Business side of mental health practice with Keith Myers

Dan King: [0:00] Hello, everyone. Daniel King here today with Keith Myers, who is an associate Dan King: [0:06] professor and director of clinical training at Point Loma Nazarene University. Keith has an extremely varied background in a lot of different elements of the mental health world. So, I'm very much looking forward to a wide-ranging conversation with Keith today. Keith, welcome. Keith Myers: [0:21] Thank you, Dan. Thank you so much for having me on the podcast. I've really enjoyed following you along the last few months, and I'm really excited to talk more about it. Dan King: [0:31] Yes, let's dive in. So I know something you're very passionate about is teaching Dan King: [0:36] counselors the business side of therapy. Could you speak a little bit to your previous business experience and some of the low-hanging fruit that you've learned from it that other counselors should learn? Keith Myers: [0:47] Right. Absolutely. I think, you know, being both a, you know, licensed professional counselor and also a professor of counseling, I think I've witnessed kind of the two sided gap in knowledge with clinicians, you know, both on the for profit side and community mental health clinics, as well as like the nonprofit side. I remember a few years ago, I was consulting an agency and I said, one of the first things you need to do is bring in the CFO into the clinical meeting and talk about the gap between revenue and, you know, how much it costs to have a clinician on a full-time salary, benefits, you know, 401k match, all the things, right? And how that, how that gap is really significant. And what, that's why, you know, like with time and nonprofit, that's why there was, you know, they're, they're targeting millions of dollars of grants so they could, you know, they could kind of fill that gap in between what insurance was bringing and what was actually needed. And I just remember several of the counselors just being like, you know, just kind of stuffed during the headlights verbally. Keith Myers: [1:52] Like they're just like, OK, what? I had no idea that, you know, billing seventy eight dollars an hour for insurance wasn't paying my weight in being here. And so that was like kind of like a shock and awe for me of like, OK, this epiphany of like there's a real gap here, I think. and then like reflecting on the last several years of teaching counselors and academic programs, noticing that. Keith Myers: [2:18] Really, you know, we're not really teaching counselors to be business people. We're teaching counselors to be counselors. So it's interpersonal skills, it's theoretical knowledge, it's research, right? It's a lot of the softer side of skills. And so then there's the gap on the academic side because we don't want to necessarily create more coursework and that charges the student more money. And so it's a real paradox sometimes. How do we fill the gap on the academic side? How do we fill the gap on the clinical side of knowledge? And can we start this process earlier, educating clinicians about the business side of therapy? Dan King: [2:52] Is there a case to be made that in this field, because so many folks are either self-employed or owners of small businesses in some way, is there a case to be made that very early on we should be teaching people at least the basics so that they get exposed to what it's actually like and they can make an intentional decision about, yeah, business ownership is my thing or hell no it isn't and I'm okay with that? Keith Myers: [3:15] Oh, absolutely. That's my, that's where I fall as far as this, that side of that argument. Like you do, we, do we teach earlier or do we, or do we kind of let it play out? I think you got to teach earlier. I think prevention is the best medicine in this context too, where it's like, Hey, how do we, you know, I've got a class right now that it's kind of a typical class called professional community development. And it's all about like the professional side of, you know, and the personal side too, that kind of inter integrates together. But what i talk about is here's the here are the 12 lessons i wish i'd learned in grad school you know and a couple of them are how to start a practice in llc versus s corp and insurance or not insurance and how to choose a building and how to choose a population and how to market yourself you know and how to niche down with professional identity and all the things that really you know Keith Myers: [4:02] we start thinking about okay how do i market myself as a therapist it's very different than being. Dan King: [4:08] And how the two relate, I think, is interesting because there's how you show up clinically and then there's how you show up on LinkedIn, Facebook, wherever you're doing your marketing. And I think so many clinicians strike me as such humble, sensitive souls, right? It's all well and good to be with a client in a setting where you can be who it's easier to be who you think you are versus who you need to become to do marketing. There is an identity shift for so many clinicians. Keith Myers: [4:36] That's a great way to say it. And I always tell people, you know, be yourself, be yourself, be real, be yourself. And also know that, you know, doing the uncomfortable thing, telling that same person you told the other three times about your niche, right? Telling them a fourth time. Sometimes we need to, people need to know like five or six times before they really start to think of you as the expert, right? In this particular area. So I know it feels redundant and I know it feels like you're just kind of, you know, tooting your own drum, beating your own drum, but like you need to keep beating it because people are not going to make that association without those conversations. Dan King: [5:09] I think so much of the training, which is very, very deep training, and I'm not a clinician, but I have done sort of executive coach training and practice as a coach and there are some similarities. There is such a beautiful listening container that you're able to build and the reality of marketing is you got to talk about yourself you got to assert yourself you have to be proud of yourself and so i think those two i think those two trainings um can sometimes run contrary to each other absolutely Keith Myers: [5:37] Like how to be an active listener and then how to be an active promoter are two different very different things right and so if you just listen all day then you're going to be you know, broke basically like you know because you're not you're not going to be able to like say like hey here's why clients should consider me here's why you should refer to me as another professional in the field another colleague in the field maybe maybe a higher level of care like a psychiatric hospital or an intensive outpatient program you know how how do you get people to refer you on an outpatient level um yeah it could be really challenging it is definitely a shift so that's one of the things I talk about is like, and then how to talk to clients about money, you know, like clients come in and be like, okay, like you accept insurance. Right. And, um, you know, you're my copay's $20. Right. And like, you know, and being able to say like, well, you know, Hey, I don't, maybe I don't accept that insurance, but here's how I work around that. Um, here's, you know, here's some accommodations that we have, uh, for this and that. And here's how we help you, you know, empower you to, to be able to maximize some of your insurance, even though it might not be fully available. I'm speaking from a self-pay, you know, more of a self-pay model. But I've been in the insurance side of it too. And, you know, when you have like 85% of your claims get. Keith Myers: [6:54] Reimbursed, but then you have 15% maybe that aren't being reimbursed or they develop a snag. Like who do you have in billing to be able to advocate for that? And those kinds of obstacles can really ruin a small group practice. We talk about 15% of revenue and sometimes it could be more or less than I was talking to a colleague recently who had literally had not been paid by a certain payer for like two months because they shifted all the way how they pay they're clinicians and if you were on the old paychecks they shifted into this kind of credit system now you know you're two here you're two months behind in your revenue that's what creates real hardships for people and so being able to to have people or training to know how to advocate for yourself in those kind of situations is really helpful. Dan King: [7:40] Yeah oh yeah there's so much i mean each each of those alone could be a whole class so i think clinicians and their boundaries with respect to money is a fascinating subject because clients will test both that if you're a practice owner or a clinician at a group practice patients will will test your boundaries right around money and it's all well and good to want to serve people but there's this sort of energetic place you come from where you don't want to serve more than you you can serve and being able to provide for yourself being able to be financially sustainable is going to give you the energy to serve people so much more effectively, right? But so much of the training is help the world. But of course, if you can't help yourself, you're not going to do much good helping the world. Keith Myers: [8:24] Absolutely. And I think, you know, there is I think there is a bridge there because we talk so much in our academic training, like, you know, know yourself and like be self-aware of your own biases and life experiences and traumatic things you've lived through. And so how do I be aware of my family of origin, how that's going to impact me sitting with a client that's dealing with family of origin things. Right. And I think so. I think there's an opportunity there because we don't talk a lot about the psychology of money. And for so many people that's a derogatory shame-filled uh topic that has a lot of emotional weight to it and so it's easy to just want to avoid it it's easy to just not want to talk about it and a client you know misses a few sessions and doesn't pay me okay that's okay i'll they'll eventually they'll pay you know and so it's it uh it can be really tricky it. Dan King: [9:11] Can it can i was glancing at reddit the other day and i was glancing at a thread where clinicians who either currently work at group practices or thinking about working at group practices were complaining about owners and how they take too much and how, you know, owners are constantly seeking an unfair deal. And not only did it strike me as very sort of stridently anti-money, anti-capitalist, right? It also struck me as, ooh, I'm not sure these people have healed their own relationship with money, right? Nor do they have an appreciation for the burden that a typical practice owner bears. Important, of course, to understand that the typical therapist, you know, is carrying a lot of weight of others and that's a role we have to respect. But it's important, I think, for clinicians to also appreciate that group practice owners typically bear a burden that they might have a hard time relating to as well. Because all of that overhead, both the physical overhead, the non-physical overhead, the energetic weight of running a group practice, typically with no business training, it's a lot and we have to respect them too. Keith Myers: [10:14] It's a lot, you know, and I definitely empathize with my, you know, with my colleagues. They talk about the low-hanging fruit, I think you said earlier, but like the low-hanging fruit of the, you know, venture capitalist, you know, experiment that's gone wrong so many times or there's been publicized, right? Like, okay, we're coming in, we're making a change, we're adding profits, you know, we're changing things up, we're scaling, et cetera. And yeah, there's a story there definitely that's been told many times. And also you don't have to go very far even in a solo practice like i have like even a solo practice to know revenue costs like the the time and details and things you have to navigate in a group practice especially you've got people you're managing you've got systems you're managing and guess what when one person walks out or when one system breaks down it falls on you right or the operator so like that is a real stressor and um there there's got to be compensation for that Right. And then you want to be sustainable and you want to have a profit or, you know, depending on how you're structured. But it's yeah, it's really challenging. Dan King: [11:19] Let's turn to the practice owners. We've been talking a lot about what the clinicians can learn, especially when it comes to business and financial matters. What is most important in your experience for group practice owners to learn? Let's say you have in your class someone who you know has the chops. They have the potential to become a pretty good group practice owner. What are the most important lessons, if you could teach them something in advance of actually starting that group practice, what would be important to teach them? Let's say they don't hate money they've done some of their work there what do you what else are you going to teach them Keith Myers: [11:52] I would say talk to people who've done it you know um talk to the clinician who's a practice owner and talk to five of them and get to know their story get to know some of their early obstacles get to know some of the early wins and things they watched out for and things they wish they'd have known before they started you know ask really good questions that that people who have done it have the hindsight now to be able to like advance you know have the benefit from. So I would say, like, talk to people who are doing it and have done it to get that insider's perspective, because otherwise... Keith Myers: [12:25] And a lot of it still is going to be growth and a lot of it's going to be a learning curve. And I'm still learning. I'm still learning how do we navigate these waters of telehealth and VC and all the things that are coming up here. But yeah, I would say listen and talk to people who have done it. And then a couple of other things I would think is expect it to be really hard for the first year or two. And expect that you will not get you whatever estimate you set as far as revenue goes deducted by 15 to 20 percent because you're going to over inflate that probably and so you need to like especially if you're doing especially if you're doing payers and insurance you're going to you know you're going to talk to a few people you're going to try to get information and some of that information is elusive depending on what state you're living in but like talk to people who are billing insurance and then like hey are there anything that they have done strategically to improve their payer reimbursement. If so, that's not the rate you're going to get. You're going to get the bottom of the barrel, right? You can get the $70 stigma reimbursement that starts at the beginning, right? Like you're going to get that. Dan King: [13:28] You call it a stigma reimbursement? Keith Myers: [13:30] Well, I said stigma, even though I mentioned payers on here, but yeah, stigma, stigma, I guess. It could be hard to tell the difference sometimes. But I think that's one of the things that I learned with helping a group of investors start of a profit for profit clinic a few years back was they went in with a certain expectation of this is going to be you know here's how we're creating our budgets and this is going to be the reimbursement i was like it's that's too high and so it really did it really did affect them the ability to to to scale the profit level they were expecting yeah. Dan King: [14:03] To the extent that you can share sure tell me more about that how did it go were you able to overcome that initial problem Keith Myers: [14:10] Yeah. So I was a clinic director at the time and, you know, it was a it was a model franchise model. And so they're starting a new for profit clinic and it was all about 95 percent insurance based revenue. And, you know, some of the original numbers that they had come out and talking to me about was, hey, we're basing it on this this average number per session, you know, for reimbursement. And I said, I think that's too high. You know, so that was like, I think there was definitely like some influence that was, that was received from that feedback. And didn't really see it, didn't really see it played out until those claims started coming in later on, you know, and some of this is it took a couple of months to get those first claims coming in. Then once it started coming in, they started getting more, more frequent, more regular every couple of weeks. But yeah. So I think some of that feedback was was received, even though the model wasn't fully changed. And so I knew that it could be a could be a roadblock. And so, yeah, so it's it's, you know, anytime that you partner and there are a lot of good things about partnering with with with these owners. And they were they were really fabulous as a whole, like really being able to like listen and really be able to take in, you know, the feedback I was giving them, the clinicians were giving them. But it created it definitely created an interesting space because you had kind of the clinical side of things and you had the operational side of things and you had to, you know, be able to hire the clinicians and so forth and mentor them. So, yeah, I think it's definitely doable. Keith Myers: [15:38] I learned a lot of things going through that process that I would do differently now if I was going to start my own for profit clinic, for example. But yeah, it could definitely be tricky because there's a lot of nuances that you don't know unless you're in the thick of it. Dan King: [15:52] There are. And it's very natural, even speaking as an investor, it's very natural for investors to approach mental health like they would other industries. And while every industry is different, some industries are more different than the norm. And this one is more, this one is different. Keith Myers: [16:07] Well, and you asked me the original question, maybe I got a little sidetracked. But I think for me, what would be something that I would tell owners is, like, clinicians are... Maybe crudely, as my dad used to say, we're a weird breed of cat. I mean, we are like as a group of people, we are a little unique and we take we this is a stereotype. So it's not doesn't doesn't it's not true for everybody, but like we tend to over process. We tend to take time to like we tend to move slower. We tend to, you know, collaborate really well. We tend to listen really well. And then it's like you need to execute on this tomorrow. it's like that could be a struggle right like executing faster making at taking action faster all those things can be challenging but but a lot of good around like thinking through things strategically and the the experience of the client the experience of the clinician all things that are really important to run a really good group practice um so yeah those are some things that stand out. Dan King: [17:09] I've often thought that the best business partnerships feature a combination of speed and slowness. So yeah, in business, you ultimately have to execute, you have to do things, but you also have to reflect. So I am a proud member of Team ADHD, which means I tend to move pretty quickly. Yeah. And I break things and I can be a bit impulsive. Slowing down is part of my medicine and I need people around me that are a little bit more cautious and careful. Some of that rubs off on me and i have as i've matured as a business person i hope or at least hinting in the direction of maturing i have slowed down a little bit myself but i still it's still very helpful to have those guardrails and this is part of the reason i'm so bullish on clinician non-clinician partnerships because that that combination of speed and slowness um it it kind of reminds me of the dao te ching a little bit right it's it's like a middle way here for Keith Myers: [18:01] Sure well i appreciate that and thank you for thank you for saying that you know i think i think uh the last couple of years i've learned to speed things up you know for me it's like hey don't let this good idea just fall by the wayside let's execute faster let's execute every month faster than i think i should you know and uh i love that you're slowing down i love i'm speeding up and hey well you know figuring out together as we go through this thing called growth in life yes. Dan King: [18:25] I'm conscious what one other theme i'll throw into the mix for today and that is veterans so something near and dear to both of our hearts is work with veterans. And congratulations on getting approved to do that EMDR talk for veterans. Keith Myers: [18:40] Yeah, I appreciate that. Dan King: [18:41] I saw that on LinkedIn. That is super impactful. Can you speak to me about why that's important to you? Keith Myers: [18:49] A number of years ago, I found myself, I'd been fired from a job, I was looking for work, couldn't find a place to land. And finally, out of the blue, sort of, but not really, but this opportunity came to work with veterans at one of our local hospitals. And I started working there, and I was like, wow, this population is like my, my people, you know? And it was, you know, it's interesting, right? Like this is back in like 2000, like 11, 2012, but it's interesting, right? As a therapist, you know, we like to tell ourselves like, yeah, I'm a, I'm self-aware and I understand myself and all these things, know that stuff. Right. And I was like, why does this resonate so well with me? Like, well, my dad served in World War II, my brother served in the Air Force and Navy. Right. So there's a lot of military subculture and values and things that are, that, that I kind of grew up with and then kind of sitting with clients it's like yeah the personal professional kind of mixes well here with that you know values like selfless service and honor and duty and those kind of things like so um yeah so that was how i got started seeing um veteran clients and then i've continued that both in my solo practice as well as my research and my some of my publications and my writing my academic teaching i. Dan King: [20:02] I think it remains just given the gravity of the mental health issues they experience, it remains an underserved population in the group practice world, which is unfortunate because group practices, sort of group practices to me are the front line of the mental health crisis, right? Dan King: [20:18] More than 60% of American mental health patients are going to outpatient group practices. It may not be the sexiest part of the solution, but it is a core part of the solution. And so you look at the gravity of mental health issues that veterans face and group group practices have to play a bigger role in that journey. So I am, I am a huge advocate of it happening. And yeah, my, my dad's a veteran as well. So this is near and dear to my heart too. So thank you for advocating that. Keith Myers: [20:46] You're welcome, man. Thank you for, thank you for bringing that up. Yeah. And I think there's a, there's a whole like gap in knowledge because, um, and while I haven't served myself, you know, being knowledgeable of like military culture and, what that means for people. There's this huge resource called the VA, right? But then there's all these other people that don't feel like connected to that or feel like they're falling through the cracks or disenfranchised. Or what happens when you don't get an honorable discharge from the military? You don't get any access to VA benefits a lot of times speaking, and they're trying to change that a little bit. But yeah, so it's really a thing where I'm trying to train and educate people that are in the group practice, the front lines, you say, especially veterans that that are disconnected from the VA. How do we teach military culture? How do we teach, you know, what are some of the common clinical issues for veterans and how do we bridge that gap? Dan King: [21:35] You're bang on there. Military culture is a distinct thing. And without feeling some kind of connection to it, without an interest in it, I think it could be a hard population to serve. It's probably part of the reason that group practices are underserving veterans. Keith Myers: [21:50] I would assume so. Dan King: [21:51] That's a whole podcast in its own right. Keith Myers: [21:53] It is, yeah. Yeah, I'd love to talk more about that one day. Maybe we will. There you go. Yeah. Dan King: [21:58] Keith, as we move towards the end of our time together, we've talked about some meaty stuff. I think there are great insights here for the audience on all kinds of business and therapeutic issues. But I'm curious, what you do for fun when you're not doing your many, I think you've got about 20 jobs. So when you're not working your 20 jobs, what do you do for fun? Keith Myers: [22:17] Well, I got a few. Yeah. And one, one, my teaching, my teaching is my passion. That's my private, that's my big one. But yeah, no, for fun, I like, I like getting outside. I've got two, two boys, nine and six. So they're always running me, pulling me ahead, running me ragged around, you know, that you get so much energy for the entire universe. I like sports. You know, played when I was younger. And now if I play, I'd probably get injured. But I like watching sports now. So Atlanta Braves, Ohio State, football, all those things are fun. Keith Myers: [22:47] Yeah. And I enjoy reading for fun, too. So my students are like, how do you get time to read? And I was like, well, I've read this textbook three years ago. So I'm going to read the textbook. Now I can read this novel. See, I can diversify my interests. So I enjoy reading as well. That's a fun hobby. Dan King: [23:01] What are you reading right now? Keith Myers: [23:03] Well, you know, it's interesting. thing i just finished uh dave ramsey's book build a business you love that's an interesting one um that was good and then um i'm also i finally got around to reading um i've had clients and students tell me that i need to read tony robbins master the money game and it's it's an older book you know been around a long time so i just finished that so i really liked that a lot that was like okay that's that's opening my mind and like how much i really need to focus on retirement except for like, okay, I need to, I need to kick that into gear and extra notch. So that was really great. So those are two that I just read. Dan King: [23:36] Awesome. Awesome. Well, thanks for coming on, Keith. It was a pleasure and look forward to chatting again. Keith Myers: [23:42] Pleasure as well. Thank you so much, Daniel, for having me.