FOLIO 04 · Sub-segment breakdown
Six sub-segments, six different rates
| Sub-segment | In-person rate | Telehealth rate | Notes |
|---|
| Psychotherapy (individual) | 30 to 38% | 12 to 18% | Telehealth shift most complete in this segment. |
| Psychiatry medication management | 28 to 35% | 12 to 16% | Shorter visits, easier telehealth fit. |
| Group therapy | 25 to 32% | 14 to 20% | Social commitment lowers rate even in person. |
| Intensive outpatient (IOP) | 32 to 40% | 18 to 25% | High visit frequency compounds drop-out. |
| Substance use treatment | 35 to 45% | 20 to 28% | Active relapse risk drives elevated rate. |
| Couples and family therapy | 22 to 28% | 12 to 18% | Two-party accountability lowers rate. |
In-person rates anchored to Kruse et al (BMC Health Services Research, 2018) and sub-segment estimates. Telehealth figures are indicative: the no-show reduction from telehealth varies widely by setting and is smallest, and occasionally reversed, in low-broadband and low-digital-access populations (Greenup & Best, BMC Health Services Research 2025).
FOLIO 05 · Why it runs high
Five compounding factors
Mental health no-shows are not the same problem as primary care no-shows. The drivers stack differently and the standard reminder-based interventions do less work. Five factors compound to produce the elevated rate.
- Stigma and ambivalence. Many patients in the first 4 to 6 sessions are still actively deciding whether to engage with treatment. Each session is a re-decision point that does not exist in chronic disease management.
- Symptom-driven avoidance. Depression reduces forward planning. Anxiety increases avoidance behaviour around the source of distress, sometimes including the therapy itself. PTSD and trauma symptoms increase no-shows after sessions that touched difficult material.
- Long booking horizons. The mental health access shortage means many initial appointments are booked 3 to 8 weeks out, sometimes more. Forgetting risk compounds with lead time, and forgetting is among the most commonly cited reasons for missed appointments (Kaplan-Lewis and Percac-Lima 2013).
- Payer mix. Behavioral health serves a higher share of Medicaid and self-pay patients than most medical specialties, importing the structural barriers documented in the Medicaid no-show folio.
- Lack of external accountability. A chronic disease management visit has a clear external referent (the lab result is due, the medication needs renewal). A therapy session is a private commitment that bends more easily under competing pressure.
FOLIO 06 · Telehealth shift
The telehealth shift was the single largest economic lever
Mental health was the most rapid and most durable telehealth adopter post-pandemic. Federal and industry survey data indicate that a majority of behavioral health visits are now delivered via telehealth, with the share highest for established-patient psychotherapy. The economic impact on practices has been substantial.
For a 6-clinician psychotherapy practice running 48 session-hours a day at $175 per session, the pre-pandemic all-in-person book lost roughly 35 percent to no-shows, or 17 sessions a day, $2,975 a day, $654,500 a year. Shifting to 75 percent telehealth at 15 percent no-show and 25 percent in-person at 35 percent residual no-show shifts the math: weighted no-show rate becomes 20 percent, lost sessions 9.6 a day, $1,680 a day, $369,600 a year. Annual recovery: roughly $285,000 from no-show reduction alone, on top of the patient-experience and access benefits.
The regulatory environment supports this. CMS extended telehealth parity for behavioral health indefinitely under the Consolidated Appropriations Act 2023, and most commercial payers have followed suit. Audio-only is permitted for established-patient behavioral health visits without geographic restriction. The unanswered question for 2026 to 2028 is whether the in-person requirement for initial psychiatry visits returns; current CMS rules require an in-person visit within 6 months of starting telehealth psychiatry, with periodic re-establishment.