Things I Didn't Learn in School: The Numbers Game

An important skill to have if you want to do therapy for a living is getting clients to show up. As I discussed in a previous post, most salaried positions require a minimum number of "billable hours" per week (usually around 65% of the total hours worked), and both fee-for-service jobs and private practice only pay for billable hours. For all of us, there is a definite incentive to get clients in the door!

How hard that is depends in part on the population. With privately-insured populations, you or your agency may bill the client for no-shows or late cancellations (i.e., less than 24 hours notice). That puts some of the financial risk and incentive on the client - sharing the financial burden of no-shows. Of course, it's important to check the provider contract to make sure there isn't a clause barring this practice, and remember to bill the client rather than the insurance company (which won't pay for a service that wasn't provided!)

However, Medicaid does not allow its clients to be billed for no-shows. And since policies have to be applied uniformly to avoid discrimination, that means practices who treat anyone with Medicaid insurance can't bill any of their clients for no-shows. Except for private practices and very affluent communities, the majority of clinics fall into this category. Furthermore, clients dealing with poverty may face difficulty arranging reliable transportation, childcare, and phone service - all of which can interfere with attendance. 

The end result, at least where I work, is an average show-rate around 70%. If the productivity requirement is 65%, that means you have to have someone scheduled every hour just to meet the minimum! There go those bonuses, or that pay differential for fee-for-service staff, right? Not necessarily!

First, there are things you can do to get your show-rate up. Start by communicating to clients that you're reserving a time just for them, so it's important for them to be there, or cancel so that someone else can have the time. Reminders help - appointment cards, phone calls, postcards. So does a prompt follow-up by phone (or failing that, letter) to find out what happened and reschedule when someone no-shows. 

Then, you can hedge your bets by scheduling more people. Since a "billable hour" is really 45-50 minutes, you can schedule using 45-minute increments. That adds up to 10 clients in an 8 hour shift, with 30 minutes for lunch.

Those who are more daring can consider overlapping sessions - a form of double-booking. You would schedule the second session for around 15 minutes sooner than the first session would end, with subsequent sessions starting the full session length after than second session. So, for example, using 45 minute sessions: 9:00, 9:30, 10:15, 11:00.... Or using 60 minute sessions: 9:00, 9:45, 10:45, 11:45. Using this system, clients wait no more than 15 minutes (and only if everyone before them shows up, so it's best to schedule frequent no-showers early in the day), but you lose no more than 30 of 45, or 45 of 60 minutes.

It's important to think about your goals - both for productivity/income AND keeping your job manageable. It's possible to err on either side - too little productivity makes it hard to pay the bills, but too much can quickly become overwhelming, and make you less effective as a therapist!