Scaling state by state, without giving up efficiency.

Hospital Gift Shop delivers flowers, balloons, and patient gifts to hospitals across the US. The account runs state by state, across two very different location types: partner and non-partner hospitals. Each behaves differently, and growth depends on rolling a consistent structure out across dozens of states without efficiency slipping as coverage expands.

• A rebuilt state structure. Campaigns were rebuilt state by state with standardized naming and segmentation, so every state reported the same way and partner and non-partner locations could be read separately.
• Budgets matched to the footprint. Budgets and bids were aligned to each state's footprint instead of spread evenly.
• Test, then scale. Iterative tests on bids, coverage, and query control ran across states. What worked rolled out everywhere, and what didn't was cut.
• Efficiency as the guardrail. CPA and ROAS were the signals that set the pace of expansion.
• Partner locations built from zero. Partner state campaigns launched for the first time and are ramping as they learn.

Account-wide, conversions grew 24.5% and conversion value 23.4% year over year, while CPA fell 2.4% and ROAS rose 1.6%. Non-partner state campaigns drove the story: conversion value up 56.2% and conversions up 50.5%, with ROAS up and CPA effectively flat.

The growth was broad, not lucky. 36 new states launched, 48 state markets recorded spend, and among the original 11 states, 7 grew value, 8 improved ROAS, and 7 lowered CPA. Every region, Midwest, Northeast, South, and West, held roughly 4x ROAS as coverage expanded.