As health plan leaders seek to close care gaps and improve member experience, it’s time to shift the paradigm of missed care from a failure to an opportunity for impact. Missed appointments are a significant and often overlooked problem that costs the U.S. health system approximately $150 billion per year. However, the concern is more than just an issue of ineffective appointment scheduling, it is also a symptom of member engagement, health equity, and systemic design problems. For payers, missed appointments have high costs as they interrupt continuity of care, inflate avoidable health care costs, decrease potential savings, and perpetuate inequities, particularly among historically marginalized and rural populations.
The real reasons why people don’t show up
It’s no secret that social determinants of health impact care outcomes. What’s often underestimated is the extent to which these nonclinical factors impede members from getting scheduled care even after they’ve made that all-important first appointment.
1. Financial barriers
Whether it’s simply being uninsured or the expense of deductibles and co-pays, 28% of American adults in 2022 reported delaying care in the past 12 months due to cost. But costs can deter patients from accessing care even when they have coverage. That’s especially true for Medicaid patients who, despite having insurance, have 56% greater odds of no-showing an appointment when compared to commercially insured patients. The fallout from these missed care appointments is cumulative, as we are seeing right now, for example, with delayed care attributed to the Covid-19 pandemic. Left untreated, care gaps can lead to unmanaged chronic conditions, increased ED usage, faltering quality scores, and more. But when payer partners help close the gap by making it easy for patients to receive that care, the impact can be transformative.
2. Logistical challenges
Care may also be missed due to logistical barriers even when members want care and are eligible for it. Reliable transportation can be a huge barrier for members to get care. On average, there are about 3.6 million missed care episodes per year due to lack of reliable transportation. Those who are more impacted by transportation barriers include: elderly members, rural populations, and members with physical or cognitive challenges. These missed care costs do not even take into consideration the cost of future health issues from missing earlier appointments. As health concerns compound, costs associated with care rise.
Many Medicaid and Medicare Advantage programs provide non-emergency medical transportation (NEMT) benefits to address these access barriers, however few members are using NEMT benefits to get to their care. In fact, only 4–5% of Medicaid members used NEMT services between 2018–2021. This low utilization is due to poor member experience, onerous processes, and NEMT options that are not well integrated with the scheduling of the appointment itself. Simply making transportation available is not enough. A transportation solution is only effective when it’s easy to schedule, convenient, and, ideally, connected to the workflows that drive care coordination to the point of care. Otherwise, it’s just another friction point in the care journey that can cause missed care.
3. Motivational and communication gaps
Just because a benefit exists does not mean members understand how to utilize it. Many members don’t know where to start, how to find an in-network provider, if they are eligible, or what to do next. The solution is not to send members more messages, it is to send them better ones. Generic one-offs that sound robotic, non-contextual, and impersonal will be deleted or ignored. Personalized, empathetic, and human messages that clearly outline next steps will be read and taken more seriously.
Messages matter, and framing is important. The difference between a member hearing, “We’ve reserved this time for you” vs “It’s up to you to take this time to meet with your provider” is not simply communication vs messaging, it’s the difference between reminding members you’re in it together and expecting members to shoulder the burden on their own.
When health plans are human, when they meet members where they are at, with communication and education that’s accessible, personalized, and effective, members are more confident, engaged, and likely to take action.
4. Systemic disengagement: “Remind and wait” doesn’t work
If you’re part of a health plan that sends automated “reminder” messages (email, text, phone voicemail) and then doesn’t do anything to engage members, you’re not alone. “Remind and wait” means a static, time-bound outreach followed by nothing. Even worse, it’s usually from an untracked, unblocked phone number so there’s no way to ask questions, clarify details, or find help.
This method is alien to the way most of us tackle any complex, emotionally loaded decisions. But it’s exactly what we expect chronically ill, high-risk, low-income, multi-burdened, and language-diverse members to do on their own, with no human connection, no response system, and no outreach from their plan.
And when referral-to-appointment completion rates are under 35% that means a majority of referrals are failing and care is being missed, not because members don’t care or don’t try, but because we haven’t engaged them effectively.
Fixing no-shows through “remind and wait” suggests the problem is in messaging instead of engagement. Engagement is about connecting, in person or remotely, finding where members are stuck and helping them get unstuck, actively reaching out instead of passively responding, and closing loops as well as opening them.
Designing better systems: Reminders to relationships
Improving no-show rates is not just about perfecting our reminders, it’s about redesigning the member experience from the ground up. It’s about creating systems that reflect and accommodate the realities of members’ lives. Here are three ways to put design first when driving care completion:
Eliminate friction – Members tune out when scheduling is too hard. Moving from passive referrals to real-time scheduling, ideally at the moment of engagement, eliminates a significant source of friction. Integrating this functionality into member-facing channels like nurse hotlines, rewards portals, and over-the-counter (OTC) benefit platforms makes access both immediate and frictionless.
Drive behavior – Members are more likely to feel seen, valued, and supported when communication is personalized and tailored to their unique needs and circumstances. Timing, tone, and touchpoints can all be adapted to reflect the preferences of each member. By showing members that you care and that their role in their care journey is active, you can earn their trust, strengthen relationships, and drive them to close gaps in care.
Adapt to real life – Members are diverse, and so are the barriers they face to access care. For some, it’s transportation, for others, it’s mobility limitations, living in a rural community, or having both caregiving and work demands. A member-first approach to care access identifies these challenges and tailors access to care to meet them. This could include offering transportation assistance, telehealth, after-hours appointments or care coordination, to name a few. Regardless of the solution, the goal remains the same: Removing as many barriers as possible and providing care that’s truly accessible.
What health plans can do now
Transitioning from reminders to relationships starts with intentional systems design. Every member engagement touchpoint is an opportunity to close gaps in care and ensure care continuity. Each interaction that a member has with a care management team member is an opportunity to schedule an appointment. Here are four easy ways health plans can make a difference, starting today.
Invest in a smarter referral infrastructure that closes the loop. Get past scheduling as the finish line. Plans should ensure members follow up to complete care and report data to close care gaps.
Make sure scheduling is connected to engagement and care coordination, to avoid silos and unnecessary friction.
Identify high-risk members using data, then proactively engage to keep them from falling through the cracks.
Track the entire care journey, not just referral. If you’re not measuring completion, you’re not closing the gap.
From missed appointments to measurable impact
No-shows are more than an operational pain point. They are missed opportunities to improve outcomes, close equity gaps, and deepen member relationships. They can be transformational when plans shift from passive outreach to proactive, relationship-based outreach, resulting in:
Better outcomes – Recommended visits aren’t complete, chronic conditions aren’t optimally managed, preventable complications aren’t caught early, and care isn’t as effective when members miss appointments. When we reduce no-shows, population health metrics increase.
Reduced inequities – Low-income, rural, and minority members are more likely to miss appointments. When we engage to understand what’s getting in the way and help members overcome these barriers, we address the complex causes of no-shows and take important steps towards achieving health equity.
Improved quality scores – Completed care is what drives performance for CAHPS, HEDIS, and Star Ratings. But if we’re not addressing the core issues members face when it comes to accessing and acting on care, we can’t expect to change members’ minds about completing appointments, or getting members to give us good ratings.
It’s time to take no-shows off the back burner. Let’s stop treating missed appointments as a member issue and start seeing them as a strategic opportunity to do better by our members and our business by building trust, closing gaps, and delivering care that is not only accessible but actionable.
Source: Nuthawut Somsuk, Getty Images
Kevin Healy is a seasoned healthcare executive with over 25 years of leadership experience spanning health plans, provider organizations, and healthcare technology firms. He currently serves as CEO of ReferWell, a digital healthcare company specializing in personalized member engagement and point of care scheduling. In this role, Kevin is leading the company’s next phase of growth by expanding the reach of its platform and care concierge services to better connect patients with the care they need.
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