The Gruber Hearings and Representative Blake Farenthold’s Questions

Jonathan Gruber gave testimony to Congress today regarding his role in the development of the Affordable Care Act (ACA).

Representative Blake Farenthold R-Texas, 27th District asked Mr. Gruber the following question: Would you consider the ultimate solution to rising health care costs to be a single payer or government run system, completely government run system?”

The question is off the mark, way off the mark, and it demonstrates politicians’ inability or unwillingness to understand what health care is. If a central payer system were structured properly in America, health care costs could actually increase. They might not, but they could because a properly structured central payer would free the doctor patient relationship from undermining control and interference from the payer. The major goal of a central payer structure is to make sure that anyone, when he/she feels the need, can get up and go to the doctor or emergency room without obstruction from the fear of huge medical bills. If there is some lowering of national health care expenditure because of the efficiencies of a central payer compared to private health insurance, then that would be fine. But this is NOT a goal to be sought after. Doctors and hospitals welcoming everyone in their community to enjoy unobstructed access to first class health care is the goal, and that is not happening at present. A properly structured central payer could easily make that happen.

The government can’t run health care. For goodness’ sake, look at the Veterans Health Care debacle! There is nothing wrong with a central payer structured to perform one clerical function: the collection and disbursement of the people’s money for payment of their health care bills. Money in and money out. There is everything wrong with the government trying to run health care!

The doctor patient relationship is health care; politicians, insurance companies, public payers, drug companies etc. are not. Only when the politicians create a structure, which separates the business of medicine from the medicine of medicine and makes the former subordinate to the latter, will we have a health care system which serves all of us. And this can be accomplished while maintaining very good profitability for necessary health care businesses. However, the politicians seem unwilling to think this through. I wonder why.

R. Garth Kirkwood, MD                                                         


HIV Pandemic—Origin

Reports indicate that the origin of the HIV pandemic has been determined:

Whether these reports are correct, I do not know, nor do I possess the medical, scientific, epidemiological knowledge to make that determination.

However, I would not ignore the ongoing work of Edward Hooper [ go to ] nor his exhaustively researched, wonderfully written and very cogent book, The River, which explore this subject. 

R. Garth Kirkwood, MD


Eliminate the V.A. Health System or, At Least, Appoint a True Clinician to Run It.

The V. A. Health System is the purest form of socialized medicine, i.e., a health system in which the government owns and operates both the financing of health care and its delivery. In America, this particular system of socialized medicine is reserved for our nation’s veterans.

The problem is that it doesn’t work. Actually, it can’t work. Why? Because health care, which is defined by sound, ongoing, non-conflicted doctorpatient relationships, is not considered its primary goal. Administrative bureaucracy by operating as if its own survival was most important has paralyzed the doctors who, in my view, should be ashamed of themselves for putting up with it.

There can be no fix until the administrative bureaucracy separates its functioning from the functioning of the doctorpatient relationship and not only views the latter as more important but also creates the platform upon which this relationship can evolve to its full potential. The quagmire of ineptitude, fear, and cover up will remain unchanged until the president appoints a true clinician with many years experience in private practice outside the VA System as the chief of its operations. And this person will have to have the following outlook: The goal is to get our veterans diagnosed and treated within the confines of sound, ongoing, non-conflicted doctorpatient relationships. And she/he will also have to have the mentality to plow the road to accomplish this goal.

The corollary for this in the American health care system in general is that the same type of true clinician be appointed chief of a central payer, which functions to accomplish the same goal for our non-veterans by separating the business of medicine from the medicine of medicine and views the latter as paramount.

Even better may be to eliminate the V.A. System and have one system for everybody which functions in the manner described.

A comment about this essay is that you will still need people who understand how systems operate to create the type of change called for. I guess that’s true. But what I see now is a whole lot of people who understand systems obstructing the delivery of health care. How’s that working out for us?

R. Garth Kirkwood, MD

The VA Health System, the American Health Care System, and the Doctor—Patient Relationship

The VA health system, the purest form of socialized medicine, and the American health care system, a hodgepodge of private & public 3rd party payers coupled with individual out of pocket spending to a myriad of health care businesses, both show signs of disturbing core difficulties as evidenced by the current VA investigations and the Affordable Care Act.

Why is it, do you think, that there are so many problems across the entire spectrum of health care in the USA? Is there a common denominator for all the problems?

The common denominator is that none of the systems of health care in America actually promote health care. They promote political footballs; vote-getting agenda driven rhetoric; administrative job creation in local, state, and federal government; big pay days for health care administrators; and fodder for the news-television-radio media. But actual health care, who cares?

WELL!   What is a really good health care system? A really good health care system is one that achieves clear and equal access to sound, ongoing, non-conflicted doctorpatient relationships in an affordable manner for everyone living in America. This cannot happen in our current environment. It won’t happen until the doctorpatient relationship is freed from the influence of any 3rd party payer of doctors’ salaries  & bills or of other additives to doctors’ personal income and until all the doctors and patients step up to the plate to recognize, understand and accept the responsibilities of their own unique doctorpatient relationships.

The doctorpatient relationship is a hothouse flower and must be regarded and treated as such by everyone including doctors and patients themselves. It’s this relationship, this equilibrium of trust, which defines health care, not the doctors & patients nor any one or group of human beings involved in health care.

Until this relationship is removed from the clutches of the dollar bill administrators, including those at the VA health system, health insurance companies, and government 3rd party payers like Medicare & Medicaid, our health care system will continue its downward spiral into a lush dollar-green grazing range populated with politicians, huge numbers of administrative personnel, and CEOs of the various health care businesses chowing down on the roughage and with patients herded into defined, barren (devoid of proactive advanced specialty thinking and intervention) holding pens never to be heard from again–except of course in the cases of the politicians themselves, who immediately call for and receive the most advanced specialty care available for their individual ailments.

How can we free the doctorpatient relationship from the administrators’ dollar bill stranglehold? The Senators and Representatives in our Congress functioning as true servants of the people (an old idea but completely new concept for them) create a central payer legislation, which separates the business of medicine from the medicine of medicine; demands sensible healthy (not greed-driven) profit for the necessary health care businesses; and demands that the equilibrium of trust between the doctor and the patient function and evolve as it must for each individual case without interference from budget managing administrators who create career advancement and bonuses based on a counter-intuitive concept, cost control.


R. Garth Kirkwood, MD

Veterans Administration Health System = NO! NO! NO! to Socialized Medicine

The allegations regarding awful performance of the Veterans Administration health system are the subject of news reports and articles during recent months.

I suspect that these reports are just the tip of the iceberg of nationwide difficulties, and that, although the current administration’s responses to them may be sorely inadequate, these difficulties didn’t begin when President Obama won the presidency.

The purpose of this essay is to discuss the nature of the problems within the American health care system in general using the Veterans Administration health system as an example.

Did you know that the V. A. health system is the purest form of Socialized Medicine, which refers to a health system in which the government owns and operates both the financing of health care and its delivery?                                                                         

How many of these allegations about mismanagement or worse in the V. A. health system are true, I do not know. But something is going on. What is the result of this something? Apparently, some veterans are dying and others suffering some other type of harm due to improper care possibly related to delayed or withheld treatments. If this turns out to be true, then how could it occur? One answer could be that V. A. administration officials, who wield more power than individual doctors, are directly interfering with the sound, ongoing, non-conflicted functioning of the doctorpatient relationship. This type of general interference is a recurring theme both on this blog and in my book, Socialized Health Care Reform.
Questions I have are, Where are the patients’ individual doctors in all this? Are they mute? Did they fail to learn or simply ignore the physician’s duties for a sound, ongoing, non-conflicted doctorpatient relationship?
Or is it more that because they work for a massive government bureaucracy which pays their salary they have been systematically, persistently and pervasively kowtowed into submission under fear of retribution, dismissal and pursuant damaged reputation.

This is the effect of a system of socialized medicine, the end result of which is socialized (manipulated, obstructed, controlled) doctorpatient relationships.

The next questions are for me to answer: Is the central payer system, which I describe on this blog, any better? Could it fall prey to the same kind of difficulties the V. A. health system is plagued with? The answers are as follows:

  1. My system does not meet the economic definition of socialized medicine noted above because there is no change of ownership or transfer of ownership to the government of any hospital, clinic, practice or other health care business.
  2. However, a central payer could still socialize (manipulate, obstruct, control) doctorpatient relationships, for example by refusing to pay for certain procedures, disallowing procedures, threatening the doctors with continually lowering reimbursement, forcing hospitals to accept lower reimbursement, bonuses for physicians, clinics and hospitals for directing patient management a certain way, etc. These type of events can be greatly curtailed if the Congress sets up up a central payer with legislation, which prohibits the payer, the Executive branch and the Congress from, in any way, interacting with the doctorpatient relationship.  Of course, this would require thoughtful, clear, unambiguous language and intent. I really don’t know if politicians are capable of that.
  3. For my system to really work, there is another very important event which must take place: Doctors must come to the fore, accept and fulfill the demands placed on them by the sanctity of the doctorrelationship and demand completion of their orders in a timely fashion without the fear of retribution from the central payer or from any hospital or clinic which pays their salary. In fact, I believe that doctors shouldn’t be in the employ of hospitals, clinics or health systems, that they should have their own unique, independent private practices in which it is much easier to recognize that each patient is their employer.
  4. Significant changes in the essence of how our health care system functions must occur, if we are to have true health care reform. Regarding the Veterans Administration, the V. A. health system clearly demonstrates what we must avoid. Maybe the V. A. health system should be completely privatized including the ownership of the V. A. hospitals and clinics, and the entire V. A. health system budget be directed to a central payer, the make-up of which I have described.

R. Garth Kirkwood, MD

Central Payer Working Structure

Following my last essay on hospital interaction with a central payer for the American health care system,, I participated in a brief discussion on Twitter:

Garth Kirkwood ‏@garthkirkwood Mar 26
@kateloving 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

Hospital Interaction With A Central Payer

I do not believe that all the businesses, which operate in America with health care as some part of their mantra, are necessary. If I were directing the operation of a central payer system, I would endeavor to stop paying for them. My list of necessary health care businesses can be seen in the diagram above.

How do I see the central payer interacting with these businesses for the accomplishment of the two major goals of our health care system:

  1. non-conflicted functioning of sound, ongoing doctor patient relationships for everyone and that everyone can afford,
  2. absolute significant profitability of necessary businesses to a level short of greed?

Let’s start with hospitals. Hospitals account for a major part of our health care expenditure in the USA.

Running a hospital is a complicated, difficult job and our hospital CEOs and CFOs and their entire staff should be commended. However, there are several things that I think should be corrected with regard to hospitals in our health care system:

  • They are functioning as independent business fiefdoms, and although that may be good, the non-profit status of the majority of them is bogus in my opinion. Calling a business with hundreds of millions of dollars in revenue and with exorbitant executive salaries non-profit is just wrong in my view. They should all be labeled for-profit and pay taxes.
  • Medical decision making is being greatly influenced by the dollar bill.                                                                                                                                                                                                                               Decision making in medicine must occur within the context of the equilibrium of trust called the doctorpatient relationship, and it must stay unencumbered and non-conflicted by the dollar bill. Otherwise, you wind up practicing dollar earnings and profit instead of practicing medicine. Doctors must rise against hospital administrators and tell them in certain English that medical decision making simply does not fall under their purview, ever. In my view, a hospital administrator’s job is to direct the operation of the cleanest, most well-run physical plant possible for the purpose of helping the doctors accomplish the clinical decision making of the doctorpatient relationship in a straightforward, comfortable, convenient manner. They need to make their hospital a lovely place for doctors to practice. However, any pressure to practice medicine a certain way, which places the financial well being of the hospital in a position to influence clinical decision making, is out of bounds. Examples of this are pressure for earlier discharge, managing illness in an outpatient setting when an inpatient admission is clearly the correct way to go and pushing home health nursing checks in favor of frequent follow up at the doctors’ offices. Hospital administrators must remember that doctors have one employer, the patient, regardless of who directly pays the doctor’s income. This doctor (employee) patient (employer) relationship takes superiority over business administrators’ machinations of how best to practice medicine. A central payer must recognize and accept this same concept. The job of a central payer is to administer payment of the bill for the work performed and not determine when, where, how often, or how that work is accomplishedIf this theme of the authority of the doctor patient relationship remaining free of dollar compromise is not central to our health care system, then what we currently have will never changeThe practice of medicine in America being socialized (obstructed, manipulated, controlled) by 3rd party payers, both private and public, and hospital administrators with their medical-business personnel.
  • I believe hospitals are often staffed by a spreadsheet mentality instead of by experienced knowledge resulting in safe patient to nurse ratios in various different units within the hospital.
  • Central payer approved certificates of need for that local community with regard to hospital construction projects are also a consideration.

With this in mind, how do I see a central payer interacting with individual hospitals in an effort to make sure that they sustain good profitability? The central payer should hire very experienced health care administrative personnel, doctors, nurses, technicians, physical plant engineers and private sector health care data mining experts thoroughly experienced in medical coding and in the costs of services and products related to those codes. These people should be older, mature with many years experience perhaps even retired from their health care career, and their job would be to discuss and negotiate payments with current hospital CEOs and CFOs. This negotiation is not an argument or a contest about saving money. It is an effort to determine the exact cost of hospital admissions for various medical codes in that locale and then to apply a payment amount which significantly exceeds that. I believe this can be accomplished in a straightforward manner. I would greatly simplify the medical coding system to help this process along and I would not hire unaccountable Washington, DC bureaucrats to work as part of a Central Payer.

There is an interesting (2006) article, which describes the state of hospital billing and gives some idea of the enormity of the task I have described.

There must exist a trust between the necessary health care businesses’ leaders and the experienced people working for the central payer, both of which groups share a common goal: To keep these businesses genuinely profitable while making the health care system affordable for the American people and while ascertaining that the decision making within the doctorpatient relationship remains free of dollar thinking.

R. Garth Kirkwood, MD

A Central Payer for the American Health Care System: Financing

Presuming that over the coming election cycles we choose candidates who place common sense over ideology, civil service over serving corporate masters and who therefore get their politics right, I am hopeful that they will arrive at a structure for our American health care system which resembles the structure I have drawn above. Please see my two previous posts for a general explanation of this figure and how it should be created:

How do we finance a 2 trillion dollar health care fund which I say should pay for everyone’s entire health care bill without the need for deductibles, co-pays, cash out of pocket at the place of service, insurance premiums, health savings accounts or any other business derived dollar garnering mechanisms? Is 2 trillion dollars annually enough? I have a reference, which states that health care spending in 2012 increased 3.7% to 2.8 trillion dollars ($8,915 per person).

My feeling about these figures is this: If you can’t run the American health care system with an annual budget of 2 trillion dollars, there is something wrong with you. I believe I could. Actually, I believe I could do it for significantly less than 2 trillion dollars while keeping all the necessary health care businesses very profitable and while leaving the doctorpatient relationship alone to do its work.

What are my specific ideas for financing? I have discussed this at length in my first health care book, Equal Health Care For All.  However, since the publication of this book in 2007, my thinking regarding the financing of a central payer has changed for a couple of reasons:

  • Some of the ideas in this first book promote, inadvertently I would add, the redistribution of wealthThis concept, I think, encourages further anger, resentment and discrimination towards the impoverished.
  • I avoided the concept of a national sales tax on all our purchases as contributing to this health care fund believing, at that time, that it would be quite regressive for the economically less-well-off and noting the adage, 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. Given the absolute plethora of people now receiving food stamps, my thinking regarding this mechanism of financing has changed, i.e., I think it is an important consideration.
Some specific ideas for financing a 2 trillion dollar health care fund annually and for reducing unnecessary health care spending:
  1. Do we really need the Department of Education? Send that budget to our health care fund.
  2. Can we not identify some more of the government waste, fraud, abuse and unnecessary spending and send those monies to our health care fund?                                                                     
  3. Should we reduce our government’s annual charity to other countries, at least until we have clarified how to pay for our own health care expenses, and send those public monies to our health care fund?                             
  4. Unhealthy choice taxes: tobacco products, alcohol, gambling.
  5. I bet there are many other examples of federal, state and local politicians just wasting cumulative totals of hundreds of billions of dollars of our money on unnecessary, self serving discretionary spendingIt needs to stop and all that money be directed to our national health care fund or be accounted for by future significant reductions in required tax payments in those locales.
  6. A national sales tax on our purchases. This spreads the financial burden across all economic strata in America, i.e., everyone pays by being taxed on what they consume. Nothing is free in the USA.
  7. Efforts to reduce the total annual required amount of our health care fund by eliminating unnecessary health care businesses, greatly simplifying the coding for health care payment, removing the bogus not-for-profit status of the majority of our hospitals, i.e., since they function as independent business fiefdoms, then they pay taxes like other businesses. Send this money back to our health care fund.
Some potential benefits of creating a central payer, which is funded by ideas like these, are that the Medicare portion of the FICA tax can be deleted; no more taxes for Medicaid; auto insurance premiums can be greatly reduced (no more health care liability in their policies); and removal of the words, indigentpoorunable to afford it from our health care lexicon
Future essays will discuss actual mechanisms of how a central payer should interact with necessary health care businesses.
R. Garth Kirkwood, MD



A Central Payer for the American Health Care System: Creation

Subsequent to my last essay,, in which I introduced the following figure,  Structure for American Health Care with Central Payer,

I received via Twitter, a cogent question. The conversation is reproduced here:

Rebel Bill ‏@Rebel_Bill Dec 4
@garthkirkwood I don’t trust government to wall that $2 Trillion off, do you?

Garth Kirkwood ‏@garthkirkwood Dec 4
@Rebel_Bill @garthkirkwood Thanks Bill. No, not at present. Future elections must result in a Congress that creates a proper structure.

I am saying that we must elect politicians who will create a structure which serves the American people and which they must then leave alone to do its job without their interference and without their looting, diverting of accumulated money thus destabilizing the system. Is this possible? Is it possible to elect politicians who will function as true civil servants and remove their own personal agendas of ideology, power accumulation and re-election from their work? I don’t know. But, if we can’t, then our country and its people will be stuck with the absolute farce of Obamacare and the equally farcical non-accomplishments of previous congresses regarding our health care system.

So, politics and politicians are necessary. I have known this, but I have not previously read or heard this stated as eloquently as Charles Krauthammer did in his book, Things That Matter (ISBN: 978-0-385-34917-8). I paraphrase and quote from the Introduction–page 2:

  • While science, medicine, art, poetry and other wonderful pursuits may promise purity, elegance even transcendence, they are fundamentally subordinate and must bow to the sovereignty of politics.
  • You can have the most advanced and efflorescent of cultures. Get your politics wrong, however, and everything stands to be swept away.
  • We must know politics because of its capacity, when benign, to allow all around it to flourish, and when malign, to make all around it wither.

It’s quite clear that the politics regarding the American health care system is not just destructively wrong now but has been so for decades and that our health care system is withering. Who bears responsibility for this? The politicians who have served in Congress, the federal employees, operatives and lobbyists who have taken over the process of writing legislation, and us, who continue to put up with it. However, the latter group, i.e., us, has an excuse: When both major political parties support self aggrandizing, rhetoric spouting mouthpieces, who are afraid to step out of ideological line, what choice do we have except to not vote at all, which assures their ongoing existence. Perhaps the TEA PARTY will lead us out of this quagmire. However, they will need to be 24 hours a day vigilant to not fall into the same traps.

So how do we get our politics right?
  1. Elect better people, who truly wish to serve the public and who despise the concept of sucking the government teat!
  2. Demand from the candidates written oaths that they are going to try to accomplish defined, detailed agendas set forth by the American public at the grass roots level far prior to election day. And after election (6 months to 1 year), when that doesn’t happen because of lobbying, deal making or just ineffectiveness in the grand swamp (Washington, DC), the guilty politicians are unceremoniously removed from office and forced, under penalty of perjury, to tell exactly why they were unsuccessful in accomplishing what they took an oath to do as candidates.
  3. The rooting out of the pernicious, dangerous evil clarified by the removed politicians on an ongoing basis until this abscessed swamp is drained of every ounce of pus.
A poem for my current views on politicians and their interaction with the media:
Zoos’ birdhouse chatter
Of chatterbox magpies;
Park benches’ head bobbing
Pigeons pecking for grain;
We inhale parasitized air.
R. Garth Kirkwood, MD

A Central Payer for the American Health Care System: Introduction

My figure, Structure for American Health Care with Central Payer (please study it), reveals several basic, common sense understandings, which I believe are critical for successful health care reform. Without these basic concepts guiding the actions of the central payer, it will turn into a debacle like the implementation of Obamacare and into a socialized system that imposes waiting lists and other obstructions to the proper practice of medicine. These understandings are as follows:

  1. Dollars from the American people support the entire system. These dollars belong to the American people and not to the central payer and not to the politicians or government. The politicians should have ZERO access to this money.
  2. A 2 trillion dollar fund (? > $2 trillion) will have to be created annually, located such that it is under the control of the central payer (and forever untouchable by any politician in any branch of government including executive order from the President), and used for the payment of everyone’s entire medical bill including medicines on an ongoing basis without co-pays, deductibles, or the nonsense of covered-uncovered care.
  3. The monies from this fund will be distributed by the central payer to necessary health care businesses. Not all businesses, which have health care as some part of their mantra, are necessary for the proper practice of medicine. Indeed, some are detrimental to this.
  4. The interaction of the central payer is with the necessary health care businesses only (not lobbyists, not medical organizations, not political action groups, etc.). The central payer should have no access to the doctor patient relationship, either direct or indirect. I think direct is easy enough to understand. No person in the central payer should, in any way, be able to influence or directly interact with the functioning of doctor  patient relationships except for those in which they are the patient. Indirect is a little more difficult to grasp. An example would be not funding a procedure or trying to dictate, regulate, or even suggest when or how often a procedure should be performed. The central payer’s role in the health care system is to pay the bill for the work, defined by and completed within the context of doctor  patient relationships, of the health care businesses which participated in that work. Its job is not to determine what that work is.
  5. The stance of the central payer regarding the business negotiation of price paid for service and product must be one that ensures that necessary health care businesses remain financially sound for daily operations and generate substantial annual profits, which are clear and transparent. I believe the American people would welcome this, and I do not believe that they want to see their superb necessary health care businesses bankrupted by a central payer.
  6. The entire system exists to achieve clear and equal access to sound, ongoing, non-conflicted doctor patient relationships for everyone living in America without bankrupting people in the process. Doctors and patients need to comport themselves so that these adjectives, sound, ongoing, and non-conflicted  can be readily ascribed to the functioning of this equilibrium of trust, , which must exist between them.

R. Garth Kirkwood, MD