Will Nicholson M.D.

Blog 6.11.10 06:00

MPR has published my Commentary on the Nurses' Strike at their News-Q website.

As I write this there are nurses still picketing in the rain.  Even after my eleven-hour shift was done and after  the news cameras have gone home and everyone else has been asleep all night, the hospital remains buckled-down for the last hour of it's twenty-four-hour strike.

I hope that things went well overnight and now that the picketers are coming back to work, if media coverage of the contract negotiations continues I hope they'll ask what I think is the most important question: In a state where United Health Care can make billions on insurance, Medtronic can make millions on devices, and the U of M can make millions on patenting a single drug why is the talk about our basic medical services so often one of diminished revenue and slashed funding?  ... could any of the previous examples profit without the clinics and hospitals who use what they offer?

I'd love to see some clear leadership on these issues, but for now I'm just happy to get back to work, and in an hour I hope the patient care and administrative teams at my hospital can put the strike in a constructive context and go back to doing what we do best.

Blog 6.10.10 21:45

St. John's hospital continued to provide top-quality patient-care at a slightly reduced volume and clearly decreased exuberance today.  With closely supervised, picket-line crossing, agency nurses filling the posts vacated by our long-time colleagues who were out front protesting we certainly got the job done right, but there wasn't much joy to it.  As I double checked my work and glanced at some of the strike coverage in the media I was annoyed to see largely unqualified or clearly biased people sounding off.

This isn't a soap-opera.  This is a terrible predicament for our community's hospitals and those who depend on them.  The administrators I work with don't have fangs, they didn't get any government bail-outs, they're trying like crazy to keep our hospital out of the red and the last thing they want to do is short-change their employees.  The nurses I know work their butts off every day, they are critical to patient care and they shouldn't have to worry about getting laid-off or getting their benefits cut.  The core of the problem isn't that nurses or administrators are bad, it's that the hospital needs more money.  

It's an untenable situation and instead of trying to find a solution it's much easier point fingers at the nurses or the administration and argue about who is more at fault. 

Blog 6.10.10 04:30

I'm getting an early start today.  The hospital has made extensive preparations for the strike and things should run smoothly.  Part of me wishes I had today off so I could avoid all of this, part of me is happy to be going to work.  I'm not thrilled about working through the strike, but I love doing my job.  Many of the nurses I've talked to said the hardest thing about striking is that they can't take care of patients on strike day.  I totally understand. 


The physician's role in all this is unique, and awkward.  I was raised to respect organized labor.  My profession is what I call dis-organized labor.  Although many of us are employed, doctors really can't strike.  Legally we're not supposed to form unions.  On the other hand most of us don't run hospitals or fill the "management" role these days either.  Our main organizing body the Minnesota Medical Association has had little to nothing to say about the nurses strike in the way of guidance.

The tragedy of today is that I've spent four years working through challenge after challenge with the incredible patient care team at St. John's hospital - a team that includes and depends on both nurses and administrators - and today we are divided. 

Blog 6.7.10

My last day at work before I return for the nurse's strike.  It really looks like it's going to happen.  I had been quite optomisitc that the hospital could work things out with the nurses - we've worked through so many other things in the past - and that there would be some way to avoid picket lines.  I feel a bit sick about the whole thing and feel strange getting paid to work on a day where people I've depended on for my whole career are forgoing their pay to fight for something they believe in.

Blog 6.3.10

My insurance project is winding down.  I've used a ton of the products out there and have learned a lot.  I'm now looking at getting onto my employer's insurance plan, which presents some interesting questions of it's own.  It's been strange trying to balance the human experience of events like finding out your insurance policy fell through when you're sick with the analytical, objective approach I'd like to take in presenting the findings of this project.  I admit I've lost that third-person cool a couple of times and even bought two policies for a while because I didn't trust the company I was using.  On the other hand there's already a library of objective analysis of insurance by people much smarter than I am, but we still haven't fixed the system.  I'll keep you posted.

Blog 5.28.10

The Minnesota Nurses association announced their intent to strike on June 10th.  When one of my nurse-colleagues told me about the planned strike a day ago I was astounded.  Like most physicians, I support nurses.  The disorienting thing is that if anyone ever asked me I would say that the hospital I work for supports nurses as much as I do.  I'm not sure why there is such a disconnect.

It's a surreal moment.  To think that the future finances look so bad that the people who run the local hospitals are willing to risk a strike to try and save money on the next nursing contract.  In a counrty where we pay nearly twice as much for health care than anybody esle you have to aks yourself where the money's going.

Blog 5.19. 10

I recently received a refund from a Health Savings Account I started with my new job.  The amount of money I had in the account didn't come near paying for a new pair of glasses, but it helped.  The idea of designating dollars for predictable medical expenses into a tax-free savings account seems like a good one.  It's not realistic to imagine that an HSA would cover the cost of catastrophic health care or offset much of the cost of managing a severe chronic disease, but the next time I have to get glasses I'll have increased my monthly contribution so the account balance is large enough to cover the whole cost.

Blog 5/15/10

As thirteen state attorneys general contest the constitutionality of the "individual mandate" to buy health insurance I am reminded of a 12-year-old who doesn't want to clean his room.  While I'm not impressed that the government has mandated us to purchase products without also mandating that the products be affordable I am even less impressed with the "individual freedom" argument against having every American pitch in and pay for health care.  Individual freedoms demand individual responsibility.

Everyone has seen an adolescents throwing similar tantrums.  The 12-year-old child who shouts "You can't make me!" when asked to pull their own weight in the family by cleaning their room may appear to be a champion of personal autonomy, but in reality just wants his mommy to keep cleaning up after him.

When uninsured people get sick we don't just leave them in the street, we treat them.  That costs money and if the sick person can't pay those of us with insurance cover the difference, just like the mom cleaning up the 12-year-old's room. The argument against mandating health insurance might hold more philosophical water if the people making it would voluntarily forgo care when they get sick.

No one is more frustrated with the inefficiency and waste in the health care system than I am.  It is true that people may not get back dollar-for-dollar the same amount of money that they paid for health insurance, but if we can find a way to get everyone to contribute at least a little bit, it's a lot easier to argue that no-one should ever go without treatment.


Blog 5.11.10

The Real Cost of CoPays?

As I understand them health insurance co-pays are a tool the insurance company uses to get people to only see a physician if they need to.  If you have to pay $35 every time you get an apt. you go in less often than if it was free.  It seems like a reasonable idea that there is some way people are deterred from seeing a physician for inappropriate reasons, but the problem is that co-pays apply for all appointments.  This often places a barrier between my patients and effective follow up care.  I've had numerous patients who cannot afford or don't want to pay the co-pay for a follow up visit for a serious illness who then end up being hospitalized because of their poor follow up.

The person's attempt to save $35 ends up costing tens of thousands of dollars due to a hospitalization which likely could have been prevented by good follow up care.  Physicians should have the power to wave the co-pay for medically necessary follow up appointments.  Heck, we should pay some patients to come to follow up appointments!  These sort of generic approaches insurance companies use to modify patient behavior are often medically counterproductive and don't meet the minimum standard to "first do no harm."    


Past Medical History

I just completed the application interview for a long term insurance plan.  It's a pay-as-you go plan - with an option to cancel at any time - that I bought on-line.  I've had a tougher time finding true short-term plans due to the fact that I've been using them for so long.  Many products limit the amount of time you can use short-term insurance and there's a state law that you can't have more than 365 days out of the last 555 on short-term insurance.

I interview people about their health history all day long, but was surprised that some of my own medical history was a bit murky when I had to think back.  In the last ten years I've had care at about 5 different locations.  Being a student for most of that time meant I moved a lot.  It must be incredibly labor intensive for insurers to hunt down all of that past information.  In fact, it would be tough for me to track it all down if I ever needed it.  Another argument for a universal health record.


The L.A. Times recently reported that WellPoint and Blue Shield of California will stop dropping sick policy holders.  The most interesting part about this move by private insurers to stop one of their most infamous practices is that it had already been nearly abolished due to public scrutiny.  Just like Wall Street, the insurance industry decrys government regulation, but if they would operate in a public and transparent way in the first place so that consumers could freely scrutinize their risky or ethically questionable practices maybe the market rathar than the rule-of-law would be the reforming force they answer to.

It amazes me that these people call themselves professionals but don't believe their practices should be held to public or professional scrutiny.  They wouldn't last a day in my profession.


Income Trumps Insurance Provider

Minnesota Community Measurement released their 2009 Health Care Disparities Report recently.  It compares "Best Practices" data for Minnesota's publically administered health insurance programs with data from private insurance programs.  The report shows that public programs are still behind private programs when it comes to many quality measures, but they are closing the gap.

Maybe I'm too cynical, but as someone who has spent a lot of time caring for patients on Minnesota Health Care Programs (i.e. Medical Assistance, MinnesotaCare and General Assistance Medical Care) the disparity was not as large as I thought it might be.  Remember, they are comparing the patients who can't get private health insurance - often because they are too poor or too sick - to the patients who can.

I'm not so sure the insurance provider is the real issue.  As a physician I treat every patient by the same standard regardless of who they are or what type of insurance product - or lack of one - that they carry.  Many of the challenges I have helping patients reach our best practice goals have less to do with the patient's health insurance than with their socio-economic status.

It might be more instructive to analyze the same data based on household income instead of insurance provider.


MPR's News-Q Published my latest Commentary about health care reform and it's affect on the average health care consumer.
















This Time Magazine article mentions an interesting bill that would mandate transparency in pricing for all medical costs.  A great idea.  The author's hope is that market forces could then help push down health care costs.  In addition if patients and doctors both knew the cost of things she thinks they might actually have a conversation about the risk, benefit and necessity of any given intervention or test.

I'm working on a commentary about a similar idea. One limitation to the "savvy shopper" approach to cost-containment in health care is that much of the time we're not talking about a healthy person shopping around for the best value on LASIK surgery, we're talking about sick people or distressed people.  It is completely unreasonable to expect someone who is acutely ill or worried that they might have cancer to shop for a good deal at the same time.  Sick people have enough to think about already.  It would be like expecting a soldier who is taking fire in battle to shop around for the best price on his or her next ammo clip.

As far as relative cost being a conversation starter.  I do believe physicians should know the cost of the tests and interventions they prescribe.  However, generally it's  a big enough of a challenge for me to deal with or explain a patient's medical concerns during the time I have without any foray into cost analysis.



This Washington Post article was astounding to me.  First, I did not know that the new health care reform legislation mandated that insurance companies spend at least 85 cents of every dollar on health care.  Second I did not know that so many companies fell well short of that mark.  Especially since public programs like Medicare put more than 95 cents of every dollar into health care.  I believe that private industry often has the edge over government when it comes to efficiency and keeping down costs.  Apparently this is not the case in the health insurance market.  Medicare is nowhere near perfect, but if it is a challenge for the  private sector to limit themselves to run at only 3x greater operating costs than one our nation's biggest bureaucracies then we have a serious problem.

It also seems brazen to me that they refer to the proportion of money they spend on patient care costs as a "medical loss ratio".  They should flip the equation and start measuring the "administrative waste ratio" instead.



The Prescription Needs to Change

Writing a prescription is the main way I can get things done as a physician, but I'm not a prescriptionist.  People don't come to me for a prescription they come to me to get healthy.  A prescription is a relatively shoddy tool in fact.  It's a one-way form of communication and there's really no guarantee what you prescribe will be done.  It's really just a very formal suggestion and the number of people who actually fill the prescription and take the medicine as directed is surprisingly low.

For some illnesses taking a medicine is so important we need some type of prescription confirmation, just like Fed-Ex or UPS has for packages:  an alert from the pharmacy if the prescription goes un-filled, an automatic generic back-up if a patient cannot fill a more expensive name-brand, even a certified person to go check in and make sure the patient is taking the medicine correctly.  For medicines like breathing medicines for people with severe lung diseases, heart medicines for people with heart failure, psychiatric medicines for people with certain mental illnesses, immune modulators for mothers with Hepatitis or HIV physicians need a better tool than just a prescription to make sure the patient gets better and stays better, we need follow up.

Every day somebody gets hospitalized at my hospital just because they didn't take the medicines they need.  For the types of illnesses above it would be better for the patient's health and society in-general if my profession could step into the information age and close the communication loop that is started by a prescription.

Blog 4.14.10

Pitching the Sale

Health care providers are sick of being the only ones in the equation who are honest with patients.  A big part of our job is to discuss the risk and benefits of any intervention or decision.  It can be a lonely, thankless job.  Patient's often get frustrated because their doctors "make everything seem so complicated".  Often times that's because it is.

But we're competing with snake-oil.  I can't tell you how many times I've had to break it to a patient that they've been mislead by the insurer, pill company, or political figure and that the product they've been sold on won't meet their expectations.  (Late-nite infomercials notwithstanding.)  The medicine that made the sad person happy on TV is actually riddled with side-effects, there isn't much evidence that it works and it's not covered by their insurance.  The health insurance policy with the cool advertisements that remind them of Starbucks and nice customer service doesn't actually cover the care they need.  Even though the politicians "fixed Medicare" the Medicare service a particular patient needs is still screwed-up.  And no, there is no simple, easy way to lose weight that does not involve eating less or exercising more.

Physicians aren't perfect and sometimes we are too enthusiastic about a new treatment or test, sometimes we misinterpret the evidence.  We could certainly try to treat patients based on the  hyperbolized claims that are sold to them instead of hard evidence and science, but the results would be terrible and eventually the Board of Medical Examiners would revoke our licenses.  Physicians have something called ethical standards that compel us to put honesty and patient safety before a slick sales pitch or a convenient sound-bite.  In a world full of profiteers and opportunists it's a real buzz-kill.

People wonder why physicians aren't more effective in commercial or political circles.  A big part of the challenge for us is effectively communicating  in an environment where the preferred language is 50% bullshit.



I've accumulated a bunch of sad stories about uninsured patients lately:


A patient who had to stay in the hospital for an extra 4 days because rehabilitation centers don't have to take uninsured patients and it wasn't safe for them to go home, so instead of paying the rehab center the person will have to pay the much higher cost of an extra 4 days of hospitalization.

A single parent who works full-time as a health care provider at a for-profit corporation. The person is considered a "contract" employee so they don't qualify for health insurance.   They were unable to afford medicine for a chronic treatable condition and are now hospitalized with a severe, preventable complication.

A patient who lied to their doctor about the duration of their illness because they just got health insurance and don't want the condition to be considered "pre-existing" and excluded from coverage.

A patient who's insurance didn't have a prescription drug benefit couldn't afford the medicine they needed to go home with.  The only solution was to keep the patient in the hospital and give them a similar intravenous medicine for the next 3 days because the insurance did cover that.

Some days the bazaar bureaucracy of health care makes me feel like I'm living in a Franz Kafka novel  where mankind is tormented by situations purely of its own creation.


Understandability:  It's worth a try.

One of the biggest ongoing criticisms of health care professionals is that we don't explain things in terms that people can understand, but at least we try.  Medicine has gone to great lengths to be more patient-friendly in the way we convey data.  Helping patients understand their options improves not only their decision making, but the overall quality of their care. Still, we can do better.

I cannot help contrasting the efforts of health care providers against the ever more obscure and confusing world of health care finance.  I cannot understand my own doctors bills at times.  I am often mystified by the process by which I am reimbursed and I have a hell of a time finding the actual total cost of any intervention that I might prescribe for a patient.  I can't imagine how my patients feel.

Much criticism has been leveled against patients as lazy consumers who are not taking an active role in managing the cost of their own care.  But do we really give them a chance to do so?  Where do we expect them to start?  With the bills from their doctor and their insurer that don't match?  With their 16 page insurance policy pamphlet that reads like fortran?  With the text of the new health care reform law?

Obama talks a lot about transparency as a cure for much of the trouble with health care finance.  I agree, but if something is completely unintelligible to start with it doesn't matter how transparent we make it.  American's deserve to understand their own medical bills and health insurance policies.  If I can take the time to explain an appendectomy to an eight-year-old or adrenal suppression to an eighty-year-old, health plans could at least direct a small detachment from their army of accountants to help break the cipher code of their products into layman's term.


Reform is no good if there's no one around to actually provide health care.

Governor Pawlenty has proposed cutting over 80% of MERC disbersements.  Medical Education and Research Costs (MERC) funding is what makes almost all of the medical education in this state possible.  This would absolutely decimate the state's ability to train the physicians and other health professionals we will need as our population ages.  Below is a fact sheet circulated by the University of Minnesota. 

While the rest of the country forges ahead with health care reform our Governor is all but eliminating the funding that makes training the next generation of health care providers - especially primary care providers - possible.  I understand the allure that Pawleny's slogan "no new taxes" has to Minnesotans.  I wonder if they realize it may also mean "no new doctors" in their community.


MERC Fact Sheet

(Medical Education and Research Costs)


·         MERC is the state program to compensate hospitals, clinics, and other health care providers, including the University’s Academic Health Center, for a portion of the costs of clinical training for health professional students and residents.


·         Some facts about the state law:

o   MERC covers clinical training of medical students and residents, dental students and residents, pharmacy students and residents, advanced practice nursing students, physician assistant students, and chiropractic students.  

o   The purpose of the fund was and is to compensate hospitals, clinics, and other health care providers for a portion of the costs of clinical training.

o   MERC is administered by the Department of Health.  MERC funds can only go to organizations that provide clinical training to students and residents from one of the state’s Sponsoring Institutions (e.g. University, Mayo, Hennepin, St. Scholastica, state colleges).  In essence, the money follows the students and goes to hospitals, clinics, and pharmacies.  Nursing homes are no longer eligible for MERC funds.

o   MERC funds come from three sources:  PMAP (the state’s Prepaid Medical Assistance and prepaid GAMC programs); federal Medicaid matching funds obtained by the Department of Human Services; and the cigarette tax.  


·         MERC funds are distributed two ways:

o   Dedicated payments to the University of Minnesota (Academic Health Center and Dental School) and University of Minnesota Medical Center, Fairview:    $5.35 million in 2009.

o   General distribution to eligible hospitals, clinics, pharmacies, and other providers based on their proportion of public program revenue (medical assistance, prepaid medical assistance, general assistance medical care, and prepaid general assistance medical care):  $60.7 million in 2009.


·         The Governor’s proposed cuts are estimated to be:

o   32.5% cut in dedicated payments to the University of Minnesota (Academic Health Center and Dental School) and University of Minnesota Medical Center, Fairview for the 2010, 2011, 2012, and 2013 distributions. 

o   87.5% cut in the general distribution to hospitals, clinics, etc. in FY11.   By eliminating the state monies in PMAP, the Governor eliminates the state’s ability to get federal matching funds


·         Impact of cuts in dedicated payments:  $1.74 million annually for four years (estimated) $7 million total:

o   School of Dentistry student clinics in Twin Cities, Willmar, Hibbing

o   Community University Health Care Clinic serving low income patients in South Minneapolis

o   Training programs at University of Minnesota Physician clinics

o   Training programs at University of Minnesota Medical Center, Fairview

o   Funds for area health education centers in Hibbing, Willmar, Fergus Falls, Crookston, North Minneapolis.


·         Impact on community hospitals, clinics, pharmacies:  $53 million in FY11 (estimated):

o   Sites with AHC students and residents:  $32 million cut (estimated).

o   Sites with students from other sponsoring institutions:  $21 million cut (estimated).


·         Biggest impact (cuts estimated in millions) :

o   Abbott Northwestern            $ 2.1

o   Children’s Minneapolis          $ 3.6

o   Children’s St Paul                     $ 1.5

o   UMMC, Fairview                      $ 5.4

o   Other Fairview units               $ 2.1

o   Gillette Children’s                    $   .9

o   Health East                 $ 2.8

o   HCMC                                           $ 7.5

o   Hennepin Faculty Assoc        $   .9

o   St. Joseph’s                                $    .8

o   Mayo                                            $    .3

o   Mercy Hospital                          $ 1.1

o   North Country Regional        $   .8

o   North Memorial                       $ 2.4

o   Park Nicollet Memorial          $ 1.0

o   Regions Hospital                       $ 3.7

o   Rochester Methodist             $   .3

o   St Cloud Hospital                      $ 1.8

o   St Lukes Duluth                         $   .6

o   St Mary’s Duluth                      $ 1.1

o   St. Mary’s Rochester              $ 2.6

o   United                                          $ 1.9

o   Unity                                             $    .8



It's time to get real about American health care.  Our health care system is operating on the flawed assumption that  we can meet unlimited demands with limited resources.  It is troubling to me that when this idea is brought up, it is often used as grounds for excluding one group or another group from the health care system.  This commonly justified by a moralistic argument.   As though, if we simply didn't have to pay to care for a certain group of people our problems would be solved.

A non-smoker doesn't want to pay for treating smokers with emphysema or lung cancer.   A skinny person doesn't want to pay for obese people's health care costs.  A rich person doesn't want to pay for poor people's care.  A law abiding person doesn't want to pay to keep criminals healthy.  A man doesn't want to pay for women's health coverage.  A young, healthy person doesn't want to pay for Medicare benefits.  A native citizen doesn't want to pay for an illegal immigrant's care.  A person who washes their hands doesn't want to have to pay for people who don't wash theirs.  A person who doesn't want or need family planning services doesn't want to pay for them for people who do.

It is tempting address a scarcity of resources by offering different levels of coverage or exclusions based on each group of people's health status and lifestyle choices, but let's learn from the past.  That patch-work, piecemeal approach to distributing health care is exactly the strategy that got us into this mess in the first place.

Every single human being in America deserves health care.  Period.  It is always easier to blame the other guy, but the truth is that we are all in this together.  The way to fix American health care is for all of us to look honestly at how we manage our own health and realize that we can all do better.  Even doctors.

3.10. 10

Another big earthquake:  Over 700 dead in Chile.  Please send support if you can.


Safe Electronic Health Records

I just completed the training for our Hospital's new Electronic Medical Record upgrade and couldn't help thinking about the $19.2 Billion in the American Reinvestment and Recovery stimulus bill  has invested in health information technology.  I have used most of the major EMR products during my medical training and if the public understood how clunky these things are they might not be as enthusiastic about what they're investing in.

I support EMRs without reservation, but establishing minimum standards is essential.  An EMR should be held to the same standards as the physicians who use them.  Because they are integral to managing critical patient information in life-and-death situations, the products and the people who develop them must be held to the same standards that any other health care provider is held to.  Currently they are not.  When it comes to reliability, safety and interoperability there should be zero tolerance for error.  Especially before tax payers spend $19.2  Billion. 

EMRs Should Never Crash - I've worked a hospital when the EMR crashed.  This should not be an option.  A physician can't just quit working in the middle of a busy day, nether should an EMR.  No patient's care should ever be compromised by EMR failure.  The computer geeks in my college dorm ran parallel servers so that their online role-playing wouldn't be interrupted, I'm sure the billion dollar EMR industry can figure it out.

EMRs Should Talk to Each Other - Between the hospitals I've worked at the EMR's don't talk to each other.  Imagine if I was caring for a patient who was transferred from another hospital down the road but I refused to talk to the doctors at that hospital and they refused to talk to me.  Even hospitals or clinics with the same brand of EMR may have different versions of the soft-wear that don't talk to each other.  Interoperability is one of the key advantages and cost-savers associated with the EMR and in a world of smart phones should not be negotiable.  The biggest challenge is not preserving confidentiality, it's that the software makers don't play well together and have not agreed on a common language to speak.

EMRs Should be Cost-Effective - Physicians swear to "First do no harm."  This means that if you only need one a physician will never try to sell you two.  We don't come up with gimmicks just to inflate our personal profits.   Because they are so intimately involved in patient care ERM makers should be held to the same standard.  EMRs should not be Wall Street's next jack-pot health care industry.  Health care should not get more expensive because everybody has to buy and EMR, it should get less expensive if the EMR Industry can actually deliver on their claims. 

EMRs Should be Care-Centered -  The primary function of many EMRs is billing.  They improve the billability of chart documentation, they  may not improve the quality from a care standpoint.  Take a look at most EMR products it is obvious that they weren't designed by physicians and nurses for improving patient care.  EMRs need to have formats that are easy for patients and their care takers to understand just like physicians need to have better handwriting.

EMRs Should Not be Beta-Tested on Patients - Having worked with some very clunky EMR systems, I can tell you no other industry would put up with the number of glitches and problems that these products have.  There should be minimum standards for quality in this industry that will protect patients from errors and protect providers from wasting patient care time on hold with a tech-support hot-line.

I am very excited about EMR technology and am embarrassed that health care is so far behind other professions in the adoption of useful technology.  But just like any new medical technology or any aspiring practitioner, there are basic standards that need to be met before I trust them with my patient's health.


A Tourniquet on GAMC

I agree with the Governor Pawlenty's diagnosis of the problem with General Assistance Medical Care.  GAMC is horribly inefficient and financially unsustainable...just like every other insurance program in this state.   I disagree with the treatment strategy of placing a tourniquet on GAMC without planning a definitive solution for the problem. 

It's a good deal for lawmakers because they can say they "saved" GAMC at a fraction of the cost, but all they have done slashed funding for the state's sickest neediest population and dumped it in the laps of the state's health care providers.  Pawlenty hasn't made GAMC any more efficient or financially sustainable, he's just made it somebody else's problem.

Late Friday afternoon the Governor and State Legislature came to a deal to save the General Assistance Medical Care benefit.  The Governor had previously "unallotted" funding and then vetoed a recent Bill to restore funding at a lower level.  The deal provides a trickle of continued revenue and punt's the hard decisions about how to distribute the very limited resources to Minnesota's health care providers.  Instead of a traditional fee-for-service model, where GAMC pays health care providers an agreed upon amount for each service rendered, there will be a capitated system where a much reduced pool of money is allotted by the state to cover the cost of care for GAMC patients and it will be up to+ "Coordinated Care Organizations" established by the 15 Hospitals with the highest volume of GAMC patients to divvy up the funding.  If the cash runs out the hospital will have to cover the difference by either cutting services or increasing fees for their other patients - or finding funding elsewhere.  Minnesota has tried capitation before, needless to say it was no cure-all for health care.

Minnesota lawmakers have tied a tourniquet around GAMC and are depending on Minnesota's health care providers to do the hard work of keeping the program viable for the patient's who depend on it. 

3/5/10 (late pm)

My fiancee Leah and I met with Greg Vercellotti - a mentor and good friend of mine - and his wife Jane for dinner tonight.  "Choose your role-models wisely." was the first advice he ever gave me.  He has been absolutely right.  There are convenient role-models and then there are good role models.  Trying to follow Greg's example as a virtuoso clinician, brilliant researcher, powerful leader and a stead-fast, uncompromising advocate for patients has never been easy.  He simply considers it "being a good doctor", but in medicine there is always an easier path available.  Even slightly straying from the harsh discipline of evidence-based reasoning and the not-so-easy pledge to "first do no harm" has won many of my colleagues tremendous wealth and fame outside (and occasionally inside) the practice of medicine.

We spent the evening chatting about life, medicine and politics.  I ate a terrific steak (and half of Leah's) and was reminded that there is nothing anemic about health care reform. When health reform is lead from the front-lines of the battlefield instead of from the PAC office it becomes an emergent issue of national security and human dignity instead of a detached, minutia-driven stand-off.


A spade is a spade

...regardless of its political affiliation.  According to Merriam-Webster:  nonpartisan means "free from party affiliation, bias, or designation".  There is nothing in that definition about being wishy-washy or skirting reality.  If you point out something that is painful or inconvenient to one party it doesn't mean you  are biased towards the opposing party.  Being honest or factual may be politically inconvenient, but it is essential to making good decisions.

In a recent Commentary I mentioned the erosion of the American public's confidence in President Obama's health care reform efforts over the last year.  I described this as being due both to the blatantly partisan gridlock in Washington and the due to the soap-opera the media created around the recent Massachusetts Senate race. 

I have since been criticized by people from both sides of the aisle for being biased.  By the left for suggesting that some of the public's "hope" has been lost and by the right for pointing out - in the context of describing America's loss of trust for a democratic initiative - that Senator Scott Brown is a former nude-model.

I don't think either of these observations make me a partisan.  Over the course of this project I've gotten used to knee-jerk criticism along party lines.  I actually appreciate the input, because if I'm dead wrong on an issue I want to know about it.  The thing that concerns me is readers who have implied that if I make any criticism of anyone on either side of the aisle it violates being non-partisan.

Being non-partisan does not mean pulling all your punches. 

If one party declared that the earth was flat would I be a partisan for pointing out that they are wrong?  If objectivity is going to win out over political gamesmanship some people are going to get offended.  We must respect each other's opinions, but defend the facts first and foremost.


Check out MPR News-Q and my commentary on Nonpartisan Health Care Reform!

Kerri Miller's Health Care Forum

The Event:

I attended an interesting health care discussion last night.  It was hosted by MPR's Kerri Miller and will be aired in close proximity to President Obama's Health Care Summit.  The discussion was lead by a panel of experts who included the President and CEO of Franciscan Skemp Healthcare from the Mayo Health System, the President and CEO of Healthpartners,  the Blue Cross Professor of Health Insurance at the University of Minnesota School of Public Health and a family physician who works for Fairview Health Systems.

It was a very interesting conversation about the wonkish side of health reform.  The discussion started with a general condemnation of President Obama's compromise plan for health care reform by the two insurance executives and the public health professor.  Their strongest objection was to the regulatory control the government would be able to exert on health insurers.  Interestingly the Blue Cross professor unequivocally defended the recently infamous 39% insurance premium hikes by the Anthem-Blue Cross corporation.  The family physician used the opportunity to steer the discussion toward the effect of our insurance system on individual care.  Kerri Miller then welcomed the audience into the discussion and  the event took on a life of its own.

The quality of audience input made the conversation especially interesting.  Clearly the auditorium was packed with health care insiders and advocates who were often more interesting than the panelists.

In Retrospect:

As the conversation went on it became evident to me that the one view-point not represented very well in the discussion was the most important one:  The Patient.  This is a challenge common to all such forum's I've attended, for the simple reason that sick people, uninsured people and average health care consumers don't have a well funded public relations division or CEO they can send to these types of forums to represent them.  If a patient representative is present they're usually not professionally trained to dominate this type of conversation so they are often not as effective as the other representatives on the panel.  The result is often a lot of very well-informed chatter about minutia.

I suspect every national health care think-tank and every congressional hearing in Washington D.C. for the last 30 years has had the same challenge.  Regardless of the massive power the panelists may wield, when staged as an academic discussion between a bunch of special-interest funded policy geeks, reforming health care boils down to an unapproachable mire of complex ideas and insurmountable challenges.  And it is.  There are a thousand compelling reasons that we shouldn't rush in and reform health care right now and there is really only one reason that we should:  It's the right thing to do.

That fact is easily glossed over by expert panels - actually, it's not even on many of their radar screens - but in a nation where we believe all people are equal no one should be denied access to basic health care because of the state they live in, their age, or who their parent's employer is.  In the most affluent nation in the history of the world - recession notwithstanding - every citizen should have access to basic health care that is as good or better than that of the citizens of any other country we would call a peer.  Though the wonks are far smarter and far more powerful than I am, they easily forget the one fact that I am reminded of every day I go to work: every member of my community deserves health care.

Our nation's inability to provide affordable, sustainable health care to its citizens isn't due to a lack of talent or resources, it's due to a failure of our moral compass that loses the forest for the trees.


Here's a letter I wrote to the Star Tribune regarding the Governor's veto of GAMC funding:

Vetoing Minnesotan's Health Care

Dear Editor,

I appreciated Warren Wolfe's article about Governor Pawlenty's veto of the state legislature's bipartisan bill to save Minnesota's General Assistance Medical Care program.

All of us in Minnesota understand the Governor is willing to make tough sacrifices to balance the budget.  He's been doing that since he was elected.  As a family physician who cares for GAMC patients I have to take issue with the Governor's lousy math skills and his backwards logic.

The Governor and I both know that neither unallotting nor vetoing state funding for Minnesota's sickest, neediest citizens will make the cost of their care go away.  He also knows that the Minnesota Care program is not designed for or funded appropriately to meet their needs.  The governor is letting the political calculus of his national ambitions crowd out the needs of the citizens whose health and safety he was elected to protect.

As an elected leader in a nation where all people are equal, if Pawlenty believes that cutting people's  health insurance is an acceptable way to balance the budget , the first publically funded insurance benefit on the chopping-block should be his own.

 Will Nicholson M.D.


I've just finished a stint of 9 days on the hospital service, it's given me a bunch to write about.


Best Medical Practices Conflict with Medicare Regulations

One aspect of hospital care that many people are not familiar with is the regulation Medicare puts on length of hospital stay.  An interesting example is the "3 day stay" requirement for Medicare to cover a stay in a transitional care facility after discharge from the hospital.

Many Medicare patients require a brief stay in a transitional care facility in order to help them recover before going home.  Transitional care facilities help patients who are recovering from an illness by continuing to provide close medical monitoring and intensive rehab therapy at a fraction of the cost of hospital care.  They are a great option for complex or elderly patients who aren't sick enough to keep in the hospital but have a high chance of failing at home.

As you can imagine there are many patients who are well enough to go to a transitional care facility after only one or two days in the hospital instead of three.  This is a good thing!  The patient got better quickly, but unfortunately due to a seemingly arbitrary Medicare regulation the patient's speedy recovery actually counts against them financially and sets up a conflict between the physician's obligation to "do no harm" and the financial best interest of the patient.   

In the case of a 1-2 day hospitalization, a physician will recommend discharge knowing that Medicare will refuse to help pay for the patient's transitional care.  If patient is not healthy enough to go straight home the physician cannot in good conscience send the patient home.  It is simply not safe for them to do so, but if the patient doesn't have the resources to pay for transitional care out-of-pocket, to the tune of thousands of dollars, it may spell financial disaster for them.

Hospitals have gone to great lengths to improve efficiency and decrease the length of stay for most patients, thereby lowering health care costs and improving the quality of patient care.  This seemingly archaic Medicare regulation presents a substantial barrier.  Fortunately in Minnesota there are some great programs like UCare that Medicare patients can enroll in.  UCare manages the Medicare benefit of the patient and does away with arbitrary requirements like the "3 day stay".  In that respect I love taking care of UCare patients.  There's plenty of room for innovation in this system, the opportunities are immense.






















*** This entry has been posted as a Commentary on MPR News-Q***


It's interesting to observe Toyota recalling millions of vehicles.  They've spent a great deal of time apologizing for not living up to the quality and safety standards that America - rightly - expects.  Our entire auto industry has minimum standards which everyone agrees upon.  The U.S. has a Department of Transportation that enforces these standards.  Could we apply the minimum standard model a little more assertively to health insurance?  Perhaps it's time our Health Insurance industry sets some higher national standards for quality, safety and value.  Good providers could then be rewarded for meeting those standards, providers who's services did not meet standards would end up in the same boat Toyota is in. 

We could use the level of quality, safety and value that other countries achieve with their health care systems as the minimum standards.  (I think we can all agree that an insurance product offered to an American consumer should be at least on par with the standards of other nations.)  Competition within the market would then hopefully push all the insurance products to offer services at a cheaper rate or a higher level of quality than the minimum standard and consumers would have an objective starting point from which to assess any given product.


I bought another 30 day insurance plan today.  I'm running low on options as far as products to purchase.  There is a rule in Minnesota that you cannot have short-term insurance for more than 365 of the past 555 days.  I'm not there yet, but the amount of time I have been on short-term plans (approximately 200 days) seems to make me ineligible for certian products, based on the online applications I've been filling out.  I wonder if the fact that I'm on short-term insurance for an extended time elevates my risk level from the insurance company's point of view.  It would be interesting if using short term insurance was a health risk in their eyes, since they all sell the products.  Should there be a warning on the contract?  I'll have to get more information on this.


Now is a perfect opportunity for congress to implement evidence-based, common-sense health care reform.  Things like making electronic medical records affordable and inter-operable, stopping pharmaceutical company influences that are not in the patient's best interests, and finding a way to make keeping patients healthy in the best interest of their insurance company, promoting the use of generic drugs when they are as effective as brand-name medicines should be the first priorities of our government.  There is enough common-sense out there to cut through the political fray.


It's been a wild ride since Leah donated our food budget to Haiti relief.  Her gesture attracted significant media attention.  As a result, we are going to try and donate the rest of the budget in return for donated wedding services that people have contacted us with.  The experience made me realize there are tons of people out there who want to help and have something to offer, but often that something isn't cash, food, medicine etc.  What we need is a Craigslist for disaster relief that would connect people who would like to donate services and goods that are not specific to disaster relief, but could be sold and the cash then donated.


My Amazing Fiance

Today my fiance donated the food budget for our wedding to Haitian relief efforts through Partners In Health.  I am still in awe.  Here's the letter she is circulating to inspire other brides to do like-wise:

Today I donated the food budget for my wedding  to relief efforts in Haiti.

Getting married and planning the perfect wedding is something most women, including me, dream about for a very long time.  The perfect dress, decorations, catering, flowers, cakes, the list goes on and on.  It is my chance to be "queen for a day" and it feels great.  My fiancée and I have been planning our wedding for a few months now, meeting with vendors, setting our budget and having many long conversations about creating the perfect wedding.

 Running in tandem with our wedding planning conversations over the past few days has been the horror and human tragedy in Haiti.   I woke up Sunday morning and sat down with a cup of coffee and the newspaper and read  about people with no food or water, having limbs amputated in makeshift hospitals in a last chance effort to save their lives.  I suggested to my fiancée right then that we should donate part of our wedding budget to disaster relief in Haiti.  Anyone who has planned a wedding knows how tight the budget can get, but without a moment's pause he said "YES! I love you SO much!" 

We have decided to donate our food budget - 25% of our wedding funds - to aid victims of the Haiti earthquake.  Our friends and family can go without a fancy wedding dinner, especially if it means helping provide food, medical care and shelter for those desperately in need.

The tragedy in Haiti is so huge I hope that other brides- to-be will take this message to heart and find a way to donate to a relief organization.  Find something in your wedding budget that you don't need and just cut it out.  Assess what is most  important to you on your wedding day, harness your bride-power, and take action to do something that will make your wedding unbelievably meaningful!  Your wedding will be spectacular, and the money you donate will make a huge difference to someone in dire need.



Leah Bogen


Here's an interesting story from Haiti:

CNN's Sanjay Gupta M.D. stayed at a field hospital after the U.N. evacuated their Physicians and Nurses because the area was considered unsafe.  It's tough to imagine the right thing to do from a Physician's point of view.  On the one hand, the first rule of First Aid is to make sure that the area is safe for the rescuer before attempting rescue.  The worst thing medical personnel can do is inadvertently add themselves to the casualty list.  On the other hand, it would be very difficult to leave patient's you've already started caring for.  The fact that the world was watching via CNN's cameras adds an extra level of complexity.  I'm not sure where the ethicists or public opinon will fall on this one, but thankfully the rest of the staff were able to return to the hospital in relatively short-order.

No doubt, Goupta will be both lauded and criticized for the personal risk he was willing to take.  In a small way I can understand his predicament, but cannot imagine what a difficult decision it would be.


Unallotting Health

What are the 30,000 Minnesotans whose health insurance was unilaterally slashed by Governor Pawlenty going to do this year when they get sick?  This is a question I hope Minnesota's Congress has an answer to as they start their new legislative session.

In tough economic times there is no end of challenging issues  but, as cash gets tight do we really want to be a state that was willing to put our citizens' health care on the chopping block?  What kind of precedent does that set for future budget-balancing solutions?

Minnesotans trust public officials to protect our health and safety  against threats, financial or otherwise, not to use wholesale "unallotment" of a large population's health insurance  as a quick fix for the year's balance sheet.

In Minnesota our health care should not be denied when it becomes inconvenient or bargained with for political advantage.  A relatively defenseless group of our state's neediest people should not be expected to give up health insurance to help make up the difference in the Governor's unbalanced budget.   

As a family physician I have an obvious bias on this issue.  My job is to help my patients stay healthy, and many of my patients depend on General Assistance Medical Care to do so.  I sincerely hope the Minnesota Congress has a more ethical strategy to address budget woes than the governor has initially chosen. 

Governor Pawlenty certainly has the right to disagree with me when it comes to the importance of funding General Assistance Medical Care.   I respect the governor's point of view but would only suggest that he re-examine the internal consistency of his personal philosophy:

As a leader in a nation where all people are equal, if you believe that cutting health insurance benefits is an acceptable way to balance the budget , the first insurance plan on the chopping-block should be your own.

Note:  Urgent Aid to Haiti

If you are interested in helping Haiti rebuild but can't hop a plane tonight the Clinton Foundation - Bill Clinton is the U.N. Envoy to Haiti - has an easy way to donate the most needed resource:  Money

Text "HAITI" to 20222 and $10 will be donated directly to Haiti relief efforts and the charge added to your cell phone bill.  (You have to do a follow up text to confirm your donation.)

For more info check out


NASCAR Health Reform

In medicine we are excruciatingly critical of our own objectivity.  Bias is the enemy.  There are studies examining the bias of research based on who funds it, studies examining the bias of education based on who funds it and even studies examining the bias-causing effects of a free pen or free sub-sandwich on a physician's prescribing practices.  Even so - to the eternal frustration of my profession - some bias is inescapable.  There was a day in the distant past when physicians were treated to trips to Europe, given large stipends and lavish dinners by industry sales persons trying to promote a product.  However, over the last 20 years Physicians have systematically attempted to minimize or eliminate these influences because of one revelation:  Even the most innocuous of these enticements were causing physicians to make decisions -often on an unconscious level - that were not always the best ones for their patients.


Contrast this with the decisions being made in the interest of the American people by our elected representatives - who are often accepting millions of dollars from speical interest groups.  What level of bias - conscious or unconscious - is associated with that kind of financial relationship?   And these dollars aren't tied to some luxury like free lunch or a pen, they are crucial for that politician's re-election and difficult to refuse.  In that sense politics is more like NASCAR where the competitors depend on large corporate sponsors to keep gas in the tank and the engine running.  In that sense I like NASCAR.  You always know who is working for who.  It says it right on their jacket or hat or the hood of their car.  There is no illusion that the driver's skill alone won the day.


Campaign finance reform has been tried in the past, but has just moved the money further behind the scenes.  Without a ton of money the show cannot go on.  There is certainly the argument that since large organizations can't vote they need to use large cash donations to represent themselves in the government. Cash that politicians need to fund their own re-elections.  Perhaps America's lawmakers should go in the opposite direction that physicians have gone.  Since some bias is inescapable, don't minimize bias, just be up-front and transparent about it.  Just like NASCAR.  When a congress member debates health care maybe they should have a big colorful logo patch on their blazer for each of the health care companies and organizations that are are giving them money.  That way when we watch them debate we can see - just like in NASCAR - exactly who is paying to keep them in the race.


It's the end of the 6 months I set aside to opt-out of my employer's health insurance and it's time to double-down.  I'm going to keep the project going until June.  There's more to learn and many more products to test-drive.....  no sleep 'till brooklyn I suppose.


Year Retrospect

It's interesting to compare January of my last year as a resident  versus this January during my first year as a practicing physician.  A lot has changed since graduation in July.  Not that my first six months in practice have been a cake-walk.  Practicing without a net for the first time is a harrowing experience no matter how prepared you are, but at least I now have some control over the amount and frequency that I am working.  In the last six months since my goals have been simple;  get 8 hours of sleep - usually at night, eat healthy meals - and chew them, exercise more days than not, and fit back in my clothes again.  Essentially to get close to as healthy as I was before I started medical training.

Most people are familiar with the rigors of medical training due to the fact that it's been dramatized on prime-time television for the last decade and a half.  Often the T.V. version is a bit over the top.  In real life there's less social intrigue, less flattering costumes and worse background-music , on the other hand television doesn't come close to representing the level of intensity, exhaustion and frustration med-students and residents go through.  That kind of stuff doesn't make good television and  it doesn't make healthy doctors either.  We've got one of the highest rates of depression, suicide, alcohol and drug abuse and even divorce of any profession....yet we're the nation's guiding force on health.

I love my profession and every day I feel profoundly privileged to practice medicine.  The training has been the most valuable experience of my life.  There are parts I loved and parts I absolutely wish I had never done.  As an arduous means to a very rewarding end I am thankful  to have been allowed to do it.  But when you turn the clinical eye inward and examine the experience you see a troubling undercurrent of shameless hypocrisy.

It's a level of hypocrisy that we need to address as a profession.   If training requires us to break many of the rules of good health that we espouse to our patients how long can our credibility last?


Universal Coverage May be Cheaper than Expected ...or Remembering There is a  Return on Investing in Health


Recently a Harvard Medical School Study published in the Annals of Internal Medicine showed that the cost of covering the uninsured may actually be cheaper than initial estimates.  The researchers did a simple but brilliant thing, they found a way to estimate the financial benefit that might result from keeping uninsured people healthy.   They found that it costs Medicare an extra $1,000 annually to cover a person who was even intermittently uninsured between the ages of 51 and 64 years of age - before their Medicare benefit kicked in.  They estimated that remedying the problem (Yes, being uninsured is hazardous to your health.) and extending health coverage to all people 51 to 64 years of age would offset the costs to Medicare by $98 billion.  Overall this would lower the estimated cost to Medicare of insuring that group of people from $197 billion to $99 billion.

There are significant financial benefits to keeping people healthy - especially people with chronic disease - they are just more complicated to estimate.  Although on an annual budget the money associated with health is often in the negative "cost" section, investing in health of one's citizens or one's employees is not just throwing money away.

As a family physician I see examples of this every day.  The benefits of health are varied and more challenging to quantify than the simple cost of a monthly premium, co-pay or medicine, but the benefits often far out way the costs.

It's easy to add up the cost of  the medicines and doctor's visits it takes to keep a diabetic patient healthy for 5 years, but the value associated with the fact that a patient was able to stay healthy enough to keep their job and care for their family is seldom estimated as a comparison.  We know the annual cost to closely manage heart failure to the dime, but the value associated with the fact that a grandparent remains healthy enough to care for her grand kids and cook dinner for them after school for another year cannot accurately be priced.  The war veteran with lung disease who cares for his wife at home in order to keep them both out of a nursing home, the widow who can still run the church holiday raffle after her stroke, all of these are patient's who I've had to convince someone - an insurer, a drug company, a family member - that the cost of their care is a small cost in dollars for a very large benefit  to the patient's  family or community.

We have spent a great deal of agony on the financial burden of health care costs.  It's time that America stops to consider the immense human benefit of maintaining good health.


The Dental Health Conundrum

                One  ongoing challenge to the medical system is patients who end up in the ER due to dental infections.  They come to the ER because they have no dental insurance and may or may not have medical insurance.  It is difficult to schedule a dental appointment if you don't have insurance.  (Especially if you don't have the cash around to pay for the service immediately.)  People know that ER's will evaluate and treat them (approx. cost $1000) no matter what their insurance or financial status is.  Unfortunately, most emergency rooms are not set-up for emergency dental interventions and rather than extracting the tooth - which is most often the definitive intervention - dental infections get treated one of two ways:

                Option #1:  If they are uncomplicated they are sent home with antibiotics and analgesics and referred to a dental clinic for tooth extraction (approx. $200-500) or root canal ( approx. $500-900).

                Option #2:  If they are complicated - at risk for severe infection or having uncontrollable pain - they are often admitted to the hospital, placed on IV antibiotics and emergently evaluated by an oral surgeon (approx. cost >>$1000) and are still most likely to end up following Option #1 in the end.

                There are very few dental equivalents of the ER out there and huge numbers of people who go without dental insurance, so the scenario above occurs with painful frequency.  If patients could find an emergency dentist in a pinch they might be able to get away with one bill that's only a few hundred dollars.  As it is now these folks end up with two bills totaling often over a thousand dollars.  Plus it can take them weeks to get an appointment at one of the dental clinics for the uninsured. 

                For some reason the dental health system is totally separate from the rest of health care.  As a family doctor - a generalist - I had very little training specific to the teeth.  Why the teeth have separate status from all the other organs of the body escapes me, but regardless the situation presents some unique problems.  Since dental care is separate there are totally different billing standards, totally different insurance plans and different requirements on the profession.  Where the health care system is required to have at least emergency care that no one can be turned away from, the dental system has a different standard.

                Although the profession was a pioneer of preventative care (i.e. brushing and flossing) I hope they can figure a better system for emergency care.  Or maybe we'll have to start teaching tooth extraction in medical school.



I went to the optometrist because I needed a check up and new glasses.  The insurance plan I bought this month doesn't cover eye-care, but they were having a sale.  The eye exam cost over $100 and the glasses were considerably more than that.  On the wall of the clinic there was an ad showing how the clinic's charity had provided a homeless person with glasses and he was able to then learn to read and get a job.  It's a great story of charity, but it amazes me that something as basic as vision could be financially out of reach for any American.  Should the cost of eyeglasses come between anyone and getting a job?

 Corrective lenses are another thing that are often carved out of health insurance coverage, why vision care is considered different than care for any other chronic condition does not seem to have any relevant justification to me, especially considering how essential vision is to daily function.

As part of the recent health care reform bill the state of Minnesota is working on establishing an "essential benefit" set that all insurance would be standardized to cover.  I would suggest that vision care be considered essential.


Minnesota Leads on Health Care:  Health Care Reform

The Minnesota Legislature with the hard-won support of Governor Pawlenty  in 2008 enacted S.F. 2780 a broad and largely bipartisan health care reform package that involved both evidence-based and market-driven initiatives.  The bill outlines a plan for common-sense reform with expanding access, reducing cost and improving quality as its main objectives.  The bill required a great deal of compromise and was passed without becoming  terminally mired in party-politics.

Governor Pawlenty's recent 10 point state health care proposal (summary to come) is at times redundant with, or counter-to the state's current reform plan.

Here is a summary of the bill's objectives adapted from  the Minnesota Medical Association:

Medical home
The bill supports the medical home model—coordinating care primarily for patients with complex, chronic conditions. Both clinics and clinicians (physicians, advanced practice nurses, and physician assistants) can serve in this role. The commissioners of health and human services was directed to develop and implement standards for certification of medical homes (described in the legislation as “health care homes”) by July 1, 2009.  These are currently still being finalized. The model will be evaluated in three to five years by the commissioners of health and the commissioner of health and human services.  

Development of Health Care Homes are an attempt to more proactively approach chronic illness - where most health care dollars are spent.  They are a product of the realization that improvement in community-based primary care is one proven way to reduce cost and improve health outcomes.

Essential benefit set
It establishes a work group that will make recommendations on the design of an essential benefit set that includes coverage for a broad range of services and technologies that are determined to be clinically effective and cost efficient. The work group will report to the Legislature by January 2010.

Public health
The bill will provide $47 million for statewide grants to be awarded in 2010-2011 for programs aimed at reducing obesity and tobacco use.  These projects are currently under way in most counties

Move toward universal coverage
The package is expected to expand health insurance coverage to 12,000 more Minnesotans. The bill would increase health coverage in state programs by enrolling 7,000 more people in public programs by making people without children who have incomes up to 250 percent of the federal poverty guideline. The state hopes that additional tax incentives will encourage 5,000 Minnesotans to buy insurance in the private market.  Governor Pawlenty vetoed the original proposal which would have expanded coverage to 40,000 Minnesotans due to cost.

Cost and quality transparency
The legislation directs the commissioner of health to develop a uniform and valid methodology for calculating providers’ combined performance on cost and quality and to promote payment reform that rewards quality and efficiency. 

Note: The Minnesota Medical Association has set up similar evaluation for insurance providers as well which could also be useful to improve competition on the other side of the equation.

Bundled services
The bill directs the commissioner of health to establish definitions for at least seven baskets of care, or  a set of related services, and suggests that they include in those sets treatment for coronary artery and heart disease, diabetes, asthma, and depression. Providers may then choose to establish a price for each basket.

Note: This provision is strongly supported by Pawlenty.  The idea is a competition based one, the problem is that it breaks care into a "basket" instead of recognizing it as a continuum.  It also puts smaller provider groups and providers in under-served areas at a disadvantage because they may not be able to provide all of the services in the bundle.

Electronic prescribing
The bill will establish standards by 2011 for physicians who write and send prescriptions to pharmacies electronically.

 Note: MN has already joined a national registry to monitor prescription drug abuse, however the program was approved without adequate funding.  An estemated 20% of Americans have used prescription drugs for non-medical purposes.

Looking Forward:  Outside of what may be done in the legislature, the State Commissioner of Health has broad power over implementation of this reform in the coming 3-5 years.  The Commissioner's work could help these new programs succeed or turn meaningful innovation into political doggerel.


Here's a link to and a copy of the article I wrote for Minnesota Medicine the publication of the Minnesota Medical Association.  It's a summary of the first steps I think physicians could make to try and put health care reform back in the hands of people who actually perform the care.

A Clinician’s Approach to Fixing Health Care

While the national debate about health care reform seems to become more abstract and outlandish every day, the realities of our broken system are ever more immediate. I recently received a flyer announcing a fundraiser to help a local physician pay his medical bills. It reminded me that in a health care system as dysfunctional as ours, even physicians are not safe from catastrophy.  

It is disappointing that in our current attempt to overhaul the health care system the insurance industry, drug companies, and political partisans have taken center stage while those of us working on the front lines with patients have been largely left on the sidelines. Understandably, many physicians avoid politics altogether because of the dishonesty, shady tricks, and winner-takes-all tactics used by the various players. It is a risky proposition to wear a white coat into a room full of mud-slingers.  

Although wading into the morass of American political discourse is daunting, actually taking some first steps need not be that difficult. For one thing, we don’t need to take those steps alone. We physicians need to approach the challenge of fixing the dysfunction in the health care system the same way that we approach treating disease—by collaborating, working as a team, and applying our professional standards to the process.

Working as a team is as important to influencing health care reform as it is to caring for patients. Just as organizing as a practice group allows individual physicians to reclaim power over their weekly routine, organizing as a profession gives individual physicians more power over their future. And as with sharing call duty, if each of us contributes, the result is better for everyone.

One of the most convenient ways physicians can do this is through our existing professional organizations. Yet only about 20 percent of physicians belong to our biggest and oldest professional organization, the American Medical Association (AMA). This is clearly not enough to give physicians the upper hand in the health care reform debates.

Working as a group can be cumbersome. Many physicians are reluctant to participate in organized medicine because of differences of opinion within others in the group. As professionals, we need to realize that even though we may disagree with one another on certain issues, we have more in common with our fellow physicians than we do with the other interest groups vying for control of health care. We need to make participation in our professional associations a priority.

When physicians are not involved in organized medicine, a minority may misrepresent the majority opinion. For example, a recent nationwide poll of physicians published in The New England Journal of Medicine found that a solid majority, 73 percent, of physicians supported some form of public option for medical insurance. Yet it was only very recently that the AMA shifted its policy in that direction. Regardless of how you feel about a public option, you can see that when only a handful of physicians are making the calls, the interests of the majority may not be served. The public is hungry for our input, and we must represent our profession accurately.

To make sure that happens, we physicians need to do politically what we do as clinicians. When it comes to patient care, physicians are great at interspecialty collaboration. We keep the greater goal—helping the patient—ahead of individual disagreements. Unfortunately, we have often let turf disputes get in the way of the best interest of the profession as a whole when it comes to our professional organizations.

As an example, I was stunned when a lobbyist representing emergency physicians at the Republican National Convention last year told me that reducing health care costs by stemming the flood of nonacute, nonreimbursed care into ERs was not in the interest of emergency physicians. His response was, “If you [a family physician] think you’re going to take away 12 percent of our ER patient population, you’re crazy.” From his point of view, he was advocating for his constituents. I met other lobbyists from other medical specialties—including my own—who were not much more enlightened about the importance of taking a team approach to problem-solving, an approach the physicians they represent depend on every day.

In contrast, the well-funded lobbyists who represent health insurance and pharmaceutical companies have agreed to team up to advocate for the greater causes of their respective industries. Even as the organizations they work for battle each other mercilessly for market share on a daily basis, they have cooperated on national health care policy, and their impact is undeniable. If physicians could somehow speak with a single voice about health care reform, we would have unparalleled influence.

In order to speak with unity, we need to find principles about which all specialists can agree. We all believe that science is the basis of our practice, we’re committed to the patient’s welfare, and we value the ethical and professional codes of conduct that guide our patient interactions. As we become more politically engaged, we need to unite around the same principles that guide us in our practice every day.

The training, background, and instincts that help us care for ailing patients in our daily practice need to be applied on a larger scale as our nation attempts to care for its ailing health care system. Although it may not seem like the most natural extension of our scope-of-practice, getting involved in this political debate is necessary. We can start by working together as a profession, collaborating with other specialists, and setting the bar high for ethics and professional standards. With so many standing in the way of effective health care reform, it’s time for physicians to take these simple steps and get things moving in the right direction.


Victim of the Fine Print Once Again

One of the health insurance products I've looked at was a low-cost/high-deductible plan that was heavily advertised as offering a couple of free doctor's visits per year - no copay, no deductible.   On the surface this seems like a nice idea, it encourages access eve for people who are trying to save money.  For a healthy person, maybe it would encourage them to get a physical or go be proactive about some other health care issue.  However upon closer inspection the "free visit" only includes the physicians fee.  It does not include the cost of any of the tests or procedures that may be done. 

This seems deceptive to me.  While there are many things I can take care of in an office visit without additional charge, but tests and procedures are also an integral part of the services I offer and use to diagnose and treat disease.  It's like advertising a free visit to the barber, but actually only paying for the barbers consultation - and not covering anything like actually having the barber cut the customer's hair.

These kind of bait-and-switch gimmicks are not making the job of America's health care consumers any easier.  I would never use cheap gimmicks on my patients and I don't think any third party payer should either.


Minnesota Leads on Health Care: Minnesota Care

Minnesota Care - Minnesota has one of the lowest rates of uninsurance in the nation.  Our Minnesota Care Health insurance program is one of the main reasons for this.  Minnesota Care is an excellent example of Minnesotans working together to improve things for everyone.

Description - Minnesota Care is a subsidized health insurance program for working people who cannot afford private insurance but don't qualify for Medicaid.  Minnesotans eligible for MN Care pay insurance premiums just like everyone else but their rates are lowered by a subsidy which is funded by a 2% tax on doctor's visits and other health care services.

Background - The program was started in the Arne Carlson administration.  It would not have been possible without agreement from both political parties as well as Minnesota's doctors, hospitals and health care consumers that in our state; people work hard and pay taxes should be able to afford health insurance.

Benifits - Minnesota Care benefits Minnesota's citizens by offering an affordable option for health insurance.  It lowers the impact that unreimbursed care would otherwise have on everyone else's hospital bills. It helps physicians keep their patients who would otherwise be uninsured. It keeps people   off of  the completely publically funded medicaid program and paying their own money into the system which helps broaden the health care safety net for all of us.

Challenges:  MN Care is not without challenges, one of the biggest challenges is surplus.  The fund made by the 2% health care tax has been repeatedly raided by the Pawlenty Administration and paid into the general fund instead of being used toward MN Care as it was intended.   This raises the question of whether we should continue to tax one of the least affordable necessities of life to pay for general state spending.  The alternative would be to cut the tax to 1% and give people a break on their health care costs, or leave the tax and expand the programs we have to use up the annual surplus.


Today I had the opportunity to give a presentation to residents on health care reimbursement and reform at the Department of Family Medicine at the University of Minnesota.  Reviewing the material and building the presentation was very interesting.  I spent a great deal of time trying to boil down the ideas as simply as possible.  It is interesting that as a profession we have a very hard time understanding the convoluted method by which we are paid.  I wonder if other professions have similar challenges.

If I can figure out how I will post the power-point slides.


Here's an article I wrote for the U of MN Department of Family Medicine.  It was published this month in their Family Medicine Connection newsletter as:

An Experiment in Health Care

Wednesday July 22nd was my day off.  I slept late and woke up to a voice-mail from the department coordinator at my new job asking me to call CNN about an interview: They wanted to know why I dropped my employer's health insurance benefit.  Two hours later I was in front of a camera on a live national satellite-feed being questioned about going-it-alone in the consumer health insurance market while 1.5 million people watched.

Three weeks after residency I was well-prepared to run a code or manage a shoulder dystocia.  I was not prepared for television interviews.  Fortunately similar principles apply.  Who knew applying the skills I learned during my medial training to the arena of health care reform would land me in front of the glare of the national media?


The night before that interview, an article I wrote had been posted on the internet.  It outlined a project that I had started:  Instead of accepting the health insurance benefit from my new employer I had gone onto the consumer health insurance market to buy health insurance as an individual - just as many of my patients have to do - and I was finding it challenging.

During training I learned to think objectively about medical challenges. I also learned that addressing the ills of an individual patient often cannot be separated from addressing the ills of the system as a whole.  The cardiac arrest, the distressed newborn, the health insurance crisis I wanted to approach them all with the same medical objectivity and honesty of method.

After three years at a residency clinic I was painfully aware of the inadequacies of America's patchwork health insurance system. Every day its complexities and short comings hinder the family physicians' ability to care for our patients.  As we toil to provide the same level of care for patients insured by the government, by their employer, by a commercial plan or patients who go without insurance. Our patients get sicker faster and die sooner.

I wanted to investigate health insurance, but without a large grant or research team I designed the project as a case-study using myself as the case - hopefully one with a good outcome.  I planned to start with the proverbial low hanging fruit and learn about the people who are trying hard to do the right thing but still aren't succeeding.  I wanted to become an empowered health care consumer - the essential unit of the individual insurance market.  I wanted to see what challenges I met as I made purchasing decisions and what advice I might offer.


By the time I left the television studio that afternoon I had three more requests for national interviews on my voice-mail.  With the media saturated by national leaders weighing in on health care, I was astounded that the level of interest in my little project was so high.

As an advocate for Family Medicine I hope the public sees that our profession already holds many of the  keys to solving our biggest health care challenges.  Our community-based, whole-patient approach has been repeatedly proven to provide the most effective, cost-efficient care available.  Unfortunately, I think the public's trust in many health care experts is eroding, but because family physicians continue to share their daily struggles, patients' trust in their family doc remains. 

As a physician who works with patients every day I don't think that this can be over-emphasized. The health care debate has grown so abstract and bazaar, so fraught with ulterior motive, and political calculation that the best service a physician offer is to remind people through the fray that above-all the practice of medicine puts the patient first.


No one has been more surprised by the attention the project has gotten than I am.  While it's too early to make many conclusive recommendations, it has been a fascinating experience.  In addition to learning about the challenges my patients face, I can also better understand the complex value of what we do as a profession.  The front-lines experience that family physicians earn is a rare asset which cannot be imitated or mass-produced.  The trust we have built with patients by being there with them in the trenches remains solid even while the health care system frays.   It makes me very proud to be a family physician.

Although I don't see any easy health insurance solutions on the horizon, I hope that my project's findings are helpful.  I hope that the family physicians' core conviction that effective health care always puts the patient first continues to resonate both in clinical practice and in the public discourse.  I am ecstatic to be done with residency, but the training certainly has led me in interesting directions.


Presentaion: TriagePolitics - Fixing Health Care from the Front-Lines

I had the opportunity to give a presentation with the above title to the students a the University of Minnesota Medical school today.   It was a noon conference during "Primary Care Week" about my experiences and observations from the front-lines.  It was a great privilege to me to be able to present my half-finished findings, relate some of the interesting things that have happened to me so far, and to see how tuned in many of these students are to health care reform.  The main point I wanted to get across was that the frontier in medicine is not just patenting the next molecules and inventing the next cure, it's figuring out how to get the cure to the people who really need it in an affordable, sustainable way.  I hope I get a chance to do this type of presentation again soon.


Would Consumers be better off with Health Scores?

Since pre-existing conditions complicate the consumer's ability to operate in the marketplace - short of elimination of the pre-existing condition -  perhaps a model like the one used for the consumer credit market would be applicable.  Each consumer would get a "health score" which would be similar to a credit score.  The insurance market could tier products based on score ranges and by doing healthy things people might be able to improve their health score.

This would allow consumers to know where they stand when negotiating in an objective way, insurance could more easily assess risk of an individual, but the problem would remain that sick people - those who need coverage the most - would have the lowest scores.  It would be difficult to make sure there were products available to them without some type of mandate to provide them affordably.

In addition there would certainly be added risks for patient confidentiality and access to the score would be problematic.  Plus there could certainly be a negative impact on the physician patient relationship:  "Doc, If you report that I didn't follow your recommendation my score will go up and I won't be able to afford insurance."

The trouble is, things that make the market more manageable often are not appropriate to the medical field.  As a professor of mine once said:  "Buying health care is not buying hotdogs."


In the mail today I received a statement of insurance from 10/1/09 to 10/30/09.  This effective date is over a week after I originally applied.  In that week I had an illness which could easily have been considered a pre-existing condition for the term of this insurance plan and every one I apply for after that.  If that illness had been a serious or long-term one the cost I would have paid for the opportunity to switch insurance companies would have been astronomical.






















In a consumer-driven health insurance market this presents a problem.  The threat of pre-existing conditions ties the consumer to the insurance they currently have.  Every time you switch to another insurer you risk that that insurer will exempt any health problem you have as pre-existing.  There is much less risk to shopping around and switching other products on the consumer market.  If you don't like your car or your shoes you can buy new ones, there is no risk to changing brands.  A functional consumer health insurance market would allow the consumer the same freedom.


A consumer-driven health care market cannot function under the threat of pre-existing conditions. 




I received a call from the customer service center at the insurance company I've been trying to buy a plan from since September twenty-second notifying me that my short-term health insurance policy application from September twenty-ninth - the one they told me they had no record of - actually had been processed.  I would be getting confirmation and plan details in the mail soon. 


Four days ago they told me my application never existed.  I'll believe this conformation when I see it.





I re-applied for insurance and was sent a confirmation number again.  I called the insurance company to confirm that they'd received the application this time.  The customer service department from the company states that they no record of any recent re-application.  I gave them the confirmation number they sent me by email and apparently they have no record of that.


Evidently they sent me a confirmation number for my records that they didn't record themselves or else can't find.  This is getting incredibly frustrating.  If I practiced medicine this way I would not be allowed to stay in practice long.  Patient's would get hurt.


Throughout this project one of the huge discrepancies I’ve run into is the fact that these companies set their own standards for quality.  These standards are much lower than patients expect and much lower than standards physicians practice by.  How do you reconcile the profession that pledges to do no harm with an insurance market that is driven by a buyer beware mentality?  If the insurer loses my policy or screw up the processing apparently it's just lost revenue for them.  They don't seem accountable for the fact that it could mean complete ruin for me the customer.  Perhaps it is up to me as a consumer to govern myself accordingly, but they sure don't tell you about that at the outset, and honestly our health care system can do better.


I’m sure there is a legal disclaimer at somewhere that absolves them of any problems with processing my application and with any problems using their web site and if they tell me I have coverage when in fact I do not.  If I don't have health insurance it's not their problem.  Technically it's not my problem if the people in my community and the people I treat don't have health insurance, but at some point people deserve to expect more from their doctor and their insurer and their whole health care system.  At some point we have to make this our problem.


After these repeated screw-up I've applied to another health insurance company today which I did find reliable for short-term insurance.  Another day with no insurance.


One thing is for sure: I have not become the ideal health care consumer yet.  I was doing pretty well up to this point.  At least my hearing came back.


I got ahold of the insurance company.  There was a type-o on my credit card information so my application did not get processed.  The operator took my credit card number and said that my original policy from 9/23 would be effective immediately.  I was very relieved.  She then called back later and left a voice mail stating that I am NOT covered.  I have to totally reapply and that my coverage will only start after my application is re-processed.  One more day without health insurance.



I got a notice in the mail today that my health insurance benefit was actually not approved.

"Thank you for applying for Short-Term Medical insurance through [Company Name].  Your application is being returned to you for the following reason:  An invalid credit card"

My credit card is good.  It's the weekend and the customer service line was not available.  I'll have to sort this out in a few days, but at this point I continue to have reduced hearing in my ear, no clear cause to attribute it to and my concern about this being a pre-existing condition is now quite real.

On Thursday the customer service person assured me that I've had coverage since the twenty-third, but that  was inaccurate. 

I am sick and have no insurance.  I was lead to believe that I did.  In the last three days if I had needed to go to the ER or seen a neurologist for this condition I would have done so thinking I was insured.  I would be stuck with the bill now.  If this ear condition is not a benign, self-limited one and my hearing does not recover I might be stuck with the cost of care for it indefinitely.  All because of a problem with an online application and some bad information from customer service.

Here’s something many of my patients deal with all the time that I’m just starting to understand in a first-hand way and with the heightened concern of someone who knows the worst case scenarios in extant detail, I've seen so many people go down this road but never thought I'd be on it myself.


At what point did I fail as an insurance purchaser?  I certainly could have planned a week in advance and had time to sort the problems out along the way, but the other products I’ve used did not require that and were set up to be approved by the following day.  The product I bought seemed to be the same type of product and had the same next-day gap programmed on the application.  I saw no disclaimer stating that sorting through the approval process could take a week.  I'll have to check the policy more closely when they send it.... if I can ever actually buy one.




I woke up yesterday morning with impaired hearing in my right ear.  Originally I thought I was getting a cold, but I have developed no other symptoms, no headache, no cold, nothing, just an ear that feels plugged but is not.


Without associated symptoms this seems a little more ominous from a physician's point of view.  I've often felt like my ears were plugged when I had a cold coming on - usually a bad one.  One time the symptom even persisted for a while after the cold itself had completely resolved.  I've never had hearing loss as an isolated symptom before.  While it is still most likely a viral illness throwing off the function of my inner ear, I cannot help but think of things like mini-strokes and tumors that can cause isolated neurological deficits.


I also cannot help thinking about the way my insurance plan has been screwed up over the past few days and how - if this did turn out to be a serious condition - my current insurer might try to shrug off my symptoms as a pre-existing condition.  A faulty on-line form and poor customer service could mean that I've got to cover the cost of medical care and work up for a stroke or tumor because my coverage was not seamless.  Amazing.


I called again regarding my health insurance plan approval and the customer service person confirmed that the short term plan I applied for on the twenty-third was approved - she didn't know anything about the application from the twenty-second - I should be sent a packet explaining my benefits by mail.  I was getting a little nervous about that.  Especially because I feel like I'm catching a bit of a cold.  Due to my occupation I'm at higher risk for catching H1N1.  I would prefer to be insured if I've caught pandemic flu.


I re-applied for health insurance on-line this morning.  I re-did the application and this time I was sent a confirmation number.  I called customer service to check on the status my application from yesterday because I still haven't gotten any confirmation for that one.  I spoke with two people both of whom could not tell me if my health insurance application was approved or if either application had been received.  They did tell me that they were having some trouble with their computers and that may be why I had so many problems with the on-line form.  One promised to check with another department and then call me back.  She did not.  I explained to both of them that I am very concerned because I do not know if my health is insured or not.

9/22/9 - p.m.

I applied for my next short term insurance policy on-line today.  The web site seemed to not be working correctly and I ended up filling out the same form at least 6 times.  Each time some of the information I entered would get an error message and I would have to go back and start from scratch.  Eventually it seemed to process but I never got a confirmation email.

Posting 9/22/09 - p.m.

Are the same kind of people and the same kind of values that ran Wall Street and America's financial system into the ground  also running our health care system?

Here is a press-release for an event that took place today at the national headquarters of UnitedHealth Group in Minnetonka.  It raises some very interesting questions.... How do we reconcile the culture of do no harm with the market economy without making the patient pay the price?























Marchers Demand That UnitedHealth Group Stop

Denying Health Care To Generate Profits

Rally Part of Nationwide Day of Action on Health Insurers

Called “Big Insurance: Sick of It”


Minnetonka, MN     As health insurance companies spend $641,000 a day to oppose health care reform,  Minnesota’s Health Care for America NOW (HCAN) campaign coalition – including the Minnesota AFL-CIO, SEIU, AFSCME Council 5,, Minnesota Nurses Association, ISAIAH, TakeAction Minnesota, and many others – marched on the corporate campus of UnitedHealth Group Tuesday morning.  The health care action was part of a national day of action called “Big Insurance: Sick of It” featuring the stories of people who have been denied care or dropped by health insurers in order to generate excessive profits for CEOs and shareholders.


The marchers carried seven hundred and forty-four green balloons emblazoned with white dollar signs -- symbolic of the $744 million in unexercised stock options held by UnitedHealth CEO Stephen J. Hemsley.   In 2008, UnitedHealth generated $75.4 billion in revenue from seventy million customers, while denying claims, raising premiums, co-pays and deductibles. 


In addition to the green balloons, marchers at the front carried a blown up policy document, asking that Hemsley sign the pledge to support real health care reform and end the abusive health insurance industry practices that UnitedHealth Group is a part of.  The pledge demands that UnitedHealth Group:


·          Not stand between a doctor and a patient when it comes to deciding what care that patient needs.   


·          Not deny coverage or raise rates for individuals or businesses based on a pre-existing medical condition and end arbitrary caps on payments for necessary medical care.


·          Terminate any policy or incentive that rewards employees financially or otherwise for denying care and rejecting claims.

·          Not use any resources – including funds, employees, and facilities — to lobby against and oppose any aspect of the health reform proposals supported by President Obama and being considered by members of the United States Congress, including but not limited to a national public health insurance option available on day one.

Diane Johnson, a long-time R.N. and Secretary of the Board of Directors of the Minnesota Nurses Association, was one of the marchers carrying the Hemsley pledge.  Standing in front of UnitedHealth Group’s corporate offices, Johnson said “I’ve seen the decaying of our healthcare system since the 1960’s, when people actually got the care they needed.  But nowadays, it’s more and more profits for insurance executives.  Real preventative care means having affordable coverage so you can actually go to the doctor.”


Laura Askelin, President of the Minnesota AFL-CIO’s Southeast Area Labor Council, told the crowd that “Working families are sick of insurance companies standing in the way of health insurance reform. The average cost of health insurance in Minnesota has doubled since 2000. Working families watch the cost of health insurance go up, while receiving less and less. The time for health insurance reform is now.  If the insurance companies win, we lose.  It’s that simple.”


I can't help but cringe when I hear about the huge salaries and bonuses of Health Insurance CEOs like Stephen J. Hemsley at UnitedHealth Group.  While I steadfastly believe that Americans should be able to profit -  even get filthy rich - if they provide a product or service that is innovative or useful, when I look at the health insurance industry it just doesn't add up.

The service health insurers provide gets more meager and less affordable every year, the proportion of customers who can afford the service shrinks as well, yet somehow the profits and bonuses continue to roll in. This business model that disconnects profit from performance would not work for me as a family physician or for anyone I know in any other business.  As the rest of America gruels toward recovery from our financial crisis and braces for crisis in heath care these health insurance executives seem to be  acting like Wall Street investment bankers before the melt-down

While I have no desire to be an alarmist I do think we are foolish if we do not learn from history.   I can think of no time in America when there was a disconnect  between profit and performance in a core American Industry and good came of it.

Are the same kind of people and the same kind of values that ran Wall Street and America's financial system into the ground  also running our health care system?

The event in Minnetonka today started to ask this question.  It's one the Insurance industry needs to answer.


Posting 9/22/09 - a.m.

73% of American Physicians Support a Public Option

A recent poll  published in the New England Journal of Medicine shows that 73% of physicians polled favor at least some form of public option when it comes to expanding health care coverage to better meet the needs of America.  This is in comparison with 27% of physicians who favor private-only options.


This is a huge revelation for a profession whose largest organization, the AMA, originally raised the specter of "socialized medicine" in opposition to Medicare.  Since then we in medicine have dealt with the strengths and weaknesses of both publicly-funded and for-profit insurance providers on a daily basis.  We watch the way their imperfections affect both our patients and our practices.  Both are far from perfect,  but apparently nearly three-fourths of physicians surveyed  believe that more Americans should have the option to enroll in a publicly funded insurance option.


There are two reasons I think many physicians support a public option for the consumer health insurance market.


1.  Insuring people is the right thing to do.  By and large those who would be served by a public option are people who work hard, pay taxes and have the right to expect affordable access to health care.  In America, public insurance is already offered in some form or another to many other difficult to insure groups.  Why shouldn't hard working Americans who can't find private insurance have to live without insurance when the poor, the very ill, the elderly and even the convicted criminals in our prisons have access to it?  The spectrum of people the for-profit insurers are able to offer affordable products to is continually shrinking.  If providing an affordable product for the 45 million Americans who are uninsured is not part of their business model then we need to have products on the market that will serve that need.


2.  A wider variety of options often produces the best results for a varied patient population.  Physicians guide our own practices using objective, scientific  comparison  whenever possible.  For example  when it comes to prescribing medicine to patients:  In general if a generic medicine is as good and cheaper than a name-brand medicine we recommend the generic.  If the name-band medicine has advantages for a patient that are worth the extra cost we recommend the name-brand medicine.  Why not extend a similar dynamic to the consumer health insurance market?  I don't see any pharmaceutical companies going out of business, why should insurance companies?


This survey changes the game.  If health care reformers want to claim to be "physician driven" they will have to include a public option.  Even though the large majority of physicians support a public option it remains to be seen if we as a group will be able to help effectively drive reform.

Posting 9/21/09

Today I discharged a patient from the hospital and had to spend  20 minutes on the phone wrangling with her insurance company in order to convince them to cover a medicine that is critical to her recovery.  I could not help but wonder how the insurance company gained veto power over both the physician and the patient.

Everybody has heard the stories of people's care being denied due to ridiculous oversights or clerical mistakes.  Most people don't hear about the hours of time that physicians and our staff spend trying to get care covered for our patients, stuck on phone trees or filling out endless appeal forms.

As a family physician I practice with the best interest of my patient in mind.  By and large family physicians have been proven to consistently provide  effective and cost-efficient care for their patients.   I have seen no convincing evidence that this extra layer of bureaucracy imposed by the insurance companies saves my patients money, or improves the quality of their health.

What is more concerning is that I'm not sure their denials of care - both on the individual medicines and tests I try to prescribe for my patients or in the high profile cases you see on TV - pass the principle of "first do no harm" which the rest of us in health care govern ourselves by every day.

The majority of denials I have seen do not seem motivated by conserving limited resources to get the best care to the most people possible, they seem  to be based on arbitrary and procedural technicalities: filling out the wrong form, forgetting to check a box, not using the preferred name for a nearly identical generic drug.  While not all of these denials end up as multimillion dollar or life-and-death cases many of them increase the chance that harm will be done and make it harder to give good care.

There are many cases similar to my patient whose prescription was denied today that do not end as well.  Many times, after hearing that their prescription was not covered and being unable to pay for it themselves -instead of calling their physician - patients will simply go home without it.  This greatly increases the risk of a relapse and repeat hospitalization for the same problem.  I have seen far too many re-admissions to the hospital over a medicine that costs only a few dollars that the insurance company wouldn't cover.

Posting 9/16/09

MPR News Q published my commentary on holding congress to a higher standard when it comes to Health Care:

Posting 9/13/09

President Obama held a health care reform rally in Minneapolis yesterday, bringing the national debate deep into the epicenter of his mid-western support network.  In his speech he talked about how he learned a lot about firing up a crowd from an unlikely woman in an out-of-the-way berg who upstaged him with her enthusiasm.  I hope the President will also take some time to learn about how to fire-up health care from our decidedly off-the-beltway state.

Minnesota has consistently upstaged the nation when it comes to health care reform.  We are one of the highest value Medicare states and we have one of the lowest levels of uninsured citizens in the nation.  We operate and flourish on one of the lowest rates of reimbursement in the country.  If the other states in the union could be as efficient as Minnesota we would well on our way to solving the national health care crisis.

The main reason for this is simple: We have community leaders who - until very recently - always held the serving the people as their highest priority.  Their political parties, pocket books and personal interests had to take a back seat if they wanted to keep their jobs for very long. 

Posting 9/10/09

One Physician's Reaction to President Obama's Health Care Address to Congress:

Here is a person who is approaching the health care crisis with a rationality of method, an inclusiveness of dialog and a clarity of moral conviction that I cannot help but agree with - regardless of whether I agree with each individual element if his plan.  This is a huge step in the right direction for health care reform.  I hope that the other parties involved are able to elevate their rhetoric to a similar level and that from this point on the debate is approached with professional candor instead of teenage melodrama.

Posting 9/9/09

Here's a link to the CNN interview I did today

Posting 9/2/09

Senator Al Franken visited St. John's hospital for our Community Leader's Breakfast today.  He made an early morning appeal for health care reform to a skeptical crowd of business leaders, physicians and hospital administrators.  I had worked the overnight shift but finished up in enough time to see him. 

He was quite knowledgeable about health care reform and  was "off message" in enough of his comments that  he seemed genuine.  He clearly advocated for the democratic brand of health care reform but acknowledged that there is not a well delineated "Obama Plan" for one to endorse or condemn.  Following his speech he answered numerous questions from my colleagues and community partners.  Many of them were concerned that more government involvement in health care would have bad consequences in the future.  Some of these questions were clearly "talking points" packaged as a question, others were very well thought out.  As Franken navigated these the whole event stated to echo the same flat rhetoric that we've heard from both sides for months now.

I was able to ask a question at the end and started by trying to explain to the Senator that at my hospital we work every day to improve the health care we provide.  We go about it the way doctors try to do just about everything.  We look at things objectively, we follow evidence based practice, we work as teams, and we put the patient's needs first when it comes to health care delivery.  We achieve outstanding outcomes.  When we look at the way congress has gone about delivering health care reform we see them using the exact opposite methods:  We hear lies, fighting, self interest and utter disregard for the evidence or the patient.  The question most of us have is how could we ever feel comfortable  when people who don't uphold our professional standards presume to regulate -or deregulate - our profession.

The senator did agree that much of the health care debate had become quite ugly and irresponsible - and he gave some great examples of local politicians who have completely invented their own reality when it comes to health care - but he did not know how we could hold that debate to a higher standard of professionalism and ethics.

I was very pleased that Senator Franken came to see us at our community hospital on the front-lines of the health care crisis.  I am glad he got to see first-hand that it's not so much that we oppose change or even oppose the ideas he has for change.  What many of us oppose most is the utter disregard that so many of our "leaders" have for principles that we hold and protect as sacred.


Posting 8/28/09

Recommendation #1: Know What You're Not Buying

After two months of navigating the commercial health insurance market my first recommendation to health insurance consumers is simple:  Know What You're Not Buying


One of the biggest frustrations consumers have happens when they purchase a health insurance plan and then find that the care they need is not covered under the plan they have purchased.


Every health insurance policy has coverage exclusions - health care costs that aren't covered by the plan. When you compare insurance plans they are presented as a list of benefits ( what is covered and how much of it is covered) not as exclusions.  What is far more useful is to understand specifically what is not covered in each product.


Health insurance consumers need to be able to look at a product and say "If I buy this plan get and then have a baby the cost of that is not covered."  or "If I buy this plan and my child needs medicine x, medicine x is not covered."  or even "If I purchase this plan and get sick during the second half of the month and can't pay my premium the following month my care from the previous month is not covered."  Knowing what is not part of the benefit package will better allow consumers see where the holes in their coverage are, not be surprised by exclusions that are built into their policy and hopefully avoid financial hardship.


Unfortunately, you often have to essentially read-between-the-lines and look closely at the fine print to understand the full extent of any plan's  exclusions.  To make the market more consumer friendly what is not covered really should be listed in bold-print at the front of every plan.  Consumers could then more easily know if the product they are considering is appropriate for their needs.

Posting 8/27/09

Hold Health Care Reform to a Higher Standard


As a family physician I've spent a lot of time debunking myths about health care that my patients  see on the internet, on late night TV or in the back pages of magazines.  I never thought I would  have to debunk myths about health care from our elected officials and supposed leaders.

Recently I've had patients ask me about "death panels" and instead of being able to spend time helping them with their very real health problems I've had to spend time refuting patently false accusations about health care reform.  I can think of no worse waste of  health care dollars.

The reason people trust health care professionals is because our profession is based on service, honesty, and making the needs of our patients our highest priority.  People don't - and often shouldn't - trust politicians and political commentators  because many of them operate under a similar guise of public service but they act in purely self-serving ways.

Before these types of people presume to regulate and reform my profession they should at least be required to hold themselves to the ethical standards of the profession.  A primary goal of health care providers is to tell our patients the unbiased truth so that they are best able to make the decision that is right for them... not us.  In a democracy like America it is critical that those at the center of the health care debate have the same goal.

In health care we improve outcomes by working as an integrated team as well as through respectful and constructive competition.   This is never accomplished by spreading lies about one of our colleagues' opinions or motivations.  We are able to respectfully disagree, compromise and work toward the best interests of our patients regardless of personal and philosophical differences.  If our political leaders worked together instead of against each other  many of the common sense problems our health care system faces would already be fixed.

Most importantly, in health care we all pledge to "first do no harm".  The health, safety and best interest of each individual patient in the health care system is our highest priority.  Physicians would never spread lies to create fear and hysteria during the middle of a health care crisis, neither should our political leaders.

Those of us on the front-lines of medicine honor these principles under penalty of law and loss of license.  In American medicine we call it upholding professional standards.  In American politics we call it statesmanship.  In both cases anything less should be considered malpractice.


To view the CNN interview I did today go to  and it's posted under "Doctor's Serach for Insurance"

Fox 9 News in the Twin Cities also did a segment about the health insurance project which aired at 9 pm today.


Here's a link to my brief letter to the Star Tribune regarding Governor Pawleny's criticism of health care reform efforts in respect to his own record on health care reform:


Here's a link to the Fox News interview I did this morning - it's titled "Trading Places"


Will Nicholson Biography:

Will Nicholson M.D. practices family medicine a few miles from where he grew up in Minnesota.

He attended the University of Minnesota, Duluth and received a Major in German Language and Literature. Dr. Nicholson was uninsured for year after his college graduation while he applied to medical school and tried out for the U.S. Olympic Cross Country Ski Team. (Obviously one of those went better than the other.) He attended medical school at the University of Minnesota Twin Cities, then completed a 3 year family medicine residency at St. John's Hospital and Phalen Village Clinic in St. Paul Minnesota.

Dr. Nicholson has the greatest job in the world as a family physician. He works at St. John's hospital in Maplewood, Minnesota. He is currently researching the health insurance market from the consumer stand point. He also has ongoing research in the area of sports medicine. He participates in health care reform because America's patch-work health insurance system makes it hard both for patients to access his services and for him to do his job helping them. He is currently active through the Minnesota Academy of Family Physicians, the Minnesota Medical Association, the National Physicians Alliance and Take Action Minnesota.  He supports a wide variety of health care reform organizations.

Posting 7.22.09

Here is a link to the ABC News online article -

Posting 7.22.09

Here are links to two of  the media spots that occurred today and the Text of my commentary on MPR News Q.

MPR News Q Commentary -

CNN Interview - posted under:  "Doctor's medical trial"

Why I said 'no' to my employer's health plan

by Will Nicholson, M.D.

July 22, 2009


On July 1, the day after graduating from a three-year residency in family medicine, I dropped my employer-based health insurance.

I learned in medical school that addressing the ills of an individual patient cannot be separated from addressing the ills of a health system as a whole. For me, uncoupling my employer from my health insurance provider is a first step toward a clear understanding of America's health care system.

In the United States, employers provide a health insurance benefit for about half the people who need it. Many of my patients belong to the other half.

The other half also works hard, also pays taxes and depends largely on the individual insurance market to find an affordable health insurance option. Many of them don't find one. My concern is that this other half of the market is not being treated justly.

I wonder how many participants in America's health care reform negotiations are members of the non-employer-subsidized half of the insurance pool. I wonder how many elected officials, pundits and health policy experts understand the concerns of that other half.

Physicians do not practice medicine in a bubble. Although our professional organizations have often been inarticulate, and indeed counterproductive when it comes to health reform, most physicians are working on the front lines of the health care crisis every day.

America's patchwork health insurance system is inadequate. It hinders physicians' ability to care for our patients at nearly every turn. It has also been shown to make many of our patients sicker faster and die sooner.

My goal in venturing into the individual health insurance market is to add first-hand knowledge of the patient's side of the system to my current experience from the physician's point of view.

I hope to assume the role of the fabled empowered health care consumer. One of the most persistent theories in American health policy is that the key to excellent, affordable health care is for consumers to make shrewd purchasing decisions when it comes to health insurance. Physicians treat people as patients, not as consumers, so it is an unfamiliar idea to most of us.

Regardless, after seven years of medical education, I should be one of the most empowered health care consumers out there, and should be able to make exceptionally good health care purchasing decisions.

Like any other scientist -- and like any of my colleagues studying diabetes or osteoarthritis -- I will gather information, formulate hypotheses and report my findings. My hope is to help my fellow consumers make better decisions, and to gain insight into where the system might be improved.

So far the experience has been challenging, pitting the value I place on preventive care and high quality against my sense of economic feasibility. The complex menu of available insurance options has led me to believe that the first thing empowered health care consumers need to decide is whether we want to purchase health care or health insurance.

The most affordable products out there are high-deductible plans that may qualify as health "insurance," in a sense, but they certainly are not healthy or caring by any stretch of the imagination.

I hope my experience as a health care consumer will teach me how to help my patients with a problem that medical school never taught me to treat.

Posting 7.16.09


Resolving the inequalities of the American health care system must be a key component of health care reform.  In addition to tackling the issues of uninsurance and under-insurance, we should not miss this opportunity to address the disparities of care that persist based on a patients race and ethnic background.  Disparities my patients have to deal with every day.


Here in Minnesota the infant mortality rate of African American babies is twice that of white babies.  Tragically, health care inequality can be a life and death issue in minority populations.   Infant mortality is not the only problem: minority patients are also less likely to have a regular doctor, they have higher rates of uninsurance, and a lower life expectancy.


There is no denying that multiple factors - things many of us take for granted - contribute to these problems.  It is often harder for minority families to afford the high cost of  health insurance.   In many minority communities physical access to health care facilities is a challenge.  Many communities even lack safe green spaces and parks for exercise and stores to buy fresh, healthy groceries.


Sadly, in many situations where resources are available disparity persists.  One of the communities with the highest infant mortality rates in Minnesota also hosts one of our most advanced pediatric hospitals.  The medical system has made great improvements since the Institute of Medicine's landmark 2002 study showed that people of color received lower quality and less comprehensive treatment even with comparable insurance and comparable illness.  We still have a long way to go.


America needs a health care system where everyone, regardless of factors like race, gender, geography or income has access to and actually receives quality, affordable care.  Economic inequality should be addressed by guaranteeing affordability based on income and offering all Americans the same public and private options.  Inequality in access to care should be addressed by fixing chronic shortages of health providers in under-served minority communities and creating incentives for hospitals and doctors that promote good health for those communities.  For these changes to happen Americans need to demand them.


On behalf of my patients and the physicians who care for patients like mine I urge everyone to demand an end to health inequality in America.  America's promise of equality for all cannot make exception for health care.  We can’t wait any longer for high quality, affordable health care that works for all people.


Will Nicholson M.D.

Posting 7/3/09






















Today I requested information on Cobra coverage from my previous employer so I could compare it to the other options out there.  Cobra is an interesting program, a bridging insurance when you lose your job.  If it's affordable it seems like a grand idea, but what I've heard from patients is that when you lose your job and you don't know how you're going to get by financially the last thing you want to do is write out a check for thousands of dollars of health insurance you may never use.  If all else fails I can use the cobra coverage, I've got a couple of weeks to try and find another plan on the individual market before I become ineligible to start Cobra.  I think I'm insurable, but it's crazy to try and think back to all of the things over my life that might be considered "pre-existing conditions".

Posting 7/2/09


I have a plan.  It's a small one.  My plan is meaningless in one sense and essential in another.  I am going to drop my employer-based health insurance.


The idea will be to enter the consumer health insurance market as so many of my patients do and try to learn.  I want to try to help all the people who are doing the right thing - working hard, paying taxes and trying to buy health insurance - use the system most efficiently or at least avoid pit-falls.  Hopefully along the way I'll learn a bit about how to improve the system as a whole.


I've already spent a year uninsured.  I was trying out for the U.S. national cross-country ski team and applying to med-school.  I didn't have the cash to chase my Olympic dream and pay for health insurance.  It was funny to go to the med-school interviews without health insurance.  At one point I had a close call with catastrophic illness and I will never go without insurance again.  The fact that anyone in this country has to is a travesty.

Day One 7/1/09

It was strange waking up today.  I didn't sleep in.  I expected to have a huge weight lifted off my mind, but I still seemed to be hardwired in high-gear.  A resident no more, but still stuck in resident mode.  A little groggy after the graduation party last night.  This was a day I wanted to start differently.









































The proverbial first day of the rest of my life.

 But today started exactly the same as usual:  Coffee.  Exercise used to be my coffee.  Seven years ago I started every day off running.  Literally.  Later long hours at med-school made my shoulders sink kyphotic into books and my waist-line softened from subsisting off vending machines.  Exercise became less enjoyable, morning caffeine essential.  I now tell patients to eat right and exercise regularly, but don't follow my own advice.  The ideals that had driven me to become a doctor were gradually eroded by the process of becoming a doctor... I was exhausted today anyway.  I felt like I'd just finished a marathon.  It was too easy to avoid exercising.  It was cold out.  I was being a wimp.  At least there was coffee. 


Day One after residency and I was realizing that reinvention might be a slow process.


Leah could see the usual stress-lines setting into my forehead as I looked out at the cool summer morning.  She whispered that we were going on a field-trip this morning.  We got lost driving there and for the first time in a long time it didn't really matter.  I wasn't going to be late for anything else.


She had set up massages for both of us.  A great surprise.  We spent an hour on the massage table and then hiked along the river.  At lunch I noticed that the huge weight started to lift.


I could change this things.


I did not wake up to a gleaming new life, but I could reclaim that feeling I had at the start of all of this.  That first day of medical school fervor, that feeling that I had a cause greater than just my own survival to fight for.  I could still remember that feeling when my white coat was brand new and I charged into the hospital hell-bent to heal the sick and fix the system.  It was a really good feeling.  I called the benefits department at my new employer and asked to cancel my health insurance benefit.

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