We live in a world that desparately needs our services.

Nearly 1/2 of the world’s population, 3 billion people, are living on less than $2.50 a day, with more than 1.3 billion of them dwelling in desperate poverty. According to UNICEP 22,000 thousand children die each day due to poverty. Many of the world’s population are starving, dying of preventable diseases and beyond the reach of affordable healthcare services

The average North American enjoys a standard of living for most of human history has been unfathomable. Therapists in the United States earn on average $82,000/yr. Therapist’s income is 22 times higher than the global average placing most of them in the top 4% of the richest people in the world. If you want to check how your salary ranks go to How Rich Am I? . The fact that most therapists in the US are rich could skew how we percieve the problem of poverty and accessible, affordable healthcare.

By a Global Standard, Majority of Americans Are High Income

Recent civil unrest in response to police shootings in the United States has accentuated the social and economic disparity between the “haves” and the “have nots”. The economic gulf is widening not only in the US but between North America and the rest of the world. However, North Americans are not immune to the effects of poverty. From inner city gettos to rural small town poverty continues to cause havoc and pain in our patients lives.

If you are a North American therapist, the reality of our economic situation and professional status presents us with enormous responsibility to provide affordable and accessible healthcare.

So what are we to do?

The poor are our fellow human beings, our brothers and sisters.

This article addresses three fundamental questions therapists especially private practice owners will face when considering the cash practice model.


Are Cash Practices For The Rich?

One of the recurring arguments against a cash practice business model is that they cater to the rich. There’s an assumption that the poor simply do not have the money to pay for much needed healthcare services. I explore beneath the surface of a few assumptions regarding cash practices and the relationship with the poor/rich.

First a couple of disclaimers.

I am not an expert. There are people who have devoted their lives to making a difference in the lives of the poor. The economics of heathcare is a complex subject.

Hopefully, I come with an attitude of humility and teachability. Our clinic provides care to referrals from several free health clinics in our community. We provide physical therapy services to inmates at a correctional facility for the mentally ill. We want to “help without hurting” but we often have nagging feelings that we could do better.

Secondly, there is no “one-size-fits-all” when it comes to how each therapist should respond to the poor and rich. Each therapist has an unique calling, set of beliefs and skills that will influence their approach to this subject.

Some therapists will work within the institutions where they are employed, while others will volunteer and support non-profit organizations that serve the poor. Some therapists feel called to a full time career as a front line worker. I’m not proposing one “right” way to do it but my musings on what might be the questions behind the question.

Who Are The Rich?


The West tends to embrace a material definition of poverty- not having the sufficient money to provide for the basic physical needs for themselves and their families. People in North America tend to look at the symptoms of poor people as not having enough money to buy “sufficient” material things or basic services like healthcare.

Therefore, the signs of someone being rich is having more money than they need for material things and services like physical therapy. What if there is more than meets the eye when diagnosing who is rich and who is not. Who is poor and who is not.

Therapists are trained to look beyond signs and symptoms to underlying diseases in their patients. The disease causing the patient’s problem is often not easily seen and can vary widely between individuals. Patients are not always aware of what is really affecting them. They might not be completely honest with themselves or healthcare professionals. Even when a diagnosis becomes known it may take years of effort to make lifestyle changes to correct the cause of the symptoms.

To form a more complete understanding of poverty/wealth it might benefit us to look beyond the signs and symptoms to the underlying cause.

In his book Walking with the Poor, Bryant L. Meyers, describes the fundamental nature of poverty:

Poverty is the result of relationships that do not work, that are not just, that are not for life, 

that are not harmonious or enjoyable. Poverty is the absence of shalom in all its meanings.

If we consider Meyers’ definition of poverty that extends beyond material poverty then I believe we as therapists are able to operate beyond our cultural biases regarding wealth and poverty.  Meyers points out that a “poverty of being” is a major part of the brokeness that low-income people experience in their relationship with themselves and others.

People with abundant means can suffer from a “poverty of being” too. The tabloids and talk shows are filled with the stories of the rich and famous who are suffering from a poverty of genuine, loving relationships.


I remember working with multiple patients over the years who were materially poor but relationally rich. I was amazed that they could be in so much pain and dysfunction yet still have a better attitude about life than I did. I encourage therapists especially business owners to embrace a more wholistic view of poverty/wealth.

How we diagnose or define poverty isn’t merely an academic exercise. The way we define it will play a significant role in our attempts to make care accessible and affordable to as many people as possible. We should develop payment policies, payment programs and patient on boarding processes that do not contribute to a “poverty of being” in neither the poor or the rich.

Am I Helping Or Hurting?

When our patients come to us for treatment for their physical aliments we can do more harm if we make two crucial mistakes:

  1. We focus on alleviating symptoms at the expense of focusing on the underlying problem
  2. We misdiagnose the underlying cause and implement the wrong treatment plan

Either one of these mistakes can actually lead to patients really not getting better and possibly make their condition worse. Having a sound diagnosis of a patient’s underlying problem guides the plan of care with each patient. In the present environment the plan of care should include the payment of care.

When thinking about how we collect payment for our services. If we misdiagnose a person’s underlying relationship with money either rich or poor, we will not improve their situation and we might actually make their lives worse. And in the process we might also harm ourselves and our profession’s value.

We do not want to contribute to the individual’s “poverty of being” by our own attitudes and beliefs about money. In Powerlessness of the Poor Jayakumar Christian, a development practioner argues that the econmoically rich can suffer from “god-complexes”. Medical practioners are especially vulnerable to a subtle and unconscious sense of superiority when deciding what’s best for thier patients, especially low-income people whom they percieve as inferior to them.

Unfortunately, the way the healthcare community acts towards economically needy often communicates that we are superior and they are inferior. Somehow our payment policies and our conversations about money with patients must take into account underlying issues. In our clinic we have found it extremely helpful to work along side other agencies in a holistic manner as we try to empower individual’s to overcome their inadequacy and deep sense of shame.

Have I Made Peace With Profit?

Therapists are not alone with their struggle with how to charge for their services. Many professionals in the healthcare services industry are conflicted and confused when it comes to money.

In today’s healthcare economy the cost of care is making its way into everyday conversations with patients about thier care. Therapists will need to “make peace” with money within themselves in order to better serve their patients. Our negative beliefs and misunderstandings about money will be exposed when we talk to patients about money.

Most Therapists Work In A Cash Practice


First, most therapists work in a cash practice. Unless you accept eggs or a side of beef as a barter payment you’re in a cash system. Some where, somehow someone is paying cash for the services therapists provide. The money might be channeled through the insurance system or a government program but someone is paying cash in order for our patients to receive care.

Even if your work for a non-profit, service oriented organization it still must make a profit in order to serve it’s primary customers and fulfill it’s mission. The cash might come in the form of grants and donations but it’s still a cash-based organization.

Many therapists can trace their struggle with money because they have not reconciled working in a service industry with profit. 

For many the concept of serving and helping others stands in opposition to making a profit. For some, service is seen as somehow see as the “better” of the two. Making money off patient’s pain or disadvantaged position seems somehow dishonest or wrong.

Service = Good        Profit = Bad

But what if your job is in a service oriented business like physical therapy. It’s part of your job to provide a livelihood for both yourself and the organization you work for. If you are in private practice you directly feel that your own viability and the lives of your employees depends on making a profit from your patients.

Now you have the ingredients for an internal conflict that can spill over into  conversations with yourself and others. You may say things like:

How can I be a person who helps others and takes money from them?

How can I possibly take money from patients when they appear not to have the resources to pay for the services they really need?

Any practice that accepts cash from patients must care more about money than serving people.


Doctors, dentists, therapists, ministers and counselors of all kinds wrestle with this internal dilemma all the time.  There is no one right way to reconcile serving people and making a profit. However, unless we resolve this inner conflict it will be difficult to develop new business models that are in step with how our patients are paying for their healthcare.

Because consumers are now paying the up front cost of care, they’re seeking out professionals who have transparent payment policies and are able to communicate them in a clear and compassionate way.

There are tens of milions of consumers who are either self-pay, have high deductible insurance plans or don’t have insurance who are looking for affordable health care options.

In my view it’s our professional responsibility to help them get the care they need without putting up obstacles about money. Patients shouldn’t be denied affordable care just because we refuse or don’t know how to talk about money.

Where Do I Start?

One place to start is to examine your thoughts and feeling about money and profit. 

Perhaps you have negative beliefs about money that effect your view towards cash practices. Maybe you grew up without a lot of money in your home and money was in short supply for basics needs. You might have grown up in a home where it was taboo ever to talk about money. You might have heard money is the root of all evil and nice people don’t talk about money.

These beliefs will play out in our practices. 

We might be hesistant to charge what we are worth because we believe no one will pay my full fee. We might take a more passive approach by not discussing cost of care upfront with our patients then look the other way when the hospital sends them to collections.

If you believe money is evil then you might not raise your fees when justified, putting your employees jobs at risk when you have trouble making payroll.

I suggest resolving any beliefs, feelings and behaviors that impede the care you provide and the growth of the organization you work for.

Reading good books about money can help you clear out false beliefs and become a better money communicator. Here are a few that might challenge your beliefs about money:

The Energy of Money- Maria Nemeth Ph.D.

When Helping Hurts- Steve Corbett, Brian Fikkert

Thou Shall Prosper- Rabbi Daniel Lapin

Sell Yourself Without Selling Your Soul- Susan Harrow

I haven’t answered the question raised in the title of this post have I. It’s a question for each of us to answer for ourselves. Hopefully I’ve shared enough of an answer to facilitate further discussion in the comment section or on social media. I’d love to hear your views.

What do you think? What are your thoughts on cash practices and therapists role in providing affordable care to people who desperately need our help?