?

Log in

No account? Create an account

Previous Entry | Next Entry

Winter has returned, altho not with a vengeance. It's due to be above freezing for all of the upcoming week for at least part of each day. Kids have a snow day. Shops are sending out emails saying they are closed for the day. At some point, we will be going out to shovel, but probably not just yet.

In the meantime, health care and no-shows. What could they learn from airlines?

Here is what triggered this:

http://www.medpagetoday.com/PatientCenteredMedicalHome/PatientCenteredMedicalHome/56021

Like a dipshit airline from the 1990s, the thinking here is, hey, lost revenue! Lost opportunities to help!

Back in the 1990s, the no-show rate for airlines was about 20% Yes, you read that right. We know people who had a family member in an airline. The people we know _always_ flew standby, because their connection had the information to steer them to flights that were guaranteed to have space. How did they do this? Well, apparently, travel agents could (and maybe still can) book nonrefundable tickets without payment. Yeah, no-showing on that is no hardship. Must have been good for a few percentage points.

http://usatoday30.usatoday.com/money/biztravel/2005-12-19-bump-usat_x.htm

With a huge fraction of tickets booked online, that practice has dropped dramatically, and the industry no show rate is down closer to 12%.

https://operationsroom.wordpress.com/2014/02/10/an-airline-that-doesnt-overbook/

JetBlue doesn't publicize their We Don't Overbook Flights policy, but I was not too surprised to discover they had one. I'd never seen anyone get bumped voluntarily or otherwise, and it seemed like Back In the Day, every flight I was on left late as this complex negotiation wasted everyone's time. And generated MORE no-shows from missed connections.

JetBlue has a lower no-show rate, in part because most of us fly from our origin to our destination in a single leg. The opportunity for us to no-show on leg B, C, D, etc. is minimized when those legs don't exist. Even if our initial flight is hours late, it just uses up our theme park time; it doesn't cause us to miss a connection, at least not a JetBlue connection.

Returning to the original Pelzman article about medical no shows:

"It reminds me of smartphone apps where people can make reservations at restaurants, with very little sense of responsibility. Theoretically you could make 20 reservations for dinner Friday night, keep none of them, and it's no skin off your teeth. The restaurant wants you to make a reservation at their place, but they certainly don't want you not showing up.

In the olden days, you actually had to call the restaurant to make a reservation and speak to the maître d', and there was somehow some shame in not showing up for that reservation. In fact, many places would take a credit card and hold it for you, and use that to make sure you kept your reservation.

You feared not showing up and then dared try to make another reservation. Missed a dinner reservation last week? Table by the bathroom."

DisneyWorld has been through a lot of this. They now require credit cards to hold many reservations (at least one was requiring full pay up front, but it may be gone now since Flying Fish was under renovation last time I checked) and will charge $10 or more dollars per head if you no show. If nothing else, it motivated you to call and reduce the size of your party if you are wondering whether you are really going to get there, and some members definitely won't be there. But there were definitely years when I booked a nice table every night of our trip, and canceled half. I still do some of that, but instead of calling three hours before the reservation, I now make sure I call at least 24.

Strategically _overbooking_, however, does not seem like something that a person making doctors appointments is likely to do! I think the airline analogy might be a better one. In which case, thinking about what leads to no-shows might be worth contemplating. One thing I do sort of wonder about: how many no-shows are people who decide not to bother to come in because they knew how late the doctor was running, and just didn't show up for their scheduled appointment, because they would have waited, run out of time, and left? Are they counting no-shows as people who came, waiting for the time they had, and left, missing their appointment? Because that isn't THEIR fault!

For that matter, Pelzman's math is odd.

"If you think about it, that represents several practitioners sitting around essentially doing nothing for an entire year."

Whenever I've seen a no-show situation while I was in the waiting room, they just reduced how far behind they were. No-shows were sort of a win, basically. I suppose their may have been circumstances where there was no one waiting. Catch up on your charting? Eat lunch?

Pelzman is focused on repeat offenders, which makes sense. But his solution does not make sense. Send a warning letter? Come on! You have a patient portal. If you want to know _why_ they are missing appointments and you START with a warning letter, you aren't going to learn anything useful. They'll just get defensive. Communications 101. ASK! Find out why your 5,941 repeat offenders are not showing up. Are they missing one appointment, rebooking, missing that appointment, rebooking, etc.? In that case, something has gone haywire with their lives. Find out what it is! Are they missing every other appointment? Why do they have so many appointments in a year that there are 3-10 that they CAN miss? (And how on earth are they keeping a job/staying in school when they are having that many appointments?) I've canceled well baby appointments because the kid was too sick for a shot and I didn't want to have the argument about whether the kid was too sick for a shot (also, by and large, my providers trusted my judgment on this sort of thing anyway). Are these chronic disease monitoring appointments that a patient is skipping because they wound up in the ER somewhere else with something much more serious?

"The addition of a new telephone electronic reminder system seems to be chipping away a little bit at our no-show rate. The system calls patients (for whom we have an active telephone number) reminding them of their appointment 48 hours in advance, giving them the option to confirm that they are keeping the appointment, or selecting an option that allows them to tell the practice they will not be keeping it. This created availability has been extremely helpful in getting us a bunch of same-day or next-day appointments for patients who want to be seen urgently."

Wait, it's 2016 and that's a NEW system? What the ever living fuck is wrong with you people?

Doctors may think of patients booking appointments with them as going out for fine dining. But I never would. I think that people straight up forgot, and then were in tears when they didn't get the reminder call, and then rebooked. Lather rinse repeat. A lot of people don't maintain accurate calendars, and we shouldn't link health care provision to that level of personal organization (I completely forgot to put the kids' neurologist appointments on the calendar -- if I hadn't gotten the call, I would have missed them. Altho, in the event, the first call is the office rebooking because of a schedule change so, you know, whatever the fuck).

Pelzman is basically a tool and a fool. He's so focused on the wrong being done to his people, that he can't even think straight. Medical care is NOT like a dining reservation. If people are missing appointments, you _definitely_ should take a look first at your appointment reminder system, second at your wait time in the office, and third at accuracy and availability of directions to the office. I know a ton of people who missed a first appointment because they went to the wrong location, or it took much longer to get there and park than they had anticipated, and they gave up when they knew they were an hour late. That'll carve the no-shows down to a manageable level, and you can start to understand why people aren't showing up, categorize, and design solutions for the bigger chunks. I'm betting some of those repeat no-shows books first appointments with multiple providers, and never got around to canceling once they picked someone _because they assumed you would do that for them_. Honestly, if you have people booking first appointments with multiple providers and not showing up, _why_ did you even let them do that? Without so much as logging their explanation for non-appearance and an action plan to get them to the next one? How is this not worth charting?

"It does seem fair in the big picture, however, that if you've made multiple appointments to see one of our providers as a new patient, and just don't have the courtesy to call and cancel, you just don't show up"

The Lurie Center/LADDERS recognizes the new patient problem. There is a social worker assigned to shepherd you through the fill-out-the-paperwork process to get you actually in the door eventually. I'm not sure I would have made it through without that level of assistance. I sort of wonder if that's a common situation -- and I really, really despise this guy for being so unsympathetic that he can't even _imagine_ that there might be Best Practice out there to help.

Tags:

Comments

( 2 comments — Leave a comment )
jinasphinx
Feb. 10th, 2016 05:31 am (UTC)
Re: Wait, it's 2016 and that's a NEW system?
It's pretty amazing how backwards some industries are. I read Patrick McKenzie's blog posts, as I think have you. After he made the bingo card creator, he noticed that masseuses and hairstylists have a no-show problem and so he made an appointment reminder SaaS. Turned out that those kinds of businesses were not a great target market, but then he found he could sell it to hospitals... which is kind of mind-boggling, that they didn't already have a solution in place and that a one-man company could sell to that big of an organization.
walkitout
Feb. 10th, 2016 01:55 pm (UTC)
Re: Wait, it's 2016 and that's a NEW system?
Thank you!

I do not typically read McKenzie, except when you've had something to say about him. But I do remember the appointment reminder system. It was in the back of my head when I was writing about the no show stuff, and I thought about mentioning it, and then thought, oh, but that was for a really small industry.

I am _flabbergasted_ that he was able to sell it to hospitals.

The really nice thing about McKenzie's system -- and I think he mentioned this -- was that he could sell it as a only-do-it-when-you-need to thing. That is, they could make the reminder calls when they were waiting for the next customer, making productive use of down time. Which is apparently _exactly_ the problem in a typical urban residency setting, which is where the no show problem is at its worst. Typical suburban practices which mostly see kids and their parents tend to not have a problem with downtime -- their problem is figuring out how to keep up with the wave of often not completely necessary business (ear infections that would resolve at home as fast as if they visited a doctor).

One of the things that caused me to stop posting again and again about no shows was when I noticed that the context for no show problems was so buried, that it was hard to know what the solution was. Usually, once the context was surfaced, the solution was apparent. Altho apparently nothing in management is obvious if your industry is sufficiently backwards when it comes to management.

I find it utterly amazing that it took increasing regulation on health care to get many elements of the industry to adopt the most basic of good practices when it comes to management, documentation, communication, etc.

Edited at 2016-02-10 01:55 pm (UTC)
( 2 comments — Leave a comment )