Tuesday, April 17, 2007

I Don't Charge Enough

First, I feel like as bloggers, we're becoming oddly linked in blogging rhythm: we've all got Springtime blogging mania and the posts seem to come in bursts.

Scroll down for:

  • Podcast 15, by the lovely Clinkster

  • Fat Doctor Feeds Her Kid Dog Biscuits, by Yours Truely

  • Clink's thoughts on altruism in Because it Feels Good

  • Dinah's review of Reign on Me as You Order Salad Like a Shrink

  • Roy's thoughts on Shrinks on Call in : ER Call

  • and finally, both Roy and Clink did a synopsis of the Shrink Rappers' venture out in their dueling posts on Human Sacrifice in Moche Culture. Will I ever get these folks out for crabcakes and beer?

And that was all in the last 72 hours, we're a very busy blog!

Okay, Okay, This post is called I Don't Charge Enough and it was inspired by the fact that a patient told me today she was glad to see I'd raised my rates, I undervalue my services (yes, she was serious), and if that wasn't enough, I came home to a blog comment by Sophizo telling me I don't charge enough, and a shrink she knows gets $300/ hour.

I don't charge $300/hour.

Okay, so I left residency and in addition to a job I got, which I think paid $42/hour (this was a while ago), I joined a private group practice. My fee was set by the group, it was about $10/ hour over going rates, but there were secretaries who submitted directly to insurance, the patient only made the co-pay, and in a fit of total ignorance, I joined the Blue Cross network, not realizing that by doing so I was discounting my fee by roughly $35/session, often to people who could well afford to pay full-fee. I stayed with the group for years, during which time my fee didn't change. I left to go out on my own, solo, no secretary, and I opted out of Blue Cross, didn't take insurance, and my patients were left to pay full-fee and struggle by themselves with their insurance companies. My fee was now on the low side, but with this new burden on my patients, I couldn't raise my fees, I just couldn't. Time passed, I still couldn't raise my fees. More time passed, I was having an issue. My rent went up, everything else went up. Somewhere in there, I changed my other job and made more money at that. My husband's career was going well. We wanted for nothing. So 12 years later, and my fee was exactly what it was when I started my private practice, I was embarrased when other shrinks asked what I charged, more embarrased when I saw the look on their face and heard how much more they were charging. I had an issue.

On the one hand, the I-don't-take-your-insurance policy scares a lot of patients away. But, it doesn't mean that I see only rich people: I have patients who struggle, who enjoy few of the luxuries in life, who rarely go to an extravagent restaurant, never purchase new cars, never go on vacation. They pay out of pocket, and this is their choice: there are cheaper places to get treatment and I work at some of those cheaper places. For those who want psychotherapy with a psychiatrist, however, out-of-pocket is often the only way to get it. Some of my patients have no health insurance and foot the whole bill. They come as they can, I don't make demands that everyone come at a certain frequency, but for those who come weekly, or even bi-weekly, psychotherapy is expensive. Let's see, at Sophizo's suggested $300/session, let's say the average patient comes 45 times a year given their vacations, my vacations, holidays, sickness, snow, whatever--$13,500/yr, up front and hope your insurance sends you back $60/session if they're generous. Sorry, Sophizo, I might be richer, but this isn't reasonable to ask from anyone. Even at my undervalued fee, psychotherapy is a large, regular expense, it's hard for me to ask that of struggling people who are suffering. As is, my fee is hard for some patients, they are giving up something else to be my patient. I hope it's worth it.

On the other hand, there is this funny message that I undervalue my work, I don't want to think and I don't want anyone else to think, that I'm worth less than the guy down the hall (by definition, I am-- my patients tell me everyone else's fee, I believe I'm the cheapest on the hall) and while I've finally caught up to the standard fees, I still charge on the low end.

So after years of grappling with this, I'm left to say that it's fine that I charge on the low end--- I have lower overhead than a lot of docs who pay secretaries and have large offices, my fees are discounted only by Medicare and I don't have many medicare patients, I want for nothing and I wish that I could do this for free enough that I take an occasional pro bono case and recently started volunteering a couple hours a week for a great organization that serves the neediest of the needy. Is that altruism, per Clink? It makes me feel good, it's my way of giving back to a world that educated me with scholarships and low-interest student loans, to a world where I've spent more time helping the suffering than being the sufferer, and something about it makes my life richer-- not altruism. In all honesty, perhaps a funny mix of gratitude and guilt. That's okay to admit, right? And did I really just write a post trying to justify why I don't charge more?


ClinkShrink said...

I was making up my mind to charge twice as much but then I remembered I don't charge at all.

You're a good person. Max deserves a mom like you.

Gerbil said...

Ah, but is it altruism?

Rach said...

Dinah, at the end of the day, you do whatcha gotta do. And really, if you're happy, isn't that all that matters?

sophizo said...


I've been thinking about how I want to respond. Do I want to defend him for what he charges? Do I want to applaud you for what you don't charge? Do both? I don't know. I guess the way I see things, it's a simple supply and demand issue. You could charge more, but you choose not to. That is a rarity in today's world. Based on what I've read on here (without ever meeting you or talking with you), you seem like you are great at what you do and your patient is right. I'm glad you explained why you don't charge more because logically it makes no sense to me. I guess that's why I am not in any kind of social field! I'm all about logic. When I see a LCSW can charge $100-120/hr and a Ph.D or Psy.D charge $150/hour, then seeing an MD charge $250-300/hr doesn't seem too far off (at least around here).

Since the guy I am talking about is a highly sought after child psychiatrist who specializes in autism, bipolar, and ADHD (all the dx's de jour), he is very much in demand and since his specializes in children there is a very low supply. If he was just a generalist, then I would be surprised if he could charge that much unless he was in NYC or LA. There are plenty of adult psychiatrists (around here). Not all are good, but the numbers are there to justify a lower price.

I guess in the end, no one is right or wrong. It is all personal choice. You choose what you want to charge (even if you are worth more) and patients choose what they want to pay.

Oh yeah...on a side note...his average patient comes every 1-3 months. Only a few are every week (most extreme cases). Everyone gets the full 30 or 50 minutes. No 5 minute med checks from him.

I hope this all made sense. I was a little taken aback the first time I read the post and waited until I read it a few more times to respond.

And Clink should triple or quadruple what she charges! ;-) BTW Clink...last night on the WE channel there was a documentary on women who work in male and female prisons. They even did a segment on some women who worked in the mental health part of a prison. I immediately thought of you and wondered how a segment on your work would look.

Ok...back to work for me! (since I don't earn anything NEAR $300/hr) ;-)

DrivingMissMolly said...


I confess that the fact that my doc charges so much makes ME value HIM more.


Anonymous said...

Okay, the fees thing is my issue, though I believe I now charge what other shrink psychotherapists in private practice charge (I know several at the same fee, one $5 more, two $15/session more, but most charge what I charge, I think). Sorry it's not $300/hr and thanks to anyone who thinks I'm worth that, and when I compare to lawyers, dammit, I AM worth it, but let's be real, no one is really "worth" hundreds an hour and it's a bit of exploitation when it's all supply and demand. I'll just be happy my student loans are done with....really, the loans and rising malpractice rates (which prompted me into a reality check) are what inspires some of this stuff.

Okay: any service gotten through an academic institution costs more, much more. The money doesn't all go to the doc, much of it goes to overhead and the institution. So, I work at a clinic in an academic institution: it costs a lot to have a therapy session there, probably close to $200, this isn't with me, it's with a social worker, many with much less experience than I've had (this is the reality, clinics don't hold staff for long and often get the newbies). I don't know what the social workers get paid, but maybe $25/hour (does that sound right?) they are salaried. And really, few people (maybe none) pay for the services, most have medicaid which pays what it pays, or medicare, which pays what it pays, or no resources. If you have money, you go to someone in private practice with, the most important thing: PARKING. I am much cheaper (as is every private practice shrink I know) than the so-called rate at a public clinic. And the academic shrink? He does charge more, he's got his name, he's got his secretary, 35% at least goes to the institution.
And psychopharm guru's who see patients less often charge more. And I do make a lot more seeing 2 patients an hour than 1.

My best to everyone. Poor Roy hasn't commented but he's taken to pandering on the blog for contributions.

NeoNurseChic said...

Great post, as usual. I don't see it as a message that you don't value yourself or your work. (I know you don't see it that way, but just sayin - neither do I!) I see it as you are content with your life, and you don't need to continuously raise fees and watch your patients grimace as they pull out their checkbooks...having them confess in their appts that they are not sure they can keep coming because they're up to their eyeballs in debt and even though they value your services more than a lot of the other things they have to pay for, they just can't keep up. It's a testament to your character that you know you have everything you want in your life, and so you keep the fees at a reasonable level. That's really cool - and rare.

Most people are gonna charge whatever they can get away with in order to be really rich.

I have a hard time with fees for piano teaching and performing. Recently, I was asked to set a fee for accompanying a women's choir, and I was like...hrmmm.....$150 for the season? Then I found out that at the minimum rate I should be charging, it is over $400 for the season - at the MINIMUM! Woah.....charging over $400 for something I love doing and am excited about? Ok...I could definitely use the money! But still, it is guilt-provoking! I still haven't responded to that - my proposal stands at $150 even though I've been told to fix this. I'll get around to it once my conscience recovers. However, my piano-playing isn't saving someone's life or anything. Vulnerable patients aren't paying my piano fee.

I look at my psychiatrist - he's a fellow. I'm sure he probably could use the money, yet he sets aside up to 3 appts a week (usually he's the one trying to get that 3rd appt in, even if I have to push things around and come into the city on days I'd rather not...) for me to come...when I pay a whopping $25. Recently I told him I couldn't afford to come 3x/week. We had a discussion about what value I place on psychotherapy. He did not say anything like, "Gee...guess you don't place high value on this" or anything like that! But I actually felt bad - like I was sending a message that I didn't value our work, and that's not true. But paying $25 per appt plus $15 for parking...well, it adds up for someone whos rent takes up almost an entire paycheck, save about $200.

Last night, I was at my friend's house and he was saying, "Well don't nurses make a lot of money?" I think he was surprised that I have no savings... I'm comfortable talking about my salary at this point with him, and I said what my monthly salary comes to and gave him an idea of what I pay for rent and so on. He said he only makes a few hundred less per month than I do as a PhD student, so now he never wants to leave school. Haha.... Granted, I only work 36 hours a week, but I'm really hoping that I get a raise this year (never know...but I hope so!!) so that I don't have to go back to 40 hours or take a 2nd job. Health-wise, it's important for me to keep my schedule on the lighter side. (I say as I'm about to embark on 3 12's in a row starting tomorrow, and I have the cold from hell....)

Anyhow - just wanted to say that I think it's commendable not to overcharge even though you can, and there are people who would pay it. It's nice of you to take on pro bono patients from time to time and to do some volunteering. I'm lucky that my psychiatrist has done so - he did say that next year when he's finished with training, he might have to charge more, but I know it'll still be something I can afford, and he's going to be farther away, so I don't think I'll come this often anymore.

Anyhow - gotta get to bed,

Take care,
Carrie :)

DrivingMissMolly said...


Interesting comment...

I DO think that Dinah undervalues herself.

The way I see it, she already works at a public clinic. She already gives to the community.

She can raise her fees nominally for current patients but charge new patients a new and more market value rate. That way the patients that see her already benefit from the fact that they have been with her so long, but the new patients pay what's fair in the current market.

I think it's great that she doesn't want to charge alot, but even though she lives comfortably now, you never know what will happen. She can sock away the extra $$ for her children and grandchildren, or endow a scholarship or do something else.


Dinah said...

I'm so glad everyone still wants to pay me more!!!

Carrie: Residents and Fellows are paid a salary, the fees go to the hospital. It's hard for them to find good psychotherapy patients to work with and so the hospitals often allow them to discount their fees so they can get the learning experience. It's very hard for residents to get patients who consistantly come over time even once a week, much less 3 times a week, so you are offering your dear psychiatrist a great educational opportunity. Rest assured, however, that even though he isn't profiting financially from seeing you, he was under no obligation to bring you with him from another institution and under no obligation anywhere to offer you this intensity of treatment: I would assume he likes working with you and is devoted to you.
Disclaimer: that's actually the only model I know, your world could be totally different, maybe he does get paid from his collected fees.

Anonymous said...

One of the most difficult things to do is to figure out what your time is worth and then to charge for it. That's why there are agents for superstars..I know...they are way overpaid. Sometimes this has nothing to do with self worth and everything to do with just being a really nice, wonderful person who wants to make sure that she is not putting the screws to someone.
For those out there that don't have a mini breakdown over raising their fees, shame on you.

NeoNurseChic said...


No I think you are spot on with it - I think you know the institution where he is a fellow quite well, actually - as it is one of your alma maters! Not your psychiatry alma mater, but still - I'm sure you're right in how the fees work. Where he was a resident is my alma mater, and I know that's how things worked there. However, once he finishes this year, his pricing is up to him for private practice. He will mainly be doing inpatient work - I assume in geriatrics.

I think he does like working with me - which is nice. I think I'm the only patient who came to the new hospital - don't know if he offered that to other patients, and I didn't ask. I know he couldn't take many because he only has clinic officially one day a week and he works obviously with geriatric patients. This past week, he was dragging out the end of the appointment to get me to tell him something, and I wouldn't.....and sometimes I wonder if, on some level, it's like someone who wants to finish the end of a really good book or wants to hear a really juicy piece of gossip. The interest in knowing what is going on in someone's mind - I can see it. I didn't withhold the rest of the story on purpose - just wasn't ready to talk about it - and he really was trying to get me to say it, but finally I just said, "I'm not telling you this...not today anyhow." ha... It's weird to have someone want to know things about me that I don't even want to know about me. That's the best way I can put it!

Anyway - I understand what Lily is saying....but I still think it's nice of you. I don't believe anyone can look at your pricing and state you are undervaluing yourself however. The reason why I believe this is because you are only undervaluing yourself if you don't believe you are worth more than you are charging. If you know you are worth more, but choose to charge less, then you value yourself just fine - but have made a choice to charge less. If you didn't personally believe your services were worth charging at least market value or more, then you'd be undervaluing yourself.

But for the record, I think you are quite valuable. I won't say how much I'd be willing to pay because frankly I can't afford much. I've always felt badly about paying my psychiatrist less because I feel like that puts some stamp on how much I value his services, however to me, it's actually invaluable....."priceless" in the MasterCard commercials sense... What I am able to pay for the service has absolutely nothing to do with the value I place on it...and I guess that's why I separate out the value of service versus the price. But that's just me.....

Take care,
Carrie :)

Roy said...

Dinah, you are priceless!