Accountable Care Organizations (ACOs)

An ACO is a network of doctors and hospitals that shares responsibility for providing care to patients. Hospitals, physician practices and insurers across the country are announcing their plans to form ACOs, not only for Medicare beneficiaries but for patients with private insurance as well. ( ) ACOs would make providers jointly accountable for the health of their patients, giving them strong incentives to cooperate and save money by avoiding unnecessary tests and procedures. ACOs would create savings incentives by offering bonuses when providers keep costs down and meet specific quality benchmarks, focusing on prevention and carefully managing patients with chronic diseases. In other words, providers would get paid more for keeping their patients healthy and out of the hospital. ( Ibid: see above link )

All of this rhetoric is just another part of a decades-long attempt by payers, both private and public, to interfere with the functioning of the doctorpatient relationship. This concept/reality of ACOs inserts the dollar bill into the doctor’s thinking and completely conflicts the functioning of the doctorpatient relationship, just like HMOs did in the past. Why do payers try to do this, to influence the doctorpatient relationship? Because that is where the money is spent. This relationship is the proximal cause of dollar spending within a healthcare system. If you contol this relationship, then you control medicine. A dollar quest is destroying sound, ongoing, non-conflicted clinical decision making in America.

Accountable care organizations take up only seven pages of the massive new health law yet have become one of the most talked about provisions. ( Ibid: see above link ) Who wrote these provisions into the Affordable Care Act ( ACA )? It certainly wasn’t the politicians. They didn’t even read the ACA before they signed it into law. So, just who is it that writes this stuff into federal legislation and for whom do they work?

Interference with the functioning of the doctorpatient relationship by payers offering financial incentives to reduce the ordering of tests; to reduce hospitalizations; to reduce referrals to specialists is every bit as conflicted as any doctor, who does unnecessary procedures to enhance his/her own income. The words, sound, ongoing, non-conflicted doctorpatient relationships, have ceased to be part of our medical lexicon because of this blind quest for dollars.

The duty of doctors in the American healthcare system is to develop a sound, ongoing, non-conflicted doctorpatient relationship with each patient they see. The combined efforts of both doctor and patient develop this mutual trust, through which non-conflicted clinical decision making occurs. The doctor’s job is NOT to reduce hospital costs. The doctor’s job is non-conflicted clinical decision making for each individual patient. If a doctor can help a hospital by trying to increase efficiencies, such as same-day admission for elective surgeries and other procedures, or perhaps discharging a patient a day or two earlier provided that out-patient follow up with the doctor can be arranged without significant hardship for the patient and provided that the doctor envisions a very early post-discharge office follow up to be the same or superior to the hospital follow up that would have occurred, then that is fine. HOWEVER, WHAT MUST NOT OCCUR is alteration in clinical decision making to satisfy the financial needs of the hospital or of the patient’s public/private 3rd party payer.

Doctors can avoid this conflicted situation by :

1) NOT working for any hospital, integrated healthcare system, HMO, or healthcare management plan. They must keep themselves INDEPENDENT from these employers. That way, these employers will not have a hold over them. The patient is and needs to remain the doctor’s sole employer.

2) NOT accepting any payment from any 3rd party payer. This does NOT MEAN refusing to see patients, who use these 3rd party payers. In my view, a doctor should see any patient, who wishes to be seen. The patient needs to be told up front that he/she is responsible for the bill. This does NOT MEAN demanding up front payment or demanding payment all at once. It does mean letting patients know the doctor’s charges; establishing an EASY, REASONABLE payment plan for each patient; and providing the patient with documentation of his/her visit(s) and/or procedure charges, so that reimbursement from the 3rd party payer can be acquired by the patient. I believe the vast majority of patients, who trust their doctor and recognize the doctor’s clinical expertise and hard work, will keep up with regular payments for an EASY, REASONABLE payment plan, which they have participated in developing with the doctor’s office staff.

Just think doctors: No more insurance company or public payer paperwork!

Hospital administrators need to get this message: Step Back! Stop trying to buy/control doctors and their practices. Your dollar profit is a distant secondary goal behind sound, ongoing, non-conflicted clinical decision making. In fact, since the vast majority of hospitals in America are not-for-profit, their billing departments need to be transparent and report the very lowest possible, break-even prices for all hospital services, based on STANDARDIZED OVERHEAD ACROSS THE ENTIRE COUNTRY.

All 3rd party payers need to get this message: An independent doctor is autonomous and not beholden to you. Each individual patient is his/her employer. Take your propaganda and other insidious, financially based healthcare manipulations such as medical homes; primary care services; accountable care organizations; bonus payments for certain appropriate goals; potentially avoidable complications; and all your other verbiage and put them in the garbage, where they belong.

Healthcare reform in America will come a long way, when doctors return to concentrating on practicing medicine, i.e., establishing trusting, professional relationships with their patients, and when they refuse to any longer be the employee of any hospital, integrated health system, other care plan and refuse to accept payment from any 3rd party payer.

Future posts will include discussion of how I believe doctors should approach billing, including reasonable charges; and of hospital charges vs. true costs based on standardized overhead expenses.

R. Garth Kirkwood, MD

Single Payer or Central Payer

These two concepts, single payer and central payer, are the same, if the payer exists at the federal level of government and only at that level.

However, each state developing its own single payer means the greed-driven, ideology-driven machinations emanating from state legislatures’ networking with healthcare businesses will creep into the cities, towns, and villages, like uncontrolled undergrowth in a rainforest which entangles forward movement. Vermont’s Green Mountain Care could be an example (

One properly structured, federal-level central payer could drain these 50 state-engineered swamps and thus could absolutely and significantly lessen healthcare business-political interaction within our healthcare system.

Okay now, Wait for it, Here it comes: The political rhetoric of infringement on states’ rights! While our politicians vociferously argue about this and appear on cable news programs righteously defending the Constitution and states’ rights, etc., etc., do you believe that any of the them, state or federal, really give a damn about an individual’s health care or worry about how their deal making with the healthcare business sector infringes upon the doctorpatient relationship?

Whatever happens with the American health care system: Whether ObamaCare is repealed or not; whether RomneyCare, Ryan’s Roadmap, HillaryCare, GreenMountain Care, or AnyOtherCare comes to the fore, the uncompromising, fundamental tenet for true reform is that equal access to sound, ongoing, non-conflicted doctorpatient relationships is the primary goal to be served by every part of our healthcare system. The dollar bill and ideology, although not necessarily bad goals, must be relegated to a supportive role for bringing to fruition the achievement of this far more important, altruistic reality, i.e., health care for everyone. Absent that, we remain stuck in our current, quirky, American quagmire begging for change, while we watch the politicians, healthcare corporate leaders, lobbyists, federal and state operatives, think-tanks, and others bob for the best position to siphon their individual swamp’s dollar-green slime into their own coffers.

A properly structured central payer can achieve true healthcare reform. Fifty single payers will not, nor will the previously proffered, convoluted tweakings of our complex, anti-doctorpatient relationship, dysfunctional system.


R. Garth Kirkwood, MD

Vermont’s Future: Green Mountain Care

The Vermont governor, Peter Shumlin (D), has signed a bill, which proposes to set forth a strategic plan for creating a single-payer and unified health system for Vermont. (

For a pdf of the bill use the following link:

In this post, I am going to discuss a couple of the eleven Principles, which are the framework for reforming health care in Vermont. They are recorded as Sec. 1. on pages 2 & 3 of the 213 page pdf of the bill. I will give the number of the principle and place the exact words in italics, and then my comments will follow as non-italicized text.

Principle (3) The health care system must be transparent in design, efficient in operation, and accountable to the people it serves. The state must ensure public participation in the design, implementation, evaluation, and accountability mechanisms of the health care system. If the legislators really mean this, such that the general public really understands what is being done for (to) them and such that the general public has an important, deciding voice in the design and implementation etc., then I applaud them. Do you think the legislators really mean this? I will hold my applause for now.

Principle (4) Primary care must be preserved and enhanced so that Vermonters have care available to them, preferably within their own communities. WATCH OUT ! We are getting into medical rhetoric land. Why is the distinction made for primary care. What about specialty care? Is it possible that they are trying to create primary care holding pens with the aim of reducing specialty referral, i.e., the concept of medical homes? Why are specialists not the first point of medical contact for patients? If that were the case, there would be an expanded knowledge base at the point of first contact and one less layer of referral for the patient should he/she need that type of specialty care. Why should patients have to go through the process of a referral, when they often know the type of specialist they need and/or want to see? The medical specialists such as cardiologists, lung doctors, gastrointestinal doctors etc. have to undergo general medical training prior to specialty training. They are capable of providing “primary” care but the reverse is not correct. I am wary when legislators start differentiating about the types of medical care patients should receive. How do they know?

Principle (5) Every Vermonter should be able to choose his or her primary care provider. Again, no mention of the specialists. And why does this principle use the word provider and not doctor? Oh, of course, we have to include nurse practitioners and physician assistants, who follow all the appropriate protocols. I wonder who writes up all those protocols; what is the basis of knowledge that supports those protocols; who pays the salary of the protocol writers; and who funds the institutions, which pay those salaries and provide that basis of knowledge.

Principle (7) The health care system must recognize the primacy of the patient-provider relationship, respecting the professional judgment of providers and the informed decisions of patients. Oh, so politically correct and inclusive. The essence of medicine is the doctorpatient relationship, and the distinction I make is a whole lot more than splitting hairs. The primacy of the doctorpatient relationship, the medicine of medicine, should be served by the entire system. The dollar bill, currently the primary endpoint for the business of medicine, needs to be designated as the servant of the doctorpatient relationship, which is the exact opposite of the current state of affairs. Moreover, careless terminology, such as patient-provider, designed to lessen the importance of the doctorpatient relationship and elevate the importance of legislators, legislation, and the business of medicine within our healthcare system, should be understood for exactly what it is: Deceptive, undermining propaganda. Other questions: Who is it that pays the providers’, doctors or others, salaries? For whom do they work? Are these providers independent, meaning that the patient is the employer? Or do they work for hospitals, integrated health systems, or health management plans, which, because they pay the salary, can interfere with medical decision making?

Principle (1) (last sentence) All Vermonters must receive affordable and appropriate health care at the appropriate time in the appropriate setting, and health care costs must be contained over time. Wow! Just, who is it that defines appropriate? Do you think that the governor and the legislators are going to go see a provider for their illnesses, or do you think they are going to obtain, for themselves, immediate appointments with real doctors, who will often be specialists?

Good luck Vermonters! I can tell by the smoke and mirrors of this politically correct, official, altruistic sounding rhetoric that you are going to need it.

R. Garth Kirkwood, MD