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Will Nicholson M.D.


The only reason physicians are of much use is because we help people solve their problems.


When I graduated from residency I was frustrated.  I wanted to write an open letter to America’s Medical Education system outlining the things they did that were injurious to those they had been entrusted to train.  I also wanted to write an open letter to America’s health care system describing the ways that I had seen us fail to do no harm.


But I got into this profession because I wanted be someone who solves problems not just one who complains about them.  It is easy to criticize, to tear down, or to destroy.  (And at times it may be necessary to do so.)  It is quite another thing to construct, or cure or create. 


Since I didn’t have any actual solutions to offer I decided not to publish those letters.


I think about that every time I roll out another op-ed or blog post or do another interview.  Health care has enough problems.  I want to contribute to the solutions.



…after a blustery run with the dogs:


I know the above sounds a bit Pollyanna-ish, but I would like to challenge our nation’s leaders to hold themselves to the same standard when it comes to health care.


Anyone can score political points complaining about the health care system, but a real leader would offer a viable plan to improve things – not just a list of worn-out clap-trap talking points.


Here's an interesting NPR segment I stumbled across about ER overcrowding being due not to uninsurance but to lack of access to primary care.  This isn't the impression I get from Minnesota, but I wouldn't argue with the American College of Emergency Physicians.  Even though "insurance for all" may not be a cure all, I still think it's a step in the right direction.




There but by the grace of God go I.


I was stunned to hear crowd members at the CNN/Tea Party Republican debate last night cheering “Yes!” when Congressman Ron Paul, MD was asked if a 30 year old who didn’t buy health insurance should be allowed to die if he became gravely ill.


It’s 23:30 into the link below:




Sick people are not the problem in our health care system, they are actually the whole reason that we have a health care system.  I am all for personal responsibility and for eliminating waste in health care, but tying to save the life of a 30 year old person – regardless of their insurance status – doesn’t seem like waste to me, it’s the reason I go to work.


The richest, most talented nation in the world should be able to make sure that all of its citizens get the health care they need.  This growing sentiment of “blame the patient” may be politically convenient, but this kind of cannibalistic scapegoating doesn’t solve any of our problems.


Instead of kicking sick people when they’re down, we need to be demanding more from the people who actually have the power and make the decisions.  Doctors like myself and Congressman Ron Paul, MD should be leading the charge, not just shrugging our shoulders and avoiding the issue.


Introduction to More Refugee Physicians

I was invited to meet with a group of 10 Cuban refugee physicians today through the African And American Friendship Association for Cooperation and Development.  Their stories are very frustrating.  They were brought into America especially as health care workers, but once they got here the Cuban government refused to release their credentials so they cannot verify their license.  They have studied for the board exams and gone to great lengths to learn about American health care by working and volunteering in the health care field, but without clearance through our licensing organization to apply to residency they have no chance to get trained to practice medicine in the U.S.

Brought here as health workers but now unable to actually re-train in their field.  It sort of turns the American Dream on it's head.

These people were aware of our Preparation for Residency Program and its work training immigrant and refugee physicians and they've been working on finding grant money or even securing personal loans to try and help replace the funding that was cut in this year's state budget deal.  It is hard for me to explain to people - and to the press for that matter - that simply replacing the $150,000 that funded our program does not address the severe financial blow that cutting 24 million out of MERC funding has done to the foundation of medical education in this state.

Medical Education will have to make up that money on its own.  It would be like asking public schools to spend most of their time holding bake-sales - they'll have very little time for actually teaching students.  What is lost is the ability of the organization to do creative and innovative things because they're stuck just trying to make ends meet.

The more of these physicians I meet though.  The more I think that not just Minnesota, but the national medical education system needs to find a way to give them a fair shot at residency.  They came here under very unique circumstances and they may require some unique assistance to become eligible to apply for residency, but if they have the brains and talent and determination to make the cut why not give them the chance?  I want to make sure we keep the best and brightest minds going into my profession, no matter where they're from.  The lumbering machinery of medical education shouldn't get in the way of the talented, determined physicians it is supposed to serve.


MPR Segment about Training Somali Physicians

Today MPR aired a segment about the training program I've been working on that helped 3 Somali physicians get back into the practice of medicine... and then got de-funded in the state budget deal.


We are currently working to review and publish the results of our project in hopes of finding an alternate funding source.


Another example of why preventative care should be available to everyone.

I recently took care of a diabetic gentleman in his 20s whose blood sugars had been so badly controlled he had developed a gangrenous foot ulcer - a very advanced complication for such a young person.  I asked him about why he had such a bad track record of diabetes control - explaining that it had likely been the main reason he was having to face possible amputation of his entire foot. 

This was no irresponsible free-loader.  He was a mathematically gifted child of first generation immigrants who had been working his whole life in the family business trying to help make ends meet.  Trying to live the American Dream.  The family business had trouble getting insurance coverage and the young man clearly indicated that he was willing to sacrifice his own health - by not accessing the needed helath care - in order to help the business and the rest of his family succeed.

Insulin is cheap, amputating someone's foot is expensive.  Why not make the medicine that is essential to this young man's survivial available to him so that instead of being sick and dying prematurely he can be a prodcutive member of our society and his family?


Funding to Retrain New Immigrant Physicians Cut.

The State budget "fix" eliminated the funding for the University of Minnesota Medical School's Preparation for Residency Program as part of the HHS budget by crossing out the following text in the final draft:

33.12 (3) $1,800,000 to the Academic Health Center. $150,000 of the funds distributed to





33.13 the Academic Health Center under this paragraph shall be used for a program to assist

33.14 internationally trained physicians who are legal residents and who commit to serving

33.15 underserved Minnesota communities in a health professional shortage area to successfully

33.16 compete for family medicine residency programs at the University of Minnesota.

Up until this point we had been reassured that funding would remain intact - as it had in all previous budget scenarios.  For $150,00 we trained 3 new family physicians to work in under-served communities.  Since training a single medical student in Minnesot costs many times that, I wonder how lawmakers envision this to be a cost-savings to the state.

I guess the next step will be to publish our results and attempt to find funding for the program elsewhere.






The Institute of Medicine recently recommended that women’s contraception be offered free of charge by insurance companies.  While buzz over the controversy bubbling up because of conflicting reproductive beliefs seemed to dominate the discussion the idea that some medicines are so useful they should be given away free is an interesting one.


Some health care expenditures actually save money.  We know that certain medicines work very well.  Patients who take them consistently are healthier and their care is much cheaper than patients who are non-compliant.  Most of these medicines are also quite cheap.  The limiting factor is often patient compliance.  Giving away these medicines – and medical care for the diseases that require them - for free could be a win-win situation.


An example would be the 21 year-old homeless, single mother I admitted to the hospital for a fainting episode.  The patient had hypothyroidism – a condition where the thyroid doesn’t produce a hormone crucial to your health.  The patient hadn’t taken her thyroid medicine for over a year (since her child was born) and her blood test showed a thyroid hormone deficiency that was nearly off the charts.


The medicine itself costs only a few dollars a month and if the patient had taken it she could have avoided a costly ER visit, hospital admission and numerous costly tests.  The reason she identified for not refilling her prescription:  She couldn’t afford to pay the $150 to see her regular doctor to get the prescription refilled and her blood tested.  Because she couldn’t pay $150 her ultimate health care costs will likely exceed $5,000 for this fainting episode.   Plus, for the last year this homeless single mother was sick from her thyroid deficiency.


So if it’s cheaper to actually treat a patient’s illness and keep them healthy than it is to wait for them to have a preventable medical crisis why not do it?   


Filling the Physician Shortage

Here’s the address to the front-page Star Tribune article written about the problem of unemployed immigrant physicians which includes coverage of the program I have been teaching:


I also included a copy of a follow-up letter I sent to the Strib.  I sent similar letters to out state’s legislative leaders.  I am happy to be involved in such a positive project and working with such exceptional and talented individuals.



Letter to Star Tribune 7/6/11


There is currently no funding for the training program for immigrant physicians that you featured in your article "Immigrant docs find careers DOA”.  Our program was made possible by innovative leadership from Minnesota’s immigrant communities, state lawmakers, the U of M and local hospitals. 


With the co-operation of all these groups we were able to get three physicians back up-to-speed in a fraction of the time and at a fraction of the cost it takes to train a brand-new physician from scratch.


Gridlock at the state government and a trend away from state level investment in health and education has left the future of this innovative program in limbo. 


So while there is a critical need for these physicians and while I would love to help train a new group of physicians this year, our program will be effectively shut-down unless our state leaders find it worthy of support.



Will Nicholson M.D.

Associate Professor, University of Minnesota Department of Family Medicine


The Prescription Should Address the Problem

How is it that after piling the cost of two wars, the Wall Street bail-out and tax cuts for the wealthy onto the national debt without blinking, congress decides draw-the-line at paying Medicare costs for elderly folks.  The AP article at




summarizes the mind-set of both parties in Washington.  Does doing no harm to Wall Street’s bonuses or doing no harm to corrupt war contractors’ profits take precedent over doing no harm to sick old people?  Which of us voted for that?


If we don't use draconian measures on those other groups we really shouldn't subject seniors to voucher systems and "spending targets".  Especially since everyone I know in health care is already trying to stretch their Medicare dollars as far as possible.  I'd like to invite the architects of these arbitrary cost-control measures to come down into the trenches with the rest of us, get some multiple-drug-resistant bacteria under their nails and take care of a few sick folks with us.


Maybe then they'd see that putting economic barriers between doctors and sick people will not save money.  We don't need another health care solution that was cooked up in a board room or thought up in a think tank.  They don't work.


We will fix health care when we start focusing on patients instead of budget gimmicks.

I will try to outline some examples of in upcoming posts.


Consumers Unimpressed with Health Care

As we look to "consumer driven" models for guidance on how to reform health care it's good to check back with consumers occasionally.  Harvard/Robert Wood Johnson Foundation study asked Americans to give a report-card grade to their health care and a significant majority gave American Health Care a "C" or lower.  In fact more than one out of 10 gave American Health care an "F".

Needless to say there's plenty of room for improvement.  I don't know many doctors who are comfortable with a "C" grade in anything.

The more instructive part of the study from my point of view were the less publicized findings that show that health care consumers may need more help than we realize before they can become an effective force to mold health care improvement.  For example, a solid majority of people polled did not perceive significant Racial or Ethnic Disparities when it comes to quality of Hospital Care when in reality there are significant disparities, they are wide spread and have been well documented.

In addition, about half of those polled said the available quality measures wouldn't be likely to induce them to chose an unknown provider or unknown facility.  For example 57% of those surveyed said they would chose a familiar hospital over one that was highly rated.  This goes directly against the principle that the consumer will pick the highest-quality option if given a choice.

The power of American consumers to shape health care is undeniable, but this study shows that the tools we've developed to help consumers make good decisions are inadequate and that the information they use to make decisions may not always be accurate.  I don't think that this means consumers can't make good decisions.

Every day at work I help people make life-changing decisions like whether or not to have surgery, what medicine to take or what kind of cancer treatment to use.  In medicine we use a process called informed decision making, where we make sure the patient is not just told about but actually understands all the options as well as the risks and benefits of each before making a decision about their health.  By doing this we help people make the decision that is truly right for them.

If our national leaders plan to abdicate a substantial part of the responsibility for reforming health care to consumers  they need to first give consumers what they need to succeed.  If we don't make sure that every consumer has the right tools, accurate information and the ability to make truly informed decisions we'll be asking them to "drive" health care reform with a blind-fold on.


Reshuffling the Deck ...Chairs

The following NYT Editorial regarding House Republican Medicare reform is well titled.  “Reshuffling” the costs and responsibilities of Medicare is one convenient way to make them disappear from the federal government’s balance sheet.  The cost, inconvenience and liability of insuring Americans over 65 would shift away from being the responsibility of America’s federal government toward being entrusted to America’s insurance corporations. Medicare recipients would shift from passive “beneficiaries” to more active “consumers” who are expected to shop for the best deal using a voucher system.  It’s a politically intriguing idea but from the perspective of a family doctor who measures success based on curing illness not winning elections the word “shuffle” brings to mind the old expression about the deck chairs on the Titanic.


The Republican Medicare Reshuffle

New York Times Editorial, April 14, 2011


Representative Paul Ryan and the House Republicans are portraying their budget proposal for the next fiscal year as a courageous effort to finally bring federal spending on Medicare under control. An analysis issued last week by the nonpartisan Congressional Budget Office finds that the Ryan proposal would sharply reduce federal spending — but at the price of shifting more of Medicare’s costs onto beneficiaries and their families.

How much more? Calculations derived from the C.B.O. analysis show that in 2022, when the Ryan plan would kick in, the typical 65-year-old would pay $6,400 to $7,000 more per year than would be paid for comparable coverage under traditional Medicare.

Mr. Ryan’s proposal would change Medicare from an entitlement program in which the government pays for a defined set of medical services into a “premium support” program in which the government would give beneficiaries money to help them buy private insurance. He contends that competition among health care plans and more judicious use of health care services by beneficiaries can help bring down the cost of health care and reduce the federal government’s burden.

But the C.B.O. says a private plan offering comparable benefits would be a lot more expensive than traditional Medicare because the private insurer would have higher administrative costs, would need to make a profit and, in an extrapolation of current trends, would pay hospitals, doctors and other providers substantially more than Medicare does. Beneficiaries would have to pay higher out-of-pocket costs or buy skimpier policies.

The Ryan plan has no chance of becoming law while the Democrats still control the Senate and the White House. But if health care becomes a defining issue in the 2012 elections — as it should — everyone under the age of 55 is on notice that Mr. Ryan’s plan would impose heavy costs on them when they reach age 65.



Say what you want about re-elections and C.B.O. cost-analysis, the fact that we are even discussing these measures is a philosophical victory for the congressional conservative bloc.  But if the federal government spends less on health care does that mean that the real cost health care will come down?  Unfortunately just as the “Affordable” Care Act did just a little bit to actually deliver health care in a more affordable way, the House proposal doesn’t lower the real cost of health care it just moves much of the cost off the government’s ledger. 

Don’t get me wrong, I’m a huge fan of balanced federal budgets and well shuffled deck chairs.  I don’t think health care challenges will sink our ship, but the biggest iceberg on the horizon is the total cost of health care and the House Bill doesn’t do much to avoid it.





I just got back from a trip to rural Costa Rica.  It was fun to chat with some of the residents about their health care system. Health care there is government run and is less costly than ours is, but it also offers less services. There was no local hospital or ambulance service where we stayed.  People who were very sick had to be flown to the capitol from the nearest airport. (20km away on mostly dirt roads)  There were two local physicians in the town who had store-front clinics and were on-call for emergencies.


Costa Rica spends 7% of their GDP on Health care to our 15% and overall their life expectancy, child mortality rate etc. are inferior to ours.  (I haven’t reviewed all of the WHO data.)  The people, locals and expats alike, didn’t seem to share the general sense of angst about health care that is so consistently projected in America.  People were aware of the short comings of their system but seemed satisfied that at least everyone had some level of care and that things are getting better – which generally they are.


It was disconcerting to come back home where health care is leaps and bounds ahead of Costa Rica and see the same old media personalities evoking HealthCaremageddon.  Whatever happened to calm, even-handed leadership?





It is a classic conservative argument to say that since so many elligible people haven't even signed up for subsidized insurance programs it makes no sense to expand the existing ones yet.  This article from US News and World Report proves that point when it come to low-income children's health insurance.  Parents have a very tough time enrolling or apparently even knowing if their child is enrolled in their states CHIP plan.  So it's not just Electronic Medical Records that need to get more user friendly. 

These kids don't get to pick their parents though, so while the assertion is true it doesn't get us any closer to solving the problem.  The strategy of "blame the patient" may end the conversation but it doesn't change the fact that Americans deserve better.  The strategy of  "blame the patient's parents" is even less useful when it comes to America's children.


Here's an interesting article from The Washington Post which discusses some of the challenges to making electronic medical records more user friendly.


 Electronic Medical Records Trapped in the Dark Ages

Every time I look at a smart phone I get fed up with Electronic Medical Records.  If a device that costs a couple hundred dollars can do so much cool stuff how is it that health care systems across the nation are spending tens and hundreds of millions of dollars on Electronic Medical systems that operate at a level  that would have been state of the art in the 1990's.

This is an industry where the product has fallen far short of the demand.  It's dominated by a few providers who are making huge profit and selling an entry level product that is inferior and then charging health care systems inflated prices for multiple "upgrade" options.  The most frustrating thing is that the government is putting huge pressure on physicians to invest in this inferior technology without setting minimum standards that the technology should live up to.

I've worked with most of the Electronic Medical records that we use in hospitals in the twin cities and I'm at the point where I think an open source product needs to step in.  If Linux, FireFox and Mozilla can be competitive products, why not use collective innovation to push the envelope in EMR development?  Lord knows the corporations in charge aren't doing it and I'm not sure what higher level of disgust and loathing physicians - the "consumers" - need to express to get an improved product.


I have to veer away from health care for a moment:

My new teaching contract has demanded much of my energy lately and at the same time has made the events of Wisconsin's budget crisis all the more relevant.  I'm a teacher.  I don't belong to a union.  But no matter how you feel about unions or fiscal policy the "We're Broke!" message is a counter productive approach to any kind of reform - health care budget or state payroll.

The richest nation in the history of the world - even in recession - is not broke.  But we're wasting a heck of a lot of money.  If you ask me I think the average american is way too generous.... to the rich people.  While helath care is one of the most profitable industries around, Americans pay twice as much as other countries for health care and most of us get less in return. While wealthy Americans have never gotten wealthier at a faster rate Americans have cut taxes for the richest americans and demand nothing in return.  As the banks resume thier huge executive bonus payments and their corporate jet purchases Americans have bailed out the banks to the tune of $700 Million and don't even ask to be able to keep our homes or our retirement savings in return.

I think it's time that we demand a better return on the huge investments we've made in the health care industry and the banking indusrty and every high-income person who just got another tax cut (including myself) before we go back to demanding more, and more, and more from the working folks in America.


It's sad to see even the democrats cutting health insurance benefits for working Minnesotans.  Governor Dayton's budget defends a great deal of our health care infrastructure from cuts, but in the end 7,200 adults on MinnesotaCare will lose coverage.   For the most part those of us in health care are breathing a sigh of relief.  (See the Minnesota Medical Association statement below.)  It could have been worse.

I am proud to see my traditionally right-of-center professional organization respond to the state's health care woes by not only advocating for innovative health care reform, but by standing up for the social safety net that so many of our patients depend on.


Dayton budget avoids clinic payment cuts

[MMA News Now, February 15, 2010] Gov. Mark Dayton released his budget proposal Tuesday that relies heavily on tax increases in order to minimize budget cuts to schools, health care programs, and aid to cities. The budget does not include any recommended physician payment cuts.

The Governor's budget maintains $12 billion for health and human services in FY 2012-13, after a net 2.8 percent reduction from the forecasted budget.

This includes targeted reductions of $680 million as well as investments of $81 million and another $250 million in provider rate increases to offset health care surcharges.

The governor's budget protects health care eligibility for children and retains coverage for all but 7,200 adults on MinnesotaCare who have incomes above 200 percent of poverty or more than $1,815 a month for single adults or $2,452 a month for households with two adults and no children.

“We appreciate Gov. Dayton’s effort to protect Minnesota’s health care safety net, but we are concerned about the loss of MinnesotaCare coverage for 7,200 working Minnesotans,” said MMA President Patricia Lindholm, M.D., in a prepared statement.

Health and human services represents 30 percent of the Governor's general fund budget and 40 percent of all expenditures for the FY 2012-13 biennium.
The governor's budget increases Medical Assistance surcharges on providers a net total of $627 million and reduces nursing facility rates by 2 percent and home and community based service rates by 4.5 percent.
The governor's budget would jumpstart Minnesota's Health Benefits Exchange by leveraging federal planning dollars and includes $20 million per year for the Statewide Health Improvement Program.

The budget includes a delay of the rebasing of hospital payment rates in 2013-2015 that would result in cost savings to the general fund of about $130 million. The budget also include a 0.5 percent rate reduction for outpatient hospital services under Medical Assistance and MinnesotaCare.



I have a new part-time job.  I'm an associate professor for the U of M Department of Family Medicine.  Teaching physicians is a daunting and rewarding task - and it has been a redefining experience in my career.  I've gained a ton of insight into the how and why of my own profession and myself.  Great fodder for blog content, but of course I'm way behind in posting things these days.  I'd also planned to convert to a true "blog" format but have not had the time to figure out how.  I'd rather have this monolog be more of a dialog.

Here's a link to the class I'm teaching.


I spent yesterday at the Minnesota Medical Association's "Day at the Capitol".  Watching a gang of white-coats converge on the state capitol was a fun thing.  My own experience talking to legislators really reinforced to me that most folks are trying to do a good job.

I'm a lot more optimistic that my profession can help drive positive change in health care.  Rather than offering wide sweeping, well organized leadership on health care issues, if my profession could just keep telling their stories of the human side of medicine to the people making the laws it would make a huge difference.  People making health care decisions get so swamped with partisan hype that the thing that's most important gets lost in the clamor - patients.


I have just reviewed the Bob Dole, Mitt Romney and 1993 Republican Congressional health care policies.  I am very surprised about how much hostility Obama's health care reform has recieved considering how close it is to these - ostensibly conservitive - health care plans.  I can also see why democrats really haven't been that thrilled with it.

The interesting thing is that I've observed previously that good health policy should transcend the super-majority.  Apparently it might actually transcend party altogether!






I had the honor of being a panel member at an MPR forum on health care reform led by Kerri Miller last night. The discussion was thoughtful and in-depth.  I found myself surrounded by folks vastly more qualified and far more eloquent than I am when it comes to discussing national health policy.  And for the most part rather than trashing on each other their messages were POSITIVE.  I started to feel the way did back when I watched the presidential debates as a kid. I would always feel great because it seemed like whoever won the election our country would be in good hands, both candidates were clearly such compelling leaders.

There are so many talented people and such immense recourses pouring into health care that we have no choice but to succeed.  However I fear the debate of who is more to blame is getting us nowhere right now.  Health care needs more leadership not more resources.  We need leaders who spell out a positive,  proactive plan instead of just hammering on the "horrors of socialized medicine" or "the evil corporations" or making patients into scape-goats.

There is no reason Medicare and Medicaid couldn't be less antisocial.  There is no reason corporations can't be less evil.  There is absolutely no reason for so many people to gang-up and blame the patients.  But someone has to lead in that direction.

If America could have a national health care dialogue more like the one Kerri Miller ran last night I think people would sleep better at night and we might actually get something done.


Blog 1.10.11

"Repealing the Job-Killing Health Care Law Act" is actually the title!

I've attached the text of the House of Representatives "repeal" act that was scheduled to be voted on this Thursday.  Clearly no line exists between political high-drama and objective policy making.  I don't care how you feel about health care reform, the addition of the hyphenated "Job-Killing" shows its authors value sensationalism before substance and their flare for it isn't helping their cause at all.  What if our fore fathers had stuck "England Sucks!" in the preamble of The Constitution?

So here it is, the "Repealing the Job-Killing Health Care Law Act.":

This Act may be cited as the ''Repealing the Job-Killing Health Care Law Act.'


"(a) JOB-KILLING HEALTH CARE LAW.—Effective as of the enactment of Public Law 111-148, such Act is repealed, and the provisions of law amended or repealed by such Act are restored or revived as if such Act had not been enacted.

"(b) HEALTH CARE-RELATED PROVISIONS IN THE HEALTH CARE AND EDUCATION RECONCILIATION ACT OF 2010.—Effective as of the enactment of the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), title I and subtitle B of title II of such Act are repealed, and the provisions of law amended or repealed by such title or subtitle, respectively, are restored or revived as if such title and subtitle had not been enacted."

Blog 1.5.10

I am flying to Florida today to learn about how the rest of the American Medical Association's PACS do their job.  I can't wait to get more experience working with politically active physicians from other states!

I am very impressed with the political agenda the new Republican congress has laid out.  Opneing session with a repeal of health care reform - although hippocritical to a party that's trying to reduce the deficit and largely counter productive - gives them a great deal of room to bargain.  Tim Pawlenty the governor of MN has done the same thing with great succes.  It would be equivalent to having Obama and the democrats starting 2009 with a mandate for Single Payer health care and then negotiating from there instead of coming out of the blocks with a compromise bill.

Blog 1.3.11

Today is the first day of my first teaching job.  I am training three talented physicians from Somalia so that they can apply to residency and become practicing physicians in america.  Teaching is always a humbling experience, I am very excited to begin.

Blog 12.29.10

MPR ran my commentary on Private Health Insurance scaring Seniors yesterday.  The article took me a while to research and I think it's pretty even-handed, but I suppose that's for the reader to decide.

Blog 12.23.10



 America Steps Up

The American heroes who worked  to clean up the rubble of the World Trade Center won their battle for 5 years of health care coverage today.  While I applaud congress's action to extend health benefits to the every-day  people who provided our countries' most immediate and most meaningful response to the attacks of 9/11, it is embarrassing as an American and a physician to see that the people who raced into the disaster and at their own risk searched vainly for survivors, recovered bodies and worked to heal the gaping wound that was left there are still begging and arm-twisting to get health care.


If we don't take care of our heroes what kind of nation are we?  What kind of message do we send?  What valid argument against life-long health care for these people's aliments is there?  We can't say that they don't deserve it when we provide health care for incarcerated criminals without question.  We can't say that we are concerned about fraud and abuse of the program when fraud and abuse run rampant and unchecked in the rest of the health care system.  We can't even credibly argue that we don't have the money to spend when our leaders have wantonly wasted billions on our later response to 9/11.   We will never be able to prove that every single ailment treated directly resulted from digging through the rubble of the World Trade Center, but for God's sake these people were digging through the rubble of the World Trade Center don't they deserve the benefit of the doubt?


If our nation doesn't take care of its heroes this time, the next time there is a disaster who is going to show up?

Blog 12.19.10

In this article from the Kansas City Star presents the argument by folks like Former Governor Howard Dean that killing the individual mandate won't kill the expanded benifits offered by the new health care reform bill.  I think it's pretty clear that insurance companies have hung their hats on the mandate as the thing that will make reform cost-effective.  I think lawmakers have done the same.  Dr. Dean talks about rolling enrollment with penalties for signing up late as a remedy or a "mandate-lite", but I can't help but wonder: If knocking out the individual mandate leaves insurers unwilling to cover a certian part of the population, will we have to re-visit the "public option" to cover that population? 

As much as I hate to go there - and regardless of how you feel about your constitutional rights - getting everyone to pay into the insurance pool and eliminating the costs of unreimbursed care are the keys to making health care affordable.  Americans aren't going to give up the new benifits they've gained from health reform, so we can't go backwards any more.  If private insurers are telling us they can't cover everyone without an individual mandate then we - especially conservatives - should be asking who's going to fill the gap?

Blog 12.12.10


Repealing health reform law could have dire effects, CMS chief tells Congress



This article from the AMA is one of the few sources I've seen lately where a doctor – albeit a political appointee - talks about facts and health care reform.  The “repeal” lobby doesn’t want to acknowledge that there were actually some good things in the law.  They also don’t want to admit that health care was racing more quickly towards bankruptcy before the bill.  It makes a better sound bite that way.  I welcome all view points, but if you are forsaking earnest dialog for blatant political opportunism  you should stay out of health care... there are sick people here who deserve better.


Nobody thinks health care reform is perfect, but stamping out fraud, rewarding efficiency and cost-effective care, and simply establishing the idea that everyone should have and contribute to health care are big steps in the right direction.  I wonder how Bob Dole feels.


Blog 12.11.10


They’ve reached the same understanding of the dangers of smoking that they did with atomic radiation in the 40s.  There is no safe level.


Here’s a summary of the Surgeon General’s new report.   


A very common response I get from patients when I suggest smoking cessation is that they are “cutting down”.  From the point of view of addiction management cutting down is a fallacy, and now the medical data agrees.  Cutting down doesn’t count.  Sorry.


Blog 12.7.10

One of the reasons that physicians have less of a positive impact in health care reform negotiations is because their payments through Medicare are constantly on the chopping-block.  For the third time this year physicians  have had to use tons of political capitol to push through another temporary band-aid to a flawed Medicare reimbursement formula that if not fixed would result in a 20-30% pay cut for Medicare services.  Here's a Politico update on the latest "doc-fix".

So instead of focusing on responsible health reform in Washington my profession is constantly on the defensive.  The flawed formula never gets permanently fixed because politically it's apparently easier to pass an emergency patch than it is to acknowledge that there's a problem with the math and budget more money for Medicare patients.  You can see why so many physicians have little trust in Washington.



Blog 11.30.10


My wife’s car died last week and we’ve found ourselves unexpectedly having to shop for and buy a new car.  Thanks to my new job, for the first time in my life (I’m 32) I’ve actually been able to save up a month’s salary as an emergency fund.  So the unexpected expense around the holidays will be challenging but not catastrophic to deal with as it could have been.  If this had happened when I was as student or working on a resident’s salary I don’t know what we would have done.


Everything breaks-down eventually and being able to prepare for it ahead of time is a great feeling.  I think this is one of the elements that is lost on our health care debate.  Paying health care costs is not an option.  There’s a cost effective way to plan for, prevent and pay for future health care costs and then there’s what we’re doing now.


While my broken down car may get left on the side of the road, we don’t just leave sick people in the street to die in this country.  If you come to my hospital critically ill we will treat you.  It will cost money.  There is no negotiation.  No physician in America will ever refuse emergency services to a patient regardless of their financial situation and just about everyone in america is going to need medical care at some point.  So why we don’t acknowledge and plan for that cost is beyond me.


Part of it is that we use the cost of health insurance as a proxy for health care.  Up until now health insurance has been optional.  It think that has made the idea of health care costs seem optional as well.  It’s only the individual mandate and the ban on excluding pre-existing conditions proposed with health care reform that brings health insurance costs closer to being in line with actual overall health care costs.   The truth is that our health is going to cost money.


Once you accept that idea then things like preventative care make more sense.  Just like when you accept that the car you buy will have a finite life-span and will have maintenance costs along the way.  With that in mind most people opt to change the oil rather than continually rebuild the engine.  I'm not advising that we treat people like cars, but it's interesting that many Americans are more rational about vehicle care than they are about their own health care.

Blog 11.24.10


A newly elected republican congressman - who also happens to be a physician - named Andy Harris raised a few eyebrows when he complained that his new government sponsored health care didn’t start soon enough.  Since he was elected on a platform of dismantling health care reform his comments caused excitement on both sides of the isle.  Here’s the Politico article. 

The right tried to use the fact that his insurance has a month-long delay before kicking in as an example of how bad government run insurance is.  The left tried to point out the irony that a candidate who ran on the assumption that the government should stay out of health care was obviously eager to start his own government sponsored health care coverage.


The thing that troubles me is that as a physician – representing my profession in congress – who will be influencing national health care policy he apparently didn’t know about COBRA the short term insurance benefit that allows people to bridge the gap between jobs.


Taken out of context it’s challenging to interpret the rest of his comments, but I hope he hasn’t been out of medicine so long that he has forgotten how many of his patients – even though they were asleep – faced far greater challenges with health insurance than he ever will.

Blog 11.18.10



After a demanding week of rounding in the hospital it was frustrating to read this Reuters summary of a new Commonwealth Fund study showing “A third of Americans say they have gone without medical care or skipped filling a prescription because of cost”.  If we could fix this it would be much easier to do my job.  American’s pay nearly twice as much as other countries for health care we should be getting better results.


Lately a lot of people have been asking me why I work on health care reform and my answer that I “do it for my patients” has been falling flat.  I’m not sure if it’s because times are so tough that people look at altruism with suspicion or if I’ve just started to sound like Polly Anna.  It’s the truth though. My patients deserve better. America’s hard earned health care dollars have build the best health care system in the world and it’s time that pays off for my patients with the best outcomes.


On a more egocentric note, I work on health care reform because I am incredibly competitive. I want to be the best doctor I can be and give the best care there is and I can’t do that without the best system there is backing me up.  Patients don’t just come to me for a diagnosis or a prescription, they come to me to GET BETTER.  I don’t go to work every day with the goal of just following guidelines and best practices I go to work with the goal of helping my patients GET BETTER. Results matter and America should be kicking the Netherlands and England and France’s butts in any quality measure you can think of.  When I read about studies like the Comonwealth Fund one I get that same feeling I got when I bombed a test or got smoked in a ski race.  I hate that feeling, but it keeps me motivated to keep working on something I personally find pretty boring.


It’s a mistake to write-off people like me as bleeding heart liberals trying to build the health care system into a national group-hug.  This is just how some of us kick-ass.


Blog 11.9.10

This Wallstreet Journal article on smoking cessation is pretty eye opening.  As anti-smoking funding has been cut states have noted that the previously declining rates of smoking are now going back up or stalling.  As the cigarette companies discovered long ago about advertising:  You really do get what you pay for.  A cheaper solution might be to eliminate cigarette ads.

Blog 11.3.10

 State Medical Groups Bypass Pawlenty

In Minnesota the we still cling the widely held assumption that at the end of the day leaders are going to set aside their differences and do the right thing for the people they serve.  That kind of statesmanship is the tradition in our state.  It's also the reason we have one of the most cost efficient health care systems with one of the lowest uninsured rates in the nation.  Decades of hard work by republicans, democrats and independents alike have built a health care system to be proud of, but the it's taken only a few terms of partisan grid-lock to start fraying at the edges.

I was absolutely irate to hear that Governor Pawlenty  planned to opt-out of new initiatives in the Patient Protection and Affordable Care Act (unaffectionately  known as "obamacare") that would qualify Minnesota to receive $1.46 Billion in federal matching funds.  In the middle of a recession, facing a huge budget deficit and a health care system in crisis what statesman refuses a lifeline based on ideology.

To have the states doctors and hospitals have to carry the ball that the governor dropped as - outlined in the article below - doesn't seem right.  I don't care what party you're from, if toeing the party line is more important than serving the public good you're not from the Minnesota I know.


Blog 10.28.10

This MPR report "Health Law Hardly At Fault for Rising Premiums" is pretty ironic.  It details how insurance companies are falsely blaming health care reform for large increases in individual health insurance rates.  The article then acknowledges that the reform measures do little to slow the rising cost of health care - which legitimately is increasing insurance rates.

So while it may not be true that health care reform is increasing your health insurance premium today, it clearly hasn't done enough to keep a lid on costs in the future.  The reform bill we have is a start, but at some point America is going to have to leave their sound bites and campaign rhetoric at the door and get to the real business of cutting health care costs.  And those insurance companies who are using health care dollars to fund misleading commercials are going to have to take a long look in the mirror.


Blog 10.11.10

 Here's an interesting article regarding branding illness from CNN contributor Carl Elliott MD, PhD.  It is frustrating that in america we direct so many health care resources and public awareness campaigns towards diseases with newest patentented drugs and  most profitible treatments instead of towards the worst illnesses whith the most realiable cures.

Blog 10.7.10

Health Care Reform is an ongoing process.  I've noticed people talking about health care reform in the past-tense and it makes me uneasy.  I know Congress passed a massive legislative reform last year, but as Washington has proved, things don't change just because it's the law.  Reform isn't real until it is enacted.  As this New York Times article, Waivers Aim at Talk of Dropping Health Coverage points out, insurers and employers are pushing back hard against individual measures in the reform package... and concessions are being made.

While it was tempting to frame passage of Health Care Reform legislation as a smashing victory or defeat and then move on to the next issue, the truth is that health care takes place in real time, and so must its improvement.  Like much in medicine there is no magic wand; so while the details get hammered out I hate to see so many people giving up early and walking off the field.

As the wonks and lobbiest gleefully pit "ObamaCare" against "DieQuicklyCare" I hope health care providers and consumers will stay involved in the fight.  Nevermind what you local congress person says, there is no victory until all of my patients have sustainable, high-quality health care. 

Blog 10.6.10

Summer Break:  For some reason my "Back Soon" message didn't get posted in June.  I spent the summer getting married and compiling the results on my year-long health insurance purchasing project.  I hope to be posting some of those results soon.  In the mean time Blog posts will re-start on a weekly basis.  Yes, I'm back.

[Previous Blog Entries have been moved to the "Blog Archive" page.]



Will Nicholson M.D.
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