Sunday, June 12, 2011

Guest Blogger Jesse: When Patients Don't Pay




Dinah asked that I “blog on what you do when patients don't pay.” I’ll try to put that question in a larger context. If a patient is seeing a physician for treatment of a mole, or of a fever, the treatment of those illnesses has no relation nor is affected by when or how the doctor is paid (other, of course, that the doctor might refuse to treat the patient). In psychodynamic therapy, where the therapist is helping the patient with relationships, anxieties, attitudes, and conflicts, everything that occurs is potentially helpful if it is understood. Observing and thinking about actions and feelings is a part of the treatment, as important a tool to the therapist as a stethoscope to a cardiologist.


Money is something loaded with meaning to most people. What does it mean that the patient forgets to pay? Does it mean “if you really cared about me you would not charge me”? Is it a reflection of anger for something that occurred in the last session? Is it a displacement of feelings from something else (“my boss didn’t give me the raise I expected”)? Is it completely inadvertent (Freud famously said “Sometimes a cigar is only a cigar”)?


There are so many possibilities, and the psychodynamic therapist wants to understand them. How the patient relates to the therapist is some part of how he relates to others. The patient hopefully starts to watch his own actions and attitudes, and also tries to understand them. A nonjudgmental stance helps the patient do this.


The therapist himself needs to be comfortable dealing with the subject of money. Sometimes beginning physicians fluctuate between feeling they are too inexperienced to be paid and feeling that they deserve anything they ask. We physicians might even (unfortunately) take on the attitudes of the insurance companies themselves (“Identification with the Aggressor”).


There are times when the treatment needs to be discontinued, or the patient referred for other care. Clearly, if the therapist has allowed a patient to go a long time without paying, without good reason thoughtfully discussed, both doctor and patient have unwittingly colluded in avoiding very important issues.


Many therapists believe it is important for the patient to pay something, regardless of his economic state. It is part of the patient’s self-esteem. It indicates a professional relationship, one in which the patient essentially is employing the therapist (physician, lawyer, accountant, et al) and in which the therapist has professional obligations to the patient. It is therefore part of the professional boundaries.


There is a curative aspect to the attitude I’m describing. To the extent that the patient can increase his ability to examine his own actions and feelings in a nonjudgmental manner he gains control over areas of life which may have been becoming increasingly difficult for him.


What have others experienced in this regard, and how do you think of these issues?


119 comments:

Sunny CA said...

I almost always pay within a couple of days of getting a monthly statement. For quite a long time I felt that my psychiatrist was being too casual about it. He knows I have a good memory, so he would just say at the beginning of the session "Payment for April is due and your balance is $_______." or he wouldn't say anything and I would count the number of sessions in the month and mail the check when we got to the last day of the month or just after I had the last session in the month. Then I started teaching four high school sciences as my first teaching position and some things in my life started falling through the cracks and the no-bill system stopped working for me. I would forget and it had nothing to do with Freud. There are only so many things a person can do in a day.

My psychiatrist who has been in practice more than 40 years has told me numerous times that not being paid and being stood up for appointments has never been as bad as it is now in his practice.

HappyOrganist said...

I think payment is an important part of professional boundaries. It IS a loaded topic. And it's been interesting to me to notice my own tendencies in that area. i.e. I don't mind getting stuff for 'free' or for less than what other people pay. But I've found that it can lead to problems in a professional relationship. Ever since the experience I'm referring to, I often prefer to Not be given special deals by professionals I see. Generally - not always. ;D

Sarebear said...
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Sarebear said...
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InnocentlyGreen said...

I agree it's a professional boundary and should be respected. They should see us as professionals that have learned something and have specialized in it and we are helping them with the use of our knowledge. Even if the patient-therapist relationship gets close, we're still professionals, not just friends.

I've had patients not paying, but it was because the session was so intense they just forgot. And usually by the time they get to their cars to drive off, they remember and come running back apologizing. If not then, than definetly at the beginning of the next session.

Anonymous said...

"Even if the patient-therapist relationship gets close, we're still professionals, not just friends."


IG's statement is true but I hope they don't get too close. When the professional crosses the line that even payment cannot protect, I do hope that all monies are refunded to the patient and then some. I'd like to see that happen, in addition to the loss of license to practice, in cases where doctors and patients get "close".

Alison Cummins said...

Where I live, psychiatry is paid for by public insurance so nobody has to worry about that. Qualified psychotherapists though can be quite pricey, which is tough when the reason you need psychotherapy is that you're so messed up you're underemployed or can't work. Free or very low priced psychotherapy exists but has significant limitations: it's limited in duration and/or provided by inexperienced or underqualified individuals.

I went to a hospital-based outpatient clinic seeking CBT for depression. I was assigned to an MSW experienced in CBT for phobias, and charged the second-lowest rate on the sliding scale. After a few sessions I asked about getting the lowest rate and was rebuffed with "that's just for people on welfare." My income at the time was significantly less than welfare, but I didn't have the spirit to argue.

I stopped going because he was so obviously clueless and unhelpful. (We spent a fair amount of time talking about his student days and new baby, on my dime.)

Later I went back to the clinic when I was working again and paying the full rate, and assigned to an experienced clinical psychologist with a PhD. (Ultimately seeing her didn't help either, but it wasn't as obvious. I kept seeing her for two and a half years.) When I stopped being able to pay the full rate, she asked me to see her at her home office in a fancy neighborhood, because then she wouldn't have to pay for office space at the hospital. That's when I understood that the individual psychotherapists at the clinic were not salaried and I wasn't being subsidized. I was upset that the sliding scale was coming out of the psychotherapist's pocket. I'm not used to that system and it felt humiliating, like charity, and took away some of my were and agency in the relationship. I was too ashamed to bring it up and we didn't discuss it.

Her fancy house in the fancy neighborhood didn't have a waiting room. I was supposed to wait in my car until the exact hour of my appointment then ring the bell. I didn't have a car, so I sat on her step instead. That was a problem for her, and we spent several therapy sessions discussing my reluctance to comply with her request.

Later, when my unemployment insurance was about to run out, I gave her my last cheque which was enough to pay in advance for six sessions at her lowest rate. (6 * $30 = $180) She wanted to discuss how I was trying to make her responsible for managing my finances for me. I was unable to make her understand that I needed that money to eat, and that if I didn't give it to her for safekeeping I was going to use it for necessities and not be able to see her at all. That giving her the money was me doing what I needed to do to make a commitment to therapy. When those last six weeks were up and I had to stop seeing her, she wanted to explore my resistance to therapy. She just didn't get it.

In my experience, money has been a significant obstacle to therapy. I can accept the theory that paying something is important to maintain a professional relationship, but I have trouble when the therapist is paying for my sliding scale themselves. It becomes a personal thing between the two of us, and not something we are all entitled to by virtue of our humanity and participation in society.

I don't pay for my family doctor out of pocket. She's paid for by the state, and her money is her business. I like it that way. I'm the same as anyone else, whether I'm making a lot if money (as I am now) or little to no money (as I have in the past). That's important to me. I don't want the burden of being "more equal than others" just because I happen to have a good job.

And yes, my relationship with my family doctor is professional and I don't abuse it.

rob lindeman said...

This issue affects all of us.

A doctor-person relationship should be contractual, but it is not.

Virtually NONE of my families pay me for my services. This raises the question: for whom am I working? I might claim that I am working for the child, but his family is not paying me. Most of the time, I'm working for the State.

Don't agree? Those of you who have cash-paying clients, ask yourselves - do I think about this person differently because he's paying me with his own money?

IMO, EVERY family should pay me for their services. People pay for what they value and value what they pay for. If folks paid for the services they received, the world of medicine would look very different today. Ditto psychiatry.

moviedoc said...

Agree with Rob. In analytically bases psychotherapies payment may have special meaning, but it is a critical part of any professional contract, even for med management encounters. A patient's attitude can be very different when an insurer or Mom pays the bill. What I really object to is the reverse situation when by law a provider must pay for a foreign language or sign language interpreter, sometimes resulting in the provider actually paying for the privilege of treating the patient. Not OK in my book. We need to push back.

rob lindeman said...

moviedoc,

Happily, I've never encountered a situation where I had to pay to see a client. You observe correctly that the law demands that we do this and that we must push back. How much deeper does the State have to get into our business (not to mention our pockets), for a critical mass of our colleagues to stand up and say "enough!"?

Anonymous said...

Posts about money are so interesting. And posts about how psychiatrists squeeze money out of their patients is fascinating!

rob lindeman said...

[does that count as an 'ad hominem']

in any case, it reminds me of a joke:

Neurotics build castles in the air; psychotics live in them; and psychiatrists collect the rent.

Anonymous said...

Wow, Dr. Lindeman, I'm speechless.

I thought such "jokes" went out with ethnic slurs, gay bashing, and the like.

Dinah said...

So I think was thinking along the lines of What-to-do-when-the-patient-doesn't-pay for Dummies. Jessie's post talks about what might be behind not paying in a psychodynamic sense, but what to do when the patient doesn't pay because they are having either real or perceived financial difficulties--- pretty much everyone talks about financial angst in therapy. Or when someone else has agreed to pay the bill--usually a parent-- and they aren't? Or when the patient repeatedly says, "I'll send a check" and doesn't, or "spouse takes care of bills, I'll tell him/her to pay" and payment doesn't come promptly?

moviedoc said...

OK, Dinah: Send the pt a 30day notice of discharge, but let them resume if they pay up. We don't do anyone a favor by letting them build a big debt. We are not in the lending business. Banks do that. We can't afford to treat all the poor of the world. If we really want to be that kind of hero, we should be vaccinating children in Africa, not letting pts build a balance due so they can keep buying cigarettes.

Dinah said...

MovieDoc: This is why your patients are happier to see your dog.

moviedoc said...

Dinah: I know that.

Duane Sherry, M.S. said...

Value.

Offer your clients (patients) more value, and they will come back, willing to pay... In fact, word of your service will carry... to family, friends, associates.

It's a healthy business model.
One that's worked well for years.

Something as simple as helping children get off psychiatric drugs, as was initiated at LSU a few years back -

http://psychrights.org/articles/081215IrwinGetKidsOffDrugs.htm

This is a much-needed service, and one that not only doctors can be involved in, but psychotherapists as well.

From Ron Unger, L.C.S.W. -

http://recoveryfromschizophrenia.org/therapists-guide-to-reducing-medications/

Duane Sherry, M.S.
discoverandrecover.wordpress.com

Anonymous said...

I can't pay you, because I have to get Fluffy groomed, pay for cigarettes, cable, my iphone, internet service, and shop at Whole Foods, oh, and there was this blouse on sale and I haven't bought clothes in soooo long...there is just no money left for medical visits.

This is definitely not limited to psych patients, I went to college with people who always seemed to find the money for the fun stuff, but for some odd reason never could find the money to pay their bills.

Even with people who are responsible, things can happen, but it needs to be discussed. No one should be expected to work for free.

Leslie

Anonymous said...

I would make an exception to my above comment, and that's with involuntary treatment. I was very upfront from the beginning that I did not want the treatment, did not have the money for it and even if I did have the money, I wouldn't pay it. So, that was an unwise investment on their part. I've paid all other medical bills, but I'm not going to pay for involuntary treatment.

Leslie

jesse said...

So to address Dinah's questions, the first thing you do in all of those examples is talk about the situation with the patient. Is the doctor able to change the financial arrangement? If in private practice, he usually might have that option. He might agree to lower the fee, change the frequency of visits or length of the sessions, and so on. He might be willing to allow the patient to take a longer time to pay the bill. Or it may be decided to discontinue treatment until the financial situation improves.

In those situations where the patient is one spouse but the other holds the purse strings, it is assumed that the patient has the ability to make sure payment occurs, but of course this might not be so. So, if the patient continues to make appointments for which payment is not being made, and acting like it is not his responsibility, that in itself is an important issue to be discussed.

There are no absolutes (well, a few... while it may be ethically OK [but full of psychodynamic problems] to accept something instead of money, in a barter arrangement, quite obviously there are certain things no practitioner should ever accept); the principle is that the financial arrangements are a part of the therapeutic process and need to be understood as such. If in doubt, the psychiatrist could always ask colleagues for their advice.

Anonymous said...

A few years ago my son saw a psychiatrist who held a no-missed session policy; ie, you paid for every monday at 5:00 pm whether or not you were there, regardless of how much notice you had given that your older sister was getting married that night or if you were scheduled to have your gallbladder removed. to me that's just as appalling as a patient who doesn't pay. talk about making it all about the financial.
please tell me you lot don't hold with policies like that.

Duane Sherry, M.S. said...

Leslie,

Re: Payment owed for involuntary treatment

If a cab driver saw you walking on the side of the road, and forced you into the back seat of his cab...

Took you for a long drive... one that lasted days, or weeks, while he kept the meter running.

How much would you owe him for the trip?

I'm not encouarging you to make a decision, one-way or the other...

Only you were there, Leslie.
Only you know what happened.

But if the cab driver were working for a company that had a history of doing this... It had happened more than once, and the company in-fact encouarged it...

The real question might be how much does the driver/company owes you?

In fact, it might not be whether you owed a bill...

It might be much larger than that... In terms of punitive damages that would shut down the cab company once-and-for-all (at least the one in your town).

Food for thought.

Duane Sherry, M.S.
discoverandrecover.wordpress.com/freedom

moviedoc said...

Anon. That full fee policy makes sense for psychotherapy if the pt. has the same time slot every week. FWIW, here's my policy: If you call me before I call you when you don't show up, you pay $50 (which is not the full fee) unless I can fit you in later (which is soo much easier when you do 50' med checks. If you call first, even after the time of your appointment, no charge.

Duane, forget the punitive damages, that's kidnapping.

rob lindeman said...

Please tell me insurance does NOT pay for involuntary incarceration and drugs!

Anonymous said...

It does not make sense to charge for a well in advance cancelled session just because the patient has the same slot every week. My grandmother used to see a hairdresser every week at the same time. I do not believe she was charged if she had to cancel an appointment.
I wonder what happens when the doctor makes a mistake and books two patients for the same hour. Or what happens if the doctor falls ill on the morning of an appointment and has to leave suddenly.It happens.In such cases, does the doctor reimburse the patient for parking costs or perhaps even lost wages for the time the person had to book off to make it to the appointment. or the babysitter that needed to be paid to look after the kids? Now that would be something. An doctor who would charge even if plenty of notice is given ought to consider these things.

Dinah said...

I once heard of a psychoanalyst who charged her analytic patients for "her" vacation (and for theirs, obviously). I can't imagine who would agree to this, or how I would ever fill a practice with such expectations.

I charge full fee for all appointments that are not canceled 24 hours in advance except if there is the sudden onset of an illness, or a weather event. I'm somewhat lenient even on this, especially if I can give the patient an appointment within a day.

I think we have our own personality styles, I know docs where it's 6 weeks until their next available appointment, but I won't offer appointments more than 4-6 weeks out, because what if I got the opportunity to do something fun? I do better with life being a bit flexible, and this way I can almost always fit someone in distress in within a couple of days. It works for me.

Insurance pays for involuntary treatment. I'm not sure I really understand the idea of "NO involuntary treatment." People commit suicide and murder all the time, if they or their loved ones involve a mental professional first, we should let them proceed if they say 'I don't want care after all"?" Or do we arrest someone who has been pulled off a bridge? And if you get a psychotic depression that leads you to believe that your children would be better off dead and the devil wants you to kill them, and this comes to the attention of a psychiatrist, you want to be allowed to kill your children?

rob lindeman said...

Dinah,

It's a very narrow question. Insurance contracts spell out their terms in exacting detail. This is why no one reads them. The specific question is: is the payer obliged to cover "treatment" that the covered-life undergoes involuntarily?

If insurance is cancelled (not an unusual circumstance: it happens to my Medicaid families all the time), and responsibility falls to the individual, do hospitals demand payment from individuals who refused admission?

moviedoc said...

Anon, as Dinah implies, we can implement whatever policy patients will agree to. I particularly like your comparison to hair dressers. I wonder to what extent talking to them can be just as therapeutic as talking to a psychotherapist. I can tell you, tho, that I have known psychotherapists who did charge pts. when it was the psychotherapist's fault, and find it disgusting.

Rob, it seems to me a hospital would have a hard time collecting for a refused admission unless the patient signed an agreement to pay, which one hopes they would not.

Lisa said...

When would a psychiatrist or therapist even consider discussing payment with a patient? In my experience, all payment is only discussed with the person at the front desk. Payment is to be made before even entering the psychiatrists office. No payment, no appointment, no excuses. My credit card on file at my ex p-docs office had expired and I completely forgot to bring in the new one. Despite having a year-long history of paying and arriving to every appointment (on time even when the doctor was late), I was not allowed to go into this appointment, though I was of course billed for it. It was a completely humiliating experience. I have never been to a psychiatrist or therapist who did not require payment before being seen and I've never been to one that did not say, "Any discussion of payment must be done with the front office, not me."

I find the idea of payment for health services so degrading in America. I'm chronicly uninsured so every appointment must be paid by cash or credit card. Believe me, I wouldn't feel a loss of self-esteem if the doctor suddenly said, "Hey, I'm not going to charge you $300 to see me. I'm going to discuss with you what you can pay now and we'll re-evaluate when your finances change." I would think I finally found a doctor that realizes s/he went to medical school first to heal the sick and injured and second to earn a dignified living...NOT to strip patients of their dignity and cash when they are at their most vulnerable.

Many doctors use the argument that we'd all be willing to pay our accountants or lawyers should the time come. This is a poor argument as the comparison does not hold. An accountant or lawyer does not hold a person's health in the palm of their hand.

The other argument that doctors should be adequately reimbursed for their time spent in school is a foolish one. I hold a PhD and yet no one in my field is jumping up and down demanding a $250k a year salary.

I don't dispute that a doctor should be paid. After all, we as a society agree that all people have the right to earn a dignified wage. I'm against the way payment is extracted from the sick at their most vulnerable. If doctors understood how humiliating it is for patients to go into intense debt simply for the pleasure of being well, I think all doctors would be moved to support a single-payer health care system as well as push for reforms in medical education so that it isn't such a financial burden on medical students.

Health care shouldn't be the business it is. It should be a system that provides care to the most vulnerable while also enabling doctors to live at a standard appropriate to their position.

moviedoc said...

Lisa, refusing to "see" a patient because of non-payment may be considered unethical abandonment.

So if you're deciding how much I should make, tell us how much. Throw out a number.

rob lindeman said...

Moviedoc,

The number isn't what you or I or Lisa says it is, it's what the market will bear... er... um.... oh never mind. Forget I even mentioned The Market!

Lisa said...

I am by no means attempting to decide how much one person should make over another person. I wrote quite clearly that doctors deserve to be compensated according to their position. If you are asking me how much one should be charged for a psychiatrist/psychotherapist appointment, then I think it should be an amount one is willing and able to pay that will also enable them to get well and maintain a dignified standard of living.

I would hope that doctors would band together and say, "We want to make X amount of money for our work with non-elective health care procedures and we want to make that much without being slaves to our medical school debt. Here's a plan on how to accomplish this."

It just seems foolish for doctors to continue to fight against non-paying patients and insurance companies instead of banding together and making meaningful changes to how health care is administered.

moviedoc said...

Lisa, either the market determines the fee like Rob says, or someone else decides. If the docs "band together" it would be considered a strike. Could we get away with that, Rob? I keep hearing its illegal. But there are lots of ways to strike without banding together.

I do agree with Lisa to the extent that: I charge way too much and make way too little.

rob lindeman said...

"I would hope that doctors would band together and say, "We want to make X amount of money for our work with non-elective health care procedures and we want to make that much without being slaves to our medical school debt. Here's a plan on how to accomplish this.""

What? We should fix salaries? prices? Good thing the rest of the economy doesn't work this way... er... um... oh never mind again.

rob lindeman said...

moviedoc,

Don't get me started on MD unions, strikes, etc...

Lisa said...

Should doctors be allowed to strike? Absolutely! As far as I'm aware, nurses are allowed to strike and they provide some of the most important care to patients.

Dinah said...

Lisa,
If I had a pay-at-the-door before you enter or be sent away policy, I wouldn't be asking Jesse what he does when patients don't pay!
I run a classy joint, no goons.

Lisa said...

Rob, I'm also not stating that doctor's salaries be fixed at X amount. I'm trying to say that doctors are entitled to demand a certain minimal standard of wage while in the process of altering the way health care is paid.

rob lindeman said...

Lisa,

Of course, docs CAN unionize and strike. The question is SHOULD they?

The point I haven't made explicit is the following: Many of us [fewer every day, truth be told] have this THING about professionalism and responsibility and ethics. Some of us believe that withholding our labor by striking is beneath our professional dignity. I, for one, believe this.

Lisa said...

Dinah, I think if more classy joints existed here in Texas, I might have a different view on the business of psychiatry. For the insured, it's difficult to even find a psychiatrist who accepts insurance, it's difficult to find one who charges less than $200/hr, and it's difficult to find one willing and able to work with one's personal finances. Which is why I am so surprised that Jesse even hinted that some p-docs or therapists even discuss payment with their patients, let alone collect it directly from them.

Perhaps it might be beneficial if there was a post on what p-docs do when patients are unable to pay.

Lisa said...

"Many of us [fewer every day, truth be told] have this THING about professionalism and responsibility and ethics. Some of us believe that withholding our labor by striking is beneath our professional dignity."

How, then, could it be above a doctor's professional dignity to withhold labor by inability to pay?

rob lindeman said...

Lisa,

Now you lost me. Why on earth should I or any of my colleagues give away our services?

Lisa said...

I'm not saying to give away your services for free. I'm arguing your comment on why doctors do not or should not strike. If your argument is that they do not strike because withholding care would be beneath their professional dignity, then wouldn't withholding care for any reason be beneath their professional dignity, even if a patient has an inability to pay?

rob lindeman said...

[Am I really explaining this?]

Willing seller (me)
Willing buyer (you)
contract for services

--

Strike

--

Willing buyer (you)
Unwilling seller (me and my union)
no services

--

It is beneath our professional dignity to withhold services from willing buyers. It is not beneath our professional dignity to withhold services from non-paying buyers. To the contrary, professionalism DEMANDS that we be paid for our services.

Are you still not getting it?

moviedoc said...

Lisa, "willing and able to work with one's personal finances" sounds to me like a euphemism for: "willing and able to loan money to patients or reduce their fee." I'll repeat, docs are not in the business of lending, and if we reduce our fees for some, the feds insurance companies can claim we're defrauding when we use our unreduced fee on claims. That's why I don't do professional courtesy.

lisa said...

Rob, there is no need to insult me when I've clearly not taken to insulting your position or intelligence.

And, yes, I now understand your position though I'll admit I had a difficult time reading between the lines. It might have been easier to clearly state this from the beginning.

moviedoc, I appreciate your explanation. It does seem that doctors can appear to be in the business of lending when they bill for their services rather than charge up front.

However, I'll continue to state that I am in no way arguing that doctors should not be remunerated for their services. I think the system of who pays, who pays how much, etc is a flawed one that needs obvious change. I think it would be worthwhile if doctors (and patients!) fought a more public battle to change the system.

My position obviously comes from a very personal experience where I was seeing a doctor who withheld services when a genuine error occurred. I was charged for an appointment that I was not allowed to have without the decency of simply billing me for the appointment after the fact (as they did anyway). When I made my formal complaints, I found that this isn't an isolated experience.

moviedoc said...

"a more public battle to change the system"

Before our psychiatric patients go public we have a long way to go to remove stigma. And IMO few psychiatrists have the spine to really demand change.

jesse said...

I know of very few therapists who would charge for a session cancelled well in advance. Even those who do hold to the rule that if they can fill the time in some meaningful way they do not charge for it. There is leeway in interpreting this. Obviously, if they fill the hour with another patient they do not charge the first, even if that second patient took that hour at the very last moment.

The understanding, in analysis, is that everything that occurs has meaning and feelings that are to be explored, without judgment from the analyst. So if a patient cancels his session to go to a wedding the analyst does not judge "a wedding is OK, but if he went off to play pool I would charge him."

Very few people are in 4-5 day a week analysis in which the same hours are held, and even 2-3 sessions each week in long term therapy is nowhere as common as it was.

Very often our feelings about these things have to do with the model we apply. Analysis is a commitment in which the analyst agrees to hold certain hours long in advance. If we did not pay per session, but per semester, like for a college course, we would think of it differently. If you choose to miss a few days of a college course for a wedding, or even after an accident, you are not reimbursed.

In clinics or offices where there are secretaries who handle the payment, feelings about it should still be able to be discussed with therapist, who may or may not have any control of the policy.

Duane Sherry, M.S. said...

Inspire your patients.

Inspire them!
And they will flock to your doors.

And the financial aspect of having your own business will take care of itself.

For example, hire a good accountant.
You'll have plenty of money to afford one!

Duane Sherry

Anonymous said...

Moviedoc:My grandmother found her hairdresser appointments very therapeutic and she always looked great. She was not from an era in which people sought out psychiatric care. It certainly was not discussed.
In those days people who needed psychiatrists were locked away out of sight, usually until they died.
This was before sorrow became depression, and so on.

Dinah, My doctor has the same policy that you do. No charge if sufficient notice given and no charge if the cancellation is due to unforeseen circumstances like flu on the day of. Seems to make a good living ,all in all. Much more than my grandmother's hairdresser R.I.P. to them both.

jesse said...

Lisa, it is very unfortunate that your psychiatrist refused to see you simply because your credit card did not go through. I agree with almost everything you wrote here.

It is a privilege to be a physician. Our work is to help others. Most of us make a good living. I think most physicians would gladly lower fees for a patient in need (and for those of us in private practice this has to be on an individual basis).

Moviedoc, what Medicare and some insurers are afraid of are physicians who write off their copayments so that they can get more patients into their offices and charge for services that are not needed. I know of many good doctors who do as you do, but I have never heard of a doctor with a typical private practice having any action taken against him because he lowers his fees selectively for those in need. If he lowers his fee in a very large percentage of cases it may appear (or be) that his "standard fee" is actually a falsely inflated fee for these reasons. To be able to treat a patient in need is an honorable tradition in medicine, one of which we can be proud.

Duane Sherry, M.S. said...

moviedoc,

You wrote:

"Before our psychiatric patients go public we have a long way to go to remove stigma. And IMO few psychiatrists have the spine to really demand change."

I'd like to say:

"Thank you."

Duane

Anonymous said...

Rob writes, "Please tell me insurance does NOT pay for involuntary incarceration and drugs!"

My insurance didn't pay, and I didn't either. I refused to answer any questions about my finances other than to repeat, I do not want this, I will not pay for it, and I want to go home. I did not agree to the treatment nor the costs associated with it, so as far as I'm concerned there was no financial agreement or obligation.

Now, with any voluntary medical treatment then that's a completely different story, and I would not give anyone a difficult time about paying what is owed.

Leslie

Sideways Shrink said...

I have a sliding scale that only slides down to $100 an hour because after the financial melt down of 2009, I can't afford to slide any lower. With my student loans equaling the mortgage on our small rambler outside of the hip city in which I much prefer to practice, I had to set some limits on what my time was worth.

Plus I dropped Medicare. I was looking at an explanation of benefit and saw the phrase "psychiatric adjustment". So I Googled the phrase. It turned out that in 1996 Congress decided in some spending bill to make psychiatric patients the only patients to have to pay 50% of the usual and customary Medicare fees to the provider. Besides CMS assigning psychiatry the lowest Relative Value Units of any specialty, Congress "adjusted" the reimbursement burden onto the severely mentally ill and the elderly which really shifts the collection of payment onto psychiatric providers. In private practice this is an outflow of time coordinating care and a financial zero sum gain in which, as a bonus, your odds of being audited go through the roof.

I have a consistent no show/24 hour cancellation fee because I treat a lot of patients with ADD and a lot of younger adults in their 20's. I charge the fee whether they are sick or not, etc. They agree verbally and in writing in advance.

Anonymous said...

As a patient I found it best when my doc and/or therapist had a clear, consistent billing process. The expectation of me handing a check over at the end of a session is my preference. I thought it was interesting that my current therapist was taught this process as a student as the school felt they needed to learn to not be squeamish about dealing with money and patients.

I do find it frustrating that some dont take insurance or help file out of network claim forms (or charge session time - a $120 to fill out forms is painful.) I know all the reasons docs/therapists give but in the end it still feels only about them getting more bang for their buck and as a patient I feel used by it.

Oh and as someone subjected to involuntary treatment. My experience was the resident who signed the commitment papers could not be bothered to contact his attending to also sign the papers (or let me see the attending when I requested or call my doctor.) Sixteen hours later when the hospital went to release me they forced me to sign the "i will pay forms" that I had refused to sign earlier, telling me I couldnt go unless I signed. So I signed and left. Then went to med records, made a copy of the commitment form that was clearly missing one of the two required signatures, proceeded to the hospital legal department and informed them I would sue if they billed me.

That was over ten years ago. Outwardly it showed I was improving in learning to take care of myself. Inward I am still afraid of how powerless I was in that ER.

rob lindeman said...

Latest anon,

Would that all "voluntarily" committed people had your intelligence and strength of character! I suspect there are a fair number of other stories out there (perhaps more than a fair number) of people who were coerced or forced to sign for services they did not want, thereby obliging them to pay for that service.

Sideways Shrink said...

Having maxed out the number of patients who had lost their insurance who I could see for $100 psychotherapy sliding scale visits in my private practice, I had an Aha! moment. After my feasibility study proved my basic perception to be the case, it turned out that there is no place in my county where people who do not qualify for government aid (Medicaid and/or Medicare)could get reduced cost (e.g. sliding scale) medication management. For people who are not completely impoverished, can demonstrate financial need, do not need case management, lack private insurance but have short or long term financial circumstances which mean they can pay on a set sliding scale for their medication management psychiatric prescription services, these people are out of mental health. In my research I found that NAMI rated my state as having an urgent need for this very sliding scale care. Were cancer care to be rated, my state would be rated in the top 5 in the country. Per mental health care, this is astounding in the context of the number of private/nonprofit hospitals who have closed their inpatient treatment units since I came back from res 10 years ago.
My solution is BOLD. I have marshaled all my contacts--which are few and recent as I am from a poor family to put it bluntly. My solution has been to start a nonprofit psychiatric center to serve just this "lower-middle" patient financial need demographic. The Center will not offer psychotherapy services as there are many other places in this county that offer free or sliding scale psychotherapy.
Sure, as a non-card carrying socialist (because there is nowhere to go to get a card I want). This is not the systemic change I want and doctors are not going to go on strike despite their social power, so this is my best solution.
I am the president of the board and the executive director, but I will never give up doing psychotherapy. The fundraising prospects look good at this point. I/we have assembled a Board of directors, a mix of public health people, those with a passion for mental health, and an admixture of the two who happen to know wealthy people in the community so we can do meet and greet fundraisers. Regardless, this nonprofit will not be a martyr project or it will have to fold. I have 2 kids and a jazz musician husband to support.
That is one solution, when all of your psychoanlytic training fails, for what to do when your patients can't pay (besides getting really pissed off....)

rob lindeman said...

Sideways,

Strong work! Just curious, how'd you do that without the help of the Benevolent State? ;)

moviedoc said...

It's not all about the money, sideways. Good for you for dumping Medicare, but I dumped it, and the insurance contracts for all the terms and regulations I refuse to operate under, not the low fees.

Anon: IMO it is wrong -- unethical, fraud, whatever -- to use psychotherapy time to fill out forms, call in prior authorizations and accomplish other administrative tasks. To me the psychotherapist who does this devalues the treatment. Imagine if a cardiac surgeon filled out forms during a procedure just so they could stick it to the payer for the time it takes. However, I do believe we should be paid. I charge $50 for a prior auth for meds, but I do it otherwise on my own time.

Sideways Shrink said...

Rob,
Good Gawd,
What world is it in which you think anybody from ER secretary to ER orderly to ER doc to whoever has to sign off in the psych unit actually WANTS to participate in involuntary psych commitments? It is a money losing/emotionally wrenching proposition. There are only 2 hospitals in my county of 2 million where people can be involuntarily committed. In my county, home of the biggest software manufacturer in the world, a person has to have a verbalized plan for suicide that they will not back down from for the Bachelor's educated county department of mental health professionals to decide they must be involuntarily committed. From experiences with civil disobedience, I am no fan of the police, but some patients are safer on suicide watch in jail because the police will hold them due to their disruptive behavior prior to being picked up. The county MH "professionals" do not consider this kind of thing.

The reason I can not do child psych and could not be a pediatrician, in fact, is because I would have a difficult time dealing with the way parents treat their children. Children are so easily victimized by their parents. You must see this everyday. While my mother was molested by her pediatrician, I do not assume pediatricians are perpetrators. I stay in the room, but, I trust our pediatrician and I trust pediatricians in general. (And do not pretend you have never heard of children being molested by pediatricians.) I sympathize with my patients who have been involuntarily hospitalized, but it has never happened while I have been their doc because I have either seen it coming way in advance and prevented it or talked them into a voluntary stay.

I do not understand why you can not trust psychiatric providers as fellow physicians to make ethical decisions. And to suggest that we make these decisions for financial gain is ludicrous.

Also, I agree with Lisa, since there are non-healthcare apparatchiks on this blog, if you could back off the insider speak when conversing with one of them it would be not only educational for all, but also polite and dignified.
As always, I learn a lot from your contributions. It reminds me of my undergrad conferences at Reed College.

rob lindeman said...

Sideways,

I'm afraid I'm going to disappoint you. With the exception of my late colleague Mel Levine, I haven't even heard of allegations.

We're moving "WAY off-topic" as we were warned above, but as a result of fear of future law-suits, I don't have my patients disrobe and examine the (clothed) girls in the presence of mother or nurse. The boys never disrobe in my presence unless it's a wee-wee problem, and in those cases you can be sure that I worry this kid is going to to sue me in 25 years.

Back to the topic at hand. The bottom line is this: In a perfect world (that I despair of ever seeing) Docs and clients will contract one another freely for services. The market will decide how much money changes hands. It is an almost metaphysical certainty that this amount of money will be substantially less than what I charge today (so it follows, less than what I collect)

Sideways Shrink said...

Rob,
I am not suggesting that you perpetrate on children. I am drawing the obvious parallel between children and adult patients who are psychotic or delusional: neither are able to consent to appropriate treatment or payment arrangements. That is when fellow human beings armed with their humanity and training and what can seem like an unbearable amount of responsibility to make decisions for them when they can not make the decision for themselves and there is no parent or guardian there to make the decision for them. Just as I am not suggesting you are a perpetrator, you need to consider that when you suggest that shrinks on this blog site who participate in involuntary hospitalizations should not be paid for such difficult work you are stating, along with the rest of most of the culture, that the work of shrinks is worth nothing as well as being brutal and cruel. Dinah's post title of a few days ago "Are We not Thugs?" is ever so appropriate. We are either deemed to hang out with crazy people or deemed to deprive people of their civil rights. Which is it? I was training in New York when the schizophrenic man hit the young woman named Kendra over the head with a brick. How did the song go? "Freedom's just another word for nothing left to lose?"

rob lindeman said...

Forgive me, Sideways, the parallel between children and crazy people may be obvious to you, but it is not obvious to me. Nevertheless, there is a parallel, just not the one you prefer:

Let's stick to payment arrangements, the topic at hand. If a parent does not want my services, and objects when I practice on their child without their consent, not only do I fail to justify a claim to get paid for my time and effort, but also I have committed assault against that child.

Similarly, when a crazy person refuses my services but I "provide" them anyway, I have no reasonable expectation of being paid.

Anonymous said...

Sidways, your positions are quite reasonable, your actions commendable.

Anonymous said...

Damn blogger ate my words.

Shorter version of my disappeared post: my first-ever relationship with a p-doc was soured because things were not clear ahead of time about payment types and billing. Turns out there was some form she didn't take (checks? credit cards? [shrug]) and when I made the horrific faux pas of, you know, asking, she acted like I let a smelly one rip. That relationship didn't last long for a number of reasons, but that was not a good first impression.

These days, I put crisp neat bills into chic ivory envelopes *just* *so*. And while I can now afford a pro who charges $100 for 30 minutes, I recently let one go because I can probably find a street hooker who will hector me about how I should be on AAPs for a lot less.

rob lindeman said...

Hooker + Anon: Willing seller, willing buyer, terms of contract spelled out in advance. No force, no fraud, no coercion. Perfect!

Anonymous said...

Anon, I would have liked to have been a fly on the wall when you talked to the legal dept. Good for you. I don't get how anyone can threaten a person to sign a document and then try and call it an agreement, talk about crazy.

If I understand you correctly, the resident signed your commitment papers because you were considered too ill to make the decision to decline treatment, but somehow you're supposed to be well enough to sign a paper to agree to pay for treatment you don't want? I don't get their logic.

I suspect the only reason I wasn't billed was because they later found where I had written on the consent form that I didn't agree to it. Had I not written in that statement, I probably would have been screwed. I am fairly confident they would have denied using threats to get me to sign the consent for treatment (and to pay the costs associated with it), even though that's exactly what they did.

Sideways Shrink mentions Kendra and the man who killed her. What's ironic about Kendra's Law is that the person who killed Kendra asked for treatment but was turned away. It's hardly an argument in favor of forced treatment, if anything it argues money would be better spent on people who request help.

Leslie

Anonymous said...

Wait, now I'm confused. I saw the word Kendra and NY and I thought Sideway's Shrink was referring to the Kendra of Kendra's Law. But, I don't remember there being a brick involved in that situation.

Leslie

Sideways Shrink said...

Mea culpa? Around the same time a woman was pushed into an oncoming subway train by a mentally ill man. Perhaps she was Kendra? I was also training in Manhattan on 9/11. I saw so many shades of post traumatic stress.

Exalya said...

Since I'm only a second year med student, I really dont know alot about this subject. Forgive me if this is a silly question: do doctors in private practice ever do a sliding scale based on patient income? I'm sure this would be difficult to do (and probably very controversial), but it seems like it might be helpful for some uninsured patients.

jesse said...

Exalya, many doctors I know in private practice do lower their fees, but none use a set "sliding scale." One can lower fees as one finds appropriate to the situation and one's ability to do so. It is not at all difficult to do if you use your own judgment. Again, what is important is talking to the patient and exploring the situation.

Anonymous said...

I know some doctors and some lawyers who do either sliding scales or pro bono work because they feel they live privilged lives and truly want to help others. No one should have to suffer financially if one allots a certain proportion of the practice to caring for the less fortunate. You will be a good role model for your children who will learn the value of giving back to society. If people view it as working for free and as debasing their hard earned credentials, that is a pity and a very selfish attitude. No one doctor can take on all the patients who cannot afford full fee but if every doctor took on a few, we would live in a better world. Not perfect, just better. This does not extend only to professionals. All sorts of people contribute their time and money to various causes. Dos it harm anyone to help build a Habitat for Humanity home or some other worthy pursuit? We are a very selfish society.

Anonymous said...

Leslie,
Its impressive how well one needs to be to navigate the healthcare system. Personally I would have liked to have been a fly on the wall when the resident got chewed out for not following procedure and getting a second signature. He screwed up and everyone around him knew it at the time (the police officer who transported me to the psych hospital apologized directly to me at the time.) Being calm and reasonable in the face of unfair treatment should have made it clear I was no danger to myself or others.

Moviedoc - doc wont fill them out at all on their own but did offer to "help" me fill them out.

Question for all who dont take insurance for whatever reason - how often do you stop to think that your patients could be paying more than a car payment a month to see you. Plus the time missed from work. Part of the stress I deal with in therapy is the impact the therapy has on my life.

I do not expect or demand anyone work for free but I wish my time and money were treated with more respect. So when I hear about how much of a hassle it is to take insurance or file claims I would like to point out that I then have to figure out those same forms you dislike and I have to spend more of my working day to pay for my time with you. In addition to being chronically ill.

You want to get paid? Start by not rejecting the forms of payment your patient can provide (insurance)

Dinah said...

Anon,
http://psychiatrist-blog.blogspot.com/2007/11/why-shrinks-dont-take-your-insurance.html

Anonymous said...

Dinah - I've read it and have not much sympathy. All those worries about the insurance you talk about are now my worries only I have no back door doctor access to the insurance company to get answers and have to fill out paperwork that makes no sense. And I'm not likely to see any money.

Every other doc I see manages to take my insurance. And yes I know they see more patients per hour and all the other things.

But really, as a patient that needs help and it trying to manage an expensive cost (see above where its more than my car payment a month) all I here when docs say they dont want to work with insurance is them saying "It is too hard and you are not worth the effort" and "It is more important to get the most money I can from my patients"

Dinah said...

Anon,
the doctor has no "back door." When I participated in BC, I had 3 secretaries and used to routinely get checks for $12.44 and could never figure out what that was for. Working was a hobby. Can you imagine your hassles time 30 a week for a doctor without a secretary. Even with 3 secretaries, I often was not paid for sessions, only because the insurance is so complex, I really could never follow what sessions I had been paid for and what sessions were not.
I will tell you that I hear from patients that some insurance companies reimburse easily and well (mail them the statement, they send a check for 80% of the fee).
If the insurance companies a) all reimbursed at reasonable rates, and b) got rid of all the hoops and rejections for every possible reason, then psychiatrists would participate.
Sorry to sound defensive--
If someone tells me they have a cash flow problem, I'm always willing to let them wait until they get reimbursed from the insurance company to pay.

rob lindeman said...

Dinah,

Calculate your overhead, figure out how much money you want to make, charge your clients fee-for-service, and leave the hassles behind.

(Rob, you'll say, it's not that simple. Dinah, I respond, yes it is)

moviedoc said...

"Question for all who dont take insurance for whatever reason - how often do you stop to think that your patients could be paying more than a car payment a month to see you. Plus the time missed from work. Part of the stress I deal with in therapy is the impact the therapy has on my life."

I don't even do "therapy" anymore. I sympathize with your plight, but you must know that there are probably millions of people who might envy your position, thinking more about their next meal than car payments, and sadly it will probably get worse before it gets better.

Anonymous said...

it has been said by a rather interesting russian novelist that the main character in any american novel or film in the last century is a black briefcase filled with money. do you want the major character in your american industry to be that briefcase? if yes, okay. i'd say you're not in 'good' company, but you're in company with many others (eg talk left, live right). if no, change the focus of the discussion. or, if you're serious about it, get involved politically and change the players. few people have the guts to do the latter, however. they make waves.

jesse said...

Dinah's position is essentially the one I take. Fixed "Sliding Scales" may work in a large clinic but not in a small office without a secretary. It is not an exact equivalent of "if you earn over X you pay Y, if you earn A you pay B." The fee that would be impossible for the two session per week patient might be no problem for the one who comes once every few months. There are so many considerations.

There are so many problems with taking insurance that few psychiatrists in private practice can do it. The claims are generally set up by the companies to be as difficult as possible to submit correctly, while their premiums are extremely easy to pay. Secretaries in large offices take courses on how to submit claim forms. Often a doctor's office will employ one person who does nothing but handle the insurance.

Just to mention one issue: If I accept the insurance of just one patient who has coverage from Company G I have to accept their rules and fee caps on all patients with that insurance, even if they are well off enough to easily pay my full fee.

So, I discuss each situation with my patients and work out an arrangement with which we all are comfortable.

moviedoc said...

I could go for a scale that slides up, but for me somehow they always seem to slide down.

Sideways Shrink said...

I have these annoying socialist beliefs that partly stem from having been raised in a union family. I take insurance because to not take insurance would be to sell out working class and middle class people. I have finally found a billing service that is operated by the company that operates my EMR which I used to do my own billing and charting for 5 years, Office Ally.
However, I really despise a certain HUGE insurance company which begins with the letter "U" and actually has the phrase health care in its name. I only contract with the company because some of my old time patients have this insurance. I go in cycles of taking their new patients for 3 to 6 months and then send them a letter telling them I am not taking new patients for 11 months. They pay so little I get resentful of the flood of patients that come my way and that's when I know it is time to send the letter. Their CEO makes $30 million base salary a year.

jesse said...

Their CEO should qualify for Moviedoc's highest Sliding Up Scale, but I bet they would pay nothing for his treatment even then.

Sideways, what you are doing is indeed admirable. I do see patients with very little money, but I lower fees on an individual basis. It seems like all of the Shrinks on this blog truly care about their work and their patients, but we have different models within to work.

jesse said...

And I hate to say this, but here in Maryland that HUGE insurance company is one of the better ones. No kidding.

moviedoc said...

But where do you suppose that CEO gets the $30 million? From wealthy psychiatrists like us? More likely it's from those working class and middle class people that I believe we sell out if we do "accept insurance." Speaking of which I have that very company to thank for my decision to require payment by the patient. Several years ago the U company demanded that I repay them ~$500 they determined they had paid me by mistake. When I discovered both state and federal law entitles them to do so for years after payment, I decided to avoid ever depositing a check from an insurer with my name on it. Let them go after their subscribers.

Lisa said...

I have to agree with moviedoc re: docs sell out by accepting insurance. I think it's an admirable way to strike against the system. If docs all banded together and completely stopped accepting insurance it would force us patients to get on the wagon and demand change in the way health care is financed.

rob lindeman said...

With respect, Lisa, Doctors don't need to band together to stop accepting insurance. They can do so as individuals. In fact, "banding together" would effectively limit supply of providers. That's what unions do.

You don't need a PhD in economics to notice that, with respect to payment, there is a complete separation between the client and the doctor.

People pay for what they value and value what they pay for. A free market in mental health services will determine how many will do the job, and what the price of an hour with the therapist is worth.

jesse said...

To second what Moviedoc mentioned, I once deposited a check from Blue Cross, made out and sent to me, for a patient I was treating. I am not a "participating provider." Years later I got threatening calls and letters from BC asking that I refund the money, which of course I had credited to the patient's account! BC told me I should bill the patient for it, but he had long since moved out of state. They threatened legal action against me if I did not comply.

There are so many reasons for not signing on with those companies.

Off topic, but there is a powerful article by Deborah Sontag in today's NY Times called "A Schizophrenic, a Slain Worker, Questions."

moviedoc said...

Jesse, we both failed to mention that if you don't pay the payer back they can take it out of another patient's reimbursement.

Yes, Rob! One at a time we can drop a contract or even accept fewer patients with Medicare or other payer. We must stop protecting our patients (and enabling the payers) and stick to treating them.

Anonymous said...

Jesse, I also read the article in the NYT and wondered if it would come up. It's really unbelievable that this guy who had a history of multiple violent assaults was on the street. Why wasn't he locked up? Armed robbery, assaulting a homeless man, etc sounds like someone who shouldn't be one the street. This wasn't a case of someone who was "potentially" violent, this person was violent again and again and again.

The problem is some people want to use these examples to create laws that make it easier to incarcerate people who haven't ever hurt anyone, because of concerns that they "might." That's scary.

Also, you can see why people who are depressed would be terrifed to be in a psych ward. Who wants to be locked in a facility with someone like that?

Leslie

rob lindeman said...

Money paragraph:

"The arrests began in the summer of 2003 when Mr. Chappell, then 19, was charged with armed robbery and assault. The victim was a homeless man with $96 in his pocket. Mr. Chappell accosted the man twice, slashing his forehead the first time and then punching him in the eye, causing an injury that required surgery, according to court records. The charges were dismissed."

The charges were dismissed. The man committed a violent crime and the charges were dismissed. Now he's killed someone. This is a crime story, and a bad one at that.

Anonymous said...

Rob said: "People pay for what they value and value what they pay for. A free market in mental health services will determine how many will do the job, and what the price of an hour with the therapist is worth".

Great for people who can participate in the free market. You know, those with jobs, mortgages, car payments. I have no axe to grind. I can afford it. Many people cannot, and that is not because they are out boozing and buying cigs. Doesn't take a PhD in economics to figure that out either. On the other hand, it doesn't necessarily hurt, despite the fact that there are very few one handed economists.

Sarebear said...

People pay for insurance because they can't afford the costs of medical care without it.

if there's not enough providers taking insurance then people will stop getting medical care, or only getting the worst things treated at the ER and not paying for it, which puts it's own burden on the health care system. Many people who can't afford insurance or health care do this already.

I once let a bladder infection turn into a kidney infection with a temperature of 104 because I had no money to go to the doc; it had to get so bad I could barely get out of bed that I went, and I can't remember how long it took us to pay the bill (nowadays he probably wouldn't see me if I couldn't pay any up front, thank goodness he did that time or my system migh thave been damaged from not going to the doctor cause I wouldn't have no matter how bad I felt).

this has shifted from the original topic but I strongly disagree with any position that urges doctors to stop taking insurance; I understand that some may decide this because of their own personal and financial and business reasons, and I have no problem with that. But someone said that doctors taking ins is HARMFUL to patients, or implied something like that? HOGWASH. A lot of people get care who otherwise wouldn't, and THAT's not harmful. The opposite would be.

Donning my flame-resistant suit . . .

ClinkShrink said...

SareBear: You have seniority on the Shrink Rap blog. Nobody gonna flame you and get away with it.

Dinah said...

Sarebear,
The theory behind mass refusal of insurance participation by doctors isn't to freeze patients out of care (the way many, but not all, are now). The idea would be that this would force insurance companies to alter their policies so that doctors would then want to participate: that they might make the process of submission easy and the reimbursement rates reasonable so that most/all doctors would want to participate, and then many more physicians would be available to everyone. The idea would be to open access to care..that would be the theory.

As is, many of the poor are covered by Medicaid, the disabled by Medicare, and the wealthy have good insurance. It's the working, uninsured poor who are in the worst shape. And the working insured poor have limited choices for psychiatric care because shrinks like me just can't cope with the submission (re: rejection) hassles, and the low rates.

It all seems unfair because it is unfair.

As a solo private practitioner working part time, there is just no way I can deal with the insurance companies and the aggravation-- I'd rather work for free.

Anonymous said...

Geez, one of you asks for hot ,hot,hot and another steals the voice of another culture to provide reasurance that there won't be any flames wars. Odd ducks.

Sarebear said...

I understand that those are the reasons behind ideas of masses of doctors standing up to insurance as a group or groups, but the reality would negatively affect alot of people, although one has to wonder what SHORT of a massive doctor uprising WOULD get the ins. co's attention, anyway . . . but I certainly understand individuals opting out of the system, like you, even if it leads to a profession like yours tending to have more opt out of the insurance system than others.

There don't seem to be any decent solutions, I just HAD to pipe up to the notion that doctors accepting insurance is bad for patients . . .

Thanks, Clink! :)

Anonymous said...

As Sarebear pointed out - limited availability of docs + high cost means patients typically opt to forgo treatment instead of fight the system. Docs not taking insurance is a plus for the insurance company as it raises the likelihood a patient will not get treatment at all - one less thing the insurance needs to reimburse.

I find it hard to see how you can both the support the argument of not taking insurance but also demanding involuntary treatment of the sickest of patients.

Rob - is it really free market if I require the services to live? As someone with Borderline personality disorder I should not give up treatment any more than I should not get treatment for my diabetes. But as someone with BPD my choice of providers is not only limited by providers insurance status and treatment offerings (not much works well for BPD) but by provider discrimination (somehow I am bad, difficult patient even before I walk in the door.) In a free market I would be paying every extra dime I had for treatment and that to me looks like extortion.

In the face of everything I want to keep the life I've built. My husband, my home, my job, my family, my friends are all important to me. As a borderline I know its very real how easily I could screw it all up and be alone. Ongoing treatment stands in the way of me giving in to irrational parts of myself. There isnt choice here, I do what I must and I will pay what I have to.

I'm not saying as docs you should treat everyone or treat patients for free but remember that not all patients you turn away are worried well.

Lisa said...

Medical care shouldn't use the models of a free market economy. It's not retail or the service industry where one can go and shop for diseases or cures or treatments. Patients shouldn't view their doctors as simply a good to consume when they have a broken finger or they got to fat from eating McD's. As it is, patients (in America, at least) live reckless lifestyles with the view that health care is simply another thing to consume and their doctors should do what the patient wants because s/he is buying their time. It's ridiculous! No wonder so many doctor related blogs are complaining about how rude and unappreciative patients are {not this blog :)} Health care is very different than purchasing a shirt or the services of a masseuse.

Sarebear, there are a lot of problems with the way health care is distributed and financed. Insurance companies simply do not have subscribers best interests in mind. Their primary goal is to make the most money by (as plenty of providers have pointed out) not adequately compensating the doctors and denying necessary care whenever possible.

People have to take responsibility for their wants and needs. If doctors as a whole stopped accepting insurance, people wouldn't just sit around and allow their illnesses to fester. Eventually someone will get mad and someone will do something about it and people will start demanding changes.


I have a side question: Say a doctor found herself at the scene of a car accident. The ambulance has been called and none of the injuries are life-threatening. Still, the doctor assists while waiting by helping to clean up cuts and scrapes until the ambulance arrives. Would the doctor send a bill? Just general curiosity.

Anonymous said...

Lisa - I think you are missing the part where patients are sick and dont exactly have extra energy to fight the system. And patients with mental illness are too drown in stigma to have a voice for change. It seems the only change that happens for them is forced treatment.

Yes healthcare needs to change in America. I would love to have a single payer system not tied to my employment. But right here and now I am ill and I need treatment and my employer sponsored insurance is all I have that helps me afford it.

Do you think people going without care will make a difference? We let people go without care now. We let them freeze to death in the streets and starve as we walk by. To make ourselves feel better we blame them for not being good enough or trying enough or working enough to live.

I'm not interested in dying for a cause or being the example that helps change things. I'm not stoic enough. It is not my fault I'm sick and I work hard to take care of myself but I can not do it alone. Needing help shouldnt make me a lesser person. It does not demonstrate how I am a failure and does not mean I deserve to suffer more than others

Anonymous said...

Teachers working in public school ought to have this figured out by now, too. Indidividual teachers already opt out of the system in which they are overworked and subject to all sorts of hassles. These teachers work in private schools. Now is the time for all teachers to abd together and opt out en masse. Groups of teachers can set up their own fee based schools. They could offer so much more this way. If all teachers opted out or rather into the free market system of schooling, psrents would have to stop smoking and drinking and lazing about and would finally be motivated to get a job to pay for they child's education. Bus drivers, if you are listening to this, opt out also, buy a bus of your own and charge 5 dollars a block to anyone who does not want to walk. Band together and all do this. It is a free market, unshackle yourselves and be free.

rob lindeman said...

Answer to the "car accident" question: I can send a bill, but the victim is under no obligation to pay it. BUT, in states with no Good Samaritan law, I may be sued if there's a bad outcome! By the way, what's the usual and customary charge for assisting at a car accident? Just asking.

There was a confusing comment from someone claiming that health services need to be paid for by third parties because she needed the service to live. What other good in your community does someone ELSE buy for you because you need it to live?

Regarding the high cost of services: let me speak from my own experience doing pediatric primary care. If the free market operated here, there would be WAY fewer pediatricians and the costs of obtaining my services would be much lower. The regime of third-party employer-based and governmental reimbursement has mangled the economics of my profession beyond recognition

Anonymous said...

Rob wrote: "What other good in your community does someone ELSE buy for you because you need it to live?"

In a humane society a community provides the necessities of life to those in need. Some communities provide all manner of goods and services to people in need. Those of us who can afford it and do not help live with a false belief that they or their family members will never ever be in need.

Dinah said...

I don't really think doctors should 'band together' and abandon insurance companies in an organized way.

The insurance companies must provide some level of service, and if people paying the premiums are not satisfied, then a competition between them is created. Unfortunately, people don't tend to complain to their employers (the decision makers about the policies offered) about their mental health care because....

I know it bothers people that shrinks opt out, and it does give the insurance companies a break--I have patients who don't bother submitting their claims even though they could use the money and have the coverage.

Does it bother people that insurance companies create a system of hassles so that doctors won't participate and patients are left with the high-volume practice shrinks?

The educational system may not be a bad analogy-- everyone gets the basics for free, you want more or different then you're free to go to a private school or hire tutors. Where we live the public schools are so bad that the private schools have lots of competition for their 25K/year kindergartens. There do seem to be comparable issues.

Market pressures--perhaps it keeps medical school competitive and ensures a higher quality of doc, but who knows? It was a long, expensive, ride to get here.

This is our first post with over 100 comments. Go Jesse!

moviedoc said...

Medical care with insurance is not really free market in that insurance acts as a subsidy and drives the price up. Also it has morphed from insurance to prepayment. Paying for treatment of BPD from the first dollar is like using auto insurance to pay for oil changes. If medical care ever becomes a "right," we'll need to provide for those 40k people who died because they couldn't see a doc way before we provide psychotherapy. The problem with making a right is that society can't force me to work. Read Atlas Shrugged. I feel like Pied Piper, MD already. Think about how this looks to the people you hope will become physicians. It's probably not consistent, I'm leaning toward single payer myself, anything to shut down the health insurance industry completely. This isn't working.

Anonymous said...

What happened to "first, do no harm"

Is it like most things in this country? Available to only those who can afford to pay for it?

Rob - please reread - I didnt demand free services. I asked for docs to consider helping by accepting the payment resources I had such as my insurance. As to your question about other services - I like the other Anons response.

Dinah - if you know your patients arent filing the forms and its hurting them why do you not offer to help?

Anonymous said...

Moviedoc - you're right, what we have doesnt work and everyone deserves to be paid for the work they do. I've read some interesting numbers that looked at the total amount paid by an average worker and his employer across a lifetime that show that amount would typically be enough to cover an average persons lifetime medical expenses. Problem is when we are young we cant borrow against future money we might earn when we are older (oh wait, thats what most people are doing with college and look what negative impact med school loans are having on even this conversation)

Bottom line is I am trying the best I can to take care of myself with the resources I have and its frustrating to run into so many complications and feel so shut out by the same people claiming to want to help.

We all want the world to be different. One thing therapy teaches me is to accept the world as it is and work with what I have.

Dinah said...

Anon: I do.

Anon a few anons ago with borderline personality disorder: if that's your only diagnosis, no matter how bad and how disruptive to your life your condition is, insurance doesn't pay for treatment of personality disorders.

Alison Cummins said...

If the free market worked so well, we wouldn't have felt the need to implement safeguards for the neediest.

Personally, I want to live in a society where my fellow-citizens have all had access to a good education. It makes life better for me. I want to live in a society where the poorest have access to welfare and aren't begging in the street. I want to live in a society where everyone has clean water, even in poor neighborhoods. Where all children's milk is pasteurized, not just the well-off children. Where we all have access to good health care, including mental health care.

I live in Canada, so I pretty much have all these things. They improve my quality of life. I pay taxes for these things and do so happily, because I want them. I also make significant donations to Centraide/United Way and to FAVL (Friends of African Village Libraries) because the opportunity to make the most of life is something we all deserve.

We've tried a lot of things over the years. Pure charity, which in all societies over the world has ended up with widows putting their children on the street to beg. Debtors prison and poorhouses, which deny the poor and ill the means to change their situation. Prohibition was an attempt to protect women and children from husbands and fathers who would otherwise drink away all their wages, but we ended up going with minimum wage laws and welfare instead so that families of alcoholics didn't have to starve.

If the free market worked so well for medical care, there wouldn't be a market for health insurance and Canadians would not be so satisfied with our single-payer system. There would never have been a perceived need.

So you can squawk all you want about how wonderful the free market would be if we'd only just try it, but we have tried it. We didn't like it.

Alison Cummins said...

Moviedoc,

I read Atlas Shrugged. It was horrible.

Nobody has said anything about forcing anyone to work. Under a single-payer system, we all have equal rights to access the existing health care. If we don't find it sufficient we can agree to pay more into the system.

rob lindeman said...

This revisionist history of the economics of medicine would be amusing if this stuff weren't so damn serious. I recommend everyone read Paul Starr's "The Social Transformation of American Medicine" Starr is a committed Socialist and no lover of the free market, but he tells the truth about how we got into the mess we're in. He places the blame squarely at the feet of the medical profession. Much as I disagree with Starr's prescription, his "history of present illness" is devastatingly on target.

With due respect to my interlocutors, America did indeed enjoy a period of relative market freedom. Then came licensure, socialization, the growth of the hospital and worst of all, employer-based third-party insurance. The history is all there, folks. Go and study it.

Anonymous said...

Dinah - its nice to know you help patients with paperwork.
-
Living with BPD I've learned and faced a lot of places that consider me incurable/untreatable aka hopeless cause.

I avoided the insurance noncoverage issue as I started this path with a depression diagnoses as a teenager. It was several more years and doctors before one of them clued me into the BPD. (I'm pretty sure the first one knew and didnt tell and one later tested and still didnt tell)

I will also acknowledge I find using "depression" as a better descriptor/cover for my psych meds when dealing with my non-mental health provider specialists for my other chronic illness issues.

The stigma of the diagnosis is frustrating. People expect BPDs to be a mess and I'm not. I've been there and it was horrible and I wont go back even when it means buying Linehan's book and reading myself because I cant find a dbt group that meets after work. Or paying full price for therapy when I do find finally find a good match with a provider.

I wish more providers understood BPDs are redeemable. I'm not hurtful anymore. I play well with others, hold down a job and have lasting meaningful relationships. But I dont do it alone.

Everyday I wake up and know my brain lies and I am not to trust it and with help I will hold the line against it.

Alison Cummins said...

Rob,

Sorry for my ignorance. Can you please review for me the bit about all women who needed a forceps delivery in 17th century England having equal access to a doctor who could perform one?

moviedoc said...

The Lounge Lizards offer their wisdom:

http://www.youtube.com/watch?v=xNuCfD5bICQ

Anonymous said...

I started to see a new therapist recently informed me that patients are permitted one same day cancellation per calendar year. I asked her if there were exceptions in the the event of an emergency and she said that she is "afraid not." She is a very nice, caring ,competent person but I suffer from severe anxiety and have been worrying about this ever since she informed me of this ,which was last week, following my first cancellation. Compounding this is that I have Medicare. She does not accept Medicare, but she is a specialist in D.B.T. and I had a great deal of trouble finding someone who accepted Medicare who is really trained in D.B.T. so in desperation I agreed to pay her out of pocket. She charges $175 for a 45 minute session. I have paid her out of pocket for a number of sessions. Hopefully, Medicare will be reimbursing me about $106 of the $175. HOWEVER, should I be unable to make an appointment due to illness or emergency, I will be liable for the FULL $175 for the session that did not take place, other than the approximately $69 that would ordinarily be my share of the fee, as Medicare will not reimburse for a session that did not take place.
$175 would be too expensive for me for a session that DID take place ! I do understand that doctors do need to be paid and that if appointments are canceled on the same day a therapist may not be able to fill the time slot. I am curious as to the opinions of the therapists who are reading this.
I have only been seeing this therapist for about 2 months. I am not sure whether to continue seeing her or whether to look for someone else. I am not speaking of canceling for a frivolous reason ,obviously.As it happens, two days after she informed me of this, I was in a minor car accident on the way to a doctor's appointment. One of the things that went through my mind immediately was "Would my therapist bill me for a session if I am in a car accident on the way to session with her ??"
Perhaps, one way or another, therapists might benefit from knowing that for patients such as myself, the anxiety about worrying about such a billing policy can exacerbate their patients original symptoms. I am not sure if I was still in the car after the other car slammed into me, or later in the day, when I first thought of whether my therapist would have billed me. I DID have to cancel therapy the week before- because there was a car accident in front of me on the highway and state troopers came along and closed down the entire highway ! I can tell you that I will be one resentful patient if I am behind another car accident, which results in a road closure (yes, I saw another such scenario 24 hours later in the opposite direction- highway closed in opposite direction with many police, fire and emergency vehicles due to an accident )which interferes with my making it to a therapy session, or I have a medical emergency, or there is some other circumstance beyond my control,and I am billed.
I think in writing this , I have made my decision, but I hope therapists reading this who do bill for all cancellations that are not 24 hours in advance will take circumstances that are beyond a patient's control into consideration. (both road closures could be verified , I am sure, with local traffic reports, news,etc).

moviedoc said...

Anon: Your "therapist" should (There's that S word again.) have informed you of the policy at the start.

To the best of my knowledge the only way to treat Medicare subscribers without "accepting" the maximum allowable charge is to "opt out." If she opted out, Medicare requires that she have you agree in writing that you will never bill Medicare for her services.

Anonymous said...

I was involuntarily committed to an eating disorders unit on a psych floor of a major hospital for several months. Now I am expected to pay for it....over $20,000! What will happen if I refuse to pay? I do not believe I should be held responsible since I did not choose to be there and was locked up against my will. I was NOT suicidal.

Anonymous said...

As a Canadian, I just shake my head in amazement at what Americans go through. What I also find very interesting is how so many people justify the way things are. Somehow they think just because something is the way it is, well it must be right then. For example, believing that to have a professional relationship there needs to be payment by the patient. That's hogwash. I know this for a fact because nobody pays the doctor directly here and our relationships with doctors are perfectly professional. As for appreciating it more if you pay, that's BS as well. In fact, it's easier to appreciate a doctor's service and see them as giving people when you're not negotiating a fee and handing them cash when you're sick and vulnerable. Americans are SO WEIRD sometimes. It really makes me scratch my head in amazement.