Is Money Eroding My Conscience?

Wed, Aug 24, 2011

career, confessions, income, work

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.

26 Responses to “Is Money Eroding My Conscience?”

  1. Frugalbeautiful.com. says:

    My phone is about to die so I'll keep this short- the fact that you're even having these ethics questions for in your heart and mind means you're on the right track to finding a solution, or even just a decision that makes a crummy situation bearable without feeling as if you've sold your soul in the process. I wish three were easier answers but kudos for you for sharing such pertinent questions with us! I know its a process to make the best of these situations!

  2. Daisy says:

    I think it's awesome that you are even THINKING about this. Many people just wouldn't care. 

  3. Mutant Supermodel says:

    Oh wow that kind of thing would eat at me too. I guess if everyone was insured, you wouldn't have this issue. This sucks for you. Hope you figure something out that works for both parts- financially and emotionally

  4. Hunter @ Financially says:

    Don't lose any sleep over it. You clearly have a conscience and it's a great sign that you are communicating your concerns. I think everyone needs to make ethical decision all the time. It's the nature of capitalism. We all sell out to some degree, it's simply unavoidable. I think it's ok, within reason, and that line in the sand is defferent for all of us.

  5. guest says:

    hi love your blog! Just want to say its not you its the system you work for. I was born in America and lived there again briefly 10 yrs ago but for the most part I live in England and i will say as much as people diss our healthcare system i would rather not have to worry about insurance if me or my children are sick. So you should not feel bad for working in a system designed to make money rather than help those in need.

    • Anonymous says:

      Exactly! Great to see someone's perspective from another country.

      I hate for this to turn into a politics discussion, but I'm envious of countries who can say 100% of their citizens are insured. I love that you are so willing to work with the difficult cases. That woman in the cop car could easily be my daughter/mother/sister. Thank you for taking care of *everyone*. Seriously.

      But, we all have to make a living, and not only are we leaving these uninsured people from necessary therapy, but forcing great people like you to quit because of the uninsured policy… our system just plain reeks. Andrea, your post just drills home this point.

      Again, thank you — great post.

  6. Kyle Taylor says:

    Well, first off - don't feel bad about talking about your job. I, for one, am happy you found something you enjoy and I'm happy to read about it. :)

    This is such a tough issue and I really feel for you. I know it's a heated subject, but do you think the new healthcare law, which will require people to have insurance, will solve this particular dilemma? Although that particular portion doesn't go into affect until 2014.

  7. JT says:

    This is going to sound really bad, but hey, it's my honest viewpoint.  You wanted a new job to earn more money, and perhaps more importantly, spend time with your son.  As you've said before, you feel like your son needs more of your time after countless 40+ hour workweeks.

    While you're working with people who are not bringing you any revenue, you're giving your time away when you could be spending time with your son.  It's not like anyone is spending time with your son while you're helping someone else out.

    So, since there isn't any benefit to you to work with the uninsured, and you're losing valuable time with your son, I don't think you're greedy or unethical in the least bit.  You have a certain amount of time on this planet.  You have needs to be met, and others rely on you.  Spend your time where it benefits you most; whether that is at home with your family, or at work making money to provide for your family.

    It'd be one thing if your blog were titled "my-life-is-so-flippin-awesome-and-Im-a-billionaire.com," but it isn't.  You have financial and family needs to take care of.  Take care of you, because even if you give your heart and soul to fixing other people's problems, there won't be anyone to take care of yours.

  8. Little House says:

    If only everyone had insurance, your life would be easy and you'd LOVE treating all of your patients. You are thinking ethically about them and still providing services for them and that's more than some would do. I think you're doing the best you can given the circumstances.

  9. Andrea says:

    Hmmmm, tough. Here's a question, do you donate to causes? Have you considered taking a few hours per month and making that part of… giving, rather than a monetary gift? It's a tough choice but like the others have said, I'm glad this is bothering you because you CARE and so many others don't.

  10. I appreciate all of you who took the time to comment. This is an issue that's weighing heavily on me right now, and it's nice to be able to share it here and get constructive feedback. Thanks for helping me look at things a little differently!

  11. Crystal @ Home Ins C says:

    Why not look at your uninsured hours as volunteer work?  Make sure you hit your necessary weekly needs for insured hours so you can get paid, spend the time you need with your son, and make sure you allow yourself a certain number of "volunteer" hours as well?  You'll stop playing watch-the-clock as much, feel great for contributing to society, still make the money you need, and hopefully feel better overall.  I'm not suggesting you go absolutely crazy with it, but if you notice your schedule for the week has 5 uninsured instead of 2 uninsured, maybe you can see the extra 3 people as "pro-bono" work towards great karma?  I don't know, but I feel a lot like you do in regards to empathy it seems, and that would make me feel better.  Plus, you may be surprised how it works out.  Maybe you'll meet a combo of people that really would work well together and help each other in a group session…

    • I don't mind the idea of pro bono work, but the worry is more that I'll have to repay the agency for the monetary loss they take when we exceed our hours. The amount i get paid is 1/3 of the actual cost of a session, so the agency loses the other 2/3 every time I exceed my limit. If I spend 8 extra hours seeing uninsured clients in a pay period, I would owe the agency almost $1000. Which they would take from my next paycheck, potentially leaving me with no paycheck at all depending on how much billing I had.

  12. Shaun @ Smartfamilyf says:

    Could you take the uninsured for free then write them off on your taxes as charity? I've heard of primary care physicians doing that. I'm not sure what type of flexibility you have in doing such things.

  13. Ashley @ Money Talks says:

    Do they pay out of pocket?  If so then they can get as much therapy as they are willing to pay for.  If not then why are you feeling guilty for providing them a free service? I don't expect people to work for free to provide me a service.  The fact that they are getting anything for free is nice.  So they get group therapy for free. Or 15 mins per week.   That's better than nothing, which is what they are paying.

    You shouldn't have to work for free… that's crazy.  If you want to do it as volunteer work that's great, but don't feel guilty for not. 

  14. priskill says:

    Late to the party, first time reader, LOVE the blog!  

    No, you will not become a money-hungry jerk!!  Not possible given your profession and passion for helping people — I'm a special ed teacher so I, too, am not rolling in dough, though my salary is set.  As stated above, the fact that you are thinking about this stuff is proof — and you are only human for being inwardly relieved that someone is absent, thereby freeing up more of the 2 hours alloted to you.  You CANNOT impoverish yourself or your son to assuage all the ills of the world, no way!  Clearly, you give so much to so many as is — it's also necessary to nourish yourself first, economically AND mentally.  Please, enjoy that dinner at home on the couch and time with your son and goof-off time (if you can get some :) so you can return to the trenches refreshed.  

    I am selfish and silly, so your blog really touched me — I hope you find the financial security and comfort you are seeking — you deserve it!

    • Thanks so much for stopping by and commenting! Glad to have a special ed teacher reading - you probably come closer than a lot of other people to understanding what I do for a living - especially the low salary part of it!
      I hope you'll stick around and hang out with us!

  15. SKW says:


    I've just read your post and a few of the comments and I just want to say I find you very brave to actually write about your doubts on this matter, and to admit what you're thinking and how you feel you're being influenced.

    As others have said, it's good to see that you question your own motivations because it means you care.

    I don't have any advice to give you on the subject ; it seems to me you're doing a very good job in a very tricky situation.

    Take care and all the best for the future.


  16. MaryMikell says:

    Coming into this discussion late, as I just found your site after a friend posted it on Facebook.

    1) Thanks for sharing your journey! As an about-to-be-single Mom, I so appreciate knowing I'm not the only one struggling. and 2) as an uninsured person who has, in the past, sought out therapy for various reasons, I think that if someone wants and needs a service, and are capable of paying out of pocket, that's what should happen. If they're not capable of paying, why isn't Medicaid or Medicare kicking in to cover their medical expenses? If someone's severely disabled by a mental illness, it seems to me that they'd be covered?

    I'm sorry you're going through this. The amazing lady we saw when my daughter was going through some mild depression issues gave us a discount on her service. Our church also kicked in for a certain number of sessions when money was tight- which may be an option for some of your folks, if they're affiliated with a church that does that sort of thing.

    Best of luck sorting it out. It seems to me that the agency should be looking after you better- and not making it your responsibility to deal with the insurance issue.

    Take care


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