Diagnosis

RX 02 · JUL 10 '25 · 12 LOCATIONS · SPECIMEN · FROM BASELINE 247-B

CONFIDENTIAL · RX 02FORM 247-D

Bottleneck. Theory of constraint. The smallest set of changes that moves the multiple — ranked by leverage, not effort. If we hadn't found them, this document would say so, and we would leave. Engagement scope, if any, is quoted from this document and nothing else.

PRESENTING COMPLAINT — IN THE OWNER'S WORDS, AT INTAKE

"Growth has flattened at twelve locations. Marketing spend is up 22% year over year, new patients are flat, and the board no longer trusts the marketing slide. We are two years from a process we'd like to run with a banker."

FINDINGS SUMMARY — PULLED FROM BASELINE READING (FORM 247-B, DAY 0)
VITALDAY-0 READINGCONFIDENCEREADS AS
New patients / mo213HIGHflat — demand reaching phones grew 11% YoY
Collections / mo$1.03MHIGHsteady · 79.8% of gross production
NP acquisition cost, fully loaded$246MODERATE2.1× the board decks · no industry figure to compare it to
Attribution coverage2 of 12 channelsHIGHspend is steered blind
Answer rate, per desk78% · 68–96% rangeHIGHdesk variance exceeds channel variance
Booking rate, per desk35% · 20–44% rangeMODERATEsame pattern, same desks
Case acceptance43%MODERATEbelow average — but volume presented is what's short
Broken appts — no-show + late cancel22.4%LOWreal; the instrument needs a clean quarter first

FULL METHODS AND FLAGS IN THE BASELINE READING. NOTHING IN THIS DOCUMENT USES A NUMBER THAT DOCUMENT CANNOT DEFEND.

THE CONSTRAINT — SINGULAR, BY POLICY

The system's binding constraint is intake: demand already paid for is lost between the ring and the booking, so every dollar added above the leak buys less than the last one.

Theory of constraint: until the bottom-half desks answer and book at the top desk's demonstrated rate — a rate this network already achieves at North-04 — added acquisition spend subsidizes the leak. Attribution blindness is real but subordinate: it hides the leak, it does not cause it. One constraint is named because a diagnosis with two constraints is a to-do list.

THE SMALLEST SET OF CHANGES THAT MOVES THE MULTIPLE — RANKED BY LEVERAGE, NOT EFFORT

CHANGELEVERAGE (I×C÷E)EXPECTED MOVEMENTCOST / MOSEQRX
Instrument every desk on the intake rubric; weekly readout reviewed with the people who took the calls51.2booking 35% → 43%+ in 90 days (~30 NP/mo)$4K1Rx 03
Overflow + after-hours routing to staffed desks; coverage for the two known lunch gaps35.3answer rate 78% → 90%+ (~22 NP/mo now to voicemail)$6K2Rx 03
Attribution build-out: 2 → 10+ channels traceable click-to-chair32.2no direct NP gain — carries the pool that makes № 4 safe$5K3Rx 02/04
Reallocate spend by loaded cost per NP, per channel; zero-spend the untraceable bottom third27.6loaded cost / NP $246 → ~$210 at flat volume$0 net4Rx 01
Broken-appointment repair: one status definition across 12 locations, then reminder-cadence pilot13.6honest read first; movement priced after a clean quarter$1K5Rx 03/04

LEVERAGE = 12-MO MARGIN IMPACT ($K) × CONFIDENCE (0–1) ÷ EFFORT (INTERNAL DISRUPTION 1–5). RUBRIC: DIAGNOSIS-SOP.MD. MARGIN IMPACT, IN ORDER: $128K · $94K · $92K · $92K · $34K — ALL DERIVED FROM THIS GROUP'S OWN 90-DAY COLLECTED VALUE PER NEW PATIENT ($574) AT ITS OWN 62% CONTRIBUTION MARGIN, NOT FROM AN INDUSTRY FIGURE. CHANGES 3 AND 4 SHARE ONE $92K POOL — 3 AT ENABLER CONFIDENCE, 4 AT RESIDUAL; THEY ARE NOT ADDITIVE.

Diagnosis — the conversation

GO / NO-GO · BOTH OUTCOMES DESIGNED · SPECIMEN

CONFIDENTIAL · RX 02FORM 247-D

Two paths, written with equal care. The no-go is not a failure state — it is the outcome that proves the go means something. Your call, made with the numbers in front of you.

PATH A — GO · OPERATE (RX 03)

  • Scope: the five changes overleaf, in sequence — nothing else. Quoted fixed from this document; the quote does not float with what we find later.
  • Cadence: weekly readings (Form 247-R), monthly reviews with finance in the room, quarterly recommitment with the same data we'd use to end it.
  • Retest at month 6 (Rx 04): same instruments, same three locations, same finance team in the room. The numbers either moved or they didn't.
  • Success, priced: changes 1–2 alone model to ~50 NP/mo at ~$360K/yr incremental collections against ~$120K/yr program cost. Total collections will move by a small single-digit percentage, not by the new-patient percentage — new patients are a minority of an established group's production, and any report claiming otherwise is not measuring what it says it is.
  • What this will also cost you, forecast now: the patients this buys are less established and more insured than the ones already on your books. Expect case acceptance to fall 2–4 points, FFS/cash mix to fall 1–3 points, the 4100 write-down line to rise, and 90-day production per new patient to fall 3–6%. Payback lengthens before it shortens. These are not risks — they are the mechanism, and they will appear in your board pack as regressions with our name on them.
  • What would make us wrong in your favour: nothing. If a monthly pack ever shows every vital moving your way at once, treat it as a measurement defect and call us on it.

If the numbers don't move by retest, the quarterly review will say so in our handwriting before you have to ask.

PATH B — NO-GO · WE SAY SO AND WE LEAVE

  • When this path is right: the constraint is one we cannot move (capacity, clinical staffing, ownership decisions outside marketing's reach), or the model doesn't clear your hurdle rate. Then the honest prescription is: don't hire us.
  • You keep everything — baseline reading, instrumentation in your name, rubric, frozen definitions, this diagnosis. That was the deal (FAQ Q.10).
  • We put the no-go in writing with the reason stated plainly, so your next partner — or your own team — starts from the reading, not from zero.
  • No exit fee, no "lite" retainer, no keeping a hook in. The engagement concludes at the fixed fee already paid.

A no-go delivered well is the cheapest decision this document can hand you. We have written them before and will again.

RECOMMENDATION — STATED, NOT HEDGED

GO ☒NO-GO ☐  The constraint is movable, the network's own best desk proves the target rate is achievable in this payer mix, and the model clears the hurdle at conservative confidence. We recommend Path A, sequence as ranked. If change № 1 hasn't moved booking rate by day 90, treat that as the retest come early — and reread Path B.

WHAT WE WILL NOT DO — STRUCK BY POLICY, NOT BY OVERSIGHT

Anything on this list that a future vendor proposes should be asked to show the constraint it moves.

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DIAGNOSING PARTNER, ADMEN

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REVIEW GATE — SECOND PARTNER, PRE-DELIVERY

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DECISION — CLIENT CFO / OWNER · GO / NO-GO · DATE