Episode 160: Overcoming Financial Obstacles in Private Practice [featuring Michael Fulwiler]

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Transcript

PATRICK CASALE: Hey, everyone. You're listening to another episode of the All Things Private Practice podcast. I'm your host, Patrick Casale. I'm joined today by a repeat guest and friend, Michael Fulwiler. He's the Director of Brand at Heard, the financial back office for therapists, and the host of Heard Business School and new show for therapists building their own businesses. Also, the creator of Therapy Marketer, a popular newsletter for therapists. And was previously the Chief Marketing Officer at the Gottman Institute.

Michael, it's good to have you on. We're going to talk a little bit today about a pretty extensive, and well-researched, and detailed financial report that Heard ran on analytics in terms of the financial forecast for private practice owners, and kind of do some deep diving into what we think is happening behind the scenes.

So, thanks for coming on. Did I miss anything on your bio? And tell us a little bit about why this report feels really significant for the private practice world.

MICHAEL FULWILER: Bio is great. Thanks, Patrick, for inviting me back on the show. This report is the output of a national survey that we conducted. It's actually the second year that Heard has done this report.

Two years ago, we surveyed therapists nationwide. And was the first time that we did it. And I thought it would be cool if 100 therapists responded because I didn't know if, you know, therapists would be open to the idea of responding to a survey about their finances. We had 1200 responses who we surveyed, which was pretty amazing. And I think just like a really great indicator and signal that therapists are interested in this type of information, which isn't generally publicly available, right? Like, what's the average profit for a therapy practice by state? How much are, you know, therapists making from insurance companies? And, like, which insurance company pays the most? Like, those kinds of questions were things that we were really interested in.

So, we did this report two years ago for the first time. We decided to do it again. This past year. We had 2268 responses to our survey, which was up 87% year over year, which was, you know, really exciting and really a representative sample of therapists across the country. We had responses from all 50 states, including Washington DC social workers, psychologists, mental health counselors. So, really a wide range and some pretty interesting data.

PATRICK CASALE: Yeah, and I think when we're talking about money and therapy, they don't seem to always go hand in hand, especially, in terms of comfortability about talking about this stuff, which is always fascinating to me, especially, when we're talking about private practice ownership opposed to community mental health therapy. Because I'm like, "Well, if we're in private practice, we have to treat our business like a business."

And I know how uncomfortable it is for so many of you that are listening to talk about money, to raise your fees, to talk about rate increases, to reinforce certain policies and procedures. And I understand it's very nuanced. It's not just black and white.

So, what is some of the stuff that really stood out to you guys when you kind of took these reports and took a look at them. Like, what are some of the main points that were like, "Oh, that's pretty eliminating."

MICHAEL FULWILER: Something that stood out to me was 89% of therapy practice, and I should clarify, these are private practice owners. So, 89% of private practice owners that we surveyed reported that they made less than $100,000 in profit. So, that's income after expenses. I think there's this like conception that therapists make a lot of money, you know? Which you look at therapists [INDISCERNIBLE 00:04:57]. There's general public, maybe not therapists, but people think, wow, like therapists must just be rolling in the dough. They're charging 150, 200, $250 a session.

But in reality, of the therapists that we surveyed, at least, and again, that's over 2000 therapy practice owners only 10% are making six figures after expenses. And that number was actually down year over year. So, that was 2023 financial information, if we look back to 2022. So, when we surveyed two years ago, 65% of therapists made less than six figures. So, this percentage of therapists that we surveyed, you know, year over year went down in terms of their profit, which, I think, is interesting.

A takeaway for me, or how I interpret that data is that expenses are up for a lot of therapists. We also asked year over year, like, have your expenses gone up? And over 50% of therapists said yes. Yeah, when we asked therapists that they have raised their fees to keep up with inflation, and, you know, rising interest rates, only 33% of therapists actually raised their fees. So, it's just math, right? Like, if your expenses are going up, but your fees aren't going up, your profit is going down.

PATRICK CASALE: Yep, yeah, it's a fascinating paradigm because you would think to keep up the cost of inflation, and market costs, and just cost of living, that's why so many therapists, and I imagine a lot of you listening have fee increase verbiage in your informed consent, annual fee increase verbiage, but how many of you actually increase your fees? How many of you get to November, December, and you think, "I don't know if I can go up this $10 an hour. I feel like my clients aren't able to make that work for them."

I also think we're seeing a large number of tech companies, and marketing companies, and online platforms come into the field. So, that's kind of impacting where clients are ending up in terms of landing spots for therapy. So, there are all these things that you have to combat.

But a lot of this is when I say cultural, I mean cultural professionally where the profession in itself I bet if you polled, I don't know if this was a question you asked, but might be one to ask next time and include is like, how many of you have business training? And I imagine that the percentage would be quite low, maybe like less than 10%.

So, helpers in the industry of, like, relational work, and support, and holding space, but with very little business acumen and very little understanding of how to keep the lights on besides, like, "I know I just see X amount of clients a week and that's just how it goes. And I don't know how to really, like, track consistent income. I don't know how to plan for the future. I don't know how to, like, plan for PTO." All of these things that go into running a business. And really, you know, getting out of the black, so to speak, and definitely avoiding the red.

MICHAEL FULWILER: Definitely, yeah. And there's the emotional component of it as well, right? Like, I think it's easy to think about, like, the practicality of my expenses are going up. I need to increase my fees to maintain my profit margins. But when you're talking about clients who are people, who, you know, they may not be able to afford if you increase your rate. So, whether that's reality or not, maybe there's a little bit of a scarcity mindset there, of like, if I increase my fees by $10 or $20 I'm going to lose all my clients. When, in reality, that probably isn't the case, maybe in some cases. But I think there's that as well, which just adds to the nuance and difficulty of it.

So, you know, I don't want to shame anyone for feeling, you know, worried or scared about raising their fees. And when you think about it as a business it just makes sense, right? And it's something that, you know, if you don't do you're going to, essentially, be taking a pay cut.

PATRICK CASALE: Yeah, and you know, I think about what you're saying is absolutely correct. Like, you know, it's the industry of relational work. You're working with people. There's a power dynamic. Ultimately, we've been kind of conditioned in graduate school and community mental health jobs, and even in itself, that you don't get into this field to make money, you're not going to profit, you can't help people and be profitable at the same time, which is just utter bullshit.

But like, that's a really deeply entrenched belief. So, it's really hard to unpack that without feeling guilt, and shame, and shying away from these conversations because…

And again, you mentioned like which insurance companies pay the most? Insurance companies have a situation where they have created so much fear in conversation around rate setting so that nobody knows what anyone else is being paid and nobody even knows how much their CPT codes are going to pay them before they even sign the contract. A lot of the time, you don't even have the fee schedule until after you sign the contract. And that creates this dynamic of like, I really can't talk about the money. Like, you know, this is taboo which is unfortunate because it really does keep the profession playing a bit small in a way because the profession is so valuable for society in itself.

And I think when you start to examine this stuff and like, start to unpack this stuff, it does allow you to have a different lens and perspective when you're thinking about your day-to-day, operations, your month-to-month, your year-to-year. And starting to think about, like, what are some of the goals that I have for myself as a small business owner?

And I think that's really important to examine as well because otherwise, you're kind of just, like, going through the motions without a plan of action, and just, like, throwing stuff against the wall and seeing what sticks.

MICHAEL FULWILER: Definitely. And when it comes to insurance it's by design, right? My understanding is that when you get credentialed with an insurance company, it's part of the contract that you sign that you're actually not supposed to talk about what your reimbursement rates are. Like, there's an NDA that you sign, which, I think, that's bullshit, right? Like, it should be information, and you should be able to make an informed decision about who you want to be paneled with.

That was another, you know, takeaway from this report for me, as well, as we asked therapists, do you take insurance? Like, my anecdotal sense is that more therapists are going cash pay, but actually, the majority of therapists still take some form of insurance. 73% of therapists that we surveyed take some form of insurance. And therapists who take insurance are making less than therapists who are out of network, which is not surprising. The average reimbursement rate across the board, and you know, this probably is skewed higher from therapists who are in California and New York and in cities. But the average insurance reimbursement rate of therapists surveyed was $122 per session, which is 25% less than the average cash pay rate, which was $157.

So, on average, you know, if you're taking insurance, you're making like at least 25% less than if you were, you know, out of network.

PATRICK CASALE: Yeah, it's wild, right? And I'm just thinking about that number and that seems pretty on the nose, you know, being in North Carolina.

I went to book a massage for my wife the other day, and like, an 80-minute massage was like $140. So, like, when we're talking about 60-minute therapy sessions getting reimbursed at like, I don't know, $120 with all the education that goes into the licensure process, the supervision, the student loan debt, the importance of it, the fact that you only have so much capacity to see so many clients in a week as a solo practitioner. And it's just amazing how these rates can really prohibit us from staying in the profession long-term.

And we see such an intense level of burnout for a lot of reasons, not just money, but money plays a role. And it does lead to this almost shameful exodus from the profession because so many people are like, "I just can't do this. Like, I love the work, but I can't do this because it's not sustainable for me financially. I can't even pay my freaking bills, and I have a master's or a PhD." And I hear so many unfortunate stories of just people feeling like failures or like I should never have gotten this degree. I shouldn't have pursued this because this career path doesn't feel viable for me anymore.

MICHAEL FULWILER: And going back to raising your fees, with insurance it's a little bit more difficult, right? Like, you can go to an insurance company and try to renegotiate higher rates, but if you're not raising your rates, your cash pay rates, the only way to make more money, if you're doing one-on-one therapy is to see more clients, right? So, you're either charging more or you're seeing more clients. Like, those are the two ways that you can make more money. And if you're not raising your rates and you're seeing more clients that's a path to burnout.

PATRICK CASALE: Yeah, you're exactly right. It's a catch-22, right? Like, it's like, do I see more clients and overextend myself? Do I raise my rates and do I struggle with that whole process?

And like you said, the mentality of like, if I raise my rates $10, $20, and it does not have to be for existing clients. Like, that's what I want people to hear right now, is like, it does not have to be a black and white process. It can be, you know what? I'm going to give my current clients six months for my rate increase. And I'm going to give them as much preparation as possible. Some of them may be able to do it. Some of them may not. Those who may not do I keep them on on a sliding scale. Do I do I get flexible. That's the beauty of being your own business owner. But then you can say, going forward, for any new clients my rates are going to increase to this.

So, you can get a little bit more comfortable without having to completely dive into the deep end in terms of just doing a blanket, like, overhaul. And for some of those of you who are listening, that may be the more comfortable scenario instead of saying, "I'm just doing this practice-wide."

I think practice-wide works better because it's cleaner in a lot of ways. But also, I understand that there are individualized circumstances within your practice. So, I think you have to step back and do that evaluation, zoom out a little bit so that you can zoom in. Because we're so often in our businesses, like working in our businesses instead of on our businesses, and we lose sight over, like, the granular stuff that is really going to be the sustainability long term because what I don't want to continue to see is talk to different therapists and practice owners who are like, "I'm going into coaching. I'm going to go do something else. I'm going to go back to bartending."

Like, there are so many of these stories, and it's really unfortunate because we do such valuable and meaningful work yet we undervalue the work that we do because of the value in congruence, in terms of the why behind why we got into this field in the first place. So, it's really a nuanced conversation.

MICHAEL FULWILER: Definitely, and most therapists care a lot about accessibility. You know, we asked do you offer a sliding scale? Do you offer pro bono slots? And most therapists said, yes. That number is 75%, just wanted to make sure I get it. So, three in four do, right?

I think the thing with sliding scale that you need to be careful of, and Tiffany Mclean from Lean and Make Bank talks about this, that don't let sliding scale be a crutch for not charging your full fee, right? Like, if a client can't afford your full fee, absolutely, you know, a sliding scale is great, but don't like undermine yourself and your value by offering everyone a sliding scale just because you don't feel worthy of charging your full rate.

PATRICK CASALE: Yeah, 100%. I've said this before on this podcast and other places like, and this is so common, right? Like, when I first started my business, I was so desperate to get out of community mental health. And I really wasn't confident in myself as a business owner. People would call me, "Hey, I want to work with you. I found your information wherever." And before we even talked about money, I would already offer the sliding scale. I'd be like, "My rate's $100 an hour, but I also have a sliding scale [CROSSTALK 00:19:17]-

MICHAEL FULWILER: Whatever you can pay it's fine [CROSSTALK 00:19:18].

PATRICK CASALE: Even like, yeah, let's do 30. I'm like… And that was all on me for not being just confident and comfortable enough to talk about the money. And what would end up happening is some of these clients would come in and they would pay maybe 20, $30 a session. I was just happy to get it because I was like, it's still more than I was making at my agency job. But then we'd be talking in session, and maybe they'd talk about a vacation, or a new car, or a new purchase, and I would find myself getting kind of resentful, not at them, specifically, because it's not their fault that I agreed to this number, but at myself for saying like, "Why did I jump immediately to offering this reduced fee slot when it wasn't even asked for in the first place."

And I think that's what happens to a lot of new clinicians, especially, is like this lack of belief that anyone's going to pay you for therapy or understanding that people, you know, value their money and where it goes in different ways. So, we can't make blanket assumptions for every single person who calls you. A lot of people who come out of community mental health, where maybe were working a lot with folks who were state-funded, they had low resources, etc. So, there's this assumption that that means everybody who's looking for therapy falls into one category, which is inaccurate. So, it's just really about having a good understanding.

And I think what a lot of therapists don't do, and we used to do this in my coaching programs is like, week one, we would say, like, okay, what's the number that you need to make to keep the lights on, pay the bills? That's important. Like, you got to know that number. How many hours do you want to work a week to obtain that number, right? That's how we kind of create our rates. And then, we need to know what do I want to make? Like, what's ideal? How many weeks of time off do I want to have? Like, what's the quality of life I'm looking to pursue? That's how we inform our rates, not like… What ends up happening is people will post some Facebook groups, including my own, like, "What's everyone charging for therapy?"

And you'll get 500 different answers. But the only way that those people who are responding have decided how they are going to charge their fees is doing the same thing, right? Like, so asking everybody else does not take into consideration your needs, and your bills, and your profit, and your expenses, and like, the individualized situation. So, you really do have to get more clarity when we're doing these things. Otherwise, you're just, again, flying by the seat of your pants without a plan.

MICHAEL FULWILER: 100%, yeah. I think, you know, our goal for this report is to provide more transparency around finances and hopefully, help therapists to benchmark what they're charging, what they're making, how they're doing compared to other practices.

But you're absolutely right. Like, when it comes to setting your fee, what most people do is they'll go on Psychology Today, or they'll go on a Facebook group, and they'll look around and see what other people are charging. I've talked to therapists who, especially, if they're newer to private practice, I look around, I see what other people are charging, I'm going to charge a little bit less, right? So, it'll be more appealing.

But you don't know what those therapists their situations are, right? Like, maybe they're supported by a partner, and their practice is more of a hobby, and so they just charge lower rates to be more accessible. Like, you have no idea their financial situation and where they're coming from. So, it's more about you, and your values, and the lifestyle that you want to create for yourself, and backing out of that.

PATRICK CASALE: Absolutely. And also, like, there is a negative in terms of Psychology when we try to undervalue or undersell our services, right? So, like, if you do go on Psych Today, for example, and you're like, "Okay, everyone in my area charges 150. I'm going to charge 75." What ends up happening is clients will be scrolling through and not every client, but a lot of clients will see 150, 150, 140, 125, 175, 75, the psychological implication and correlation that your mind makes is, "Ooh, that's not as good. This person's not as experienced. I'm not going to call this person." Like, so counterintuitively you're already setting yourself up for a situation where you're kind of shooting yourself in the foot by trying to have the best of intentions. So, it's just really interesting when we start breaking money stuff down, especially, in this profession.

MICHAEL FULWILER: Yeah, 100%. We had Jeff Gunther who I know you're friends with as well, on our show. And he was talking about how he's had resistance to raise his rates in his own practice, you know, because he feels like if he raises his rates, he needs to be, like, more serious as a therapist. He can't joke around and like bullshit as much because it's like, "Oh, if, well, I charge this premium fee, I need to, like, button up and, you know, be more legit."

Which, like, fuck that, right? But that's just like, I think, the mindset and just where, like, the money stuff that comes up for people, right, is like, "Oh, if I'm going to charge this premium fee I need to like, you know, be a more serious professional." When in reality, like, I think, to your point, actually, a premium fee can be a signal of a good therapist, right?

And I know me, personally, like, if I'm looking not just for a therapist, but any service provider, I'm probably not going to go with the cheapest option just because, to me, that signals like, lower quality.

PATRICK CASALE: Absolutely. And Jeff could charge $1,000 an hour because he has such a huge following, people would pay just to spend time with him.

MICHAEL FULWILER: Yeah.

PATRICK CASALE: But, I mean, I've been in those situations too where I've been struggling financially, and I either had to rely on the shitty insurance that I had because I needed that $10 copay, or I had to go to, like, open path where, you know, people were offering sessions from 20 to $60. And those were times in my life where that was a necessity. And now, you know, I've had a therapist for about three years who's private pay. She raises her rates every year. And I find it so funny because she'll approach the fee setting like, "Okay, so it's January. I just want you to know that we're going from like 195 to 205 in two months. Is that okay?" I'm like, "Just do it now. Like, can we just do this now?" Because I want to help you do this. Like, the $10 isn't going to make a difference at this point in my life.

And I also understand I'm paying for a certain service and value. And I think there's so much liberation and freedom in having a private paid therapist who doesn't have to, like, do things, specifically, for insurance diagnostic purposes. So, there's all these ways to conceptualize it and make it work, but it's fascinating for sure.

Let's pivot a little bit as we start to wrap up. So, you work for a company that is really designed to help therapists sustain, and thrive financially, and get a better understanding of where the money goes, and how to set themselves up for future success. Can you talk about that just briefly and how Heard can help people who are listening?

MICHAEL FULWILER: Yeah, absolutely. So, when therapists go into private practice many of them tend to feel very overwhelmed about the financial management of their business. You know, suddenly you need to be your own bookkeeper and accountant. You have to figure out, you know, not just how much to charge, but what happens with that money after you charge it. You know, where does it go? Does it go into a business bank account or a personal bank account? And how do you pay yourself? And all these questions of managing your financial back office.

I think a lot of therapists understand their front office, and have, you know, HER, that they do their scheduling, and notes, and documentation, and all that. But when it comes to the back office, historically, it's been very cobbled together. Like, therapists will have a spreadsheet and, you know, they'll keep receipts in a drawer, and they'll have, like, one weekend where they try to figure everything out before they go see their CPA to do their taxes.

So, our goal at Heard is really to streamline all of those, you know, financial processes for your practice in one easy to use online platform. So, we help therapists manage their bookkeeping on a monthly basis. We provide financial reports that are very, like, simple and clear and easy to understand. On a quarterly basis we help therapists estimate their quarterly taxes. And then, annually, we prepare and file both business and personal taxes for therapists.

PATRICK CASALE: I like the one-stop shop idea, you know, because I think, like you said, so many people are piece mailing it together, doing it themselves where like, "Oh, I have familiarity with Turbo Tax from back in the day." And it's like, this is a bit different now that you have a business, and you have deductions, and you have contributions potentially. So, like, you really need to know where that money is going.

And for those of you listening like, listen, I know there's a lot of shame in the money conversations, whether it's about retirement, whether about taxes, whether it's about fee setting, give yourself a little grace in this and just like, if we can just start new today with new habits that will be really beneficial for you and your career. And that can mean like, hell, if you're not contributing anything towards retirement, $50 a week is better than nothing. If you're having a hard time with quarterly taxes, or understanding bookkeeping, or understanding your taxes in general, getting a CPA, getting a platform like Heard, getting someone in your corner to help you, like it does not have to stay this way, and you can make these changes pretty immediately to set yourself up for future success.

Michael, any last-minute tips, suggestions, anything you want to share with anyone that's listening right now?

MICHAEL FULWILER: Yeah, one of the big takeaways for me from the report that's related to this topic is we asked therapists like, how they're doing their own bookkeeping? And 53% said that they do their own bookkeeping. Most are doing it using a spreadsheet. Some are using like a DIY software like QuickBooks.

But then, we asked, how much time are you spending? And 52% of therapists are spending two hours or more per month doing their own books and managing their finances, which is over 20 hours a year, right? So, when you think about it that way, as you think about yourself as a business owner, like, how much time are you spending on your business instead of in your business? And how much could you save by outsourcing, or getting help, or just getting your time back? And that's a big part, you know, of what we do at Heard, is just give time back to therapists. They can make more money, or they can watch Netflix and relax, right?

So, yeah, thinking about that too of like, how much time are you spending on stuff you don't really want to be doing? And can you get help by outsourcing that?

PATRICK CASALE: Yeah, I love that, you know. I think, you know, I know this conversation today was more money-focused, but time is our most important currency, right? It's the one we don't get back. For most of us who become private practice or small business owners, it's because you want more free time. It's because you want more autonomy. You want more control over your situation. So, time for me is everything. I'd rather outsource things I don't know how to do or don't want to do so I can spend more time doing the things I want to do. And that, typically, leads to making more money in the long run because then I can be more focused on the things that bring me joy instead of the things that I kind of either do not want to participate in, or I'm just like begrudgingly moving into. So, really love that perspective for sure.

Michael, tell the audience where they can find… I know you have a really cool newsletter, and then, anything for Heard that you want to share. And we will get it all in the show notes, too.

MICHAEL FULWILER: Definitely. So, we'll provide the link to download the report. It's a 35-page PDF, so definitely encourage you to read through it with, you know, a cup of coffee or, you know, tea. Our website is joinheard.com. We have a ton of free resources, and webinar recordings, and other downloads, you know, all about managing your finances for your business. So, recommend checking that out.

We just launched a new podcast you had mentioned earlier, Heard Business School, excited about that. Definitely want to get you on the show. We had Dr. Melvin Varghese as our first guest. So, that's up on YouTube [INDISCERNIBLE 00:31:42]. Yeah, I know he's awesome. And then, also, yeah.

So, personally, you know, I have 10 things at all times, and you're the same way, I know. I write a newsletter for therapists called Therapy Marketer. So, if you just put that into Google it should show up. Hopefully, I have good enough SEO. But yeah, that goes out every week if you're, you know, interested in learning more about marketing for your business.

PATRICK CASALE: Love it. And all of that stuff will be in the show notes so that all of you have easy access to everything Michael just listed.

Mike, thanks for coming back on, man, it's always a pleasure. It's been great just staying connected over the last couple of years. And congrats on all the success. And looking forward to coming on the podcast, too.

MICHAEL FULWILER: Thanks, Patrick.

PATRICK CASALE: To everyone listening to the All Things Private Practice podcast, I almost said Divergent Conversations because I'm just sleep deprived, new episodes are out on Saturdays on all major podcast platforms and YouTube. Like, download, subscribe, and share. Doubt yourself, do it anyway. And we will see you next week.