Last week I had the chance to go out for coffee with a fellow IBCLC, Michelle, who has been in private practice for 12 years. One of the many things we discussed was how many hours of work go into each home visit that we do, what we charge for a home visit, and how that computes into an hourly wage. Seems like it’d be incredibly easy to compute that hourly wage- if I spend two hours in someone’s home, then I just take my fee and divide it by two, right? I was charging $120 for a home visit, so I figured the math was easy (even for me).
Except… is that two hour home visit really only two hours of work? Michelle gently prompted me to think about all the time spent working before and after the visit as well. The wheels in my brain started to spin and once I got home, I wrote out all of the time that actually goes into each home visit.
I started with the obvious- it takes time to drive to and from the client’s home, and that time is included in my fee. I have a 10 mile service area, and on average I spend 45 minutes round-trip getting to and from my visits.
What about the preparation I do before a visit? I speak with the family, find out what the problem is and when they are available, make sure they have my intake and consent forms and have read my “before your visit” page, schedule a time that works for them, and locate any childcare I need. I spend time prepping for the consult by gathering handouts and reference material to bring with me, depending on what the family is going through. That’s an average of 40 minutes of work and prep before I set foot in my car to head to the client’s home.
Once the visit is over I do my charting for the encounter and write a report that I fax to the family’s pediatrician and/or OB or midwife, with another copy sent to the family directly. I always intend to chart during the visit, but more realistically I spend my time waving my hands emphatically in the air, talking to the baby, and not writing down a single note. That means that my post-visit charting and reporting after the visit takes about 60 minutes.
It turns out that I actually spend an average of between 4 and 5 hours working on each “1-2 hour” consult. This does NOT count any time I spend doing free phone/email/text follow-ups for the next two weeks. Obviously it also doesn’t count all the time I spend doing general admin work like answering my phone, writing emails, running to the bank, update or edit my website, do my own accounting, read as many articles and books as I can get my hands on to keep my knowledge current, give general free breastfeeding advice to around 5 families a day who are not and will never be paying clients, answer breastfeeding questions on Facebook and Reddit to try to stem the flood of bad information out there… the list goes on and on. All of those “extras” aren’t directly related to the time spent on each home visit, but they are all part of my cost of doing business.
So, 4.5 hours of work for each 1-2 hour home visit. I’m a freshly-minted IBCLC and I’d never heard anyone talk about this before. Was it just me? Was I just really, really slow? Did other IBCLCs take less time working before and after each consult?
I asked a large group of IBCLCs, many of whom have been in private practice for lots and lots of years (you know who you are- I know who you are- I am NOT calling you old). Here are some of the answers I got in no particular order:
Paula Santi, IBCLC- Albany, California– 4 hours
Jennifer Welch, IBCLC- Montreal, Canada– 5 hours
Debi Miller, RN IBCLC- Columbus, Georgia– 5.5 hours
Laura Gruber, IBCLC- San Antonio, Texas– 3-4 hours
Jennifer South, RN IBCLC- Pensacola, Florida– 4.5 hours
Christine Roca, IBCLC- Bethlehem, Pennsylvania– 4.5 hours
Michelle Kunschke, IBCLC- Sacramento, California– 5 hours
Leah Segura, IBCLC- Midland, Michigan– 5 hours
Joy Funston, RN IBCLC- Central Virginia– 5 hours
It’s not just me! Turns out that MOST of the private practice IBCLCs I spoke to estimated that they do at least 4 hours of work for each initial home visit, not including any phone or email counseling after the visit.
So in terms of the fee I charge for a home visit, that means that I divide it (conservatively) by 4 to see what my hourly wage is. And that number doesn’t look too bad…
… until you look closer.
See, most private practice IBCLCs work for themselves. That means we pay self-employment taxes on our earnings, along with any other taxes related to owning and operating a business. Math is not my strong suit, but my understanding is that you should expect to pay at least 30% of your income in taxes if you are self-employed. As I just opened my private practice I haven’t done this yet, but I know it’s coming.
That brings my hourly wage down to my fee, minus 30%, divided by 4.
Which wouldn’t be terrible (but certainly not great for someone with a graduate degree and such in-depth knowledge, and of course it doesn’t include health insurance, paid time off, or any benefits at all)… if I didn’t have business-related expenses. The IBLCE exam was around $800 all by itself. I spent about $300 for this year’s membership in both USLCA and ILCA. Malpractice insurance is around $100 a year. To register as a Limited Liability Company in Massachusetts is $500, and then $500 a year after that. I designed my website myself but I pay for the domain and hosting. I have to pay monthly for an online fax service to send reports with. I pay for all my own advertising and marketing. I pay to print my forms and my handouts for clients.
Then there’s continuing education- IBCLCs spend a TON of money on conferences, courses, and books. We have to earn 75 Continuing Education Recognition Points (CERPs) to re-certify every five years- each CERP is about an hour of course time, so that’s a total of around 75 hours of additional education. We pay for all of those CERPs out of pocket on top of a re-certification fee of $470.
But wait, there’s more!
Am I dating myself with this one?
IBCLCs need at least a few key pieces of gear. Have you ever stopped and thought about how much money a highly sensitive baby scale costs? I’m guessing you haven’t, since I certainly never did.
something tells me these scales aren’t sensitive to 1-2 grams…
The Tanita BD-815U is well-loved by IBCLCs as the “affordable” baby scale. It’s currently $844.99. That’s considered “affordable” because the comparable Medela scale is over $1,500. Many IBCLCs also keep various breastfeeding supplies on hand- nursing pads, syringes and tubing for finger feeding, nipple shields, hydrogel pads for nipple healing, nipple creams, cold packs, sometimes formula (please do close your mouth, it happens!)… can you see how it all adds up incredibly quickly?
Once I did all the math, I realized that at my current price I’d have to see 44 babies this year just to break even. Not to pay myself a penny of salary, not to make a living wage, not to contribute financially to my family in any way- just to break even.
I know, muffin, I’m making the same face right now!
Listen, I know that a lot of people think private practice IBCLCs charge a lot of money. Our fees may seem high to you; but when you really break it down, we are not rolling in the dough. Not by a long shot. As the fabulous lawyer-and-IBCLC Liz Brooks says, “being an IBCLC in private practice is not for the faint of heart.”
(TL;DR: I raised my fee. If you’re also a private practice IBCLC, perhaps you need to as well.)
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