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A billion dollar suggestion to the administration

February 27, 2009
by Ann Borders
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First, read Charles Curie's blog. He has artfully described the gravity of the situation as we sit at the crossroads of behavioral health policy. For my part, I've taken advantage of the White House's web site and offered my two cents about a situation that surely costs the healthcare system billions each year. The majority of the clients served by our provider organization are Medicaid recipients.

Over 40% of this population 'no-show's' (fails to keep appointments, and also fails to notify us of cancellations). From my discussions with colleagues, this phenomenon isn't unique to Indiana.

A few years ago, we imposed a modest fee for no-show's, but were quickly reminded that such a fee could not be imposed on a Medicaid recipient. So we had to 'stop before we started.' The cost to our organization alone is about $1m. per year. Imagine the fiscal impact when all Medicaid providers throughout the country are taken into consideration.

With resources so slim these days, it is unconscionable for providers to be sitting on their hands due to no-show's when their organizations have long lists of people waiting to be seen. It may sound like a small thing to suggest to CSM that they re-think their policy about fees, but it is incumbent on all of us to offer solutions. We might as well go that route, for the prospects of a behavioral health bailout are slim to none!



Ann, I might suggest you contact Gail Lawson, CEO of Sound Community Services in New London, CT - http://www.soundcommunityservices.org. She has found a very elegant and inexpensive piece of technology to help deal with no-shows and as a result has seen a dramatic decrease in no-shows.

People with Medicaid have very limited budget, so they are probably not going to pay for missed sessions. People who skip appointments should be re-assigned to group therapy - a much more cost effective way to treat patients. My opinion has been that the behavioral health field has overutilized the 1:1 format. Don't get me wrong, 1:1 therapy has its place. But not with everyone. Skipped appointments should be an indication for group therapy unless there are other circumastances that contraindicate this approach,

Staff should never have scheduled time for paperwork. They should book every hour/ time slot for clients and use the no show for catch up. I agree that most services can be offered on a group basis. Our clients do not carry agendas nor calendars and their life is chaotic a symptom of their illness. Perhaps staff could telephone their clients instead of having them come in if accessibility is an issue. Don't punish clients! Find ways to work with their limits.

True enough you can not charge them for covered services they receive. But it seems to me that if no service was provided as a result of the "fail to keep" then you should be able to charge the person for not showing up. How would that be different that if you provided them a service not covered by Medicaid? You could charge them for that. The other question is then what real chance do you have to collect anything and what do you do if they don't pay you?

Great point, Ann! If I miss an appointment a provider will charge me—not my health insurance. Something similar is needed in Medicaid to reduce costly no-shows. Such "small steps" can add up to big savings and are definitely worth CMS's consideration.

Ann Borders

President and CEO, Cummins Behavioral Health Systems, Inc


Ann Borders is president and CEO of Cummins Behavioral Health Systems, Inc., serving eight...

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