Building a Better Group Therapy Practice Business Model with Lisa Savage

Lisa Savage [00:00:00]:

I had moments of doubt that we were going to survive and moments of doubt I had 77 people looking at me and I had to tell them, we're not going to make payroll on Friday. That was the hardest thing I've ever had to do.

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Michael Fulwiler [00:00:16]:

This is heard business school, where we sit down with private practice owners and industry experts to learn about the business of therapy together. I'm your host, Michael Fulwiler. To make a real impact, sometimes you just have to take a leap of faith and dive into what you're truly meant to do. Today's guest did exactly that, and she hasn't looked back since. Elisa Savage is a true pioneer in the therapy world. She's the founder of the center for Child Development and co founder of Clinicians of Color. Boasting nearly two decades of experience in the mental health field, Lisa has built the largest black owned mental health practice in the country, providing over a thousand sessions a week. Her journey from starting with no business background to leading a successful, thriving practice is truly inspiring.

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Michael Fulwiler [00:01:03]:

I've had the pleasure to get to know Lisa through Hert's partnership with clinicians of color, and I'm a huge fan of her work. In our conversation, Lisa shares her know how on building a successful and extremely supportive group practice. Her approach to hiring and retaining top talent, including offering competitive salaries and benefits and maintaining a balanced workload, raises the bar for group practices to what she should be. Table stakes for the industry we also discuss navigating the complexities of dealing with insurance companies, advocating for fair reimbursements, and managing billing processes. It's a conversation that encourages us to take risks, keep going despite hardships, and be the change we wish to see in the world. Here's my conversation with Lisa Savage.

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Michael Fulwiler [00:01:49]:

Lisa Savage, welcome to the show.

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Lisa Savage [00:01:51]:

Hi, Michael. Thank you.

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Michael Fulwiler [00:01:53]:

How are you today?

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Lisa Savage [00:01:54]:

I'm good.

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Michael Fulwiler [00:01:55]:

Well, I really appreciate you coming on. We connected on social media a few years ago, and I've been following you and your work since. You're such a pioneer in this space and such an inspiration for me, and I'm excited for this conversation.

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Lisa Savage [00:02:11]:

Oh, thank you. I'm so honored to hear you say that. You know, you do the hard work and you don't know who reaches, so I appreciate hearing that.

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Michael Fulwiler [00:02:20]:

Michael, you started the center for Child Development in 2007, which was almost 20 years ago.

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Lisa Savage [00:02:29]:

Can't believe it.

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Michael Fulwiler [00:02:30]:

Yeah. Congratulations on your upcoming 20 year anniversary and here in a few years, why did you decide to start your own practice?

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Lisa Savage [00:02:37]:

I decided to start my own practice. I had worked for healthcare centers for almost all my career. I started out working, actually, for an agency in Philadelphia, where we worked with people who were impacted by HIV and AIDS. And then after that, I transitioned to working into healthcare facilities. But I'm the kind of person who really needs a lot of space to grow. I have a creative mind. I like to operate outside of the margin, so to speak, to be as creative as it possibly could be. And that just was not possible working for somebody else.

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Lisa Savage [00:03:12]:

And so I thought, you know what? You got the skills. You got the education. You have the ambition. Go ahead and open up your practice. I had previously been employed at a group practice just for maybe less than a year, and it was awful. It was an awful experience. I dealt with a lot of racism, and it just was not a good fit for me for a lot of reasons, but the racism, definitely the top reason. So at that point, I decided, I'm gonna jump ship, and I'm just gonna take a risk and do this on my own.

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Lisa Savage [00:03:44]:

And I have not looked back. I have not looked back.

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Michael Fulwiler [00:03:46]:

What was that experience like in the beginning for you? Taken a business class in graduate school. Did you have any context for starting your own business?

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Lisa Savage [00:03:57]:

So, you know, it's interesting. No, I hadn't taken a business class, but I'm a risk taker, and so I knew that if once I made the jump, I could do it. But I was thinking about this this morning. I come. I'm a third generation business owner. My grandfather owned the business, my father owned a business. And I think that made a little easier for me to think about jumping into being self employed. I did not know my father or grandfather to work for anybody else.

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Lisa Savage [00:04:25]:

They had always owned their own businesses. I think that was probably part of, even though I might not have been conscious at the time, was it just seemed like the thing to do. I didn't have any savings in the bank. I had house. I had a car. And I still was like, I need to do this, and I need to do this now. And I did. And I think an important message to people is that sometimes you decide to do these things and you don't have everything in place, but you figure it out as you go along.

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Lisa Savage [00:04:54]:

Obviously, I've learned a lot of lessons in the process that as a result of mistakes that I've made, but I'm still standing, almost, like you said, 20.

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Michael Fulwiler [00:05:02]:

Years later, I want to get to those mistakes and those lessons. Could you describe some of the challenges that you had when you first started your practice?

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Lisa Savage [00:05:12]:

The challenges. The challenges. So I think, you know, this will resonate with a lot of your listeners is if you're an insurance based practice, you're going to hit obstacles. And so my clientele is mostly folks who have Medicaid. And while that's not a bad thing, you know, it's a niche that I've chosen. It's definitely not a bad thing. But managing all of the iterations of how Medicaid works, so many years ago, it was states manage Medicaid on their own, and they created these mcos, these managed care organizations, and each MCO has their own policies, their own way of doing things. And so in the beginning, trying to navigate all that, figure that out, how do I build this company, how do I build that company, and then how do I get paid? So that was a huge struggle.

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Lisa Savage [00:06:06]:

And again, at the time, I was single, at a house, I had a car, I needed income to come in. So that was really hard. Probably one of the challenges that I would say I'm probably most proud of overcoming is just navigating that whole insurance, the complexities that come along with accepting insurance so that I could get paid. Now that I have a group practice, it's a little bit easier. There's still challenges, but it's easier because I know that funds are going to come in. Back when I started on my own, there were times when funds weren't coming in either because the MCO changed or the MCO wasn't paying us, and it was all on me. So that was a huge challenge for me to overcome, to even get to the point where I thought I was comfortable enough to be able to bring on people that I could then pay on a consistent basis.

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Michael Fulwiler [00:06:56]:

For people who are listening, who are unfamiliar, how is billing Medicaid different than, say, billing insurance and then, you know, being out of network?

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Lisa Savage [00:07:06]:

So it's pretty much the same. Medicaid, at least in Delaware, pays on par with the commercial insurances, which is fantastic. But I think some of the nuances with Medicaid, and I gotta admit, Delaware, their system is a lot easier than other states. However, when you are billing Medicaid, just in terms of how you do your clinical documentation, it has to be on point, because Medicaid is for us, it's been the company or carrier that has audited our charts the most, because we see so many people who have Medicaid, and so being mindful of ensuring that your documentation is going to meet the standards that Medicaid accepts, because they will claw back money. We've never had money clawed back from commercial insurance plans, even though our records have been audited. Medicaid has been the number one provider for us that's clawed back money. We've since learned, like, what the expectations are and we're meeting them, but that's hard because when you're hiring people who may not necessarily understand they make a mistake in their records, then the practice has to pay for that. That's an important point for anyone who's looking to bring on associates is building in systems so that you know what the documentation looks like, particularly if it's being billed under your tax id and your group NPI.

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Michael Fulwiler [00:08:30]:

Definitely, yeah. And so in the beginning, did you kind of learn that by doing, was it something that you had learned working in the group practice before you started your own, you know, business? Did you hire a biller? How did you just, like, navigate that?

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Lisa Savage [00:08:44]:

So I learned nothing in the group practice that I was previously in that, you know, they had their billing department and they did all the billing for us. So I really learned kind of on the go. I hired my sister, who is still my office manager, who still does my billing. So she's been with me for a lifetime, but work wise, she's been with me for over 20 years doing my billing. And at the time, we were doing paper claims, so there was no electronic billing. It was all paper claims. And so you would have to, she would have to complete the claim, mail it in to the insurance company, and pray that it didn't get lost. And a lot of times it got, quote unquote, lost follow up by making phone calls, which is a nightmare.

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Lisa Savage [00:09:26]:

And so I feel like we learned about billing, like kind of trial of fire, because that was brutal. That was absolutely brutal. And then having to hold on to all those, that paper, like, you know, just keeping all that paperwork so you have a paper trail, and then it's all electronic, and that's great. It is fantastic. We get paid a lot more quicker. Obviously, the claims get to the insurance companies a lot more quicker as well. But she was also learning as she went along, too, because she's a teacher. That was what she did for years, and then she decided she was burned out from that, and she came to work for me full time.

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Lisa Savage [00:10:00]:

And so it was a matter of she and I kind of figuring this all out, learning in Facebook groups, talking to other people who did the work to ensure that we were doing the things that we needed to do to get paid.

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Michael Fulwiler [00:10:12]:

It's wild how quickly technology changes. Right. And business changes. The idea that you would be mailing in, you know, these bills. Yeah, I mean, it just makes me think about, you know, credit cards before online banking, right? It's like you're just charging your credit card. You have no idea what your credit card bill is. And then you just get a month, like a bill in the mail. At the end of the month, you can't go and check your statement online, and then you just, like, check in, and you hope you don't get charged interest.

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Michael Fulwiler [00:10:40]:

Like, how did people do that before?

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Lisa Savage [00:10:44]:

And that's exactly what it was like, you know, and. And it was a lot of claims, you know, so it wasn't just a handful. It was a lot of claims, particularly once we hired our first associate, it was tons of claims. And then we quickly we pivoted to electronic health records. And, of course, that that made our lives a lot better. And those electronic health records have gotten better over the years as well. So they're much more efficient than they used to be and simpler than what they used to be as well. So it's helped, from a business perspective, us, to really kind of operate, you know, on autopilot.

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Michael Fulwiler [00:11:16]:

Could you talk about some of the unique struggles of being a black business owner?

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Lisa Savage [00:11:23]:

That's such a great question, because I think people don't recognize some of the nuances of being a black business owner. And I thought about this a lot. One of the things that I think, for me is exceedingly burdensome is working in an area that there are not a lot of people of color doing this. When I first opened my practice, I was one of very few black mental health professionals in Delaware who had private practice. It was me and maybe a handful of other people. And I felt a great deal of pressure to over perform, to establish credibility. So if I made any mistakes in my practice, any errors, I took that so seriously because I didn't want to be perceived as not being as good as. And that still is an issue for me.

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Lisa Savage [00:12:15]:

Extremely protective of my reputation, very protective of my brand, because I never want anyone to look at my practice and go, that's a black owned practice. We expect that. We didn't expect any more from them. And so that's a burden that I, as a black mental health professional and business owner, carry with me all the time. I think the other thing, too, is that even the internal struggles that a black business owner has with people that. Who are not black, who work for me, and I'm not saying my current people at all, I don't want to want that to be confused. But in the past, with other people that I've hired, the stuff that I put up with that seemed to be so racially based or racially biased was very, very stressful. Very stressful people assuming that you didn't know what you were doing or that they knew more than what you did.

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Lisa Savage [00:13:06]:

Even though I've been. I'd been in practice for some time. Could I prove that it was racial because I was. Because I'm black? No, but it very much felt that way. You know, I could just go on and on about stories about people that worked for me, which is always an interesting and kind of weird dynamic. Like, you're working for a black owner, but you don't trust this person, and why don't you trust this person? And so it's kind of some of the insidious things that happened sometimes when you're a black person running a business. And so those are struggles. It doesn't happen that much anymore.

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Lisa Savage [00:13:39]:

I feel stronger in who I am as a business owner, and I. I've been around for a while, so I kind of. I think I've established a whole lot of credibility, but I think mostly it comes from feeling that level of confidence within myself and not looking for people around me to validate that, which I think was, in part the issue when I was being challenged by some people on some things that I was very sure that I knew that I was doing right. And so, yeah, it doesn't necessarily happen solely externally, but sometimes it can happen internally as well.

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Michael Fulwiler [00:14:18]:

Was that experience consistent in graduate school as well? I've talked to black therapists who are the only, you know, black person in their entire program. They didn't have a, you know, black instructor or professor like, through graduate school. And just the lack of representation can be, you know, really isolating is that.

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Lisa Savage [00:14:39]:

You know, I was very fortunate because I went to the University of Pennsylvania, and my graduate program had a considerable number of people of color, and which was great. And we had our instructors, our professors, I think, were well represented as well. The time that I went to Penn, Penn was very focused on anti racism work, and that was a huge push in our learning, in the whole ecosystem, in the school's social work, which also, I think, equipped me to be able to do some of the advocacy work that I do, to be able to talk plainly about racism and focus on biases and helping people to understand how their own biases show up in business and in their clinical and therapeutic relationships and feel comfortable having those conversations with people, because it was a huge part of my education when I was at Penn.

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Michael Fulwiler [00:15:35]:

I want to come back to your advocacy work. Later in this conversation, I want to talk about clinicians of color as well, which is an amazing organization that you co founded. Before we get to that, I want to stick with the business here for a few more minutes. I would love to talk about any mistakes that you made when you either first started your business or when you were growing your practice. When you look back, were there things maybe you wish you had done differently or things that you learned from?

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Lisa Savage [00:16:06]:

This is what I say to people these days is when I first started, I had hired all contractors. Everybody was a contractor, which was a mistake because for a couple of reasons. One, when you hire a contractor, you don't have a whole lot of say around how they do what they do, when they do it, and that has the potential to damage your brand. And so after a couple of years of having contractors, I was like, you know, I talked to my lawyer and she said, you know what? I think you're smart to think about transitioning people to an employee. It was very scary for me because when you think employee, you think, you know, a whole lot of overhead. But she helped me through that process and that was great. And I don't look back. And I would strongly advise people not to bring on contractors.

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Lisa Savage [00:16:51]:

There's just a whole lot of nuances that having a contractor can bring. That's just whenever I'm guiding people, I always guide people toward bringing on employees. But that was probably a mistake that I made in the beginning because when people weren't doing the work in the way that I thought they should be doing, I didn't have a whole lot of say over that. So I ended up having people leave because they didn't want to do things the way that I wanted to do. And I also knew I had very little leverage in making that happen, so I wouldn't do that again. I also would have hired more help sooner than what I did. I was reaching the point of burnout probably in like 2012. I remember, yeah, it was before I had moved to Baltimore.

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Lisa Savage [00:17:33]:

I remember sitting in my house in Delaware. It was late one night and I was doing payroll and I was falling asleep and I was trying to do payroll and I was falling asleep. And finally I was like, forget it, I'm just going to go to bed and wake up and finish this in the morning. But I recognized I was burning out. Like, I was working 24/7 like just kind of, you know, nonstop. And it is at that point that I realized you are on the verge of burning out because I was still seeing clients at the time. Too. Managing people, doing payroll.

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Lisa Savage [00:18:06]:

So if I had to do it over again, I would have hired help sooner than what I did. Again, people sometimes react to that because hiring help means that you're going to have to pay people. But what I learned is that hiring help people also means that you're going to bring in more revenue, you're going to have better systems in place, and you're not going to burn out. And so that was another big mistake because I reached the point where I was like, I don't know if I could do this anymore. Like, I don't know if I want to do this. And those are all signs you are burning the candle at both ends, girl. You need to make some changes. And I did.

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Michael Fulwiler [00:18:39]:

Yeah. I mean, outsourcing can feel expensive, right? You know, we talk to folks all the time at heard who. This idea of outsourcing, your bookkeeping and your accounting and your finances can feel like a big investment. But when you sit down and think about how much time you're spending, if you're spending 2 hours a week doing your books and managing your payroll, and suddenly that becomes 8 hours a month. And you think about it, well, if I could see four or five more clients, how much more income could I generate? You know, if I save that time, I could be spending it with my family, or I could be reinvesting it back in my business. Right? So I think that's definitely a big mindset shift of thinking about, yeah, you got it.

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Lisa Savage [00:19:24]:

Because that was me. I was doing my own books. And then at some point, my lawyer said to me, you're not a bookkeeper, Lisa, she was very right about that because I hated that. It just took up so much time just to kind of wrap my head around, like, how to even operate quickbooks. Like, that was way outside of my wheelhouse. So bringing in experts, people that do this for a living, it takes the burden off of the business owner, and I think it also lends to your credibility as well. When you have systems in place and you have other experts doing the things that are outside of your expertise, there's.

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Michael Fulwiler [00:20:00]:

This idea of sticking within your zone of genius. Right? Like you're the clinician. Like no one can do therapy the way that you do. Focus on that. That's what gives you the most energy. These other things in your business that you're not an expert in, that's outside of your zone of genius. Just get those off your plate, because it's not just the time, but it's also the energy part. It just sucks your energy.

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Lisa Savage [00:20:26]:

Absolutely. It does. Absolutely.

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Michael Fulwiler [00:20:29]:

Staying on this topic here, is there anything that surprised you when you started your own business that you weren't expecting?

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Lisa Savage [00:20:37]:

So I can't say this as a surprise because I have managed people before, but managing people is hard. So I just want people to understand that it is hard. And I've been in management for a very long time, but it is hard. It's, you're managing people. People are complex. I also think that, you know, people don't necessarily hold the same values that you do as well, which is fine, that's fine. But how does that blend in with your vision for your business? Does this person's values align with the values of your business? And so those things were shocking. Not shocking necessarily, but every time I encounter a difficult management situation, I am kind of like, oh, man, here we go again.

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Lisa Savage [00:21:24]:

I thought that we wouldn't deal with this again, but those kinds of things come up again because you dealing with people, we're complicated as individuals. I think the other thing that was surprising to me as well, this might sound silly, but just how rapidly my practice grew, like overnight, it was like, wow. Oh, my gosh. You know, I went from this 400 square foot office, which is really tiny. So now we have over, what is it, almost 6500 office. Yeah. And I sometimes look at that and go, wow, how and when did all this happen? But it does, it happens very quickly. The need is pretty intense for mental health services.

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Lisa Savage [00:22:04]:

And so being prepared for growth, because I think we don't want to be surprised by growth, but often it can happen so quickly. But being prepared and expecting that you are going to grow, like, I didn't think that I was going to grow out of that 433 square foot office. Here I am less than 20 years later, and we're in, you know, 6500 square foot space, which is wild to me, but good.

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Michael Fulwiler [00:22:32]:

That's a great segue. So you, you've grown, you know, your practice into the largest black owned practice in the country, which is incredible. Your business is doing over a thousand sessions a week, you know, which is wild, I'm sure, for you to think about, right when it was just you in the beginning. When you look back over the last two decades, what do you feel like are some of the keys to success for your business in the way that it has grown? You mentioned it grew quickly, but I'm sure that there's some things that happened along the way.

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Lisa Savage [00:23:08]:

When you look back, I'm going to tell you, developing relationships with people is so important. It is so important. My practice is in Delaware. I live in Baltimore currently, and I miss being that close to the Delaware community. I still travel Delaware occasionally, but having those relationships established with people who will refer to you, people who know the work that you do, is just really, really important to me, and I worked really hard at creating those relationships. I think it's also important for people to think outside of the box. Think about. Look at your area where you're practicing in, and think about, what are the needs of my community, and how do those needs of the community match with my passion? I loved working with children and adolescents, adolescents being probably my favorite age group to work with.

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Lisa Savage [00:24:00]:

And so when I started looking around the community, before I grew my practice, I started thinking about, how can I better meet the needs of kids? How can I better meet the needs of parents? My office is located in the suburbs of Delaware, so a lot of the kids that we work with live in this city, or they live in very rural areas that are difficult to get to my office. And I thought, what about taking services to the kids? And where do kids spend their time? Schools. Okay. And so I started cultivating relationships with schools one school at a time. And before I knew it, like, the first year, I had four middle schools that I was responsible for. That went really well. The next year, the district. One of the districts said to me, can you take on our elementary schools? And I was like, yes, I can.

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Lisa Savage [00:24:44]:

Even though I was like, I don't know. But, yeah, okay, I can do it. I'm not gonna let you know I can't do it. And that was when I hired my first associate, Rebecca, who's still with me, and she served the elementary school kids, and I did the middle school kids. And then from there, it just kind of grew. Establishing those relationships, establishing your expertise. I would go into a school, and they knew that Lisa was the mental health expert, so to speak, in the school, created relationships with the school counselor and the deans and the administrators, but also with the parents as well. So I would attend things like the back to school night, or, you know, if they had, like, end of the school year fair, I would go there.

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Lisa Savage [00:25:27]:

So parents knew who Miss Lisa was and who the center for Child Development was. So creating that visibility and that connection to the communities that I serve.

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Michael Fulwiler [00:25:38]:

Hiring is a big challenge for group practice owners. Can you talk about how you've been able to not just hire therapists in what is becoming a more and more competitive market, but also retain them?

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Lisa Savage [00:25:52]:

Prior to the pandemic, we had no problem hiring people at all. We were, you know, constantly hiring, constantly getting resumes, and it was great. During the pandemic, things changed because I think a lot of mental health professionals thought, you know, I'm doing this virtual work, and I'm working for this person. I could do this on my own. And they're right. They absolutely could, except until they realize that it's hard when you have to do it on your own. It's really hard. All that billing stuff that I talked about and learning on, you know, the business end of this is.

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Lisa Savage [00:26:22]:

Is challenging. And so the way that we have established things is, while we're a private practice, we pay people a salary, which is really kind of unheard of in the private practice field for various reasons. I remember when I transitioned to salary, I had so much anxiety because I knew that at the end of two weeks, I had to have money to pay my people, regardless of what my bank account looked like. So paying people a salary, offering benefits, so we offer health insurance, dental insurance, we do a matching 401K plan, and we have other various benefits that we offer people as well. Most private practices don't do that because they operate on either you're paid hourly or you're paid a percentage of the revenue that you bring in. I knew that in order to stay competitive, and I also knew that the people that I was hiring needed stability. They needed a salary, they needed benefits because we hire a lot of people who are fresh out of graduate school, and they're young, and this is their first job, and they need benefits. And so recognizing who I wanted to attract and retain, I knew I had to do something a little bit different.

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Lisa Savage [00:27:36]:

And it's worked out. I think we've been on the salary model, my goodness, maybe six years now, and it's worked out quite well, and it's helped us to retain people. It's helped us to attract people who want to operate within a private practice, don't want to work for a public agency, but our salaries can never match the salary that, say, a person who works for a tech mental health company, we can't pay people $90,000. We just can't. And we're also not going to ask people to see 30, 40 clients a week in order to generate that revenue, to be able to pay them those top salaries. We're not going to do it. So we feel like we have a balance of a decent salary. It's a decent salary also, coupled with we have the goal of 25 clients during the school year and then 20 clients a week in the summertime with tons and tons of time off because we do mostly school based.

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Lisa Savage [00:28:31]:

So when schools are closed, our therapists are still getting paid, and they also have some downtime over the holidays. They get off, and then the summertime things slow down dramatically. So we offer kind of some built in benefits, and then we have some tangible benefits that we offer them as well.

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Michael Fulwiler [00:28:49]:

Could you talk about some of those trade offs between being self employed and working at a group? Because on one hand, it seems to your point, like, why would I work.

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Michael Fulwiler [00:29:00]:

For this group practice if my work is fully virtual and I could just go out and do this on my own, you know, work for myself? I think folks may not realize, like, all that's involved, you know, in private practice.

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Lisa Savage [00:29:14]:

Yeah, you're right. I mean, I, we've had people come and go. People have come, worked for us for a little bit, and then they branch off into their private practice. And so what they don't recognize is that all of the stuff that goes on behind the scenes, that we don't bother them with the credentialing process, paneling with insurance companies, negotiating your rates and all that kind of stuff, they've never been privy to because we take care of that for them. And I think it's always shocking to people when they have to do that on their own. They go, oh, my goodness. Because getting credentialed is very difficult and time consuming, and there's a lot of pieces that you have to have in place. We pay for malpractice insurance.

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Lisa Savage [00:29:53]:

People don't have to pay for their own malpractice insurance. Plus, in my practice, at least, there's a guarantee you're going to get paid. So if you, you don't see, you know, your 25 clients, you're still going to get paid. Now, yes, we have some consequences that people don't have to, have to deal with, but you're still going to get paid at the end of two weeks. If you're in solo practice by yourself and you're doing this, your income is going to vary. It is not going to be the same. You're going to have some great weeks and you're going to have some not so great weeks. And speaking from somebody who came from solo practice, those are hard because your bills don't stop coming.

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Lisa Savage [00:30:27]:

You still have to pay your rent. If you're renting someplace, you still have to pay whatever overhead that you have to pay. Also, when you're self employed, you're paying your own taxes on your own behalf. When you're working at a practice where you either being paid as an employee or have salary, those taxes are being paid on your behalf. And if you get behind on your taxes, that is not a fun place to be. A lot of people are disciplined to pay those quarterly taxes, but some people aren't understanding how to structure your business, how to pay yourself. Those are all things that people, one, we don't learn those in school. Right.

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Lisa Savage [00:31:04]:

And unless we have a good accountant bookkeeper who can help to keep us on track, you can make some significant financial mistakes pretty quickly. Sometimes they're difficult to bounce back from, especially owing the government their money. Owing taxes is not fun. I mean, I've seen people do it time and time again, and I tell them, you've got to put, when you get paid from the insurance company, that is not your money. And people have a hard time wrapping their mind around it. I go, well, some of it might be yours, but not all of it. And so those are the things that I encourage people to think about before they step out there and decide this is something that they want to do.

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Michael Fulwiler [00:31:41]:

Yeah, I think it ultimately comes down.

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Michael Fulwiler [00:31:42]:

To risk and stability.

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Michael Fulwiler [00:31:45]:

Right?

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Michael Fulwiler [00:31:45]:

Like, if you're someone who, you know, has a higher tolerance for risk or is, you know, that's okay, kind of, you're maybe feel okay going out on your own and taking that risk versus you know what, like, that feels pretty risky. Like it feels safer to have a full time job with the salary and benefits and all that. Right. Same thing with stability. Knowing that if I have a full time job with the salary, I'm going to get it paid every two weeks or every month, and that income is going to come in versus in private practice. It might go up, it might come down. The summer months may slow, and it will.

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Lisa Savage [00:32:22]:

It absolutely will. There's just no getting around it. Knowing the cycles of your business is important, too. I know the cycles of my business when it's going to be busy. When you're starting out in private practice, you don't have that cadence built yet, you know, so it's hard. And if you want to buy a house, for example, and you have to prove your income, being self employed in solo practice, it's a challenge. You can. You can work around it.

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Lisa Savage [00:32:45]:

Of course there's ways to do it, but it is. Those are some challenges that people don't necessarily think about when they become self employed.

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Michael Fulwiler [00:32:51]:

Yeah, I think especially for therapists who are new to the field, maybe, you know, just graduating or working towards licensure, I think working for a group can also be a really great learning experience as well, just to see how the businesses run, you know, to see if that's something that you want to do or, you know, if you'd rather just, you know, it's like, do you want to work in the business or work on the business? Right.

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Lisa Savage [00:33:13]:

Correct. Absolutely. I've had people who've come and gone, who've come back to say, lisa, I wish I had listened. I wish I'd stayed with you because this is not easy, you know, and I'm always respectful when people decide that they want to do that. But I always tell people, ask me the questions first because they're going to be some things that you don't necessarily know about.

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Michael Fulwiler [00:33:32]:

Yeah. And I'm sure if someone, you know, who works for you wants, you know, has a dream to start their own business, you're fully supportive of that.

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Lisa Savage [00:33:39]:

Absolutely. Absolutely. That is unquestionable. There are a couple people now that I'm very good friends with who have stepped out on their own and actually some of them are doing quite well. They've gone through some of the ups and downs and now they're kind of finding their even keel. But they remain in contact with me because I wish everybody well on this journey. It is not easy. No matter how you look at it, it's not easy.

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Michael Fulwiler [00:34:01]:

What advice do you have for therapists who are considering working for a group practice? Are there certain red flags or, you know, things that they should be looking out for during the interview process before they decide to take a job?

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Lisa Savage [00:34:20]:

I've heard horror stories and it always saddens me when people find themselves in a group practice that really isn't operating, I think, in with integrity. So, for example, if someone says, you know, sign this non compete clause that you will not practice within 25 miles of this private practice, like to me, that's just very, very oppressive to people. I would, I don't have people sign a non compete clause because I'm very confident in my practice and, you know, I'm good with that. So we don't have people signing on compete clause because I feel like, again, it's oppressive. So that's something to be on the lookout for. I think if it's a reasonable non compete clause and you feel like you can live with it, then okay, maybe that's fine. But if it's really something that feels very difficult and unreasonable, I would question that. I would also suggest that anybody who's, if you're going to be a contractor, read that contract over.

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Lisa Savage [00:35:17]:

Have your attorney read that contract over because the contract is going to be written to benefit the practice owner, not necessarily the contractors. Make sure that you have some guidance when you read the contracts. Look at what the expectations are going to be of you. How many clients are you going to be expected to see? Can you, can you do that again? You can get easily burnt out providing clinical work, and then there's always documentation that has to come along with doing the clinical work. So you want to make sure that you have time to be able to do that as well. Look at. I think this is really key, is how long have the other associates worked for that particular practice. I think that says a lot.

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Lisa Savage [00:35:58]:

It says a lot. I'm always very proud to say that my people, like Rebecca, has been with me since the beginning. Her daughter is 13, so Rebecca's been with me. She was my very first associate, so she's been with me for 13 years. And I have. The people have been with me for more than. Except for the people that we recently hired, my leadership team, ten years or more, which says a lot. So look at who's been at that practice and how long have they been at that practice.

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Lisa Savage [00:36:23]:

I think that's important. What type of split are you getting? There are some standards to how that happens. If you're going into a practice based on a split, depending on your expertise and the level of experience you have, 60 40 is pretty common. 50 50 sometimes is common, but look at the split and then compare that to your expertise, your training and experience that you have in the field.

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Michael Fulwiler [00:36:48]:

So in addition to being a business owner, everything that we've talked about, you're also the co founder of clinicians of color. What is clinicians of color and why did it start?

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Lisa Savage [00:37:00]:

Yeah, so thank you for asking that, because I absolutely love clinicians of color. We started clinicians of color back in 2015, so we've been going strong for a while. And we started it because during that time, like, I have been part of therapists, Facebook groups for years, forever, just various groups, you know, them, we've all been a part of them at one point or the other. And back then, I felt completely overlooked, and I felt like my expertise was never considered, and if I had something to say, it was ignored. And I was like, oh, this is so frustrating. And there were other people who spoke up with me as well. It wasn't just my experience, and there were certainly allies who saw what was happening as well. And so Kim, who's my business partner for clinicians of color and co founder, and I, we just kind of literally, not literally, but we bumped into each other on Facebook, and she messaged me and she said, you know, if you ever want some assistance in creating something of our own, let's do it.

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Lisa Savage [00:37:59]:

I was like, yeah, that's a great idea. And that was how clinicians of color was born. Kim and I have only met each other in person three or four times. Like, that's it. Since we've been in business, we've only. Because she lives in New York and I live here in Baltimore, we've only met each other in person, but it's been the perfect business marriage, so to speak. We really balance each other out quite nicely. So clinicians of color is a platform where we educate and elevate BIPOC mental health professionals so we get them access to trainings like EMDR, brain spotting, ifs, and we provide support, we provide technical support.

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Lisa Savage [00:38:37]:

We help people to build their practices so that they're sustainable. We help people to avoid some of the pitfalls that I talked about earlier in this. And it's become quite the nice community, and we want it to be seen as a community where we. We gather together, we do things together, we support each other. In our Facebook group, we have close to 23,000 members, and it's growing every single day. It's been wonderful. It has been wonderful. Oh, we also have a directory.

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Lisa Savage [00:39:04]:

I forgot about the directory. We have this big directory where we match people in the community, in different communities, to therapists who are from their cultural background or racial background.

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Michael Fulwiler [00:39:15]:

And you've invited her to speak, you know, to your community as well. We've done the workshops together, which have been really great. And the community is always super engaged and asks a ton of questions, and it's always really fun.

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Lisa Savage [00:39:28]:

That's great. I mean, and there's a lot of. There's often a lot of chatter about heard in the group. People love heard. Kim loves heard because she uses you guys. So there's always a lot of positive chatter in the group. And we do appreciate when you guys do those workshops because they are very helpful. And I feel like people, it's an opportunity for people to learn, but also get connected to a resource as well that can help their businesses.

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Lisa Savage [00:39:50]:

And you guys focus on mental health professionals. So that's, like, excellent.

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Michael Fulwiler [00:39:55]:

Where can people go to learn more? They're listening to this.

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Lisa Savage [00:39:58]:

They can follow me on TikTok, which is my favorite platform these days. I'm clinicians of color on TikTok. And then they can also go to our website, which is Academy Academy dot cliniciansofcolor.org. academy dot cliniciansofcolor.org dot. And that's where they can learn a lot about, like, the trainings and the practice building resources that we have. We have this membership that people join. We're doing a lot of really innovative things with artificial intelligence, which is also another passion of mine. So anybody out there that's interested, check us out, or follow me on TikTok.

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Michael Fulwiler [00:40:37]:

Great. We'll drop that link in the show notes as well. I'm glad you mentioned artificial intelligence. I just really appreciate your openness to technology and software. I know that you've also been using measurement based care as well in your clinical work. Can you talk a little bit, just quickly, about that and how you think about the role of technology going from paper billing 20 years ago, building practice today?

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Lisa Savage [00:41:06]:

Yeah, I love using measurement based care. It just has transformed how we do the work that we do in my practice. So our clinicians have to do assessments on every single client with a certain cadence, depending on what the presenting issue is, and then the supervisors are able to go in and look at the measurement outcomes. So if a clinician is struggling treating a kid who has ADHD, it's not reason for us to punish that clinician, but it's reason for us to say, hey, maybe we can support you more by getting you more training. Our clients like it, too, because it gives them some concrete examples of how they're improving. Sometimes therapy can be kind of vague. Even if you have a treatment plan and you're working on goals, these assessments help our clients from session to session to know where things stand. And it helps the therapist to know I'm not having much success with this client.

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Lisa Savage [00:41:59]:

What else do I need to do? And so they can bring that back to supervision and get guidance and like I said, more education or training on how to work with kids who are presenting with maybe some challenges that that therapist doesn't have the experience with. I mean, the other thing I should mention, too, I think it's important, is that we bill for these assessments so it's increased our revenue, something that we didn't know. And I've been encouraging people to check out. Well, we use blueprint, so I've been encouraging people to check out software where you can actually bill for these assessments as a way to increase your revenue. It's been wonderful for us.

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Michael Fulwiler [00:42:33]:

I want to make sure that we talk about your advocacy work as well. Why is that so important to you?

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Lisa Savage [00:42:39]:

It's really important to me because I consider myself a community based provider. And so if I'm in communities, particularly marginalized communities. And I've worked with marginalized communities all my career. I started out working in HIV back in the day when it just impacted gay and bisexual people. And so that was my first foray into being in the community, doing advocacy work, because at that time, I mean, if you were impacted by HIV, that was the stigma behind having HIV was awful. And so all the advocacy work that I did there is really what kind of set the pace for me in my professional career to continue doing that. So I like working with marginalized communities. If I'm working in a community, I have to also understand what keeps people from not being healthy.

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Lisa Savage [00:43:32]:

What are some of the things that are going on in communities that are keeping people from not being healthy? Toxic stress, trauma, generational trauma, racism, sexism, homophobia. Those are things that I really help on a grander scale, as much as I am able to, to mitigate. But I also help people to understand that this is outside of you. This is not your fault. Your living in poverty is not your fault. But we're going to help you to figure out how you can survive and be your best person, be your best self, even despite some of the circumstances that are going on in your life.

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Michael Fulwiler [00:44:07]:

We talked earlier about some challenges that you faced when you were starting your business and growing your business early on. What are some challenges that you're facing right now, almost 20 years in? So I imagine they don't go away, right?

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Lisa Savage [00:44:21]:

They don't go away. They did not go away. They transform. The most two recent challenges was Covid. That was the most recent one where one day we closed down, we thought we'd be back within a couple of weeks, and that that never happened. We didn't come back for, I don't know how long, two or three years. So that was a big challenge. And then this most recent one was a cyber attack on change healthcare that really could have closed my practice within a couple of weeks.

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Lisa Savage [00:44:48]:

That was worse than Covid. That was worse than Covid because at least everybody knew that Covid was happening. When change healthcare was attacked, hardly anybody knew unless you were directly impacted by it. And all of our claims went through change healthcare. All of our claims, 100% of our claims. And so because we could not get claims to the insurance company, that meant we could not get paid. And we thought, okay, they'll be back up within a week. And it was not a week.

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Lisa Savage [00:45:16]:

It went on for over a month and a half, where we then had to pivot to manually entering in claims, kind of like it was back in the olden days, you know, the first week that it happened, we were sending claims in through the mail, and I was like, this is just not going to work. And then we figured out another workaround that still required a lot of labor, but did get us paid. It was traumatic. I hope and pray that I never experience anything like that again. But we survived. I had moments of doubt that we were going to survive. Had moments of doubt. I had 77 people looking at me, and I had to tell them, we're not going to make payroll on Friday.

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Lisa Savage [00:45:55]:

That was the hardest thing I've ever had to do. It was very tough because I know I need my paycheck. I know that people who worked for me need their paycheck. We were able to then pay them a little later than that, Friday. I think that Wednesday we were able to pay them right after it first happened, but it was horrendous. It was awful. And I will scream to the rooftop that one company should not have that much power, that if something like that happens, that it stands to bring down the entire healthcare system, because that's what we were looking at. Their fingers are in everything, and it makes me angry to think that that's allowed, because I know that Chief Justice Merrick Garland tried to stop that from happening, because he saw this and it went through anyway.

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Lisa Savage [00:46:45]:

And here we are. So that has spurred me to do even more advocacy work around insurance reimbursement and around not letting these insurance companies have all this power. So, you know, it was a very difficult time. We are survived. We've survived it. We're going to continue to survive it. God forbid something like that should ever happen again. But we learned some lessons from it, and one of those lessons is not having all your eggs in one basket.

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Lisa Savage [00:47:12]:

I mean, that's, I think, a big lesson. Not that if I had, I mean, I have clinicians of color, so personally, I knew I was going to be okay, but I don't know that I could ever have another business that generates enough money to meet that payroll if we weren't getting paid. So, as a solo practitioner, yes, it makes sense. As a group practitioner, it's a little harder to have something else to subsidize another business. And we shouldn't have to operate like that. We really shouldn't have to. Yeah. So I've been doing a lot of advocacy and meeting with congresspeople and writing letters to our professional organizations who, frankly, let us down during this time.

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Lisa Savage [00:47:47]:

And I'm just gonna be honest about it. I did not hear back from our professional organizations after emailing them a couple of times. That's disappointing. And I really want to highlight, that wasn't what I expected. I thought they would get back to us because it's such a huge issue. It wasn't just Lisa issue. It was impacting social workers and counselors and psychologists around the country.

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Michael Fulwiler [00:48:09]:

We appreciate the work that you do and continue to do. We're coming to the end of our conversation. We like to end with a segment that we call the footnote. And so my final question for you is, what is one thing that you want folks to take away from this conversation as a takeaway?

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Lisa Savage [00:48:29]:

Is do it. Is to go ahead and do it despite the fears, despite some of the obstacles, is to go ahead and do it. If this is your passion, do it. I think people can hear in my voice that I have a lot of passion about the work that I do. If you feel that passionate about the work that you do, I think it's important to follow that passion and see where it leads you. It may transition, it may transform over time. But if this is something that you're very passionate about, I strongly encourage you to do it.

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Michael Fulwiler [00:49:01]:

Lisa, thank you so much. I am so grateful for you, appreciate your collaboration and partnership and excited for folks to hear this conversation today.

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Lisa Savage [00:49:11]:

Thank you very much. It was my pleasure. Michael, I appreciate you asking me to be on.

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Michael Fulwiler [00:49:17]:

Thanks for listening to this episode of Heard Business School brought to you by Heard, the financial back office. For therapists, visit the Herd resource hub at joinherd.com to support you in your journey as a private practice owner. And don't forget to subscribe on YouTube, Apple, Spotify or wherever you get your podcasts. We'll see you in the next class.