Tuesday, February 05, 2008

Ethical Dilemmas In Private Practice Shrinking, Part I

1) You have a bipolar patient who has been depressed and unable to work for months. You've been putting a lot of extra work into his care. You've been seeing him for about half your usual fee, but you know that even this isn't really affordable to him. After a while he switches to hypomania and is able to get back to work part-time. He comes in for an appointment and hands you a check that is not only larger than his usual reduced fee for that session, but in fact larger than your normal fee. He thanks you for putting in extra time in helping him and says the extra money is to compensate you for that. What to do?

2) You are seeing a woman whose brother (who lives out of state) pays for her treatment. She often cancels appointments less than an hour in advance. After letting several such incidents slide, you review your cancellation policy with both the patient and the brother, sending each a copy. The following week the patient cancels another appointment. At the next visit, the patient reports back that the brother called her to say that missing appointments is very expensive, and she had better get to all of them (he was not aware she had already missed another). She relates that she assured her brother that you would be "lenient" in applying the policy and wouldn't bill him for the missed appointment, because you know that she has a serious psychiatric problem and sometimes has difficulty leaving the house. She relates that her brother "will really let me have it" if he is "billed for nothing". What to do?

3) A therapist across town refers a teenage girl to you for medication evaluation. You've seen her several times (once with her mother) and feel you have a good rapport. You receive a phone call from mom, saying that she feels her daughter's therapy with the current therapist is "not going anywhere" and she would very much like you to see her daughter for both meds and therapy. You need the business and think the patient would be rewarding to work with, but you don't want to step on the toes of the person who referred her to you in the first place. What to do?


Anonymous Anonymous said...

Not sure where the dilemma is. There are two separate actions here. One is a business transaction- pay money, receive service. The other is simply the service delivery.

It seems that you have set rate(s), that you have fairly clear and specific terms. So the first two are simple things that an office manager would usually take care of:

1) figure out what he owed at the discounted rate you are charging and either return the rest or keep it on file as a credit for future services.

2) Charge her for the missed appointment and explain that you aren't going to be lenient because, well, the policy is that she pay for an appointment because your time is also valuable, you could have provided treatment at that price to another individual or done some other work that was not possible because you were waiting for her. I suppose that if you really think she didn't understand the terms the first time because your explanation was too obtuse that you would give her a pass on that appointment. Personally, I think it sounds like she is trying to see how much she can push the edge, because if she has that much difficulty understanding you I doubt she's getting much out of any of your sessions. It also sounds like she is trying to avoid being honest with the brother if she didn't tell him at that time that she had already missed a session.

3) It may be more comfortable for her to see one person than two, and sounds like the other person can't prescribe. I'd rather not have to tell the same thing to two people if one will do, and if there is a better rapport at the one-stop shop, it's a no-brainer. If the other person is a competent and confident professional they should accept this, and you can always return the favor by sending an appropriate referral back that way in the future. The implication in this question as framed is that the patient is something that is poached, or taken improperly from someone else. The problem I see with that thinking is 1) the rapport or intangible factors of the therapeutic relationship are known to be a significant variable in treatment outcome. This is supposed to be medicine (of sorts?) in a pseudo free market economy. Should you deny (possibly) better care because you might hurt another clinician's feelings? Besides, how can you just say, "no, I can't see you because the other guy was taking your money first."

I do think that as a professional courtesy you should contact the other therapist, but that's something that you would do anyway with folks that are sending referrals.

2/5/08, 7:12 PM  
Blogger Turboglacier said...

Well, just a bit more explanation then:

In (1), it's not so clear what he "owed", because I spent many extra hours (outside of actual sessions) consulting with inpatient docs, specialists, therapist, family... writing reports, putting in requests for Medicare, disability, medication prior-authorizations... etc. Normally I might charge for ?all ?some of that time, but in any case it would add up to much more than the extra in his check.

In (3), my usual feeling is that the best therapist for you is the one who already knows you. If you feel it "isn't helping", it might be worth discussing that with your therapist before jumping to a new one. All too often the less-known is idealized over the better-known, and the result may not be positive.

2/5/08, 8:07 PM  
Blogger Ladyk73 said...

I think it is very important to have clear rules and boundries.

(I am a social work intern-if only I could be successful doing any of the things I am suggesting.)

I think you should have a very clear charge schedule and policies and such. It is important for you (as your own boss) so payment issues do not become therapy issues.

But they do suck.

I am in grad school *grin*
and I am bipolar, and in therapy.
I bounced a check once to my psychologist. I was charge the bank fee, and an additional fee. I forked over $70 to clear a $15 mistake. It sucked.

As far as the teenager? I agree with the grass is always greener bit. Client "stealing" is never pretty. If you wanted to take on the teenager, I would talk to the referring therapist (with permission).


2/5/08, 10:10 PM  
Blogger NeoNurseChic said...

Tough dilemmas....

1. Not sure. If all the extra time you put in is still worth more than the extra he gave you, and he says he is compensating you for that, then I don't really see a problem in keeping it. You've still technically discounted him by not charging him for every extra mile you went to. I'm trying to put this in perspective since my psychiatrist allows me to see him for a fraction of what I should be paying him, but I've never given him an extra check to make up for it or anything. If I did, I think all I would want in return is for him to say thank you, and to continue to work with me. The question you have to ask yourself is, "Is this check a reasonable amount of money to accept for all the work I have done for this patient over the past few months?" If what you did is worth more than the check, then I think it is okay to keep it, as he wants to reimburse you for that extra effort. If what you did was worth less than the check, then that would be more of a dilemma....

2. I think this woman is testing you, and trying to use you to avoid a confrontation with her brother. I think that you really need to enforce your policy. While the patient may have a psychiatric disease that causes her to have problems leaving the house, she is still coming to you for help - and perhaps she would honor that commitment more knowing that you will be sticking to your policy. Maybe you need to have a conversation with the brother and the patient together in order to state your expectations and allow them to also share their feelings in your presence? That way the brother can also reinforce to the patient that he is trying to help her, but he cannot help her if she will not hold up her end of the bargain and go to the treatment sessions.

3. This is a tough one, and I think you've gotten good feedback on it. Are there other issues going into the mother's statement for why she would like her daughter to see you for therapy? Perhaps it WOULD be easier to see the same person for everything. I know I certainly find it to be quite a blessing to be able to see the same person for meds and therapy. Has the mother/daughter discussed their feelings with the therapist? If you decide to do therapy with this patient, which sounds like something you both feel would be a rewarding experience, I would probably at least discuss it with the other therapist, explaining the situation and that you weren't trying to steal the patient. I really don't know the best way to handle that, but ultimately the mother and daughter have a choice of who they see for care, as consumers. I don't think you should feel badly that they have chosen you - it's just difficult to know how to best smooth over the transition with the other therapist.

Take care,
Carrie :)

2/6/08, 1:46 AM  
Anonymous Norm said...

1. I don't see an issue with the money. Is he not aware you've been charging him less? Is he not aware that you've spent untold extra hours? Is this not his way of saying thank you?

2. No opinion, although I think the people who suggest she's pushing the boundaries may be right.

3. Talk to the other therapist. This seems like a no-brainer to me but I am not a therapist and have no idea what the usual practice is. But, client hires therapist. Client is not bound to therapist. Client can change therapist. Fact that he referred client to you is awkward, but that's all. I'd be more interested in whether kid is interested in changing. Don't think it should be her mom's call.

2/6/08, 10:19 PM  
Blogger Doreen Orion said...

1) Unfortunately, in our line of work, putting in extra hours for all the things you mentioned is simply considered part of our "usual" hourly fee - unless we discuss it with the patient beforehand. (And, if taking insurance, good luck getting the insurer to reimburse for any of it.) In this case, it seems to me that banking the extra bucks is tantamount to taking a tip (and indeed, the patient seems to be presenting it as such) so as much as I might be tempted, I would not do it. I would, however, tell him that since he is now working again, it is time to renegotiate his fee (ie back to your usual one, if possible). This might also be the time to explain that, in the future (since he is self pay?) you will charge your usual hourly (prorated) rate for all those extras you do for him outside the "therapuetic" hour.

2) I would explore with her why, given you were completely clear missed sessions would be charged, she thought they would not. I wonder if there's something underlying her feeling you would be "lenient" and her brother would "let [her] have it."
And, I would charge for the appointment, explaining (as a previous commenter said) that if given appropriate notice, you could have filled the hour. I would also offer to have a session with her and her brother (by phone if he's out of town) to discuss, if she likes.

3) In these situations, I usually ask the patient to discuss this herself with the therapist before making the switch. There could be something valuable for her to learn about why she does not seem to be connecting with that therapist... or not, but I would not get between their relationship until it is severed by one of them.

Gosh, this stuff is easy to figure out when you're not sitting in the chair at the moment, huh?

2/7/08, 11:38 PM  

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