The Keystone Standard

Per-clinician profitability, defined precisely.

Most owners know their total revenue. What each clinician seat actually earns, after the full cost of that person, is harder to see. This page shows how to measure it, and which costs the quick math leaves out.

The quick math misses three costs

When most owners try to figure out if a clinician is profitable, they do a quick subtraction: billings minus the clinician’s pay. That is not wrong, but it is incomplete in three ways that matter:

No-shows reduce effective billings. A 10% no-show rate on a $10,000/mo clinician costs $1,000/mo before anything else.
Employer payroll taxes are a cost of employment. FICA alone adds roughly 7.65% to a W-2 wage, and the practice pays it.
Supervision and overhead exist because of each seat. A pre-licensed clinician consumes supervision hours, and every clinician consumes a share of rent, admin, and software.

The Keystone Standard: four layers, one number

The fully-loaded per-clinician net runs four layers in order. Each layer answers a more complete version of the same question: what does this seat actually produce for the practice?

Layer 1: Effective billings

Gross billings at full caseload, minus the no-show and late-cancel haircut. This is what the practice actually collected (or expects to collect) from this clinician’s sessions, not a projection at 100% attendance.

Formula: Gross billings × (1 − no-show rate)

Layer 2: Total comp cost

The clinician’s take-home pay plus what the practice pays in payroll taxes on top of it. For a W-2 employee that load is typically 7.65% of wages (FICA). A 1099 contractor carries no employer load, though that comparison rarely survives contact with benefits and compliance.

Formula: Take-home + (Take-home × employer load %)

Layer 3: Supervision

The direct cost of clinical supervision this clinician receives. A pre-licensed clinician using two hours of a supervisor’s time a week at $80/hr costs the practice roughly $690 a month, and that cost rarely shows up anywhere an owner looks.

Formula: Supervision hours/mo × supervisor rate

Layer 4: Overhead share

Each clinician occupies a seat that consumes a share of fixed practice costs: rent, admin payroll, software subscriptions, malpractice, and utilities. The simplest allocation is total fixed overhead divided by the number of active clinician seats. More precise methods exist; this is the floor.

Formula: Monthly fixed overhead ÷ number of active clinicians

The Keystone Standard formula

Effective billings
− Total comp cost (pay + employer taxes)
− Supervision cost
− Overhead share
= Fully-loaded per-clinician net

This is a decision-support metric, not a certified accounting figure. The assumptions (overhead allocation method, supervision rate) belong to the owner. Confirm cost categorizations with your accountant. The point is to surface a number that is honest about what each seat costs.

What does the number tell you?

These are the bands we use, drawn from running our own practice and from the Snapshot’s defaults.

Underwater

Negative net. The practice subsidizes this seat from other revenue. Can be temporary (new hire ramping, supervised clinician). The question is whether it resolves.

Thin margin

Net is positive but under 10% of effective billings. It covers its costs, but one bad no-show month can put it underwater.

Healthy

Net margin 10-30%. The seat covers its full cost and puts real money toward overhead and owner pay. A working seat looks like this.

Strong

Net margin above 30%. Getting here usually takes a high rate, low admin drag, and a light benefits load on the seat.

Status labels are derived from per-clinician net margin (net / effective billings). They’re a starting point for a conversation. Context matters: tenure, ramp stage, supervision stage.

Compute it for your own numbers

Enter one clinician’s numbers. Nothing leaves your browser. This runs entirely on your device.

Example numbers to start. Change the fields to see your practice.

Gross monthly billings · Enter what you'd bill at full attendance. We take no-shows off on the next line. (Bill $10,000 at a 10% no-show rate and $9,000 is what actually lands.)$No-show / late-cancel rate · % of sessions missed%

How they’re paid

Their split (% they keep)%Employer payroll-tax load · ~7.65% FICA; add FUTA/benefits if you pay them%Monthly supervision cost · hrs x rate; 0 if fully licensed$Overhead share · The slice of rent, admin, software, and malpractice that belongs to one seat. There's no perfect split. By hours, headcount, or rooms, applied consistently, beats allocating zero.$

Fully-loaded net is what a clinician’s seat actually nets the practice. Start with their collected billings, then subtract their pay and payroll taxes, any supervision, and a fair share of overhead. Contribution is what a clinician’s billings leave after their own pay and payroll taxes, before the practice’s shared overhead. Take off their overhead share and you reach fully-loaded net.

$1,368/mo

Fully-loaded net (Keystone Standard)

Healthy

$8,100

Effective billings (after no-shows)

$900/mo in missed sessions

$5,232

Their pay (fully loaded)

Take-home $4,860 + taxes $372

$2,868

Contribution before overhead

where most dashboards stop

$16,419

Annual fully-loaded net

This clinician contributes $1,368/mo to the practice — a 17% net margin after pay, overhead, and supervision. Over a year: $16,419.

Inputs are your own estimates, and nothing leaves your browser. Employer payroll taxes, supervision, and overhead are the items most dashboards omit; that is why the fully-loaded number differs from a simple billings-minus-split read.

Want the full picture across every clinician? Run the full Snapshot free.

Common questions

Questions owners ask about this number

What is the fully-loaded per-clinician net?

It's what a single clinician seat nets the practice after every cost that seat creates: effective billings minus total comp cost, minus supervision, minus that clinician's share of overhead. It's the number that tells you whether a seat is actually profitable, not just busy.

Why isn't billings minus pay enough?

Billings minus pay ignores three real costs: no-shows reduce what actually collects, the employer pays payroll taxes on top of wages, and every seat consumes a share of supervision and overhead. Leave those out and a seat that's underwater can look profitable.

How is this different from a contribution margin?

Contribution margin stops at billings minus their pay and payroll taxes. The fully-loaded net keeps going: it also subtracts supervision and a share of fixed overhead, so it answers whether the seat covers its full cost, not just its direct pay.

Related tools and pages

What is this clinician really worth? →: the standalone version of the calculator above
Is this clinician profitable? →: a quick contribution view, without the full load
What does losing a therapist cost? →: flips the fully-loaded net into a retention case
Full Snapshot →: every clinician, your draw, and where the money goes, in one run

Use the standard

The full Snapshot runs the Keystone Standard on every active clinician at once, using your real comp structure, overhead, and supervision rates, in about five minutes.

Run the full Snapshot free →

Free. No signup. The free read runs in your browser.