Article
For the past quarter of a century, patients in Norway who fail to attend a hospital appointment have been charged a fee. The system now needs to be reviewed – or abolished entirely.
Illustration: Coyau / CC BY-SA 3.0 / Adapted by Tidsskriftet
Patients who fail to attend scheduled appointments at Norwegian hospitals without giving at least 24 hours' notice can be charged a non-attendance fee (1) . The fee was introduced in 2001 and, in 2009, was standardised to correspond to the co-payment charge for outpatient consultations (currently NOK 443). It was increased to double the co-payment charge in 2015, triple in 2019 and quadruple in 2023 (2) .
However, the increases do not stop there. A further increase will be made in 2026 as a result of this year's national budget. The co-payment charge for outpatient consultations in the specialist health service was raised by 10 %, which has correspondingly raised the non-attendance fee (3) . In addition, budget negotiations secured NOK 31.4 million through a new measure: the fee was increased by half the co-payment charge (4) . As a result, the non-attendance fee now stands at NOK 1993 per missed appointment (1) . Patients receiving mental health care or substance use treatment remain partially protected, paying a fee equivalent to the co-payment charge.
The symmetry between the co-payment charge and the non-attendance fee was disrupted when the latter was doubled in 2015
Symmetry in the legislative preparatory work
Symmetry in the legislative preparatory work
Three challenges are associated with the current system of non-attendance fees in Norwegian hospitals. The first is that the fee has grown disproportionately. The authority to charge a fee for non-attendance is established under the Specialist Health Services Act, and the preparatory work for the Act from 1998 notes:
'The provision [on introducing the non-attendance fee] must also be viewed in the context of the authority to determine that the patient should not pay in the event of delays [...]' (5) .
Then, as now, although this rule is probably less well known than the 'no-show fee', patients are not charged the co-payment if their hospital appointment is delayed by more than one hour, provided they were not notified of the delay in advance (1) .
The symmetry between the co-payment charge and the non-attendance fee was disrupted when the latter was doubled in 2015 (6) . This also upset the balance between the financial loss incurred by patients and by hospitals for missed appointments, since the legislative preparatory work intended that patients and hospitals should face comparable financial incentives to attend appointments on time (see also (7) ).
Lack of legal protection and documented effect
Lack of legal protection and documented effect
Second, the current system does not provide sufficient protection for patients. Because the fee is not regarded as an individual administrative decision under the Public Administration Act, there is no formal right of appeal (8) . Although patients can , in practice, be excused from the fee if valid reasons are presented, this leads to inconsistent practices both within and between hospitals (9) . If the fee had been equivalent to the co-payment charge, the argument for shielding hospitals from the administrative burden of making case-by-case decisions would carry more weight (6) . However, with the fee at its current level, the system is legally untenable with respect to patients' rights.
Since the rate of non-attendance in health care (or anywhere else) will never be zero, it is reasonable to question the rationale behind an ever-increasing non-attendance fee
Last but not least, it is unknown whether the fee effectively reduces patient non-attendance (2) . And just to stir the pot: compared with other countries, missed appointments at Norwegian hospitals is a marginal problem. On average, about 4 % of appointments are missed (2) . While this represents a substantial number of appointments, 96 out of 100 patients still attend as planned. Since the rate of non-attendance in health care (or anywhere else) will never be zero, it is reasonable to question the rationale behind an ever-increasing non-attendance fee. This point is reinforced by the fact that the fee seems to function primarily as a source of revenue for the national budget.
What is the solution?
What is the solution?
One solution is to retain the non-attendance fee but to reduce it significantly. If the fee reflects the co-payment charge, it can be justified as a moderate and symmetrical compensation to the hospital (2) . In addition, formal appeal rights should be established, and patients who could not reasonably have prevented their absence, or who are particularly vulnerable, should be exempt from the fee. This would make the fee a balanced means of compensating hospitals, a fair approach to patients and a clear financial incentive to attend appointments or cancel them in advance.
The manuscript was developed based on my doctoral research project, which was carried out in collaboration with Eli Feiring and Bjørn Hofmann. The project, however, was limited to empirical investigations of the debate on the patient non-attendance fee and how it is perceived by the public, and the conclusions expressed in this manuscript are entirely the author's own.