Community Mental Health Journal Volume 2, Number 3, Fall, 1966

FEE

SCALES

IN

MENTAL

HEALTH

CLINICS

HARRIS E. KAROWE, M.D.*

The range of fees which families of identical income might be required to pay at different mental health clinics is deplorably wide. Data have been collected regarding fee scales at a small but representative group of clinics which offer psychiatric service to children. Implicit is a plea for the establishment of some central committee which would furnish a nationwide recommendation as to simple and relatively uniform sliding fee scales for nonprofit mental health clinics irrespective of their location or of the socioeconomic characteristics of their communities.

One of the administrative problems which confronts many community mental health clinics and child guidance centers is the setting of appropriate fees for services. In the summer of 1962 the Schenectady County Child Guidance Center queried some 30 such clinics to obtain a guide for revision of its own fee scale, which both the professional staff and the Board of Directors of the Center regarded as unrealistically low. The clinics replying are located in various sections of the United States, but the majority are in the northeast. No correlation is detectable between the fee levels at the various clinics and the size of the community served nor the economic status of the community. This statement is based on the following data as of the end of 1961 both for the city and for the county in which each responding clinic is located: population, effective buying income per capita, effective annual buying income per household, and per

cent of households with annual cash income in each of five ranges (up to $2500, $2500$3999, $4000-6999, $7000-9999, and $10,000 or higher). The range between the fee charged a family by the least expensive clinic and that charged the same family by the most expensive clinic proved to be extremely wide. This discrepancy in fee set by presumably similar clinics for presumably similar services was surprising. Furthermore, it would seem reasonable, excluding special circumstances related to the mode of financing the operations of an occasional clinic, that a family should encounter little variation in cost of mental health clinic service when it moves from one community to another. For these reasons, some of the data regarding treatment fees at 22 responding clinics are recorded in Table I. Because the income ranges and fee ranges used as units by various clinics were not identical, some extrapolation was

*Dr. Karowe, a psychiatrist, is Director of the Schenectady County Child Guidance Center, Inc., and Associate Clinical Professor of Psychiatry, Albany Medical College, N.Y. 219

THE COMMUNITY MENTAL HEALTH JOURNAL

220

necessary occasionally to permit comparisons. A table comprising more nearly all of the fee scale data may be obtained by writing the author, Fee scales were of two basic types: (a) fee charged for each interview and (b) fee charged at a weekly rate, regardless of number of sessions per week. In most

instances, the fee is based on the gross income of the family and the number of persons dependent on the income. There is considerable variation in the diligence which apparently is exercised in ascertaining the proper figure to represent the family's income: e.g., one clinic has an elaborate procedure for very conscien-

TABLE 1 THE NUMBERSOF

CLINICS CHARGING SPECIFIC FEES, P E R W E E K OR ( P E R INTERVIEW) BASED ON ANNUAL INCOMES AND 3 AND 6 PERSONS DEPENDENT ON T H O S E INCOMES

under $2400

$2400 to $3600

83600 to $4000

Annual Income $4800 $6000 $8000 to to to $6000 $3000 $10,000 Number of Dependents 3

Fee

3

6

3

6

3

6

under $1.00

19

11

4

6

i

4

(5)

(7)

(1)

(4)

3 (3)

2 (2)

5 (4)

5 (4)

2.00-2.99

2 (3)

2 (1)

3.00-3.99

1 (1)

1.00-2.99

4.00-4.99

S.00-5.99 6.00-6.99

1

4 (5)

3 (4)

2 (1)

S

2

(a) (1)

3

6

3

3 (1) 1

5

(2) (4)

3

4

3

(2)

(2)

(2)

1

4

1 (3)

2

(1)

25.00-29.99 30.00 and up

3

6

4 (2)

(!)

2

4

(1)

(i)

(2)

(i)

2

1

1

1

1

1

3

(1)

1

1

(1)

1

1

1

(1) 1

1

1

2

I

2

1 (2)

3 (4)

(1)

(2)

2

2

(1)

(1)

(4)

(2)

1

3

1 (2)

3

1

1

(1)

(1)

(1)

(1)

(1)

(2)

1

1

14.00-24.99

~2.00-24.99

6

(1) 1

(2)

1

1

(2)

19.00-22.99

3

2

12.00-12.99

17.00-18.99

6

over $20,000

(1)

11.00.11.99

15,00-16.99

3

$16,000 to $20,000

1

10.00-20.99

13.00-23.99

6

$12,000 to $16,000

1

(2)

9.00-9.99

6

to $12,000

(I) 1

7.00-7.99 8.00-8.99

3

1

1 (i) 2

6

$10,000

(1) (2)

2

2

S

5

1

(1)

(2)

(4)

(a)

(2)

(3)

(I)

(2)

2 (4)

1

1

(1) l (2)

(I)

I (i)

2 3

2

I

1

1

I

(2)

(3)

(2)

(3)

1 (I)

(2)

(I)

(2)

(I)

2

2

1 (2)

3 (2)

1

1

1

2

2

1

1 (1)

1 (1)

4

2

5

4

6 (1)

6 (1)

2

Note--Figures in parentheses denote the number of clinics charging fee (to the left) per interview. Other figures are number of clinics charging fee per week.

HARMS E. KAROWE tiously estimating adjusted income and total gross income, while some clinics merely ask, "What is your income?" Not all clinics set different fees for diagnostic and for treatment interviews. Justification for a lower fee when the family has entered into treatment at the clinic is, of course, that psychotherapy is an extended process and, at a given fee, constitutes a much greater financial stress than does a diagnostic study at the same fee per session or per week. Three clinics avoided the entire issue of fee scale by setting the fee at a certain fraction of the most recent annual federal income tax paid by the family. Two clinics set the fee per week at 1% of the tax paid; the other clinic has a fee per session of 0.6% of the tax. The merits of this technique are obvious: it is simple and rapid; it takes into account all income, significant unusual expenses, number of dependents; it is not composed of steplike increments but rather is continuously graduated; it is predicated on the family's real ability to pay, making it especially equitable. Nevertheless, it has not yet found wide acceptance. The Schenectady County Child Guidance Center Board rejected this method in favor of the more traditional sliding fee scale. It is as though more secrecy should surround a family's financial affairs than the other personal affairs ordinarily dealt with in the course of psychiatric study and treatment. Most clinics provide for free service to families unable to pay. Most clinics have a maximum fee. Some of these centers refer those families whose income places their

221

ability to pay even above that represented by the maximum fee to private psychiatrists; other clinics do not have any "cutoff point" or income ceiling for eligibility for clinic service. It is not unusual to find a three or fourfold variation between fees which would be charged the same family at different clinics. In some instances, the highest fee would be some 500% greater than the lowest: e.g., the weekly fee for a family of four persons with an income of $6500 would be $2 at one clinic and $12 at another clinic. If a mother and child were each being seen once per week and the family moved from the county served by one clinic to a clinic in another area only 70 miles (or 2 counties) away, the cost to the family could rise 900%, from $2 to $20 each week. In only one instance (for a family of six with income between $3600 and $4800) did as many as six clinics fall within any one fee range for families in similar circumstances, except for the extremes on the fee range. At t h e low extreme, where the fee is under $1, all the clinics are grouped which render service free or with a very nominal charge to the low income families. At the high extreme, where the fee is listed in the table merely as over $30, are grouped all the clinics with fees ranging from $30 to as high as $50 and more. It also was unusual for even four or five clinics to set the same fee; most often, only one or two or even no other clinic would have a fee identical with that of any given clinic.