The New Health Care Front Door

Why Patients Don't Come & What Causes No-Shows?

This is Part 2 in a free 3-part training series. Part 1 (patient no-shows & inefficiencies) is here, and Part 3 (reducing no-showshere

In the previous section, we learned:  

  • Why patient no shows is a pressing problem in the healthcare industry
  • And, how practices lose about $200 per no show 
  • And, $150,000 per year in total lost revenue because of no shows 
  • Finally, we learned why patient no shows is not the actual problem
  • And, learned how systems thinking principles can help us reduce no shows

In this section, let’s dig deeper, and learn why patients end up not showing up for their appointments.

To learn the same, we’re going to hear from both the practitioners and the patients so that we have both the perspectives.

So, let’s get started.

After we received the graduate committee’s approval to work on “Reducing Patient No Shows”, our first goal was to further validate the hypothesis. 

Our initial hypothesis was that “Patient No Shows is a recurring problem for dental practices. And, practices lose time, money and resources when patients fail to show up for the appointments.”

In order to test the hypothesis, we first created a “Thesis Survey” to understand the different problems and challenges faced by dentists. 

Below is the survey we sent out to them.

Here’s the link to the survey

Feel free to submit your responses – if you’d like.

First, we reached out to private solo and group practices in both the U.S. and Canada to validate our hypothesis.

In addition, we also reached out to ‘Not for profit’ community dental clinics, University dental clinics and also DSO practices.

We did not reveal this was a research on “No Shows” as it would lead to biased responses. 

Therefore, we designed the survey as a generic survey on “Problems and challenges in dentistry” and wanted to check if they are mentioning “No Shows” as one of the problems. 

We reached out to 1685 dentists via email and asked them to provide their inputs as below.

Obviously, not everyone participated in the survey. 

Most of them did not even open our email. 

Some of them opened the email but did not provide their inputs. 

However, a total of 42 practitioners took their time and provided their inputs. 

Take a look at some of their responses below. 

As highlighted in the red boxes in the image above, almost all the dentists that participated in the survey indicated that “No Shows” is one of their “Top 3 Daily Frustrations” in their practices. 

In addition to no shows, they also shared a few other challenges, threats and the problems they are facing in their profession. 

Take a look at their responses highlighted in blue as below. 

As you can see, in addition to “Patient No Shows”, there are other threats and problems that are facing dentists today. 

DSOs will continue to grow

For one, Dental Service Organizations (DSO) continue to grow across the country. 

In fact, DSOs operate, own or control approximately 16% of the total practices at the time of this writing. 

As per reports, DSOs will grow at approximately 15% annually over the coming years, implying U.S. penetration could reach up to 30% by 2021.

While DSOs have an annualized growth rate of 13 percent to 14 percent, solo private practices are shrinking at 7% per year”, according to the Health Resources Institute of the ADA.

The math couldn’t be any clearer. 

DSOs will continue to capture greater and greater market share, along with an increasing portion of the dental dollar, while solo private practice will continue to experience decreasing market share and declining revenues.

Drastic Reduction In Insurance Rates

Insurance plans have crushed the average income of a dentist by reducing the rates. 

A typical dentist made over $200,000 not too long ago

That number is like $140,000 today, according to PayScale data. 

The fees are way lower than what they used to be as an average dental office accepts half a dozen different providers that have ultimately reduced the average income of dentists. 

In addition, they also shared with us a few other problems and challenges such as: 

  • Student loan debt that takes decades to pay back
  • Employees not showing up
  • Employee attrition rate
  • Holes in the schedule
  • Running behind schedule
  • and so on…
As you can see, as a dentist with limited to no help in the business side of dentistry, there are so many problems and challenges that are facing private practice owners today. 
Some of these problems are beyond the practitioners’ control. 
And, some of the problems are within their control. 
Patient No Shows is one such problem that is within the practices’ control. I’ll share with you more about the same in a minute.  
But, the responses from all study participants validated our hypothesis that “Patient No Shows is a recurring problem in their dental practices.”

Why patients don’t come? - Practitioners’ Perspective

After we validated the hypothesis, we then wanted to understand the reasons why patients end up not showing up for their appointments. 

In order to understand the same, we conducted further interviews with practitioners to get insights on no shows in their practices. 

We asked them how no shows impact them, why they think their patients don’t show and the steps they have taken to reduce it. 

Let’s take a look at a few practitioners and their insights on no shows as below. 

We face 1 or 2 No Shows every day; No shows are high among people from lower socio-economic households, because they don't want to take off their work; taking off their work means loss of pay which prevents them to skip, miss or postpone their appointments. The only way you can help such patients is by taking your practice to their door (pun intended).

Dr. Gruenberg, DDS

No shows are a daily occurence in our practice; weather, fear of the dentist, lack of education, feeling of entitlement are why patients don’t honor their appointments; moreover, insurance companies have convinced people that they need to have dental insurance to goto the dentist; interventions such as, dentists connecting with patients over a call days before the actual appointment will help; above all patients need more dental IQ.

Dr. Hamamcy, DDS

We face several no shows every single day in our community clinic; No shows are a result of fear of the dentist, trauma, and lack of trust and empowerment; screening patients to understand their past experiences and trauma is necessary; implementing a holistic approach to help patients get over their fear and trauma will help reduce no shows.

Ms. Kellett, Dental Program Supervisor

Facing No shows everyday; No Shows are higher in new patients than existing ones; patients more likely to miss appointments with dental hygienists, people with low dental IQ also tend to miss appointments; increasing dental IQ among patients and building patient-doctor trust and relationship by establishing authority will help reduce no shows.

Dr. Williams, DDS

Facing no shows regularly; using a combination of practice management systems and patient recall systems in our practice to remind patients about their appointments; automating patient follow ups and reducing front desk dependency & inefficiency is necessary; developing patient-doctor trust and relationship via office tours, awareness campaigns would also help reduce no shows.

Dr. Mighion, DDS

Facing No Shows every single day in our practice; patients don’t show up because of work, sickness; lack of any commitments also makes them not show; front desk staff needs to be constantly reminded to follow up with patients; dependency on human follow ups should be reduced & human inefficiency needs to be eliminated to reduce no shows.

Dr. Ra, DDS

Coming across no shows every single day; despite continuous appointment reminders, patients still end up not showing; lack of insurance, unable to afford treatments & lack of dental IQ are why patients don’t show; automation of front desk follow up is essential to reduce no shows.

Dr. Reddy, DDS

Facing No shows on a daily basis, a couple of them in fact; Logistical reasons such as patients moving out to different cities, socio economic reasons, lack of insurance are most common reasons; front desk staff inefficiency in the followup process needs to be addressed; had to let go front desk staffs that were inefficient.

Dr. Badie, DDS

Community clinic associated with the university faces 40% No Shows; patients don’t show up because the treatments are expensive; they might not need such expensive treatments; patients need to see, like and trust the dentists; there should also be an effective followup system to address patients’ forgetfulness; Dental IQ among patients also needs to improve.

Dr. Puttaiah, DDS

We lose about $265 on every missed appointment; patients don’t show because they don’t see their health as a priority; they don’t want to take off their work; have been using softwares to send appointment reminders; more dental IQ among patients will help reduce no shows.

Dr. Moore, DDS

Though the preliminary research interviews were carried out among dentists, the reasons why patients don’t honor their appointments were almost the same regardless of the medical specialty.

But, as you must have noticed by now, there is no one specific reason or root cause for no-shows. 

From the above interviews alone, we can list out the following reasons why patients don’t show as below:

  1. Unable to take off work
  2. Socio economic status
  3. Loss of pay
  4. Weather
  5. Fear of treatment & pain
  6. Lack of education
  7. Lack of health IQ
  8. Lack of insurance
  9. Unable to afford treatment
  10. Past trauma
  11. Patient forgetfulness
  12. Followup & front desk inefficiency
  13. Expensive treatments
  14. Lack of doctor trust 

As you can see from the list above, there are various systems, human and societal inefficiencies – that result in patient no-shows. 

But before we take a look at these inefficiencies, let’s also hear it from the patients and ask them what stopped them from showing up for their scheduled appointments.  
This will help you understand the No Show problem from the patients perspective so you can create better systems to reduce no shows in your practice.  

Why We Don’t Come? - Patients’ Perspective

Any research is incomplete without including the perspectives of all the main stakeholders involved in the topic in question. 

Therefore, in addition to understanding the practitioners’ perspective on no shows, it’s essential that we also understand the patients perspective. 

To do the same, we reached out to a few dental practices wanting to speak with some of their patients that did not show for their appointments in the past.  

Due to HIPAA regulations, privacy concerns and time constraints, the practices were not able to share the info we requested. 

However, research studies have already been conducted in various healthcare settings to understand the patients’ perspective on no shows. 

Let’s take a look at 3 such studies conducted at the following locations:

  1. University of Nebraska Medical Center study conducted at a family clinic located in an ethnically diverse neighborhood and serves a predominantly low-income population

  2. University of Kansas School of Medicine study conducted at two urban, university-affiliated family medicine residency outpatient clinics


  3. Journal of Family Medicine and Disease Prevention study conducted at a multi, specialty medical group affiliated with a larger hospital network 
Let’s take a look at all of them one by one.  

1. 'University of Nebraska Medical Center' study conducted at a family clinic located in an ethnically diverse neighborhood and serves a predominantly low-income population

As part of this study, researchers from the University of Nebraska Medical Center had interviewed 34 adult patients coming to the university affiliated family practice clinic for outpatient care.

The University of Nebraska Medical Center Institutional Review Board provided human subjects approval. Each subject was provided with a description of the study, informed of the right to not participate, and given an alias.

The researchers developed an open-ended interview guide on the basis of extant literature to elicit personal experiences of missed appointments and perceptions of accessing health care. Interviews were kept brief, for 12 to 15 minutes.

The following were the interview questions that the researchers used for this study: 

Table 1:
Interview Questions

  • I’m researching why a lot of people make doctor appointments but do not show up. Why do you think people do this?
  • Tell me about a time you or someone you know had an appointment but didn’t or couldn’t come.
  • What made it hard to keep the appointment with the doctor? [Or] Is there anything that makes it hard for you to keep an appointment?
  • Do you have to make any special arrangements to get here? (Transportation, child care, insurance company referrals, work, other)
  • How difficult is it for you to be on time for your appointment?
  • How do you know when you or someone in your family needs to see the doctor
  • How did you decide to choose this clinic?
  • What do you come here (the clinic) for?
  • How do you feel about having to see the doctor (eg, worried, anxious, hopeful, etc)? Why?

Researchers interviewed 32 women and 2 men. 

The respondents were all adults, median age 40 years (range, 22 to 78 years). 

Three interconnected themes emerged from the interviews as barriers to appointment attendance as below:

  • Emotional barriers
  • Perceived disrespect of the patient’s beliefs and time 
  • Distrust and lack of understanding of the scheduling system
Transportation and child care were logistical barriers. But respondents noted they could be overcome.

a. Emotional Barriers to Keeping Appointments

Twenty-two participants (65%) mentioned emotional barriers to keeping appointments. 

At times, the negative emotions about going to see the doctor were greater than the perceived benefit of keeping the appointment.

For some, the delay between the scheduling and keeping of the appointment contributed to this dynamic. 

bPerceived Disrespect of the Patients’ Beliefs and Time by the Health Care System

Fifteen participants (44%) commented on issues of respect by the health care system. 

From their viewpoints, health care staff did not respect patients, discounting patients’ time, opinions, and feelings.

Waiting was one way disrespect was communicated: 

  • Patients wait to get an appointment time, 
  • Patients wait in the waiting room, 
  • And, patients wait in the examination room. 

Ms. E explained, “Part of it, too, may be that there’s so many appointments scheduled … that it’s just an assembly line thing…. People want to be treated like human beings. They don’t wanna be cattle just running in the lounge.”

c. Lack of Understanding of the Scheduling System

Forty-one percent of the participants indicated they did not know what happens in a clinic if there is a failed appointment. 

Ms. S speculated, “Maybe they just go to the next patient.” 

Participants seemed unaware of the financial impact of a failed appointment and believed a no-show may actually be a positive event for the clinician and staff. 

When asked what the staff and clinician do if someone does not show for a scheduled appointment, Ms. H stated: “I don’t know. I guess they get free time.” 

2. 'University of Kansas School of Medicine' study conducted at two urban, university-affiliated family medicine residency outpatient clinics

This study was conducted by researchers from the University of Kansas School of Medicine. 

The researchers randomly chose 25 patients from two urban, university-affiliated family medicine outpatient clinics. 

All the 25 subjects were previously dismissed from the clinics for missing three or more scheduled appointments during a five-year span (July 2012 to July 2017).

They were interviewed over the phone about reasons they did not keep their scheduled clinic appointments. 

Data from 25 participants (21 females and four males) were included in the study. Fifty-two percent of the participants were Caucasian, 32% Black, 12% Hispanic, and 4% Asian. 

Five themes emerged from the data analysis as major reasons the patients missed scheduled appointments:

  • Forgetfulness 
  • Transportation issues 
  • Personal health issues 
  • Family and employer obligations 
  • Other issues, such as anticipated long clinic wait times, bad weather, and financial problems. 
The identified reasons were based on the patients’ responses. Some patients had more than one reason for missed appointments.

a. Forgetfulness

Many of the responses demonstrated that patients often forgot about their appointments. 

Patient A stated, “[I] had a lot going on and forgot.” 

Patient B offered more detail when she said: “sometimes the people that live in my home just forget, you get busy with life (children and other appointments) and you just end up not making it. There’s a lot of information being thrown out at us every single day and we just forget.”

b.  Transportation Issues

Unreliable transportation was another reason patients missed their scheduled appointments. 
Many of the patients do not own a vehicle and have to depend on family members and/or friends to take them to and from their clinic appointments. 
If these “good Samaritans” fail to take them, the patients miss the appointment. 

Patient C explained, “I did not show for my appointment because [I have] no car, no transportation, or transportation doesn’t follow through.”

 c. Personal Health Issues
Personal health issues were one of the reasons for missing an appointment. 
A good number of the responses explained that due to worsened clinical symptoms, some patients lacked the physical strength to make their scheduled appointments. 

Patient F stated, “[I have] a lot of health issues that keep me up at night, so I have been up all night.” 

Patient G said, “I injured my leg and it was hard to walk on, so I did not want to leave the house.”

 d. Family and Employer Obligations

Work, family and other commitments often take precedence over personal health, especially when it comes to outpatient care. 
They perceived these competing priorities as more important than keeping their scheduled appointments. 
Some patients are employed on a temporary or seasonal basis and would rather go to work than keep their scheduled appointments. 
Impromptu work assignments are a reason for missed clinic appointments. 
Thus, work often takes precedence over keeping the appointments.
e. Other Reasons (long waiting time, affordability & weather)

Some of the patients shared that they did not keep their clinic appointments because of long wait times in the waiting and consultation rooms. 

This concern was shared by Patient J, who stated: “I don’t show up for my appointment because I don’t want to sit in the waiting room, waiting for more than 30 minutes or within the clinic room itself.” 

Other patients shared that financial problems (e.g., inability to afford the co-pay) were a reason. 

Patient K explained that, “My insurance ran out and I didn’t have money for the visit.” 

3. 'Journal of Family Medicine and Disease Prevention' study conducted at a multi, specialty medical group affiliated with a larger hospital network

Compared to the previous 2 studies, this study was conducted among a large sample with 675 patients.

The subjects of this study had missed their appointments in the past at Griffin Faculty Physicians (GFP) and Griffin Hospital Wellness Clinic (GHWC).  

The researchers from the Department of Medical Education at The Griffin Hospital, conducted a telephone survey in which these patients who missed scheduled appointments from July-September 2016 at GFP and January-September 2016 for GHWC were contacted by telephone from August-October 2016 following a standard script.

The study examined the free text data from the telephone survey relating to reasons for missed appointments was carried out. 

Out of a total of 675 patients who missed their appointments, 218 (32.3%) attended the telephone calls. 

The following themes emerged from the study:

  • Forgetfulness: Out of these 218 patients, 82 (37.6%) reported that they forgot about their appointment or did not know that they had an appointment 
  • Personal Issues: 35 (16.1%) of the patients reported personal issues as the reason for missing their appointments
  • Transportation: 15 (6.9%) of the patients reported a lack of transportation as the reason for not completing their appointment

a. Forgetfulness

The study found that forgetting about the appointment or patients not being sure that they had an appointment was the most common reason for missing an appointment.

Forgetting an appointment can be the outcome of many factors such as not understanding the importance of the appointment, how the appointment reminder system works, and social and psychological conditions of the patients.
b. Personal Issues
The second most common reason reported for missing an appointment was personal or work-related issues. 
The study cites that it is difficult to quantify complex factors like personal issues, but better communication between the patient and healthcare providers is the key to understanding personal issues and coming up with solutions for such
problems and thus enabling patients to complete their appointments.
c. Lack of transportation

6.9% (15/218) of patients in our study reported the lack of transportation as the reason for missing their scheduled appointments. 

In a previous study titled “Traveling Towards Disease: Transportation Barriers to Healthcare Access”, it was found that patients from low socioeconomic backgrounds faced more transport barriers to healthcare access and 10-51% of patients reported that transportation was a barrier to healthcare access.
The following table shows the reasons that patients provided on why they missed their appointments. 
Reason For Missed Appointment Number of Patients Percentage of Patients
Forgot/Did Not Know/No Reminder Call
Personal/Work/Unrelated Issue
Problem With Transportation
Too Sick To Come
Problems With Insurance
Not Satisfied/Negative Emotions
Patient Expired
Used Another Source of Care
Thought The Appointment Was Not Essential
Other Reasons

The following chart provides a graphical representation of the different reasons why patients said they missed their appointments.

As you can see, patient no – shows by and itself is not the problem. 

Instead, it’s a result of multiple inefficiencies that ultimately result in patient no shows as we just learned from both the practitioner and the patient’s perspective. 

Now that we know the different reasons why patients don’t show, let’s now take a look at how these inefficiencies and systems failure create a “Wall of Barriers” between patients and providers. 

In addition, let’s also explore what you need to do to tear down this wall to make it easy for your patients to get the care they need from you so you can not only help more patients but also start growing your practice. 

Click here to read part-III now.

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