This is a proposal for a presentation written for a fall conference of licensed counselors. This piece could have been titled “Why the Birdhouse? Part II”
Four years ago, after wrestling, figuratively speaking, with sliding scales, Medicaid reimbursement, and client’s with no insurance, I began an unusual fee structure in my practice: I extended to my clients that they may determine their own fee. Rather than I set the rate they must pay, they choose what they will pay.
In order to aid their decision, on my website, they are given some data including the break-even cost per session as well as the average fee other clients pay. Realizing that under such a system some clients may feel some shame (for example, those who could only afford less than the break-even rate) I go one step further and tell my clients in our first session that they need not report how much they choose to pay; or even if they pay. Fees are monitored collectively rather than individually so no one who cannot afford care will be told they cannot come. Everybody comes. They do their best, as do I, and it all works out well for everyone. The initial impulse of most outsiders hearing of this system is shock that such a system works at all. The widespread presumption is that, given the choice, clients will choose to pay as little as they can which would turn out to be less than I need. However, my clients consistently, reliably, every year I have done this so far, contribute more than I need; not less. In modern parlance, this system is profitable. But that, as you may have already guessed, is far from the point.
The tangible changes this system has brought about have nothing to do with my income. The most tangible, of course, has already been stated: No one is turned away. The other is clients may come at the pace that feels best for their needs rather than their budgets. Surprisingly many, essentially all, come no more often than is necessary. They feel no pressure, in either direction, to come more or less often, than they need.
The intangible outcomes of this fee structure are, in my opinion, more impressive. Because sessions are not conditioned on payment, my clients understand plainly that our time together is unconditionally for them. The part which money plays in creating distance is eliminated and we are all singularly-focused on their healing. This, as you may imagine, allows a deeper trust to develop. Everyone still knows there is an expectation to pay, and of my trust in their sense of responsibility to do so, by which we generate a mutual respect knowing our reciprocal needs are being met. As such, they sense no fear, self-protection, or defensiveness on my part; as if my client’s might hold some threat to me. Due to my willingness and vulnerability, they relax more quickly, are less guarded, and share more freely. It allows us to be both more honest and heartfelt with each other and therefore, it seems safe to presume, the therapeutic changes in the scaffolding of the mind begin sooner and last longer.
In this presentation I will describe how and why this system works including practical logistics, the necessary boundaries, the nature of the relationship, and the disclosure of information. For those who are troubled by the role of money in our health care system, our economy, and our interpersonal relationships, this presentation makes a small contribution to the long process of discovery of new ways to care for others and to live well together.
This will be a simple presentation requiring only a few images (e.g. graphs), a description of the fee structure and its outcomes, followed by a long-ish Q&A conversation with the audience. One hour should be sufficient time but, if there is interest, we could take ninety minutes. I am grateful for your considering this presentation proposal. This is my first. Thank you.