I have frequent consults with beginning or seasoned practitioners looking to get on Medicaid as private practitioners. Their logic on the surface makes a lot of sense coming from their agency backgrounds. A majority of their patients in agency are on Medicaid, and they may want to keep them as they transition to private practice. And many of us went into this work because we want to help a range of people, including the most impoverished or differently abled. These are laudable goals, and I want to assert that they are not incompatible with private practice. But I do think that Medicaid is, at least in terms of building one.
What happens when your patient misses their appointment? With Medicaid you cannot charge them for a missed appointment. And after they miss two or three, you may have the conversation about “are you really interested in treatment?” They say yes, miss again, and you fire them, or don’t call them back and feel guilty and frustrated; or they drop out of treatment feeling like they’ve failed yet again. And in Massachusetts, the newest vendor of Medicaid, Beacon Health Strategies, is trying to change the provider contract to say that you are not allowed to fire them for no-shows! Outrageous, but hey, you signed the contract, so until NASW or APA fights this statewide that is your agreement.
This is such a lose-lose! Private practitioners are not able to make a living, low-income patients are not able to get consistent treatment, and everyone feels like a failure, except the insurance company which pays nothing. But there is a way to build social justice and healthy treatment into your practice right at the beginning, I call it my Pro Bono + 5 session.
Imagine this, you decide that you want to start out in private practice, and while you are building it you want to be able to take referrals from your old agency, which usually has mostly Medicaid patients. So you call them and let them know that you have 2 immediate openings for your pro bono plus 5$ sessions.
Your what?
You explain that while you don’t take Medicaid, you are offering two sessions in your practice where you contract with the patient that as long as they are on Medicaid you will never charge them more or less than $5. You don’t participate in Medicaid, but you won’t bill Medicaid either. You’ll only ask them for a nominal $5 fee payable each week as part of your committment to building a socially just practice. When you meet the patient, you explain this to them, and explain your no-show policy. They keep their appointment, they pay the $5. They miss the appointment, they pay the $5. If they’re sick or unable to make the session, you’ll gladly offer them a phone session, because they’ll still be paying the $5. This is made clear the first appointment, with whatever your normal policy is. You see, you can’t do phone therapy on Medicaid, but on your PB+5 plan you can. For the patient, they are getting a great discount and affordable treatment. For the beginning private practitioner you are getting great clinical experience, including talking about the fee and your therapeutic contract, and feeling like you are doing some diverse work, which hopefully helps you feel more confident in being circumspect when filling the rest of your week. The referring agency gets to win in that they can refer someone immediately. Win-win.
This is not a new concept. Freud created the Vienna Ambulatorium to provide free psychoanalysis almost 90 years ago. We all know that Freud saw many upperclass patients, but he also allotted some time for low-cost or free treatment. You can do the same. And I suggest that you set a fixed number of sessions right at the start of your practice, which will help you later keep the number of full-pay or insurance appointments fixed as well. So what do you think?
