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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by pegasus on April 11, 2011, at 10:23:16
I've been pondering something a lot lately, and am wondering whether you guys might have some helpful ways of looking at this. The issue is that I'm going to be starting my own part time private practice next fall in a mental health related field. I'm finding one of the stickiest issues about the whole thing, for me, to be money. I really want to be able to work with folks who don't have a lot (which is a lot more people than those who have a lot). But, then, how do I afford that? I hate the answer that I just can't. It's so unfair to so many people who can't afford regular fees.
One tricky bit is that my husband is not at all in favor of my practice being a money sink, even for a little while. Even though I have another part time job that is more lucrative. And I can't really blame him. It's been expensive to get through school, both in terms of time away from my family and in terms of actual money. He's been supportive, but I think enough is enough. My practice will have significant expenses (office rent, insurance, supervision, continuing education, etc.). And, of course, we have living expenses just like anyone, although we try to be frugal.
I've heard folks here talk about how Ts that can really reduce rates for low income clients are more ethical. And I agree to some extent, and want to be ethical in that way. But is it unethical to not reduce my rates if I can't afford it?
Maybe the answer is that I'll need to get a good base of clients who can pay before I can take on clients who need special arrangements. It just seems to cold to approach it that way. But if my practice doesn't support itself, then this becomes an expensive hobby, which is not at all what I'm after (or my potential clients, I'm sure). I want this to be my life's work.
I wish there was a fairy godmother who paid for everyone's therapy. That way clients could get the help they need, and Ts could make a living, all at the same time.
Any thoughts?
Peg
Posted by pegasus on April 11, 2011, at 15:26:20
In reply to ethics of therapy and payment, posted by pegasus on April 11, 2011, at 10:23:16
I think this is partly so tricky because therapy is one of those places where social and market norms clash. There's a great book that discusses this (among other things): "Predictably Irrational". When I first read about social and market norms in there, I immediately thought of therapy.
So, the idea is that when exchanging items and services, we tend to operate either in social mode or in market mode. And crossing from one to the other creates icky feelings. For example, if you try to pay your mother-in-law for Thanksgiving dinner, that is very rude. You're trying to operate in the social realm using market norms. Or, if you ask a friend who is a tax professional to do your complicated taxes for free, that's rude, too. You're trying to operate in the market realm using social norms.
Therapy seems to operate in social and market realms at the same time, which is really confusing. Sometimes we apply social norms (giving gifts, hugs - sometimes, creating warm interpersonal relationships), and sometimes we apply market norms (payments, appointments). Crossing from the social realm into the market realm (i.e., at payment time) is jarring on both sides (in my experience at least), and unhelpful to the parts that operate in the social realm.
Maybe the trick is to try to separate the two realms as much as possible? But how?
- P
Posted by annierose on April 11, 2011, at 19:58:24
In reply to clash of social versus market norms, posted by pegasus on April 11, 2011, at 15:26:20
I agree with your husband. Being self-employed myself, and weathering the storm of the current economy, my "job" has been more "hobby" than good pay the past two years ... and it gets old FAST. I've been in business for over 20 years, so I was able to keep my staff in place, and cut my pay to make it through. Now, I want a pay check.
I say all this to say that I think most therapists have mostly paying clients and that maybe they accept one or two on a sliding scale - but the rest are paying clients (either through insurance or self-pay). If you can financially help one or two clients at any one time, that is HUGE. I would guess very few therapists (if any) see anyone for "free" - so if there current fee is $120 maybe they accept $40 or $50.
The face that you are considering this before setting up your practice tells me what a wonderful therapist you are becoming. Good Luck!!
Posted by TherapyGirl on April 11, 2011, at 20:21:09
In reply to ethics of therapy and payment, posted by pegasus on April 11, 2011, at 10:23:16
In my opinion, as long as you don't email a client an hour after her father dies whining about billing issues, you're ethical.
Oh, wait, I made this about me. :-)
Can you sit down and come up with a ratio of private/insurance pay clients to sliding scale clients to see what would pay your bills while still making therapy available to those without other resources? It may be that even at the beginning you could do a certain percentage and then perhaps that percentage could grow as you develop your clientele.
Posted by emmanuel98 on April 11, 2011, at 20:41:56
In reply to ethics of therapy and payment, posted by pegasus on April 11, 2011, at 10:23:16
Both my p-doc and my t take insurance and are on panels, which makes it easy for them to find patients and easy for the patients to afford it. Niether takes Medicaid, though both put in significant time at public mental health facilities, so they've certainly done their part. Insurance panels pay less usually than out-of-pocket clients and my p-doc and t both complain about the work -- billing, not getting paid on time, screw-ups, etc. But with insurance you can see low to middle income folks and get a reasonable rate.
Posted by Daisym on April 11, 2011, at 22:37:23
In reply to Re: ethics of therapy and payment, posted by emmanuel98 on April 11, 2011, at 20:41:56
I think most folks doing Human Service work agree that the one thing they hate talking about is money. It is unfortunate that somehow we've come to think about caring flowing "for free" and if you get paid, "it isn't real." I remind people oftent that we have to feed our own children too.
I think you need to remember that not-for-profits exist to serve those without resources and those entitites usually use interns as sort of "slave-labor" and are often government subsidized. Plus, agencies like mine can fund-raise. Try not to set yourself up to think you are doing a disservice to your community by charging - you aren't. And people who can pay often need as much help as those who can't.
The best advice I can give you is to create a policy document that outlines all the pay issues - amount, expected pay schedule, what happens if insurance refuses, who bills insurance, missed sessions, vacations - theirs & yours - phone calls, emails, etc. And then have them sign a copy. You keep one and they keep one. That way there are much fewer billing surprises. I won't say there won't be any but at least it is all out in the open. And then, if there are issues - bring them up. If they are yours, I recommend asking for a few minutes after the session ends. If they are the clients (like a bounced check) it should come up during the session in as brief a way as possible. I try to think of it as modeling open and honest behavior of everyday transactions.
I agree with establishing a couple of slots for sliding scale after you get a healthy client load. Start up can be expensive and difficult.
But how exciting! Good for you.
Posted by emmanuel98 on April 12, 2011, at 0:44:26
In reply to Re: ethics of therapy and payment » emmanuel98, posted by Daisym on April 11, 2011, at 22:37:23
I once complaind to my p-doc (who I saw for weekly therapy) that this was all about money. If I lost my insurance and couldn't pay him, he wouldn't see me. He said that's not true. I would see you and you could pay whatever you could afford, even if was only $10/week.
Of course, he is semi-retired and drives late model cars and seems very well set financially. so it isn't so much of a hardship for him. If he were younger and just starting out, I would feel guilty paying him that little.
Posted by pegasus on April 12, 2011, at 10:23:06
In reply to ethics of therapy and payment, posted by pegasus on April 11, 2011, at 10:23:16
Thanks everyone. Yikes, it's good to hear about some things to avoid, although I'm hoping I'm sensitive enough to avoid some of the things you all have had to deal with. And Daisy, thanks for the advice about things to do. I'll have to consciously build that into my plan.
I still hate that I have to charge a full fee to most of my clients. But, it's good to be reminded of the role of non-profits and grants. That's where I've been up until now. And I see how huge the need is, so I want to be able to help. One things that's nice about working in the non-profit world is that the payment and the therapy really *are* separated, at least from my point of view (I don't get paid by my clients, and the fees they pay have little relationship to my compensation). I am struggling with losing that separation.
Come to think of it, I went through this transition in my first career as well, when I moved from academia (a lot like non-profit) to the commercial world. Suddenly everything was about revenue, which was hard to get used to, and went against a lot of my values. Funny how I've never felt guilty, though, in that career, about asking for a decent salary. But, then, the company never seemed so vulnerable as my clients do now. But the work wasn't as important, or influential either (from my perspective, at least).
I'm trying to remind myself, also, that there are some good things that come from paying for therapy. In my own work, I know that I need to be more clear about how valuable it is to me. I can't be flippant about doing the work or not. It keeps me working hard every session, and helps me feel better about asking for what I need.
- Peg
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