A recent Medical Post column, “Finding Value” (March 8, p.26), caught my eye. Written by Dr. Jonathan Marcus, (bio: ... a family doctor and entrepreneur in Toronto. He writes and speaks on practice management with an emphasis on uninsured services) “How to explain no-show charges to patients” offers docs a script to encourage patients to pay for appointments they missed.
Before I share some of Dr. Marcus' tips, I want to say that it is accepted business practice in some professions (including medicine) to charge clients who don't keep their appointments. The rationale is solid: You reserved my time and have to pay for it regardless of whether or not you attended the appointment.
Having said that, I think there are 2 ways to look at no-shows. The traditional approach is that the patient is at fault and should bear the cost. Another approach is to consider how the appointment system a medical office uses may be a factor in missed appointments.
In specialty practices, long wait times for consultation mean some patients will honestly forget about their appointment. In Saskatchewan, some of our patients travel from the north and may have limited travel resources. We may have sent an appointment time that is inconvenient because of work, school, child care, etc.
In our practice, we've decided not to charge patients for missed appointments for various reasons, not the least of which is we don't want the nuisance of running a collection agency.
I think I could agree to disagree with Dr. Marcus on the relative merits of charging for no-shows. But, I'm uncomfortable when I read his suggested script for convincing patients to pay up. As I can't find a link to the article, I'll quote liberally and try to be true to the context.
In a previous article, he had offered suggestions on how office staff can collect outstanding bills. In the current article, the bill is still outstanding.
However, if your staff is unsuccessful, here's what you can do to get paid most of the time while maintaining a good doctor-patient relationship.
This is part most doctors are going to be uneasy with. We don't often have experience with the nitty-gritty business side of medical practice, and are worried that we'll affect the relationship with our patients.
During your patient's appointment, deal with his or her health concerns first, of course. Then bring up the outstanding bill.
We're off to a good start. I would be very uncomfortable with asking my patient for money before dealing with their medical problem. I think it would sour the entire visit. Also, I wouldn't want to surprise my patient with a no-show charge. I suspect that one of Dr. Marcus' previous articles suggested posting a waiting-room notice explaining the no-show policy.
Patients may give reasons for missing appointments and I recommend you waive bills for excuses such as family illness, etc. You might want to reduce rather than waive fees if the patient has financial difficulties. Paying a few dollars keeps patients accountable and reduces future no-shows, while respecting their financial situation.
Now I'm in the judge and jury. I have to decide if their story is worthy of a break. (In the case of a family illness, would my patient have to bring a doctor's note? To a doctor?) How will I judge their degree of financial hardship?
It’s important that you discuss outstanding charges in a nonjudgmental, relaxed manner. The first thing I say to patients is, “I’ve been your doctor for (however many) years. I love our doctor-patient relationship and hate to have to charge you for this.”
Is this a mixed message? I love our relationship, but I’m going to charge you for missing an appointment.
I may add, “This fee is not a punishment. It just covers the cost of running my practice.”…
…By this point, most patients have agreed to pay.
Some patients may still hold out. When this happens, I remind them I usually see patients on time for their appointments and I’m able to do so because I don’t double-book. The flip side is that I expect them to respect my time by paying for appointments they miss.
Dr. Marcus runs his clinic on time, but what about the other doctors to whom he is offering advice. If they don’t run on time, and/or double-book, are they still entitled to bill for no-shows? The real “flip side” is allowing patients to submit an invoice for the time they spend in the waiting room beyond their scheduled appointment.
At this point the situation is usually resolved. Rarely, patients continue to protest. If they do, I then say, “Someone has to be responsible for the missed appointment and there are only two people in the room – you and me. Who should it be?” It’s incredibly difficult for a patient to look you in the eye and decline to accept financial responsibility when you say this.
I mentally role-played saying this line to a patient, and it made me cringe. If a patient couldn’t look me in the eye because of something I said, I would be ashamed of myself. I have all the power in the relationship. Surely my patient would be concerned that their care may suffer if they don’t whip out their wallet, pronto.
What’s the next step if a patient digs in their heels and refuses to pay? The implication is that the doctor will end their relationship. (The relationship he loves…)
Having this conversation with patients reminds them of important aspects of the doctor-patient relationship: commitment, concern for patients’ well-being, reliability, timeliness and responsibility. This strengthens the relationship, decreases future no-shows, and helps you collect payment smoothly.
I’m not sure how this policy demonstrates concern for patients’ well-being, but it certainly does put the onus on them for timeliness. However, timeliness in the doctor-patient relationship cuts both ways. Patients will sometimes semi-jokingly say they feel like sending me a bill for the time I kept them waiting. If I were to charge them for missing an appointment, I bet I would actually see some similar invoices from them.
I suspect this tactic will decrease no-shows, but perhaps by driving patients away from the practice. Of course, given the difficulty people have in finding a family doctor or seeing a specialist, patients are unlikely to abandon a doctor, regardless of how they are treated. Once again, all the power is in the doctor’s hands.
If Dr. Marcus and I have such opposite views, then who’s right? We could argue, or we could collect the evidence. The evidence we look at depends on our goal.
If we implement his strategy with the intent of maximizing practice income, then we should compare the additional revenue from no-show patients with the cost of collecting that revenue. Include staff time and the even-more expensive physician time spent convincing patients to pay up. The value of the missed appointment should be discounted in the equation as the time was likely spent in some other useful activity, such as returning calls or reviewing lab results. Is there some way to calculate the value of lost goodwill?
If our goal is to reduce no-shows, then we could compare the no-show rates in two similar practices with different no-show charge policies. Comparing my Saskatoon urology practice with Dr. Marcus’ Toronto family practice is apples and oranges, but it’s interesting to note that he reports a no-show rate of 10-15%. Our clinic’s rate is the same.
It’s easy to be critical, so let me offer a suggestion for an alternate script for “no-show patients”:
I noticed that you missed your last appointment. Because your well-being is important to me, I want to find out how I can help you with appointments in the future. Is there a particular time of day that you prefer? Could my staff call you the day before the appointment as a reminder?
If you can’t make an appointment, I appreciate it if you can call as soon as possible. That will let me schedule another patient in that time, and that helps shorten our clinic’s wait time. Then, the next time you call for an appointment, I’ll be able to see you promptly.
Dr. Marcus’ advice may win the battle, but I fear it will lose the war.