Dear Dr. Mossman,
Each month, I see my patient, Mr. R, for a 15-minute medication management appointment. At his latest visit, Mr. R mentioned his financial difficulties. He also observed that our office needed to have some carpentry work done—not a surprise, because he’s known in our area as one of the best carpenters around. He suggested that I hire him as payment for the next 6 appointments. What risks might I encounter if I oblige him?
Submitted by “Dr. Z”
Nearly 29 million Americans are uninsured,1 and even more have trouble accessing mental health care.2 Many psychiatrists struggle to provide affordable services while remaining financially viable.3,4 For outpatients with limited means to pay for care, spacing appointments to fit their budgets might compromise treatment.5 Simply not charging patients poses its own clinical and ethical challenges.6-8
As a result, some mental health professionals make barter arrangements to help their patients enter or continue treatment. To answer Dr. Z’s question on whether exchanging services might be a way to arrange matters with some patients, we explore:
- the idea of bartering for psychiatric treatment
- related ethical and legal considerations
- when and in what situations bartering might be appropriate.
Think of what I’m saying: Bartering for treatment
“Barter” refers to exchanging commodities, products, or services of equivalent value without using money.9 In 2010, Nevada Republican Senate candidate Sue Lowden encouraged barter for health care and harkened back to an earlier time where “they would bring a chicken to the doctor; they would say ‘I’ll paint your house.’”10
Such payment arrangements have been encouraged as health care has become increasingly commoditized.11-13 This happens through both direct barter between physician and patient and barter exchanges. Barter exchange systems have been set up on Web sites (as of 2013, at least 400 such online exchanges were available14), local communities,11,15 and social programs. For example, through the “Swapping Guns for Therapy” program, psychologists in California gave free or reduced-fee care for people who traded in their guns.16
Try to see it my way: A prevailing view of barter
Several psychiatrists recommend against bartering for treatment, for a variety of reasons.7,8,17-19 Simon18 argues that a stable fee policy is part of a proper therapeutic framework, and money is “the only acceptable medium of exchange when receiving payment from patients.” Emotional distress and the power differential inherent in treatment might prevent a patient from making an accurate assessment of the value of the bartered goods or services,7,8,17,18,20 which could lead to future claims of undue influence from trading goods or services below market value.17 To avoid the possibility of exploitating the patient, Simon18 recommends that the psychiatrist’s professional fee be “the only material benefit received from the patient.”
The American Psychiatric Association’s code of ethics states that “it is not ethical to switch a doctor–patient relationship to an employer–employee one … and, in most cases, such an arrangement would be unethical.”21 In some therapeutic settings, employing a patient risks inappropriate self-disclosure and intrusion.16
More than other physicians, psychiatrists pay special attention to professional boundaries, the technical term for the “edge of appropriate behavior,” within which safe, effective care can occur.22,23 Although some boundary crossings can be harmless and even constructive, repeated boundary crossings are the forerunners to improper behavior, including sexual relationships with patients.24-26
Out of concern that bartering could become the first step down a slippery ethical slope toward patient exploitation, mental health clinicians have deemed the practice “ethically troubling,”19 said it did “not usually work out well,”7 and declared it “so fraught with risks for both parties that it seem[ed] illogical to even consider it as an option.”27
While I see it your way: What barter proponents say
Reports of bartering for chickens28 and purchasing fuel from a patient in remote Alaska29 show that not all physicians agree and why they feel that professional codes of ethics reflect an urban bias.28,29 In many rural areas and small towns, access to mental health services is limited, and patients often interact with their doctors outside of clinical encounters.23,29-31
Bartering can benefit a physician’s practice by:
- reducing the need to discount services
- eliminating bureaucratic burdens of traditional insurance arrangements
- facilitating development of a patient base
- allowing patients choice and flexibility in seeking medical care.6,16,32
Bartering could confer certain clinical benefits, such as:
- enhancing trust and empathy32
- encouraging patients to make their needs known constructively6
- modeling financial self-care6
- helping the doctor to feel fairly compensated for providing thoughtful care6
- acknowledging the patient’s cultural values15,33
- affirming that patients and doctors both produce things of value.16