Is there really a demand for child psychiatrists?

[Sharpie1]

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I keep hearing, "there's so much need" when it comes to child psychiatry. However, around the NY tri-state area, that hardly seems to be the case. If you just google "child psychiatrist" and the town you are in, many many pop up. I don't understand, is there really a need for them, or is that data a few years outdated and people still seem to think there is? And psychiatrists--forget about it! There are indeed way fewer CHILD psychiatrists than there are general, it seems like there is a psychiatrist on every corner! I just don't get it, how can there be such a need when there are so many around?

 

[billypilgrim37]

That's because there isn't a shortage of anything in the New York Tri-State Area.

 

[OldPsychDoc]

Waiting times for new patient intakes around here (a well-regarded midwestern metro area) are well over 2 months--and that's for patients with insurance and/or ability to pay.
Head 3-4 hours out of the metro, and well...good luck with that. 🙁

 

[pingouin]

Waiting times for new patient intakes around here (a well-regarded midwestern metro area) are well over 2 months--and that's for patients with insurance and/or ability to pay.
Head 3-4 hours out of the metro, and well...good luck with that. 🙁

Yeah, same situation here- different but still large Midwestern city.

My most recent experience was when a friend called me about her 13 y/o son. She works in mental health, knows a bunch of psychiatrists, and called 3 in a row who weren't taking new patients at all, 3 more whose offices never returned her call, and was begging me to ask a favor of a personal friend of mine who's a child psych. He got them in after I called him- but it took 5 weeks and would have been 8 if there hadn't been a cancellation.

 

[digitlnoize]

In my hometown of 80k people in the SE, there are ~5 child psychiatrists. Wait times are 6 months to 1 year.

 

[PETRAN]

What kind of patients do child psychiatrists diagnose/treat? Are they all ADHD/Conduct (+ the anxiety/depression/adjustment/OCD)? or it is autism/neurodevelopmental disorders as well? I'm a bit confused about what kind of doctor is the most appropriate for neurodevelopmental disorders. With specialties like neurodevelopmental pediatrics and child neurology it looks like they are many types of medical professionals around for this patient group.

 

[billypilgrim37]

With specialties like neurodevelopmental pediatrics and child neurology it looks like they are many types of medical professionals around for this patient group.

Neurodevelopmental disorders are a pretty heterogenous group, so it depends on what the disorder is and what's going on. It's probably not unheard of for the developmental pediatrician to be working on the bedwetting and the constipation, the neurologist to be working on the seizures and tics, the pm&r doc to be working on the spasticity, the geneticist working on the preventive care, the cardiologist following the congenital malformation, and the psychiatrist giving the risperdal after they go after their sibling with a knife and bite the dog's foot off after tearing the bathroom a part and stabbing themselves with the shards of glass they broke off the mirror...

And God bless the general pediatrician who has to keep that ship afloat...

 

[Bartelby]

In Virginia I know hospital administrators in my hometown who already want to talk to me about future employment, and they would be willing to throw benefits at me/anyone for doing child psych. And I'm an MS-IV.

Also wanted to say I am interested in Petran's question about child scope of practice. I am more interested in general but will give a child rotation a chance during fourth year.

 

[PETRAN]

Neurodevelopmental disorders are a pretty heterogenous group, so it depends on what the disorder is and what's going on. It's probably not unheard of for the developmental pediatrician to be working on the bedwetting and the constipation, the neurologist to be working on the seizures and tics, the pm&r doc to be working on the spasticity, the geneticist working on the preventive care, the cardiologist following the congenital malformation, and the psychiatrist giving the risperdal after they go after their sibling with a knife and bite the dog's foot off after tearing the bathroom a part and stabbing themselves with the shards of glass they broke off the mirror...

And God bless the general pediatrician who has to keep that ship afloat...

lol, ok i see what you mean. There are many developmental pediatricians and pediatric neurologists in private practice though that work with neurobehavioral disorders ( rett/wilson/ autism spectrum etc. even ADHD) on their own, without cooperating with child psychiatrists (they may cooperate with child neuropsychologists and speech pathologists etc. for the assessment and rehabilitation for sure, but not psychiatrists). Maybe thats the case for the big university medical center but i have the impression that these doctors are managing these patient groups (pharmacologically) on their own. I don't know if they are totally trained to do so (i think they are?). It seems that they are many pathways to neurobehavioral/neurodevelopmental disorders.

 

[billypilgrim37]

Maybe thats the case for the big university medical center but i have the impression that these doctors are managing these patient groups (pharmacologically) on their own. I don't know if they are totally trained to do so (i think they are?).

From my experience, the other docs will treat pharmacologically except for lithium and neuroleptics. Stimulants, antiepileptics, antidepressants they feel more comfortable with.

 

[dl2dp2]

I keep hearing, "there's so much need" when it comes to child psychiatry. However, around the NY tri-state area, that hardly seems to be the case. If you just google "child psychiatrist" and the town you are in, many many pop up. I don't understand, is there really a need for them, or is that data a few years outdated and people still seem to think there is? And psychiatrists--forget about it! There are indeed way fewer CHILD psychiatrists than there are general, it seems like there is a psychiatrist on every corner! I just don't get it, how can there be such a need when there are so many around?

Even in the tri-state area, my impression is that there is still a shortage, especially for non-private pay patients. Yes, there are a lot of child psychiatrists listed, but you can try to call some of them and see how much they charge. My guess is the bare minimum is in the range of >$350. Few child psychiatrists take insurance, and those that do very rarely do therapy. Well-known child psychiatrists in the NY area can not uncommonly charge $800-$1000 an hour. It seems that lower income children with significant behavioral problems have a very slim chance to get proper treatment ANYWHERE in the US.

Regarding pathologies child psychiatrists see, it appears to be a range and depends on the age.

Keep in mind that each psychiatrist can only see a small number of patients at any time, and often they have other jobs in addition to private practice. It's highly unusual to have a psychiatrist who has hundreds upon hundreds of patients, like a typical primary care doctor.

 

[Sharpie1]

sluox, are you a child psychiatrist?

 

[dl2dp2]

sluox, are you a child psychiatrist?

No but I know quite a few. Keep in mind though the fellows I know come from very good fellowship programs, so this might bias things a bit. However, they are usually not from top residency programs. The fellowship is not known to be competitive.

The other thing though is to realize that child is by NO MEANS a gold mine. Most of the child fellows I talked to said that it's fairly rare to do full time child private practice, because charging one hour for a child case often entails 2x-3x as much work for collaterals with teachers and parents, which ends up cutting into your time seeing adults for $250 an hour. So under usual circumstances, child psychiatrists maybe make 30-50k more than an adult psychiatrist. If you are running a mill, things can be very different. This is true throughout psychiatry, in that the ceiling can be very high if you milk the system cleverly. The difference in a large market like a major metro is that it's usually more viable to set up pure therapy shop or pure cash only shop, but this doesn't mean that you'll MAKE significantly more--in fact, usually it means you'll take a pay cut. And just like in other fields, on AVERAGE your salary is lower in major metros. That said, I don't think it's unrealistic to make 300k+ as a child in rich suburbs (i.e. Westchester/CT), but I don't know the market that well to say for sure.

I suspect though that the barrier to make cosmetic dermatology level dough is STILL very high, especially if you are an FMG from a 2nd tier residency program. It's not clear to me how you'd be able to spin this if this kind of thing is your goal. I HIGHLY doubt that child psychiatry is the way to do it. Yes, MAYBE 10-20 child psychiatrists in NYC makes > 1 million, but I'm not sure what's harder, that or becoming a cadiothoracic surgeon.

Check this article:
http://www.nytimes.com/2011/06/05/fashion/when-a-childs-anxieties-need-sorting.html?scp=1&sq=child%20psychiatry&st=cse
I would imagine maybe there's ~10 people at that statue (i.e. division head), and maybe with an assorted number of people who specialize in very specific things, like child PTSD or child addiction, that can potentially make that kind of money.

 

[IAmAUser]

.

 

[Sharpie1]

No but I know quite a few. Keep in mind though the fellows I know come from very good fellowship programs, so this might bias things a bit. However, they are usually not from top residency programs. The fellowship is not known to be competitive.

The other thing though is to realize that child is by NO MEANS a gold mine. Most of the child fellows I talked to said that it's fairly rare to do full time child private practice, because charging one hour for a child case often entails 2x-3x as much work for collaterals with teachers and parents, which ends up cutting into your time seeing adults for $250 an hour. So under usual circumstances, child psychiatrists maybe make 30-50k more than an adult psychiatrist. If you are running a mill, things can be very different. This is true throughout psychiatry, in that the ceiling can be very high if you milk the system cleverly. The difference in a large market like a major metro is that it's usually more viable to set up pure therapy shop or pure cash only shop, but this doesn't mean that you'll MAKE significantly more--in fact, usually it means you'll take a pay cut. And just like in other fields, on AVERAGE your salary is lower in major metros. That said, I don't think it's unrealistic to make 300k+ as a child in rich suburbs (i.e. Westchester/CT), but I don't know the market that well to say for sure.

I suspect though that the barrier to make cosmetic dermatology level dough is STILL very high, especially if you are an FMG from a 2nd tier residency program. It's not clear to me how you'd be able to spin this if this kind of thing is your goal. I HIGHLY doubt that child psychiatry is the way to do it. Yes, MAYBE 10-20 child psychiatrists in NYC makes > 1 million, but I'm not sure what's harder, that or becoming a cadiothoracic surgeon.

How feasible does $200,000-250,000 sound if one were to accept insurance?

 

[digitlnoize]

How feasible does $200,000-250,000 sound if one were to accept insurance?

Depends what insurance pays around you, but I think it's pretty doable. From what I've heard insurance pays $60-80 for a med check. 3 of these an hour = $180-240/hr x 40h/wk x 46wk/yr x 0.8 (to remove 20% overhead) = $265k-$350k. Roughly.

Now if med checks pay less in your area, obviously that's a problem. Peruse some websites or call some local offices and see what you can come up with, but I would think it's doable.

I wouldn't get hung up on trying to clear a mil/year. That's going to be hard in any field. Just make some good money per hour and enjoy your life people!

 

[Lokhtar]

Only 20% overhead?

 

[digitlnoize]

Only 20% overhead?

Yes. This has been discussed many times on this forum, but in the "Ease of setting up a psychiatry private practice" thread a few threads down from this one, ManicSleep says this:

Your overhead should not be 40% in psychiatry. In other medical specialties, overhead can routinely be 50-60% or even higher.

Psychiatry is a very low overhead specialty and you need to use that to succeed. For a 4 person group, you could be as low as 10 percent but in a metropolitan area 20% is more accurate with outsourced billing. Your 'prime downtown' idea doesn't sound like the best idea to me. I would go with a pretty nice area but a well appointed office. Your patients will come. You can always get an office in a prime area later if you want to attract cash patients.

There's no reason that you can't have a very low overhead psych PP, even if you take insurance. Most of the psychiatrists I know share a receptionist with a few other psychiatrists, splitting her salary, and other than that, just pay for office space.

 

[Sharpie1]

Depends what insurance pays around you, but I think it's pretty doable. From what I've heard insurance pays $60-80 for a med check.

Can anybody confirm this? Something tells me around NYC it is much less, lol. Lovely place to live ain't it! High living expenses + lowest salaries. Wish I could leave but family obligations will keep me here for decades to come!

 

[dl2dp2]

Can anybody confirm this? Something tells me around NYC it is much less, lol. Lovely place to live ain't it! High living expenses + lowest salaries. Wish I could leave but family obligations will keep me here for decades to come!

There's no way to confirm any of this. Right now it seems as if you can make 200k+ fairly easily. But who knows what's gonna happen to YOU in particular? By the time you start practicing, who KNOWS what's gonna happen. Does any of this matter at all to any decision that you'll make? I would caution you against going into psychiatry or child psychiatry based on how much money you would make. It sounds like you are simply feeling anxious and need reassurance, but the reality is nobody can give you a guarantee. And hate to break it to you, but you do not need 200k to live very comfortably in the tri-state area. And in the end your family cannot force you to live in a particular place. These choices in life are YOURS and all these "external factors" are nothing but a neurotic reflection of your conflicts.

 

[digitlnoize]

Can anybody confirm this? Something tells me around NYC it is much less, lol. Lovely place to live ain't it! High living expenses + lowest salaries. Wish I could leave but family obligations will keep me here for decades to come!

Not sure about NYC, but it's a decent approximation of things in the mid-south east. Google the CPT codes and see what you can dig up...it's hard, but possible to find some real numbers...

 

[digitlnoize]

I am only a pre-med student, but I read this forum regularly. I usually find the posts here to be inspiring and enlightening, but as a student with an interest in pediatrics and psychiatry, I find it disheartening to see a thread about a need for child psychiatrists turn into a discussion about how to make a lot of money. If there is a need for child psychiatrists, shouldn't health care providers be interested in going into child psychiatry in order to help children who might not otherwise receive appropriate care (as opposed to going into child psych in order to take advantage of the high demand)? Sorry if I sound like an idealistic pre-med student...I guess that is precisely what I am.

Absolutely agree, but people do still want an income for some reason. I mean, why don't all doctors take a $50k salary and just give care away for free?

I'm hoping to have a private practice 3-4 days a week and do charity/need-based work or inpatient work at a state institution or something a couple days a week. That way I can make a decent hourly wage, not work myself to death, and still help the less fortunate.

The problem is that the shortage is so bad, that even the "fortunate" people who can afford care still can't find it. So, who in their right mind would take a poorly paying gig helping people who, by definition, have no money, when there's a huge market of paying patients that also need help just as badly. People will, almost always, take the paying job over the non-paying one.

My strategy in picking a specialty has always been to pick something that I enjoy most (the main criteria), that will let me have my own place, work decent hours, have a healthy work-life balance, with a fair (but not excessive) salary, and provide some charity care in my spare time.

 

[biophilia]

Absolutely agree, but people do still want an income for some reason. I mean, why don't all doctors take a $50k salary and just give care away for free?

I'm hoping to have a private practice 3-4 days a week and do charity/need-based work or inpatient work at a state institution or something a couple days a week. That way I can make a decent hourly wage, not work myself to death, and still help the less fortunate.

The problem is that the shortage is so bad, that even the "fortunate" people who can afford care still can't find it. So, who in their right mind would take a poorly paying gig helping people who, by definition, have no money, when there's a huge market of paying patients that also need help just as badly. People will, almost always, take the paying job over the non-paying one.

My strategy in picking a specialty has always been to pick something that I enjoy most (the main criteria), that will let me have my own place, work decent hours, have a healthy work-life balance, with a fair (but not excessive) salary, and provide some charity care in my spare time.

Looks like you posted just as I deleted my post (I decided that perhaps it wasn't my place as a mere pre-med student to make a slightly critical post in this thread), but I really do appreciate your honest response.

Personally, I think I would take a poorly paying gig if I were able to make a difference in children's lives, but perhaps I do not know myself as well as I think I do. As a pre-med student, maybe I can afford to be idealistic and imagine I wouldn't care about money because I don't have to make any real decisions right now. I don't know.

While I don't think there is anything wrong with wanting to make money and live a balanced life, given the need for child psychiatrists, I would think that being able to serve people who might not otherwise receive appropriate care would be rewarding in ways that money never could be [and again, I feel a need to apologize for my idealism (naivete?)].

 

[digitlnoize]

Looks like you posted just as I deleted my post (I decided that perhaps it wasn't my place as a mere pre-med student to make a slightly critical post in this thread), but I really do appreciate your honest response.

Personally, I think I would take a poorly paying gig if I were able to make a difference in children's lives, but perhaps I do not know myself as well as I think I do. As a pre-med student, maybe I can afford to be idealistic and imagine I wouldn't care about money because I don't have to make any real decisions right now. I don't know.

While I don't think there is anything wrong with wanting to make money and live a balanced life, given the need for child psychiatrists, I would think that being able to serve people who might not otherwise receive appropriate care would be rewarding in ways that money never could be [and again, I feel a need to apologize for my idealism (naivete?)].

I definitely agree, but that's kind of my point. You can make a difference in children's lives in a well paying gig in this field. You can serve people who might not otherwise receive appropriate care WHILE getting a salary. That's how bad the shortage is in most places. Even the rich can't get a child psychiatrist.

I definitely applaud your empathy and willingness to sacrifice. For myself, like with most things with me, I'm probably going to opt for somewhere in the middle. I don't have to be the highest earning doctor who doesn't care about anything but money, but I also don't have to live in a shanty in the name of self-sacrifice.

I think it's possible to strike a balance between serving the "underserved" (which, again, in child psych is pretty much EVERYONE) and serving those with insurance.

Look at it this way: You've got 1000 kids in your town with untreated psych problems. 700 of them have insurance or money. You only have space in your schedule for 100 new patients. Who do you take? The 700 kids with payment need treatment just as much as those without. Or, do you do, first come-first serve? That would probably work out fine as you'll hopefully wind up with a 70/30 split of paying/non-paying.

Let me know if you'd like me to delete your quoted post in my post...I think it's fine though, I like idealistic pre-meds!

 

[Chimed]

Looks like you posted just as I deleted my post (I decided that perhaps it wasn't my place as a mere pre-med student to make a slightly critical post in this thread), but I really do appreciate your honest response.

Personally, I think I would take a poorly paying gig if I were able to make a difference in children's lives, but perhaps I do not know myself as well as I think I do. As a pre-med student, maybe I can afford to be idealistic and imagine I wouldn't care about money because I don't have to make any real decisions right now. I don't know.

While I don't think there is anything wrong with wanting to make money and live a balanced life, given the need for child psychiatrists, I would think that being able to serve people who might not otherwise receive appropriate care would be rewarding in ways that money never could be [and again, I feel a need to apologize for my idealism (naivete?)].

My suggestion to you is to do everything you can to continue to cultivate your desire to help underprivileged children. Keep your idealism and guard it. It is needed in this field and is the ingredient that will make you a great doctor someday. However, as already mentioned, it is very reasonable to think about salary and working conditions. Otherwise, you might find yourself burned out and bitter over what you're doing. I feel that one just needs to make sure that money is not the driving force and principle motivation for doing this profession. If it is, everyone suffers.

 

[Technotronic]

🙂

 

[IAmAUser]

.

 

[Sharpie1]

this is very true. some graduating fellows i know are having a hard time finding local jobs. one was recently offered a full time position for 120,000.

was this at an academic institute?

 

[IAmAUser]

.

 

[Manicsleep]

Only 20% overhead?

Think about it this way. Lets say you take insurance and you make 70 dollars per patient, per 20 minutes. Thats 210 per hour. Lets say you work 55 hours per week to account for no shows, emergencies and to finish administrative work (calls, prior auths, emails etc) but actually see 40 hours worth of patients.

210x40x48=403k and 20% of 400k is 80 thousand. 4 weeks of vacation.
Lets say 30k to billing, including losses, if you hire someone and share the costs with someone else. 3 psychiatrists can easily have 1 biller who also does some secretarial work and 90k for such a person, with benefits etc is overkill. You still have 50k for lease, utilities, malpractice etc. You shouldn't need more than 20k if you are in a group.
That leaves you 30k for other expenses. How much of this will be used depends on if you are solo, work less etc. You may even pay more if you do multiple things that typically raise overhead. For example if you want to work 20 hours, solo, with your own secretary/biller, in a fancy office space then your overhead will be quite high.

The only problem with this is that it can take time to build up to having patients that fill 40 hours a week so you may not be filling your time slots immediately.

BTW, my equation still leaves you with about 300k in salary.

 

[biophilia]

I definitely agree, but that's kind of my point. You can make a difference in children's lives in a well paying gig in this field. You can serve people who might not otherwise receive appropriate care WHILE getting a salary. That's how bad the shortage is in most places. Even the rich can't get a child psychiatrist.

I definitely applaud your empathy and willingness to sacrifice. For myself, like with most things with me, I'm probably going to opt for somewhere in the middle. I don't have to be the highest earning doctor who doesn't care about anything but money, but I also don't have to live in a shanty in the name of self-sacrifice.

I think it's possible to strike a balance between serving the "underserved" (which, again, in child psych is pretty much EVERYONE) and serving those with insurance.

Look at it this way: You've got 1000 kids in your town with untreated psych problems. 700 of them have insurance or money. You only have space in your schedule for 100 new patients. Who do you take? The 700 kids with payment need treatment just as much as those without. Or, do you do, first come-first serve? That would probably work out fine as you'll hopefully wind up with a 70/30 split of paying/non-paying.

Let me know if you'd like me to delete your quoted post in my post...I think it's fine though, I like idealistic pre-meds!

I think you know yourself fine, keep that idealism long enough to get through your med school interviews. they'll love it. I felt the same way in college on my way to med school. then you sacrifice your life for the next 8-10 years, not infrequently being belittled by support staff, nurses, attendings, other services, your family who doesn't think psychiatrists are real doctors anyway, coming out with 320k of debt, and you start to have to prioritize yourself. at least i did. kind of sad really...

(i'm just off of a 26 hour shift so probably more bitter than usual 🙂)

My suggestion to you is to do everything you can to continue to cultivate your desire to help underprivileged children. Keep your idealism and guard it. It is needed in this field and is the ingredient that will make you a great doctor someday. However, as already mentioned, it is very reasonable to think about salary and working conditions. Otherwise, you might find yourself burned out and bitter over what you're doing. I feel that one just needs to make sure that money is not the driving force and principle motivation for doing this profession. If it is, everyone suffers.

Thanks for your supportive, kind replies to my post, digitlnoize, Chimed, and IAmAUser!

Digitinoize, I have read that children who are disadvantaged/poor are not only unlikely to see a child and adolescent psychiatrist, but also unlikely to see any health care provider for diagnosis and treatment of a mental health condition, whereas children with private insurance are much more likely to see a health care provider for diagnosis and treatment of a mental health condition (e.g., a child psychologist who has a history of working closely with a pediatrician or NP). While all children may be "underserved" by child and adolescent psychiatry, those without private insurance and the the ability to access appropriate alternative services are truly underserved by the mental health community. Does this ring true to you?

IAmAUser, what you wrote makes me kind of sad, too. Do you think most programs effectively wipe out students' and residents' idealism by constantly putting them down throughout their formative years? Why doesn't this change over time, as residents who were made to feel inadequate move on and become attendings responsible for shaping the attitudes of future psychiatrists and attendings?

 

[digitlnoize]

Digitinoize, I have read that children who are disadvantaged/poor are not only unlikely to see a child and adolescent psychiatrist, but also unlikely to see any health care provider for diagnosis and treatment of a mental health condition, whereas children with private insurance are much more likely to see a health care provider for diagnosis and treatment of a mental health condition (e.g., a child psychologist who has a history of working closely with a pediatrician or NP). While all children may be "underserved" by child and adolescent psychiatry, those without private insurance and the the ability to access appropriate alternative services are truly underserved by the mental health community. Does this ring true to you?

Makes sense to me. I mean, the underserved are underserved for a reason. They're less likely to see anyone, not just mental health, so it makes sense that they'd be less likely to get a referral from their FP, for example.

 

[Chimed]

IAmAUser, what you wrote makes me kind of sad, too. Do you think most programs effectively wipe out students' and residents' idealism by constantly putting them down throughout their formative years? Why doesn't this change over time, as residents who were made to feel inadequate move on and become attendings responsible for shaping the attitudes of future psychiatrists and attendings?

I don't think so at all. You have to just not be naive to the fact that there are A-hole attendings in every field and not be bothered or surprised when you work with them. That's not always easy, I know. The best way to counteract that is to seek out mentors whom you respect and want to emulate. Work with them as much as possible. There are a lot of very compassionate and dedicated doctors. Pay attention to those, not the ones that put students or residents down. Ignore them.

One of the reasons I wanted to go into child psych is that the attendings seemed more empathetic for their patients and easy going. There is a great need for that, especially in working with kids. In fact, I think teenagers are the best BS detectors and if they pick up you're not there to try to help, they'll call you out.

 

[billypilgrim37]

One of the reasons I wanted to go into child psych is that the attendings seemed more empathetic for their patients and easy going.

And they play more video games!

 

[pingouin]

And they play more video games!

I already wanted to do child psych, but the day I got to shadow in clinic and play Battleship with a kid clinched it for me.

 

[billypilgrim37]

I already wanted to do child psych, but the day I got to shadow in clinic and play Battleship with a kid clinched it for me.

Ah, sounds like somebody is going to be applying to Yale and CHA here in a few years 😉

 

[pingouin]

Ah, sounds like somebody is going to be applying to Yale and CHA here in a few years 😉

Mmmmm.... probably a little out of my preferred geographic region.


Wait- am I allowed to even be posting here if the above is true?! 😕

 

[billypilgrim37]

Wait- am I allowed to even be posting here if the above is true?! 😕

Well, you just might not be able to bill for Battleship therapy.😉

 

[digitlnoize]

If disadvantaged, underserved youth are less likely than advantaged, underserved youth to receive mental health treatment from another provider, then would turning away a child with private health insurance in order to see a child without health insurance be more likely to ultimately lead to a good outcome for both children than turning away a child without private health insurance in order to see a child with private insurance?

Only if the advantaged underserved child eventually gets served. Hence the problem. It's like this (forgive the long analogy):

Imagine you're the only waiter in a busy restaurant. Everyone else is home sick. You've got a restaurant full of tables (45% Rich, 45% Poor, and 10% clearly malnourished and starving), what do you do? Do you try to serve them all, and provide terrible service to everyone? Do you only serve best-dressed, obviously wealthy tables? Do you only serve the sloppily dressed, obviously poorer people? Do you serve the starving people first? What if they can't pay?

Some people try to serve everyone, and either work themselves to death, burn out, or fail miserably. There might be a rare one or two who are especially gifted and talented and succeed. Like the amazing waiter who could handle this restaurant scenario well.

Some people only serve the rich people, because they reason that they can't serve everyone, so they prioritize the tables that will bring home the most tips. Since you're going to be serving, say 50 tables that night, might as well make it the best 50, and ignore everyone else, since they weren't going to tip you well anyways.

Some people will serve the starving people first, because they clearly are in trouble. Others will tell them to go to the soup kitchen down the street, since they can't even pay their bill, let alone tip you.

A few people would serve the poor, but not starving, people first, because they feel wronged by the wealthy and want to give the finger to the man. This group is probably the smallest, because they a) have some clear issues, and b) will soon be poor and starving themselves.

Finally (and this is where I fit in), some people will try and focus on a practical mix of the above, asking the hostess to limit the number of available tables, and put people on a waiting list. The waiting list will be so long that we would advise the starving people to look elsewhere (possibly the soup kitchen) while they're waiting, but that we would buzz them when their table was ready if they didn't find anything else in the mean time. You may even have the chef feed a couple of the most starving people out the back door.

Ultimately, everyone will pick the option that appeals most to them. A lot of people will pick the only wealthy option, but I should also point out that many self-pay customers are not only wealthy. Read up on the Access Healthcare model of Family Practice, where a doc in North Carolina opened a Fee-For-Service office and was surprised to find that 50% of his patients had no insurance or were poor. These people preferred the cash model because the prices were clearly listed and they could budget ahead. They knew exactly what service would cost, and it wasn't exorbitant. Food for thought.

 

[DrGachet]

A few people would serve the poor, but not starving, people first, because they feel wronged by the wealthy and want to give the finger to the man. This group is probably the smallest, because they a) have some clear issues, and b) will soon be poor and starving themselves.

Would you please expand on this? I'm not sure I follow.

 

[TexasPhysician]

this is very true. some graduating fellows i know are having a hard time finding local jobs. one was recently offered a full time position for 120,000.

however, if you do private practice and are willing to take insurance you can fill up quickly. there is indeed a shortage of child psychiatrists, even around here, who will accept insurance.

to start a cash only practice takes some time, reputation, and business sense.

I am sure certain areas like NYC and CA are more saturated with child psych docs. Overall though there is a huge demand.

120k is a joke in most areas of the country. Our graduating general psych residents are pulling 200k+ in the private sector. One is starting at 250k from general. The child people are pulling more.

Some of the current PGY-3's (almost 4's) already have general psych gigs being offered to them over 200k in their area of choice.

 

[digitlnoize]

Would you please expand on this? I'm not sure I follow.

Well, who would choose to treat only poor patients, but not truly needy ones, and not rich ones? People with a grudge against the rich, or people who want to feel better about themselves, or...you get the idea.

I'm sure there'd also be people who would treat (I mean, feed) the poor AND the starving willingly, and be truly self-sacrificing, but I'm not sure if I included them in my fantasy waiter land...

 

[billypilgrim37]

There are plenty of people who chose to treat predominantly folks on Medicaid. We usually call them "assistant professors."

 

[DocHolliday21]

1) Yes the NYC area has a ton of psychiatrists, but due to the population density, the demand is still great. I have a family friend who tried to see a child psych doc and had to wait 3 months. If your planning on practicing in the NYC area, don't sell yourself short. Your still a very valuable commodity.

Another thing. There is a big difference between a psychiatrist and a good psychiatrist. NYC area has a lot of psychiatrists.


2) Insurance question. If an adult med check is billed at $60-80 and initial 1 hr appointment is billed somewhere around $250 (no idea personally, I got that number off another thread), then how much does the child psych doc charge (or reimbursed) for each service? It can't possibly be the same right considering each child/ adolescent patient takes much more time than the adult patient? Also considering they average $20-40K more than the adult psych docs, I'd imagine the reimbursements would be higher no?

 

[digitlnoize]

2) Insurance question. If an adult med check is billed at $60-80 and initial 1 hr appointment is billed somewhere around $250 (no idea personally, I got that number off another thread), then how much does the child psych doc charge (or reimbursed) for each service? It can't possibly be the same right considering each child/ adolescent patient takes much more time than the adult patient? Also considering they average $20-40K more than the adult psych docs, I'd imagine the reimbursements would be higher no?

As far as I understand it, insurance does not differentiate, unless you're coding by time, which (as I understand it) you probably shouldn't be.

Of course, most child docs I've come across only take cash, then give the patient a superbill to file with their insurance on their own. If there are no child psychiatrist providers for that insurance accepting patients in that area, they can apply for a waiver to get your cash service reimbursed to them at in-network rates. Takes some leg work on the patients part, but better them than your office staff.

I think all doctors should switch to this method. "yes, we take your insurance, but you'll have to collect the money yourself. You pay us and your insurance company will pay YOU back." It makes so sense for us to be acting as the go-between. That was a bad move back in the day.

 

[Chimed]

1) Yes the NYC area has a ton of psychiatrists, but due to the population density, the demand is still great. I have a family friend who tried to see a child psych doc and had to wait 3 months. If your planning on practicing in the NYC area, don't sell yourself short. Your still a very valuable commodity.

Another thing. There is a big difference between a psychiatrist and a good psychiatrist. NYC area has a lot of psychiatrists.


2) Insurance question. If an adult med check is billed at $60-80 and initial 1 hr appointment is billed somewhere around $250 (no idea personally, I got that number off another thread), then how much does the child psych doc charge (or reimbursed) for each service? It can't possibly be the same right considering each child/ adolescent patient takes much more time than the adult patient? Also considering they average $20-40K more than the adult psych docs, I'd imagine the reimbursements would be higher no?

Those averages may be due to the fact that private and university clinics will often hire CA psychiatrists at a higher salary. This is true for inpatient jobs as well. I'm not sure how that works out for the clinic in regards to reimbursements, though.

 

[billypilgrim37]

I think all doctors should switch to this method. "yes, we take your insurance, but you'll have to collect the money yourself. You pay us and your insurance company will pay YOU back." It makes so sense for us to be acting as the go-between. That was a bad move back in the day.

Many of my patients can hardly tie their shoes without their case managers helping them out!