QUESTION: My doctor’s office recently posted a sign that says patients will be charged $60 if they miss an appointment or fail to give a 24-hour cancellation notice. The sign, which is taped to the receptionist’s glass booth, also says the fee for a missed annual physical exam is $120. I have heard that many Ontario doctors are no longer paid strictly on a fee-for-service basis. I assume they are not out-of-pocket any money if patients don’t show up for appointments. How can they justify these fees?
ANSWER: You are correct – there has been a change in the way a lot of Ontario physicians are paid under the provincial health insurance plan.
Many doctors who work in group practices are now paid a flat fee, per patient, per year. The amount is adjusted to take into account the age, gender and medical complexity of the individual patient.
This arrangement is known as capitation. It essentially means the physician gets the same amount regardless of whether you have just one appointment or 10 appointments a year.
So, in a sense, you are also correct that a doctor paid on a capitation basis doesn’t really lose money if a patient misses an appointment. But physicians who still work fee-for-service would be out of pocket because they are unlikely to fill the vacant spot at the last minute.
However, protecting the doctor’s income is not the sole motivation for imposing a “no-show” fee.
It can also serve as “a deterrent to the patient who doesn’t show up or cancels at the last minute because that becomes a burden on another patient who could have taken that time slot,” says Prithi Yelaja, a spokesperson for the College of Physicians and Surgeons of Ontario (CPSO).
In other words, when one patient is a no-show, another patient suffers.
The CPSO, which is the medical licensing and regulatory body in the province, permits doctors to impose these fees so long as patients are told in writing of the potential penalties for not showing up. In your case, the sign posted near your doctor’s receptionist serves as the advance warning.
“It’s up to individual physicians if they charge it or not. We just determine that they are allowed to charge it,” says Ms. Yelaja.
Some doctors feel the cancellation fee will encourage patients to behave in a more considerate manner toward their fellow patients.
But not everyone is convinced that this is the best way to foster respectful behaviour. It may do more harm than good, says Sally Bean, an Ethicist and Policy Advisor at Sunnybrook Health Sciences Centre.
“Depending on how the policy is enforced, it can disadvantage people from a lower socio-economic status,” says Ms. Bean.
“They may have precarious employment, or inflexible employment.” It might be hard for them to get time off work to go to the doctor, she explains. If they miss a medical appointment for work-related reasons beyond their control, they may be further penalized with what amounts to a fine for failing to provide a 24-hour cancellation notice.
Ms. Bean says physicians need to carefully consider the impact these charges could have on some of their patients.
Will the doctor waive the fee if a patient has a personal emergency and can’t make it to the appointment? If exceptions are made, then how do they ensure that rules are applied fairly? And what happens when someone doesn’t pay the fine; will the patient be prevented from booking a subsequent appointment?
So a cancellation fee could potentially lead a physician into an ethical quagmire of sorts.
“I think a lot of doctors are just using it as a deterrent,” speculates Ms. Bean. “They probably don’t intend to enforce it unless someone is a repeat offender.”
She also believes most patients want to keep their medical appointments. “I suspect, in the vast majority of cases, the patient isn’t being intentionally willful or disrespectful by not showing up. For whatever reason, the patient simply can’t make it. But admittedly, few circumstances prevent the patient from calling in advance.”
Of course, some patients will forget they have an appointment. That can understandably happen with appointments that are booked many months in advance.
Dr. Douglas Bradley, a sleep specialist at Toronto General Hospital, has come up with a relatively simple way to ensure the vast majority of his patients show up as planned.
He has his secretary phone patients one week before their appointments. The reminder seems to do the trick – his rate of no-shows and last-minute cancellations is 10 per cent.
By contrast, an informal survey of other specialists at the hospital found that the no-show/cancellation rate was between 20 and 25 per cent for doctors who didn’t provide their patients with a pre-appointment reminder.
That suggests a phone call can more than halve the number of patients who fail to keep their appointments. (It might also be possible to send email reminders to patients.)
It’s worth noting that there are significant differences in the booking schedules of medical specialists and family doctors working in group practices. A patient might see a specialist every few months or just once a year. For family doctors, the bookings tend to be made much closer to the time of the actual appointment. So a reminder notice may work best for specialists who see patients less frequently than family doctors
Still, Dr. Bradley, who is paid on a fee-for-service basis, thinks doctors are justified in charging cancellation fees when patients fail to give adequate notice of not being able to make an appointment. He also feels the policy doesn’t disadvantage poorer patients more than wealthy ones.
“What is so difficult about picking up the phone and cancelling?” he says. “If you fail to show for an appointment without giving notice, you are depriving someone else of seeing that physician.”
Nonetheless, Dr. Bradley has demonstrated in his own medical practice that doctors can take some proactive steps – like appointment reminders – to limit gaps in their schedules.
“It is better to rely on preventative rather than punitive measures to ensure patients show up for their appointments,” he says.