Why is my cost per lead so high?

Cost per lead is a fraction: what you paid, over the leads you counted. It goes wrong on both lines. Three of the four leaks below sit in the top line: clicks paid for that, in our experience, rarely become a patient. The fourth sits in the bottom line: how a lead is counted. Each one shows in your own Google Ads account, with the labels Google uses.

Leak 1The searches your ads actually show for

A keyword is what you bid on. A search is what a person typed. Google's own distinction: "A search term is a word or set of words a person enters when searching on Google or one of our Search Network sites." The two drift apart, and in our experience the drift is where budget goes.

The report that shows it is the search terms report, which "provides insight into the searches that trigger your ads and how those searches are performing." To open it: "Go to Search terms within the Insights and reports sub-menu." Read it for a competitor's name, for "free", "jobs", "salary", "how to become a", and for towns you do not serve. Each of those is a paid click with, in our experience, no patient behind it. Add them as negatives, and read the report again in two weeks; in our experience it refills.

Leak 2A landing page that does not match the ad

The ad makes a promise: a treatment, a price, a city, a question answered. If the page it opens is the home page, or a page about something else, in our experience the person leaves, and the click was paid for either way. Google grades this. Its Quality Score has three parts, two of which are about the match: "Ad relevance: How closely your ad matches the intent behind a user's search." and "Landing page experience: How relevant and useful your landing page is to people who click your ad." Google is careful to call the score "a diagnostic tool meant to give you a sense of how well your ad quality compares to other advertisers", and says "Quality Score is not an input in the ad auction." Each status is based on "a comparison with other advertisers whose ads showed for the exact same search over the last 90 days" (Google's Ad Rank page says the auction's quality side can include its own auction-time measurements of the same things, and that higher quality ads can often lead to lower CPCs; the third question below quotes it). Our reading: a "Below average" on landing page experience is a prompt to look at the match between the ad and the page, not a dial to turn.

The fix is one page per promise, with the thing the ad said in the first screen and a way to book that works on a phone. It is slower than changing a bid, and in our experience it is where the cost per lead on a clinic account is decided.

Leak 3Calls nobody answers

In our experience this is the one that is easiest to skip. Google's call reporting explains what you are paying for: "A customer taps your ad to call you. You're charged for a click, which is the same CPC as if the customer were clicking on an ad that goes to your website." A call that rings out costs the same as a call that books.

With call reporting on, Google's forwarding number lets you "track details like call duration, call start time" and "whether the call was connected", and Google's conversion measurement page says you can "check the "Call Details" report to view individual call durations." Read those details for a month: how many calls were not connected, how many ended inside a minute, and what time of day they came. The fix is the phone, not the ads: who answers, what happens after hours, and how fast a missed call is returned.

Leak 4Counting the wrong thing as a lead

Google counts whatever you tell it to count: "You choose what you identify as valuable, like a purchase, sign-up, or phone call, and Google Ads will then help you get the most out of your campaigns." With call reporting it will "count phone calls of a specified duration as conversions", and it lets you "adjust the "minimum call length" threshold".

So a cost per lead can look fine because the definition is loose. Count every 15-second call and every form fill and the number is cheap on paper, whatever the calendar shows. Count booked consultations and the number rises; in our view that is the version worth managing. Make the definition something worth money, write it down, and compare months on that definition only. The same point sits in what to ask a marketing agency before you hire them, question 7.

The number itselfWhat a cost per lead should be

Not an industry average. The cost per lead you can afford comes from what a patient is worth to you over time and how many of your leads become patients. Our ad spend calculator works that out from your own figures, and our ad benchmarks page gives sourced ranges by category for a sense of scale. Compare your account with your own number first.

This weekFour checks, in this order

Open the search terms report and add the obvious negatives. Open the top three landing pages on your phone and read them as the ad promised them. Open your call reporting data and count the calls that were not connected and the short ones (the Call Details report lists each call's duration). Then write down what a lead is, and recount last month on that definition. If your agency runs the account, ask for all four in writing; how to tell whether they are doing anything is the companion to this page.

Sources, read 2 and 3 October 2026, Pacific time: Google Ads Help, About the search terms report; About Quality Score for Search campaigns; About call reporting; About conversion measurement; About Ad Rank. Sentences and labels are quoted as the pages read on those dates; Google changes them without notice, so check the live page before you click.