In his letter in the November 2, 2001, issue, Dr. Wun Jung Kim raised a number of questions concerning a letter written by Robert T. Fintzy, M.D., who explained in the August 17, 2001, issue why he had retired as a practicing child and adolescent psychiatrist. Primary among the reasons given was the inability of patients to pay for their child’s care. In his letter, Dr. Kim expressed being perplexed by the increasing number of child and adolescent psychiatrists in private practice who are paid out of pocket, suggesting this might represent an ethical dilemma.

Practicing child and adolescent psychiatrists confront many ethical dilemmas. One of the most significant is the delivery of care in a coherent fashion without the needless interruption and inadequate reimbursement and funding by managed care organizations. One could see the movement toward child and adolescent psychiatrists’ seeking out-of-pocket payment as suggesting they are price gouging or attempting to offer care only to those who can afford it. There could be a broader motivation. Child and adolescent psychiatrists are fed up with being manipulated and manhandled by managed care, having any chance of continuity of care are destroyed. These clinicians may want to help patients without managed care’s pernicious invasion in ongoing care.

As a recent attending on an inpatient unit, I was astonished by the number of cases that had received poor follow-up and infrequent psychiatric care, despite a significant number of medications being started at high doses. Ethical dilemmas are a child who has an early-onset psychotic disorder or bipolar but is given only 10 sessions a year, a child psychiatrist’s squeezing care into 15-to-20 minute sessions every three to six months for medication management due to limited reimbursement for sessions, and a 12-year-old’s gaining more than 110 pounds in one year from several psychotropics being started without a treatment plan for the discontinuation of meds due to limited sessions with the child’s psychiatrist.

I predict that the trend toward out-of-pocket payment will not only continue but increase. Child and adolescent psychiatry has and will become more needed. A growing established knowledge base moves child and adolescent psychiatrists into an elite class of physicians. The care they provide ain’t a little Ritalin and psychotherapy anymore! It is the diagnosis of numerous comorbid conditions, often requiring multiple medications and intensive interventions with parents and children. This expertise demands adequate reimbursement. As child and adolescent psychiatrists become more sophisticated, they will continue to request more money and the ability to see patients as needed. Ultimately, what constitutes adequate care for children with serious psychiatric disorders has to be funded by managed care at a competitive market rate or it will lose more child psychiatrists. This is an issue that represents many dilemmas that are not going away.