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



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