#PTonICE Daily Show – Thursday, August 17th, 2023 – Reschedules, cancels, and no shows: oh my!

In today’s episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses average arrival rates in physical therapy, what the research says about how to improve arrival rates, leveraging technology to improve arrival rates, and creating policies & systems that ensure your clinic still gets paid for missed appointments.

Take a listen to the podcast episode or read the full transcription below.

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Good morning, everybody. Welcome to the PT on ICE daily show. Happy Thursday morning. Hope your morning is off to a great start. My name is Alan. I’m happy to be your host today. Currently have the pleasure of serving as the chief operating officer here at ICE and the faculty member on our fitness athlete division. We’re here on Thursdays. We talk all things leadership Thursday, small business ownership, practice management, that sort of thing. Leadership Thursday also means it is gut check Thursday. This week we have a 17 minute AMRAP, as many rounds and reps as possible in 17 minutes of the following 21 plate ground to overhead. Our Rx weight there for guys 45 for ladies 25. So grabbing a bumper plate, hinging down, tapping one side of the plate between your feet and then up and over overhead, almost like a snatch. Moving into 15 cows on the rower for guys 12 for ladies and then finishing with a small dose nine burpees to plate. So looking for somewhere between three to five rounds of that great workout for home, the garage, the basement, the clinic. Just need a rower and a bumper plate. Great to maybe take out to the park as well and sub the row for some running or something like that. So that is gut check Thursday. Course is coming your way. We have so many about to enter a very, very busy season for ICE here as we get into the fall, get away from the summer, school starts back up, that sort of thing. We have a couple hundred courses coming your way between now and the end of the year. So if you’re looking for live courses, head on over to p10ice.com, click on our courses and check out our map to see what’s coming to your neck of the woods. Some online courses I want to highlight. Pretty much all of our entire catalog of eight week online courses are starting back up after Labor Day. So if you don’t know about our online courses, they are eight weeks online. They are synchronous, which means that you meet with us every week. They are not completely self study, a mixture of lecture, of reading, of homework and of live meetups. They’re meant to simulate the feeling of a two day live course, but stretched across eight weeks to make it a little bit more accessible, save you a little bit of money on travel. So online courses, pretty much like I said, all of them are starting after Labor Day. We have ICE Pelvic Online. That’s our entry level online pregnancy and postpartum course. That’s going to start September 4th. We have Fitness Athlete Essential Foundations taught by yours truly Mitch Babcock, Kelly Benfee and Guillermo Contreras. That’s going to start September 11th. The very next day, September 12th, Brick by Brick is going to start very relevant course to this day of the week to Thursdays. We talk all things practice, startup and ownership and management in that course. Injured Runner Online also starts September 12th and then Virtual ICE will open back up September 26th for our next quarter of enrollment. So let’s get into today’s topic. Let’s talk about how do we handle, how do we get better at when a patient reschedules, cancels or no shows. I want to talk today about three main topics. I’m going to talk about what are the average no show cancellation rates, what we would call an arrival rate across the country, across physical therapy, what’s normal, what’s abnormal. I want to talk about how to improve those arrival rates. And then I want to talk about how to get paid when somebody does not show up for those appointments.


So let’s start at the beginning and let’s talk about what is a normal rate. If you have been practicing physical therapy for a while, if you have been practicing in a traditional clinic, you may have heard that the common recommendation for the maximum arrival rate is about 93%. That is to say that 93% of your appointments show up for their appointment that day. That there’s some margin of error. We recognize that 100% of people probably won’t make it, but pretty typical. 93% is the standard that’s set and sometimes enforced by the clinic that you work for. Maybe if you fall below that, maybe you get a warning, maybe you get a talking to, or maybe they actually dock your pay for visits underneath that 93%. What’s awesome about this topic is that we actually have a lot of research, surprisingly, supporting the numbers that I’m about to tell you. So we have a great survey back from 2015 of about 7,000 outpatient physical therapists. This is from Bo Kinski and colleagues, sorry if I mispronounced this, of 7,000 outpatient PT’s looking at a couple of different things. Looking at finding the average cancellation no-show rate, but also finding what things seem to help fix that. So across the country, we see an average no-show cancellation rate of actually about 10 to 14%. So thinking you may have been told 93% is the gold standard, in reality, somewhere between 85 to 90% is actually probably more realistic. If you had 10 patients scheduled for the day, you could expect maybe eight of them to show up for the appointment. You could expect maybe one to two appointments to be unfilled. I like this survey because it goes a couple levels deeper. It asks why. Now knowing that rate, knowing that 10 to 14% rate, why do people not show up for the appointment? What is the number one cause? The number one reason why patients do not attend their appointment is not that they can’t afford it, not that they don’t like you, it’s that they forgot and that the clinic that they went to physical therapy to had no reminder system. So that’s a huge error, that’s a very easy fix. When we delineate outpatient physical therapy from hospital-based outpatient physical therapy, so private practice versus hospital-based, we see that hospital-based clinics actually the no-show cancellation rate of a private practice clinic. Why is that? I would imagine it’s probably due to having a modern reminder system, but again, that number of 93% isn’t the gold standard that we think it is. In private practice, we can expect maybe 85 to 90% arrival rate, a little bit lower in hospital-based, maybe 75 to 80% arrival rate. Now this survey looked at the concept of a multi-method reminder system. What does that mean? That means that the patient received multiple reminders across multiple communication methods. That they usually received some sort of automated phone call reminding them of their appointment. They received probably a text message and then maybe also an email message. So they received two to three different reminders ahead of their appointment across different modalities, basically reminding the patient as much as possible of their upcoming appointment. Now they found that those clinics that used a multi-method reminder system had a significant reduction in no-show cancellation rates, about a 50% reduction. So they cut their no-show cancellation rate in half just by having a reminder system. And we’re going to talk about how to set that up at your clinic here in a minute. The second reason that clinics did better with no-show cancellation rate was those clinics who had a 24-hour appointment change policy. That is inside of 24 hours, you will be penalized if you cancel or reschedule or no-show your appointment versus if you give more than a 24-hour notice that you need to reschedule your appointment or otherwise cancel it. So those clinics which had a 24-hour policy and enforced that policy on their patients also had a reduction in their no-show cancellation rate. So that brings us to the question of if 10 to 14% is the mean of the average of no-show cancellation rates across the country, then how realistic is 7%? The answer is not very, right? Even if you are treating one-on-one for an hour and you maybe only have eight patients on your caseload for the day, it’s probably unrealistic to expect 100% of those people to show up every day. That we have to recognize at some level that the reason we see so much overbooking in traditional physical therapy clinics is it’s just that leadership strategy to limit the impact of those inevitable no-show cancellation rates. That if you see eight patients in a day and 10 to 15% don’t make it, you may see five to seven patients. So kind of the aggressive leadership solution here is just to make you see more patients. That if you see twice as many patients and you still have that 10 to 15% no-show cancellation rate, then you’ll still see more patients than originally intended and scheduled to and the clinic won’t lose as much profit. But that being said, that is an aggressive way. That is a way that puts all of the burden of the work on the therapist and none of it on the ownership, none of it on the leadership and none of it kind of on the backend logistical side of the clinic. Instead of making you see more patients, why don’t we just have a 24-hour policy that we enforce? And if we’re not using a reminder system, why don’t we start using one? Why don’t we do some more conservative approaches to reduce that no-show cancellation rate, especially now knowing that we have research that supports, does those actually improve our no-show cancellation rates? So let’s talk about that.


Let’s talk about aside from having a reminder system, aside from strategies to remind patients to get to the clinic and aside from having a policy, how can we approve improve those arrival rates? You know us here at ICE, if you’ve been listening to us for a while, Jeff Moore, our CEO says it best. The first thing you can do to make patients show up to physical therapy more is make sure that you’re focused on getting good and not getting busy. That when people see results, when they begin to associate value with their physical therapy appointment, they come to their appointment more often. I think this is so overlooked, especially in a higher volume clinic where a therapist may be expected to see multiple patients per hour. By providing lower quality care, patients aren’t able to get results or they’re not able to get results as fast as maybe they want to. They don’t really associate physical therapy as a valuable use of their time and it makes sense that they find better stuff to do and that you get that message at 4.55 p.m. that your 5 p.m. patient is not going to make it in today. So really focus on getting good, not getting busy. We also need to recognize that people are not stupid. When they show up to PT and they see that you are working with three other people at the same time and you have forgotten about them in the corner at the TheraBand station or on the recumbent bike or the pulleys, again, that really begins to lower the value proposition that patients have with physical therapy and it’s not surprising again that they begin to find better stuff to do with that hour of their time. The counter argument here is that you can get so good as a physical therapist, I’m good enough that I can see multiple patients at once or patients aren’t as fragile as we think. We don’t need to give them one-on-one care, but we need to recognize that at some level, patients are paying for it, especially if they’re paying cash for a one-on-one visit. They are expecting one-on-one treatment. Even if you are an insurance-based clinic and using a patient’s insurance, that insurance is still paying you based on one-on-one care. And not only that, but the patient expectation is that you are going to give them the care that they need. And I often relate this to other professions of you would lose your mind if you had a therapy appointment with a psychologist, a mental therapy appointment, if you showed up and there were three other people getting mental health therapy at the same time as you. No one would put up with that, but for some reason, it’s just expected and normalized that that’s the kind of care that we give in physical therapy. So then it’s no wonder that patients, again, find something better to do with their time for the hour. So really focus on getting good and not getting busy, of taking really quality care of that patient that you have on your schedule for that hour. And you’ll be surprised how much they come back to physical therapy when they see their range of motion improving, when they see their balance improving, when they feel stronger, when their pain is getting better, whatever their goals are, as they can see progress towards their goals, it’s much more likely that they’re going to come back to physical therapy. And I think that is often overlooked. My second point with improving arrival rates is to leverage technology, implement that multi-method reminder system. It’s 2023. There is no reason why your clinic does not have automated reminders, text, email, phone, whatever. It’s all built in to a modern EMR. If your EMR does not do this, you need to get an EMR that does this. If your front desk person is still calling people by hand to remind them of their appointment, you’re a little bit behind the curve, right? to do the work for you so that you can focus on treating your patients while the technology sends out those reminders for you. We need to recognize that people are busy and that the more we can be prominent in front of mind with reminders, the more likely people are to attend their appointments. We have research that supports this, right? We can cut these no-show cancellation rates in half with a multi-method reminder system, but also it gives the patient a chance to reschedule if they know they already can’t make it, right? That text reminder, when they get that phone call, when they get that email, it gives them multiple chances to reschedule. And if they don’t, it also kind of builds the case for you against them that you gave them plenty of chances to reschedule and they still did not. And that makes it a little bit easier to charge them money, which we’ll talk about in a few seconds here. So remember, we can cut that rate in half, that no-show cancellation rate in half with a multi-method reminder system. So if you’re still using Google Drive as your EMR, if you’re still using paper documentation and scanning it into a computer, consider getting a modern EMR. They’re not that expensive. EMRs, we’re big fans of Jane here, obviously, at ICE, other EMRs, Prompt, PT Everywhere, pretty much all the modern web-based EMRs are going to offer reminders and more often than not, they’re free for you to use. So why not use them, right? It’s one more push of a button when you’re building out that patient chart for them to get reminders. In addition to reminders, leverage technology to create an online booking and waitlist system so that when you do send that reminder, it should come with a link where it says, hey, if you can’t keep this appointment, please click here, right? So that your appointment comes off my schedule and that you get a little link to rebook at a time that works better for you. So we still keep that visit on the schedule, but we also open up that visit to maybe somebody else who can use it so that we don’t have a missed slot on our schedule. Pretty much just like reminders, modern EMRs are very good at having automation with waitlists of where when a patient reschedules and a slot opens up, usually automatically or with the push of a button, you can pull people in from your waitlist and make sure that that slot stays filled without having that patient get charged for cancellation or no-show because they were able to go in on their own and reschedule their own appointment. So make sure we’re leveraging technology whenever possible to do this work for us. My last point here on improving arrival rates is probably something that we don’t consider very often of making sure in that initial evaluation that the patient actually has the time and or money to come to their physical therapy appointments. I feel like a lot of time patients feel beholden to maybe a referral they had from a doctor or what you tell them of some sort of verbal contract of the doctor said I have to come here three times a week for six weeks or maybe that’s what you wrote on your documentation is the physical therapist and they feel like they have to come no matter what, even if they know they do not have the time or money. I feel like this is something that should be discussed as we’re wrapping up our initial evaluations that just doesn’t get done. As we’re building the bike for that patient, we’re explaining our findings, we’re demonstrating that we can help that person reach their goals by showing them some improvement in that first visit and as we begin to discuss what that plan of care might look like, also making sure that the patient is on board, right, including the patient that conversation of hey, Diane, this seems to be a pretty irritable tendinopathy. You know, I think I would like to see you here in the clinic twice a week, probably for at least the next four weeks. And instead of stopping there, take it one step further. How do you feel about that? Right? What do you think about my plan for your care? And we don’t necessarily have to ask, hey, can you afford this? Or do you have the time for this? But that’s what we’re hinting at of how do you feel about coming here twice a week for four weeks? How do you feel about coming here once a week for the next four weeks and getting the patient’s input because that’s a great time for them to say, that’s going to be tough with my schedule. You know, I have 17 kids or I work 30 jobs. I won’t be able to do that, right? That’s a great time to make sure that person does not get put on your schedule for a bunch of visits that they’re not going to attend. And then making sure we’re following the law, right? No surprises act that was passed last year that were very transparent with how long we think the plan of care is going to take and what that’s going to cost that patient. Whether you’re charging cash, whether you’re billing insurance, you need to provide that information upfront to the patient. I would argue you should be doing it even if it’s not the law, just so you don’t have people on your schedule who are not going to show up. But being very forthright and how long you think it’s going to take and what’s that going to cost and get that patient’s input on it before we talk about scheduling out for their visits.


My last point here of talking about what average arrival rates are, what improves arrival rates is how do we get paid when somebody does not show up to the clinic? This is another area where I think physical therapists are very uncomfortable with asking people for money to come to rather not come to their appointment. And it’s an area where again, when we look at the research, what improves arrival rates, multi-method reminder system and having a rescheduled cancellation policy that is enforced. If you don’t enforce it, you can’t get paid for these missed visits. And if you try to enforce it like halfway through the plan of care, the patient is probably going to be upset versus if you’re straightforward from the start in your intake paperwork and with your expectations before they begin physical therapy, it’s not as jarring to that patient when you charge them for that canceled or rescheduled appointment. So remember, combination of a reminder system and a clearly stated 24-hour rescheduling policy that’s enforced are the keys to reducing your no-show cancellation rate by as much as 50%. So first things first, create a policy. What do you want your policy to be? Make sure that policy is very clear, very transparent and that patients see it before they actually come to the clinic. So for us here at Health HQ, this is the first thing that patients see when they go through their intake paperwork. They see our cancellation no-show policy. They see our rates. They know what they’re going to be charged. They know the maximum they can be expected to pay out of pocket if they do have insurance and they’re going to see what they can be expected to be charged if they cancel or reschedule appointment within 24 hours. So ensure you have a policy, make sure it’s actually written out, make sure that it gets in front of patients before they commit to a plan of care and then decide on what you want to charge that person. Decide on what your rate will be. I would argue it should be what you would want to get paid for that hour even if the patient had come. A lot of clinics will have what I would call a dinky, kind of a really lackluster enforcement policy where maybe if you don’t show up to your appointment, you’re charged $10 or $15. That’s really not enough for people to have skin in the game. Being charged $10 or $15, especially if you don’t actually enforce it, is really not going to set the expectations for your patients the way you want it. For us, we want to be sure the patient, sorry, the therapist gets paid as if they had seen that patient even if the patient no shows or cancels. So we charge $75 and we enforce it. Right? How do we enforce it? Well, you should probably start obtaining payment methods before the plan of care begins. So again, somewhere in your intake, transparent, clear, laid out should be what you charge for cancellation, a no show, a reschedule, the amount, and that you should take a payment method and have that payment method on file even before the initial evaluation happens so that even if they don’t show up to the evaluation, your therapists are able to get paid for that hour. And then actually enforce it. You have to enforce it. You have to rip the bandaid off and actually do it. If you don’t do it until somebody has done this to you 19 times, it’s going to be difficult to actually start enforcing it because you’ve let them get away with it so many times. Maybe your personal policy in your mind is that everybody gets one freebie. Whatever that is, stick to that and then start actually enforcing it. What you’ll find is that when you enforce it, guess what? The first time that patient gets charged that money, guess what they never miss again? Physical therapy. Or they reschedule so that they don’t leave an empty spot on your calendar book. So recognize that we have to enforce this. Yes, it’s uncomfortable, but the more you do it, the sooner you do it in the plan of care, the more you’ll find patients will either adhere to it or they might decide therapy with you is not for them and that’s okay too because the end result is we want people on our schedule who are actually going to come to physical therapy. We need to recognize that this is not unusual. Oftentimes we said, well, this isn’t something physical therapists do. They don’t charge people for not coming to appointments. Literally every other industry on the planet does this. When you make an appointment to get your haircut or whatever personal beauty grooming thing you do, they have a reschedule cancel no show policy where if you don’t show up to your appointment for whatever reason, you’re probably going to get charged a little bit of money. Massage therapists do this. Lawyers do this a lot. You have to pay money upfront to even talk to a lawyer, right? You have to have that retainer money on file. Dentists do this. Other healthcare providers do this. This is very, very common across a wide range of industries except for physical therapy. People often ask me, why do you think that is? I think it’s because we spend a lot of time with our patients and we begin to almost view some of our patients maybe as friends or at least acquaintances, which makes it that much harder to begin to charge that person for missing a physical therapy appointment. So we need to recognize that yes, it is difficult, but again, every other business does this. Every other industry does this. The sooner and more comfortable you get with enforcing this, the less awkward it’s going to feel. And remember, leverage technology to fill those missed appointment slots so that ideally the therapist still gets paid for that person not showing up, but maybe they can also fit another patient into that spot still. I love when I pull up our schedule and I see that somebody has canceled, they’ve been charged for it, and we’ve been able to pull another patient from the wait list to fill that same slot. That therapist went to work, came to work here that day thinking, I’m going to see seven people and they actually got paid as if they had seen nine. That’s fantastic, right? That’s way better than systems where you may be expected to clock out if a patient doesn’t show up and not get paid at all for your time, or you may be expected to clean the toilets or something like that in that missed time versus actually getting paid for that time and either being able to use that time for whatever you want or trying to fit another patient into that slot. So remember, it’s really important here. This is all an end, not or situation that there are different components to this that we need to implement. It’s not just we need to charge people for not showing up. It’s not just we need to have a reminder system that we need to understand that at some level, having 100% arrival rate is unlikely. People not showing up is unavoidable, whether kids, family emergencies, that sort of thing. But there are things that can be done to reduce those rates. They’re not unavoidable that we can deliver great outcomes to patients so that they do not find other reasons and other things to do instead of coming to physical therapy. We absolutely have to get with the program and begin to leverage technology, begin to send these reminders out if we’re not doing it already, begin to use technology to have a waitlist system so that we can fill empty slots quickly, create and actually enforce a policy, get credit cards on file, begin to actually charge people for not coming to those appointments, hold them accountable, hold their feet to the fire, but also recognize and have that conversation early on of what is realistic for that patient. Do they actually have the time and money to come to therapy two or three times a week? Or do we need to look at maybe, hey, I can see you once every other week, but you’re going to have to be really judicious at home with your homework because you’re not coming here as much. So having those conversations early and often in the plan of care so they don’t come back to bite us later on and then utilize technology to get paid for those visits and fill those empty slots. So reschedules, cancels, no shows, not to the end of the world, things we can do better to get better at them, I should say. Leverage technology, enforce a policy. So I hope this was helpful. I hope you all have a fantastic Thursday. Have fun with Gut Check Thursday. If you’re going to be on a live course this weekend, have a wonderful weekend with our faculty on the road. We’ll see you all next time. Bye everybody.

24:17 OUTRO

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