How to ethically increase access to care during COVID-19

How to ethically increase access to care during COVID-19

By Jordan Cattie, Ph.D.
July 27, 2020


COVID-19 is an unprecedented public health crisis with both mental-health and financial impacts. Psychologists’ skill sets are critically important in meeting the challenges of the present moment.

Yet many clients are losing financial security (job loss, reduced hours due to furloughs, changes in insurance benefits) while potentially relying on mental-health treatment more than ever. Being able to contribute and offer relief is an important value for psychologists. But to best serve our clients it is important to thoughtfully and ethically navigate the ethics of billing and payment.

Many psychologists are asking: How can we use our skills for the common good and give clients a financial break as needed? How can we adapt our practices and policies to ethically consider current economic realities?

Relevant standards appear in the Informed Consent to Therapy (10.01a), Fees & Financial Arrangements (Standards 6.04), and Conflicts of Interest (3.06) portions of the ethics code. Usually informed consent includes the cost of the therapy, types of reimbursement accepted, payment schedule, when fees may be renegotiated and policies regarding missed appointments and late payment.

Standard 6.04 adds that any anticipated limitations to services because of financial limitations should be discussed as early as possible. Currently, millions of Americans are experiencing financial difficulty; instead of being the exception, validating and normalizing conversations about financial impacts of COVID-19 and treatment/payment should become the rule.

If finances are not discussed, clients may experience shame or guilt related to their ability to pay. They may reduce frequency of mental health services to a subtherapeutic level or skip needed appointments if unable to pay a balance that is due.

This brings us to conflicts of interest. According to Standard 3.06, psychologists must be aware of when financial matters might impair their objectivity, competence or effectiveness. Unintentionally (and invisibly when not discussed), financial strain can impair therapy. Psychologists also must be mindful of their own limits and clearly articulate how and when they are able to provide financial relief and flexibility to clients, as their own financial concerns can also interfere with therapy.

Many psychologists offer some flexibility for clients who experience difficulty paying for services, either temporarily or ongoing (e.g., sliding fee, maintaining a set pro bono caseload). However, making exceptions to overall practice policies can quickly become ethically complicated and raise equity concerns.

For example, factors such as implicit bias or financial literacy can systematically affect which clients ask for or receive financial assistance.

Instead, psychologists can be proactive and transparent. Develop a financial policy that applies equally to your entire practice and make it available to all clients. This way, you can be prepared to discuss finances and invite clients to choose from among available options (e.g., reduced fee, payment plan, flexible scheduling, pro bono, assisting with referral to another setting or others selected by the provider). Document the plan that is agreed upon and when it will be revisited. Check in with clients to normalize and validate the experience of new or exacerbated financial difficulties, and be clear and specific about how you can help; vague statements like “we can work something out” often exacerbate anxiety.

Finally, utilize an ethical decision-making model in consultation with colleagues to promptly collaborate around challenges you may encounter. Reference guidelines on providing financial breaks to patients can be found at https://www.apa.org/monitor/2009/01/fees.

After witnessing multiple interconnected crises, many psychologists may wish to help in new ways to increase access to mental healthcare. Consider engaging in advocacy with like-minded colleagues to pursue patient rights, expand access to mental healthcare or telemedicine or promote social justice.

Consider donating supervision or consultation time to trainees or professionals in your area; sharing your skillset in this way can disseminate specialized services and training to new and lower-fee settings. Finally, consider volunteering for and supporting community groups that provide peer support. These groups create valuable and free-of-cost opportunities for peers to connect with and support one another.

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Jordan Cattie, Ph.D., is an assistant professor in Emory University’s Department of Psychiatry & Behavioral Sciences. Her professional activities are focused on increasing access to mental healthcare for OCD through clinical services, training, and advocacy. Her email address is: jordan.cattie@emory.edu.

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