New research from Clinekt puts a number on the revenue US specialty and primary care practices lose at four points in the patient journey: new patients who never book, referrals that never schedule, visits that never happen, and patients who never come back. The gap averages $107,000 per physician a year, 7.7% of practice revenue.
Revenue base: MGMA median total medical revenue per FTE physician, $1,394,821, the latest public figure.3 Each lever is a chain of sourced and estimated factors; see the method under each one.
Each one is from a named public source, linked at the bottom of the page. The model below uses the conservative end of every range.
None of the four shows up as a line on the P&L. A call that rings out, a referral that sits in a fax queue, a no-show that is never rebooked, and a patient who was told to come back and never did all look the same from the inside: an open slot.
New patients who reach the practice and never book: 2.3% of practice revenue. 29% of healthcare calls go unanswered or to voicemail, and 43% of online bookings happen outside office hours.
How we quantify itReferrals that never schedule: 1.9% of practice revenue. About half of specialty referrals for older adults are never completed; 29 in 100 are never even scheduled.
How we quantify itVisits that never happen: 1.2% of practice revenue. Single-specialty practices miss a median 6.8% of visits; academic specialty clinics miss close to 18%.
How we quantify itPatients who never come back: 2.2% of practice revenue. Follow-ups lapse in every specialty; one pediatric cardiology clinic lost 45.9% of its patients to follow-up.
How we quantify itThe two levers a practice cannot pull are reimbursement and labor cost. The gap in this report is the one it can.
Reaching a practice is still the first place a new patient is lost. Across healthcare, 29% of inbound calls go unanswered or to voicemail, and 36% in specialty care.6 In a 2026 MGMA survey of practice leaders, 36% said more than one call in ten goes unanswered at peak, scheduling is a top-three call reason at 81% of practices, and 70% reported front-office staffing instability.7
Demand does not keep office hours. On Zocdoc, 43% of online bookings happen outside 8am to 5pm, with late-night booking highest in urology and dermatology.8 Across Clinekt's deployments, 82% of patients try to book outside office hours. On the web the leak is quieter: health websites convert about 2.3% of sessions,9 and in Clinekt's experience fewer than 1% of the patients who reach a practice website ever request an appointment.
Invoca platform data across healthcare callers, 2021.6 The model uses the all-healthcare figure, not the higher specialty figure.
Specialty practices live on referrals, and referrals leak. In a study of 6,785 specialty referrals for adults 65 and over, only 71% were ever scheduled, and 70% of those were kept: about half were never completed.10 Primary care physicians report completion of 79% to 83% for referrals overall.11 Between a quarter and half of referring physicians do not know whether the patient was ever seen.12
The referral is the one lead a practice has already paid nothing for, which is why it is the most expensive one to lose. In physical therapy, 60% of patients referred by a health system went to an outside clinic.26 Among health system executives, 96% call leakage a priority and 75% a significant financial obstacle.25
Weiner, Perkins and Callahan, 2010: 71% scheduled, 70% of those kept.10 The model uses 25%, below the study's 50%, because the sample is older adults.
A no-show is the one leak every practice can see, and still the one most practices only charge for. Single-specialty practices report a median no-show rate of 6.8%, and 42% now charge a fee.14 Specialty clinics at academic centers run close to 18%,13,16 and the worldwide average across 105 studies is 23%.15 The one published cost figure, $196 per missed visit, comes from a 2016 study of ten clinics, not from an industry body.13
The slot is not the loss. The loss is the share of missed visits that are never rebooked, because nobody owns the follow-up. This lever counts only those.
Sources 13 to 16. The model uses 10%, close to the practice median and well under the clinic averages.
The quietest leak is the patient who was told to come back and never did: the six-month follow-up, the annual skin exam, the post-op check, the overdue hygiene visit. Unlike a no-show, it never creates a visible opening. In one pediatric cardiology clinic, 45.9% of 8,940 patients were lost to follow-up.17 In glaucoma, a three to four year gap in care roughly doubles the risk of blindness.18
These patients are already in the EHR with a last visit date, a diagnosis, and a return interval. Nobody has to find them. Someone has to reach them, and most practices have no one whose job that is.
A Clinekt estimate anchored to the 45.9% lost-to-follow-up rate in source 17 and set well below it. Of the 30, the model credits recall outreach with bringing back one in eight.
The dollar gap per physician is the same across specialties in this model, because MGMA's specialty revenue figures are not public. What changes is how many visits it takes to fill it, and how many physicians share it.
| Specialty | Active physicians, 20242 | Revenue per visit | Gap per physician, in visits a year | Visits a week | National gap, direct patient care |
|---|---|---|---|---|---|
| Primary carefamily medicine, general practice and internal medicine | 255,124 | $1865 | 577 | 12 | $23.0B |
| Pediatrics | 62,485 | $1695 | 635 | 13 | $5.6B |
| OB/GYN | 44,046 | $2805 | 383 | 8 | $4.0B |
| Cardiologycardiovascular disease, interventional cardiology and electrophysiology | 32,148 | $3355 | 320 | 6 | $2.9B |
| Orthopedicsorthopedic surgery plus orthopedic sports medicine | 23,084 | $4195 | 256 | 5 | $2.1B |
| Ophthalmology | 20,096 | $3075 | 350 | 7 | $1.8B |
| Gastroenterology | 17,219 | $265* | 405 | 8 | $1.6B |
| Dermatology | 13,601 | $2685 | 400 | 8 | $1.2B |
| Urology | 10,910 | $265* | 405 | 8 | $1.0B |
| Otolaryngology | 10,316 | $265* | 405 | 8 | $0.9B |
| Pain medicine | 7,351 | $265* | 405 | 8 | $0.7B |
| Rheumatology | 7,071 | $265* | 405 | 8 | $0.6B |
| Twelve specialties | 503,451 | $45.4B |
Physician counts are AAMC active physicians by specialty for 2024.1,2 The national column applies the AAMC share of active physicians in direct patient care, 83.9%, then multiplies by $107,000. Revenue per visit is the AHRQ MEPS mean expense per office visit by specialty, 2016, the latest all-payer figure;5 rows marked * use the all-visit average of $265. Primary care is family medicine, general practice and internal medicine; the gap there is $23.0B of the total, and $16.7B sits in the ten adult specialties. Dentistry, oral surgery, physical therapy and behavioral health carry the same four leaks but a different revenue base; use the calculator with your own revenue per provider.
Three inputs. The model applies the same four lever shares to your revenue per provider, so a practice that knows its own numbers gets its own answer.
7.7% of revenue in total: 2.3% engage + 1.9% refer + 1.2% keep + 2.2% return. Estimates in the model are set low; see the method under each lever.
The four leaks share one cause: the work happens between visits, outside office hours, and off the schedule. Clinekt's agents do that work autonomously, with no added FTEs, workflows, or anything for the staff to babysit.
Answers every call and every new patient, day or night, and reaches every referral the day it arrives. Engages new patients and autonomously converts them into booked visits.
Meet the Inbound AgentFinds the overdue patients already in the EHR, the follow-ups, annual exams and unscheduled treatment, and brings them back fully autonomously.
Meet the Recall AgentRuns campaigns built on the practice's own patient profile, so the demand that arrives is the demand the practice converts best.
Meet the Outbound AgentConfirms every visit, rebooks every no-show the same day, and follows up between visits so the plan of care finishes.
Meet the Care AgentThe report is a revenue gap model, not a survey. It combines public benchmarks from MGMA, AAMC, AHRQ, CMS and the AMA with peer-reviewed studies of referral completion, no-shows and loss to follow-up, and with what Clinekt has learned across more than one million patient interactions.
Every factor that has no public source is marked as a Clinekt estimate and set on the low side, so the total reads as a floor, not a ceiling. Replace any factor with your own and the arithmetic still holds.
Median total medical revenue per FTE physician, $1,394,821, from MGMA's 2018 data set, the latest figure MGMA has published outside its paid DataDive.3 MGMA reports revenue per FTE physician rose 14.9% from 2020 to 2024 in physician-owned groups,4 so today's base, and the gap, are larger. The calculator accepts your own figure.
Each lever multiplies three or four factors to a share of practice revenue: 01 Engage 2.3%; 02 Refer 1.9%; 03 Keep 1.2%; 04 Return 2.2%; 7.7% in total. Sourced factors cite the study they come from. Estimated factors are chosen below the published range where one exists (25% of referrals never completed against a published 50%; 10% no-shows against a 6.8% practice median and 18.8% clinic mean; 30% not returning on time against 45.9% lost to follow-up).
Scale every estimated factor in the model together and the answer moves with it. Halve them all and the gap is still $54,000 per physician and $23 billion nationally. Raise them all by half and it is $161,000 and $68 billion. The headline is the base case, which already sits below every published range the model draws on.
AAMC active physicians by specialty for 2024,1,2 reduced to the share in direct patient care (83.9%), multiplied by the per-physician gap. Twelve specialties, 503,451 active physicians, 422,545 in direct care. Physician and clinical services are a $1.1 trillion market,24 so the $45 billion gap is about 4% of it.
The gap in visits divides the per-physician dollars by the AHRQ MEPS mean expense per office visit for the specialty, 2016 data.5 In today's dollars each visit is worth more, so the visit counts are generous.
Four Clinekt figures appear in the report and none enter the model: more than one million patient interactions, a 12% average increase in appointment volume, 82% of patients trying to book outside office hours, and Baldwin Bone & Joint's 263 leads, 159 appointments and 60% booking rate in one quarter.
See what the gap costs your practice with the calculator above, or download the report.
The patient engagement gap is the revenue a practice loses between a patient's intent to be seen and a completed visit: new patients who reach the practice and never book, referrals that never schedule, scheduled visits that never happen, and patients who were told to return and never come back. Clinekt's 2026 model puts it at $107,000 per physician a year, 7.7% of practice revenue, and about $45 billion a year across twelve US specialties.
About 29% of healthcare calls go unanswered or reach voicemail, and 36% in specialty care. Counting only the calls from patients trying to schedule, the share the practice never hears from again, and the share that was new-patient revenue, the model puts the loss at 2.3% of practice revenue, or $32.4K per physician a year.
In a study of 6,785 specialty referrals for adults 65 and over, 29% were never scheduled and a further 21% were scheduled but never kept, so about half were never completed. Primary care physicians report overall completion of 79% to 83%. The model uses 25% never completed, below both figures.
Single-specialty medical practices report a median no-show rate of 6.8% (MGMA, 2023 data). Specialty clinics at academic centers run near 18%, and the average across 105 studies worldwide is 23%. The one published cost per missed visit, $196, comes from a 2016 study of ten clinics.
The per-physician gap of $107,000 is multiplied by the number of active US physicians in twelve specialties, reduced to the share in direct patient care. The per-physician gap is 7.7% of MGMA's median total medical revenue per FTE physician, built from four levers whose factors are each sourced or labeled as a Clinekt estimate set on the low side.
A 15 minute walkthrough of the agents that answer, book, recall and follow up, on a website like yours.
