show.”
Data analysis There were six missed visit types to assess: new Medicaid, follow-up Medicaid, new private insurance, follow-up private insurance, botulinum injection Medicaid, and botulinum injection private insurance. Botulinum toxin injections are used to treat spasticity in children with cerebral palsy and are billed as procedures. Average billing and reimbursement data for each visit type were estimated by the clinic’s financial staff based on average coding for these patients in our clinic, available data, and financial staff’s experience, as reimbursement varies among insurance companies. Patients with self-pay and combination insurance were treated as patients with private insurance based on recommendations from the financial staff. Data on the number of scheduled patients and the number of no-shows for each site were retrieved from the electronic record. Number of each type of visit and number of visits from each type of payer were stored in several different data sets; so, the proportions of the six missed visit types for each month were estimated by detailed record review of 1 week of data from that month.
Ethics This study was approved by the Indiana University Institutional Review Board.
FIGURE 1. No-show rates by month at the Riley Outpatient Center, Riley North, and average combined no-show rate. (The color version of this figure is available in the online edition.)
The average reimbursement for a follow-up patient was $49.16 from Medicaid and $112.85 from private insurance. The average reimbursement for a botulinum injection visit was $151.00 from Medicaid and $210.00 from private insurance.
Clinic volume
A total of 10,831 visits were scheduled during the academic year studied: 7808 were scheduled at the primary site, the Riley Outpatient Center location downtown (ROC); and 3026 were scheduled at the primary satellite clinic, Riley North.
No-show rates
The yearly no-show rate for both sites was 26% and ranged from 21% in April 2014 to 39% in January 2014. At the ROC, the no-show rate ranged from 21% in November 2013 to 39% in January 2014. There were 2130 missed appointments (27% yearly no-show rate). At the Riley North satellite clinic, the no-show rate ranged from 14% in April 2014 to 40% in January 2014. There were 668 missed appointments (22% yearly no-show rate) at the satellite clinic. Of note, Indiana had record-breaking cold temperatures in January 2014. (See Fig 1 for variation in monthly no-show rates.)
Results
Estimated revenues lost for each month and for the year
Estimated billing and reimbursement per visit
The yearly billing loss for both sites was $788,733.58, and the total reimbursement (payment) loss was $257,724.57. The yearly reimbursement loss was $189,700.99 at the ROC and $68,023.58 at Riley North. The monthly reimbursement loss from missed appointments at both sites ranged from $15,652.33 in October 2013 to $27,042.44 in January 2014. (See Fig 2 for variation in monthly losses.) The average loss per no-show was $101.83 at the ROC and $89.06 at Riley North.
The average new patient visit was billed at $411.00. The average follow-up patient visit was billed at $231.40. The average botulinum injection visit for spasticity involved injections in two limbs and was billed at $625.00. Billing did not depend on insurance status. The average reimbursement for a new patient was $126.56 from Medicaid and $219.40 from private insurance.
200
L.M. Guzek et al. / Pediatric Neurology 52 (2015) 198e201
FIGURE 2. Revenue lost by month at the Riley Outpatient Center, Riley North, and combined loss from both clinics. (The color version of this figure is available in the online edition.)
Discussion
Missed appointments in this pediatric neurology group were an important source of financial loss. Academic pediatric neurology groups face particular challenges because they serve a large number of Medicaid patients; are often referred the most complicated patients; and need to supervise pediatric neurologists-in-training. However, academic pediatric neurology groups must monitor and improve their financial health to continue serving these missions. The amount of revenue lost because of missed appointments has been studied in other specialties and clinic settings. For one family medicine residency clinic with a 31.1% no-show rate, the clinic’s yearly income was reduced between 3% and 14% because of missed appointments.8 This family medicine clinic was able to replace more than half of their no-shows with walk-in appointments. This would be challenging to do in most academic pediatric subspecialty clinics at Riley Hospital where the patient population may be drawn from all over Indiana. In an outpatient adult endoscopy clinic with an 18% no-show rate, the daily monetary loss was 16.4% of the total potential revenue.9 An endoscopy clinic has substantial differences from a pediatric neurology clinic. While the endoscopy clinic is procedure based, few of the neurology appointments include procedures. There has been little work on financial losses because of missed appointments in neurology. Avitzur10 described an administrator who analyzed the cost of noshows in his 13-physician private adult neurology practice in 2001, and found the practice lost more than $131,000 a year from missed appointments. The patient population in this previous study is different from the population in the present study because it includes adult patients and is a private practice, making the findings difficult to apply to academic pediatric neurology clinics. In the present study, the yearly reimbursement loss because of missed appointments in this pediatric neurology clinic with a 26% no-show rate was $257,724.57 during the July 2013 to June 2014 academic year. This number was based on estimated reimbursements. Billing losses were $788,733.58. These monetary losses represent lost opportunities to improve patient access and care, or to expand other parts of
an AMC’s missions, including education. This number includes losses from only one subspecialty clinic. There are more than two dozen outpatient clinics at Riley Hospital, and all have no-shows that contribute to economic losses. These clinics could provide more care for more patients if they could retrieve at least a portion of the losses. Several strategies have been studied to address missed appointments and the associated costs. One of the most common strategies used to target the no-show rate is a telephone or text-message reminder, but there are mixed results on the effectiveness of this strategy. While Sawyer and colleagues.4 observed a 12% decrease in the number of no-shows in an adolescent clinic with the implementation of telephone reminders, Satiani et al.11 did not observe a decrease in the number of missed appointments at a vascular laboratory clinic. Overbooking is another potential solution used by some clinics to lessen the costs of missed appointments. Berg et al.9 found that booking an additional nine patients a day in an endoscopy suite decreased the economic loss. However, overbooking comes with risks. If all patients show up on a given day, patients are likely to have an increased waiting time, which increases the risk of future no-shows. Long waiting times is one of the reasons patients miss appointments.12 The Riley pediatric neurology clinic has tried mail reminders, automated phone call reminders, and phone call reminders from clinic support staff, with no substantial decrease in no-show rate. Some causes of no-shows, such as the record-breaking cold in Indiana during January 2014, would be difficult to predict and address. Predicting no-show patterns, then using targeted overbooking, could improve clinic flow. Daggy et al.13 developed a model to predict a patient’s no-show probability and used that information to determine when to overbook in a Veterans’ Administration hospital. Pediatric neurology and other subspecialty clinics could use a similar approach to attempt to decrease their no-show rate and improve their financial performance without decreasing patient satisfaction. There are several other reported approaches to decreasing no-shows that do not appear to be good options for our clinic. Some practices have reported decreased noshow rates with no-show fees, but Medicaid and some other insurances do not permit providers to charge them.14 Almost 70% of the individuals seen in our clinic have Medicaid health coverage, and our group has had concerns about charging no-show fees to some patients and not others. Implementing an advanced access schedule that allows patients to obtain appointments within a day or two has been observed to be helpful in decreasing the no-show rate in some centers15 but not in others.16 We have had concerns about whether an advanced access model would work in a pediatric subspecialty environment with high referral volume and a large catchment area. Heptulla et al.17 tried the advanced access model in a pediatric endocrinology clinic and found that although it did decrease patient wait time for appointments and increased patient and family satisfaction, it did not significantly decrease no-show rates. There are several limitations to this study. This study only looked at the direct costs from missed appointments, the amount of payment that the clinic would have received
L.M. Guzek et al. / Pediatric Neurology 52 (2015) 198e201
had the patients shown up. The true costs of missed appointments are believed to be much higher. Scheduling appointments, getting patients ready for an appointment even before they walk into the hospital, and corresponding with referring doctors all cost time and money. In addition, only 1 week a month was used to look at the patient composition that made up the no-show population. These data were then applied to the rest of the month. This study also does not take into account less immediately quantifiable losses from no-shows. These include decreased patient access, longer waiting times for appointments, possible negative effects on patients’ care and on patient satisfaction, and inefficient use of staff and other clinical resources. Missed appointments hurt the economic health of academic pediatric neurology clinics. Further work is needed to analyze the economic effects of applying strategies to decrease the no-show rate in this setting. A good first step could include using predictive modeling to informatively schedule and overbook patients for a period of time and analyzing the effects it has on no-show rate and costs. In order for a health-care system to take care of patients, it must first take care of itself. On airplanes, parents are instructed to put on their own oxygen masks before putting them on their children. Similar to oxygen for a passenger, revenue is critical for health-care groups’ survival. Pediatric neurology is a small subspecialty with few procedures and low reimbursement rates. Pediatric neurologists need to find new strategies to solve their financial issues if they are going to continue providing care well into the future.
3.
4.
5.
6.
7. 8.
9.
10. 11. 12.
13. 14.
15.
References 16. 1. Subspecialties CoP. Pediatric Neurology. 2014; http://www.pedsubs. org/subdes/Neurology.cfm. 2. Collins J, Santamaria N, Clayton L. Why outpatients fail to attend their scheduled appointments: a prospective comparison of
17.
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