DSM-6? Don't Get Your Hopes up.....

 

I just spent a while reading all the papers in the American Journal of Psychiatry about the future DSM (1-5).  As you might expect many people have many things to say and that is as true inside as outside the field.  We are on the cusp of another epoch of DSM articles in the popular press that will predictably vary from inadequate to horrific. Those articles will claim that the DSM is published as a source of revenue for the American Psychiatric Association (APA), as a way for pharmaceutical companies to make money, and as a “Bible” for psychiatrists.  There will be philosophical musings tangentially related to the field but extremely critical.  There will be the usual antipsychiatry screeds about how it is unscientific, how there are better systems out there, and how the diagnoses are mere labels that mean nothing. Most of those opinions will be written by people who have never practiced psychiatry or been treated for a mental illness.  It seems that just about anybody believes that they are an expert in psychiatry.

For those of us familiar with the field - our backgrounds are more uniform. A significant number of people are like me – undergrad science majors who are always interested in biological science and medicine. We practiced in acute care settings and saw people with significant medical comorbidity.  We made plenty of medical and neurological diagnoses that nobody else made and were a resource for that kind of referral.  We knew early on that many of the diagnoses listed in the DSM were questionable and we never used them. It turns out we are the last people the DSM is designed for and after reviewing recent opinion pieces I will tell you why and how it can be corrected.

The lead paper by Oquendo, et al (1) briefly reviews common cited problems with the DSM and possible remedies.  The first criticism is that it is atheoretical. That is less of a problem than described.  Any reader of the DSM sees immediately that despite the stated atheoretical stance there are clear stated etiologies for DSM listed diagnoses. To keep it simple, I refer any reader to the table Diagnoses associated with substance class (p. 482).  That table contains 127 diagnoses associated with specific substances.  There are similarly many diagnoses that identify a psychosocial factor as being involved in the etiology.  Categories versus spectrums are listed as problem 2, despite the fact there probably are no spectrums (from the genetic side) and all polygenic medical conditions (hypertension and diabetes mellitus for example) have the same limitations. There are 4 additional uninteresting points and proposed solutions.  One of the subcommittees is focused on the Dahlgren-Whitehead framework for social determinants of health.  At the same time another committee is looking at instruments to assure a more comprehensive sociocultural assessment.  It made me wonder whether anyone on the committee had ever read a current comprehensive psychiatric assessment.  Every psychiatrist should have concerns about more checklists.

The second paper by Cuthbert, et al (2) was about biomarkers and biological factors. The discussion was long on biomarkers and short on biology.  To neuropsychiatrists this section of the DSM has always been a disappointment. As an example, the section with the most biology – neurocognitive disorders has surprisingly little discussion of associated medical features (like a gross characterization of EEG in delirium) or a discussion of neuropathology without any additional discussion of what that looks like clinically.   The Oquendo committee (1) has proposed changing the name of the DSM to the Diagnostic and Scientific Manual because it is no longer used to collect statistics.  If that occurs, they need to put a lot more science into it, and this is the area for it. 

I have proposed a separate DSM for psychiatrists in the past but a separate volume on the current science of psychiatry would be as useful. I am talking about more than just a review of unproven research, but how the science-based psychiatrist translates what we know so far into clinical practice.  I would start with a rewrite of the section on Neurocognitive Disorders and all the important variations before worrying about plasma biomarkers and whether they are FDA approved. There are volumes written on this subject that have been lost on the DSM.  To cite a few examples – should a psychiatrist be able to recognize presentations of encephalitis, meningitis, and the various presentations of vascular dementia from their own assessment and available imaging and lab studies?  Should a psychiatrist be able to diagnose various forms of aphasia and do the indicated evaluation? Of course, they should – and it is all part of the rule out criteria for psychiatric disorders. It is not enough to leave the medicine and neurology of psychiatry to somebody else.  But very little is mentioned in the DSM except the rule out conditions: “the disturbance is (or is not) attributable to the physiological effects of a substance or another medical condition (or mental disorder).”  That is too vague for psychiatrists.  

The Structure and Dimensions Committee (3) is charged with coming up with the most clinically useful structure of the future DSM.  That involves incorporating recent research.  They have produced a lengthy table summarizing the total categories, named categories and prevailing frameworks and theories used for all the DSM starting with the first one. That number goes from 4 to 22 categories in the DSM 5-TR.  There is usually criticism about diagnostic proliferation – but not much about category proliferation.  When I encounter these numbers – I remind myself that we started with a unitary psychosis model in the 19^th century.  By 1918 (6) the situation not much better with the major diagnostic categories being psychosis or not psychosis. It could be argued that early diagnostic and classification efforts failed to recognize or include mental disorders that had been observed since ancient times rather than lower numbers being more ideal.

The fourth paper (4) is focused on Quality of Life (QOL) as an essential part of psychiatric diagnoses. They establish premises based on the often-quoted literature on disability associated with psychiatric diagnoses.  They describe a bidirectional relationship:  “… symptoms of a mental illness can impair the individual’s functioning in daily life, and poor functioning can in turn lead to or exacerbate the symptoms of a mental illness.”  The paper has two definitions of QOL.  The author’s definition is “a person’s subjective perception of their emotional, psychological, and social well-being.”  The paper also contains the World Health Organization (WHO) definition of QOL “incorporates how an individual feels about their emotional, social, and physical well-being, which can affect and be affected by their mental health condition(s).”  WHO further defines QOL as “one’s perceptions of their position in life, contextualized by the culture and value systems in which they live, in relation to their expectations, goals, and standards.”  There is a related discussion on the Global Assessment of Functioning (GAF) from previous DSMs.  QOL metrics were decided to be subjective rather than clinical ranking like the GAF.  The GAF was also thought to conflate symptoms of mental illness with functioning even though there is a clear relationship. 

The authors discuss the World Health Organization Disability Assessment Schedule 2.0) (WHODAS-2.0) and it’s use to rate psychiatric disability. It is a 36-item, 100-point self-administered, 6-dimension rating scale.  Administration and scoring in full clinical schedules was considered a limiting factor, but clinically the question is what happens with more identified problems?  Does the treatment plan expand proportionally?  Will psychiatrists be expected to either treat directly or develop referral sources for all the disabilities identified as communication, mobility, self-care, interpersonal, life and societal activities. Additional briefer QOL instruments are discussed as well as brief interventions.

A critical concept that was not mentioned was the patient’s baseline function. With every patient I saw, I had a subjective (and often other informant) description of their baseline level occupational, academic, and interpersonal functioning.  In some case it involved activities of daily living (ADLs) and instrumental activities of daily living (IADLS).  On inpatient units those ADLs were often documented by occupational therapists.  In my outpatient Alzheimer’s Disease and Memory Disorder clinic – every new patient had their ADLs documented by the RN staffing the clinic.  It required hours of work per day that were not reimbursed.  My clinic was eventually shut down because of that unreimbursed work and my refusal to do the work myself for free. The additional cost and time for these assessments is a reality factor in the modern rationed health care system.

The fifth paper is entitled: “The Future of DSM: A Strategic Vision for Incorporating Socioeconomic, Cultural, and Environmental Determinants and Intersectionality.”  The definition of intersectionality is “a framework for understanding how various social and political identities—such as race, gender, class, sexuality, and ability—overlap and intersect to create unique combinations of privilege and systemic discrimination.”  I have a problem with the use of a vague term that is used rhetorically being implemented in a DSM.  The DSM is a target of rhetoric and putting rhetoric in the manual is likely to amplify its role as a target.  I have also reviewed ample evidence that the major journal of the APA – was unable to separate rhetoric from reality in the case of clear historical evidence about racial discrimination.  This highlights the need for clear definitions and avoiding political rhetoric in any rethinking of this manual.  It also highlights the need for clear evidence rather than rhetoric and that commentaries – even in the flagship journal of the American Psychiatric Association cannot be depended upon for that evidence.

Intersectionality is unnecessary to get at what the authors hope to accomplish.  Cross cultural psychiatric evaluations are the case in point. They involve an assessment of cultural differences and how the culture affects disease definitions and presentations, the sick role in that culture, and how demographic factors affect how a person is advantaged or disadvantaged in their original or adopted culture. The authors suggest it is necessary to promote various public health prevention strategies and promote health care equity.  As far as I can tell, health care equity in the US is strictly in the purview of politics and in one year a massive amount has been destroyed by the Trump administration.  Political features should be avoided as much as rhetorical features in a DSM, especially given the abysmal track record of physician medical organizations in politics.

The authors define socioeconomic, cultural, and environmental determinants of health (SCE-DoH) as the key focus (along with intersectionality). These determinants are all well known to any psychiatrist who has recorded a social history for a detailed assessment and that should include all of us.  They conceptualize them as modifiable or non-modifiable risk factors and how they may be relevant for prevention strategies.  Much of the prevention is outside the scope of psychiatric practice and advocacy by professional organizations has questionable impacts.  They also use the Dahlgren-Whitehead model of main health determinants and cover suggestions of screening patient populations for these variables.  They conclude that the next DSM should include recommendations to use multiple “vetted instruments” to make these SCE-DoH assessments.  They give an example of how this assessment can be built into routine clinical care.  Interestingly, the psychiatric assessment is not included in the “routine diagnostic workflow” (see figure 2).  Looking at the strategy 2 where the SCE-DoH is used to determine “management as usual” versus “enhanced case management” – I made that determination myself for 40 years. For the last 25 years that “enhanced case management” was not available for most people needing it. That tells me that the suggested assessment is already being done by some people and the necessary resources are not there.  I found myself documenting that fact in too many cases.

The Committee realizes that they cannot create an additional burden on clinicians who already have unrealistic demands and provide far too much work for free in rationed environments.  That translates to less time to do comprehensive assessments – not more.  

Even though these are very preliminary statements about the future DSM – I am not very hopeful at this point.  The commentaries so far seem directed at criticisms from outside of the field rather than what psychiatrists need.  Apart from the criticism I have offered so far what is noticeable:

1:  The lack of commentary on medical and neurological diagnoses – in any psychiatric classification it is either explicit (or implicit) that what are considered the current psychiatric diagnoses are not caused by a substance or another medical diagnosis.  The non-DSM diagnostic systems are generally just focused on the listed symptoms of these disorders and there is no provision for other medical conditions.  It is also not explicit enough in medical training. At some level this is explained away and needing to utilize whatever resources are available.  That is not enough.  The DSM should have a section of diseases by system that need to be diagnosed if they are present and at least a reference to how that should be done.  There is not nearly enough information on what medical diagnoses psychiatrists make.  This is also an important feature for resident education since it would suggest how much clinical medicine and neurology residents need to be exposed to and whether they are seeing relevant cases.

2:   Philosophical criticisms while minimizing biology and history –  in several of the papers the authors talk about “natural kinds” and “carving nature at the joints”.  This is philosophy speak that has been used to obfuscate the field. The first time I encountered these arguments they struck me as obvious nonsense.  That was first suggested by Thomas Sydenham when he made this statement in about 1640:

“In writing the history of a disease, every philosophical hypothesis whatsoever, that has previously occupied the mind of the author, should lie in abeyance. This being done, the clear and natural phenomena of the disease should be noted — these, and these only…” (7) 

DeGowin and DeGowin (8) summed up the process over the next three centuries:

"For several thousand years physicians have recorded observations and studies about their patients.  In the accumulating facts they have recognized patterns of disordered bodily functions and structures as well as forms of mental aberration.  When such categories were sufficiently distinctive, they were termed diseases and given specific names.”

It seems that the conceptual clarity here requires no reference to naturalism or essentialism.  It only requires empiricism and a determination of sufficiently distinctive.  In my long and intensive career – the only place I have encountered these philosophical arguments was in a literature that was generally critical of psychiatry.  In the process it also requires psychiatrists to suspend the idea that empirical adequacy is not all that is required, but also all that we were taught. 

Conceptual expansionism or semantic drift has been used to criticize the DSM and psychiatry and that needs to be called out wherever it happens.  By that I mean a concept that is developed within one academic silo that is suddenly applied without precedent or a clear basis to psychiatry.  On this blog I have criticized several of these applications including epistemic and hermeneutical injustice.  Although none of the Am J Psychiatry papers used the term, I did encounter folk psychology now being applied to criticize the DSM (9) in a mailing.  That is a concept I was familiar with from Andy Clark’s work (10).  If you are not familiar with the concept a generally accepted definition would be:  “The everyday ability to predict and explain the behavior of ourselves and others by attributing mental states—such as beliefs, desires, intentions, and fears.”  In other words – you see somebody doing something and come up with a theory of why they are doing it.  I have written about it on this blog as a reason why many people seem confident in their knowledge of psychiatry and psychology even though they have never been trained in either. There are several theories of how a folk psychology theory can apply, but the original debate centered on how the ascribed beliefs, desires, intentions, etc. had no neural equivalent and therefore that at some point these mental states would be replaced by more scientific terms. In other word suggesting that the DSM is folk psychology is basically saying the signs and symptoms used as descriptors have no brain equivalent and therefore it is an invalid classification. This argument is essentially the same argument that there is an explanatory gap between what most people consider consciousness to be and the neural substrates that causes it.  Consciousness is approximately represented in neural substrate and the same thing can be said for mental disorder symptoms.      

3:  The continued lack of focus on what might be useful to psychiatrists - 

When I think about a DSM that might be useful to psychiatrists or at least the kind of psychiatrists I am used to working with – there needs to be more than the usual slicing and dicing of diagnostic criteria.  Adding more work with more rating scales is also a disappointment.  A manual breaking down the current work with examples and a suggestion of the potential exhaustive data points might be. For example, pointing out that the typical phenomenology of a disorder should be adequately represented in the history of the present illness.  That obviously includes any precipitating factors irrespective of what they might be – biological or sociocultural. The next section should include a discussion of the past psychiatric and medical histories as well as comorbid conditions.  Psychiatrists should be expected to know relevant medical diagnoses, how medical comorbidity affects psychiatric treatment, and medical causes of psychiatric presentations.  The usual disclaimer about medical conditions is as inadequate as a disclaimer about sociocultural aspects of care.  The new DSM should not be a mere collection of psychosocial determinants completely devoid of medicine.

A more formal formulation section should be there.  In the DSM-5 for example it is referred to as a “concise summery of the social, psychological, and biological factors that may have contributed to developing a given mental disorder.”  (p. 19).  There are multiple ways to write a formulation (behavioral, psychodynamic, neuropsychiatric, and others) and they should all be discussed in the DSM.

4:  A theory section on the biology of psychiatric diagnoses – why they are complex and how that complexity should be approached.  There are experts in the field who can comment on how polygenes produce quantitative diagnoses that can blend imperceptibility into the normative states.  Some of those same experts can discuss the statistical methods used to try to improve classifications and how that works clinically.  There should be a comparison with other commonly described quantitative disorders like hypertension and diabetes mellitus Type 2.  The classification system of rheumatology could be discussed as a direct comparison to the DSM.

I have written about the problem with the term transdiagnostic. I do not think it adds and specificity to interventions.  In psychiatry what is considered a transdiagnostic symptom can also conceal a potential primary problem. One of the most common scenarios I encountered in practice was longstanding insomnia prior to the onset of depression. In the transdiagnostic scenario, insomnia could be considered just that or a symptom of another disorder rather than a primary sleep disorder. All these issues including categorical versus dimensional diagnoses should be covered in this theory section written by our experts.  There are plenty of reasons not to blindly accept the transdiagnostic jargon as being that relevant.    

Psychometrics can be discussed in the theory section.  We have all heard and read about reliability of diagnoses for decades and a lack of validity. Reliability statistics are available for a range of DSM categories and that could be included as a single graphic with a brief discussion.  The discussion of validity needs to be more extensive and nuanced rather than just dismissed.  Study groups from DSM-5 were working on 11 validity indicators.  It is time to see them on graphics like what can be constructed for reliability. The data should be included where it exists.

5:  A genetics section:  Genetics and the associated molecular biology is the future of medicine and psychiatry. A summary of that data should be available in the DSM as well as the clear importance of this information.  At the biological level, the discussion should be clearly focused on changes in brain systems associated with disorders and the problem of many genes affecting these systems.   

6:  Definition/Threshold of a disorder:

There is always criticism about the dysfunction threshold for making a diagnostic assessment.  There is never much discussion about why it is necessary or why there are consensus diagnoses.  Even a superficial look at other specialties that treat polygenic heterogeneous entities invites comparison.  Rheumatology is a case in point:   

“Rheumatologists face unique challenges in discriminating between rheumatologic and non-rheumatologic disorders with similar manifestations, and in discriminating among rheumatologic disorders with shared features.  The majority of rheumatic diseases are multisystem disorders with poorly understood etiology; they tend to be heterogeneous in their presentation, course, and outcome, and do not have a single clinical, laboratory, pathological, or radiological feature that could serve as a “gold standard” in support of diagnosis and/or classification.”

A recent review of polymyalgia rheumatica (PMR) in the NEJM (11) looked at diagnostic algorithms for both acute PMR and treatment.  The introduction involved the statement:  “The diagnosis of polymyalgia rheumatica is made on the basis of clinical grounds by combining characteristic signs and symptoms with laboratory findings and ruling out common mimickers such as late-onset gout and pseudogout and others.”  (p. 1099).  I counted 23 conditions in the differential diagnosis.  One of the criteria for the diagnosis is “functional impairment”.  The implication is that it is due to morning stiffness or possible pain but that is not specific.  There are limited reviews of how to establish diagnostic criteria for diseases and disorders that lack objective tests (12).  I think the degree of dysfunction is obviously relevant when assessing disorders that are based on purely subjective signs and symptoms.  It factors into routine clinical care of both known and unknown diagnoses. On this blog I have documented examples form numerous medical and surgical specialties.

That is my criticism after reading 5 current papers on the direction of the DSM.  I really do not want the next volume to look like what has been described so far. When I think about my final 1500-2500 word assessments that contain just about everything the author of these papers discuss and much more – I do not want to see all that good work sacrificed because somebody wants to include more checklists or dimensions of questionable value. I have had people tell me years and in some cases decades later, that they found those assessments to be valuable and useful for future evaluation and treatment of that same person.  

If I had to capture three elements that the future DSM planning seems to miss it is that phenomenological assessments can easily contain as much or more data than checklists, that psychiatry is a medical specialty, and that like all medical specialties the field has boundaries. The current suggestions from these papers stretch those boundaries into activism, politics, and importing criticism from other academic silos rather than a restatement of what is relevant for psychiatric assessment and classification. 

That should be the priority…    

 

George Dawson, MD, DFAPA

 

 

 

References:

1:  Oquendo MA, Abi-Dargham A, Alpert JE, Benton TD, Clarke DE, Compton WM, Drexler K, Fung KP, Kas MJH, Malaspina D, O'Keefe VM, Öngür D, Wainberg ML, Yonkers KA, Yousif L, Gogtay N. Initial Strategy for the Future of DSM. Am J Psychiatry. 2026 Jan 28:appiajp20250878. doi: 10.1176/appi.ajp.20250878. Epub ahead of print. PMID: 41593833

2:   Cuthbert B, Ajilore O, Alpert JE, Clarke DE, Compton WM, Drexler K, Fung KP, Gogtay N, Kas MJH, Kumar A, Malaspina D, O'Keefe VM, Öngür D, Tamminga C, Wainberg ML, Yonkers KA, Yousif L, Abi-Dargham A, Oquendo MA. The Future of DSM: Role of Candidate Biomarkers and Biological Factors. Am J Psychiatry. 2026 Jan 28:appiajp20250877. doi: 10.1176/appi.ajp.20250877. Epub ahead of print. PMID: 41593830.

3:  Öngür D, Abi-Dargham A, Clarke DE, Compton WM, Cuthbert B, Fung KP, Gogtay N, Kas MJH, Kumar A, Malaspina D, O'Keefe VM, Oquendo MA, Wainberg ML, Yonkers KA, Yousif L, Alpert JE. The Future of DSM: A Report From the Structure and Dimensions Subcommittee. Am J Psychiatry. 2026 Jan 28:appiajp20250876. doi: 10.1176/appi.ajp.20250876. Epub ahead of print. PMID: 41593835.

4:  Drexler K, Alpert JE, Benton TD, Fung KP, Gogtay N, Malaspina D, O'Keefe VM, Oquendo MA, Wainberg ML, Yonkers KA, Yousif L, Clarke DE. The Future of DSM: Are Functioning and Quality of Life Essential Elements of a Complete Psychiatric Diagnosis? Am J Psychiatry. 2026 Jan 28:appiajp20250874. doi: 10.1176/appi.ajp.20250874. Epub ahead of print. PMID: 41593851.

5:  Wainberg ML, Alpert JE, Benton TD, Clarke DE, Drexler K, Fung KP, Gogtay N, Malaspina D, O'Keefe VM, Oquendo MA, Yonkers KA, Yousif L. The Future of DSM: A Strategic Vision for Incorporating Socioeconomic, Cultural, and Environmental Determinants and Intersectionality. Am J Psychiatry. 2026 Jan 28:appiajp20250875. doi: 10.1176/appi.ajp.20250875. Epub ahead of print. PMID: 41593836.

6: American Medico-Psychological Association. Statistical Manual for the Use of Institutions for the Insane.  1918:  https://dn790008.ca.archive.org/0/items/statisticalmanu00assogoog/statisticalmanu00assogoog.pdf

7:  Sydenham, Thomas, 1624-1689; Greenhill, William Alexander, 1814-1894; Latham, R. G. (Robert Gordon), 1812-1888.  The works of Thomas Sydenham, M.D.  Volume 1, London. Sydenham Society.  1848-1850. P. 14  https://archive.org/details/worksofthomassyd01sydeiala/page/lv/mode/1up?q=abeyance

Translation of Medical Observations by Thomas Sydenham, London, 1669. The Preface.  Original was in Latin.

8:  DeGowin EL, DeGowin RL.  Bedside Diagnostic Examination, 3^rd ed.  New York.  Macmillan Publishing Company, Inc.  1976. P. 1.

9:  Aftab A. The Future DSM: Bold redesign, lingering blind spots.  Psychiatric Times. March 2026: 12-16.

10:  Clark A.  Microcognition: Philosophy, cognitive science, and parallel distributed processing.  Cambridge, MA.  The MIT press. 1989.   

11:  Dejaco C, Matteson EL. Polymyalgia Rheumatica. N Engl J Med. 2026 Mar 12;394(11):1097-1109. doi: 10.1056/NEJMcp2506817. PMID: 41812194.

12:  White SJ, Barker TH, Merlin T, Holland G, Sanders S, O'Mahony A, Pathirana T, Theiss R, Pollock D, Reid N, Munn Z. Methods for developing diagnostic criteria for conditions without objective tests, biomarkers, or reference standards: a scoping review. J Clin Epidemiol. 2026 Feb;190:112052. doi: 10.1016/j.jclinepi.2025.112052. Epub 2025 Nov 18. PMID: 41265667.

Troll Free Zone is Needed

 

Like many psychiatrists who watched Twitter implode under current management – I decided to try more time on LinkedIN.  I can recall a few years ago hearing that it was supposed to be a more “professional” site.  I tried the paid version to see if that might be true.  After giving it an adequate trial – I can say unequivocally it is not.  There are the usual social media maladies and more. 

For psychiatrists looking for collegial discussion that basically involves being trolled. The trolling comes in various forms, but it typically involves some absurd remarks about psychiatric practice or psychiatrists.  The usual absurdities still apply (see graphic).  There are people who will be repeating them until the end of time.  That strategy works for some politicians.  But there are a couple of variations.  I recently saw the claim that because psychiatrists only prescribe medication they never cure anyone and that it takes a psychotherapist to cure people.  One of the premises of that post was that psychiatrists get the first chance to treat people and that makes it even worse because they will not see a therapist and get cured.

That scenario is both statistically and clinically improbable.  There will never be enough psychiatrists to see everyone who needs to be seen. And psychiatrists are generally tertiary providers of all types of treatment.  As I have written about on this blog in several places – the average person I saw in practice had already seen 2-3 therapists and 1-2 non-psychiatrist medication providers before they saw me.  Prior care had often occurred over a period of many years or decades before they got in to see me.  Psychiatrists are not pulling people in off the street.  Despite the fact we are tertiary care providers – our schedules are generally full of all those people who have seen somebody else and not found that treatment satisfactory. 

Some might say that I am speaking about just a biased group of patients and have left out the group that may have improved with other treatments.  That is called selection bias and it applies in a couple of ways here.  First, all the treatment failures of other providers is a select group.  I don’t know how many improved and did not need to see psychiatrists. On the other hand – the people who did not improve are the people I want to see.  The reason I went into psychiatry was to see people with the most severe forms of mental illness.  Second, the people who are saying they are the only people who can cure mental illness with psychotherapy are only seeing the people who respond to their specific psychotherapy and most importantly who keep showing up.  Drops outs don’t count as cures.

There is also the discussion of cure.  The idea of cure depends a lot more on the nature of the illness than the treatment provider and the modality they are using.  Doing couples therapy about frequent arguments and decreasing the frequency of arguments is not the same as diagnosing dementia or depression due to hypothyroidism and treating that successfully with thyroid hormone.  In general, the treatment of severe mental illness is more complicated than that and there are mutually agreed upon goals for treatment. People return to psychiatrists for ongoing treatment because those goals are being met.    

The attitude also presents a false dichotomy of medical treatment versus therapy.   I don’t know of many psychiatrists who you can see and the conversation is like seeing your internist or family physician.  Whether they make it explicit or not – psychiatrists are trained in psychotherapy, they know how to talk with people in a psychotherapeutic manner, and they can often accomplish psychotherapy interventions in a short period of time.  I have seen people in weekly, biweekly, and monthly sessions for psychotherapeutic interventions in addition to medical treatment.  It is also the nature of psychiatric practice that long term patients will be seen in crises that occur to most of us over the course of our lifespan and that will need to be discussed.  The skillset necessary to do that requires training and exposure to the relevant resources.  As an example, I coteach a 2-hour seminar each week on psychodynamic psychotherapy and case formulation for psychiatric residents.  My colleagues in that seminar are all skilled psychodynamic and psychoanalytical psychiatrists and clinicians.  This week I am presenting on the psychodynamics of prescribing – a much more detailed discussion than the headlines or trolling remarks about psychiatric medications.     

If none of that sounds like the psychiatric practice, you read about on social media – it is not.   I have rarely seen an adequate description of how real psychiatrists practice psychiatry in social media.  It is usually a fleeting collegial discussion among experts.

Beyond the overt trolls there is also subtext.  How many times have you seen the same criticism of the DSM?  Repeatedly - even though it is a marginally significant document.  By that I mean – it is indexed to ICD codes that are the only relevant codes for diagnostic and billing purposes. The only advantage is that the DSM does elaborate more on criteria for codes, but it is very doubtful that the people using the codes are looking them up in a DSM.  Most of the diagnoses are not used.  Most of the physicians using the codes don’t own a DSM or even refer to it.  If I had to speculate, I would say that trainees in mental health fields probably purchase it as an obligatory item thinking they will learn about psychopathology.  But it is not a book about psychopathology.  It is basically a crude attempt to classify patterns of mental illness observed over the centuries of mental illnesses and refine those patterns. 

That brings up another common criticism of the DSM that can rise to troll levels. And that is - the DSM is deficient philosophically or as a diagnostic or classification system.  More pointedly psychiatry is deficient because they make, use, endorse, and sell the DSM.  The obvious problem is that psychiatry is much more than the DSM.  In all my years in acute care settings – the biggest part of my job was not deciding what page of the DSM applied to my work. My job was making sure that nobody died. Making sure they did not have a critical illness because it is hard for anyone to diagnose it in those settings.  Making sure they did not die from suicide or kill or injure somebody else.  Making sure my medical interventions did not adversely affect their medical conditions and making sure I knew what that comorbidity was.  Making sure that those catatonic and severely depressed patients were not getting dehydrated, starved, or a pulmonary embolism.  Making sure that patient with chest pain was not really having a heart attack.  Making sure that everybody on the treatment team was on the same page and not experiencing any countertherapeutic attitudes or emotions.   It is no accident that you don’t hear about that job on social media – the people criticizing psychiatrists have no idea what we do.

The DSM and psychiatry bashing can be accompanied by self-promotion.  Many people cannot promote their ideas without coupling it to criticism of psychiatry.  There is a better system.  Let’s use all the DSM symptoms and count them and rearrange them in different ways and say we have a superior system that will allow us to have superior models of mental illnesses. It reminds me of the debates of clinical versus actuarial judgment from 40-60 years ago (1).  In that reference, actuarial methods specifically the Minnesota Multiphasic Inventory (MMPI) were considered superior to clinical judgment.  But over that same period – that test was adopted to predict DSM diagnoses, was noted to be invalid for sociocultural subgroups and had to be restandardized, went from being a general psychopathology screen for law enforcement and professional schools to being used much less, and is used far less clinically. 

In the 1980s, I was interested in quantitative EEG (QEEG) research.  There were manufacturers that marketed machines with proprietary algorithms that they claimed were correlated with psychiatric diagnoses.  The analysis involved statistical probability mapping of EEG frequency bands and then cluster analysis using non-Euclidean geometry. Even more than that - it required adding clinical data to the algorithm – like whether the person was drinking alcohol, using other drugs, and what medication they were taking.  The resulting reports were not only inaccurate, but they also restricted the application to very few patients.  I have no more confidence that newer systems of phenotyping with old metrics and symptoms will get better results.

The reality for every psychiatrist is that they are face-to-face with a person that needs some degree of help.  Depending on the setting that person will recognize it to varying degrees. It takes a lot of discussion, relationship building, and analysis.  It involves talking with and building relationships with some people that most people would actively avoid.  Those kinds of relationships are critical. It takes a lot of attention to detail at the medical, social, familial, and cultural levels. It takes pattern recognition involving experience in training and in practice to determine what is the best intervention. It is a serious job that very few people want to do.

A realistic social media setting where psychiatrists can aggregate would be a plus for exchanging information, posting research and relevant papers, and discussing relevant treatment modalities.  A setting that is free of the cartoons and slogans designed to ridicule psychiatrists written by people who have no idea of what the experience of a psychiatrist is like. So far – I have not found that site.  Like I started out saying in this essay LinkedIn is like all the rest.  There are certainly many valued colleagues and references over there, but the trolls are building.

Let me know when there is a troll free site with standards and moderation and I will be there.  Let me know if you are interested in making that site and I will give you my ideas of how it can be done.  Until then this blog is my troll-free zone.                      

 

 

George Dawson, MD, DFAPA

 

References:

1:  Dawes RM, Faust D, Meehl PE. Clinical versus actuarial judgment. Science. 1989 Mar 31;243(4899):1668-74. doi: 10.1126/science.2648573. PMID: 2648573.

2:  John ER, Karmel BZ, Corning WC, Easton P, Brown D, Ahn H, John M, Harmony T, Prichep L, Toro A, Gerson I, Bartlett F, Thatcher F, Kaye H, Valdes P, Schwartz E. Neurometrics. Science. 1977 Jun 24;196(4297):1393-410. doi: 10.1126/science.867036. PMID: 867036.

3:  John ER. The role of quantitative EEG topographic mapping or 'neurometrics' in the diagnosis of psychiatric and neurological disorders: the pros. Electroencephalogr Clin Neurophysiol. 1989 Jul;73(1):2-4. doi: 10.1016/0013-4694(89)90013-8. PMID: 2472947.

4:  Fisch BJ, Pedley TA. The role of quantitative topographic mapping or 'neurometrics' in the diagnosis of psychiatric and neurological disorders: the cons. Electroencephalogr Clin Neurophysiol. 1989 Jul;73(1):5-9. doi: 10.1016/0013-4694(89)90014-x. PMID: 2472951.

Current Business Practices and Financing the Health Care Industry In the US - Don't Work

 

My last post discussed current and historical business practices to ration medical care and increase profits by reducing reimbursement to hospitals and physicians while decreasing benefits to patients.  The net result of those practices is shifting the cost of care to patients or in the extreme case just not paying the bills at all.  The current situation at Hennepin County Medical Center was the case in point. 

This morning an article came out in the Star Tribune  HCMC is too big to fail, but Hennepin County leaders say it’s now on life support (1).  That well-worn description of being too big to fail misses the point that many large county hospitals have failed.  It did not matter how many services they provided or the fact they were training physicians.  In one famous case all of the physician trainees were informed the hospital was closing and they needed to find a new training program. 

The most famous case was Hahnemann Medical Center in Philadelphia 2019.  In that case 570 trainee across 35 separate programs.  Hahnemann had been a safety net hospital for low-income populations for over 170 years.  The permanent closure of Hahnemann resulted in 20% increase emergency room volumes and an 80% increase in wait times at nearby hospitals.  An additional 12-14 Pennsylvania hospitals are at risk of closing by 2031 largely due to reductions in Medicaid funding.

The Hahnemann closure was one of the first examples of what can happen to healthcare assets under private equity management.  In the case of Hahnemann, there was a debt financed purchase of the hospital. The real estate assets were spun off into private management while the hospital was left to pay off a high interest loan and went bankrupt 18 months after the acquisition.  There was controversy about the 570 residency slots and 6 local healthcare networks bid $55M – but courts eventually ruled that they were not assets.  The properties were eventually broken up and sold to recoup the cost of the bankruptcy.  The state of Pennsylvania passed laws to prevent hedge funds or private equity from interfering with healthcare businesses that are in the public interest and they require a 6 month notice with a closure plan for any hospital in the state.

Almost on cue – the New England Journal of Medicine (NEJM) came out with three commentaries (4-6)  on what can only be described as the predatory financing of healthcare.  For the record – I consider rationed healthcare and cost shifting and all the mechanisms associated with that - predatory financing.  Healthcare is about the only field I know where you can do the work, business managers can decide not to pay you, and they are backed up by some government regulation. It is not like the work is elective or some kind of scam.  In all my years of acute care psychiatry – I was not pulling people in off the street.  I was generally trying to solve severe problems that many other people had decided required hospital care and passed on to me.  Despite that consensus – some business manager could decide against reimbursement or decide the patient should pay the bill even if they thought they were covered.

The first paper looks at the issue of health care equity and the effects of private equity (PE).  In an ideal world, private equity companies are supposed to raise capital to acquire companies, take control of them, improve their efficiency and then sell them in a fairly short period of time.  The general idea is that PE has substantially higher returns on investment than typical stock market investments.  As the PE industry has grown, the premium return for investors has become more debatable.

The first paper in the NEJM Perspective looks at the impact of PE on healthcare financing. The use the CDC definition of health equity:

“Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving this requires focused and ongoing societal efforts to address historical and contemporary injustices; overcome economic, social, and other obstacles to health and healthcare; and eliminate preventable health disparities.” CDC

As noted in the previous post the safety-net hospital concept is there to address income and healthcare insurance inequity.  The Emergency Medical Treatment & Labor Act (EMTALA) law is another.  EMTALA is commonly recognized as a rule that no emergency department can turn a person away who requires that level of care based on ability to pay. 

The authors in this piece describe accumulating evidence that PE has reduced access to care for many vulnerable populations including rural, elderly, low-income, and racial and ethnic groups.  Several policy factors and failures have led to an expansion of PE investment. There is a concern that there is limited oversight of these companies compared with publicly traded companies.  The authors provide several examples of tactics used by PE firms that have led to the failure of the medical entity, reduced or no access for patients, and greater profits for the investors.

The first tactic is a sale-leaseback transaction. The medical facilities acquired are sold to an entity affiliated with the firm and leased back to the hospital or clinic at inflated rates.  During a dividend recapitalization the PE takes on additional debt to pay investors rather than investing in the medical business. They give an example of a system where these measures led to tripled debt while senior managers got large bonuses.

Quality of care has been a marginal issue since managed care took over medicine in the mid-1990s.  In the above example, quality of care declined to the point it was ranked among the worst in the state and it was eventually closed leaving residents no access to acute care. They cite increased deaths in emergency departments and after surgeries. The same company had a venture in another state that failed as well. The formula involved cost savings at the expense of employees (lay-offs, reduced FTEs, reducing physicians in favor of extenders, and cutting low margin services).  On the administrative side upcoding, surprise bills, and higher charges are used as well as selecting younger and healthier patients. 

They suggest several fixes to the various PE problems that involve targeting management and accounting practices that can result in profits for investors, but closed hospitals, produced bad debt, and resulted in no access to emergency care for the patients involved.   Some of those suggestions include personal liability for some of the company officers and clawback provisions for profits made by some of these exploitative techniques.  There were no suggestions about adequate reimbursement for hospitals in the first place.

The second paper (3) discusses a political change at the Centers for Medicare and Medicaid Services (CMS).  Since the Trump administration is focused on denying that a lack of equity exists in the country they have changed the focus to efficiency. Efficiency as in free-market solutions is a long time Republican slogan that lacks any evidence that it is useful in healthcare.  The most significant piece of evidence that free markets do not work is the existence of Medicare and Medicaid and the remarkable number of people and services that they cover. Without those programs – none of that healthcare would be delivered and there would be considerably more morbidity and mortality.

The program titles have changed from States Advancing All-Payer Health Equity Approaches and Development to Achieving Healthcare Efficiency through Accountable Design (AHEAD).  It replaces equity plans with accountability plans including “chronic disease prevention, choice, and competition.”  On the choice side of the equation increased telehealth, and decreasing qualifications for networks and providers.  This seems to be a straightforward approach to decreasing quality to produce a cheaper product. The authors do not state that explicitly but say there is limited evidence it would work. 

The most likely outcome of AHEAD is that it will decrease investment in safety net facilities.  Combined with Medicaid funding reductions the impact on safety net hospitals will likely be significant. 

The final paper was about medical credit cards.  Before reading this paper – I could not think of a worse idea.  The threat of medical bankruptcy drives the for-profit medical industry in the US.  Most medical bankruptcies occur in the US.  That combined with medical charges and the way they are billed is the primary reason Americans are highly motivated to have health care insurance. At the time of this post the Annual percentage Rate (APR) of credit cards in the US is between 20 and 25% depending on credit rating and other factors.  About 8-9% of the population has medical debt. Three million owe over $10,000.  Since credit cards calculate daily interest – it could take 20 years to pay off this debt by paying the minimum amounts.

One in every 4 people with medical debt is using a credit cared to pay it off.  There can be incentives on both sides of the equation.  From the billing side – it is paid of on a timely basis.  From the consumer side – there can be delayed interest arrangements if the debt of paid off in a specified interval.  That has led to most medical credit card sign up occurring in medical offices.  Compared with the APR rates for typical consumer cards medical cards may be as high as 40% - people with the lowest credit ratings incurring the highest rates. 

Medical credit cards are complicated by the fact that insurance companies may not be paying the same rates for the same services that are being charged to cards due to negotiated deals.  The person paying cash pays the higher amount.  In some cases, people may qualify for medical assistance programs but they are not informed about this option.  The medical providers offering the cards may get a rebate in terms of lower transaction fees.

The overall conclusion of this final paper is that medical organizations should not actively market medical credit cards to patients. They suggest that the existing federal laws be expanded to provide transparency about terms of medical credit cards and offer more payment options. In my experience, no patient should be charged more than an insurance company for the same service just because they are paying cash and are not part of a negotiated fee schedule. Most of the health care organizations in Minnesota offer monthly payments with specified minimums – but the interest calculations may not be clear.

In summary what can be learned from the recent financial problems with Hennepin County Medical Center and these perspectives in the NEJM.  First, the public and private financing of the US healthcare system is getting progressively more precarious.  There are more safety net and rural hospital failures, less quality care, and more expansion of private equity investment.  Second, despite the emphasis on access and cost both of those measures are diminished significantly by the current financing structures. Despite the current administration’s emphasis on efficiency over equity there is no way efficiency can be maintained when there are large shifts in emergency department utilization and admissions due to the elimination of safety net hospitals.  Third – there are an endless number of ways the system can be gamed to make money or avoid regulation. Much of that gaming is in the form of rationing and cost shifting but there are also accounting maneuvers to make it seem like the required amount of financing dollars is going to medical care.  How is that possible in a system that has seen a 3,000% increase in administrators compared with a 100% increase in physicians over the past 50 years?

The only rational solution at this point is to eliminate the healthcare companies and go to a single payer system.  Single payer Medicare for all is an idea that is more frequently floated these days.  Medicare traditionally has vey low administrative costs but it admittedly is less intensive than managed care organizations. In the previous post I cite the Swiss system as saving a trillion dollars per year if applied to the US system.  I have seen experts debate how healthcare financing in other countries might affect the US.  I think the only way to find out is to bring experts from Switzerland to the US and suggest how to make that transition.

It is apparent that nether political party in the US is capable of the task. 

     

George Dawson, MD, DFAPA

 

References:

1:  Roper E.  HCMC is too big to fail, but Hennepin County leaders say it’s now on life support.  Minneapolis Star Tribune. March 8, 2026.

2: Rosenbaum L. Losing Hahnemann - Real-Life Lessons in "Value-Based" Medicine. N Engl J Med. 2019 Sep 26;381(13):1193-1195. doi: 10.1056/NEJMp1911307. Epub 2019 Aug 28. PMID: 31461591.

3:  Pomorski C.  The Death of Hahnemann Hospital. New Yorker.  June 7, 2021, Vol. 97 Issue 15, p30-37.

Excellent look at the chaos and fragmentation of health care that happens when a large safety net hospital closes and how it happens during a private equity leveraged deal.

4:  Yearby R, Alsan M. Private Equity's Transformation of American Medicine - Implications for Health Equity. N Engl J Med. 2026 Mar 5;394(10):937-940. doi: 10.1056/NEJMp2415615. Epub 2026 Feb 28. PMID: 41770029.

5:  Figueroa JF, Meara E. From Equity to Efficiency - Navigating Changes to the AHEAD Model. N Engl J Med. 2026 Mar 5;394(10):940-943. doi: 10.1056/NEJMp2514355. Epub 2026 Feb 28. PMID: 41770017.

6:  Alvarez A, Sloan CE, Ubel PA. Debt by Design - Navigating the Hazards of Medical Credit Cards. N Engl J Med. 2026 Mar 5;394(10):943-945. doi: 10.1056/NEJMp2514612. Epub 2026 Feb 28. PMID: 41770001.

Do Safety Net Hospitals Need A Safety Net?

 

 

This is about the current financial crisis at Hennepin County Medical Center (HCMC).  It is one of the flagship medical centers in the State of Minnesota.  It provides unique care that is not available anywhere else. It was the first place I interviewed at for a residency position out of medical school back in 1981. The first person I talked with was (the now late) Mark Mahowald, MD.  Dr. Mahowald was a world-famous sleep researcher and long-time head of the Hennepin Healthcare Sleep Disorder Center.  He has over a hundred publications on sleep and its implications.  He and his colleagues also trained physicians from several other disciplines in sleep medicine in their fellowship program.  That clinic is being shut down because of budgetary problems at the hospital.

After getting selected into the program at the University of Minnesota – half of my residency class (n=8) went to St. Paul-Ramey Medical Center (SPRMC) and the other half went to HCMC for the rotating internship year.  In those days both were designated as county hospitals.  That meant they were subsidized to some extent by the counties where they were located and mandated to treat anybody that showed up at their door whether they had health insurance or not.  When you have that kind of mandate you develop services that nobody else has, because you are the provider of last resort. You also develop expertise in treating people with the most severe problems largely because that is a group defined by social determinants including whether they have healthcare insurance.

Both hospitals are Level 1 Trauma Centers.  Both hospitals have burn units.  Both hospitals have extensive Emergency Medicine services closely aligned with paramedics.  Behavioral emergencies are most likely brought to these hospitals adding to the psychiatric training. Both hospitals treat the most people who require involuntary psychiatric treatment in the state.  The specialist physicians in both places are excellent clinicians and teachers.

After I completed my training – I went back and became staff at SPRMC.  I enjoyed working at a county hospital.  Reimbursement was not great, but I liked seeing people with the most severe problems.  I liked close relationship with consultants in every department and the fact that we had a certain esprit de corps.  We were all squarely focused on providing the best possible care to people whether they could afford it.

SPRMC and HCMC were on parallel courses until the 1990s.  At that point the physician group affiliated with SPRMC decided to cede control of the hospital to HealthPartners – a managed care company in 1993. Prior to that the facility had been public since its 1872 founding as the City and County Hospital, later becoming Ancker Hospital (1923) and St. Paul-Ramsey (1965).  The rationale for the merger was that SPRMC was in a market saturated with hospital beds and it assured access to an increased number of patients needing hospital beds.  It also provided access to the specialty physicians of Ramsey Clinic the associated medical group.

In the meantime, Hennepin County Medical Center remained a county hospital.  The county owns the land, physical plant, and assets.  In August 2025, the Hennepin County Board took control of the hospital from a volunteer board – The Hennepin Healthcare System that had managed the hospital since 2007.

In February 2026, the county board warned that the hospital could close as soon as May of 2026 if solutions to a funding crisis could not be found.  Repurposing a 0.15% sales tax was proposed as well as staff and programming cuts.  The tax was originally in place to pay off financing for Target Field and that should happen in the next year.  Increasing the sales tax to 1% at that point will provide $280-$341M in annual funding.  Since 40% of HCMC patients come from outside of Hennepin County this was thought to be fairer than increasing the property taxes for residents of the county.

In researching this article, I found a document on a Minnesota State web site entitled Minnesota Hospital Uncompensated Care and Its Components, 2013 to 2023. The range of uncompensated care for HCMC during that time frame was $37.5M in 2013 to $64.2M in 2023.  The highest years in the range were $81.5M in 2022 in and $65.3M in 2021.  Total uncompensated care for the entire time was $453M.  There are estimates in various documents that the uncompensated care could reach as high as $200M/year.

The uncompensated care figures can be put into perspective in several ways.  First – these numbers are the largest of any hospital in Minnesota including some with a larger bed capacity.   Second – they have become progressively larger over the years compared to many of the other 131 hospitals that have relatively flat uncompensated care totals.  Relative to the 2025 HCMC operating budget of $1.57B, the uncompensated health care for that year was is estimated at over $100M or about 6%.  There are estimates this figure will stay at $100M/year and an addition loss of $1.7B in Medicaid Revenue over the next decade.

In the short term, significant cost cutting measures have been put in place. They include shutting down 100 beds (461 to 361).  There have been staff layoffs with 100 positions eliminated.  Several programs including Sleep Medicine, acupuncture, and chiropractic care have been eliminated.  The geriatrics program has been incorporated into primary care.  Retirement fund contributions for employees have been frozen. 

But the real crisis at HCMC is that they are not being compensated for the services they provide.  It is a crisis of the American healthcare system rather than of just one hospital.  It is continually misunderstood and mismanaged at the political and business level. There is a general lack of awareness over the past 40 years that American healthcare has been taken over by business entities.  The disappearance of county hospitals like SPRMC was one of the first signs. As a physician, the other signs included the disappearance of staff who assisted with all the paperwork and a new billing and coding system that depended on that paperwork.  In my case that was three fulltime people.  The billing system was relative value units or RVUs that could be assigned a conversion factor to determine what reimbursement might be.  RVUs were tied to the billing document that was structured to contain a certain number of bullet points necessary to qualify for that RVU.  It was an easy formula to ration reimbursement – just reduce the multiplier or deny the care all together.

All that sounds boring and technical.  It was based on trying to quantify a purely subjective system.  To cite one example, from my experience in 2 successive years of billing and coding audits I went from the top ranked physician (a dubious honor) to the lowest rank without making any changes in how I recorded the notes. The only thing that changed was the judgment of the people doing the ratings. To make matters much worse, physicians learned that we were now legally responsible for any errors and that in the worst case we could be held liable for wire fraud under RICO statutes if an erroneous bill went out in the mail.  Before 911 - there were FBI raids of physician offices looking for these errors. 

When I look at the independent auditors’ data available for HCMC for 2024 – it seems like there is a straightforward loss of $40M (net operating revenue – net operating expense).  At the same time care patterns (average length of stay and average daily census) were flat.  Case mix acuity was slightly higher and the auditors’ comment that there are often no good discharge scenarios for the patients.  Discharges were higher (17,090 compared with 16, 502 the previous year).  Work RVUs (WRVUs) were 5.2 % higher.   These WRVUs are reflected in a gross patient charge figure of $3.66B.  From that figure there is a $2.1B deduction based on rate discounts with various providers and a slight add back for government subsidies that leaves a net patient service revenue of $1.337B.  Patient services are discounted by about 60% due to the way governments and insurance companies operate. 

If it seems like that is a steep discount for quality services – it is. And that discount is not evenly distributed across services. The best example is the mental health (or behavioral health) carve out.  That means that a managed care company manages mental health problems through separate system that typically reduces reimbursement to physicians by an additional 20% relative to medical surgical providers.  Medicaid carve outs typically pay 20-30% less than Medicare. The managed care system can also simply deny care (and payment) to anyone admitted to a hospital based on their subjective review of the hospital record.  In any individual patient the range for discounting services can be anywhere from 60 to 100%. 

How did the USA arrive at such an irrationally financed system of health care?  The short answer is that it was a government facilitated transfer to for-profit businesses.  When I say government facilitated – I mean all the regulations I have talked about so far and more make it easy for health care companies to make huge profits.  They have taken very locally managed businesses focused on service and quality and built large networks focused on profit and shareholder wealth.  In the political landscape this has been facilitated by a party that uses the physician-patient relationship to leverage an underlying agenda of dictating and in some cases criminalizing healthcare available to women and accusing people with no healthcare of being lazy. The problem they say is that people are not working even though most workers can not afford health care premiums especially due to the current administration. 

There are obvious solutions that American politics ignores.  Here is one that is truly cost saving, covers everybody, and provides at least the same level of high-tech healthcare as the current system while saving a trillion dollars a year.  But don’t expect it anytime soon.  Despite all the talk abut the high cost of healthcare – the real rationale behind this system is shifting money to the people at the top – businesses, CEOs, and investment funds.   The people operating this system have no interest in universal coverage or quality care.  They see a large pool of premiums and government subsidies and are focused on how to get as much of it as possible.  There is not an easier path than denying care to patients and steep discounts to hospitals and physicians.

That is the real crisis for HCMC.  They are the safety-net hospital for all those people that commercial and government insurers will not cover. They take more government discounted payers than anybody else and even then, have difficulty enrolling the uninsured in those programs.  They provide a massive level of high-quality service to these folks.  They have 239 trainees in 20 different disciplines including 29 residents in psychiatry.  Time to stop pretending that this crisis is not the result of an irrational system and start funding HCMC like it would be funded in a rational system of care.  

Like Switzerland for example…

 

George Dawson, MD, DFAPA

 

References:

1:  Hennepin Healthcare Financial Reports (2022, 2023, 2024):  https://hennepinhealthcare.org/about-hennepin-healthcare/financial-reports

2:  Hennepin County 2025 Operating Budget:  https://www.hennepincounty.gov/-/media/hennepinus/your-government/budget-finance/documents/2025-operating-budget-book.pdf

Supplementary 1:  The Swiss have roughly three times the number of psychiatric beds per 100K compared to the US.  Just another sign that the US system is rationed to make money for the people at the top (see bar graph):  https://real-psychiatry.blogspot.com/2018/07/governments-and-psychiatric-beds.html

Supplementary 2:  I tried to make the above essay as focused as possible on the root cause of this financial crisis.  There are a lot of complicating factors including the demoralization and anxiety of the staff.  It is very common for example to scapegoat the staff for financial crises.  It sems like the most common administrative approach used in healthcare.  It reads like this in staff meetings: “We are in a crisis because you are not productive enough.”  And by productive they mean not generating enough RVUs through patient contacts.

Let me describe a hypothetical scenario of what happens to a typical medical staff.  Staff meetings occurred at the time of the changeover to RVUs.  Prior to this change every physician had assigned jobs and was busy seeing patients all day long and doing the associated work.  Suddenly RVUs are calculated and there is a suggestion that not everyone is pulling their weight (not everyone is producing the same number of RVUs).  The administration decides there will be a 10% holdback of everyone’s salary until all staff have met their minimum RVU quota.  Before that announcement everyone was quite happy with their world and colleagues, but suddenly there is a competitive factor that has been artificially introduced.

It becomes clear that everyone has met their minimum RVU quota.  At a new meeting each clinician now finds that they have been billed for any assistance they get from administration as well as the lease of the old building they are working in.  They have to pay for that bill in RVUs.  At another meeting the RVUs are recalculated after a staff person points out the administrators were using the wrong calculations.  In individual reviews with the head administrators, physicians find that research and teaching do not count toward reimbursement – only RVUs though direct patient contact. Some staff are reluctant to teach due to the administrative burden and the lack of reimbursement or even good will.  Some staff find themselves travelling to distant clinics just to get enough RVUs.  Some staff quit and move to a non-RVU based system. Some staff reduce the time spent with patients to increase their RVUs and salary. 

The bottom line for this post should be that no matter how many RVUs that are compiled – if you do not get paid for most of that work – it is a losing and demoralizing proposition that is not the fault of an overworked and conscientious staff.  The staffs that I worked with in the above scenarios were all hard working and focused on doing the right thing.  In many cases they spent too much of their time and energy trying to compensate for administrative blunders and an inadequate reimbursement structure because they had the market cornered in poorly compensated or uncompensated care.     

Supplementary 3:  Length-of-stay (LOS) is a huge factor in rationing.  Diagnosis Related Groups (DRGs) are estimated lengths of stay based on diagnosis and reimbursement is based on where the LOS is relative to the DRG.  If the LOS days < DRG days there is profit.  If LOS days > DRG days there are varying degrees of loss.  In some cases of complex care the allotted DRG days be exceeded by months leading to negligible reimbursement until a large outlier figure is reached.  In those cases, additional compensation is possible.  Probate court involvement for civil commitment, court ordered medications, or guardianship and conservatorship can add weeks to the discharge date.

Reimbursement at SPRMC and HCMC is based on APR-DRG (All Patient Refined Diagnosis Related Groups).  Per diem does not apply and there is a fixed payment whether the stay is 3 days or 15 days. An exception is made if the stay exceeds 180 days.  Days 0 – 180 are still covered by the single payment but at 181 days reimbursement occurs as a cost-to charge ratio.  Although I have not found any specific breakdowns – single payment systems for complex problems especially in the absence of adequate discharge resources can rapidly decrease compensation to hospital systems and precipitate financial crises.      

Graphics Credit:

Hennepin County Medical Center - Minneapolis, MN taken on 25 August 2013.

Author:  Gabriel Vanslette

License:  CC BY 3.0 Attribution 3.0 Unported