Joe Sanok 00:00:00 The group practice boss. Conference tickets are on sale now. We expect them to sell out in just a couple days. There are only 120 of these available. Head on over to practice of the practice. Com forward slash conference to read more and grab your ticket. This is the practice of the practice podcast with Joe Sarna. Session number 119. Welcome to the practice of the practice podcast. I’m Joe Sarna, your host, and I am so excited that you are hanging out with me today. Today we are giving you behind the scenes in regards to our membership communities. And so a lot of our consultants are doing teachings every single week. every Tuesday, Wednesday and Thursday we have live teachings going on in our membership. So we wanted to give you a little behind the scenes. So we’re going to be hearing from Nicole Ball talking about what to do when referrals are slow. HR basics with Andrew. Client retention with Ashley, scaling with Nicole Ball, choosing the right project management systems, and all sorts of other things over the coming weeks. Joe Sanok 00:01:16 I can’t wait to dig into this with you. If you want help from one of our consultants, please head on over to practice of the practice. Com forward slash apply. I’ll chat with you for 30 minutes to determine if one of our membership communities or consulting might be right for you. Now let’s get started with this episode. Andrew Burdette 00:01:33 Hey, how y’all doing? So I made a spreadsheet because everybody’s been like, how does the whole base plus commission thing work? So, let me get the sharing privileges figured out real quick, real quick and cool. part of why I did this is I needed to, like, I think I overpaid people slightly, like my first go through with the whole So I need to, like, go back and adjust. but yeah, if people want to click on that link and we can walk through it or I mean, I guess I, I can screen share, right? Let me, let me try the screen share thing. So I’m going to jump into this because this has come up several times. Andrew Burdette 00:02:16 You know Heidi is asked about how does this whole thing work. We talked about this last time of just how all of this works. So let me kind of screen share and then walk through kind of what this is going to look like. So this up here so obviously like this is your pay date. So I’m paying on the first and the 15th. The payroll dates are a little different. I think the cutoff dates like the I think we’re cutting off on the 25th of the month for the first, and then I’m cutting off at like the sixth or the eighth for the 15th, I think it’s the eighth or the 15th. So those are kind of my two windows for those. So you would basically kind of fill in. Also, if you don’t know, you can make a copy for yourself of this spreadsheet and kind of play with things. but in short, so basically you’re going to have your pay period and this is going to dictate what’s included. I just plugged in a base rate of $20 an hour here for an example. Andrew Burdette 00:03:09 So my clinician worked 20 hours a week, both weeks on this pay period, because we’re just going to call it an even two week thing. 30 hours of those hour session time. So that’s actual time spent with like billable hours with an appointment. so to total things up, your total base rate that you’re paying them for that pay period is going to be $800 because it’s 40 hours times 20. the number of session hours for there, which relates to that commission total is going to be 600 because it’s 30 of those hours would be billable hours at $20 an hour. So that’s the 600 number here. in this pay period, you they got 12 sessions at $150 that were paid during that window. So that’s money received for those billable hours. So that totals $1,800. And then let’s say your insurance rate is an even 125. Nobody gets an even 125 for insurance. It’s always these weird nickel and dime things. But just for the sake of simplicity, 18 of those 18 sessions got paid at $100 125 a session from insurance, and those could have been sessions from like 3 or 4 weeks ago, depending on the timing. Andrew Burdette 00:04:18 But the payments were received within that pay period. So how this is set up is over in this column here. This is what’s paid and received within the pay period, not necessarily worked in the pay period because there’s that offset with the insurance thing. Right. So the math kind of goes is following. So cash payments are going to be 1800, which is this number here insurance received in that payment. So total commissionable services would total up to 4050. Right. So that’s the total amount of money including the hours worked and other things. So all of that there. The commission grows 4050. For simplicity’s sake, I just did a 5050 split. So half of that is $2,025. 30 hours have already are going to get the base rate regardless. So we’re going to subtract that out of the commission split. So we did the commission off the total amount of received money up here. the commission split totals to 2025. We subtract out the hourly base rate and that totals up to $1,425. So the way that timesheet breakdown goes is they get $200 of admin for ten hours of admin. Andrew Burdette 00:05:32 They get their base rate for the session hours, which is 600, and then they get the commission pay, which is their commission split less. The hours work to get them, and it’s 30 hours because there was 12 cash pay and 18 insurance hours. So that 30 hours numbers matches. So then you end up with a total of $2,225. Does everybody follow that? I know it’s like a lot of steps, but I was trying to do a flowchart. It was easier to do on a spreadsheet, but if this makes sense, this is kind of how the breakdown works. I have a question. Yes. Go ahead. Speaker 3 00:06:10 I’m following the math. And pardon me for being a little bit slow about this. Can you explain? because it’s so interesting to me, it never occurred to me to separate out like the base base rate versus commission rate. Can you explain how you arrived at that and how it works for your business? Andrew Burdette 00:06:28 Arrived at meaning the number. Speaker 3 00:06:31 the concept, the concept. Andrew Burdette 00:06:33 So the concept is, my so my insurance panel reimbursement rates vary from about $98 in the lowest one, up to about 170 for the highest one. Andrew Burdette 00:06:46 And most of them are going to be kind of in 104 to $124 that range. So like a reasonable average would probably be somewhere around about 110, because most of those are going to be on the panels that are between 104 and 124. So if one wanted to do a flat rate, you could do a flat rate based on something around that average of sessions. Right? So that’s one option. You can do several practices around here, do a flat rate per session versus a percentage. the choice to do base rate plus commission or flat rate total I guess could be the other way to do it. would be so that paying your employees for the time they’re doing notes, following up with clients, those other things, that there’s a different rate that’s not as high as that clinical rate. Because if, let’s say, like from a business costs standpoint for overhead, obviously being able to pay somebody like a 20 or $25 an hour rate to show up for a staff meeting is a lot more affordable than paying him a 65 hour salary. Andrew Burdette 00:07:53 So that’s kind of the premise behind things. The one other thing that I mentioned last week, and I’ve mentioned a couple times, is the way I’m doing things in terms of earning that commission. The other caveat is the clinician has to complete the notes, meaning completed and signed in the EHR within 48 hours. And that has to do with insurance timeliness about the likelihood they’re going to recoup things or having late notes. So several other practices in and I kind of adopted this approach to like how do I enforce note timeliness is to everyone gets paid the base rate, regardless if the notes are completed and locked and signed within 48 hours of the session, then they earn the rest of the commission when it’s paid. Is that the breakdown? Speaker 3 00:08:39 Yeah, that’s that’s really helpful. Thank you. Yeah. Andrew Burdette 00:08:42 I may eventually move to a flat rate thing at some point. I know one of the practice centers around here came up with a flat rate that was probably in that 65 ish range. And her plan was, for that really high insurance payer, which in North Carolina happens to be the state employees plan. Andrew Burdette 00:09:02 that extra difference is allows her to kind of hedge, you know, put some money aside just to keep in the business for some other things. And, you know, maybe like bonuses, like a CEO extra CEO thing or some other thing kind of like that, down the road. So that’s kind of trade offs there. And then exact numbers for you and your business are going to kind of flux depending on are you a brick and mortar operation or you telehealth. There’s different costs that come with those. and just kind of looking at your numbers in math and stuff like that, it’s a little more accounting, I’ll tell you that. And the thing I’m realizing, too, is because everything up through April 15th was under one pay structure with my 1099 that then became w-2s. I’m still in that kind of transition period of like having to account for the base rate for sessions that were done before and after. Speaker 4 00:09:52 So, Andrew, for the people that you know that are doing the flat rate per session, that flat rate is assuming the admin like that includes the admin work that you’re covering in the base rate. Andrew Burdette 00:10:10 Yeah. So the way the way they would be doing things would be my friend Jill just doing a flat rate for services. So she and I actually are doing the same numbers because it just seems reasonable. So she starts everyone at 18 for an admin rate, and then they get bumped to 20 after a year. And, her flat rate is calculated based on an average of like, payers. And how much how much of their pie chart, you know, like is it predominantly blue cross stuff, which for us is more close to 125? Is it primarily united, which is maybe in the 104 range. So she’s kind of looking at 20% of my business pays at 104 or 50% of my business pays 125. And kind of figuring out something in the middle about average range there. But that flat rate would be the sum total of like the base rate plus the commission. So I don’t know how she’s doing. She’s the only practitioner I know that is willing to front the insurance company and assume that the insurance company is actually going to pay, as they say they are. Andrew Burdette 00:11:16 I sure don’t trust them after the whole change thing. So I’m not willing to, as a small business, take that risk for floating a multi, multibillion dollar company that’s inflating the cost of everything we do. I’m just not willing to do that, but, kind of reaches out. Does that answer your question? Speaker 4 00:11:36 Well, so in your model here, you’re using commission. So for her, she’s using rather than commission. She’s just saying you did 30 sessions at. I forget what number you said she was at. She’s just taking 30 times the flat rate rather than doing okay. Yep. Andrew Burdette 00:11:57 Yeah. And so the hours that went to session time are not getting the additional admin rate that’s in even in mind the the admin rates getting paid initially. And then there’s like the when the money’s received for the services, then the rest of that comes in for her because she’s paying everything at the time of the payroll, even if it’s going to be a month before she gets a reimbursement from Blue Cross. She’s paying for that Blue Cross session at the time. Andrew Burdette 00:12:22 So she has non-clinical time and then clinical time, and it’s more of a timing thing than it is necessarily a difference in calculation. So does that make sense for everybody about how this whole thing works? It is a little complicated. I will say too, there is no good payroll system like payroll is going to be tedious regardless. I don’t know. I don’t have a good. Here’s a simple way to do it. there are payroll companies. There are local ones here to where you basically just kind of give them a timesheet and they will run payroll and calculate things for you. But it’s one of those you can either do it yourself and take the time out of your schedule to kind of do things, or you’re going to end up paying somebody that you trust enough to not screw payroll up for your employees to do it for you. And that’s not going to be your typical scheduling 15 to $25 an hour admin person. That’s going to be a bookkeeper of some kind. Worth it. Did you say it was worth it, April? Speaker 5 00:13:19 I did, yeah, yeah. Andrew Burdette 00:13:22 Yeah. My bookkeeper decided she’s not doing bookkeeping anymore because she’s doing more payroll. So I have a referral for a new bookkeeper, which is good, because it took me a while to find her, and she’s been really great. But I understand the need to move on to other things, and I’m thankful to not have to do all that. so that’s the complicated. That’s probably of payroll structures you can do. This is probably the most involved for calculating things, but to me it seems to be the way I can best maximize what somebody earnings potentials are based on the distribution of payers on their caseload. Because again my new hire like I don’t have room on my schedule for like all the state employees people. So he’s got like 4 or 5 of those people in his caseload. So basically three of those sessions pays as much as four of another. So for him it works out really well as far as pay structures go. How what other questions do people have. Like how are people currently doing pay structures or concerns about doing pay structures, especially if you’re moving over to W2? Contract world is easy. Andrew Burdette 00:14:23 You only pay them for the services they do, and then if you have a separate app and rate, it’s pretty limited on what they’re going to have to do with that and things like notes and other stuff, it’s just on the clinician to to do as part of their operating expenses or independent business. Also to for the people that kind of jumped in Right after I started, I kind of launched right into the spreadsheet. So apologies for not saying hello and hope everyone’s having a good Tuesday. It’s kind of wet and raining here, so welcome and thanks for coming. So there’s the intro 15 minutes in. Speaker 6 00:14:54 Hey Andrew I did come a little bit late. Sorry about that. my clinicians are W-2 and we do percentage commission. I primarily do that just because it’s easiest for me in terms of calculation. Just go into simple practice and look at income allocation for the pay period dates. you’re talking a lot about admin time. Is admin time expected or required to be paid. Andrew Burdette 00:15:18 So clinicians under W2 you have to pay everyone for all the hours they work. Andrew Burdette 00:15:25 So all the time that they work has to get paid. Speaker 6 00:15:28 Okay. so I actually had a clinician, somebody reported me to the Department of Labor in North Carolina because I was doing percentage commission only on billable hours. at least according to the Department of Labor. They said as long as what they’re getting paid divided by the number of hours they’re working is above the, minimum wage rate, then I’m not in violation of anything, is there? Okay. But there’s some another overseeing authority that that says they that they need to be paid for every hour. Andrew Burdette 00:16:09 They the the how you calculate whether they’ve been paid for all the time or not is what the Department of Labor kind of came in and said. So for simplicity’s sake, in my practice, here’s a base rate. Everyone gets basically 12 minutes of paid time per session to cover notes, follow up, scheduling, those kind of things. That’s a built in. They’ll get that paid whether or not it takes them 12 minutes to leave a note. But then it’s delineated like, here’s that time. Andrew Burdette 00:16:37 it’s also helpful to just kind of know how much time somebody’s spending working anyway, and that’s helpful for them about how much time they’re doing. But in terms of are you like in the wrong by doing straight commission or not? No, that’s that’s perfectly fine. And so long as what, let’s say, the clinician can document, they worked 40 hours a week and you’re paying them, you know, whatever. That would work out too, so long as it comes up above, it’s North Carolina, so it’s still 725 an hour, which is a pretty low bar. you know, it would be hard to be under 725 an hour for any number of hours worked in a clinical practice, even if you’re just doing straight commission. Speaker 6 00:17:18 Right? Okay. Yeah. I mean, the commission that my clinicians are making it like you’re making a really decent salary. I just wanted to make sure I was within the law and like that, I, you know, if I am only paying them on a percentage of their billable hours, that there wasn’t anybody else that could come and say, no, actually, you have to be paying them like administrative time or something like that. Andrew Burdette 00:17:44 You don’t again. So the math I’m like 725 an hour at 40 hours is $290. So as long as your clinicians are making more than $290 a week and they’re not clocking overtime, they’re good. Okay. I think I would also specify something in there about, you know, being clear on what constitutes a work and when overtime would kick in and what would be required for them to be in overtime status. if you’ve worked an agency job in health care and especially our field, those are all what’s classified as full time exempt, which is how all the agencies exploit us because it’s like, well, here’s 35 hours of clinical time, and now you’ve got 15 hours of documentation to keep up with all the state requirements, and then you’re 50 hours a week. but because you’re exempt, that extra ten hours doesn’t really count. You’re doing what you’re doing is fine. It’s just more of a matter of making sure there’s some record of how much time that person’s actually spending working, so that there’s not a confusion about, I worked, you know, day six and was in, you know, hour 41 through 45 when I was seeing clients then. Andrew Burdette 00:18:56 And that should be time and a half of some kind or some other thing. California’s going to have very different labor laws in terms of how this works in California, too, in terms of when you hit overtime status and when you don’t. But because we’re in North Carolina and we’re kind of a third world country when it comes to democracy and other things and labor rights, like, they can kind of get away with just about everything. Speaker 3 00:19:19 So, Andrew, if I’m doing a percentage and I guess I’ve. Speaker 7 00:19:22 Always worked at places where I was 1099 and now I’m doing w-2s for my clients or my, clinicians. I’ve always had it where you wait to get paid until the insurance pays you, And is that going to be an issue for the first couple of paychecks that are a little bit lower then? Andrew Burdette 00:19:48 I don’t think so. So my experience of switching over has been the following. So my two full time people became W-2 status effective April 15th. The first pay period as W-2 for them was May 1st. Andrew Burdette 00:20:02 Tomorrow’s the next one. there really wasn’t any lowered amount in terms of what they got reimbursed because all of that timing kind of there was already a flow of insurance coming in. And other thing, just asking them, you know, do you want me to stick with the contracted rates which were different than the W-2 rates because you’re accounting in that employer side tax and stuff like that. They were both like do whatever’s easiest for you. So just pay us our new rates even though the sessions happened while we were contractors, and that was what was agreed upon. So I’m super grateful for that, because it would have been a whole lot more math to have to figure out. and there wouldn’t have been a way to like, there wouldn’t have been a way to avoid paying the tax portion of things because of the status change. And, and the timing of reimbursement was the other part. that delay in reimbursement is, is already factored in. So you’re waiting on insurance to get paid to then pay them that timeline and that timing of payments and when the payment was paid versus when the session took place, all of that offset stays the same because that’s between you and the insurance company. Andrew Burdette 00:21:14 So all you’re talking about is what’s the percentage difference, I guess, between your 1099 status and W-2. And then when are they getting paid there? Speaker 7 00:21:23 So oh, I guess I’m talking about like I’m bringing on a new clinician. And so when they start with clients they’re not going to get Insurance isn’t going to pay them for a couple of weeks. And so I give what has come in. So, you know, whatever is on the credit cards and whatever’s come in, I do that. But their check will be lower because the insurance hasn’t paid everything. Does that make sense? And that is okay. Andrew Burdette 00:21:54 My understanding is as long as people have remittance within 30 days of the time they did the work, you’re okay. Speaker 7 00:22:00 Okay, great. Andrew Burdette 00:22:01 Thanks. And I think part of my choice is to do the admin or the base rate plus commission is that way they’re onboarding and paying attentions incentivized because they’re getting paid for that time. They’re investing to like learn how your systems work. Whereas if you’re just a straight commission model like that, time’s kind of unspoken work time, but it’s it’s still covered, but it’s covered by the commission and averaged out from that. Andrew Burdette 00:22:24 It’s not necessarily like paid for directly. And then the other part of things is there would never be a point to where 30 days would go by that somebody would not be paid for the time they spent working. Does that make sense? So in other words, like if somebody starts starts onboarding and doing admin stuff and you’re commission only and it takes you a week or two to get them on the insurance panels for supervisory building, and then it’s another month. Six weeks could go by before that. First and second weeks actually paid for, and then that could get you in trouble. Speaker 7 00:22:56 Got it. Thanks. Andrew Burdette 00:22:57 This is all the really awful, like, knowledge from doing an HR certification of just what the rules are. some of some of what was kind of on the agenda today. I realized, like last week and this week we kind of swapped a little bit maybe. So kind of how these pay structure things is definitely an employee handbook kind of side of things in terms of, you know, timing of pay. Andrew Burdette 00:23:21 Are you getting paid an hourly? does the commission come out of that or does the hourly get subtracted out of the commission total and those kind of things and all of that’s laid out in the employee handbook. also kind of on the list today for topic stuff. I’m losing track of all my tabs. looks like pay structure is benefits and, things that kind of think about with hiring. So how many people are thinking of doing benefits? So to just let you know where I’m starting people out. everyone can earn an hour of PTO at the admin rate for every ten billable hours worked. so basically that’s going to be an accrual thing. I’m not necessarily putting a cap on it. So that way part timers, full timers, whatever for every ten hours of session time, they can earn an hour off at the admin rate. That seems pretty reasonable. My understanding is you can’t specify a separate rate for paid time off. So having the admin rate and then the commission total rate kind of thing allows me to pick one of those two rates to, to serve as that reimbursement. Andrew Burdette 00:24:29 for that paid time off level. I think I decided to do a $25 a month, Q stipend, so that’ll go to the clinician. that’s something that they can kind of get every month to just pay for continuing and save up for training, some other things like that. I am planning to implement vision, short term disability, long term disability, and I think $25 some amount of term life insurance and do all of that kind of as a package deal for everybody. There’s a minimum number of enrollment. my insurance broker was able to find some companies that would be willing to do three versus five employees as a minimum. but roughly looking at quotes from April, it looks like for about $110 per person, you get all four of those. And if any of you all independent people have tried to, like, get life insurance or long term disability. It’s a nightmare trying to qualify for those kind of things or at a reasonable rate. Kind of like health insurance is really obscenely expensive. So from a cost basis standpoint, is an employer. Andrew Burdette 00:25:34 Sure. It might be between 100 and hundred and $20 a month, depending on your state for all of his different package things. But the benefits your employees are going to get far exceed what the premiums are going to be for those. And if you have a full time commission or full time clinician, they should be generating anywhere between 90 and $150,000 of revenue on an annual basis, depending on what your reimbursement rates are and their distribution of things. So if you’re talking 1500 to $2000 a year in premiums for these types of services to your employee, that’s a negligible percentage going to the employee for overhead cost to them, but they get big bonuses and things like that. Also, if you have people that are planning to get pregnant, have the short term disability signed up beforehand because, you know, perpetuating your species is somehow a disability in our country because that’s what our value systems are. Because, Sure. anyway, just things. Things I’ve learned in trying to stay this out of just how wacky stuff is in our country. Andrew Burdette 00:26:32 But, you know, these types of things are much more accessible for you as a business owner to provide on behalf of your employees. the other thing you can consider doing related to benefits is what’s called a professional employment organization or a P.O. this is where I think I was trying to explain this last time to where everybody here, we would collectively pull our employees into kind of a group in that larger group of people, then apply for a benefits package for everyone in that group. And because there’s more people in general that brings the cost down. So if you are considering things like health insurance and other things like that, that would be a cheaper way to do it if you wanted to go full on health insurance. So these are just some examples of the kinds of benefits that you can offer. another friend of mine, several friends of mine, kind of have a wellness lottery kind of thing. So that’s anywhere between 15 $100 a month. Somebody like me gets around and a half, they get picked, and then they get $100 toward, you know, to spend whatever they want, whether it’s a massage or some other things like that. Andrew Burdette 00:27:33 They can just they get a stipend to go invest in some of their self-care. They might not otherwise do it. So think of benefits, mostly like perks that you can offer to people so that they don’t have to. if you’re coming from the 1099 world, just the idea of going from contractor to where you’re technically on the hook for like your own phone system and EHR and these other things coming from that contractor model into like W-2. The fact that all of those resources are provided for you and covered really is kind of a benefit in an indirect kind of way as well, if that makes sense. Even though as employers with W-2, people were kind of required to provide people the tools to do their job as part of being an employer. Joe Sanok 00:28:22 As a therapist, I can tell you from experience that having the right EHR is an absolute lifeline. I recommend using therapy notes. They make billing, scheduling, note taking, telehealth, and e-prescribing incredibly easy. Best of all, they offer live telephone support. It’s available seven days a week. Joe Sanok 00:28:41 You don’t have to take my word for it. Do your own research and see for yourself. Therapy notes is the number one highest rated EHR system available today, with a 4.9 out of five stars on Trustpilot. Com and on Google, all you have to do is click the link below or type promo code Joe on their website over at Therapy notes.com and receive a special two month trial. Absolutely free. Again, that’s therapy notes.com and use promo code Joe on the website. If you’re coming from another EHR therapy notes will also import your demographic data quick and easy at no cost, so you can get started right away. Trust me, don’t waste any more of your time and try therapy notes. Just use promo code Joe at checkout. Andrew Burdette 00:29:28 So that’s kind of a big short summary of benefits kind of stuff. Like what are people thinking about benefits or what are some barriers around benefits that people are running into about how to think of them and what to offer? Speaker 4 00:29:40 Well, I’m just finding Andrew that it’s really hard to compete with these big corporate practices, and they’re offering 401 K. Speaker 4 00:29:48 They’re giving, you know, one, one local practice I think is giving 5400 a year towards, any student loans that the clinician still has outstanding. And then they’re giving health, life. I mean, everything that you just ticked off there, I went out to get a quote and I mean, you know, health insurance, thousands of dollars. Andrew Burdette 00:30:13 Yeah. Speaker 4 00:30:14 Yeah, yeah. Andrew Burdette 00:30:15 And just if you are thinking of health insurance, you’re required to pay 50% of the premium. Speaker 4 00:30:20 Yeah. Yeah. So I just don’t know how this, you know, I guess is the age old American weirdness to, like, how to how does a small practice. I mean, I have six people on my team. How do we compete with big corporate people? I’m trying to make the sale on, like, it’s small. You know, there’s perks of, you know, being in a more intimate environment and not being so, you know, regimented on this is how the corporation functions. And you have to do it this way or else kind of deal. Andrew Burdette 00:30:53 It’s tough. And it’s it’s definitely gotten tougher because there’s a lot of private equity in like venture capitalist dollars getting thrown into our field. and like a friend of mine’s a clinical director at a franchise practice opening up, and they’re offering stuff that none of the rest of us can offer. Right. There’s literally, like a whole HR team that all works remotely to onboard people across the whole country, around this kind of. It’s crazy, right? and yeah, I mean, I know of a local practice center too, that is is offering, like punching above his weight and we can’t figure out how he’s like, viable because you’re just like, we we run the numbers. So we’re not sure how you’re doing this either kind of thing. because it is, it is things like that for one match. And so if you’re doing a 3% match, well, that’s 3% off your total overhead for that clinician. Kind of like taxes are going to be. And there’s other things. So it it adds up pretty reasonably pretty fast. Andrew Burdette 00:31:47 so when I worked at a community mental health agency, a lot of what floated that the outpatient basically the outpatient people like me were almost money losers. Like and I think, honestly, if you factored in the amount of office space that went to us, like we probably were blanket losers in terms of and we were 1099, you know, like a blanket loser. And then realizing it was kind of a funny way to say it. so yeah, we just want to lose your outpatient people. Like. Anyway. so but they, they had a wide range of services. It was community mental health. So a lot of a lot of psychiatry, you know, type services, a lot of state funding, said Medicaid. And I can’t remember what I stood for. But in North Carolina was kind of the gap funding between people that didn’t qualify for Medicaid but didn’t otherwise have services. And there were some low income statuses. You could kind of get IPAs funding that wasn’t officially Medicaid, but still covered services in that gap of not having coverage and things. Andrew Burdette 00:32:39 so kind of like grant funding in a way, or block funding. but they also ran a lot of substance use groups, and so a lot of substance use money came in that definitely didn’t go to the clinicians facilitating those types of things. They opened up a methadone clinic. The numbers on methadone clinics are disgusting, like in terms of the amount of revenue, even just on like psychiatric providers and stuff, like it’s a whole you start to quickly realize, like how underpaid we are for what we do and just how hard we have it. Because if we’re not seeing clients, we’re not making money. And that gets to be really hard. And so these other companies, are able to do some of what they’re able to do because they have additional lines of business that are much more lucrative than what we do as a field. And that then offsets like what they’re willing to do, or willing to able or willing to and can afford to pay people. I have big concerns about platforms like, headwind. I was like, why am I I’m stuck on BetterHelp, but headway, because that’s clearly a tech company moving into like, the insurance billing space. Andrew Burdette 00:33:46 And in North Carolina, your reimbursement rates are going to be the same or higher than what you could independently contract with. You’re no longer allowed to have an independent contract if you don’t already have one to contract with them. So if you sign up first with Blue Cross three headway, Blue Cross will no longer will no longer issue you your own independent contract until you dump headway. And then you have to start the whole process again. So I don’t know how the non-compete thing is impacting that, because legally they can’t do that anymore. But it is a gentleman’s agreement between Blue Cross and Headway. So even if it’s not officially there, it still doesn’t mean Blue Cross has to paint with you kind of thing. Right? So yes. So but what I’m getting at is the reimbursement rate for Aetna is $13 higher than it is than what I can get independently through my contract through headway, which means that if headway is skimming 10% off the top and then still paying me higher than what anthem will pay me directly, then basically headway is probably making $25 more session than I’m going to, and eventually Aetna is going to look at the number of providers panel through headway and be like, you know, we’re just going to cut your rate down to what everybody else is getting paid because you’re costing us too much money, which then that’s going to trickle down to the people on those panels which are trapped because of this whole gentleman’s agreement non-compete thing. Andrew Burdette 00:35:02 So to me, this is kind of where, like as a whole industry, it’s there’s a lot of disruption going on because of different other players coming into this space and trying to, like, do some very necessary things like leverage technology to make our lives easier. And at the same time, like in that disruption, it’s going to be interesting to see how things shake out. So I don’t know how to tell you to compete about these larger companies other than it’s not a level playing field. And it’s not just simply from scale either. So when you’re I’m sure some of these others are doing things like psychological testing, which you can charge a whole lot more for. There’s if you’re doing like autism specific or ADHD specific things, several group practices around here on our local group practice that it’s been a month long discussion about billable codes and who which licenses can bill it. if so, what can you get for it? Is it better to just stick with private pay if it, you know, and try to navigate those other things? So those additional lines of service can give you some flexibility around having more cushion to then pay people those other benefits and perks. Andrew Burdette 00:36:09 But it’s got to come from somewhere, and it’s not going to just come from straight up therapy. Speaker 4 00:36:14 Well, I mean, going back to your gentleman’s agreement, what about if you’re already credentialed with Blue Cross Blue Shield, and then you go with the headway? Will they let those practitioners join if it’s in the reverse direction? Andrew Burdette 00:36:31 My understanding is, yes, but I don’t know if it jeopardizes your individual contract. Speaker 4 00:36:36 Because that’s certainly what’s happened with some people in my team that have jumped. They they were credentialed with my practice and then they jumped into growth therapy. And I think they’re providing services to both. It’s just that they’re doing the growth therapy in a, in our region that’s about 90 minutes away from where my physical location is. But it’s very frustrating. I mean, I just ran the numbers on a licensed master’s level from, I think, South Carolina. she was not going to go for one of the grow. Headway, I guess is the other one that called me a week ago. she’s going for like a corporate practice, and she came in with a number that I was like, there’s just no way at a master’s level that they would be making money off of her. Andrew Burdette 00:37:29 There are a couple practices in North Carolina. I’ve seen ads for one of them in, like your area, Karen. Like more central part of the state. it’s like an 80 over 20 split, and I’m like, this is completely unviable. It’s just not viable. So, Sounds good on paper, but I don’t know. I don’t know where the money’s coming from. Right. And, some of what I think is unfortunate, some of what I think has happened to you. And this just seems like on the lines of disruption. So BetterHelp spends more marketing than half the countries in the world make an entire year for the whole country. It’s just it’s crazy how much money they spend on marketing. Like, I don’t know what it is, but you literally can’t watch it. You can’t listen to any podcasts at all without getting better help ads regardless. And this includes therapist podcast, right. Which is kind of surprising. so from a marketing angle and part of what their pitch is, it’s like you can change therapist anytime you want and, you know, access your therapist texts and all hours. Andrew Burdette 00:38:33 And so what it it is eliminated boundaries based on what they’re telling people could be available to them as services. And it just seems like as more people have kind of paid attention to what BetterHelp is selling and how they’re selling what the service is, it does seem like in my practice, more people are just dropping out without any kind of like, nothing. They just like ghosting is going up. I will say there’s been an interesting trend of male clients coming in wanting to work on work life balance because they work too much, who then cancel because they can’t make up time. They will not take time off of work, which is the number one reason that coming in, like if I wasn’t a therapist, I would just literally reply to your email with what you sent in to say this is a problem, but I’m not because we’re not allowed to do that. That would be snarky, and I can’t do that as a therapist. But it does. You know, it’s a trend, but the just the it seemed like a couple of years ago, before BetterHelp became as dominant in terms of the culture and discussion around things, it seemed like people were a little more open about, hey, I’m discontinuing because of acts or finance or other things, or I’m really looking for somebody that does X versus just ghosting altogether kind of thing. Andrew Burdette 00:39:43 so there’s that kind of cultural shift about what BetterHelp is doing to kind of set expectations around things. most, most clinical programs don’t discuss private practice and what that looks like. It’s just there’s this big push in to go be a martyr and kill yourself at a community mental health agency and burn yourself out quickly. that’s generally the push on most programs. And so there. I think another important thing in there too, is any academic program is only geared to get you to graduate and to either get licensed or get you into the next academic program. That’s it. That’s the end of their obligation. They’re not here to talk to you, talk to you about what life is like after you get out of school, because they don’t know any different, because the people who teach only do school stuff predominantly. And the other thing is, their job is to get you to graduate, get the graduation statistic. Hey, all our people got licensed. That’s it. That’s they’re done with their KPI’s. That’s as far as they care. Andrew Burdette 00:40:40 And with that, there’s nothing about how working in the field actually works. There’s nothing about what is it like to practice the practice of therapy. Right. So because that’s not getting discussed. And then you have people that hop on indeed. And see this agency throwing out these audacious numbers about, you know, thrive works. They’ll do this like everyone’s heard of thrive works. A lot of their ads are like, you can earn up to $144,000 a year. Sure, if you’re seeing 40 people a week every week, right. That’s the thing that’s missing from that. And that’s one of the things that gets overlooked. People just see this big number and hear about, you know, the like, influence or people to talk about how much money you can make in private practice and basically what the numbers you could possibly earn as a solo practitioner, just not doing any of the business end of things and then expect us to kind of float that for them, which is unrealistic. So for those people, at least, that kind of approach me or my other colleagues around here that are like, I want to want to basically see the same numbers and have the same schedule I have in solo practice. Andrew Burdette 00:41:41 I just don’t want to do any of the business work. I’m like, well, great, you can go figure out the business and off you go, right? You can see how how difficult this is. Go try it out for yourself, you know, and if it works great, it’s not like any. Oh, well, it’s just there are these very unrealistic expectations being set because of how people are presenting what it’s like to work in our field. Along the same lines, at like, BetterHelp is kind of working against what therapy really is. That makes sense for like a soapbox kind of spiel on this. We’re never going to compete with a venture capitalist backed anything. Just like taxi companies can’t compete with Uber and Lyft now, Uber and Lyft are never going to turn a profit. But so long as the venture capitalist people are convinced it’s going to, then they’ll keep funding it. Speaker 6 00:42:24 We really try to focus on, selling the culture of working at a small group practice. I allow my clinicians a lot of flexibility, in their schedule, which they often can’t get at a larger practice that is more focused on just productivity. Speaker 6 00:42:43 And you have to work these certain hours and things like that. So they’re allowed to create their schedule. We have, weekly meetings where we meet and do case consultations and things like that. And so, and I feel like the clinicians that I’ve gotten so far, they really value that part of private practice that like, it feels kind of like a small family here, and we all get along really well. And, you know, we’re collaborative and larger group practices aren’t always like that. So, I do try and, like, sell them on that because we just can’t match other practice, larger practices, benefit packages and things like that. Speaker 7 00:43:24 Yeah. Andrew Burdette 00:43:25 Again, other things that I think is important, explaining to people about those differences is there’s other companies are going to be much more strict about if you have a 25 hour a week minimum for clinicians, they’re going to expect you to do that. So you may be booking 30, 32 sessions a week. And if nobody cancels, you’re going to be doing 30 or 32 a week. Andrew Burdette 00:43:44 So sure, your earnings are higher. But if your goal is to have something that’s much more in that like 25 to 32 hours a week total, you’re never going to get that at this larger practices because you’re going to have the additional, you’re going to have the admin time that we do for notes anyway. And then you’re also going to have the all the, All the like corporate meetings about, you know, here’s this and look at the company things we’re doing. And not to say that those are always bad, but just gosh, the number of like I spent 4 or 5 days onboarding at like a community mental health center because they require me to do that even as a contractor. And it was really interesting because I’m like, y’all are going through the employee handbook, and I’m like, it literally doesn’t apply to me because I’m not an employee, right? So yeah, I mean, there’s there’s a lot of those kind of the cultural factor. Things are harder to explain because it’s a softer thing. Andrew Burdette 00:44:34 It’s less obvious in terms of being tangible, but it really is a benefit. I mean, people in my team were kind of like, is is switching to W2 going to really change your management style about expectations around, you know, am I going to have to suddenly have a fixed schedule? What’s this going to be? Are you going to tell me when and when I can’t be in the office? It’s like, no, I don’t want to. I still don’t want to do that. We’re just doing payment exchange. That’s really the number one thing that’s changing here. So the rest of the functionality around the culture and stuff stays intact, right? Please don’t make me actually don the boss hat. I don’t like doing that. It’s never fun if I’m actually in that role, right? Like that’s different than I’m handling payroll and demoing like CRM and software that I that’s part of just this or negotiating insurance contracts or whatever. That’s fine. There’s that’s pretty level. That just means we have different people in different roles that doesn’t call into it doesn’t call the power dynamic into play. Andrew Burdette 00:45:28 And I never enjoy that personally. So yeah, I don’t know what to tell you about. I know small practices that run like those larger groups in terms of that level of structure and other things like that. And I know other ones that, are much more just very loose about things like I would prefer to be and have very autonomous people, and that’s what I want. And we still come together. We have our like weekly meet up at a coffee shop and just kind of debrief our week. And the past two weeks it’s been my one clinician is pregnant talking about how weird it is to be seven months into being pregnant and having how weird it is after a while. It’s like, that’s it. But it’s that team building and culture thing, and that’s what matters most. And that’s what I. I care about more about that over money, obviously. I want to create a living. It’s sustainable for all of us. But like, if that part’s not there, then I’m not any different than that community mental health agency that no one wants to work in. Andrew Burdette 00:46:22 Everyone gets free coffee if they come to the meeting as well, we get paid. So I want my one quarter time contractor insisted on buying your own during Friday. I was like, fine, I’m not gonna. I’m not. She’s like, the first choice is like, hey, do I have to go into mediation mode? I’m like, I’ll show you how simple this is if you want to buy it. I’m not going to argue. And there we went. So that was that. So he’s like, cool, did my job done? But yeah, the competing with the larger businesses, it’s hard because again, there’s there’s other streams of income that go in there. And some of what may be there too may have nothing to do with mental health. So for example, Ingles, which has a large local regional, grocery store chain up here. They’re one of the largest real estate owners in the area, because what they’ll do is they’ll buy out any building that another grocery store could potentially move into and then deliberately leave it vacant. Andrew Burdette 00:47:13 So they own a ton of real estate that has nothing to do with what they do as a business model, because that’s their that’s their business strategy of playing defense. The old Kmart building in West Asheville would be a perfect roller skating rink, but Ingles owns it and they suck. So anyways like so that’s that’s some of the other ways like what we run into in terms of competition. Because again, if you’re competing with an agency that owns several buildings and is renting out large amounts of that in a profitable kind of way, that allows them to spend that money elsewhere and invest it in other people with for one K matches or other things like that. But unless you’re in a position, you own a building and are renting out 2 or 3 floors of it, you’re not necessarily going to have that same extra line of business and income, Right. So I think that just maybe summarize like as you’re talking to people that are coming in, it’s it’s the cultural side of things is probably the biggest benefit that we get to create the interpersonal dynamics that we can kind of create as a, as a company owner and manager of people that really personalized one on one mentorship that we can do, which are generally not going to get at an agency. Andrew Burdette 00:48:20 the discussion you all have access to, like GPL, like GPL and Gppb. so one of I can’t remember which one of those was talking about clinical supervision and offering that through. I’m of the opinion and I think I commented to this effect that like having outside supervisors, always a nice idea if you’re someone that’s still in supervision. And that way if something goes really haywire, whatever place you’re working, your licensure level stuff’s never disrupted. I think it’s also really good to kind of have that extra layer of accountability, because if you are the boss and the administrative supervisor, as well as the clinical supervisor for licensure. There could be some conflict of interest there, right? And offering supervision is definitely a big perk that you can do to people in a or do for people. And if you can find a way to have somebody in your team to do that, rather than you as the actual hiring in charge person, you’re probably going to be better off, even if it’s like a little bit different of an expense, but that increases the retention of the person that’s doing supervision for your company as a clinician as well, because it kind of gives them an extra thing to do, kind of reduces that conflict of interest thing. Andrew Burdette 00:49:30 Because if you have to come in and just say, hey, you’re consistently late to work every day or you’re not getting your notes done and on time or these other things that are both clinical and also like administrative, you’re not having to delineate which that you’re wearing. you can absolutely do both of those. So as long as it’s clear. the person I have that teaches a legal and ethics course for state that comes in, I’ll do monthly supervision for my practice two. she has been in in previous roles like worked in community and mental health setting. So she was in charge of hiring and firing clinicians and any support teams like peer supports and other things like that, was providing the clinical supervision for everyone. And, would occasionally have to kind of bring people in and to say, hey, I need to have a conversation with you. I’m going to be clear that this is as a clinical supervisor. So this is how we’re talking in this way. And these are things that relate directly to your licensure and ethical codes. Andrew Burdette 00:50:26 And now I need to switch over to as your boss as the administrative supervisor from this business standpoint and business leadership standpoint. Let me clarify what that’s going to be here. So you can do it. It just has to do with your level of how well you are at boundary setting, and how comfortable you are about being assertive about. Here’s what that looks like, if that makes sense. But supervision would be probably the other big benefit that’s unique to our field that you can offer to people as a benefit. So we got about eight minutes before 2:00. any questions around this or left over from past things? It hasn’t been covered that you want to pick my brain or pick someone else’s brain about things? Sure, sure. Go for it. Speaker 8 00:51:08 so I recently offered a position to a new clinician, and wondering how long you would, like keep that offer open. because I don’t need to hire somebody right now, but in the next probably month or two, I would like to bring them on. Andrew Burdette 00:51:25 So it’s kind of really up to you, I guess it’s kind of it. Andrew Burdette 00:51:30 the job offer letter, that I gave to people had like a you have to accept by a certain date kind of listed in there. I don’t know that that’s necessarily true for, like, the contract world. obviously, you can kind of set how far out that offer letter is valid for. it’s really up to you, I guess, in terms of just like leaving out how long you’re willing to leave that open, that offer extended to somebody, and just have that conversation with them about, hey, I’m not I’m not in a push to hire somebody and start them this week. But, I need to hear back by, you know, on June 15th, because otherwise, like, I’m going to need to fill I need to fill this position and have somebody starting by June 15th. So, I’m going to continue to talk to people unless you follow through on the offer. Might be you could kind of couch stuff that way to kind of put a little pressure on them, or just set some deadlines and expectations about, I need to know one way or the other by X timeframe. Speaker 8 00:52:32 Okay. I had originally given her two weeks, but I’m noticing, like my own anxiety of like, I keep checking emails and seeing if she’s responded. and then I’m like, why am I doing this? I don’t need her to start right now. Like, it’s fine. Just let her you you gave her two weeks to decide. Let her have that time to decide. Andrew Burdette 00:52:51 So for me, with what I’m working. So I’ll get anxious about things like that, that I want to know something now, but realize there’s a time frame on it. And so the game I’ll play with myself is like, okay, so thank you for the part of me that’s concerned about this, because clearly there’s a reason to have this there. And, you know, are you okay to kind of like stress about it for 5 minutes or 10 minutes or whatever you said. And then kind of after that we’re going to go do something different. Right? So that’s usually successful in helping me like acknowledge that stress and then also kind of move on from it. Andrew Burdette 00:53:24 but whatever game you need to kind of play for that part of you internally to like, it’s important to acknowledge that you can’t just tell it to shut up. It’s still going to be there, right? Like it’s like saying, don’t be anxious, right. Like it’s not going to work. So yeah. So there’s your little parts work for for thinking around that kind of stuff maybe. Thank you. Yeah I think one of the hardest things to do and the longer you do this, like I do, think it gets somewhat easier because you kind of get accustomed to it, but just being able to separate out things you need as a person, and then structuring how your business functions and your relationships within people that are involved in your business from a business standpoint. And part of that’s including acknowledging their needs as well. So like for example, my clinician that just started like was getting kind of frustrated about how long it takes to build a case because we didn’t really have that discussion. And it was just like, this is normal, right? Like it takes a couple months to get there. Andrew Burdette 00:54:22 Right? And I’m sorry, we’re having this conversation 2 or 3 weeks after you kind of officially started and kind of having that. And if the stress of having a couple months to kind of on board and ramp up is too much and you need to go, I’m okay with that. Like, really like legit said, I’m like, I’m fine with that. If that’s where your stress and anxiety levels are. This isn’t for everybody. I’m not going to be upset about it, but let’s just have a discussion around that and what your needs are And that way, the part of me, it’s like, man, I’m going to be bummed if I spent six months kind of recruiting a fresh grad out of school, and it doesn’t work out personally, going to be bummed business wise. It’s not the best thing, but overall, from a business standpoint, everyone ends up where they need to go for what their needs are and balancing out that professional balance and personal needs and stress levels and stress tolerances and things. Andrew Burdette 00:55:10 So learning how to separate that about business wise, this is the timeline things need to happen on from from a logistical business standpoint. And then personally how do I like navigate that. And maybe what you learn is one maybe two weeks is too long in the future. So maybe it’s like, hey, this is good for a week and I’ll follow up in a week, and I kind of need to know something or not. And that’s just balancing your personal threshold with the needs of the business. Always an ongoing balancing act, isn’t it? Depending on how long you’ve been hiring and stuff, you’ll probably have those people at like at a somebody went to school with kind of buy me dinner in December. He was getting burned out of their location. I was like, hey, I really want to like, join your practice and stuff. He’s like, I’m going on vacation for a couple of weeks and I’ll let you know when I come back. Well, he kind of got rebooted and stayed where he’s at. Andrew Burdette 00:55:58 I would have been happy to hire him as somebody else. I worked with, when I was a grad student that, had reached out and wanted to leave, community mental health setting, and we were going to meet for dinner 2 or 3 months ago. I haven’t heard from them. I’m also not recruiting them because they’re not exactly I they’re not the right kind of avatar for who fits my practice. So they would do better elsewhere. They would be one of those ones I’d probably steer them more toward, like one of those larger agencies that can provide more stability around things, because I think they would do better there, and they’re more general in how they work with people. And that’s great. I’ve just not the right practice for you. And so I’ve kind of relief to not have to have those conversations because they kind of work themselves out naturally. But it is one of those things kind of knowing of like, I’m really wanting people to kind of specialize in XYZ with these approaches. That’s who’s going to best fit in here, as well as that high degree of autonomy and being really happy and easy to respond about. Andrew Burdette 00:56:51 Who do you like to work with and how do you like to work with them? And quick answers for that versus the I don’t know yet. thanks for coming. You’re kind of coming right up at the top of the hour. Like always, if you have questions or whatever, please send me messages and things. If there’s something you definitely want to make sure I cover for next week, let me know. Or if you want stuff covered in a different way, let me know too. I’m still kind of new to teaching a whole series of this kind of stuff, and it’s obviously really detailed. So you could kind of write out slides and slides and slides and slides for days. I don’t enjoy that particular style. But if it’s the kind of thing to have like a summary of things, let me know to I can kind of package things together and try and get stuff in a written format, so you don’t have to scroll back through the video and try to figure out where it happens. So and then if you came in late in the chat, there’s the link to the Google Drive thing. Andrew Burdette 00:57:39 I will also post that in the event link to. And then you can kind of find it and play with it and stuff like that and see if it works for you. So cool. Speaker 9 00:57:48 Thank you. Andrew Burdette 00:57:49 You’re welcome. Have a great rest of your week and see you next Tuesday. Speaker 9 00:57:53 Thank you. Speaker UU 00:57:53 Bye bye. Bye. Joe Sanok 00:58:02 Well, thank you so much for listening to the practice of the Practice podcast today. These trainings are available in our membership communities. Now we’re going to be opening up our membership communities more than just when we’re opening Level Up week. So if there’s one that you are interested in, I would love for you to head on over to practice of the practice. Com forward slash membership where there’s more details and you can get notifications when those open up. So if you are in solo practice just getting going, if you are building and sustaining a sustainable solo, practice next level practices for you. If you are looking to launch a group practice, group practice launch is for you and group practice boss is for all those group practice bosses out there. Joe Sanok 00:58:41 You know, we also couldn’t do this show without amazing sponsors like Therapy Notes, therapy notes is the best electronic health records out there. They will help you switch over from your current EHR. they also give you two months for free or just money off if you use promo code Joe at checkout. they are phenomenal. They help with automated billing. it’s going to make it easier to outsource your billing. So many reasons to switch to therapy. You know, it’s just head on over to therapy notes.com. Read about it and at checkout just use promo code. Joe. Thank you so much for letting me into your ears and into your brain. Have a great day. I’ll talk to you soon. Special thanks to the band. Silence is sexy for that intro music, and this podcast is designed to provide accurate and authoritative information in regard to the subject matter covered. It is given with the understanding that neither the host, the producers, the publishers or guests are rendering legal, accounting, clinical or other professional information. Joe Sanok 00:59:37 If you want a professional, you should find one.