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Posted: November 18, 2011

The slippery slope of the sliding fee scale

If we don't value our time, why should anyone else?

Teri Karjala

As health care professionals, standards demand we provide our clients with the highest level of service possible. But while those rigorous standards ensure high-quality care for our clients, we also maintain another responsibility: to set standards for our business that reflect what we are worth.

In building a health care business, one thing is clear: Insurance and "sliding scale fees" don't add up to a thriving, growing health care business. According to a sliding scale is defined as "a scale of fees, taxes, wages, etc., that varies in accordance with variation of some standard." But I wonder: Who sets these standards?  

The term sliding scale is tossed around in the health care field as if it is a form of client entitlement and many providers consider the sliding scale fee an avenue for giving back to the community. I view the sliding scale as additional weight placed upon providers' shoulders that inevitably builds blockage in running and building a seamless business. Moreover, the sliding scale perpetuates the misconception that profitability is not an option within the helping field, even as our expertise and education establishes our credibility, knowledge, professional acumen and eventual reputation within the field.  

Somewhere along the line, it became routine to expect professional health care services to depend upon and ride the rocky slopes of our client's economic mountains. 

Ironically, the term "sliding scale" is never applied to most other professions. Consumers, for example, don't ask the grocery clerk for a sliding scale. Imagine the look on your mechanic's face if you requested a sliding scale rate. Sounds preposterous, right?  

In "helping fields," however, it is a way of life. Dr. Larry Waldman author of the book The Graduate Course You Never Had, speaks out about how helping professionals have trained consumers to respond to the sliding scale by allowing it to happen. The essence of truth stings deeper than any other wound and as a result, clients anticipate receiving sliding scales, discounts and freebies.  

Our higher education in the helping field has trained us to provide remedies and cures for the vices that ail our clients, but it is our duty as providers to value our own self worth as well as our business. If we do not value our time, our training or our investments we have placed into our practice, how can we expect anyone else to?

Don't get me wrong; I believe sowing seeds within the community is important to promote everlasting growth. However, there are a myriad of other avenues for contribution besides short-changing your business. There's volunteering, choosing pro bono cases and a host of philanthropic endeavors all of which serve to enrich the community as well as your soul.

The key to success in private practice is knowing when to give back and, at times refusing to give in when growing a flourishing private practice. Along your journey to finding balance, you will discover why some people make it in the world of private practice and others don't. Keep in mind that once you step away from the security blanket of an agency and stand on your own two feet, the game changes and you are always it.

While in the midst of finding your personal Zen, here are some steps to help nudge you towards the direction of inner peace between the conflicts of business while lending a helping hand within your profession.

 Begin by setting clear-cut goals for your business. A business plan will enhance your vision, as well as provide guidance during long and short periods of time. Next, seek supervision to address how these goals impact your role as a helper. Supervision can come by way of mentors, or groups comprised of individuals who share the common goal of spearheading a strong private practice.  

Never underestimate your own self worth. This is accomplished by not only determining the monetary value for your services but also refusing to waver. Find ways to support your community - while supporting yourself and your business.

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Teri Karjala is owner of the Creative Counseling Center, LLC, as well as Talking With Teri, LLC. Teri’s passion for the business aspects of owning and maintaining a business has made her a sought out coach by others in the helping fields. She is a regular columnist for ColoradoBiz Magazine and speaks to therapists across the nation in building their thriving practice. Recently she has released her “How to Live Deliciously” Creative Journal Series to help inspire and empower adults, teens, and children. These are available in print at

Enjoy this article? Sign up to get ColoradoBiz Exclusives. The opinions expressed in this article are solely that of the author and do not represent ColoradoBiz magazine. Comments on articles will be removed if they include personal attacks.

Readers Respond

I find it capitalistically accurate but morally wrong that insurance providers can negotiate a rate that a person walking in off the street can not have. Are you losing money at that rate and making it up off the rest of us? Or are you still making money and charging the rest of us a surcharge simply because you can (the very reason that an insurance company can get by with charging you less). Its not in anyone's best interest for a health provider to be losing money and I would certainly not advocate it. If you want to only take on full load patients and can build that clientele you can probably make a lot of money and not need to give back to the community at all. For people that self centered I favor a progressive tax structure because I do believe those of us who do well should do well for others- one way or the other. By Burt on 2011 11 18
Granted, the US healthcare system as a whole is ranked dead last in the cost vs results equation among all developed nations. There are a myriad of factors coming into play here, but I think we are missing the point that Teri is trying to make regarding the sliding scale. My wife is a psychotherapist, running her own practice for about 18 months now. While she is in the fortunate situation of having a full client load, she is still offering sliding scale slots. She would not need to discount her work in order to remain fully booked. In her mind, however, economic conditions should not stand in the way of clients receiving critical treatment, even in the context of a broken healthcare system. That said, she is strictly limiting the number of sliding scale clients in order to protect her own practice. This way she is shouldering a share of the load and giving back to the community without jeopardizing the well-being of her business. I find this commendable and I see nothing wrong with profitable businesses, large and small, giving back to the community in some way. By Tom on 2011 11 18
Lee, I have to agree with your perspective. Coming from a national healthcare system (which is broken beyond belief because it's all "other people's money") - I see the US system as fundamentally right - except that the insurance companies place an almost crippling burden on the system. The ratio you see between 'invoiced' and 'contracted' rate is the core problem driving this differential between cost, value and remuneration. On the high end (invoiced price) a ticket price is offered which accounts for the massive overhead in collection (the brain damage of dealing with the insurance companies), the value the client receives is often more than the contracted price paid - seems like a bargain. BUT the physician must remember that the price paid for their service is only the point-of-sale price for the consumer - their true cost is the POS price plus their medical insurance premium amortized over the number of visits they make per year for service. So in the case of myself and my spouse latest year the approximate cost of to $20 doctor's office visits was around $21040 ... To fix the 'perceived' value of services problem that many physicians have, the massive 'losses' in the system (read insurance company profits and phenomenal administrative waste) has to come out of the system. By Nigel on 2011 11 18
Teri, Your points are well taken, but I feel that something is missing in this discussion. As a consumer maybe I wrongly feel like the insurance companies drive the "sliding scale", not the consumer. An example that happened to my adult son getting ready to go to the Peace Corp. I had taken out major medical insurance for him when he became too old to be on my policy anymore. When he decided to go to the Peace Corp he had to have extensive tests and vaccinations that were very expensive. The irony to me is that his insurance didn't cover any of it, but because he HAD insurance the bill went from over $900.00 to $200.00. So essentially, the people that can't afford insurance are charged the most. I totally understand your frustration in not getting compensated for your worth, and at the same time I understand consumers frustration at the unfairness in how they are charged. It appears to be a double edged sword. By Lee on 2011 11 18

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