Medicolegal Issues

‘3 Strikes ‘n’ yer out’: Dismissing no-show patients

Current Psychiatry. 2017 June;16(6):32-35

References

1. Adler LM, Yamamoto J, Goin M. Failed psychiatric clinic appointments. Relationship to social class. Calif Med. 1963;99:388-392.
2. Buppert C. How to deal with missed appointments. Dermatol Nurs 2009;21(4):207-208.
3. National Council Medical Director Institute. The psychiatric shortage: causes and solutions. https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_National-Council-.pdf. Published March 28, 2017. Accessed April 6, 2017.
4. Legal & Regulatory Affairs staff. Practitioner pointer: how to handle late and missed appointments. http://www.apapracticecentral.org/update/2014/11-06/late-missed-appoitments.aspx. Published November 6, 2004. Accessed April 7, 2017.
5. Centers for Medicare & Medicaid Services. MLN Matters Number: MM5613. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5613.pdf. Updated November 12, 2014. Accessed April 7, 2017.
6. MacCutcheon M. Why I charge for late cancellations and no-shows to therapy. http://www.goodtherapy.org/blog/why-i-charge-for-late-cancellations-no-shows-to-therapy-0921164. Published September 21, 2016. Accessed April 6, 2017.
7. Kalman TP, Goldstein MA. Satisfaction of Manhattan psychiatrists with private practice: assessing the impact of managed care. http://www.medscape.com/viewarticle/430759_4. Accessed April 6, 2017.
8. Mitchell AJ, Selmes T. Why don’t patients attend their appointments? Maintaining engagement with psychiatric services. Adv Psychiatr Treat. 2007;13(6):423-434.
9. Long J, Sakauye K, Chisty K, et al. The empty chair appointment. SAGE Open. 2016;6:1-5.
10. Doyle R, Turner N, Fanning F, et al. First-episode psychosis and disengagement from treatment: a systematic review. Psychiatr Serv. 2014;65(5):603-611.
11. Nelson EA, Maruish ME, Axler JL. Effects of discharge planning and compliance with outpatient appointments on readmission rates. Psychiatr Serv. 2000;51(7):885-889.
12. Killaspy H, Banerjee S, King M, et al. Prospective controlled study of psychiatric out-patient non-attendance. Characteristics and outcome. Br J Psychiatry. 2000;176:160-165.
13. Williamson AE, Ellis DA, Wilson P, et al. Understanding repeated non-attendance in health services: a pilot analysis of administrative data and full study protocol for a national retrospective cohort. BMJ Open. 2017;7(2):e014120. doi: 10.1136/bmjopen-2016-014120.
14. Binnie J, Boden Z. Non-attendance at psychological therapy appointments. Mental Health Rev J. 2016;21(3):231-248.
15. Jaeschke R, Siwek M, Dudek D. Various ways of understanding compliance: a psychiatrist’s view. Arch Psychiatr Psychother. 2011;13(3):49-55.
16. Boland B, Burnett F. Optimising outpatient efficiency – development of an innovative ‘Did Not Attend’ management approach. Int J Psychiatry Clin Pract. 2014;18(3):217-219.
17. Pennington D, Hodgson J. Non‐attendance and invitation methods within a CBT service. Mental Health Rev J. 2012;17(3):145-151.
18. Sims H, Sanghara H, Hayes D, et al. Text message reminders of appointments: a pilot intervention at four community mental health clinics in London. Psychiatr Serv. 2012;63(2):161-168.
19. Oldham M, Kellett S, Miles E, et al. Interventions to increase attendance at psychotherapy: a meta-analysis of randomized controlled trials. J Consult Clin Psychol. 2012;80(5):928-939.
20. Gore AG, Grossman EL, Martin L, et al. Physicians, surgeons, and other healers. In: American Jurisprudence. 2nd ed, §130. Eagan, MN: West Publishing; 2017:61.
21. Ohio Administrative Code §4731-27-02.
22. Lowery v Miller, 157 Wis 2d 503, 460 N.W. 2d 446 (Wis App 1990).
23. Brockway LH. Terminating patient relationships: how to dismiss without abandoning. TMLT. https://www.tmlt.org/tmlt/tmlt-resources/newscenter/blog/2009/Terminating-patient-relationships.html. Published June 19, 2009. Accessed April 3, 2017.

Dear Dr. Mossman,
The clinic where I work initiated a “3 misses and out” policy: If a patient doesn’t show for 3 appointments in a 12-month period, the clinic removes him from the patient rolls. I’ve heard such policies are common, but I worry: Is this abandonment?
Submitted by “Dr. C”

The short answer to Dr. C’s question is, “Handled properly, it’s not abandonment.” But if this response really was satisfactory, Dr. C probably would not have asked the question. Dealing with no-show patients has bothered psychiatrists, other mental health professionals, and other physicians for decades.¹

Clinicians worry when patients miss important follow-up, and unreimbursed office time won’t help pay a clinician’s salary or office expenses.² But a policy such as the one Dr. C describes may not be the best response—clinically or financially—for many patients who miss appointments repeatedly.

If no-show patients worry you or cause problems where you practice, read on as I cover:

charging for missed appointments
why patients miss appointments
evidence-based methods to improve show-up rates
when ending a treatment relationship unilaterally is not abandonment
how to dismiss no-show patients from a practice properly.

The traditional response: Charging for no-shows

Before the mid-1980s, most office-based psychiatrists worked in solo or small group and required patients to pay cash for treatment; approximately 40% of psychiatrists still practice this way.³ Often, private practice clinicians require payment for appointments missed without 24 hours’ notice. This well-accepted practice^2,4,5 reinforces the notion that psychotherapy involves making a commitment to work on problems. It also protects clinicians’ financial interests and mitigates possible resentment that might arise if office time committed to a patient went unreimbursed.⁶ Clinicians who charge for missed appointments should inform patients of this at the beginning of treatment, explaining clearly that the patient—not the insurer—will be paying for unused treatment time.^2,4

Since the 1980s, outpatient psychiatrists have increasingly worked in public agencies or other organizational practice settings⁷ where patients—whose care is funded by public monies or third-party payors—cannot afford to pay for missed appointments. If you work in a clinic such as the one where Dr. C provides services, you probably are paid an hourly wage whether your patients show up or not. To pay you and remain solvent, your clinic must find ways other than charging patients to address and reduce no-shows.

Why patients miss appointments

The literature abounds with research on why no-shows occur. But no-shows seem to be more common in psychiatry than in other medical specialties.⁸ The frequency of no-shows varies considerably, but it’s a big problem in some mental health treatment contexts, with reported rates ranging from 12% to 60%.⁹ A recent, comprehensive review reported that approximately 30% of patients refuse, drop out, or prematurely disengage from services after first-episode psychosis.¹⁰ No-shows and drop outs are linked to clinical deterioration¹¹ and heightened risk of hospitalization.¹²

A recent study from Scotland suggests that, in general practice, a small fraction of patients account for a large proportion of no-shows.¹³ Studies of psychiatric outpatient care find that a variety of factors are associated with no-shows, including clinical and demographic characteristics of patients, referral and practice patterns, and patients’ attitudes and beliefs about treatment (Table 1^8,14).

Jaeschke et al¹⁵ suggests that no-shows, dropping out of treatment, and other forms of what doctors call “noncompliance” or “nonadherence” might be better conceptualized as a lack of “concordance,” “mutuality,” or “shared ideology” about what ails patients and the role of their physicians. For this reason, striving for a “partnership between a physician and a patient,” with the patient “fully engaged in the two-way communication with a doctor … seems to be a much more suitable way of achieving therapeutic progress in the discipline of psychiatry.”¹⁵

‘3 Strikes ‘n’ yer out’: Dismissing no-show patients

References

The traditional response: Charging for no-shows

Why patients miss appointments

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