ROBIN HESS, A COLLEGE LIBRARIAN in Champaign, Ill., used to have a method for remembering one of her annual medical screenings she d schedule it near Valentine s Day. I d joke I had a hot date with the doctor, Hess says, laughing. But she hasn t needed to do that since 2009, when something new began reminding her robocalls from the doctor s office.

Shortly before she turned 50, Hess says, she received a polite, prerecorded message reminding her to call her doctor to schedule a colonoscopy, which is recommended every 10 years for women age 50 and up. The message kept showing up once a week until she scheduled an appointment; even after she d lain down on an exam table and had the procedure, she got yet another call and had to phone an 800 number to ask for them to stop. She s since gotten similar nudges reminding her about a physical and two Pap smears. It s the birthday gift, Hess says, that just keeps giving.

It used to be telemarketers and fund-raisers who interrupted your dinner with a phone call; these days, for a growing number of consumers, it s just as likely to be the doctor. Experts say physicians are increasingly scooping up services that pester patients via text message, snail mail and everything in between. Indeed, it s a phenomenon that s pervading the health care industry: Pharmacies aren t afraid to put out a robocall or three to keep patients from ignoring refills, and patients skipping dental treatments get the pestering treatment too. Even social networks are part of the full-court press: Although no hard numbers exist, so many doctors and medical practices are signing up for Facebook and Twitter that no less than the vaunted Mayo Clinic recently created a Center for Social Media to train docs. Already, such poking and prodding is far more common than most patients would imagine in their wildest laughing-gas dreams. Phytel, the firm that put out the calls to Hess, estimates it will make between 25 million and 30 million calls to U.S. patients in 2011 a sevenfold increase since 2007.

It s no wonder the medical profession is suddenly trying so hard. Since the recession, many large practices have seen their revenue decrease as patients stay away in droves. Research firm Thomson Reuters says that in every month of 2010 so far, the number of visits at doctors offices declined compared with 2009, a trend analysts say is unprecedented. And many of the patients cutting back are the very ones who usually frequent the exam table. The dip in demand for care is dragging on longer than many analysts expected, and health care reform has only heightened the medical industry s sense of uncertainty. The fact that at least 10 million Americans now have high-deductible health-insurance plans a great motive to think twice before going under the knife doesn t help. Doctors are calling me, totally panicked that this is permanent, says Judy Bee, a medical-practice consultant in San Diego.

In such a fevered environment, experts say, some doctors and pharmacies could be using reminders to gin up extra business, whether patients need the care or not. Harlan Krumholz, a Yale cardiologist, says he s been in meetings where doctors reported funneling more people through screenings to increase revenue for their hospital. With more doctors now working in practices owned by larger health systems, that sort of thing could become more common. Pat Palmer, founder of the Medical Billing Advocates of America, a group that helps patients with medical debt, says 2010 was one of the worst years I ve seen of doctors overcharging and dreaming up new revenue streams. She s been in the business for 15 years.

Of course, not all efforts to reach out and touch patients are money driven. Many doctors argue that reminding patients about preventive care can keep them healthier and avoid expensive complications later. (Screening Hess for colon cancer, the idea goes, is a whole lot cheaper than treating her for it.) But critics see some care crossing the line into becoming unnecessary or potentially harmful for example, full body scans with high levels of radiation. What s more, getting a nudge from a physician is far different from getting a plea from a telemarketer or the Republican Party s phone bank. Few consumers of the generation used to following doctor s orders feel comfortable questioning their physician. Critics say that makes those needling reminder calls feel like a particularly pernicious brand of hard sell. You don t ignore a doctor s recommendation, explains Jennifer Jaff, founder of Advocacy for Patients with Chronic Illness, unless you re prepared to find another doctor.

UNTIL RECENTLY, MOST DOCTORS DIDN T have the technology to nag consumers. Five out of six physicians were still using paper files in 2008. That meant something as simple as producing a list of all the diabetics under their care much less the ones overdue for screenings would have involved a dissertation-style research effort, with next to no compensation from insurers for the work. But that began to change in 2009, when the federal government provided $20 billion in subsidies to offices that converted to electronic files. Soon companies like Phytel, Callpointe and Intuit Health saw an uptick in sales of software that sifted through patient data, generating calls and e-mails when consumers failed to get recommended care. Practices using the technology claimed it made a huge difference. At Kaiser Permanente, a health care provider treating 8.6 million, patients who neglect to get screened for colon cancer are sent at-home test kits and then robocalled, phoned and sometimes e-mailed if they fail to return it. One recent study found the robocalls alone increased screening rates by 30 percent.

The problem, of course, is that not all patients want to be repeatedly reminded about what s good for them. In the past five years, the number of Americans with high-deductible insurance has more than tripled, making patients more budget-conscious. And aging baby boomers, arguably those needing attention most, don t necessarily want to hear about uncomfortable stuff like colonoscopies and mammograms, even if they can save lives. (About a third of Americans are afraid of going to just the dentist.) But that doesn t deter medical offices from putting out calls at dinnertime. That some people get annoyed, says Theodore Levin, who leads Kaiser Permanente s colorectal-screening program, is probably the cost of doing business.

The effort to capture patients attention extends far beyond preventive medicine specialists have had to get creative too. In Darien, Conn., Michael Marks and the 13 other doctors at his practice, Coastal Orthopaedics, advertised for the first time recently; they papered a local train station to promote a new extended-hours office they opened. The doctors also wooed athletic trainers at local high schools, offering a dedicated phone line and guaranteed appointments within 24 hours for any injured mini Venus Williamses or Peyton Mannings on their teams. In February the practice even started putting out a glossy magazine, Coastal Connection; a recent article described how to tell if your child has nursemaid s elbow, a subtle dislocation of the joint. We hoped people would see that and say, I guess those guys really do treat children! Marks says.

For some doctors, the reminder effort can help attract customers like Nancy DeMars, a 46-year-old former college financial-aid officer in the San Diego area. As one of the 1,100-plus fans of the La Jolla Cosmetic Surgery Centre on Facebook, DeMars gets alerts as often as two or three times a day from the office, showing pictures of successful patients or news stories on the latest cosmetic treatments approved by the Food and Drug Administration. The office also fills DeMars s e-mail in-box regularly with newsletters put out by the aptly named marketing firm Constant Contact. Coupons the center has sent her for discounts on procedures like Botox or Fraxel skin resurfacing have practically dictated when she s gotten treatments or had them refreshed. DeMars says she s spent close to $13,000 at the office since the social networking picked up: When I see the deals, I really want to just pounce on them.

Doctors have another motivation for their outreach jag: an abundance of no-shows. Elizabeth Woodcock, a practice-management consultant in Atlanta, estimates that among doctors she works with, about one in 10 patients is canceling or missing appointments these days, double the rate before the recession. Because of that, many practices have created call-in-case-of-cancellation lists they run down when patients don t show up, trying to find someone available to come in. Patients known for having empty schedules the funemployed, if you will sometimes get preemptive calls asking if they want to bump up to an earlier slot. Texting appointment reminders or tweeting about cancellations? That happens too, says Woodcock.

Not all the extra attention concerns the patients physical well-being: Some people say practices are hassling them for nitty-gritty details about their financial lives and insurance plans. Many families are getting more questions from doctors offices about whether they ve exhausted their deductibles, since offices often lose money if they haven t checked with insurers first. And taking a cue from hospitals, a growing number of doctors and billing contractors are using SearchAmerica, a division of Experian, to comb through patients credit scores and financial histories to determine the likelihood they ll pay their medical bill. Land on a list of those who don t pay promptly, says Daniel Johnson, president of SearchAmerica, and it s likely you ll get a preclearance phone call. That s when practices tell a patient an estimate of how much she ll owe out-of-pocket, and then ask how exactly she plans on paying for it.

SOME OF THE NEWEST ROBOCALL campaigns owe their existence to health care reform and Uncle Sam. In 2011, Medicare will begin several pilot programs to reward primary-care doctors when they reach important quality metrics like giving all their patients recommended preventive care. At least 6,000 primary-care doctors nationally have already begun transitioning to a model called the medical home, which involves computerizing all their records and using support staff to more closely monitor whether patients are filling prescriptions, following up with specialists and getting tests. That puts lazy, forgetful or too-busy-to-go-to-the-doctor patients squarely in many offices crosshairs. You ve got to find a way to get those disengaged patients to come in if you want to succeed financially, says Steven Schelhammer, CEO of Phytel.

Of course, a disengaged patient can simply be somebody who s putting off care for a good reason, but not all those folks are spared the headaches of the phone tree. Some large drugstore chains are particularly persistent. When Annette Licitra, a 53-year-old writer in Alexandria, Va., was still getting her prescriptions filled at CVS pharmacy, she got regular messages on her home answering machine urging her to call in about refills. It was all a bit confusing, since the drugs were never referred to by name, and she often still had plenty of pills. So she had to do something few busy professionals want to do: make several trips to the store to plead with the pharmacist to cut down some of the calls, which were often about allergy and asthma remedies she didn t need to refill regularly anyway. All those messages would ve been pretty embarrassing if I d had any roommates! says Licitra, who has since moved her prescriptions elsewhere.

CVS says patients can opt out of its refill program by calling a national 800 number; the company says it began the call program because industry studies show patients with chronic conditions fail to take their medications properly half the time. Jaff, the patient advocate, says she s seen more egregious pressure tactics from specialty pharmacies or home-nursing services that regularly deliver supplies like IVs to patients homes. The first day insurance will pay for the supplies, they re pounding on your door, says Jaff, who herself has a stockpile of medications because of such overeagerness.

With the reminders catching on more widely, it can be hard to tell where medical watchdogging stops and good old-fashioned business-building begins. Patients of Gregory Oliver, a family-practice physician in Indianapolis, have pretty much seen every tactic short of camping out on their front lawns. When any of his 32,000 active patients are due for a screening, a robocall goes out asking them to phone the office. When they get there, a neon-yellow sign glued to the back of each exam-room door reminds them of some of the treatments Oliver offers in-house, like cortisone joint injections and wart removal. The rooms boast clear plastic shelves displaying nutritional supplements Oliver sells and fire-engine red postcards with the URL for the weight-loss clinic he started when the economic downturn began. One recent afternoon, Oliver stood in a sports jacket in an exam room and promoted another of his ventures: an in-house dispensary (read pharmacy). If you fill that with us, Oliver told a patient he d just prescribed a diet aid, you ll probably save a few bucks on the price!

That sounds a bit reminiscent of Martha Stewart, who s never shied away from promoting one arm of her business through another. But self-promoters have their fans. Brownell Payne, a 50-year-old optician, says he loves that Oliver s office calls him to remind him, his wife and his three kids of all the various treatments they need. The guy s like Johnny-on-the-spot, Payne says. If you forget something, he ll find you.

WHY THE DOCTOR S OFFICE LOOKS DIFFERENT

With patient visits at traditional practices down for the first time in years, doctors are scrambling to find other ways to keep their revenue up and their businesses viable.

GOING CONCIERGE At concierge practices, patients pay annual dues typically at least $1,500 for better access to their primary-care doctors. In the past five years, the number of such practices has grown tenfold, reaching 5,000 physicians in 2009. Same-day or next-day appointments typically are guaranteed, along with 30-minute visits and the ability to call or e-mail the doctor directly.

Patients unwilling to pay the fees, however, complain that the arrangement leaves them in the cold. It s especially awkward at practices that have both concierge and regular patients. At Pacific Heart Institute in Santa Monica, Calif., doctors sent out a letter to all their clients saying that those who paid up would be given priority in obtaining access to services like in-office pacemaker follow-ups and lab tests. Richard Wright, president of the institute, says patients paying extra get better access to the doctors, not better care.

SELLING OUT TO THE HOSPITAL Since the recession began, many doctors have sold their medical practices to hospitals or larger health systems. While that can result in better coordination between primary-care doctors and specialists, many patients fume about another change: the new fees it adds to their medical bills. Pat Palmer, founder of Medical Billing Advocates of America, a group that helps consumers with medical debt, says many hospitals have all their doctors add fees ranging from $25 to several hundred dollars a visit to cover administrative costs. It s like taking your regular co-pay for seeing the doctor, she says, and doubling it.
Some consumers can get administrative charges like these retracted by disputing them. Advocates say that patients seeing doctors who are part of a larger system should also ask for multiple referrals, since hospital prices for some tests and procedures can be double the rate at private offices.

WORKING OVERTIME According to the American Academy of Family Physicians, more than one in three primary-care doctors now sees patients after hours, a figure experts say has surged among all specialties in the past 12 to 18 months. There s a growing realization that if you re working the 9 a.m. to 4 p.m. shift with a big fat break for lunch, says Judy Bee, a San Diego medical consultant, you re just not going to attract people worried about their jobs. Many offices now are open as early as 7 a.m. on some days, and as late as 8 p.m. on others.