Thoughts About American Health Care

To create a solution for any complex problem requires that we identify, name, the problem so that we can approach argument about it with an intelligible focus. As President Trump has named “Radical Islamic Terrorism” to give a focus to a destructive chaos, so too I believe that health care has to be clearly defined to achieve similar precision. So far, politicians, who say they seek solutions for the American people, have been unwilling to do this. Note that by not defining health care clearly, politicians can hide behind rhetoric, false agendas which do not serve us but rather serve the interests of their lobbyists, and can kick the political football up and down the field while continuing to get reelected every so many years. To give some benefit of the doubt to the politicians, maybe what health care really is is not clear in their own minds like it is not really clear in our own minds.

What is health care? Define it! What exactly is it that is causing such turmoil in the USA, that occupies such a prominent place in the congressional legislative agenda, and that an entire business world has evolved to ostensibly support?

Please take a couple of minutes to think about and write down your thoughts about what health care means to you individually. It’s important for everyone to have a clear idea of what they’re arguing about or for, when they discuss American health care, which effort may help to bring their politicians to a shared precision about the quests of their anticipated legislation.

Health care is the DOCTOR-PATIENT RELATIONSHIP (D-PR). Frankly, that’s all it is. On an individual basis, it’s that individual relationship, and on a nationwide basis, it is the sum of all the individual relationships. What does this mean? It means, when you get sick, you go to visit the doctor and get yourself taken care of. To do that successfully, you must develop a trusting relationship with a doctor and vice-versa. Without that health care doesn’t exist. Think about it!

Over the last century, more or less, a chaotic system of business has developed, not to support this understanding, but rather to make the DOCTOR-PATIENT RELATIONSHIP a business product with various levels of service at variously increasing prices, which you can buy if you think you need it and can afford it. It’s a bit like one car dealership sells Cadillac if you want it, but another sells Chevrolet which should serve many of your needs. The problem with this approach in health care is that no one can ever accurately predict what they’ll need in terms of the menu of offered services. Moreover, what people really need, an equilibrium of trust in the context of a DOCTOR-PATIENT RELATIONSHIP, is not itself one of the offered products; it’s not even part of the vocabulary used in the rhetoric of the health insurance companies. Part of the reason for this may be that the nature of the functioning of the D-PR doesn’t allow it to be defined as a product like cars, houses, and all the other stuff we buy during our daily lives, sometimes taking loans out to do so.

So why do we tolerate a system which sells us quasi-health care, access to insurance covereage? Does our American health care system yield clear and equal access to sound, ongoing, non-conflicted, spontaneously functioning doctor-patient relationships? Ironically, “NOT ON YOUR LIFE!”

Politicians talk about access to coverage, which means you get to pay dollars in the form of premiums, deductibles, co-pays, and other dollar garnering mechanisms to obtain a limited, delineated health care insurance policy, which policy is not defined by a patient’s need, i.e., a D-PR which will accomplish the work necessary to diagnose and treat any illness, but rather defined by business derived, pre-determined calculations of costs for various illnesses and services, calculations designed to reap huge windfall profits for insurance companies by limiting what the policy will pay out and doing as little as possible for the patient.

America’s approach to a health care system has never really served everyone well, save perhaps for the Medicare eligible, and even they have problems in that people need a Medicare Supplemental Policy in case they get a catastrophic illness which Medicare won’t completely pay for. And these supplemental policies are expensive.

Nothing is free in America, we all know that. You pay for everything you get. Paradoxically, my solution for our health care system is to take the money out of it in regards to medical decision making, i.e., the doctor-patient relationship, since the proper functioning of this apparatus cannot lend itself to a dollar mentality, unless of course you’re in health insurance, politics, or health care administration, i.e., the world of quasi-health care, which needs it to function with a dollar mentality in order for them to stay in charge and justify their own ongoing existence.

HEALTH INSURANCE COMPANIES ARE SIMPLY NOT NECESSARY! In reality, they block the access to D-PRs for everyone by filtering out the people that simply can’t afford premiums, deductibles, co-pays, co-insurance, and other out-of-pocket expenses.

What the American health care system needs is a PAYER to administer payment of health care bills from a large fund of dollars provided by everyone living in America. Remember, the health care system doesn’t exist unless the people pay their dollars for it to exist. It’s the people’s system. I’m not sure how the insurance companies have come to the conclusion that it’s their system and they’re in charge.

R. Garth Kirkwood, MD

Mr. Trump’s Health Care Plan

I do not know what Donald Trump’s future plans for our health care system are or will be. I do know that whatever his administration develops and enacts, whether it is multiple payer, single payer, some mixture of insurance companies and government payers like Medicare, it must create and ensure an environment in which the doctorlogo patient relationship can occur for each patient in the USA and function in a sound, ongoing, non-conflicted, spontaneous manner.

The dollar obstruction facing  patients over going to the doctor or emergency room, purchasing medicines, deductibles, co-pays, approved procedures and the like MUST COME TO AN END!!!

Interference with doctor functioning by hospital administrators, hospitalists, insurance companies, federal regulations and requirements MUST CEASE AND DESIST!!!

Until the doctorlogo patient relationship has the leeway to function in a sound, ongoing, non-conflicted, and spontaneously functioning manner, there can be no health care reform. The proposals from any candidate will only be status quo maintaining rhetoric without this. What does this mean? It means that the doctor and the patient within an equilibrium of trust called the doctorlogo patient relationship arrive at and proceed with decisions about the case at hand with NO INTERFERENCE from the payer or from hospital administrators.

One final thought: Of all the candidates for president, Mr. Trump is far and away the best not only because of his leadership, courage, experience, and common sense but also because he is one of us, we the people. He cares about our individual welfare as well as the welfare of America. He is the only candidate who has the wherewithal to actually accept and understand what I’ve said above and make it happen in the chaotic financial milieu of America’s health care system.


R. Garth Kirkwood

Mr. Trump’s Veterans Administration Reforms That Will Make America Great Again 

Mr. Trump’s ideas are quite good, especially that under a Trump Administration, all veterans eligible for VA health care can bring their veteran’s ID card to any doctor or care facility that accepts Medicare to get the care they need immediately

I think this means that veterans will be able to establish sound, ongoing, non-conflicted, spontaneously functioning doctorlogo patient relationships with doctors who are not part of the VA system. It’s my view that in concert with this move to have doctors in independent private practices see patients who are veterans, the doctors who currently are part of the VA system should no longer receive a salary from the Veterans Administration but rather be treated like the doctors in independent private practices, i.e., fee-for-service. In that way the competition will really increase, i.e., the competition will be about getting patients seen and properly treated as opposed to receiving a big salary for achieving some administrative quota.

Although the problems with the Veterans Administration Health System are multi-layered, one thing that I believe to be true is that the VA doctors have put up with it for years. Why have they tolerated a system that so interfered with and infected a properly functioning doctorlogo patient relationship? Removing the doctors’ status as  VA employees and treating them as independent private practitioners with the same demands of accountability, quality of care standards, and malpractice threats as independent private practitioners endure, I believe, will greatly improve veterans health care and the system which administers it.

A Properly Structured Single Payer and the Concept of Health Insurance

What is insurance and why do we have it?

Insurance is the main way for businesses and individuals to reduce the financial impact of a risk occurring. Regarding the concept of risk, running a business of any kind involves a certain amount of risk. Whether it’s the risk of fire, the risk of damage to exported goods or the risk of natural disasters, all these incidents will have a financial impact on your business if they occur. This is what the term ‘risk’ refers to. Most businesses take small steps to manage the effects of risk. For example, by installing smoke alarms and sprinkler systems to reduce the damage caused by fire or by installing security alarms to deter thieves. However, business owners also want to protect themselves against the financial consequences of something untoward happening, and this is where insurance comes in. In effect, the business can transfer the risk away from themselves and on to someone else.

This transfer of risk is the basis of all insurance.

When things go wrong it can be expensive and so, for many of these eventualities, insurance is there to take the financial risk on our behalf.

A business that provides insurance agrees to take on risks on behalf of a company or individual, in exchange for a fee. It does this by providing the business or individual concerned with an insurance contract, sometimes called a ‘policy’.

This policy will cover a person or business for many of the costs they have to meet as a result of a risk occurring and provides the policyholder with some security should the worst happen.

The fee an insurer receives from a policyholder (in return for their policy) is called the insurance ‘premium’. This premium, and the terms and conditions of the policy, are based on the likelihood of the risk happening and its value.

The insurer collects premiums on a number of policies and pools these funds, which it then invests to increase the amount of money held. Should any insured person or business make a claim on a policy, the insurer will pay out on that claim from the pool of funds.

The insurer is in business to make a profit and will be hoping that the total premiums it receives in any one year, together with any money it can make through investments, will exceed the total claims it has to pay out.

What is health insurance?

Health insurance is a way to pay for health care. The word ‘care’ refers to the medical services covered by your plan. When you choose a plan, you will receive materials that explain your benefits so you know what types of services are covered. Health insurance protects you from paying the full costs of medical services when you’re injured or sick. Just like car insurance or home insurance, you choose a plan and agree to pay a certain rate, or premium, each month. In return, your health insurer agrees to pay a portion of your covered medical costs. Payments by your health insurance are typically based on discounts they negotiate with doctors and hospitals.

Each plan is different, but you can usually find a plan to cover preventive care, like doctor visits and screenings, as well as hospital visits, ER trips, and even prescription drugs. Some plans cover vision and dental, but you may need to purchase these plans separately.

Health insurance is a type of insurance coverage that covers the cost of an insured individual’s medical and surgical expenses.

Depending on the type of health insurance coverage, either the insured pays costs out-of-pocket and is then reimbursed, or the insurer makes payments directly to the provider.

In health insurance terminology, the ‘provider’ is a clinic, hospital, doctor, laboratory, health care practitioner, or pharmacy. The ‘insured’ is the owner of the health insurance policy; the person with the health insurance coverage.

In countries without universal health care coverage, such as the USA, health insurance is commonly included in employer benefit packages and seen as an employment perk.

Is health insurance coverage a human right or another product one can buy? In some countries, such as the United Kingdom or Canada, health care coverage is provided by the state and is seen as every citizen’s right. It is classed along with public education, the police, firefighters, street lighting, and public road networks, as a part of a public service for the nation.

In other countries, such as the USA, health insurance coverage is seen somewhat differently.With the exception of some groups, such as elderly and/or disabled people, veterans and some others, it is the individual’s responsibility to be insured. More recently, the Obama Administration has introduced laws making it mandatory for everybody to have health insurance, and there are penalties for those who fail to have a policy of some kind.

An understanding of basic health insurance vocabulary is important.

Deductible: This is a set amount you have to pay toward your medical bills every year before your insurance company starts paying. It varies by plan and some plans have no deductible.

Premium: This is the amount you pay your health insurance company to keep your coverage active. Most people pay their premium monthly.

Coinsurance: This is the percentage of your medical bill you share with your insurance company after you’ve paid your deductible. Unless you have a policy with 100 percent coverage for everything, you have to pay a coinsurance amount. For example, if you have a $100 doctor’s bill and your plan covers 80 percent of it, your coinsurance amount due to the doctor’s office is 20 percent, or $20.

Copayment (or “Copay”): Your copayment, or copay, is the flat fee you pay every time you go to the doctor or fill a prescription. It’s usually a relatively small dollar amount. Copays do not count toward your deductible.

Remember the insurers want to make a lot of profit and calculate that

  • the total premiums it receives in any one year,
  • the money it makes through investments,
  • the money it avoids paying out via deductibles, coinsurance, copays, and other gimmicks such as less or no drug, vision, dental, and complicated chronic illness coverage,
  • the financial pressures (reductions in reimbursement) placed upon hospitals and doctors to be part of their provider network,
  • interference with the doctors’ practices, for example, by placing difficult to hurdle roadblocks for specialty referrals and sophisticated diagnostic testing and treatment,

will all result in huge revenues and profits.

One would think that the concept of free-market sale of health insurance across state lines would, by the force of competition, reduce the cost of health insurance for individuals. Another quagmire of legalese results from the specific insurance regulations in each state.

Can you imagine the thicket of thorny state laws from 50 states being negotiated to achieve this concept of health insurance being sold across state lines? I laugh when I think of 50 sets of state politicians, each set as buffoonish as the all-talk-no-action pols in Washington, DC, battling to avoid having their own little world of health care finance control being threatened. There will be state court battles up to the states’ supreme courts and onto federal court battles all the way up to our Supreme Court, the highest court in the land. Such great fun for lawyers, politicians, lobbyists, and legal pundits across the USA.

Let’s assume that the concept of selling health insurance across all state lines flies through in one fell swoop. What would there be then, maybe three or four or more surviving companies competing? What would they be competing for? They aren’t competing for individuals’ health care, i.e., doctor logo patient relationships. They are competing for individuals’ dollars for payment to administer payment of health care bills and to make a lot of profit for doing so. The way insurance companies make profit is to pay out less than they take in. The profit incentive along with the force of competition make dollar garnering directly affect the functioning of doctor logo patient relationships. See the list of profit making mechanisms above and connect the dots. The result is that the major fear people have about “socialized medicine,” the payer directing their medical care, happens in our “non-socialized” system.

Health savings accounts (HSAs), (another free-market business idea), are tax-advantaged medical savings accounts available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP).

The funds contributed to an account are not subject to federal income tax at the time of deposit. HSA funds may currently be used to pay for qualified medical expenses at any time without federal tax liability or penalty. My views about HSAs are as follows:

  • they’re probably okay if you have enough money to deposit into the account to pay the high deductible and expenses for non-covered illnesses, which may only be part of what you pay before the insurance company has to shell out any money,
  • HSAs also have associated account management fees. Some might say, “Oh, that’s only three dollars a month or so and the fee is justified for the work of managing the account by whoever manages it.” Well, let’s say there are 20 million HSAs in America each with an account management fee of $3 per month. That’s a nice business earning 60 million dollars per month labeled as a free-market based solution to our health care woes.

Many, maybe most, people really can’t afford the high deductibles, and although the account management fee sounds minimal on an individual basis, for a lot of people every dollar counts. There will still be a large population of people who just can’t afford to participate, and some sort of other plan will have to be made for them, which results in the financial discrimination in our health care system not being eliminated and the resentments of having a large number of Americans labeled as indigent, poor, requiring entitlements remaining.

Do you really think the concept of health insurance should continue? I say it should not continue. I say a properly structured single payer is the correct answer for our American health care system to move forward.

R. Garth Kirkwood, MD



A Properly Structured Single Payer: Functioning

A properly functioning single payer, run by the right people, has to solve many of the problems within our American health care system. If it isn’t capable of finding and instituting these solutions, then why have it? Who are these right people? They are many people with varied backgrounds in the business aspects of our health care system, and in other branches of knowledge such as computer technology, fraud investigation, pharmaceutical research and development, durable equipment manufacture, outpatient testing facilities, etc., etc. They have to be very experienced in their field of endeavor prior to working for the single payer, which experience would help them as they encounter existing problems. A well-functioning single payer pays Americans’ health care bills while trying to maintain good profitability for necessary health care businesses without sucking the financial life out of individuals living in America.

The single payer would have to have several different departments such as:

  1. Health care business negotiation in which experienced people, who have worked many years in specific health care businesses, will now negotiate on behalf of the single payer (Americans’ accumulated fund of health care money) to arrive at payment amounts for specific services and products. These amounts must not be punitive for the health care business but rather quite the opposite, designed to make sure the health care business achieves good profit. Hospitals, drug & technology companies, nursing homes, out-patient nursing services, doctors’ practices, laboratories, durable equipment suppliers and other necessary health care businesses simply cannot function properly with a negative cash flow. Their profitability must be a strong consideration on the minds of the people who are negotiating on behalf of the single payer. At the same time, the single payer must remain well solvent without the need to frequently and haphazardly increase the federal sales tax amount which all people living in America pay to guarantee their health care. This is why those who work for the single payer and do the negotiating must be very experienced in the particular business sector about which they are negotiating. They must know and understand true costs; the factors, like standard institutional overhead, price of service and products for the business, wage differences in different locales, etc., which affect these costs; the needs of the business for its employees to do well and for the business itself to maintain profitability for growth; and the nuanced business manipulations which are tantamount to greed. The people, who work for the single payer and negotiate, will have to have the attitude of meeting everyone’s needs.
  2. Fraud investigation which investigates the bills submitted to the single payer. It does not investigate the type of nor the quality of the work done. That, by its nature, is a local matter. Hospitals, medical staff, county and state medical societies all have the capability and immediacy to establish commonsense quality review programs for local communities. That’s where quality assurance must begin and end, in that local community. A Washington, DC single payer has no business involving itself in these matters. Remember, the purpose of a single payer is to administer payment for the bills which are submitted not to ensure quality of work which, again, is a local matter. The single payer investigates to assure that the work for which the bill was submitted was actually done but not its quality. Why not quality, you might ask. Because the single payer is to remote from the actual work to determine that, and, when a payer tries to involve itself with that, we wind up with regulation after regulation, which are a major problem in the American health care system today. Regarding potential fraud, which a single payer should investigate, there will be those doctors and business administrators, a few not many, who simply try to take advantage at every turn. For example, if a doctor submits bills for work that he/she didn’t actually do, the pattern of malfeasance will become clear over time and appropriate action can be taken. However, our doctors cannot operate in fear of a single payer. They must practice medicine. People, who are investigating fraud, must understand how diagnosis and treatment work and recognize that what looks like repetitious testing or multiple hospital admissions for the same illness may well be proper and indicated medical work. In this area of fraud investigation, experienced perhaps retired doctors, nurses and technicians would be helpful.
  3. Computer technology and medical coding expertise which design and continually refine electronic billing and payment services, electronic medical records, individuals’ identification and other necessary electronic services. The coding for submitted bills must be simple. The single payer doesn’t need to know or understand complicated codes for illness or various manifestations of illness. It needs to know the work which was performed and the negotiated payment amount for that work, i.e., simple coding and simple payment according to the code.
  4. Other departments as necessary for example accounting, fund management etc.

In designing a single payer two very important ideas need to be at the front of our thinking: First, that the single payer does not interfere with the functioning of the doctor logo patient relationship, and second, that the single payer be kept administratively simple. We don’t need layers and layers of bureaucracy to continually and unnecessarily inflate the amount of money it takes to ensure unrestricted access for all people living in America to sound, ongoing, non-conflicted, spontaneously functioning doctor logo patient relationships and payment for the work emanating from those relationships.

A personal anecdote might help clarify how I feel about the functioning of a single payer. I have Medicare and a Medicare supplemental insurance policy. Yesterday, I went for a cardiology follow up appointment and for some lab work. During the registration process for the lab work, the technician had to complete several questions for a computerized check list, such as my name, DOB, address. All that was fine. Then she asked, “Is your wife retired and when did she retire?” I answered the questions but thought to myself, “What in the hell does my wife’s work history have to do with me registering to get a lab test done?” This is our goddamn federal government intruding unnecessarily in my and my wife’s lives. In my single payer, that kind of crap will stop. And that’s what it is, crap, placed by Washington, DC bureaucrats who need to justify their existence.

Then I went on to see the cardiologist. Towards the end of my visit, he said, “I am required by Medicare to tell you to lose weight and maintain proper diet and exercise,” or something along those lines. I don’t remember the exact words he used. Doctors do not need phony Medicare bureaucrats and other federal operatives telling them what to say to their patients. Stay out of it Medicare, your advice is garbage. Just pay the goddamn bills, for which I have sent money to you all my working life to have happen. I do not need your interference or interference from any other self serving 3rd party payer in my medical care. This kind of stuff is exactly why so many people are afraid of a single payer. (All 3rd party payers try this insidious intrusion in some form or other to decrease what they pay and  enhance their profit). The single payer, which I am trying to describe, does not intrude into the functioning of the doctor logo patient relationship. My doctor and I can decide quite well what I need to do to maintain my health without any input from you.

R. Garth Kirkwood,MD


A Properly Structured Single Payer: Financing


Finance a single payer with a federal sales tax. There will be a lot of debate over whether this kind of tax for health care is equitable. I think it is equitable because then everyone, including the poor, would be contributing to the payment for their own health care. In the past, I have avoided the concept of national sales tax because I thought it would be unfair to the poor, believing that there is a big difference in living when you don’t have to worry about how much money is in your pocket when you go grocery shopping. However, I now believe that the quite large number of people receiving food stamps weakens this argument considerably. Thus a national sales tax to pay for funding a single payer health care system seems the right way to proceed.

How much federal sales tax would be necessary? I don’t know. Part of the answer is how much do we need. Estimates of current national health care expenditure are published.

Does it really take 2.9 trillion dollars to run our health care system (as of 2013)? Note the health care spending reported for 2007 was $2.2 trillion.

So, in six years, health care spending increased by 700 billion dollars? Why? I’m sure there are many ‘experts’ who can rattle off reasons for this. To me, it sounds like a whole lot of waste and bureaucracy. I bet I could run a single payer in an equitable manner for a whole lot less, while maintaining healthy profit for necessary health care businesses.

What percentage federal sales tax would be necessary to accumulate 2 trillion dollars? One estimate reports that 1% would equal 445 billion dollars.  I really don’t know if this number is valid. That’s what tax gurus and mathematical economists are for.

Just remember this would mean no more Medicare, Medicaid, other publicly funded health programs, private health insurance premiums, deductibles, co-pays, etc. and the expense to various sectors that go to pay for all that. It would also mean no more bad debt for hospitals and doctors, that anyone when they feel ill could get up and go to the doctor without financial fear, and that doctors could welcome all people into their office regardless of financial status without the resentment that they won’t get paid. And all employers would be out of the health care benefits business.

I would also mention that the words indigent, poor, unable to afford health insurance define a large number of people and lead to financial discrimination in the health care sector. First, these people are frustrated and angry. They have difficulty finding doctors who will see them. Thus they go to the emergency room for a lot of illness which could and should be managed in the doctors’ offices. Second, the doctors are frustrated and angry. Anyone who has been in private practice knows that  non-reimbursed visits quickly lead to a severe strain on cash flow. They don’t want to and are not putting up with it. In my view, both sides are right. How about we solve the problem with a well financed single payer, paid for by everybody? Then the words indigent, poor, unable to pay for medical care could be forever removed from our health care lexicon.

R. Garth Kirkwood,MD


A Properly Structured Single Payer: Overview



A single payer does not equate with socialized medicine; it just doesn’t. But, if not properly structured and written into legislation such that that structure remains authoritative, then it can have its functioning mired in the worst and most feared aspect of a socialized medicine system. What is this aspect? It is the payer directing the practice of medicine by interfering with, pressuring, or leveraging the doctorlogo patient relationship like our public and private 3rd party payers currently do.

The figure above is a simple outline of what I believe constitutes a properly structured single payer system. The foundation, upon which the entire structure rests, is the American people, who must fund the system. This financing, I suggest, would be a federal sales tax, which dollars accumulate in a single payer fund.

The single payer fund has several notable characteristics:

  1. untouchable by politicians,
  2. used for paying the medical bills of the American people,
  3. no deductibles, co-pays, coinsurance, or bills sent to the patient,
  4. also used for paying its own overhead including a fraud investigation department.

The single payer functions to pay the medical bills of the American people. That’s what it does. The price paid to specific health care businesses for service and product is and will be a major source of contention. The ethos of my single payer is that the health care businesses be paid for service and product in such amounts that they earn genuinely healthy profit enabling the growth of the business which can be documented to have occurred or not occurred.

To accomplish the goals set forth by this grand ethos requires tough knowledgeable negotiation between the single payer and the business. The negotiators for the single payer must not be Washington, DC bureaucrats with an ax to grind but rather seasoned business people who have labored in specific health care business arenas for many years, even to the point of retirement. These people will immediately know the difference between the needs of the business for genuine profitable growth and excess manipulation which amounts to greed. I want these negotiators to work for the single payer with an accurately intuitive grasp of the balance between proper financing of the business and affordable dollar flow from the payer. The job requires in-depth knowledge of and hands-on experience in the specific business and tough yet sincere negotiation. The businesses are not the enemy and indeed, they need to be kept profitable for the welfare of the country and its people. The lead negotiator of each business section might be appointed by the President or perhaps his/her Secretary of Health and Human Services.

This simple concept of a properly structured single payer seems right to me.

Note that health insurance companies and the burden of employer provided health benefits are not part of it. And one other thing: You don’t see the doctorlogo patient relationship in the figure. That’s because this equilibrium of trust between the doctor and the patient must remain free of influence, pressure, and demands from the single payer or any health care business. Indeed, the single payer and all the health care businesses exist to serve and support the existence of and access to sound, ongoing, non-conflicted, spontaneously functioning doctorlogo patient relationships for everyone living in America.

R. Garth Kirkwood, MD


What is health care and what is its interaction with a properly structured single payer?

Health Care is the doctorlogopatient relationship, nothing more and nothing less. On an individual basis, it is that individual relationship. On a nationwide basis, it is the sum of all the doctorlogopatient relationships. An entire health care system has developed and continues to evolve in an effort to support these relationships. The businesses of medicine are a major part of our health care system, but they are not the medicine of medicine, which is the doctorlogopatient relationship. It is important to understand this distinction because the businesses of medicine exist to support and serve doctorlogopatient relationships. I believe businesses lose sight of this and make dollar profit the primary goal. In America, dollars are very important, and I want all necessary health care businesses to be very successful. However, a more compelling expectation can be developed by our health care business CEOs: the better achieved the ultimate ambition of unrestricted access to doctorlogopatient relationships for everyone living in America becomes, the more successful our health care businesses can be.

The doctorlogopatient relationship is an equilibrium of trust between two individuals established for the need of diagnosing and treating patients based on the information shared across the equilibrium.

Sound, ongoing, non-conflicted and spontaneously functioning describe what a doctorlogopatient relationship must be. Sound indicates an extensive fund of knowledge and training, a going-out-of-your-way attitude, and a time-taking approach for investigation and explanation on the doctor’s part. For the patient, it indicates understandable delivery of information regarding the events which cause them to seek help; ability to listen to and understand the doctor’s questions and directions; and reliability at following these directions, taking the medicines prescribed and showing up for appointments.

Ongoing indicates the patient trying to see the same doctor over time and the doctor making an effort to be available even if there is no appointment scheduled.

Non-conflicted means no conflicts of interest entering into or pressuring the doctorlogopatient relationship, such as doctors ordering unnecessary tests just to make money, hospital administrators pressuring doctors to discharge patients before they are ready because hospitals are not paid on a per diem basis, insurance companies insisting on one form of treatment as opposed to a more expensive form, etc. Anything which interferes with the sincere functioning of the equilibrium of trust between the doctor and patient conflicts the relationship.

Spontaneously functioning indicates a spontaneity such as ability for the patient to see the doctor without a pre-arranged appointment when necessary and ability for the doctor to refer a patient to a more advanced specialist, whenever deemed necessary, absent pre-approval from the payer and absent the worry that the third party payer will count this as a black mark on the doctor’s record for spending more money. Doctors don’t work for the payer, they work for the patient.

The doctorlogopatient relationship is an employee —– employer relationship but not a typical one in that the employer, the patient, does not tell the employee, the doctor, what to do. Together, after exchange of information, two people decide how best to approach a problem. The doctor guides the relationship, but the patient must understand the proposed form of investigation and therapy and agree to accept the risks before proceeding. Perhaps there is more than one way of treating a condition. Then the doctor and patient decide which is best for that individual patient at that particular time. Effective communication is key, and for this to occur, the relationship must function in a sound, ongoing, non-conflicted and spontaneously functioning manner.

This idea of employee —– employer relationship is important. When some other entity is viewed as or in actuality is the doctor’s employer, allegiance can easily shift from the patient to that other entity. For example when hospitals employ doctors such as hospitalists, they might function in the best interest of the hospital and not of the patient. Insurance companies can do the same thing to doctors. Doctors should keep away from hospital and institutional employment and maintain independent practices.

A key part of a properly structured single payer is that the payer has zero influence over the functioning of the doctorlogopatient relationship. The payer administers payment of the bill but has no say over the work to be accomplished for which a bill is generated. An ongoing emphasis for this single payer has to be no interference whatsoever with the doctorlogopatient relationship either on an individual or a nationwide basis. This will be a tough pill to swallow for politicians, bureaucrats, health care administrators and business CEOs because they’ve never really understood that a relationship, an equilibrium of trust between two people not in their employ, is their guiding light. If recognition and full acceptance of this truth is not the touchstone for American health care, then the past and current failures in health care policies will persist, recycle and repeat.

Currently, the doctorlogopatient relationship is viewed as a tool by health insurance executives and hospital administrators through which and by the manipulation of they can enhance their dollar revenues. This is simply the wrong approach and, coupled with the arrogance, ego and reluctance on the part of some doctors to truly accept responsibility for their patients’ well-being, has resulted in the current miserable state of affairs for our health care system. Our delighted, self-serving, all-talk-no-action politicians use this sorry mess as a political football to be tossed back and forth in a never ending game of how long can I stay in Washington, DC and enjoy a position of elite entitlement at the tax payer’s expense.

The entire system needs an overhaul, effected by political, business and medical leaders who place the welfare of our country and its inhabitants above ideology and self interest and who wish to make our health care system the best in the world.

Obamacare is an atrocity put into law by garbage politicians.

R. Garth Kirkwood, MD



Trump: I’ll replace ObamaCare with ‘something terrific’

The Hill has reported Mr. Trump’s health care comments from his 7/29/15 CNN interview. His comments are worth discussing:

It’s gotta go, Trump said of ObamaCare. Repeal and replace with something terrific. The country’s healthcare system should rely on private health plans that are largely unregulated by the government.

Was he referring to federal government or state government or both? Was he talking about health care insurance being sold across state lines? What a quagmire of confusion that is!

No matter what idea exists to make health insurance plans competitive, the American public loses. This is because the competition is over dollars not over health care. Health insurance companies survive in a competitive market by increasing their dollar garnering activities of increasing premiums, deductibles, co-pays, requirements for co-insurance etc. and by decreasing what they will cover (pay for). If you are financially well off, this will not be a problem and our health care system will be great for you. How many people do you know that can really just take health insurance greed in stride? I’m not sure where Mr. Trump is going with this private health plan business.

Regarding poorer Americans who can’t afford insurance, At the lower end, where people have no money, I want to try and help those people, he said, adding that he would work out some sort of a really smart deal with hospitals across the country to cover the costs of care.

Mr. Trump continues separation of the indigent population. The concept of poor, indigent (the lower end) should be removed from our health care lexicon because anyone living legally in America should be able to go to the doctor without financial fear.

Some sort of really smart deal with hospitals across the country is intriguing. It seems he is bypassing the insurance companies and going to negotiate directly with hospitals. Negotiate about what? I guess the price paid for their service and product. This could be very exciting, the president of our country negotiating on behalf of the American public. Could this be the beginning of a properly structured single payer for American health care, a removal of the stranglehold that the private health insurance industry and federal/state governments have on Americans’ health care as well as the stranglehold that the poor have on the monies of those people who actually pay taxes and purchase health insurance?

Mr. Trump, where are you going on this health care thing? Are you going to continue the reality of the haves and have nots in the health care arena or are you going to create a system of health care in which everyone has clear and equal access to good health care i.e., to sound, ongoing, non-conflicted, spontaneously functioning doctorlogopatient relationships?

R. Garth Kirkwood, MD


Doctors, Reclaim Your Profession

Dr. Krauthammer has recently written two articles, Why Doctors Quit and Why Doctors Quit, Chapter 2 in the Washington Post: 

Please read his articles at the above links.

In this post, the italicized entries are taken directly from Dr. Krauthammer’s articles and the non-italicized sections are my commentary. Dr. Krauthammer describes a misery of 21st century health care in America: the abject interference with the functioning of the doctorlogo patient relationship.—an incessant interference with their work, a deep erosion of their autonomy and authority, a transformation from physician to “provider.”-–Can doctors relieve themselves of this burden? Yes, they can!

If Washington, D.C. politicians cannot create a central, ideally functioning 3rd party payer which eschews this interference; maintains healthy profit for necessary health care businesses; is affordable and paid for by everyone not just by those who pay income tax and/or purchase health insurance; and has as its sole function the collection and distribution of the people’s money to pay everyone’s health care bills, then doctors, summoning great courage, could refuse to accept any payment from any 3rd party payer, i.e., return to a first party payer system. This doesn’t mean refusing to see Medicare, Medicaid, indigent or well-insured patients. It simply means that the patients would be personally financially responsible for the doctor bills they create. Simple plans for payment over time could be developed (office by office), and the patients themselves would have to deal with the 3rd party payer with which they have contracted. The doctors would free themselves from having to engage with public and private 3rd party payer personnel whose perverse and hypocritical goal is to interrupt the practice of medicine by embedding make-work data forms which distract the doctor.—Think just of your own doctor’s visits, of how much less listening, examining, even eye contact goes on, given the need for scrolling, clicking and box checking.—Clicking boxes on an endless electronic form turns the patient into a data machine and cancels out the subtlety of a doctor’s unique feel and judgment.—Does this data entry procedure (scrolling, clicking, box checking) actually create a wall, a partition, between the doctor and patient? Yes, of course it does!

For many reasons, about which I have previously written (pages 22-24 of Equal Health Care For All and pages 22-23 of Socialized Health Care Reform), the doctorlogo patient relationship has been undergoing destruction for years and this EHR mandate which Dr. Krauthammer discusses may be the finishing blow. Why do politicians and 3rd party payers foster this destruction? Because, if you interfere with, i.e., control the doctorlogo patient relationship, then you control a gold mine. Health care bills originate with the work engendered by the equilibrium of trust between a doctor and a patient. And the less money any payer spends, the more that remains for the payers’ administrators to reward themselves and their cohorts for achieving their insidious, deceitful embedded propaganda, i.e., control the cost of health care, which disguises their real underlying agenda, control of the American people. No matter who the payer is if it conflicts your individual doctorlogo patient relationship, it conflicts your health care, a major advance towards the ultimate control, control of your body, your person. Don’t be fooled by the hypocrisy of differentiating between private and public 3rd party payers. Health insurance companies flourish by imposing financial restriction (covered or not covered) on the spontaneous, non-conflicted functioning of doctorlogo patient relationships, and in the Veterans Administration Health Care System, the most pure form of socialized medicine in the world, administrators and bureaucrats flourish while patients get shafted. Ultimately, those who are ceaselessly, persistently trying to control our health care through disruption of the doctorlogo patient relationship are positioning themselves for a high place in the order of political control over the masses. Sound, ongoing, non-conflicted, spontaneously functioning doctorlogo patient relationships are a major human force to counter the advance of this threat to our way of life, the American Way.

I note that in Chapter 2 Dr. Krauthammer says—I was in no way arguing that the bureaucratization of medicine began with Obama. It is the inevitable and inexorable result of the industrialization of everything from cloth making to food service, now extended to health care. My point is that, given the consequent loss of autonomy and authority of doctors, why are we compounding their demoralization by forcing an EHR mandate that robs them of both time and the satisfaction of proper patient care?—Why has bureaucratization resulted in the loss of doctors’ autonomy and authority in their profession? Why have doctors allowed this to occur? Is it because of the money? Has Medicare made doctors rich, and now they don’t want to give that up? They don’t know how to establish a practice without Medicare and other public/private funding money?

Do I have a solution? Yes, I do. Doctors, give up money as your primary goal and the worry about getting paid; give up Medicare and other public funding payments; give up private 3rd party payer payments. For your office and hospital interaction with patients, establish a first party payer system. When you perform to the best of your ability and training, the patients will pay their bills. Reclaim your profession. It’s quite clear that the politicians are not going to do this for you. I predict that they will never develop a central 3rd party payer system for everyone, which reestablishes the primacy of the doctorlogo patient relationship. You will have to reestablish this yourselves. If you wish to have a profession, then be professionals and give up compromising with those who intrude into your private practices by dangling dollar signs ($$$) over your head. Throw these people out with the garbage!

R. Garth Kirkwood MD