Third-party payment for psychotherapy: (2) Medical necessity

In my last post I outlined some complexities of third party payment for office psychiatry, and especially for psychotherapy.  As my example I used Medicare, the only third party payer I bill.  Some of the problems include complex billing (i.e., collecting from multiple parties), partial reimbursement, unrealistic documentation requirements, loss of patient confidentiality, and a misplaced emphasis on medication "evaluation and management" over psychotherapy.  There are also challenges specific to dynamic psychotherapy, such as obscuring the transference.  But I saved the most fundamental issue for this post: Does third party payment for psychotherapy make sense in general? This may seem a puzzling question, coming from me.  I not only value deeply what psychotherapy offers, I make my living from it.  Shouldn't it go without saying that psychotherapy should be paid for somehow, no matter where the money comes from?  My experience with public and private health insurers tells me otherwise.

"Medical necessity" is the linchpin, and frankly the problem.  The more a therapeutic encounter fits a medical model and is arguably "necessary" in that framework, the more readily it is covered by health insurance.  Psychotherapists of all stripes tiptoe uncomfortably around this issue.  Medication management fits the medical model very well, so psychiatrists who incorporate this into their psychotherapy sessions enjoy outsized reimbursement (or their patients do).  Talking about anything else, no matter how central to the patient's presentation, does not fit the medical model nearly as well.  Nonetheless, psychotherapists who offer a step-by-step approach aimed concretely at relief of symptoms emulate medical evaluation and treatment much more than those who employ open-ended, exploratory approaches to tackle dysfunctional family dynamics, chronic self-sabotage, and many other concerns for which people seek psychotherapy (and later report benefit; see Consumer Reports, November 1995, Mental health: Does therapy help? pp. 734-739, and this analysis of the Consumer Reports survey by Martin Seligman).  Note that the crucial variable for coverage is not what helps more, or relieves more agonizing misery.  It's what seems more "medical."

Using “medical necessity” as the criterion to treat human misery that often isn’t medical at all leads to much inconsistency and even cruelty.  As mentioned in my last post, insurers demand that I code my "procedure" (i.e., the session) depending on what we talked about.  If we spend the hour discussing medications, even if this focus can easily be understood as a symbolic, unconscious appeal by the patient for care-taking or some other emotional need, it's worth far more to the insurer than if we spend the same hour explicitly discussing the patient's experiences and reactions to actual caretakers.  (As added irony, the latter discussion can obviate the former in future sessions, a detail lost on insurers and most everyone else.)  Since private insurance partly reimburses many of my non-Medicare patients based on how their sessions are coded, an agitated, marginally employed, chronically suicidal patient with severe personality issues is reimbursed far less over time than a high-functioning, stably-employed patient with a medication obsession.  This makes no sense and is blatantly unfair.

The truth is, I'm the same expert — and put bluntly, worth the same amount of money — no matter what I'm discussing with the patient.  That is, as long as I have the integrity to focus on the patient's central issues, not to provide or bill for unneeded services, not to offer hand-waving in lieu of explanation, not to mindlessly prescribe medication after medication, not to casually chat and call it psychotherapy, and so forth.  In other words, I need to be a good doctor instead of a sloppy or unethical one.  I need to know when to be "medical" and when not to be.

Traditional dynamic psychotherapy fits the medical model especially poorly.  It is not primarily focused on symptom relief.  The treatment is not tailored to diagnostic categories.  It follows no step-by-step sequence.  Even expert practitioners often cannot estimate treatment duration.  After many decades of published studies the evidence base for treatment efficacy still triggers heated debates.  Arguing "medical necessity" for such treatment is at best unnatural, at worst contrived or even misleading.  (It's even more absurd to argue the medical necessity of one specific session in an ongoing treatment; to me, this is like asking whether the 10th note in a piano concerto is "musically necessary.")  Those of us who recognize the value of dynamic work and have seen patients change in important, fundamental ways are kept busy trying to pound this square peg into a round hole.  But CBT doesn't avoid this problem either: it's more like a square peg with rounded corners.

Faced with the struggle to show medical necessity, it's tempting to wonder whether psychotherapists should refuse to play this game.  However, opting out isn't easy.  Even if I chose not to be a Medicare provider — I admitted my mixed feelings about this last time — self-pay patients with private insurance would still seek maximal reimbursement for seeing me.  I can hardly blame them.  I see no way out of participating, at least indirectly, in this misapplied standard of medical necessity.

It's hard enough to assure that all Americans have access to basic health care.  Assuring that all have access to mental health care is one step harder, even when that care accrues only to the seriously mentally ill and fits the medical model very well.  It will be a very long time indeed before America deems it worthwhile to offer psychotherapy to the so-called worried well: those who have all their faculties but are miserable due to inner conflicts, self-defeating beliefs, or a traumatic past.  If that day ever comes, it will be when medical necessity is supplanted by a more fitting standard, one that judges mental distress and its treatment on their own merits, and not by borrowing legitimacy from medicine.

Third-party payment for psychotherapy: (1) "Do you take Medicare?"

From late 1996 to early 2007 I was medical director of a low-fee mental health clinic where psychiatry residents and psychology interns receive training.  Since the clinic accepted Medicare for payment, I did as well.  I signed on as a Medicare "preferred provider" and have remained on the panel ever since, even though I left the clinic for full-time private practice nearly seven years ago. I never joined private insurance panels for several reasons.  As an inveterate do-it-yourselfer, I've always handled my own billing and bookkeeping.  This is considerably harder when multiple health plans are billed, co-payments collected, and so on.  I like the straightforward way I provide a service, and the person receiving the service pays me directly.  Somehow it feels more honest than contracting with health plans to funnel referrals my way.  Private health plans also pay less than usual-and-customary fees and require doctors to share patients' private details with corporate reviewers to document "medical necessity."  Moreover, since dynamic psychotherapy has always been a big part of my practice — increasingly so over time — I'm sensitive to arguments that third-party payment complicates transference and countertransference, obscures acting-out around payment, and detrimentally takes payment out of the treatment frame.  Last but not least, as I'll discuss mainly in my next post, insurers base reimbursement on a medical model that fits poorly with dynamic work.

The upshot is that I have a cash-only (or "self pay") practice, with the exception of my Medicare patients.  Until this year, Medicare "allowed" 65% or so of my full fee.  (Medicare sets an allowed fee for a given service, and then pays 50-80% of that.  I can collect the rest, up to the allowed amount, from a secondary insurer or from the patient.  This works more or less automatically for secondary insurers, and rather awkwardly when I try to collect from patients.)  In 2013 the CPT codes for psychiatric office visits were revamped.  This made billing more complicated, and introduced odd, often illogical variations in Medicare and private insurance reimbursement — sometimes paying more than before, sometimes less.

As one of the few private-practice, office-based psychiatrists in San Francisco still on the Medicare panel, I've become a magnet for these patients.  A local medical center with which I have no affiliation used to refer several callers to me every week, until I sent a letter asking them to please not kill me with their kindness.  Medicare callers request to see me for medications only, even after I explain this is not the nature of my practice.  It's more tricky when patients claim to want therapy to get a foot in the door, and then once in my office and now my medico-legal responsibility, confess that they only wanted medication refills all along.  Some callers ask to be added to a non-existent waiting list, or to call me every month or two to see if I change my mind about accepting them as patients.  Clearly, the demand is there, the economic incentive is not.

Medicare and other third-party payers have a valid need to assure their money isn't wasted.  Sometimes my claims are rejected, as when I received a notice this week that one patient's diagnosis (Depression Not Otherwise Specified, 311) "is inconsistent with the procedures" I billed (three weekly sessions of moderate-complexity medication management, 99213, combined with 50-minute therapy sessions, 90836).  It's tempting to protest this, as there's absolutely nothing inconsistent about treating atypical depression with medication and psychotherapy.  I could take the time to marshal my arguments, compose a letter, and reveal personal details about my patient to present my case.  But it's far easier to resubmit the claim with a slightly upcoded diagnosis, e.g., Major Depression, recurrent, mild severity, 296.31, and get paid.  This uncomfortably clashes with my usual tendency to downcode slightly to protect my patient's confidentiality.  (Since pressures to upcode and downcode routinely distort the documentation of diagnoses in clinical practice, I'm skeptical of all research that uses these diagnoses to derive conclusions about psychiatric practices, disorder incidence, and the like.  Garbage in, garbage out.)

Upcoding and downcoding in such cases is not criminal mischief, but an attempt to fit traditional, mainstream psychiatry into a procrustean bed of medical-model diagnosis and procedure coding.  Public and private insurers alike sacrifice ecological validity for documentation that appears, but really isn't, "evidence based."  To take one example, as of this year we must code medication "evaluation and management" separately from the provision of psychotherapy, even if in practice these are done simultaneously and inseparably.  A 50-minute psychotherapy session (90836) that includes brief attention to medication (99212) is reimbursed at a much lower rate than the same 50-minute session with more time devoted to meds (99213 or 99214).  This makes little sense when in many cases the psychotherapy is far more clinically significant than the medications being discussed.  (You'll note that I think of the psychotherapy code first, but actually it is an add-on to the primary medication "E & M" code.)  If medications are not mentioned or evaluated at all, there is yet another code to use for psychotherapy (90834), with an "allowed fee" of $89 for 50 minutes, well below what any psychiatrist or psychologist actually charges.  If this isn't bewildering enough, some of my colleagues are now doing 52-minute sessions, an insignificant increase in duration that qualifies for a different code with much higher reimbursement.

Since cash-only practice excludes all but the affluent, I view my taking Medicare as a modest concession to avoid elitism.  I also support a single-payer health care system, also known as "Medicare for all," so participating in Medicare feels like practicing what I preach.  At the same time, it's easy to see why most of my office-based colleagues opt out of Medicare: lower pay for more paperwork, rules that don't make sense, and various factors that make dynamic psychotherapy harder to conduct and be paid for.  So far I still answer yes, albeit hesitantly, when asked whether I take Medicare.  In my next post I'll expand these ideas into private insurance for outpatient psychiatry, including whether dynamic psychotherapy resembles a medical intervention enough to fit a "medical necessity" model.

Is your therapist biased by money?

Earlier this year, blog commenter TK wrote: "Isn’t this the greatest countertransference, in this age of fee-for-service psychotherapy as opposed to psychotherapist-on-salary: How do I work around my own economic motivation in deciding whether to continue with a patient or terminate?

"In other words, how does one reconcile the consistent economic incentive to keep a client coming back to your office, particularly when one is being paid by the therapy hour instead of by salary? After all, there’s always something to work on, to improve, to understand better…

"In other, other words — and this is only partially tongue-in-cheek….Is there truth to the adage that you don’t ever want to see any psychotherapist who has openings in their practice?" 

In a similar vein, a reader named Cynthia more recently posed a challenge:

What would you think about a patient asking a therapist at the outset of therapy to report to her at the start of each session how many client/patient hours you have scheduled for that week? That would give her real insight into what’s going on in the therapist’s practice, and would help determine how important it is for the therapist for her to keep coming back. Would you personally be willing to provide that kind of information?

To me, this seems far more important to know than any therapist personal life information that would arouse normal patient curiosity.

I replied to Cynthia's comment, noting that such disclosure might appear to be a useful consumer tool not only for therapy clients, but also for anyone hiring an electrician or plumber, a lawyer, a music teacher, or a medical doctor.  For each of these, financial incentive may be a factor in determining how "important" it is for the customer, client, or patient to return.  However, none of these service providers offer this information, and presumably all would consider the question intrusive and overly suspicious.

Of course, even having this concrete information may lead to different conclusions.  An underemployed service provider may be relatively unskilled, and/or more desperate for income.  As TK offers: "you don’t ever want to see any psychotherapist who has openings in their practice."  On the other hand, overly busy providers may not be available at all, may be hard to schedule, or may not give you their full attention.  Nor is busy-ness always a sign of quality.  Some providers market themselves better, or offer faddish services that are popular at the moment.  All of this applies equally well to hiring a house painter or a psychotherapist.

Seeing a therapist is different than hiring a plumber or painter, though.  Popularity (e.g., high ratings on Yelp, or on one of the dedicated rating sites for doctors or therapists) is no guarantee of a good personal connection with you as an individual.  Rapport with a therapist is more idiosyncratic and subtle than that, a matter of chemistry.  Also, since therapy quality is more subjective than the quality of a plumbing or paint job, the impressions of others may not be as reliable.

However, even if we agree that a busy therapist is apt to be a good therapist, TK and Cynthia share a somewhat different concern.  They worry that therapist economic incentive may lead to unnecessarily prolonged therapy.  "Isn't this the greatest countertransference...?"

In a sense, yes, the wish to be paid for providing psychotherapy is the greatest countertransference.  There are important ancillary gratifications of the work — the satisfaction of helping troubled people, the intellectual challenge — but being a therapist is, first and foremost, a livelihood.  A therapist who lacks the money to buy food, or who faces eviction or mortgage foreclosure, is not in a position to "bracket" his or her own needs and put the patient's first.  I confess that when I first opened a private office in 1995, retaining my first few patients mattered more to me than it should have.  While I don't believe I harmed anyone, or kept anyone in treatment longer than needed, the economics loomed large in my mind.

However, this situation passed quickly.  I cannot speak for all therapists or all psychiatrists, but on the whole we make a decent living whether our practices are full or not.  Patients come and patients go; the economics surrounding any one patient is not a major consideration.  As in many features of the therapy relationship, the dynamics feel weightier to the patient than to the therapist.  This makes good sense, as the patient only has one therapist, but the therapist has a number of patients.  (And transference magnifies these issues for the patient more than countertransference does for the therapist.)  Thus, a vacation of either party usually matters more to the patient.  Fees and money issues usually matter more to the patient, and so forth.

As I read the comments of TK and Cynthia, I recognize a core of realistic concern that the therapist may be biased by economic incentive.  But barring specific evidence of desperation or money grubbing on the part of the therapist, I can't help but think of this as a concern magnified by transference.  Economic incentive is the default situation when hiring anyone for anything.  Do you worry that your car mechanic, tax preparer, or personal trainer is just stringing you along for the money?  We all need to keep our eyes open, but there's a point at which one's natural suspicion can give way to trust and a sense of security.  Healthy relationships reside in the sweet spot between gullibility on the one hand, and paranoia on the other.  If suspicion persists, whether in therapy or elsewhere, there is a problem.  Maybe the other person gives subtle signs of untrustworthiness.  Maybe one's own "trust meter" (transference) is a bit askew.  Figuring this out is itself the stuff of dynamic therapy; it can shed light on one's relationships inside and outside the therapy office.

Healthcare reform & psychiatry

The recent debates over U.S. healthcare reform are long overdue, yet still sadly inadequate.  (The discussion is about health insurance, actually, not the care itself.  But I titled this post "healthcare reform" since that is what everyone is calling it.)  There is no need to rehash the plentiful evidence that the current system is broken: millions of uninsured, job lock to maintain health coverage, unwarranted claim delays and denials, whole industries devoted to medical paperwork and reimbursement, and the near impossibility, given a pre-existing condition, of purchasing non-employment based insurance at any price.  Hardly anyone across the political spectrum argues for the status quo. The national debate centers on how to provide universal, or universally available, coverage to all Americans.  Some argue that with proper incentives, private insurers could cover everyone.  Similar to health coverage in the Netherlands, this proposal aims to preserve the private insurance industry and competition in the marketplace.  Others argue that health care does not follow classic supply-demand principles, and that competition among private insurers has not controlled costs.  A publicly funded, government-sponsored option is preferred to remove the profit motive and gain efficiency through standardization.

Universal health coverage is the norm in virtually all developed countries.  I believe Turkey and the U.S. are the only remaining exceptions.  Some nations, Britain for example, have nationalized health care — doctors are government employees.  Others, like Canada, use public funds to pay doctors in private practice, much as Medicare currently operates in the U.S.  These systems are not perfect.  In particular, there are longer waiting times for elective procedures, sometimes on the order of months.  But surveys repeatedly show that citizens (and doctors) of these countries are happier with their health services than Americans are with ours.  And studies also show their health outcomes are the same or better than ours, for far less money.

There are many places to read about health insurance reform that do a better job than I can (e.g., here).  From my reading, I believe a single-payer plan such as those in  Australia, Canada, and Taiwan would greatly improve health care in the U.S., while preserving patients' ability to choose their own doctors, and also doctors' ability to work in the private sector.  It's a pity this option, so popular across the globe, is a political third-rail here.  In my view, publicly funded health insurance (think Medicare) is no more "socialist" than the public funding of highways, police departments, and firefighters.

In a nutshell, that's my view of publicly funded health insurance in general medicine and surgery.  But what about psychiatry in particular?

Universal coverage would be a boon for the seriously mentally ill.  Schizophrenia and severe chronic mood disorders render many sufferers unemployable and ineligible for private insurance.  Some eventually qualify for Medicare and/or Medicaid, the limited forms of public health insurance that already exist.  The additional stigma attached to using public programs due to severe disability would abate if public health insurance became a mainstream reality.  Others with debilitating but less severe forms of mental illness do not qualify for Medicare or Medicaid, but cannot maintain private insurance due to frequent job loss, chaotic lives, depression, and so forth.  The affordability of care and treatment is a constant stress atop an already stressful existence.

Universal health coverage would change all that (see this report from the California Endowment).  Canadians talk about their comfort in knowing their friends, acquaintances, coworkers — fellow citizens — have access to health care regardless of circumstance.  Healthy Americans might feel this way, too, when the chronically mentally ill among us are assured access to care.

At the other end of the psychiatric spectrum are relatively healthy individuals who seek psychotherapy for help in living a life that is basically stable, but is unfulfilling, frustrating, anxiety-laden, or sad.  In the U.S., most health insurance, private or public, limits coverage for this type of treatment.  Many private plans cap the number of treatment sessions to 20 or fewer per year; Kaiser Permanente additionally requires that a mental health professional "believes the condition will significantly improve with relatively short-term therapy."  Medicare does not cap the number of visits, but covers only half its "allowed fee" — the patient or supplemental insurance pays the other half.

It should be noted that traditional dynamic psychotherapy, the kind I do, considers it beneficial when the patient pays for therapy himself.  Directly paying for therapy focuses the dynamics between patient and therapist by excluding distracting intermediaries.  It matters more (to both parties) that the patient gets what he or she is paying for.  Sometimes patients express unstated feelings toward their therapist in how they pay their bill; this can be interpreted as transference, moving the treatment forward.  Moreover, dynamic psychotherapy is an intensely private undertaking:  Many patients choose to forgo insurance coverage even if they have it, to avoid a public record of the treatment, or the need to document it with third parties.

All that said, many more people can benefit by psychotherapy than can afford to pay for it directly.  A universal health plan that covered therapy in a substantial way (say, as Medicare does now) would make this service available to many who could not receive it before.  Third-party payment issues are handled all the time in dynamic therapy even now.  And not all therapy is psychodynamic; I know of no concerns regarding CBT (cognitive behavioral therapy), for example, being paid by third parties.

In short, U.S. healthcare — more accurately, health insurance — reform that universally covered mental health treatment would revolutionize care of the mentally ill in this country.  Benefits could be as visible as fewer homeless on the streets and in the jails, as subtle and pervasive as a comforting sense that Americans care about each other both in body and spirit.  I hope we have the will and the wisdom to make it happen.

Charging patients for missed sessions

money_time

When Sigmund Freud originally developed psychoanalysis (the precursor to dynamic psychotherapy), he likened treatment fees to those for music lessons:

"As to time, I follow the principle of payment for a fixed hour exclusively. A given hour is assigned to each patient, and that hour is his and he is responsible for it even if he does not make use of it. This practice, which for the music or language instructor is considered normal in our society, when it involves a physician sometimes appears harsh or unworthy of his role..."

Nowadays, similar missed-appointment penalties exist in dentist offices, hair salons, and many restaurants, hotels, and spas that require reservations. The rationale in all these settings is that another patient, client, or customer cannot immediately fill the place of a no-show. The time and resources of the doctor or business have been wasted.

Freud's successors have modified and refined this policy in differing ways. At one extreme are analysts who charge for any missed session, planned or unplanned, regardless of reason. The analyst announces his or her vacation dates and holidays well in advance, and patients can choose to plan their own accordingly. A more lenient if less clear-cut approach is to waive the fee if the therapist can fill the hour with another patient. More commonly, therapists waive fees for sessions cancelled with advance notice; the amount of required notice is specified beforehand and varies considerably among clinicians. The APA code of ethics cautiously endorses this approach:

"It is ethical for the psychiatrist to make a charge for a missed appointment when this falls within the terms of the specific contractual agreement with the patient. Charging for a missed appointment or for one not canceled 24 hours in advance need not, in itself, be considered unethical if a patient is fully advised that the physician will make such a charge. The practice, however, should be resorted to infrequently and always with the utmost consideration for the patient and his or her circumstances."

Under all three of these variations, the reason for the absence has no bearing on whether the fee is charged, although obviously it can be discussed and explored in the therapy itself. Conversely, some therapists are less concerned about advance notice, and will forgive even uncanceled no-shows if a compelling reason is offered. Since many psychiatrists and other therapists have policies that differ from the APA ethical standard and from each other, it is fair to say there is no consensus in the field about these policies. Here are my reflections on this morass.

There is a certain cold logic to the draconian standard of never waiving the fee for any reason. Aside from any selfish motive to maximize the analyst's income, this policy provides the most consistent "therapeutic frame," in that subjective judgments of the analyst never enter the picture. When analysands (patients) fall ill or are forced to remain at work during their therapy hour, they may pay the fee with gratitude that the analyst is holding "their" hour, pay with some regret, or pay while bitterly railing against the autocratic, unfeeling analyst. However they react, it's all transference.

Well, sort of. For analytic theory also recognizes the "real relationship" (coined by analyst Ralph Greenson in 1967, I believe), which takes into account the realism and genuineness of two people engaged in analytic or psychotherapeutic work. Many would argue that never waiving fees, regardless of circumstance or even months of advance notice, is not very realistic for the world we live in. That is my view, too.

The next contender, to waive the fee if the therapist can fill the hour with another patient, is apparently not uncommon among psychoanalysts, although in my experience it rarely forms the policy of non-analysts. From the clinician's perspective, this policy, too, guarantees that income will not be lost. However, in this case the outcome for the patient hinges on the analyst's behavior, i.e., whether and to what extent the analyst attempts to fill the hour. Since the reality of these efforts, and therefore the actual likelihood the fee will be waived, are unknown to the patient, this approach also invites a wide variety of transferential fantasies: That the analyst strives tirelessly to fill the hour, or couldn't care less; has no other patients, or has a long, eager waiting list; is meticulously honest, or charges the fee regardless of actually filling the hour; and so forth. These reactions can usefully shed light on the patient's dynamics, moving the treatment forward.

The problem with this policy is that it trades away part of the therapeutic frame. Yes, potentially illuminating transference arises. But it would as well if the analyst unilaterally changed other aspects of the frame, such as the length or frequency of the sessions. Psychoanalysts and dynamic therapists know not to do this; consistency provides the container that allows emotional vulnerability (and therapeutic regression) to occur. Likewise, waiving the fee for a canceled session should not depend on how busy, diligent, honest, or popular the analyst is. If it happens at all, it should depend on patient factors, not analyst factors.

The most typical policy in dynamic psychotherapy is for the therapist to announce at the start of treatment how much advance notice is required to avoid being charged for a cancelled appointment. This can range from the 24 hours suggested in the APA code, to two weeks or longer. In my experience, it is most often one or two business days, although some therapists require notice by the previous session, often a week earlier.

This policy enjoys the therapeutic-frame advantages of consistency: The patient knows, based on his or her own behavior, whether a fee will be charged. This is analogous to knowing that therapy starts and stops on time, that if one is X minutes late, there are Y minutes left for therapy that day. The disadvantages are that cancelled sessions may result in lost income for the therapist, and that no distinction is made between frivolous cancellations (where the fee is still waived if announced well in advance), and dire emergencies (where the fee is charged, since such absences are generally unanticipated). Of course, therapists can break their own rules and refuse to waive the fee for a frivolous cancellation, or to waive it for a sudden emergency. The advantages of consistency are lost — traded away, in effect, for the "real relationship." Nonetheless, this is probably the best approach overall for a problem with no perfect solution.

At the other extreme, a policy of deciding, on a case by case basis, whether to waive the fee depending on the reason for the absence, is fraught with peril. This strategy pits the therapist's values against the patient's, establishes a dynamic of judging the patient, and, in effect, metes out punishment when the patient's rationale is "not good enough." I can find little to recommend it.

How about having no policy at all? With each canceled or missed session, the therapist and patient could discuss whether the fee will be charged. I find it curious that I have never heard this idea even contemplated. It could mire the treatment in endless discussion about "the shape of the table" (a Vietnam-era reference to talking about the setting instead of the topic at hand). But that is what dynamic therapy is largely about anyway. It might not provide a sufficient therapeutic frame; it might be too anxiety-provoking for both parties. On the other hand, it would underscore the collaborative, co-constructed nature of therapy.

My own policy is to waive fees for sessions canceled at least a day in advance. I rarely if ever break my own policy. It is not particularly onerous, and patients seem to understand that I could not realistically fill a suddenly vacated hour, even if canceled for good cause. When patients cancel sessions only a few days in advance, I sometimes fill the hour and sometimes cannot, but I consider that my problem, not the patient's. I feel this policy works fairly well for everyone involved. However, it isn't perfect, as illustrated by this last case:

A patient recently called on the morning of her appointment to report a bad cold. She was willing to come to her appointment that day; however, she wondered if I might prefer to see her later that week when she would be less contagious. It was an interesting twist on the typical same-day cancellation. In truth, I did prefer to delay her visit. I had a suitable free hour later in the week, and didn't want to catch her cold. By allowing me to decide, and since it worked to our mutual benefit, I obviously would not charge her for missing that day. We met at the rescheduled time, and all was well. Yet I confess to a nagging uncertainty: By solving this problem for both of us, i.e., agreeing to reschedule her at no charge, did I make a decision that really was hers? Assuming she is in insight-oriented dynamic therapy, would it have been better therapeutically for her to decide between (1) attending her hour while ill, and possibly sickening me, or (2) paying for a missed hour? I leave this as an exercise for the reader.