Ask a pediatric occupational therapist why she left her last job and you will almost never hear "the kids." You will hear a number. Seventy-five percent. Eighty-five. In a few systems, 87.5.
Productivity requirements are the quietest reason good clinicians leave pediatrics, and they are almost never discussed honestly in an interview. So let's do the math out loud.
Key takeaways
- A productivity requirement is the share of your paid hours that must be billable face-to-face time. Most pediatric settings sit between 75% and 90%.
- At 85% on a 40 hour week, you owe 34 billable hours, which leaves roughly six hours for every note, every plan of care, every parent call, and every team meeting.
- Cancellations usually do not count toward your number, so you are held to a target that depends on other people showing up.
- Documentation does not disappear when the math fails. It moves to your evenings.
- The quota is a business model choice, not a law of the field. Models exist without one.
What a productivity requirement actually is
Productivity is the percentage of your paid time that generates a bill. If you are paid for 40 hours and your employer sets an 85% requirement, 34 of those hours have to be direct treatment or evaluation with a child in front of you.
Everything else lives in the leftover 15%. Notes. Plans of care. Progress reports. Insurance authorizations. Phone calls with a parent who is worried about something that happened at preschool. Care coordination with a teacher. Supervision of a student. Your own continuing education. All of it, in six hours.
Some systems are stricter than that and count only billed units, not scheduled time. Others fold in a small documentation allowance and then quietly raise the percentage to make up for it. The label changes. The pressure does not.
The math nobody puts in the offer letter
Here is what 34 billable hours actually requires.
Say you run 45 minute sessions. To bill 34 hours you need roughly 45 sessions a week, or nine a day. Now add the reality that pediatric no-show and late-cancel rates in outpatient settings commonly run 15% to 25%. In most productivity systems, a no-show is not billable and does not count for you. It counts against you.
So to land 45 completed sessions you have to schedule closer to 55. That means your calendar is not built for 40 hours. It is built for the hope of 40 hours, which in practice means you are on site for 45 or more, and any week where families actually show up is a week where you are running.
Then the six hours of non-billable time. Spread across 45 sessions, that is about eight minutes per child for a note, and that assumes zero minutes for authorizations, zero for parent calls, zero for the reevaluation due Friday, and zero for the team meeting your supervisor scheduled at 4pm.
Eight minutes per note is not documentation. It is triage. And it explains the single most common thing pediatric clinicians say about their week: the notes come home.
Why the number keeps climbing
None of this is because someone in an office dislikes clinicians. It is arithmetic running downhill.
Reimbursement per visit has been flat to declining for years while rent, salaries, benefits, and software costs have not been. When revenue per unit stops moving, the only lever an employer controls is units per clinician. A quota is what that lever looks like from the inside.
That is worth understanding, because it tells you something useful. A productivity requirement is not a judgment about your speed. It is a symptom of a business model where the clinic carries fixed overhead and has to fill it. Change the overhead and the quota changes with it.
What it does to your clinical decisions
The scheduling pain is real, but it is not the part that makes people leave. The part that makes people leave is noticing what the number does to their judgment.
You start scheduling the child who is easy to bill over the child who needs a longer parent coaching conversation. You cut the ten minutes at the door with a mom who clearly wanted to ask something, because you have someone waiting. You keep a child on the schedule a few weeks longer than you would have, because your caseload is your number. Or you discharge earlier than you should, because a new referral bills more reliably than a maintenance case.
Most clinicians will not say that out loud. It feels like a character failure. It is not. It is what happens when you take a skilled professional and give them an incentive structure that rewards volume and is blind to everything else that makes the work good.
What to ask before you take the job
You are allowed to ask about this directly, and how a hiring manager answers tells you almost everything.
- What is the productivity expectation, stated as a percentage, and how is it calculated?
- Is documentation time counted as productive, or does it come out of the remaining percentage?
- What happens to my number when a family cancels or no-shows?
- How much of my caseload is expected to be evaluations versus treatment?
- What happens if I miss the target for a month? Is it tied to compensation, review, or continued employment?
- What is the average tenure of a clinician on this team?
A good employer answers these plainly. If the answer is vague, or if you are told not to worry about it because "nobody really hits it anyway," that is your answer. A target nobody hits is a target that becomes leverage the first time someone wants leverage.
What the alternative looks like
The reason productivity quotas exist is fixed overhead. A clinic pays for square footage, front desk staff, and equipment whether or not a child walks in, so it needs your hours to cover that.
Take the building out of the equation and the arithmetic changes. When you see children where they live, there is no waiting room to fill and no lease to defend. The visit does not need to subsidize a fixed cost that has nothing to do with the child.
At Coral Care, there is no productivity requirement. Clinicians set their own caseload size and their own schedule. You are paid per completed session, including for late cancellations inside the window, so a family's Tuesday morning does not become your financial problem. Credentialing, scheduling, billing, and claims follow-up are handled for you, which removes most of the non-billable work that quotas squeeze into your evenings in the first place.
Some clinicians build a full caseload this way. Others carry five or six children alongside a school job and treat it as the part of the week they actually look forward to. Both are fine, because there is no number to hit.
You are not slow
If you have spent a Sunday night finishing notes and wondering whether you are just not efficient enough, sit with the math above for a second.
Eight minutes per note, 55 scheduled hours to reach 40 billable ones, and a target that moves depending on whether a two year old with an ear infection makes it to her appointment. Nobody is efficient enough for that. The number was never designed to be reachable in a 40 hour week. It was designed to make sure the week is full.
You are allowed to want a version of this work where the only thing you are measured on is the quality of your care, not the volume of it.
See what working with Coral Care looks like, or read our honest comparison of Coral Care versus solo private practice if you are weighing going fully independent.
