Thesis-No-Show Project Bridgette-Noel Final

No-Show Appointments 1
Running Head: WHY ARE PATIENTS NO-SHOW FOR APPOINTMENTS WITH THEIR
PRIMARY CARE PROVIDER
Why Are Patients No-Show for Appointments with Their Primary Care Provider?
Brenda L. Bridgette-Noel, BA (Candidate for MBA)
MGT 6750: Thesis
April 2011
Advisor: Catherine Coleman-Dickson

Table of Contents
Acknowledgements…………………………………………………………………….3
Abstract …………………………………………………………………………………4
Chapters
I. Problem Statement and Need for Research………………………………………5
II. Review of Current Literature……………………………………..........................10
III. Description of the Methodology………………………….…………………. ….23
IV. Findings…………………………………………………….…………………....25
V. Conclusion and Recommendations………………………….…………………...35
Appendices:
Appendix A (Questionnaire)…………………………………………………………….41
Appendix B (Rating Average) ….……………………………………………………….42
Appendix C (Results Charts) …………………………………………………………….45
Appendix D (No-Show Letter) …………………………………………………………...48
Appendix E (Proposal for No-Show Reduction) …………………………………………49
References……………………………………………………………………………….50

Acknowledgements
I would like to acknowledge a number of people for their support and prayers through
this experience.
To my husband for his support and help throughout this process, thank you for being an
unbelievable cheerleader, my foundation, and editor. But mostly, thank you for being a great
listener during this whole process.
To my sister and friend Dorothy – you are my prayer partner and the check and balance
in my life. Thank you for the constant encouragement and the devotion that you have shown.
You have been so patient with me these past few months!
To my sister Allyson, the love that you have shown me was well received. Thank you so
much for always encouraging and supporting me throughout my education and life.
To my Children’s Hospital of Philadelphia (CHOP) family, Sharon Sutherland, MD and
Andrea McGeary, MD-Medical Director, thanks for lending your time to assist with the research
and for providing continual feedback.
Finally, thank you to my Rosemont family, Joan Wilder and Marie Bynum for your on-
going support. To Catherine, my thesis advisor, you have been so helpful and informative,
despite your busy schedule and our short time-line! I appreciate all your help and support.
Thank you.

Abstract
Missed patient visits (no-shows) continue to be a growing problem within the healthcare system
in many urban areas. Medical practices are often looking for ways to reduce the no-show rate by
analyzing patterns relating to missed appointments. The costs of missed appointments are
significant and are gaining attention throughout medical institutions. Emergency Department
overuse is about $38 billion dollars in the United States. The goal is to reduce Emergency Room
utilization by getting patients back to their medical home for continuity of care. A survey,
developed by the author, will be used to investigate some of the reasons why patients’ miss their
scheduled appointment with their primary care provider. Results from the survey will be
presented, followed by a comprehensive review of current literature surrounding interventions
for this wide spread problem. The author will examine the current model of acute and well care
access at The Children’s Hospital of Philadelphia Primary Care Center at Cobbs Creek and
investigate other health care models. The hope is to decrease the no-show rate at the pediatric
primary care practice in West Philadelphia.

Chapter 1: Problem Statement and Need for Research
Throughout the United States, health care providers and staff often struggle with patients
who frequently do not show for appointments. This is a major issue for medical practices in
several urban settings. When patients fail to show up for their primary care (PCP) appointments, it can
lead to a delay in diagnoses and detection of diseases. Missed appointments with a primary care
provider unavoidably increases emergency room utilization, which accelerate the cost of that patient care.
It is now a national initiative to get patients back to their medical home. Many governmental and
insurance companies are all collaborating in trying to find ways to improve continuity of care and at the
same time decrease cost to the health care system. The goal is to practice preventive medicine in the
medical home.
Today, a growing number of people are using hospital emergency departments (EDs)
for non-urgent care for conditions that could have been treated in a primary care office. On a
national scale, 56 percent or roughly 67 million visits are potentially preventable. If this trend is
reduced, it will allow opportunities to improve quality health care and lower the costs within the
health care system. Simplified, the problem is expensive care in the incorrect place at the
incorrect time. In 2005 the annual number of emergency department visits in the United States
increased nearly by 20% from 96.5 million in 1995 to 115.3 million. That increase was seen
over a period of 10 years (www.nehi.net, 2010). This begs the question regarding why patients
present to the ED for non-acute issues rather than to their primary care provider (PCP). Can it be
that many Americans do not have a PCP?
To further understand this wide spread issue, it is imperative to ascertain who uses the
ED for non urgent care and why that choice was made rather than seeing a PCP? A national
survey of emergency departments demonstrated that 56% of all visits were avoidable (Figure 2).
Emergency room abuse continues to grow exponentially with little intervention to changing this

pattern of behavior. According to the New England Healthcare Institute (NEHI), the overuse of
U.S. emergency departments (EDs) is responsible for $38 billion in wasteful spending each year
(March 2010). This has emerged as a significant topic of discussion—and debate. The
following graph demonstrates non-urgent visits nationwide are on the rise.
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Figure 1. Non-urgent Visits Nationwide, 1997 - 2006
Figure 1. Non-urgent Visits
Nationwide, 1997 - 2006
Source: CDC National Hospital Ambulatory Care Survey
In 2007, the NEHI published a seminal report entitled, Waste and Inefficiency in the
Health Care System-Clinical Care: A Comprehensive Analysis in Support of System-Wide
Improvements. “The research found that 30 percent, or nearly 700 billion, of all health care
spending is wasteful, meaning that it could be eliminated without reducing the quality of patient
care.” The study found six major sources of waste such as; unexplained variation of clinical
care, patient medication adherence, misuse of drugs and treatments, emergency department (ED)
overuse, underuse of appropriate medications, and overuse of antibiotics. For the purpose of this
paper, the focus will be on emergency department overuse, which was the fourth largest category
of misuse responsible for up to $38 billion in wasteful spending in the U.S. every year (NEHL
Research Brief, 2010).

Emergency departments are the only place in the U.S health care system where people
have access to a wide range of services at anytime regardless of their ability pay or the severity
of illness. Currently, the ED appears to be functioning somewhat as a primary care office rather
than a place that treats acute illnesses. The nationwide study highlights that patients present to
the ED for basic services such as prescription refills, colds, flu, diaper rash, ringworm, just to
name a few. The high costs of emergency room care impacts patients and insurance carriers and
create a drain on health care dollars. A study performed in Massachusetts showed that
emergency department overuse is high across all insurance payer groups (Figure 2).
Figure 2. Avoidable ED Use in Massachusetts by Insurance Payer
Group, 2005
24.0% 24.3%
19.3% 20.5%
28.7% 26.4%
27.8% 25.5%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Medicaid Uninsured Medicare Private
Preventable/Avoidable
Visits
Non-urgent Visits
Source: MADHCFP
The Massachusetts study also demonstrated that avoidable ED use was almost
identical across all age groups, even for patients 65 and older (Figure 3). With that said, ED
overuse encompasses the entire population, despite of age or insurance (NEHL, 2010).

Figure 3. Avoidable ED Use in Massachusetts by Age Group, 2005
20.9% 21.8%
18.3%
19.9% 19.3%
20.5%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
0-17 18-64 65+
Preventable/Avoidable
Visits
Non-urgent Visits
Source: MADHCFP
Further studies have shown that the abusers of the emergency departments have
contributed to the growing cost of health care and consumers are paying for that abuse in the
form of higher premiums. Why are the insured and uninsured, coming to the ED in large
numbers? According to Meisel and Pines (2008), the answer is economics. The way in which
health information is shared and incentives aligned, both patients and doctors are driving the
uninsured and insured alike to line up in the ER for medical care. It has been suggested that
many people without a health care background don't have a good way to judge whether
headaches, stomach discomfort, or fever are true medical emergencies. Primary care providers
have little reason to tell someone not to seek ED care, especially if the complaint is potentially
serious. If by chance the doctor advised the patient to wait and not to go to the ED and the
patient’s symptoms worsen the malpractice potential is always there. With that said, many come
to the ED because it’s a one stop shop that is always open.

Emergency department overuse is an area where costs can be reduced significantly if
patients return to their medical home for non-urgent care. Research suggests that many of the
patients that end up in the emergency room for non acute issues tend not to be followed by their
primary care providers, does not have a primary care provider or demonstrate a history of
multiple no-shows. These patients often come from low-income families with government
assisted coverage, uninsured or self-pay (Market Watch, 2010).
No-shows often correlate with access, delays and lack of continuity in care, which leads
to the following concerns. Why do patients choose to go the emergency department for non-
acute care? What are the patterns with those patients that present to the emergency room? This
paper will attempt to address common themes in these patients and examine the factors relating
to missed appointments.

Chapter 2: Review of Current Literature
In order to present a comprehensive background for this research, a review of current
literature pertaining to this topic is structured as follows. First, an overview of the problem, next
the definition of “no-show,” followed by current literature reviews from various medical
institutions, which includes primary care and specialty practices. Finally, barriers, interventions
and opportunities related to this topic will be discussed.
Non-attendance (failure to attend clinic appointments) is a universal problem in the
management of pediatric clinics. In general, non-attendance rates in the United States (US) range
from five to 55%, whereas United Kingdom (UK) figures range from three to 12% (Goldbart, et
al 2009). According to Goldbart et al, “Non-attendance has both social and financial costs.
Social costs include unused resources, such as personnel time, equipment and clinic capacity
(2009).” Primary care providers rely on appointment scheduling to keep their practice operating.
A missed appointment means the providers, nurses, phlebotomists and other support staff
suddenly find themselves with time on their hands that should be filled by sick or well patients.
However, that medical appointment time may never be recovered. This becomes more
problematic when appointment demands are high, especially during the flu and cold season or
when parents are trying to get mandated school forms or sports physical appointments for their
children.
No-shows are referred to as “missed appointments” and “non-attendance,” which will be
used interchangeably throughout this paper. No-show is defined as, “patients who neither kept
nor cancelled their scheduled appointments in advance,” (Goldman et al, 1981). This represents
a persistent problem in many ambulatory medical settings. A missed appointment limits
practices from providing care to patients and their failure to cancel appointments in advance

create substantial inefficiencies for the physician and for the medical institution. When there are
missed appointments there will be missed revenue. There is a price for no-show appointments
and last minute cancellations. In addition to affecting efficiency, failure to manage this area of a
medical practice can result in staggering associated costs. For example, if the average evaluation
and management charge for a patient with Gastro- esophageal Reflux Disease (GERD) is $150
and there are five no-shows each week, the lost revenue could be $39,000 a year or more.
In 2008, Elmendorf Air Force Base experienced 15,521 no-shows of medical
appointments, costing the hospitals in the Anchorage Bowl, Alaska nearly $1.3 million in lost
productivity. The report further showed that there were 4,493 beneficiaries, not on active duty,
they however, diverted to Urgent Care Centers. It is not their preferred method to seek care but
it created an additional expense of more than $500,000, bringing the total cost to nearly $2
million (Sorrells, 2009). To help reduce appointment no-shows at Elmendorf Air Force Base, an
appointment reminder system was established to call patients two days before their
appointments. The system sends a message identifying the patient, date and time of the
appointment. The system gave the patient the opportunity to cancel the appointment, which
freed up the slot for someone else to utilize. The downside to this system is not having correct
patients’ phone numbers for the system to perform reminder calls.
The Sibley Heart Center at Children’s Healthcare of Atlanta, which handles 30,000
outpatient’s appointments at 18 facilities annually, rolled out a new initiative to reduce a 16.7%
same day cancellation and no-show rate. The Market Watch, 2010 research showed that the
types of patients who were least likely to show often came from low-income families either on
state coverage such as Medicaid or uninsured and self-pay. Patients in that study gave the
following reasons for missing their appointments: “We couldn’t find the place, the directions

were bad, I forgot, I could not find parking and I did not have a ride.” Some of the respondents
were unaware that Medicaid provides transportation for their patients (Market Watch, 2010).
Although, patients routinely receive an automated reminder calls 48 hours before the
appointment time, five of the clinics continued to struggle with habitual no-shows. Staff
members decided to take it a step further by making personal calls five to seven days in advance
to families who have missed previous appointments. The caller verified that patients had
directions and a ride to prevent challenges associated with missed appointments. Since the
program is in its early stages, comprehensive data is not yet available. However, the no-show
rate appears to be declining (Market Watch, 2010).
A large national survey of 160 pediatric residency continuity clinics with children of all
ages including adolescents showed an average appointment failure rate of 31%. Failure to keep
clinic appointments is also a major barrier to effective and efficient health care delivery. Among
the myriad of reasons, forgetfulness is cited as number one for appointment noncompliance
among adolescents and adults (AAP, 2010). Several studies have shown that telephone and
mailed reminders are effective in improving clinic attendance among children and adults. One in
particular, was done at an inner city hospital based clinic, which examined the effect of a single
telephone call reminder on appointment compliance among 703 adolescents. The study was
divided into a control and an intervention groups. The intervention group received the
appointment reminder call while the control group did not.
Findings from the study demonstrated that the attendance rate was significantly increased
from 44.1% in the control group to 55.6% in the attempted intervention group. This represented
a 26.1% increased in the attendance rate. The completed intervention analysis, which included
the control and the intervention groups who were contacted successfully by telephone, showed

an increase in the attendance rate. Attendance was significantly increased from 44.1% in the
controls to 65.2% in the group that was contacted successfully by telephone. This represented a
47.8 % increase in attendance. The telephone call reminders were successful in improving
appointment compliance because two thirds of the adolescent patients who received telephone
reminder calls kept their appointments (Bundy et al, 2010). The only other study factor
associated with appointment attendance were patients without insurance, they were clearly less
likely to attend. The result of this study suggests that telephone reminder messages are very
effective in increasing attendance rates in a hospital-based adolescent clinic.
According to a report issued by Courtney Griggs at Fort Sill, 17,000 patients missed their
appointments at Reynolds Army Community Hospital in 2009, which cost the hospital over $1.2
million in lost revenue. The report mentioned that, “When somebody doesn't show up for an
appointment, the doctor is sitting there wasting his time, and then there are calls from other
patients who cannot get an appointment” (2009). Because patients choose not to call to cancel
appointments, it hampers productivity within the medical practice and it prevents other patients
from gaining access to see the doctor. The reporter further asserted that a no-show is not just
one missed appointment but it is two, it is a missed appointment for the person that did not show
up and a missed appointment for the patient that could not get in. Dr. Bruce Lovins, Chief of
Primary Care noted that an office visit cost about $94, multiply that by 17,000 patients and it will
cost about $1.6 million in lost revenue (www.army.mil). It appears that patients and families are
not making the connection that missed appointments are costing the government and tax payers
millions. Although there were no interventions mentioned in this report, the hospitals are
requesting that patients and families call to cancel appointments as a way to reduce no-shows.

In contrast to the study done at the inner city hospital based clinic for 703 adolescent
patients, prior research has been done to ascertain methods used to keep visit rates (show rates)
high among family medicine residency practices in the United States. This investigation was
performed because patients’ failed to keep their scheduled appointments in family medicine
residency practices, which became challenging to manage. Johnson et al researched and
gathered effective management strategies used to achieve low no-show rates. A one-page
questionnaire was mailed out to 448 family medicine residency program directors to provide data
for their residency practice for the following information.
1. The distribution of patients by age and by type of health insurance.
2. The average numbers of new and established patients seen, and the average
number of no-shows per half-day,
3. The level of satisfaction with the current methods for reducing no-shows and for
managing no-shows
4. Assessment of the impact of no-shows on resident education, continuity of patient
care, patient access to care and clinic outcome (Johnson et al, 2007).
Respondents were given the option of supplying actual data and to free text their methods
for reducing and managing no-shows. The management of no-shows was defined as “reducing
the impact of no-shows once they occur” (Johnson, Mold and Pontious, 2007). Of the 448
questionnaires, which were mailed, 141 practices responded with a total of 31.5% response rate.
The study shows that the respective mean and median no-show rates were 17% and 15%.
Practices with higher proportions of new patients (P=.03), Medicare patients (P=.008) and self-
pay patients (P=.001) were more likely to have higher no-show rates, and those with higher
proportion of patients aged 46 to 64 years (P=.002) were more likely to have lower no-show
rates. The no-show rates were not associated with the proportion of pediatric or Medicaid
patients (Johnson, Mold and Pontious, 2007). It appears that respondents were more concerned

about the impact of no-shows on patient care that is both access and continuity of care. Statistics
for the questionnaire variables are shown in Table 1.
Table 1. Descriptive Statistics for Residency Program Practice (n=135)
Variable Mean Median Range
Patients’ health insurance type
Medicaid, %
Medicare, %
Private insurance, %
Self-Pay, %
0.35 (0.19)
0.20 (0.10)
0.31(0.21)
0.30
0.20
0.27
0.0 -0.80
0.01 -0.48
0.01 -1.00
Patients’ age distribution
0-18 years, %
19-45 years, %
0.23 (0.11)
0.30 (0.11)
0.20
0.30
0.02-0.60
0.1-0.75
46-64 years, % 0.27 (0.10) 0.25 0.03-0.60
65-79 years, % 0.16 (0.09) 0.15 0.0-0.55
80 years +, % 0.06 (0.06) 0.05 0.0-0.50
Patients seen per half-day
New patients, n 1.77 (0.79) 2.0 0-4
Established patients, n 7.08 (2.02) 7.0 1-12
Total No. of patients, n 8.81 (2.23) 8.0 3.5-15
No-shows per half-day, n 1.83 (0.98) 2.0 0.4-5.0
No-show rate, % 0.17 (0.07) 0.15 0.03-0.42
Administrator satisfaction score *
Reducing no-shows 2.79 (1.00) 3 1-5
Managing no-shows 2.93 (0.97) 3 1-5
Impact of no-shows score +
Overall 3.05 (1.20) 3 1-5
Resident education 2.76 (1.07) 3 1-5
Continuity of care 3.06 (1.11) 3 1-5
Access to care 3.31 (1.10) 3 1-5
Income 3.09 (1.05) 3 1-5
* Where 1= very dissatisfied and 5 = very satisfied. +Where 1= minor impact and 5 = major impact.
The methods used by the rate exemplars fell into six categories: patient education, patient
reminders, sanctions, open access, emphasis on continuity, and scheduling rules (Table 2). All
but two practices attempted to contact all patients within 24 to 48 hours of every appointment to
remind them of the appointment. One practice administrator reported that “when a secretary,
who had been telephoning all of the patients the day before their appointment, decided to stop
doing so (without telling her supervisors), the no-show rate went from 5% to 10% within one
week.” Of the two practices that did not telephone to remind patients, one had a complete open-

access scheduling system. The clinic manager reported, “Our no-show rate, which was 25% two
years ago, went to 9% when we began calling every patient the day before their appointment and
added a walk-in clinic, and to 4% when we converted to an open-access scheduling system”
(Johnson, Mold and Pontious, 2007).
Several of the practices created no-show policies for patients who did not keep
appointments in attempt to curtail this issue. The following are list of interventions taken to
control patients that missed their appointments:
1. Patients were forewarned about the policy upon joining the practice and or when
scheduling or being reminded of an appointment.
2. Systems were created to track and document no-shows in the patients’ medical
records and scheduling system.
3. Notification to the physician of all no-shows.
4. A telephone call to the patient after each no-show.
5. Warning letters after each of the first two no-shows.
6. A dismissal letter after the third no-show in six months (Johnson, Mold and
Pontious).
According to this report, 90 % of the patients who missed three appointments within six
months were dismissed from the various practices. This may appear to be punitive to the general
public, especially, with young pediatric patients who may not be able to make the decision on
whether to present for an appointment or not. Prior research suggests that in primary care
residency program practices, those more likely to missed scheduled appointments are young
adults, unmarried and non-white patients. They seem to have larger families and less education,
whose language, race or sex is not concordant with that of the clinician, patients who have no
insurance or are on Medicaid, patients new to the practice, patients referred from the emergency
department, patients with acute rather than chronic illnesses, patients scheduled with first-year
residents or medical students, patients with a history of missed appointments and patients with

physician-identified psycho-social problems (Johnson, Mold & Pontious, 2007). Strategies used
to reduce no-show rate are reflected in Tables 2 and 3.
Table 2. Strategies Used by Exemplary Practices to Reduce
No-show Rates (n=11)
Method Practices Using Method
No. (%)
Patient education 10 (9)
On enrollment in practice 7 (64)
When each appointment is made 6 (55)
When reminded of appointment 4 (36)
After each no-show 7 (64)
After repeated no-shows 5 (45)
Patient reminders 9 (82)
Telephone call to all patients 9 (82)
Letter/card to all patients 1 (9)
No. of reminder strategies, median (range) 1 (0-3)
Patient sanctions 9 (82)
Expelled from practice 9 (82)
Required to walk-in (no appointments) 1 (9)
Open-access*
Complete
Partial (lots of work-in slots)
9 (82)
3 (27)
6 (55)
Residents work in small teams 7 (64)
Try to determine cause for no-shows 2 (25)
*Open access defined as no appointments made beyond 1 week ahead; complete open access defined
as no advance appointments; partial open access defined as some advance appointments.
Table 3. Strategies Used by Management Exemplar Practices (n=8)
Method Practices Using Method
No. (%)
Overbooking 5 (63)
Overbook all residents equally 3 (380
Overbook based upon no-show rate 2 (25)
Walk-ins and work-ins 8 (100)
Encourage/allow walk-ins/work-ins 7 (88)
Adjust schedule to demand-see all patients wanting to be seen
2 (25)
*Open access defined as no appointments made beyond 1 week ahead; complete open access defined
as no advance appointments; partial open access defined as some advance appointments.

Furthermore, open- access scheduling has been suggested as a way to improve patient flow
and increase continuity of care and patient satisfaction. An open-access system may better meet
the needs of the patients who frequently missed appointments. Two practices within the study
reported that the no-show rate dropped by 50% after they converted to an open-access scheduling
system (Johnson, Mold and Pontious, 2007). Based on this study it is possible to reduce the no-
show rates in residency practices to below 10% by using combinations of well established
methods consistently. Reducing the impact of no-shows once they occur seems to be best
accomplished by increasing the numbers of walk-in/work-ins patients and overbook the
residents’ schedules equally.
Another study was done to investigate the factors for no-shows in pediatric allergy
patients. In this research, variables such as the effects of age, gender, ethnic origin, waiting time
for an appointment and the timing of the appointment on non-attendance (no-show) were
assessed. Chi-square tests were used to analyze statistically significant differences of categorical
variables. Logistic regression models were used for multivariate analyses. A total of 442 visits in
a 21-month period were included in the study. The overall proportion of non-attendance (no-
show) at the pediatric allergy clinic was 33.0%. Jewish rural patients had 19.4% non-attendance;
Jewish urban patients had 35.6% non-attendance; and Bedouin patients had 57.1% non-
attendance (p < 0.001). Non-attendance was higher in spring and winter (43.5% and 36.7%,
respectively) than in summer and autumn (26.9% and 26.5%, respectively) (p = 0.016). The
research further noted that no-shows were not significantly influenced by gender, age and hour
of the appointment or waiting time for the appointment. A multivariate logistic regression model
demonstrated that the ethnic origin of the patients and the season of the year were significantly
associated with non-attendance. Logistical issues such as when the appointments were scheduled

and time of day were also significant predictors. The study concluded that in children attending
allergy clinics, factors that determine non-attendance include the ethnic origin of the patients and
the season of the year (Dreiher, et al, 2008). The purpose of this study was to identify factors
contributing to no-shows and no interventions were discussed.
A randomized controlled study was performed in an urban primary care clinic at the
Geneva University Hospitals serving a preponderance of vulnerable patients. “The purpose of
that study was to test the effectiveness of a sequential intervention reminding patients of their
upcoming appointment and to identify the profile of patients missing their appointments.”
Patients booked appointments in a primary care or HIV clinic and were sent a reminder 48 hrs
prior to their appointment according to the following sequential intervention: 1). Phone call (land
line and mobile); reminder; 2). If no phone response: A Short Message Service (SMS) reminder;
3). If no available land line or mobile phone number: a postal reminder.
The rate of missed appointment, the cost of the intervention, and the profile of patients
missing their appointment were recorded. Results 2123 patients were included: 1052 in the
intervention group, 1071 in the control group. Only 61.7% patients had a mobile phone recorded
at the clinic. The sequential intervention significantly reduced the rate of missed appointments:
11.4% (n = 122) in the control group and 7.8% (n = 82) in the intervention group (p [less than]
0.005), and allowed to reallocate 28% of cancelled appointments. A satisfaction survey
conducted with 241 patients showed that 93% of them were not bothered by the reminders and
78% considered them to be useful” (Perron, et al, 2010). The study concluded that a simple
reminder system can increase the show rate significantly at medical outpatient practices.
Barriers:

Access to healthcare seemed to be a major barrier; it is defined by the Institute of
Medicine (IOM) as “the timely use of personal health services to achieve the best health
outcomes.” A study done by the CDC revealed that only 18 percent of US children receive all
recommended immunization without delay in the first two years of life (Randolph, 2004). The
challenges surrounding efficient access are an issue most primary care offices faced daily. To
date, interventions addressing children’s access to care have mainly focused on health insurance
and availability of clinicians.
Conversely, health systems are increasingly examining the impact of practice scheduling
systems on access to care for patients. Diwakar and Denton asserted that,” appointment
scheduling systems lie at the intersection of efficiency and timely access to health services.
Timely access is important for realizing good medical outcomes (2008).” It is also an important
determinant of patient satisfaction. Advanced Access, more commonly called ‘Open-Access’
appears to hold promise not only to more timely delivery, but also to more patient-centered and
efficient care in pediatric practices.
There are other barriers related to access to care such as patients’ preferences for time of
day, (often evenings and Saturdays appointment preferred) in addition availability of particular
service provider is important for some patients. Still, the problem of matching supply and
demand is not simple because different patients have different perceptions of the urgency of their
need (Diwakar and Benton, 2008). This expectation can be challenging because of the practice
inability to accommodate such request due to exam room capacity and staffing. Patients’ wait
time within the office is another barrier to care. Evidence also suggests that many no-shows are
related to discomfort experience during the appointment and disrespect caused by long wait time

(Diwakar and Denton, 2008). This may occur because the provider is running behind with
complex or acute patient care.
Many urban disadvantage families do not have access to transportation, making arriving
on time for appointments difficult. Once the appointment is made if the patient is not seen by
their Primary Care Provider (PCP), it can result in an inefficient visit. Because that provider is
unfamiliar with the patient’s history and it could take twice as much time to review the medical
chart. Physicians’ personal life can result in unexpected patient visit cancellations, which are
missed opportunities for care. With that said, not only the patient but the provider can
contribute to missed appointments.
Opportunities:
Open-Access is a primary area for improvement to assist patients with easier scheduling,
which prevents delay in treatment and diagnosis. It takes away the barrier that tends to exist
within the healthcare system (Diwakar and Denton, 2008). In addition, it provides more
flexibility for parents and empowers them to coordinate their child’s care and prevents
emergency room visits.
Another opportunity is to allow for a few walk-ins per day according to challenges that
may exist within the families such as telephone access and language barriers. Some studies have
shown that overbooking is one way to accommodate patients with time constraints, for example,
working parents. The idea of overbooking is to compensate for the expected no-show that the
practice experience.
Recommendations have been made to redesign the scheduling systems to allow medical
practices to offer same-day appointments to all patients regardless of the nature of their problems
(routine or urgent). The guiding principle is, “do today’s work today.” Basically, you are

matching the supply of the clinicians each day to the daily demands for office visits. This model
will reduce wait time for appointments, elimination of “wait list,” and ultimately improve office
efficiency. This appears to be a recipe that may improve continuity of care by matching patients
with their primary care physicians, which will enhance access to care.
Chapter 3: Description of Methodology
The purpose of this paper is to determine why patients are no-shows for their medical
appointments with their primary care providers. Existing research discussed in Chapter 2, as well
as additional journal articles, leads the researcher to believe that the problem is not specific to
just primary but various specialties. Several barriers were identified as well as opportunities to
improve patients’ show rate at the researcher’s pediatric primary care practice in West
Philadelphia. However, to verify this hypothesis data needed to be collected through a survey
administered.
Research Approach

A survey was created to gather information needed to analyze the myriad of reasons why
patients are no-shows for their medical appointments. The survey consisted of three questions;
the first was multiple choices while questions 2 and 3 were open ended. Additional research was
done to ascertain internal triggers that may increase the no-show rate. The responses were then
analyzed and tabulated.
Data Collection Methodology
A survey was produced and distributed to 1200 pediatric patients. The survey was
distributed amongst four primary care centers within the city of Philadelphia. Phone interviews
were conducted as well as a paper version were created and randomly distributed within the four
primary care centers. Although 1200 patients were requested to complete the survey, and 1,024
responded, which resulted in an 85% return rate. An electronic survey tool such as “Survey
Monkey” was not chosen because the majority of the respondents do not own computers and or
reluctant to give their email addresses. This caused the researcher to look for alternative ways to
reach the sample audience to ensure an acceptable return rate. Appendix B includes a copy of
the survey that was utilized with the rating and percentage.
For this thesis, information was gathered by using published information such as Health
Care Journals, insurance carriers’ websites and The Children’s Hospital of Philadelphia (CHOP),
Data Collection Department. Children and adolescent were all included in the study because the
four primary care practices provide care for patients from age 0-21 years. In terms of
demographics the practices are located in urban areas. Internal and external variables potentially
associated with no-shows, such as payer plans (insurance), visit types (sick, return, well and new
patient) and time of day (appointment) will be measured, shown in Appendix C. Emergency

Room visits from CHOP will be reviewed from February 2010 to January 2011 for the four
primary care centers. The information will be given in a graphical and narrative form.
Quantitative methods will be used to identify patterns with the data collected. The results of the
survey will be discussed in Chapter 4.
Chapter 4: Findings
The author’s research was conducted to ascertain the various reasons for no-shows in a
physician’s office. Chapters 1-3 of this thesis presented the purpose and the objectives of the
study, provided a review of current and relevant literature relating to no-shows and examined the
methodology by which the research survey was developed and conducted. In reviewing
pertinent literature and discussing the no-show issue which seemed problematic for most
practices, it became clear that there is no single solution. Although, you cannot eliminate no-
shows completely, you can reduce their frequency. The reason and the rates for no-show vary
greatly among primary and specialty care offices. However, the financial impact of no-shows
can be challenging to manage and may affect the bottom line. Barriers were discussed as well

as opportunities to keep patients in their medical home and avoid over utilization of the
Emergency Room for non-acute symptoms. In Chapter 3, the methodology used to collect data
for this study was illustrated. The chapter outlined the survey that was administered to the
respondents in order to verify the author’s hypothesis.
Results of the survey
In this section, respondents’ answers to each question of the survey will be addressed, and
significant findings will be presented. The results in their entirety can be found in Appendix B
(illustrating total response by questions and percentage), and Appendix C (displaying pie chart
results by internal and external variables). As discussed in Chapter 3, the response choice for
question one was multiple choice, while questions two and three were open ended, which sought
to explore the qualitative in-depth opinion of the respondents.
The first question addressed the reasons why patients did not show-up for their
appointments. 38% mentioned appointment time, 17% mentioned transportation, 16% stated
insurance/co-pay concerns, 12% stated that the child was feeling better, 11% stated other-patient
related challenges, while 5% stated other-office related challenges were connected to their
missed appointments. A few examples of the 5% that stated office related challenges were,
‘appointment too far out, office error, office closed, and parent not aware of the appointment.’
This suggests that appointment times given to patients are not convenient for them and the
offices may need to delve further to gain a better understanding of ‘time of day.’ The issue of
lack of transportation appears to be more of an external issue relating to the patient rather than
internal to the office. However, further inquiries are required to learn of the available resources
for disadvantage patients.

Although insurance and co-payment are issues for some patients the government has
provided programs such as ‘Children’s Health Insurance Program’ (CHIP), so children in the
United States have the opportunity to be insured. It is a matter of educating and pointing
families to the available resources. It became imperative for the author to dig deeper to
understand what responses fell into the ‘other’ category because 16% made that choice. Upon
further investigation it became apparent that the responses noted below had to be separated into
two categories such as ‘other-patient related’ and ‘other- office related’ in order to comprehend
the feedback provided.
Some of the responses in the “other” category are as follows: dissatisfied with front
desk service, did not like the doctor, appointment too far out, appointment made and
parent not aware, family emergency, personal, loss of job, school, parent sick could not
bring child to the appointment, scheduled with the wrong doctor, out of town, custody
issues, office error, late for appointment and weather.
Question two of the 1,024 completed surveys, addressed the reason that prevented the
patients from calling to cancel their appointment. The responses are as follows: 32% stated that
they forgot/no reason given, 21% called/arrived after the appointment time, 2% noted that the

office was closed, 8% stated that their telephone were disconnected and 19% went to the ED.
The ED data is quite significant because further evidence showed that over 13,000 patients went
to the Emergency Department (CHOP, Data Collection Department) during the period of May
2010 to February 2011. Although, financial information was not available, it is important to
capture the data based on operational impact or cause and effect analysis. 5% stated that they
were not aware of the appointment; another 5% noted that it was a scheduling error while 6%
mentioned that telephone access to the office was an issue. Interestingly, the highest percentile
reflected the occasions when the patients forgot or no reason was given. This emerged as an
opportunity for improvement.
Question three was open-ended, because it was designed to solicit feedback on what the
office could do to help patients keep their future appointments. The responses of the 1,024

surveyed are as follows: 39% stated that a reminder call, email and letter will be helpful while
34% mentioned that better appointment availability can improve their show rate. 2% stated that
the site was not convenient while 25% took responsibility for missing their appointment. This
particular feedback was interesting because it did not lead to an action plan for the office.
Therefore, it can be concluded from Question three that a reminder call, mail notification and/or
appointment availability are areas that could be enhanced as ways to improve the show rate.
The next section addressed internal and external variables that may be associated
with the no-show rate such as type of visit, time of day, and payer plan (insurance). The author
researched and reviewed nine months of data from May 2010 to February 2011 from the
Children’s Hospital of Philadelphia (CHOP), Data Collection Department. The objective of this
section is to gain a better understanding of the challenges that patients and families could face,
which may perhaps prohibit their ability to receive care.
No-show data for all four primary care centers were a bit challenging to analyze because
the practices visit types varied based on need and preference. In an effort to achieve accurate
and meaningful data, the researcher looked for commonalities within each visit type and created
one standardized template across the practices. The results are as follows: Of the 601 patients
that were scheduled with the PL1 (Residents and Interns), 37% no-showed. Some of these

patients believe that because the residents and interns are in training, they are not qualified to
handle their care. While this is just a perception, it does play a vital role in the show rate.
Of the 1,796 new patients that were scheduled, 29% no-showed and of the 9,091 follow-
up (return) visits, 27% no-showed. Of the 4,309 non-physician visits, 25% did not show. 1,796
new patients may not seem to be a large number; however, every new patient visit equals 30
minutes of a physician’s time, while in essence two return patients (15 minutes per visit) could
have been seen in that time slot. With that said, the average cost of a new patient visit is $350.
To strengthen this point, 1,796 new patients that no-showed cost the four primary care practices
$628,600, which is a significant number that affects the bottom line of any operation. Of the
27,113 well-child visits (equivalent to a physical or well baby care) 24% no-showed and of the
2,173 office procedures scheduled 22% failed to show for their appointment.
Special attention must be given to ‘Sick’ and ‘After Hours’ (visits scheduled after the
office is closed) visit types since these visit types appear to be the triggers which lead patients
and families to the Emergency Room (data collected from CHOP). Of the 27,970 sick patients
that were scheduled 15% no-showed while 3,726 afterhours visits demonstrated a 19% no-show
rate. Both visit types reflected a total of 34%. Although, the patient population may appear to
be diminutive within each visit type, it is still significant because of wasted resources and the
financial consequences associated with this phenomenon.

Visit Types NS Visits Sched Visits Total Visits Total %
AFTER HOURS 894 3,726 4,620 19%
NEW PATIENT VISIT 747 1,796 2,543 29%
NEWBORN 187 2,196 2,383 8%
NON PHYSICIAN VISIT 1,419 4,309 5,728 25%
OFFICE PROCEDURE 615 2,173 2,788 22%
PL1 353 601 954 37%
SICK 4,897 27,970 32,867 15%
WELL CHILD VISIT 8,429 27,113 35,542 24%
Total 20,826 78,975 99,801 21%
The next section addresses the time of day that practices received the highest no-shows.
Scheduled appointments will be compared with the no-show visits for hourly blocks. The
purpose of this section is to determine, which time frame is more convenient for patients.
According to the data, of the 11,293 patients that were scheduled at 2pm, 3,434 missed their
appointments, which gave a total of 23%. Additionally, at 9am 12,770 were scheduled and 3,614
missed their appointments, which gave a total of 22%. However, at 8am, 10am, and 1pm 21%
missed their scheduled appointments, which is a significant percentage for any pediatric practice
that may have a long waiting-list of patients waiting to get an appointment with their
pediatrician. The data further showed that patients and families preferred the 4pm through 7pm
time frame, which demonstrated the lowest no-shows that ranged from 16% to 19%.

Appt Time NS Visits Sched Visits Total Visits Total %
7.00 0 2 2 0%
8.00 829 3,132 3,961 21%
9.00 3,614 12,770 16,384 22%
10.00 3,308 12,741 16,049 21%
11.00 1,298 5,259 6,557 20%
12.00 689 2,715 3,404 20%
13.00 3,716 13,751 17,467 21%
14.00 3,434 11,293 14,727 23%
15.00 2,298 8,440 10,738 21%
16.00 422 2,254 2,676 16%
17.00 883 3,801 4,684 19%
18.00 861 3,677 4,538 19%
19.00 233 1,212 1,445 16%
Total 21,585 81,047 102,632 21%
In this section we will address the no-shows by the various payer plans. Scheduled
appointments will be compared with the number of no-show visits for the numerous insurance
mixes. The purpose of this section is to determine if a specific insurance plan influence the no-
show rate. According to the data, of the 41,109 Keystone Mercy patients that were scheduled,
9,136 no-showed, which gave a total of 18% while 12, 642 Americhoice patients that were
scheduled, 2,687 missed their appointment giving a total of 18%. The data is quite significant
because both plans are Medicaid based, that is, funded by the government. One may conclude
that because the insurance plans are free, the patients and families may undervalue the
importance of the visits and just not show up. Furthermore, patients may not be aware that their
absence affects the practice operationally and financially.

Medical Assistance Plan of Pennsylvania (MAPA,) is also Medicaid based and is funded
by the government. Of the 773 patients that were scheduled, 133 no-showed; this reflects 15%.
Although, the number of patients scheduled versus the number that no-showed was not huge, the
impact was very similar in nature. Tricare is a military based insurance. Of the 216 patients that
were scheduled, 36 no-showed, giving a total of 14%. The commercial plans such as Keystone
East, Personal Choice, Aetna and Cigna ranged from 10% to 11% on average. Coincidentally,
practices with large Medicaid patients realized a high no-show rate compared with the above
commercial plans.
Payer NS Visits Sched
Visits
Total
Visits
Total
%
Aetna 571 5,119 5,690 10%
Americhoice 2,687 12,642 15,329 18%
Blue Plan 257 2,128 2,385 11%
Keystone
East
1,149 9,762 10,911 11%
Keystone
Mercy
9,136 41,109 50,245 18%
MAPA 133 773 906 15%
Personal
Choice
542 5,064 5,606 10%
Commerical
Other
102 1,027 1,129 9%
Charity Care 20 176 196 10%
TriCare 36 216 252 14%
Cigna 54 461 515 10%
Totals 14,687 78,477 93,164 16%

Additionally, Emergency Room visits based on payer plan for the four primary care
centers at the Children’s Hospital of Philadelphia are addressed. Data was drawn from February
2010 to January 2011 to determine how many patients from the four primary care centers went to
the Emergency Room broken down by insurance type. The objective was to confirm whether
insurance plans influence ER visits. As indicated in Chapter one and two, patients presented to
the ER for non-acute concerns, even though, they should seek care from their medical home
(PCP). Of the 14,678 patients that visited the ER, 7,353 were Keystone Mercy members while
2,533 were United Community Health Plan (formerly Americhoice) and 1,300 were Medical
Assistant of PA (MAPA). The above mentioned plans are products of Medicaid, which are state
funded. Although, no financial data was available, the findings lead to the assumption that
because the plans are free patients and families tend to demonstrate misuse and do not place
importance on it’s worth or connect the cost associated with the process.
Payer Name: 4 PCC Patient ER Visits
Aetna Better Health 137
Aetna HMO 400
Aetna POS 283
AmeriHealth Administrators 17
Blue Cross Other 19
Cigna 62
Commercial Other 15
Highmark Blue Cross/ Blue Shld 91
Keystone HP East HMO 1003
Keystone Mercy Health Plan 7353
Medical Assistance PA 1300
Personal Choice PPO 543
TriCare 34
UHC Community PA (Americhoice) 2533
United Health Care 70
Blue Shield Other 79
Keystone East POS 139
Total 13378

It is safe to conclude that there are many predictors of no-shows. The findings
established in this chapter confirmed that patients’ access to care, education surrounding the
ramification of missed appointments, telephone and or mail appointment reminders are few
recommendations that can decrease the no-show rates. Although, there is no single easy fix to
this complex problem, implementing a variety of measures can decrease the no-show rate and
boost revenue.
Chapter 5: Recommendations and Conclusions
This study strengthens the growing body of evidence demonstrating that no-show results
are significant in the pediatric population as well as general medicine. From the research

conducted and the analysis performed on the survey results, it can be determined that patients
and families missed their appointments for a myriad of reasons. Although, evidence pointed to
internal and external variables, missed appointments can ultimately affect patient care and the
bottom line of any medical practice. In general, the above stated- results provide practical
support for the foundation of the hypothesis proposed in this research.
As discussed in Chapter One and Two, missed appointments with the primary care
provider increases Emergency Department (ED) utilization, which escalates the cost of that
patients’ care. The use of the hospital ED for non-urgent care when primary care might be more
appropriate has been identified as one of the causes contributing to increasing Medicaid costs.
The study also showed that patients turn to the ED for basic health care needs. When patients
fail to keep their appointments, it can lead to a delay in diagnosis and detection of diseases,
which eventually affects outcomes. Primary care providers serve as the gatekeepers to patients
care and missed appointments limit the physician’s ability to provide continuity of care.
Recommendations
The survey data unearthed some remarkable findings that seem to prove several
phenomena. As indicated in the study, at times the appointment times given were not
convenient and 38% of the patients preferred 4pm through 7pm. Based on this finding, one
would think that adding more time slots in the afternoon and evening sessions would be the
answer, but that can prove to be challenging and costly. Incidentally, if office hours were
extended, it may not prove to be an appropriate option from an operational standpoint. It is more
prudent to overbook the earlier appointment times where patients are more likely to miss their
appointments such as the 8am to 1pm block. Overbooking the schedule to cover no-shows is

relatively easy to implement but more difficult to advertise. Provider and support staff buy-in
are critical to the success of this course of action. One can take a conservative approach by
overbooking some portions of the schedule as an introduction, expand later if successful, and
evaluate for impact. This suggestion may not reduce no-shows but can replace revenue and
increase productivity. Additionally, transportation was also a challenge for patients and families
although, transportation is external to the practice and further research showed that the State of
Pennsylvania provides transportation for patients with Medical Assistant plans. The goal would
be to place signage in key areas in the primary care center to showcase the information on the
initial telephone greeting (if an automated system exists). While confirming appointments, the
caller will verify whether the patient needs transportation and provide that information as well.
Secondly, patients should be reminded by telephone 48hrs prior to their appointment.
Studies have shown that patients tend to forget if the reminder call is made before 48hrs.
Depending on the nature of the practice (specialty care), post card reminders can be helpful. For
those patients that are habitual no-shows (offices can determine very quickly) letters should be
sent as indicators of the amount of appointments that were missed and the importance of keeping
their appointments. Patients should be linked with a social worker or office nurse if that is an
option to address no-show behavior and the effect it has on their care.
Thirdly, establish a cancellation option on the telephone menu so that patients can call to
cancel the appointment. Best practice indicates that medical practices with call-center
capabilities can add a cancelation line to an interactive voice-response system. When the caller
chooses the ‘cancel appointment’ option, the system automatically removes that appointment and
frees up the space for another. A less expensive method is to implement a voice mail system so
that the caller can leave a message indicating the cancellation. However, the concern with this

workflow is that someone has to check the voicemail on a regular basis (round the clock), which
can be a barrier if the practice is short-staffed.
Fourthly, signs can be posted in key areas of the office reminding patients and families to
call to cancel appointments if they are unable to make it, so that appointment time can be offered
to another patient. A message can be recorded on the initial telephone greeting when callers are
waiting (messaging on hold) to speak with the office. The message can read, “We know that
things come up and sometimes you can’t keep a scheduled appointment. When that happens,
please let us know as soon as possible so we can offer your appointment to another patient.”
Call our cancel line at 27/7 at 215-123-1212.
Fifthly, redesign the scheduling system to an open-access model; this is the first step for
improving access to care because it directly impacts the practice by determining appointment
availability, practice efficiency, and wait time. An open-access model allows medical practices
to offer same-day appointments to all patients regardless of their problems (urgent or routine).
The guiding principle is, to “do today’s work today” (Randolph, 2004). This is done by
matching the supply of the providers each day to the daily demands for visits. Appointment
demand is predictable, that is, winter months are labeled as the sick season, and therefore, sicker
visits are needed during that time frame. Although, many pediatric offices offer same-day
appointments for acute care, open-access expands same-day access to include routine and
preventive care (Bundy et al., 2005). With that said, continuity of care is improved by matching
patients with their primary care physician and the overall improvement of physician and patients’
satisfaction. For successful implementation provider and support staff must work together
collaboratively. This model may not work for academic practices that provide resident and
medical student education, based on the outlined program criteria. In other words, the number of

patients per resident session is set. Part of their training is to assess the patient first and then
present findings to the attending physician, which can generate a significant wait time.
Additionally, demand and supply (capacity) need to be balanced. If not, the daily demand can
out weight the office capacity, which can lead to stressful days, incurred overtime, and the
reduction of the quality of service.
Finally, create a no-show report that lists upcoming appointments of patients with
histories of no-shows. Medical practices can implement preventive measures, such as reminder
calls, post cards/letters, cancellation line, signage in the office, no-show communication on
automated telephone system, open access (if applicable) and overbooking appointment slots to
compensate for the lost revenue.
Conclusion
Based on this study, last minute cancellations and no-shows are very disruptive for a
clinical practice. Most patients do not make the connection of how a missed appointment affects
continuity of their care and the bottom line. It is important that the practice educate patients and
families that the appointment times are reserved specifically for them. In addition, private
practice’s income is directly linked to how many patients a provider sees per day. Insurance
companies do not pay for missed appointments, and it is easy to see why no-shows are one of the
costliest and stressful issues for medical practices.
This study demonstrated that there is no simple solution to preventing no-shows. Maybe
a more realistic goal is to reduce the overall rate to a relatively low level. But there are many
methods that one can embrace to prevent no-shows from governing the practice as recommended
above. In the author’s primary care center in West Philadelphia a 30% no-show rate was

historically seen. Although, a definition was given in previous a chapter for ‘no-show,’ it is
imperative that the author redefine the meaning of a no-show to tailor to the office needs.
According to The Children’s Hospital of Philadelphia, Primary Care Center at Cobbs Creek, any
patient that does not give the office at least a minimum of four hours’ notification that they are
not coming to their scheduled visit is define as a no-show. The author adopted the following
recommendations:
1. Appointment reminder calls within 48hrs.
2. Created a cancellation message on automated telephone system requesting that patients
arrive on time or cancel well in advance.
3. Overbooked the schedule during the 8am to 11am time frame.
4. Developed posters and flyers to educate patients and families on the impact of no-shows.
5. Included no-show information to “message on hold” and initial telephone greeting.
6. Created a no-show letter, waiting on approval to implement. With that said, the practice
has already seen a 10% increase in the show rate (Appendix D).
The other three primary care offices have also embraced some of the above
recommendations and they too have realized a 7% to 9% increase in their show rate. Finally, the
author is confident that the findings presented here will add to the growing body of knowledge
that will be used to assess the effectiveness and benefits to patients receiving optimum care by
their primary care provider. By utilizing some of the methods outlined in this paper, practices
can control the loss of income by managing no-shows, which will improve overall patient and
staff satisfaction.

Appendix A: Questionnaire
Dear Patients,
We are surveying patients that were recently unable to make their appointments in an effort to
help better serve our families with our appointment availability. Please take a couple of minutes
to answer a few questions.

Primary Care Centers: Please circle your practice, (Cobbs Creek), (South Philadelphia),
(University City) and (Market Street).
1. Was your missed appointment related to any of the following?
a) Appointment time.
b) Transportation.
c) Insurance or co-pay concerns.
d) Child is feeling better.
e) Other- please explain_________________________________
2. What are the reasons that prevented you from calling to cancel the appointment?
3. How can our center help your family maintain (keep) your appointments in the future?
Appendix B: Total Response and Percentage
Question 1. What was your missed appointment related to any of the following?
Category Phone Face to Face Total Responses Total %
Appointment Time 240 150 390 38%

Transportation 129 48 177 17%
Insurance/ co-pay concerns 100 60 160 16%
Child is feeling better 83 44 127 12%
Other - Pt Related 65 50 115 11%
Other - Office Related 30 25 55 5%
Total by Category 647 377
Total Responses - Q1 1024
Question 2. What were the reasons that prevented you from calling to cancel the appointment?
Category Phone Face to Face Total Responses Total %
Pt Forgot/No Reason Given 180 148 328 32%
Called/Arrived after appointment time 130 90 220 21%
Office Closed 10 6 16 2%

Pt Phone Disconnected 55 32 87 8%
Went to ED 122 75 197 19%
Not aware of Appt 35 20 55 5%
Scheduling Error 30 25 55 5%
Telephone Access to Office 46 20 66 6%
Question 3. How can our center help your family keep your appointments in the future?
Category Phone Face to Face Total
Responses
Total %
Need a Reminder (email, letter, phone) 210 190 400 39%
Site not convenient 10 9 19 2%
Patient took responsibility for missing 140 115 255 25%

appointment
Better appointment availability 190 160 350 34%
Total Patient Response 3072
Appendix C: Other Variables by Total Number and Percentage.

NS Visits Sched Visits Total Visits Total %
AFTER HOURS 894 3,726 4,620 19%
FOLLOW UP 3,285 9,091 12,376 27%
NEW PATIENT VISIT 747 1,796 2,543 29%
NEWBORN 187 2,196 2,383 8%
NON PHYSICIAN VISIT 1,419 4,309 5,728 25%
OFFICE PROCEDURE 615 2,173 2,788 22%
PL1 353 601 954 37%
SICK 4,897 27,970 32,867 15%
WELL CHILD VISIT 8,429 27,113 35,542 24%
Total 20,826 78,975 99,801 21%

7.00 0 2 2 0%
8.00 829 3,132 3,961 21%
9.00 3,614 12,770 16,384 22%
10.00 3,308 12,741 16,049 21%
11.00 1,298 5,259 6,557 20%
12.00 689 2,715 3,404 20%
13.00 3,716 13,751 17,467 21%
14.00 3,434 11,293 14,727 23%
15.00 2,298 8,440 10,738 21%
16.00 422 2,254 2,676 16%
17.00 883 3,801 4,684 19%
18.00 861 3,677 4,538 19%
19.00 233 1,212 1,445 16%
Total 21,585 81,047 102,632 21%

Aetna 571 5,119 5,690 10%
Americhoice 2,687 12,642 15,329 18%
Blue Plan 257 2,128 2,385 11%
Keystone East 1,149 9,762 10,911 11%
Keystone Mercy 9,136 41,109 50,245 18%
MAPA 133 773 906 15%
Personal Choice 542 5,064 5,606 10%
Commercial Other 102 1,027 1,129 9%
Charity Care 20 176 196 10%
TriCare 36 216 252 14%
Cigna 54 461 515 10%
Totals 14,687 78,477 93,164 16%
Appendix D: No Show Letter
(Practice address and logo)
Dear Patient,

We had an appointment reserved for you today and were concerned when you did not show or
call within 24 hours to cancel the appointment. Our policy is to call patients two days prior to
their appointment to remind them of the date and time. We perform these calls as a courtesy to
our patients and to all allow us the opportunity to rebook the time slot should the appointment
not be necessary. Recognizing that everyone’s time is valuable and that appointment time is
limited, we ask that you provide 24 hours notice if you are unable to keep your appointments.
Please call us at your earliest convenience to reschedule your appointment as your primary care
provider felt it was important to see you.
Thanks you for your anticipated cooperation.
The scheduling staff (Practice name)
Appendix E: Proposal for No-Show Reduction
Reduce overall PCC no-show rate by 7%, which adds 7,000 visits across all four sites
 Currently our net lost revenue is $2,100,328
 With a 7% reduction we can potentially increase net revenue by $541,550 for FY12

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