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?