Central Payer Working Structure

Following my last essay on hospital interaction with a central payer for the American health care system, http://equalhealthcare.org/2014/03/hospital-interaction-with-a-central-payer/, I participated in a brief discussion on Twitter:

Garth Kirkwood ‏@garthkirkwood Mar 26
@kateloving Hospital Interaction with a central payer http://equalhealthcare.org/2014/03/hospital-interaction-with-a-central-payer/ … #healthcare #singlepayer

kateloving ‏@kateloving Mar 26
@garthkirkwood I so wish USA went #singlepayer instead of ridiculous ACA. We are about to pay the piper.

Garth Kirkwood ‏@garthkirkwood Mar 27
@kateloving I agree. But the question is, “Could it be run properly?”

kateloving ‏@kateloving Mar 27
@garthkirkwood not if the Feds run it– needs 2 run state by state. 

My feeling about states being involved in health care administration is that that would require at least another 50 sets of politicians being involved. Even the thought of that is energy draining and depressing. However, as I review my basic thinking about how I would run a central payer, the issue of 50 state legislatures doesn’t really apply.

For a central payer to really be a major part of the answer for our health care woes, it must function with direct human to human interaction between the people working for the payer and those working for the necessary health care businesses. Bureaucracy must be removed. Thus, politicians and all their unaccountable federal and state bureaucrats, lobbyists, and other manipulators must be removed. The business decision making regarding the price paid for service and product would be made by career-experienced people working for the central payer and interacting with, talking with current CEOs, CFOs and others working for the necessary health care businesses and then together arriving at an agreed upon amount. The ethos is make sure the necessary health care businesses are clearly profitable yet close the doorway to greed and keep the doctor patient relationship apart from and non-conflicted by dollar thinking. I believe sincere people can make this work.

The Congress will have to create the legislation for a central payer to function in a qualitatively similar manner as the Supreme Court, i.e., outside the influence of politicians, lobbyists, and other manipulators. There are many people in America, who have spent their careers in a health care arena and have by this experience accumulated a depth of knowledge about that arena as profound as the Supreme Court Justices have accumulated about the law. We should tap that knowledge base and make it work for us. What we don’t need is Washington, DC bureaucratic, make-work denizens or state-county politicians with their deal making middlemen  supplying rhetoric, which sounds important for health care but which leads us down into the quagmire of accomplishing ideologies, vote getting, payoffs and ensuring a continuing job for themselves.

Now to revisit the original question, “Would this be one federal group or fifty state groups (or more depending on the geographical size and population of the state) dividing the work load so that it can be accomplished?” Since the following apply:

  • politicians are not involved,
  • lobbying employees of the central payer would be illegal,
  • the same ethics as apply to the Supreme Court would apply,
  • the entire work load is huge,

it makes sense to have state located branches of the central payer.

Perhaps the most important aspect of this entire process is that it be kept simple, understandable and limited in scope and personnel involved at both the state branches and the federal organizing structure:

  • human to human interaction with effective decision making regarding price paid for service and product occurring in real time and being based on medical codes and the needs of the business,
  • limited number of medical codes,
  • as little bureaucracy as possible,
  • honesty, transparency, and good will between the businesses and the payer.

If there is a will for clarification and common sense regarding our health care system, we can make this approach work. The principal goal for the payer is to preserve the finest aspects of capitalism for the benefit of the necessary health care businesses and for the businesses is to remove the word, unbridled, from their lexicon with both groups remaining cognizant that dollar thinking must not interfere with or influence clinical decision making occurring within the context of the doctorpatient relationship.


R. Garth Kirkwood, MD


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