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We can work it out: Should I hire my patient?

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 available (14)), 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) Simon (18) argues that a stable fee policy is part of a proper therapeutic frame work, 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, Simon (18) 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 chickens (28) and purchasing fuel from a patient in remote Alaska (29) 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 empathy (32)

* encouraging patients to make their needs known constructively (6)

* modeling financial self-care (6)

* helping the doctor to feel fairly compensated for providing thoughtful care (6)

* acknowledging the patient's cultural values (15,33)

* affirming that patients and doctors both produce things of value. (16)

I have always thought:

Other ethical models

An ethical approach to bartering that requires careful thought and respect for the patient's needs appears consistent with a primary goal of treatment: "to increase the capacity of individuals to make more rational choices in their lives and to be relatively freer from disabling conflicts." (20) Some authors criticize slippery-slope arguments and strict-rule ethical approaches as being too rigid, limiting, or risk-averse. (22,26,34) In Table 1s (6, 8, 16,18,27,29,31,35,37) (page 35) we list several factors that might weigh for or against a decision to enter into a barter arrangement as payment for care.

In a similar manner, Martinez (33,38) proposed a graded-risk framework that encourages examination of potential harms and benefits of a decision, potential coercive or exploitative elements, the clinician's intentions and aspiration to professional ideals, and the context of the decision. Within this framework, some bartering arrangements might be encouraged and, perhaps, even obligatory because of the potential benefits to the patient; other arrangements (eg, trading psychotherapy for menial services) might be unjustifiable. Martinez (38) argues that this approach fosters mutual decision-making with patients, discourages physician paternalism, and "demands that we struggle with the particulars with each case."

Gottlieb's decision-making model (35) recognizes that trying to avoid all dual relationships is unrealistic and not all dual relationships are exploitative. Instead, a clinician must assess 3 dimensions of current and proposed relationships:

* the degree of power differential

* the duration of treatment

* the clarity of termination.

The decision-making process also requires involvement of the patient, who if "unable to recognize the dilemma or is unwilling to consider the issues before deciding, should be considered at risk, and the contemplated relationship rejected." (35)

So I will ask you once again:

Dr. Z's decision

In the case of Dr. Z and Mr. R, a barter arrangement might work in the sense of permitting and sustaining good care. Mr. R suggested the idea and might not be able to afford care without it. Nothing in Dr. Z's description suggests that Mr. R has personality characteristics or other conditions that would compromise his ability to give informed consent or to understand the nuances of a barter arrangement. Dr. Z is not providing a treatment (eg, psychodynamic therapy) that a barter arrangement could contaminate. That the arrangement would be circumscribed limits the effect of a power differential, as would its brief duration and defined termination endpoint. Dr. Z's letter to the authors also shows his willingness to seek consultation.

There's a chance that we may fall apart: Reasons for caution

Martinez's graded-risk approach recognizes reasons for caution:

* the risk of harm to the patient or doctor-patient relationship

* the uncertain benefit to the patient

* the blurring of Dr. Z's self-interest and Mr. R's needs

* some ambiguity about possible exploitation.

Dr. Z and Mr. R have not discussed the value of Mr. R's work--which might create a rift between them--and despite Mr. R's reputation, other carpenters are available. Future med-check appointments will give them little time to explore and discuss the meanings of the barter.

Any proposed barter arrangement creates some clinical perils that can be particularly salient in mental health treatment. Patients could view themselves as "special" or entitled to enhanced access to the doctor because of exchanged services, which could take a toll on the doctor. (39) The physician's objectivity might diminish, and the business aspect of their relationship could make both parties less comfortable when discussing sensitive information relevant to treatment. (31,40) Also, the suggested barter is for services to be provided at Dr. Z's office, where confidentiality may be breeched and transference issues could arise.

A medical malpractice claim states that a doctor has breached a duty of care to a patient such that harm (or "damages") resulted. (41) Should Dr. Z and Mr. R's barter agreement turn sour and harm follow, Mr. R could sue for recovery of damages based of a claim of duress, undue influence, or other aspects of the doctor-patient power differential. (27,42,43) Given the published views we have described, a psychiatrist who barters also may be viewed as violating state regulations that measure the standard of care against generally accepted practice.

Only time will tell if I am right or I am wrong

If you face a situation similar to Dr. Z's and want to consider a barter arrangement, you can take several steps to mitigate potential risk to your patient and ensure competent care (Table 2 (5,6,15,16,32,35,39,40,44-47}). One of the most important steps is to seek ongoing consultation, both before and after a decision to barter. Ideally, the consulting colleague would know you and your circumstances and would have sufficient clinical grasp of the patient to make an informed assessment of risks and benefits. (35) This consultation, as well as your own rationale for acting on recommendations, should be thoroughly documented in the patient's records. (26,44,45)

Certain types of barter should be off limits, including:

* trading prescription drugs for goods or services

* trading for services that tie into the success of one's business (eg, business advising or marketing16)

* offering treatment in exchange for illegal or ethically unacceptable services. (48)

Beyond ethical considerations are some practical issues. The Internal Revenue Service has specific rules regarding taxation of bartered goods and services, which must be included as taxable income. (46) If possible, an independent agent should appraise the traded goods or services before the agreement. (6) When working in a group practice, the clinician might have to figure out how to allocate the received goods or services such as shared overhead costs. (28) Preferably, the patient's goods or services should be provided before care is delivered. (16) If not, the duration of services rendered should be limited, and either party should have the option to disengage from the relationship if one feels dissatisfied. (16)

A written contract, discussed ahead of time, can be a sound way to summarize the terms of the arrangement. Both sides also should consider what would happen if an injury occurred. (16) Finally, you must adhere to any relevant state laws regarding payment for services, particularly if the patient has health insurance. (32)

If the bartering arrangement does not work, you should take an open and nondefensive approach. If you believe you have made a mistake, consider apologizing. (45)


(1.) Kaiser Commission on Medicaid and the Uninsured. Key facts about the uninsured population, uninsured/fact-sheet/key-facts-about-the-uninsured-population. Published September 29, 2016. Accessed October 7,2016.

(2.) National Alliance on Mental Illness. A long road ahead: achieving true parity in mental health and substance use care, A-Long-RoadAhead/2015-ALongRoadAhead.pdf. Published April 2015. Accessed October 7,2016.

(3.) Insel T. Director's blog: the paradox of parity. May 30, 2014. Published May 30, 2014. Accessed October 7,2016.

(4.) Bishop TF, Press MJ, Keyhani S, et al. Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA Psychiatry. 2014;71(2): 176-181.

(5.) What do you do when patients cannot pay? Psychiatry (Edgmont). 2009;6(5):51-52.

(6.) Hill M. Barter: ethical considerations in psychotherapy. Women Ther. 2000;22(3):81-91.

(7.) Simon RI. Commentary: treatment boundaries--flexible guidelines, not rigid standards. J Am Acad Psychiatry Law. 2001;29(3):287-289.

(8.) Simon RI, Williams IC. Maintaining treatment boundaries in small communities and rural areas. Psychiatr Serv. 1999;50(11):1440-1446.

(9.) Compact edition of the Oxford English dictionary. New York, NY: Oxford University Press; 1971:171.

(10.) Coolican JP. Sue Lowden stands by health care plan. Las Vegas Sun. sue-lowden-draws-fire-repeating-health-care-barter. Published April 20,2010. Accessed September 20,2016.

(11.) Consumer Reports. Barter sometimes allow patients to pay for health care they otherwise could not afford. Washington Post, health-science/barter-sometimes-allow-patients-to-pay-forhealth-care-they-otherwise-could-not-afford/2013/09/30/ e7e5a55e-069d-lle3-88d6-d5795fab4637_story.html. Published September 20,2013. Accessed September 27,2016.

(12.) Ellis B. MediBid auction site lets doctors bid for patients. CNN Money, insurance/medibid. Published January 9, 2014. Accessed September 23,2016.

(13.) Ambrosino B. Surgery for sale: the ethics of health care bartering in a social media marketplace, http://hub.jhu. edu/2014/01/16/hopkins-ethicist-ponders-medibid. Published January 16,2014. Accessed September 23,2016.

(14.) Thomas C. When patients barter for health care, https:// Published July 30, 2016. Accessed October 9,2016.

(15.) Syme G. Fetters or freedom: dual relationships in counselling. Int J Adv Counselling. 2006;28(l):57-69.

(16.) Zur O. Bartering in psychotherapy and counselling: complexities, case studies and guidelines. New Therapist. 2008;58:18-26.

(17.) Simon RI. The psychiatrist as a fiduciary: avoiding the double agent role. Psychiatric Annals. 1987;17(9): 622-626.

(18.) Simon RI. Treatment boundary violations: clinical, ethical, and legal considerations. Bull Am Acad Psychiatry Law. 1992;20(3):269-288.

(19.) Walker R, Clark JJ. Heading off boundary problems: clinical supervision as risk management. Psychiatr Serv. 1999;50(11):1435-1439.

(20.) Malmquist CP, Norman MT. Psychiatrist-patient boundary issues following treatment termination. Am J Psychiatry. 2001;158(7):1010-1018.

(21.) American Psychiatric Association. The opinions of the ethics committee on the principles of medical ethics, with annotations especially applicable to psychiatry, https:// Published 2016. Accessed October 4,2016.

(22.) Gutheil TG, Gabbard GO. Misuses and misunderstandings of boundary theory in clinical and regulatory settings. Am J Psychiatry. 1998;155(3):409-414.

(23.) Crowden A. Professional boundaries and the ethics of dual and multiple overlapping relationships in psychotherapy. Monash Bioeth Rev. 2008;27(4):10-27.

(24.) Gabbard GO. Commentary: boundaries, culture, and psychotherapy. J Am Acad Psychiatry Law. 2001;29(3): 284-286.

(25.) Kroll J. Boundary violations: a culture-bound syndrome. J Am Acad Psychiatry Law. 2001;29(3):274-283.

(26.) Gottlieb MC, Younggren JN. Is there a slippery slope? Considerations regarding multiple relationships and risk management. Professional Psychology: Research and Practice. 2009;40(6):564-557.

(27.) Woody RH. Bartering for psychological services. Professional Psychology: Research and Practice. 1998;29(2):174-178.

(28.) Bartering for medical care. MGMA Connex. 2008;8(6):11.

(29.) Roberts LW, Battaglia J, Epstein RS. Frontier ethics: mental health care needs and ethical dilemmas in rural communities. Psychiatr Serv. 1994;50(4):497-503.

(30.) Endacott R, Wood A, Judd F, et al. Impact and management of dual relationships in metropolitan, regional and rural mental health practice. Aust N Z J Psychiatry. 2006;40(1112):987-994.

(31.) Scopelliti J, Judd F, Grigg M, et al. Dual relationships in mental health practice: issues for clinicians in rural settings. Aust N Z J Psychiatry. 2004;38(11-12):953-959.

(32.) Ayers AA. Bartering basics for the urgent care operator, Ayers_UCAOA_Bartering_%20Basics_2012_01_09.pdf. Accessed September 23,2016.

(33.) Savin D, Martinez R. Cross-cultural boundary dilemmas: a graded-risk assessment approach. Transcult Psychiatry. 2006;42(2):243-258.

(34.) Glass LL. The gray areas of boundary crossings and violations. Am J Psychother. 2003;57(4):429-444.

(35.) Gottlieb MC. Avoiding exploitive dual relationships: a decision-making model. Psychotherapy (Chic). 1993;30(1): 41-48.

(36.) Lane JA. The ethical implications of bartering for mental health services: examining interdisciplinary ethical standards, http:// Published 2012. Accessed October 17,2016.

(37.) Miller RD, Maier GJ. Nonsexual boundary violations: sauce for the gander. J Psychiatry Law. 2002;30(3):309-329.

(38.) Martinez R. A model for boundary dilemmas: ethical decision-making in the patient-professional relationship. Ethical Hum Sci Serv. 2000;2(1):43-61.

(39.) Salmon K, Klijnsma M. Boundary issues: employing patients as staff? Br J Gen Pract. 2009;59(558):56-57.

(40.) College of Physicians and Surgeons Ontario. Hiring patients may compromise physician-patient relationship. Dialogue. 2015;3:47.

(41.) Bal S. An introduction to medical malpractice in the United States. Clin Orthop Relat Res. 2009;467(2):339-347.

(42.) What puts a psychiatrist at risk for a malpractice lawsuit? Psychiatry (Edgmont). 2009;6(8):38-39.

(43.) Geis v Landau, 117 Misc2d 396 (NY Misc 1983).

(44.) Nisselle P. Danger zone. When boundaries are crossed in the doctor-patient relationship. Aust Fam Physician. 2000;29(6):541-544.

(45.) Pope KS, Keith-Spiegel P. A practical approach to boundaries in psychotherapy: making decisions, bypassing blunders, and mending fences. J Clin Psychol. 2008;64(5):638-652.

(46.) IRS Publication 17. p17/chl2.html. Published 2015. Accessed October 5, 2016.

(47.) Epstein RS, Simon RI. The exploitation index: an early warning indicator of boundary violations in psychotherapy. Bull Menninger Clin. 1990;54(4):450-465.

(48.) Skutch J. Savannah doctor accused of trading drugs for sex with strippers. Augusta Chronicle, http://chronicle. Published January 31,2013. Accessed October 16,2016.

Clinical Point

Barter arrangements have been encouraged as health care has become increasingly commoditized

The APA code of ethics states that'it is not ethical to switch a doctor-patient relationship to an employer-employee one ...'

Any proposed barter arrangement creates some clinical perils that can be particularly salient in mental health treatment

An ethical approach to bartering requires careful thought and respect for the patient's needs

Seek ongoing consultation before and after the barter, discuss the written contract, and adhere to relevant laws regarding payment

Bottom Line

Traditionally, psychiatrists have discouraged barter. But recent trends and pressures in the delivery of health care have made it more common. Before you accept a patient's goods or services as payment for care, get consultation and think through the ethical, legal, clinical, and practical implications. If, after consultation, a barter arrangement seems suitable, take steps to mitigate risks and to promote a positive outcome

Douglas Mossman, MD Department Editor

Dr. Marett is Volunteer Assistant Professor, and Dr. Mossman is Professor of Clinical Psychiatry and Director, Division of Forensic Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio.


The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
Table 1
Factors for and against barter arrangements

For                                  Against

Fostering psychological              Fostering psychological
separateness of the patient          dependence

Builds trust, alliance,              Motives not discussed, serves
discussable; passes "well-lit        personal interests
room" test

Patient is free of obvious           Manipulative patient, risk of
personality disorder or traits       deceiving the clinician

Barter would involve limited         More personal intimacy (for
personal intimacy                    example, babysitting)

Sole boundary crossing               Part of progressive pattern of
                                     boundary crossings

Mutual awareness of potential        Patient cannot or will not
issues and greater capacity to       recognize dilemma or salient
give consent                         issues

Time-limited or biological           Long-term or intensive
treatments                           psychotherapy

Rural setting                        Urban setting

Barter is for goods                  Barter is for services

Previously sought patient's goods    New service relationship
or services

Mutual unavailability of others      Wider availability of sought
with similar expertise               expertise

Source: References 6, 8, 16, 18, 27, 29-31, 35-37

Table 2

Limiting the risks of a barter

Assess your likelihood to exploit patients (eg,
by using the Exploitation Index questionnaire)

Seek consultation

Make arrangements with the patient directly
rather than through your staff

Review relevant state laws regarding payment

Document the risks, particularly of breach
of confidentiality

Itemize the value of services and consider
outside appraisal

Discuss what will happen if a patient is injured
while providing the traded service

Discuss what will be done if the work is
unsatisfactory or untimely

Set a limit to the extent and duration of
services, and consider receiving the goods
or services upfront

Establish how payment will be distributed
among any partners in your practice

Pay relevant taxes

Monitor and listen carefully to the patient
Consider the patient's point of view

Keep adequate and accurate records
throughout the barter transaction
Source: References 5,6,15,16,32,35,39,40,44-47
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Title Annotation:Malpractice Rx
Author:Marett, Christopher P.; Mossman, Douglas
Publication:Current Psychiatry
Geographic Code:1USA
Date:Dec 1, 2016
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