The past few months have been full of posts about work. Back in June, I decided I was over my old job. Then I had an epiphany that led to my current job (which I actually like). Some of you are probably sick of hearing about it, but I’m afraid you’ll have to indulge me just one last time.
My job involves providing psychotherapy to teenagers in a high school, and I also see adults at a mental health clinic in the afternoons. Instead of a salary, I get paid only for the hours I bill – it’s much more per hour, but I no longer get paid sick or vacation time. So if I see one client, then get sick and go home, I’m only getting paid for one hour of work that day.
I really do enjoy the freedom so far. I set my own schedule, work as much or as little as I want, and I get to spend lots more time with my son. I’m easing into a pattern and learning how to get the most out of my time at work.
But I’ve noticed that I am also changing in ways I’m not sure I like.
Throughout my career, I have made sure to provide quality treatment to every single client I see, regardless of his/her age, ethnicity, background, financial status, or belief system. I’ve jumped at the opportunity to work with the “difficult” populations that other therapists avoid – the severely mentally ill (think schizophrenia), substance users, abusive and neglectful parents, and even convicted felons. I spent an hour with a guy who reeked of cat urine without flinching (though I totally doused my office with Febreze once he left). I met with a woman in a parking lot in the back of a police car because voices told her not to go into the clinic. I can find positive qualities in anyone and I absolutely love what I do for a living.
Since I took this job, though, I’ve noticed one group of people that I avoid like the plague: The uninsured.
Don’t get me wrong – it’s not like I look down on people who don’t have insurance. I didn’t have coverage for five years when I was married, so I know all too well how much it sucks. When I earned a salary, I didn’t even pay attention to what type of insurance (if any) my clients had. But now that my livelihood depends on billing insurance companies, Medicaid, and Medicare, it’s a whole new universe.
The state pays my employer for a certain number of therapy hours each year for adults with no insurance. Those hours are divided among the 26 pay periods in the year, then divided among all the therapists in the agency. Basically, I get 2 hours every 2 weeks to see adults without insurance. If I see more than 2, I don’t get paid. And if I consistently exceed my limit, I can end up owing the agency money. Difficulty: I’m typically scheduled anywhere from 5 to 10 uninsured clients in a pay period.
We are told to “get creative” when it comes to managing the uninsured on our caseloads. “See them for 15-minute sessions once a month,” we’re told. “Put them into group therapy so you can see a bunch of them in one hour.” In other words, provide crappy services and think of the uninsured as a pain in the ass rather than real people who need help. The alternative? Lose up to 10 hours of billing.
My brain screams that this is a horrible way to treat people. Ethically, I can’t refuse to see someone just because they don’t have insurance. It goes against my values as a professional AND as a human being. When I learned about this aspect of my job, I seriously considered quitting.
Then I realized I can’t just quit my job without another one to go to.
Then I thought about how much money I can make if I stick with this.
Then I experimented with shortening sessions to 45 minutes for uninsured clients. That’s not so different, I told myself. That’s still plenty of time.
Then I shortened some sessions to 30 minutes. Most people don’t even notice the difference! I thought. It’s not like I’m throwing them out during a crisis. I’m just managing my time better.
Then I started rejoicing inwardly when an uninsured client missed two appointments in a row, because that means I could take him or her off my caseload. One less hour over my limit.
Yesterday, I was thrilled because all of my afternoon clients had Medicaid, meaning I could spend as much time with them as they needed instead of watching the clock.
Do you see the slippery slope?
I don’t want to become one of those people who is so obsessed with money that I throw my morals out the window. Yet when I’m placed in an environment where I have to balance making a living with doing the right thing, my thoughts start shifting before I even realize it.
I have to make money to eat, live, and pay my bills. But I can’t decide whether I’m okay with making money in a way that goes against what I believe is fair. Will I become one of those cynical jerks who cares more about getting paid than the people I work with? Or will I learn to be objective again, dealing with each client according to his or her needs? I don’t know what the answers are.