Negotiating Sliding Scale

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Negotiating Sliding Scale

Curt and Katie chat about the pros and cons of sliding your fee for therapy services. We look at the theories around fee-setting, sliding fee scales, and conversations around money. We discuss what actually makes a difference in determining if clients are invested and will benefit from your services. We also dig into the laws, ethics, and practicalities if you choose to offer sliding scale in your practice.

It’s time to reimagine therapy and what it means to be a therapist. To support you as a whole person and a therapist, your hosts, Curt Widhalm and Katie Vernoy talk about how to approach the role of therapist in the modern age.

Transcript

Click here to scroll to the podcast transcript.

In this episode we talk about negotiating sliding scale:

Feedback from our conversation with Tiffany McLain
Clinical theories on how fee impacts the clinical relationship
The different ways that people enter into therapy, different financial situations, etc.
A more nuanced conversation about sliding scale fee
Freud’s views on having direct conversations with clients on fee
How clinical orientation can impact how therapists view fee-setting
The idea that fee must be set at an “uncomfortable enough” that clients invest in therapy

“It has to be enough of an investment that people invest in therapy.” — Curt Widhalm, LMFT⠀

How fee paid impacts attending the last session
Different types of investments that might impact how much people benefit of treatment
Practical ways to assess what fee would be in the sweet spot for sliding scale (e.g., written out scale, financials, etc.)
Do therapists show up differently for clients who pay more or less?
How fees average out among larger caseloads
Incorporating outcome measures and practice-based evidence to assess whether you are showing up differently for clients who pay more or less
Mythology around what we have to do and what is best to do
Laws and ethics, practical considerations
Usual and Customary fees
Advertised fees
Philosophy related to how you set your fees
The impact of insurance on our profession related to sliding scale
Ethical codes on fee setting related to services provided and client ability to pay
Models of subsidy for mental health services
The need for a standard justification
The risks for insurance fraud related to fee-setting and accepting copays
The ability to adjust usual and customary fee as needed as long as it doesn’t violate state law
What we have to do and what the softer, virtue ethics might recommend
The importance of accurate billing and justification
The tension between the equity argument and the practicalities of business
Are you unfairly treating clients who are paying less?
The need for pro bono work, but not sliding scale work
The need for clinician-led discussions and opt-in from the client
Check your insurance contracts, advertise your fees correctly, written basis for a range of fees
Options for sliding scale
Other models for addressing access
How to create a sliding scale practically
Why you need to identify what you need to make on average per session

“You set your fee, but you have to charge it, or at least charge that on average in order to meet your expenses.” — Katie Vernoy, LMFT

Moving your sliding scale or pro bono work outside of your practice
Our recommendations for Open Path Psychotherapy Collective and Give an Hour

Doing some math and making sure that you are making enough per session on average:

What’s Needed:

		Required Annual Revenue (includes practice expenses, taxes, and required take home pay)
		DIVIDED BY
(Preferred number of Work Weeks per year)	X	(Number of Scheduled Sessions per week)	X	(Your typical Attendance Rate – usually 80 or 90%)

What you’re actually making on average per session:

Actual Revenue per month

DIVIDED BY

Number of Actual Sessions per month

A Message from Therapy Reimagined:

Therapy Reimagined 2021 – The Modern Therapist Conference

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We’re looking for right-match sponsors & exhibitors. We are seeking collaborative relationships that support the psychotherapist community. We commit to intensively engaging our audience with our valued sponsors and we love when our sponsors are actively involved in our conference.

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Marriage and Family Therapists, Social Workers, Counselors, Psychologists, and other mental health and wellness professionals

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Resources for Modern Therapists mentioned in this Podcast Episode:

We’ve pulled together resources mentioned in this episode and put together some handy-dandy links. Please note that some of the links below might be affiliate links, so if you purchase after clicking below, we may get a little bit of cash in our pockets. We thank you in advance!

Articles mentioned:

Pope and others: https://psycnet.apa.org/record/1976-10249-001
Freud, S. (1976). On beginning the treatment. In J. Strachey (Ed. & Trans.), the standard edition of the complete psychological Works of Sigmund Freud. (Vol. 4, pp.123- 144) New York, NY: WW Norton and Company. (Original Work Published 1913).
Menninger, K. (1958). Theory of Psychoanalytic Technique. Basic Books Inc. New York: New York.
Sammons, Katherine E., “Differences in Treatment Utilization Between Fee Paying and Non-Fee Paying Clients in a Counseling Training Clinic” (2019). Dissertations. 555. https://digscholarship.unco.edu/dissertations/555
Good Therapy article on Setting Sliding Scale Fees
CPH and Associates article: Sliding Fee Scale
CPH article: Setting Fees

Tiffany’s Fun with Fees Calculator

Alternatives to Sliding Scale within your own practice:

Open Path Collective

Our interview with Open Path

Give an Hour

Relevant Episodes of MTSG Podcast:

Overcoming Your Poverty Mindset

Making Access More Affordable

Who gets to have therapy?

Antitrust for Therapists

In It For The Money?

Who we are:

Curt Widhalm, LMFT

Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com

Katie Vernoy, LMFT

Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com

A Quick Note:

Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.

Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.

Stay in Touch with Curt, Katie, and the whole Therapy Reimagined #TherapyMovement:

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Modern Therapist’s Survival Guide Creative Credits:

Voice Over by DW McCann https://www.facebook.com/McCannDW

Music by Crystal Grooms Mangano https://groomsymusic.com

Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):

Transcripts do not include advertisements just a reference to the advertising break (as such timing does not account for advertisements).

… 0:00
(Opening Advertisement)

Announcer 0:00
You’re listening to the Modern Therapist’s Survival Guide where therapists live, breathe, and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm, and Katie Vernoy.

Curt Widhalm 0:15
Welcome back modern therapists, this is the Modern Therapist’s Survival Guide. I’m Curt Widhalm, with Katie Vernoy. And this is the podcast where we talk about all things that affect therapists, our lives, our businesses, our practice, and the things that we want to do nice for other people. And following up on an episode that we did a couple of weeks ago with Tiffany McLain, we got some feedback from some listeners about sliding scale and about the emphasis on access to mental health care. You know that this is a position that a lot of us want to do good for our communities, expand access to care. It’s something that Katie and I talk about from time to time. We wanted to speak to the sliding scale aspect of practices, of the ways that we go about this, the implications of what it means. Does it actually work with clients who pay a sliding scale fee? Do we show up fully as therapists in those sessions? And here’s the the too long didn’t listen to the entirety of the episode: It depends.

Katie Vernoy 1:27
That’s such a therapist answer. It depends. Well, I think just to summarize beyond ‘it depends,’ I think in the Overcome Your Poverty Mindset episode, Tiffany was talking about the financial capacities of clients, as well as the financial stability for therapists. And some of the arguments and I think subsequently, you did some research, I’ll turn it over to you in a second Curt. But there’s a lot of different clinical theories around how fee impacts the clinical work. And so one of the things that Tiffany was positing was that clients who pay less may not value it as much. Clients who ask for a sliding scale may be disrespecting you or may be asking for rescue. I mean, I think there was different ways to take that in, I think there was a lot of it depends. If the client is dedicated to therapy, there are a lot of different ways that you can go about identifying their fee. But the thing that I kept coming back to is that there are truly different ways that people enter into therapy. I have a hybrid practice, I do have some insurance clients and some clients that pay privately. And they’re also people who have very different financial situations. And so to me, that felt like it was more of a nuanced conversation around fee than what we were having, because I think the conversation truly was about therapists need to charge enough so that they can make a good life and they should be able to develop wealth and to, to do the things that everyone else feels entitled to do. Like we we haven’t made a vow of poverty. And so to get down into it, because I think each of us are going to approach things differently given our own financial situations, our own philosophies, even our own clinical orientation. I really wanted to be able to kind of look at, well, starting with kind of the clinical theory around it, dig into some law and ethics, and then and then touch into the practical that if you’re going to do something like this, how can you do it in a way that still makes sure that you can have a viable business that takes care of you? So starting with clinical, there are folks that say it doesn’t matter the fee, people will get the value they get and there are people that say that if people pay nothing or pay very little that they won’t value it. So what did you find in the different clinical orientations?

Curt Widhalm 3:51
Like all confusing things in our field, we’re gonna start with this, this got confused by Freud. So…

Katie Vernoy 4:00
That Freud.

Curt Widhalm 4:01
So, Freud conceded that sometimes maintaining strict fees prevented people from actually accessing psychoanalysis. But Freud was still a fan of having pretty direct conversations with clients. And this was kind of echoed through some other psychoanalytic thinkers, probably most notably, Karl Menninger, who was a big advocate of: we should be talking about fees with clients all of the time. And this is something that models to clients healthy boundaries, that there should be a fee, and kind of the overall discussion in the psychoanalytic community, from Freud’s time on through, you know, even Tiffany, you know, kind of talks about like, the clients need to pay an amount that is uncomfortable enough for them to where they’re invested into the therapeutic process. Which leads to kind of all of our theories of leading to a good psychotherapeutic alliance.

Katie Vernoy 5:02
So, you have to be uncomfortable enough for it to actually be an investment.

Curt Widhalm 5:07
And this might be kind of my oversimplification of words. But in our discussion before recording this episodes, we kind of were talking about that it has to be enough of an investment that people invest in therapy that…

Katie Vernoy 5:21
Yeah.

Curt Widhalm 5:22
And that’s totally independent of which psychotherapeutic approach that you take. But this does lead to, you know, what, what does that investment mean? And there’s a lot of really mixed research out there on clients outcomes, when it comes to what they pay. And probably one of the more cited ones on the side of it doesn’t matter was this study done in the 70s, by Pope and some other people around that outcomes of clients just kind of didn’t track based on the amount of dollars that they spent in therapy. And, you know, for, I don’t know, anywhere else in the world that doesn’t have the economic system developed around their mental health stuff like the US does, pretty much see that echoed there as well. Sorry, foreign listeners, this one’s pretty unique to American therapists. But there, there is a mixture of some of this other stuff, too. That some studies show that there’s a pretty predictable amount of dollars paid per session that can predict whether or not clients are going to show up to their last session. And this is data…

Katie Vernoy 6:40
Ooh, that’s interesting.

Curt Widhalm 6:41
…from sliding scale clinics. The research on client outcomes is really all over the board. And seems to have stopped in the early 90s. Like all of all of the analysis, meta analysis reviews that I was kind of looking at this stuff is this seems to be a pretty big popular question in the 70s and early 80s. That kind of started dying out, hasn’t been looked at a whole lot. And I think getting into some of the law and ethics will tell us kind of how those laws and ethics shifted our field at that time, to where it made it harder to research and kind of left us in this lurch of what has happened in the past still being kind of echoed as far as do good things that we should be doing as therapists, but don’t necessarily reflect the model of where our profession is today.

Katie Vernoy 7:31
So before you, we dive into on ethics, I’m really curious about the study with fee versus attending the last session.

Curt Widhalm 7:38
So I don’t have the study right in front of me, but we’ll put it in the show notes. And Katie will draw a big arrow in the show notes to this one.

Katie Vernoy 7:48
I’m not drawing an arrow, I’m just gonna put the link in there.

Curt Widhalm 7:52
But it predicted that the more that a client was paying for therapy, the more likely that they were to attend their last termination session. There wasn’t a big enough sample size to really parse out whether this was clients would reach their treatment goals versus clients who were wanting to just withdraw from therapy, and we’re just kind of ghosting their therapists. But it did say that the more that clients were paying for their last session, all of their sessions, it’s not like they were raising their fee for the last session. Don’t charge like $8 million for a last session just for people that show up. I’m pretty sure that would go back against this. But…

Katie Vernoy 8:31
Yeah, it would be pretty bad.

Curt Widhalm 8:32
The people who had more heavily discounted fees were less likely to show up to those sessions.

Katie Vernoy 8:38
And I think there’s there’s so many different reasons, but I for the folks who I’ve had at my full fee, oftentimes, they will let me know this is the last session and they’ve you know, or next session is the last session because they also don’t want to be charged again. Whereas somebody paying less, maybe less concerned about a late cancel or no show fee for their last session. Okay, so when we look at the different theories, when we look at the the clinical elements of this, it looks like there’s confusing research. People may or may not value therapy more depending on how much they pay. But my interpretation of what we’ve talked about both in this episode and before is that when people are more invested in it, so if it’s a higher percentage of their income, so somebody could be paying $100, that’s where they max out, they are uncomfortable. They’re invested, they will get a lot out of therapy, someone where $200 is pocket change may not value it as much because they’re not in that uncomfortable space. There’s also other types of investments. I worked a long time in public mental health where people were paying $0.00 for therapy. And there were folks who invested a lot in attending sessions regularly and they invested in finding childcare care and paying for public transportation or making sure they got the funding for public transportation. And so they were also very invested. Whereas there were folks who were less invested and got less out of it. So level of investment, not actual dollars, clinically has been shown potentially, that that’s, that’s more indicative of clinical outcomes than final dollars. Like…

Curt Widhalm 10:24
Oh, and this goes back to the the question of how many therapy clients does it take to change a light bulb? Just one, but they really have to want to change the light bulb. And this goes back to that question of people who are invested to make things work are more likely to make it work.

Katie Vernoy 10:46
Yes. Absolutely.

Curt Widhalm 10:47
One of the indirect ways that I think our profession has flipped this backwards, and we’ll get to kind of a practical way of flipping this back to being forwards. But one of the ways that we have flipped this backwards is by creating this uncomfortability with clients, like it’s the shorthand way of like, how much would you need to pay for this, either directly to me or overall in your life to make this worthwhile for you changing. And the even shorter hand of that is, I’m going to charge you enough, you know, I’m going to look at your whole family income, I’m going to create a little chart of how many people are in your households. And, you know, you’ve you’ve got two jobs that in your household that pays this much money, statistically, you would be uncomfortable if I, you know, match these numbers up and charge you in this box here. And I’ve seen sliding scales based solely on people’s tax returns.

Katie Vernoy 11:47
Yeah, and I mean, I think you’re talking about the ones that are like these actual written out scales that say this is a household income. And people either ask for proof of income or tax returns or rely on the honor system for clients to put forward that, that number.

Curt Widhalm 12:02
And if you’re horrified by doing this, especially in private practice, then you fall where most clinicians do, which is being afraid of asking about people’s money.

Katie Vernoy 12:13
Yes, yes. Before we move into that, the other element, because I want to touch on a clinical element that that Tiffany went into is, is the reverse. Which is the argument is therapists will show up more because the therapist financial situation is the same across all of their clients. And so clients who pay me more, and this is kind of what Tiffany was saying, I’m going to show up better for then clients who pay me less. Is there any research on that? Because I think that would have an impact on outcomes, too. If therapists are doing better work with folks who are paying more. Personally, I find that that’s not really the case. I think there are probably times when it could be. But I don’t think it’s it’s generally not how I operate. And I think ethically, we want to show up the same for every client, regardless of what they’re paying. But what what are your thoughts on that? or what have you found anything on that?

… 13:05
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Curt Widhalm 13:05
I haven’t found a lot. And so I’m going to speak a little bit more anecdotally here. I see this happening, mostly when people first move into for profit sort of situations. Where the the payment by the client is something that directly impacts the monetary life of the therapist. And this is often seen where we see people get shuffled from a free system where they volunteer, too, all of a sudden, they’re charging a client, you know, $100-$150, a session, that this is just a astronomically different price amount. I also see this when people tend to have smaller practices where people have more of their percentage of practice being tied up in a smaller amount of these clients. That if you have a larger caseload, the fees tend to average out. And anecdotally, what I’ve seen, not only in my practice, but also across a number of other people’s practice, where we’ve talked about this particular issue. Is that later career clinicians tend to kind of average out in their output unless they feel that they’re more invested in clients outcomes, and they’re doing more work. This is where that adage, don’t work harder than your clients comes in. That’s where I see it come up. But overall, anecdotally, it doesn’t seem to be something that is affecting clients. But this is where the push towards doing good outcome measurements with your clients allows for them to be able to reflect that back to you and is something where having practice based evidence with your own clients allows for you to be able to see that you might not be showing up as well. And getting that direct feedback from your clients is a really good example of it. But going back to something that Tiffany was talking about is: you are also responsible for leading conversations around are the clients only giving you better session ratings because you’re subsidizing their therapy?

Katie Vernoy 13:05
Yeah. Yeah. Yeah, I think it’s it’s, there’s so much that goes into it. And it is such a complex area. I think clinically, it’s, it’s, it’s something where we, I think we should move on to the law and ethics at this point. But clinically, it seems like there are things that could come into the room, around sliding scale, there’s not evidence that people will not get benefit, if they are paying less than your full fee. But there are things, there are considerations that you want to make sure that are there where whether it’s, are they investing appropriately, whether that’s financially or time and energy, or value or whatever? And then also, are you talking about the things that could be happening based on how fee was set? So there’s a lot of, I’m gonna call it mythology, because I was trying to look into it. And I don’t, I’m not the law and ethics expert like you are. But there’s a lot of mythology around what you have to do, or what might be best to do, as well as people that are just kind of free floating in this sliding scale arena. Some of the things that I think are important to talk about are setting a usual and customary fee. How to set your fee and then deciding on your sliding scale, whether or not there’s risk for insurance fraud, depending on how you report fees out. And I think that one may be off the off the table here a little bit. But then also, I’ve had folks talk about where you put somebody even on your schedule, like do you only put full fee, full fee clients in primetime slots? Is that ethical to do so? Do you need to kind of have the same accommodations treatment for all clients, regardless of how they’re paying? I mean, there’s, there’s so many pieces to this, that, you know, I think most therapists, at least anecdotally, set their fee, they slide a lot, they only, they basically are just negotiating client by client, and there’s not a lot of theory around how they do it. And there potentially is some risk that they’re they’re putting in by doing it that way.

Curt Widhalm 15:53
So we’re gonna put in the show notes, a couple of articles from CPH Insurance, and particularly Richard Leslie, who writes her avoiding liability blog over there. That talks about where some of this comes from, and why you’d need to be more specific in this. And while these are articles that are 10 plus years old, these still hold very, very strongly. And the earlier of the articles, Richard talks about having a usual and customary fee for a number of reasons. And part of this ends up dealing with some of the clinical stuff of if you’re seeing clients who know each other and one finds out that they’re paying way more than the other one, that that’s something that can potentially impact your therapeutic alliance there. That’s managing stuff on the clinical end of things. But where I do love Richard’s background as an attorney in this is that this also gets into needing to be aware of what your state laws are. That many states have laws that you need to be able to put a predictable and specific number as far as what your advertised fees are. And so if you have, you know, on any of the online therapy platforms, where you’ve got a range of fees going on, you need to be able to in some states be able to justify what those fees are based on. And so if you have a range that’s out there, and it’s your justification is just kind of, I don’t know, ask, you’re, you’re essentially running against your state laws right there. So you do want to do that. But where a lot of this stuff comes from, and what I was talking about earlier in the episode is the impact that insurance has had on our our profession here over the last 40 years when it comes to where these sliding scales are. And this deals with whether you take insurance or not. Because when managed care around behavioral health really took hold in the 80s. This is where lower fee therapy got subsidized by the insurance companies, by people who are paying premiums. And this has its origins even going back into the Medical Associations and ways that laws even earlier… I see Katie’s eyes glazing over so I’m going to try and make this as quick as possible. But in the US in the late 1800s physicians went from needing to provide good health to everybody to actually being able to charge more for their fees. And so this goes from a just creating health model of delivery to creating health and wealth. And so what a lot of physicians did was raise their fees. And for people who couldn’t afford those fees, those clinicians, like many of us in private practice today with our well meaning things, you start charging higher fees for some clients to subsidize paying for the lower fees that other clients would be paying. And so it was creating kind of the subsidy system. And this actually made it into the American Medical Association’s code of ethics 1957 it talked about fees should be standard and charged based measurably on the services provided and the client’s ability to pay. But that went away in the 1980s as things like Medicaid and Medicare said, you have to charge people the full fee if they can afford it in order to be able to be in network and be subsidized by Medicare and Medicaid, for thelower fee clients, and this was followed by private insurance companies and stuff too. So what we are left with is this, as providers, they’re still kind of this ethos, even though it’s only kind of mentioned in some ethical codes, we still need to provide health to people. But we still have this ability to provide wealth for ourselves. And these are in conflict here. And that is why we’re talking about it this episode.

Katie Vernoy 21:29
So what’s interesting about that is a logical way to set up your practice is to have a range of fees that allow you to charge an average rate that some people pay more if they can afford it. Some people pay less if they can’t, and you can create wealth based on kind of having your clients subsidize each other. And I think that makes a lot of sense. But with the insurance coming in, are you saying that they took that ability away?

Curt Widhalm 21:55
Saying that the insurance companies argument on this is if you’re acting like an insurance company and subsidizing some of your clients, with some of the other things, what you’re not doing is providing a usual and customary fee, unless there’s a justification that is standard for that.

Katie Vernoy 22:11
Got it.

Curt Widhalm 22:12
And especially if you’re doing this with insurance clients, and this is where we’ve all been kind of vaguely warned before of, you know, if you don’t accept a copay with your client, then you’re violating your insurance contract.

Katie Vernoy 22:26
Yeah.

Curt Widhalm 22:26
Which is absolutely true you are. And so this now becomes something where for therapists, and this is really hard to explain to clients when they want help. But for therapists, what this has done is taken this feel good, we want to provide health aspect and put it into a avoiding liability part of our profession.

Katie Vernoy 22:26
Got it.

Curt Widhalm 22:29
This is where the conflict really comes up is: We want to help people in our profession, that’s what draws a lot of us into this profession. But the fact that this particular aspect of it, of providing broader care, has a legal basis for us to really be specific for why we provide sliding scales. Because it potentially puts us in terms of insurance fraud.

Katie Vernoy 23:22
Well, there’s insurance fraud, but I I’m also hearing and maybe this is the element you’re talking about. But I’m also hearing that if I if my fee is $150. And I don’t charge more than one person that fee, my my usual and customary fee is actually much lower. And so claiming that in a you know, some sort of insurance, billing or those kinds of things, and maybe this is to to down a rabbit hole. But to me, it seems like when I say my fee is this, but I never charge it. Beyond what the insurance company says about it, are there any legal or ethical problems with that?

Curt Widhalm 24:05
So I’m going to point to the 2014 ACA Code of Ethics where they added standard A-10-C that counselors may adjust fees if counselors usual charge creates an undue hardship for clients. Even the ACA says that we need to make sure that that sliding scale or that fee adjustment doesn’t violate state law. And even they point out that when it comes to insurance companies, you really have to look at what the contract says there. So that’s in addition to whatever state laws sort of things are. When it comes to sliding scale stuff like this, that when it comes to an ethical question, a lot of the professional organizations are going to largely bypass this answer because then it gets into a whole antitrust thing of telling people how to run their businesses and…

Katie Vernoy 24:50
Ah.

Curt Widhalm 24:51
So when it comes to hard, specific ethics, I don’t think that we’re going to see anything like this, but this falls into the softer unspoken ethics, which are a lot harder virtue ethics sort of things that nobody’s going to get, you know, the ethical police coming after them, you know, you’re getting your sliding scale wrong. But a lot of these softer ethics are still going to be very much in that same spirit of helping you to avoid the legal liabilities that would come along with this. And so if you are doing anything, and this may even include things like, you know, super bills and insurance rates and this kind of stuff, that you still have the responsibility to accurately bill. You know, your usual customary fee, like you’re talking about which, you know, here in the next section of this, we’re going to talk about practicalities of how to do this, but your super bills need to reflect what you actually charged those clients. That probably also needs a number of practical things as far as what that service actually entails. You know, if you’re including letter writing in part of your session fees, and that kind of stuff, that’s going to be something where your time investment goes into that. And that might be where, you know, some of your resentment ends up coming in towards clients. You’re doing a lot of in between session work that gets unbuilt.

Katie Vernoy 26:14
Yeah.

Curt Widhalm 26:15
But this comes down to accurately reflecting what you’re doing and having a good justification for it. The ethics behind that is to help you follow the laws.

Katie Vernoy 26:25
So, I want to talk about what those laws are. But first, I’m just thinking about the soft kind of the moralistic ethics, which is, if you have a fee, you should charge it or have good reasons why you’ve done a sliding scale. I think there’s also all the other pieces around what time you schedule clients who are paying less money, you know, how long the sessions are, how you show up, I mean, to me, there’s, there’s something around like, I’m I should, so this is I feel like the kind of the morals and values ethics, I should treat all of my clients the same. And I should be able to do X, Y, and Z, like I should be equal and have equal access and all of those things. And I think I do that myself, and I and I definitely value that. But there’s also the seller, other element of I’m a business person. And so I need to reserve prime spots for people who can pay my full fee, because otherwise they won’t book with me and they won’t be able to, I won’t be able to do those things. I should be able to identify how I show up for each of my clients and what services they qualify for based on what they’re paying, and those kinds of things. And so there’s the business element of it, it’s my business, I can charge people what I want. And then there’s the ethics element of I should be equitably showing up for my clients regardless of what they pay or how they cover their services.

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Curt Widhalm 27:48
Good therapy is good therapy and bad therapy is bad therapy. That is going to be any number of the other decisions that we end up putting around people that prey on the awkward sliding scale spots on times where they’re street cleaning. And, you know, half the neighborhood parking is not available and sliding scale people have to walk past, you know, six blocks worth of, you know, other stuff that’s going on in the streets in order to get to your office. Are you actually punishing them more than in some of the more prime spots? Are you withholding other aspects of services, and this is where what you’re speaking to is we should theoretically offer all of our clients, whatever works out best for them. And there can be a myriad of rolls around that, that, as far as I can imagine we would look at are you unfairly treating people because they’re paying less. That would be where the motivations would be examined in any sort of a an ethical complaint. And some of the ways of protecting around that are really having a honest and thorough evaluation. But nobody is mandated to do sliding scale work. You know, our ethics suggests that we should do pro bono work, but sliding scale may or may not fit the pro bono part of our ethics. And that’s something where I think a lot of us make an attempt at doing pro bono work in this sliding scale sort of way that might be some of our things. You know, if you choose to do your pro bono work someplace else, you’re probably not going to do it during those, you know, hours where you can charge a full fee. It’s a long way of saying: it depends.

Katie Vernoy 29:43
Well, and I think the thing that I’m hearing is there’s there’s a need for there to be an opt in. And so I think about my first therapist who said she was doing very low fee for therapist students for so I was I was in my grad program. And I opted in to a particular time and a particular fee, because that’s where she had the space. Now, if I wasn’t aware, and she started moving me around the schedule and didn’t promise me a regular spot and and treated me in a way that wasn’t in honor of the relationship we had developed, it sounds like that is where it becomes problematic. If she’s saying, Hey, you’re gonna get all the benefits, but actually, without telling you, I’m not going to give you all the benefits. I mean, I’m just. I love going to the theater. Thinking about the people that pay for like the front row versus the obscured view, like we opt into those situations based on what we want to afford.

Curt Widhalm 30:39
What what you’re talking about, is going back to some of the listener feedback we had from Tiffany’s episode. It’s also going back to what I was reading about Meneger standpoint on this is is these need to be clinician led discussions.

Katie Vernoy 30:53
Yes.

Curt Widhalm 30:54
They they, and repeatedly led by the clinician, and checking in from the clinician on these standpoints because we don’t want the clients to be in this position of unpredictability. And am I being treated this way because I can’t afford things and they don’t know the investments that I’m putting into these things.

Katie Vernoy 31:13
So are there any before we get into practicalities? Are there any specific laws that people should be aware of?

Curt Widhalm 31:19
Definitely want to check with anything that deals with third party reimbursements, and check your insurance contracts, make sure that you’re accurately billing stuff, and make sure that you are advertising your fees correctly. If you’re saying, This is my fee. You need to charge that fee. And if you’re giving a range of fees, you need to specifically be able to say why those fees are what they are. An example of this is you know, we’ll see on some of these, you know, therapists platforms…

Katie Vernoy 31:49
Like directories?

Curt Widhalm 31:50
Directories, fees range from 130 to $200 per session. Well, you need to have probably written basis for why somebody would pay $130 and why somebody would pay $200. One example of this that I did in my practice is, when I was earning my EMDR certification, one of the requirements was having a certain number of EMDR sessions and EMDR clients in order to qualify for that. And so I had drastically reduced my fee in order to meet some of those quotas. But I had created special informed consent with those clients that here’s the basis why you get this fee for this specific amount of time. And this expires, and we will reevaluate on this date, or after I reach my certification, whichever comes first. And so these are things where these are specifically written out policies that are clinician led, that are justified. And those are the kinds of things that you need to do in your practice.

Katie Vernoy 32:51
That seems fair, it seems like a lot of work. And I think a lot of people will be like, I’m not listening. But I think these are, this is where liability rests. This is where risk is. If you cannot explain why someone has a particular fee, or why you slide from one fee to another. You could get in trouble if somebody were to question it.

Curt Widhalm 33:12
Yes.

Katie Vernoy 33:13
Okay. So practicality. So first step is obviously having a theory and writing it down. Like having a philosophy of fee schedule, whatever it is, make sure that you understand it. Now, if all of this seems very hard, one option is opt out of sliding scale.

Curt Widhalm 33:32
Yes.

Katie Vernoy 33:33
You charge your full fee. And if people need a different fee, they go somewhere else. And you you avoid those conversations. Everybody’s the same. Some other options and I think this was I’ll look for whichever article it was in, but you know, a pay what you can model, which I feel like it’s really strange; where the client pays you say, This is my fee, pay what you can every week and people pay like that seems really weird and uncomfortable, but maybe that’s honoring the client, I don’t know. Actually doing pro bono. So you have slightly you have full fee and pro bono. Or and this would be a whole other episode. So I’m just gonna throw it in there or barter. Totally, totally different episode. So there’s there’s other options. But to me, I think to close out this episode, I think it makes sense to talk about how you could do a sliding scale, following laws and ethics and making sure that you’re still taking care of yourself and potentially accruing wealth and living a good life.

Curt Widhalm 34:35
Yeah, and so I know that this is more up your alley. So I’m going to turn this over to you to really be able to describe it, but at the end of the day, you need to be able to pay your bills, you need to be able to have your income. That includes not only covering the cost in your practice, but whatever income that you need, and that’s going to vary wildly from person to person. You have a couple 100 grand of student loans sitting there Your needs are going to be different than somebody who’s potentially later in their life and has all of their retirement not only funded, but they’re back at the point where they’re taking retirement money out and don’t need the money in their pockets as much. So your needs are gonna vary differently wildly in your career. And some of the practicalities of figuring out those needs are more up your alley.

Katie Vernoy 35:26
Yeah, I mean, I think there’s, there’s a few things that come to mind for me and one is setting your fee in the first place. Because I think a lot of people will say, Okay, what is my fee? And they’ll, they’ll figure out their expenses, they’ll figure out how much the you know, both the business expenses as well as personal expenses, how much do I want to take home, that kind of stuff. They will take that fee, or they’ll take that amount per year, they’ll divide it into weeks and number of sessions and say, Okay, that’s what I have to charge. And then they start from there, and then they slide down, which then of course, means that you’re not covering your expenses, because you’re not averaging the fee that you actually need. And so this gets into math, which I know a lot of therapists don’t like. I, I actually like math. So I always hate that stereotype. But, but it’s identifying, if you need to earn about $150 a session, for the needs that you have, you have to figure out how many sessions you’re actually having per week, how many are actually being attended, as well as how many weeks you want to work. I mean, there’s so many things. And so when you actually get down to what you need to average per session, then it goes into how many slots can you have. Now, if you’re not sliding, everybody’s $150. Math is done. If you’re going to slide you have to have clients over $150, in order to average that. And so your full fee might be $180, or $200. And you slide between $200 and $100, and you have a very specific thing. So that covers your costs. And it makes sure that you’re doing what you need to do, but you have to pay attention to the averages. Because if everyone’s at $100, again, you’re not meeting your cost, and you’re not charging your, your your fee. So to me, that kind of speaks to how you’re describing the way doctors did initially with the health and wealth model. But I think there’s there’s definitely a mindset of you set your fee, but you have to charge it, or at least charge that on average in order to meet your expenses. And so I’ll put in the show notes, kind of the math that I typically do. I know, Tiffany has a setting fees calculator, we can put that there too. I think there’s a lot of different ways to sort this out. But it’s it’s something where kind of quick and dirty, it’s number of weeks, you want to work number of sessions you want to schedule and your attendance, right, usually 80% or 90% for most folks, and then you’re going to end and you can figure out what that fee needs to be for the money that you need to bring in. So you can you can do it as let me just kind of it’s a moving average, and you keep a spreadsheet, or you can actually do these are the number of slots at this amount. This is the number of spots at this amount. And this is the number of spots at this lower fee.

Curt Widhalm 38:11
And this is also where I’ll reiterate about bringing some sort of outcome measurements and deliberate practice into your practice to make sure that you’re actually showing up for those clients and that you’re leading those discussions with clients if you are choosing to have that sliding scale aspect. Because this is also about quality of care, and you showing up as well. And that way you’re still valuing the time and the energy put in by clients that we know and have some effective data that your sliding scale is working for both you and your clients still.

Katie Vernoy 38:49
Yes, yes. And I think, to me, I think that that that check and balance is so important, because I think some folks especially if they’ve done too much sliding, they start getting burnt out. And they don’t recognize that they actually will improve their clinical care if they can keep the right ratio of clients at the right rate, because they will be able to cover their expenses, show up and then actually not have lots of extra clients, not have resentment and that kind of stuff. Another thing that is easier is having two fees. So there’s not like anything in between, but like here’s my full fee, here is my reduced fee. And you can then have a number of slots there and determine whether or not you can see someone. And you then also means that you don’t go below that which can get problematic if you start sliding for a lot of folks. So there’s also another way that can be very helpful where you can do some of this either kind of sliding scale access kind of work or pro bono work where there’s organizations that will take care of that for you so you can keep your practice pristine, so to speak. One is Open Path. We actually have partnered with them and so if you tell them that you’re signing up on our recommendation, we do get a little bit of money back. Thank you very much for for that. We like to support good organizations. But they have a sliding scale that’s very tight. They market for those those clients. And it’s a way to give back and or a way to build in a little bit of a practice for folks who have less ability to pay or choosing that type of an access to a service. The other one is Give an Hour. And we’re talking with them, they’re doing great work where they primarily for military, but also people in big crisis, they did some stuff. They’ve been doing stuff for for medical workers during COVID crisis. And they’ve also been doing stuff with people, families at the border, with border separations, as well as with the route 91 shooting, and those types of things. And so that is completely pro bono. But it means that you go, you get a client, you don’t have to do that work to set up your own pro bono slots in your own practice, which then becomes more complicated. So so those are the practical things I’m thinking of. I don’t know, if you have other thoughts on your…

Curt Widhalm 41:06
I just want to say with Open Path and with Give an Hour, that you know, philosophically, Katie and I have made a very big push for individuals to charge what they’re worth. For clinicians across the board to despite their settings to be able to maximize their income and really take care of the clinician work on this. And for us to be partnering with organizations like these where it is volunteering your time, or it is deliberately accepting a sliding scale part of your practice. The reason that we choose these and how it fits within our overall philosophy is, these are opt ins, these are things that you can individually choose to do. It can be a part of how you meet some of your ethical needs. It’s not a mandate, it is not something where the industry is forcing you to work in one of these positions in order to check off a box in order to fulfill the next requirement. And so we see these organizations as very much holding our ideals of expanding access to a lot of clients. And if you’re making all of the decision points that we talked about in this episode, and following all of your laws, and ethics, thinks that these are really good opportunities to match up with them.

Katie Vernoy 42:27
So if you’d like to learn more about Open Path, like I mentioned, we are an affiliate partner with them. So if you mentioned that you found out about them from us, we will get a little bit of money in our pockets, which helps us with our ability to continue doing these types of activities for for all of you. We do have a special interview with Caitlin Irwin, one of the folks over at Open Path to talk more about how they provide these services and how you can get best benefit with them and providing sliding scale.

Curt Widhalm 42:54
So you can find our show notes over at mtsgpodcast.com. And until next time, I’m Curt Widhalm with Katie Vernoy.

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