Patient no-shows are a costly, intractable headache for healthcare providers. Millions of patients cancel, skip or reschedule appointments with their clinicians every year, creating vacant schedules and expenses that can cost the industry by one estimate $150 billion annually.
Faced with such high cost, providers and payers alike have increasingly looked to tech for answers. Stakeholders across the industry — from insurers and providers to EHR companies — are engaging directly with Uber and Lyft following the companies' high-profile entrances into the market.
Trouble getting to a provider, however, is just one of many factors fueling missed appointments. Other issues patients cite include cost of care, socioeconomic restraints, long wait times and scheduling conflicts.
Despite big promises from tech companies, an app and a platform can't solve all of healthcare's woes.
"How much of this is, they're really not that into you?" Krisda Chaiyachati, lead author of Penn Medicine's early 2018 study of Lyft's impact on missed appointments among Medicaid patients, told Healthcare Dive. "And how much is a true need and a gap in getting there?
That's the question a slew of organizations are trying to figure out, from marquee ridesharing companies and non-emergency medical transportation (NEMT) brokers to telemedicine companies and mobile health clinics.
Here's a snapshot of current efforts to reduce missed appointments:
Non-emergency medical transportation
The ridehailing industry's promises won some support in findings this week from Lyft and tech company Hitch Health. The companies launched a pilot at Hennepin Healthcare's internal medicine clinic in Minneapolis last year targeting patients who have missed appointments in the past. After a year, Lyft and Hitch found their pilot reduced no-shows by 27%.
Those results should put the wind back into the sails of industry rideshare hopefuls that may have been disheartened by the results of a Penn Medicine study published earlier this year.
That study, which looked at how complementary rideshare impacted missed appointment rates among Medicaid patients in west Philadelphia, demanded industry attention for its findings: Chaiyachati and his team found that the service "really didn't make a dent" in no-show rates.
Chaiyachati, who said the study was done in part because of the hype around ridesharing, told Healthcare Dive he found the results surprising. Given the fact that anywhere from 35-50% of Medicaid patients in that area miss appointments on a daily basis, he said, "How do we advance their care plans at the end of the day?"
Transportation is the third-most frequently identified reason for missed appointments among older adults by American Hospital Association's count. The access gap has created a market worth over $3 billion, according to an estimate from the Transit Cooperative Research Program.
According to the Journal of the American Medical Association (JAMA), CMS was accountable for pumping at least $2.7 billion into that market by way of Medicaid NEMT benefits as of 2016. While these benefits have been available for Medicaid enrollees since the program's inception in 1965, ridesharing's introduction to the industry has breathed new life into the sector.
"I've had so many hospital [executives] grab me by the shoulders and say, 'You don't understand how big of a problem missed appointments are for our facility,'" Mark Switaj, founder of medical transportation platform RoundTrip, told Healthcare Dive.
Switaj does have somewhat of an idea of how big the problem is. Before launching RoundTrip, an all-in-one transportation coordination platform, he worked for Envision Physician Services in Horsham, Pennsylvania, and medical transportation giant American Medical Response.
The founder told Healthcare Dive his "firsthand look how patient transportation services are designed" helped him understand how to help modernize the industry. RoundTrip isn't a transportation company itself. Rather, it's a "single touch-point" that connects providers, payers and existing transportation services. The platform has a built-in appointment reminder system and is HIPAA-compliant.
The company has forged partnerships with Lyft, Greater Richmond Transit Company, advanced NEMT services and a number of smaller, rural transportation companies. Hospital systems, insurance networks and patient coordinators cover the cost of the trip for most riders, 80% of whom Switaj said are Medicaid enrollees.
RoundTrip, like Lyft and Uber, also stands to gain from the growing Medicare Advantage market and the "fairly revolutionary" possibility of CMS allowing managed Medicare plans to offer a transportation benefit.
Cigna's Medicare Advantage arm partnered with Lyft in May 2017 to provide nonemergency rides to members in a handful of states. Between May and November of last year, Lyft gave more than 14,500 nonemergency rides to Cigna-Health Spring members. The payer said 92% of members who used the service have made it their preferred means of transportation.
Despite Penn's recent research, a number of studies have found ridesharing is in fact helping cut transportation costs in the industry. A 2016 JAMA study, for example, showed that a rideshare partnership between Lyft and Anthem subsidiary CareMore reduced transportation costs by about 30% per ride, or $10 per patient per ride, while hiking patient satisfaction by 80%.
Another paper, from researchers at the University of Kansas in 2017, found ambulance use decreased by an average of 7% between 2013 and 2015 in cities where Uber and Lyft were active. Chaiyachati said it may be that high and mid-income patients are using ridesharing services more than low-income patients who typically face more drastic transportation barriers.
“Many of these things aren't tested or designed for low-income patients," Chaiyachati said. "I do think there is an opportunity that, if this works for both middle and higher income patients, we can imagine this might work for low-income patients. We can ask the same question five to 10 years from now and might get a different answer.”
Calls and text messages are a more time-tested means of reducing missed appointments, though Chaiyachati says the results he's seen have been "pretty mixed."
"They're cheap to do because they're automated," he said. "There's not a lot of cost to it."
Automated reminders may not be the most effective way to reduce no-show rates, but they have been found to have at least some impact. A 2010 JAMA study found that 23% of patients who did not get a phone call reminding them of an appointment did not show.
Those who got personalized reminders had a 13% no-show rate, while patients who got automated messages missed 17.3% of appointments.
SMS reminders are a method the industry is already using widely. A recent MGMA Stat poll shows that the majority of healthcare organizations (68%) are already using text messages to send appointment reminders to patients. The 24% of organizations that said they don’t use a text message service either cited concern with their current technology or physicians' reluctance to text.
It's worth noting, Chaiyachati said, that missed appointment rates vary depending on the type of appointment.
Research from CrossChx demonstrates this well: Mental health, for example, experiences the highest no-show rate at 37%, while obstetricians and primary care physicians shoulder 30% and 18%, respectively. Further variance can be found in a retrospective study published by BMC Health Services Research. According to the study, the average no-show rate for teaching hospitals is 25%, while the rates for Department of Veterans Affairs hospitals of various sizes ranged from 9% to 16%.
BMC's research shows that appointment reminders had a very minimal effect on reducing missed appointments across facilities, only dropping half a percent after a centralized phone reminder was implemented.
Slightly better results were found recently by the VA, which launched a new SMS service in the spring called VEText in hopes of reducing missed appointments among veterans. According to VA, nearly 9 million appointments with VA providers are missed each year.
Since the program launched, the national no-show rate has declined from 13.7% to 12.2%. While the impact may seem minimal, as of July 9, more than 3.24 million patients have received VEText messages and canceled 319,504 appointments.
Perhaps a bigger problem than transportation and forgetfulness is distrust in pockets of the low-income population of the healthcare industry.
Mobile health clinics
In a June response to Penn's study, authors Katherine Rediger, Michael Albert and D.R. Bailey Miles offered criticism of complementary NEMT and text-message reminders as a solution to inaccessibility.
“Offering transportation to clinic appointments is not a panacea for complex transportation and social barriers," the authors write. "While some patients may have declined the Lyft intervention because they felt they already had access to suitable transportation, others may have declined owing to the necessity of using text messaging to access the ride.”
Advisory Board analyst Clare Wirth cited some troubling statistics during a recent conference on increasing access to care: While 25% of low-income patients miss or reschedule appointments due to a lack of transportation, a staggering 53% agreed that U.S. doctors cannot be trusted.
The figure is "especially jarring," Wirth said, and has a lot to do with why low-income patients in particular are missing appointments. Chaiyachati agreed, saying there is a "trust factor" that needs to be addressed by the industry.
One way to bolster trust in communities while reducing missed appointment rates may be mobile health clinics. If providers can't get low-income patients to come to appointments, it may be worth the investment to go to them.
"All in all, they're often less intimidating than a doctors office, akin to a primary clinic on four wheels," Wirth said. "And if they're set up well, they can generate a significant ROI."
CalvertHealth Medical Center’s mobile health clinic, for example, delivers care to the 4% of county residents with no access to transportation and those who cannot visit hospitals or doctors regularly for primary and preventive care. The vehicle is 40 feet long and boasts two fully-equipped exam rooms, a waiting room, a classroom and a wheelchair lift. The clinic schedules regular visits with community and faith-based organizations in three of Calvert's most vulnerable areas, where it largely does screenings.
Within the first six weeks of its launch, the clinic provided services to 330 residents. In another example, Harvard Medical School's mobile health clinic in Boston, which provides screenings to patients without asking them to set up appointments, helped 12% of its community catch previously-undiagnosed illnesses on the spot.
Not only did the clinic get people the care they need, but it also saved $21 for every dollar invested. And perhaps most importantly, it established trust.
Improving access to care and reducing no-show rates, Chaiyachati said, will depend on the individual.
"Low-income patients lead fairly chaotic lives. There's a way to adapt to that chaotic life to enhance their access," Chaiyachati said. "The challenge here is, how do we get people the right care when they need it and when they want it?"