Talk Doesn't Come Cheap

Gardiner Harris has an article in today's New York Times called "Talk Doesn't Pay So Psychiatrists Turn to Drug Therapy." The article is a twist on an old Shrink Rap topic--Why your Shrink Doesn't Take Your Insurance. Only in this article, the shrink does take your insurance, he just doesn't talk to you.

With his life and second marriage falling apart, the man said he needed help. But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Ah, Dr. Levin sees 40 patients a day. And the doc is 68 years old. This guy is amazing, there is no way I could see 40 patients a day for even one day. He's worried about his retirement, but I wouldn't make it to retirement at that pace. Should we take a bet on whether Dr. Levin has a blog?

So the article has a whimsical, oh-but-for-the-good-old-days tone. In-and-out psychiatry based on prescribing medications for psychiatric disorders is bad, but the article doesn't say why. In the vignettes, the patients get better and they like the psychiatrist. Maybe medications work and psychotherapy was over-emphasized in the days of old? The patients don't complain of being short-changed, and if Dr. Levin can get 40 patients a day better for ---your guess is as good as mine, but let's say-- $60 a pop and they only have to come every one to three months, and there's a shortage of psychiatrists, then what's the problem? Why in the world would anyone pay to have regular psychotherapy sessions with the likes of someone like me?

After my post last week about The Patient Who Didn't Like the Doc. On Line , I'm a bit skeptical about on-line reviews. Still, I Googled the psychiatrist in the story, and the on-line reviews are not as uniformly positive as those given by the patients who spoke to Mr. Harris. Some were scathing, and they complained about how little time he spends with them. In all fairness, others were glowing.

The article makes psychiatrists sound like money-hungry, unfeeling, uncaring, sociopaths. Either they're charging $600 a session (...oh, can I have that job?) or the financial aspect is so important that they're completely compromising their values for the sake of a buck. This doctor believes that patients get the best care when they receive psychotherapy, and the rendition Mr. Harris gives is that it's understandable that he's compromised his values to maintain a certain income. I don't buy it and I don't think it portrays psychiatrists accurately or favorably. If the doctor felt that it was the high ground to give treatment to 40 patients a day who otherwise couldn't get care, then this portrayal wouldn't be so bad. And that may be the case---I don't know him and I don't know Mr. Harris and I do know that an occasional reporter has been known to slant a story. I found it odd that there were no other options here aside from 4 patients/hour, 10 hours/day, not to mention the 20 emergency phone calls a day that he manages in the midst of all the chaos. Why hasn't this doctor left the insurance networks and gone to a fee-for-service model with a low volume practice if psychotherapy is what he enjoys and what he feels is best? Or why doesn't he devote an hour or two a day to psychotherapy? Okay, I shouldn't rag on the poor doc, I only know him through a newspaper portrayal, but I don't think this article showed psychiatry at its finest hour. And yes, I know there are psychiatrists out there who have very high volume practices.

Are In-Network Shrinks Better Shrinks?

Clink and I have been having a discussion about insurance participation. It's for the book. We think.

So I've made the statement that given that insurance companies reimburse according to their somewhat random (and generally reduced) rate of Usual & Customary Fees, that they require paperwork and hoops to jump through, and that there is financial incentive for seeing a lot of patients in less time, more so then in giving slow and thoughtful care, that in some communities there is a force of natural selection and that the Best docs may be the ones who won't participate in insurance networks. Is this completely true: of course not. Some really good docs (especially inpatient and consult-liason, where there is very little option) participate with insurance companies. Maybe they live in communities where it's the only feasible way, maybe they like having high-volume practices, maybe they just participate with one or two selected insurance companies to accommodate select patients (or because they've heard the company is easy to work with, or reimburses well), or maybe they feel it's the socially responsible thing to do. Oh, or maybe they worry that if they Don't, they won't get enough referrals and make it in private practice.

So, in thinking about this, I realized I know very little about docs who participate with insurance networks. None of my friends do. I participated in Blue Cross for 7 years---they never sent me referrals and they'd send me random checks for $12.44 (like what was that a portion of?) or $44 something. The UCR was different for each patient, and they were all much much less than going fees back then.

I've been assuming that to make a living accepting insurance, that the doc needs to see a high volume of patients. That's not to say that a psychiatrist might not be willing to see a portion of their practice as psychotherapy patients and take a lower hourly fee for that, and compensate by doing high volume work the rest of the day, or by offering different levels of care based on insurance. That's not to say that there aren't psychiatrists who don't participate with insurance but still have very high volume practices, but they make a lot more money then I do (or so I believe).

But it's occurred to me that I really don't know much beyond what I learned when I was in a group practice way back when. If you take health insurance, tell me how your practice works-- how many patients do you see in an hour, do you get paid from the insurance companies, do you like your work, do you feel the care you give is as good? And if you see a psychiatrist in your insurance network, please tell us how that goes....how long are the appointments, how often do you go in, how does the billing and co-pay work? And if you've seen both in- and out- of network shrinks, how were they different and what worked better for you?

Just A Little More Time

Okay, so I'm going to post a scenario and I want your opinion. There's no 'right' answer, I don't think, or you'll tell me if there is. I'm particularly interested in opinions from other mental health professionals, so please note in your comments if you're one of those, but as always, I'm interested in feedback from all our readers.

A patient and doctor have a long-standing relationship, they always meet for a 50 minute session, and if often goes closer to 60 minutes. Perhaps a few times they've even gone longer. It's been years, and now the sessions are scheduled erratically, so it's not a given that things can be finished up 'same time next week.' On this particular session, the patient brings up something towards the end that unexpectedly takes a long time-- maybe she wants the doc to write a new script (maybe it's even Xanax ! and the doc is uncomfortable). Some disagreement follows, and the session goes until a quarter after the hour. The doctor never formally states there will be a charge for the session that has run over and there has never been a charge for an over-time session before, though this session may be longer than any other. Is the doc justified in sending out a bill for the extra time? And if so, by how much? An extra quarter of a session, or an extra 50% given that the session technically ran 75 minutes and not 50 minutes. Does it matter if it was the last patient of the day and there's not an all-day back up for everyone else because of the extra time? Let's say it was the patient's final session and so please don't answer with "examine it in the next session" or "send a bill and see what the patient says." And don't worry about the Xanax, new script, whatever issue, it doesn't really matter Why the session ran over, the scenario is about the time and the unexpected charge.

I often run my 50 minute sessions closer to an hour, and sometime I run a few minutes over that. There have been a handful of sessions that have run quite a bit over, and it's never occurred to me to charge for something that wasn't agreed upon in advance, but I'm not saying it isn't the right thing to do-- boundaries, income, time-is-money and the doc has bills to pay, too.

Just wanted your thoughts.

The Patient Who Wouldn't Pay

I posted the latest poll on the sidebar and I thought there would be hands-down winner, that everyone would agree, the hardest thing to talk about in therapy is MONEY. Payment. Fees.

Maybe it's just from the therapist's side, but I HATE TALKING ABOUT MONEY. I really hate it. How much do I hate it? A lot.

On the phone before I meet someone, I'm very clear about a bunch of money things-- I hate this, it turns me off, but people have the right to know what they're getting into and if it isn't clear there are a lot of misunderstandings. So I don't participate with insurance companies, the patient needs to pay up front and then submit the bill so the insurance company will reimburse him directly. He needs to call the insurance company before he even comes in-- it's called "preauthorization" and if you don't jump through this hoop, some companies will refuse to reimburse at all. Many companies have a separate managed care component for mental health and ask for a treatment plan. The patient needs to find out how many visits he has before a treatment plan needs to be submitted (it may be 1, it may be 8, it may be 11, it may be never) and he has to to tell me Where to send the treatment plan to. Then he has to count the appointments so I know when the next treatment plan is due (--oh, actually I have a system for doing this, but it doesn't hurt to have a back up reminder). I tell the patient the cost of the evaluation and the cost of a regular 50 minute session. I tell them to expect to pay at the time of the visit-- that's the most comfortable way I've found to say it. A lot of people say "no thanks, I'll find someone in my network," and that's fine. I say a few other things too, like how to find my office and what to expect, and that it's fine to bring someone if that will be helpful, and definitely bring your medications.

I hate talking about money (did I mention that?). What I don't do is ask for payment during the session, it feels tacky. Most people write a check at the end---they were told this is the policy on the phone. If they don't, I send a bill at the end of the month, with all the other bills. The majority of people mail or bring a check, and it's just not a problem. Here and there, someone just doesn't pay. I hate asking. Eventually, I ask. Usually I don't, and eventually the patient pays, but I've been stiffed by a few people.

There was once a woman who'd seen me for years, payed at every session, and then had an unexpected financial crisis and now was really struggling. I didn't ask her to pay for the full session, instead, I nagged her to submit to her insurance company and at least pay the portion they would pay. Should I mention that the reason for her unexpected crisis was that she outspent her excessive standard of living? I've had this happen a few times, and I tell people to catch up at they rate that they can. In the case of people who have had true crises (lost jobs with few assets any way), I will slide their fee. But I'm not so comfortable doing that when the patient drives a late model luxury car or owns a vacation home. I'm sympathetic to their sudden financial plight, but I need to make a living, too. My hardest is the patient who struggles and struggles just to make a living, sleeps on the couches of friends, every purchase is a hardship, and I would say "forget it," I'll see you for free, but for that little drug habit--- if you can swing upwards of $50/week on your habit, another $50 for your cigarettes, a few bottles of wine, then maybe it's good to make a minimal payment on your shrink bill to that shrink who calls around to get you free samples.

Do you want to hear about the surgeon who came twice and never paid the bill? Or the patient who moans about every dime of the bill and the struggles to get reimbursed, but spends in a way most people wouldn't dream of spending on luxury trips, 5-star restaurants, homes so big the utility bills are bigger than his medical bills? Or the few patients I've seen who simply didn't pay at all--even after being asked, uncomfortably, repeatedly, just said "next time," or "I'll send a check" or "I did send a check." The odd thing is these aren't people who are talking about their financial hardships, they're people who are talking about their vacations and boats. The reality is they make a profit by not paying, because they get reimbursed by their insurance companies (often these same patients will ask to have the statements regenerated two or three times), but they never pass along the fee. This is called fraud, I believe.

Uncomfortably, I've been left to say on a few occasions, "Why don't you catch up and then call to schedule the next appointment." I hate talking about money.

I'm sorry, I sound bitter and this is an issue with so very few people. Most people, if they fall behind, they say something and I'm happy to have them catch up at their own pace, and they do. Nothing specific set me off tonight, I just was surprised that more people have trouble talking about sex than money. Maybe I'm feeling a little Grinchy. You can guess which I'd rather talk about.

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?