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.   http://equalhealthcare.org/books/  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. http://www.trivisonno.com/food-stamps-charts
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.  http://www2.ed.gov/about/overview/budget/index.html
  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? http://www.washingtonpost.com/business/capitalbusiness/federal-government-continues-to-lose-billions-to-waste-fraud-and-abuse/2013/03/08/a3fb7736-82b5-11e2-b99e-6baf4ebe42df_story.html                                                                               http://www.heritage.org/research/reports/2013/08/tight-budget-congress-can-save-42-billion-by-eliminating-bad-government-programs
  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?                                       http://www.globalissues.org/article/35/foreign-aid-development-assistance
  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, http://equalhealthcare.org/2013/12/a-central-payer-for-the-american-health-care-system-introduction/, 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


Obamacare Deductibles: Sticker Shock! A Central Payer and the American Center

An article in the Chicago Tribune http://articles.chicagotribune.com/2013-10-13/business/ct-biz-1013-obamacare-deductibles-20131013_1_health-care-overhaul-health-insurance-health-coverage points out the increasing deductibles on health insurance policies and indicates that they are occurring as a result of Obamacare.

Did anyone expect anything different to occur? Did anyone think that the health insurance companies were going to lower premiums, deductibles, co-pays, and lessen the existence of other dollar garnering mechanisms? Did anyone think that the health insurance companies were going to expand their coverage, i.e., what they pay for, without a reflex increase in consumer price to cover that expansion? Health insurance is a money-driven business, whose goal is not to enhance the health care of individuals who buy their services though the purchase of insurance policies. Its goal is dollar profit, and its sole function is to administer payment of the policy holder’s medical bills. This American goal of dollars has lead to the creation of a business empire with elongated, sinuous tentacles, which are unnecessary for the fulfillment of its one simple clerical function. Note, I do not believe that the function of assigning individual risk of getting sick and then designing insurance payment to and from the insurance company based on that risk and on profit expectations is a necessary task to be accomplished for the health care system of Americans. I believe this leads to direct interference with the sound, ongoing, non-conflicted functioning of the doctor patient relationship, which is the essence of health care.

Yet, Obamacare seems to have given this business the keys to the kingdom. The Obamacare rhetoric of new insurance regulations and rules, although they might sound good for the American people, are simply assimilated into the health insurance corporate algorithm, which then spits out new formulas for dollar garnering to maintain its profit. Thus, the rhetoric of Obamacare rather than enhancing one’s medical care actually inhibits this individual endeavor for many people.

The third paragraph of the Chicago Tribune article begins with, “I believe everybody should be able to have health insurance…” But the rest of the article goes on to explain why this hope is just not feasible in our current system. It’s not feasible because what it really says is, I believe everybody should be able to have a business relationship with companies that withdraw every last dollar from their wallets and, in return, give as little as possible of the product back to them. Health insurance companies operate this way to enhance their dollar profit, and Obamacare has made the situation much worse.

Shouldn’t the sentence be, I believe everybody should have clear and equal access to health care, i.e., to sound, ongoing, non-conflicted doctorpatient relationships, and that our politicians should have the common sense decency to set up an administrative payment mechanism for the work accomplished within these relationships that doesn’t bankrupt individuals and their families. I believe the American center would agree with this.

Until the ethos of our health care system changes such that clear and equal access to sound, ongoing, non-conflicted doctor patient relationships becomes the primary goal to be achieved for everyone living in America, i.e., until the medicine of medicine outweighs the importance of the business of medicine in the minds of our compromised politicians, healthcare business leaders, doctors, and the general American public, true health care reform for the benefit of everyone living in America will not occur.

Ask yourself these questions: When the Affordable Care Act was voted on by our Congress and made a law, which created all these insurance exchanges and health insurance mandates, etc., why didn’t the majority controlling democrats just create a central payer mechanism instead? Do you really think the effective meaning of socialized medicine (interference with sound, ongoing, non-conflicted functioning of doctorpatient relationships) and its occurrence comes only from public 3rd party payers and not from the private health insurance 3rd party payers as well?

An astute observer, who reviewed this essay before I posted it, said that I was missing the point: The Affordable Care Act is just the first step in the complete takeover of our health care system by the government. The people in America will become so completely disgusted with the health insurance industry that they will en masse beg for a government takeover of the entire health care system. This deeper layer of thinking about the Affordable Care Act may be supported by the existence of H. R. 5808 http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.5808.IH: which was introduced in July 2010 just after the Affordable Care Act was passed in March 2010.

“Complete government takeover” is indeed a scary term. In the past and now, I have advocated a central payer system, which is constructed such that the medicine of medicine, the clear and equal access to sound, ongoing, non-conflicted doctor patient relationships for everyone, becomes the primary goal and the business of medicine, dollar profit, becomes a secondary goal. I say a central payer can be structured such that it satisfies both goals and still lowers the amount of money spent on health care. Health insurance companies would eventually fade away and employers would no longer be in the discussion as providers of health benefits.

Many, I expect, believe that this could/would be catastrophic because too much power would exist in a central authority, and, given what human nature is, this would lead to total control over a very important aspect of our lives and completely defeat what I am trying to accomplish. Britain and Canada are examples of the pitfalls of central payers. In addition, the current implementation of Obamacare, which has turned out to be nothing short of a debacle, must give us further pause regarding deliberation over the concept of a central payer.

Can we not do better in America? Are there not real people, who possess enough knowledge and experience and who would work in government with moral integrity and sensible philosophical underpinning, to create a system of payment which frees the doctor patient relationship from the influence of the payer and concomitantly satisfies the need of ongoing, sensible profit for necessary health care businesses? I say there are and that we need to find these people and place them in a structure, which allows them to create the best system of health care payment in the world and which shelters them from politicians and business people in a similar manner as the Supreme Court is sheltered. This is the basis of the central payer system, which I support.

Some, perhaps many, would say that what I am espousing is socialized medicine. This is only partially true: I am indeed saying that we need to bring the business of medicine under control with proper, profitable assignment of payment to necessary healthcare businesses from a central payer. However, I am unsocializing the medicine of medicine, the doctor patient relationship, by removing influence from that payer upon its functioning. Regarding the strict economic definition of socialized medicine http://economix.blogs.nytimes.com/2009/05/08/what-is-socialized-medicine-a-taxonomy-of-health-care-systems/?_r=0 it is not true at all because I am not changing the ownership of any health care businesses.

I must be more explicit in how I see this central payer functioning, and I will do this in future posts. I will introduce these future essays by noting that a major expenditure in our health care system is for hospitals and addressing the dollars we pay to these 6500+ independent business fiefdoms is of vital importance.

R. Garth Kirkwood, MD


American Health Care: Common Sense

  1. that everyone living in America be able to go to the doctor at his/her discretion without the daunting fear of not being able to afford it;
  2. that everyone living in America pay for health care, whether they have a job or not. Employers not to be responsible for this personal responsibility. Labor unions have no say over individuals’ health care;
  3. that health care be free at the point of service;
  4. that decision making regarding an individual’s health care belongs solely to the non-conflicted, spontaneous, ongoing, and sound functioning of the doctor   patient relationship;
  5. that the payer of the bill, i.e., the entity which administers payment of the bill, has that one function and no other;
  6. that the payer of the bill be a central entity set up by Congress but which remains autonomous from the Congress and from all lobbyists, i.e., in a fashion similar to our Supreme Court. Note, if we cannot find honest, trustworthy people with the same degree of integrity and the same degree of knowledge regarding the different aspects of our health care system as the justices of our Supreme Court possess regarding the law, then our country is doomed;
  7.  that medical coding for administration of payment to doctors be greatly simplified:
  • a) office visits,
  • b) hospital visits,
  • c) consultations,
  • d) invasive procedures;
     8. that billing and payment be greatly simplified:
  • a) doctors dictate a note regarding the service provided (office visit, hospital visit, hospital consultation, hospital discharge summary, procedures both inpatient and outpatient),
  • b) the note is submitted electronically by the doctor to the payer; the note has two functions: 1. to act as a bill, i.e., once the note is received, automatic payment is generated to that doctor and/or hospital and not before 2. to be an ongoing part of the patient’s medical record,
  • c) the central payer’s function is to administer payment to doctors and hospitals, not to determine the quality of or the necessity of any visit or procedure. Quality review is done locally;

9. that the following entities, concepts, and thinking be removed from our healthcare system because of the disastrous, greed-driven business manipulation, which they have brought with them:

  • a) health insurance companies,
  • b) generic medicines,
  • c) the words, indigent, poor, unable to afford it,
  • d) Medicare, Medicaid, public versus private programs, not-for-profit, and for-profit,
  • e) primary care,
  • f) medical homes and accountable care organizations,
  • g) hospitals and medical centers paying doctors’ salaries,
  • h) the current system of malpractice lawsuits,
  • i) physician entrepreneurship,
  • j) outrageous hospital administrator salaries and hospitals using health care to  become independent business fiefdoms;

10.that patients and/or families be responsible for end of life care decisions via advance care directives within the context of the doctor  patient relationship for that patient;

11. that doctors and patients have one goal in our health care system: fulfillment of their responsibilities for creation of sound, ongoing, non-conflicted doctor  patient relationships;

12. that ridiculous rhetoric such as, a central payer automatically means socialized medicine with all its attendant problems, be recognized for what it is. Our health care is already socialized (meaning controlled, obstructed doctor patient relationships) by both private and public payers. Setting up a central payer with honest, knowledgeable people, who understand the needs of health care businesses including doctors’ practices while maintaining complete independence of the doctorpatient relationship from those businesses, is what we need in America. Moreover, the concept that states should be involved in this is just foolishness: Another 50 sets of slime ball politicians dipping their hands into the healthcare gravy train.

13. If we do not have the wherewithal in America to set up a properly run central payer, while keeping medical practice free of influence from that payer, then we are in serious trouble. Obamacare is just another in the long list of garbage political–business schemes, which will further us along the way to a completely socialized country, in which, because of redistribution of wealth, those who pay taxes and who buy insurance will pay for the health care of everyone and in which the health care will be delivered from some protocol written under the influence of business people and politicians.

R. Garth Kirkwood MD

Electronic Medical Records (EMR)

Please read the following report from Michelle Malkin. http://michellemalkin.com/2013/05/22/the-obama-crony-in-charge-of-your-medical-records/

Thank You Michelle Malkin for continuing your wonderful work.

I have recommended in the past a centralized medical record keeping system to house and share everyone’s medical record. There are just no reasons other than dishonesty, corruption, greed, and ultimate control over the American people that this type of system cannot be set up properly for everyone’s benefit.

I see two benefits to creating this type of system:
1. If it functions properly, then any and every time a person goes to the doctor or to the hospital, the doctor can immediately pull up the up to date info on the patient: a) What have other doctors thought about your case? b) What lab tests or diagnostic studies have already been done to investigate your current problems? c) Is it time to repeat some of these studies or does the current information suffice? This type of info is vital.

2. This type of communication could serve as a billing and payment mechanism for doctors’ practices and for hospitals. The doctor submits a thorough report of that office visit, the hospital submits a thorough discharge summary, the surgeons or other doctors, who do procedures, submit thorough operative reports to this EMR system. These reports have two functions: a) to bring the patient’s medical record up to date; b) to function as a bill for the service provided. Until this report is submitted, no payment is generated. However, once the report is submitted, payment is immediately sent electronically to the appropriate bank account. Officials directing the operation of the EMR system would review reports from all sources on a frequent and spontaneous schedule for one reason: to determine that the report is complete, i.e., passes scrutiny for an operative definition of thoroughness or completeness. These people would likely have to be those with some medical training. However, the purpose of this type of review is not a judgment about whether the doctor was right or wrong, or whether a surgery was successful without complications, but rather an objective determination that the work, for which the bill was submitted, actually happened. THE PAYER CAN HAVE NO SAY OVER WORK QUALITY!!! THE PAYER ADMINISTERS PAYMENT OF THE BILL, THAT’S ALL THE PAYER DOES!!!. The payer is a CLERK working for the American people and administering payment, with the people’s money sent to them by the people, for the people’s health care bills.

From this, I suggest the following: If properly set up, i.e., absent all the garbage of the ObamaCare EMR system, which Michelle Malkin so clearly describes in her essay, the absolute beauty of a central payer for everyone and the huge costs savings to be achieved from that are obvious.

Once again, we come to a point of critical thinking: Our form of government is good; it’s the people working within our government that ruin it for all Americans. What are their motives? GREED and POWER come to mind. Until these are removed from the mindset of the people working within our government, i.e., until the people who have these motives as their reason for functioning as opposed to being true civil servants are unelected or discharged, I don’t see a solution for our problems.

And to the people who might read this essay and scoff I say: I am not naive, and your complacency with the staus quo, whether out of ignorance or laziness, is UNACCEPTABLE!!! My commentary doesn’t just apply to the current administration but to many past administrations. But regarding the current administration and ObamaCare, just why is it that with all those votes in the Senate, they didn’t create a central payer which could function in the above described manner for us?

Our government, which is paid for by the people, must function for the people and not for the interests of the politicians, federal operatives, and the entities which lobby (buy) them.

R. Garth Kirkwood, MD

The American Abscess

Image over substance,
Tech games over serious thought,
Clueless over informed,
Sunglassed shrugs the mainstream.
Obama’s minions control this culture,
This baby boomer-hippy spawn,
Government pawns.

Liberals are a puzzle,
Maybe they like burkas and hijabs.
So myopic they seem about sequelae
Of misdirected jabs.
But at least they stand for something,
And like conservatives have a point of view,
Unlike the significant swathe
Who exist without a clue.

Our government is an abscess,
Which has festered for many years.
Obama & Co., like others, have found this pool
Ideal for swimming and diving
Amid a raft of cheers.
Incision and drainage is required!
Are there any civil servants unwired
With knowledge and courage enough
To slice open this necrotic mire
And completely drain the pus?

Can surgery slice deep enough?
At bottom is the core,
Absent engagement from the gimme generation,
Which splashes clueless,
Bathing in the smoke and mirrors of politicians,
Who’ve promised them everything before.

Incentives to Seek the Most Economical Means of Treatment

In the Forward, written by American economist Kenneth J. Arrow, of the text, Health Economics And Financing 3rd Edition (2007, ISBN: 9780471772590), by Professor Thomas Getzen, there is the following statement: “But insurance reduces the incentive of an individual patient or physician to seek the most economical means of treatment. As a result, new institutions and regulations develop to overcome this “moral hazard,” as it has been termed— institutions such as health maintenance organizations (HMOs), managed care by insurance companies, and regulations such as those that govern Medicare expenditures.”

I challenge the validity of the above statement: My view is that insurance doesn’t reduce this incentive because the incentive wasn’t there to begin with and that it’s right and good that this incentive is NOT part of the clinical decision making, which occurs within the context of a sound, ongoing, non-conflicted doctor  patient relationship. Thus, these new institutions developed to deal with a moral hazard of their own creation thereby establishing themselves as another type of insurance carrier within the business of medicine and reaping huge revenues and profits based on the underlying rhetoric that we must have this incentive to deal with a moral hazard emanating from the doctor patient relationship.

Can doctors create a dollar conflict within the doctor  patient relationships which they are part of? Absolutely YES! My view is that this should NOT OCCUR. To prevent it from occurring or to deal with it when it does, there are several approaches including the most important one: An absolute demand that all of our doctors come to the fore with an attitude that the dollar bill is NOT their primary motivation in seeing patients and that their patients can develop a TRUST in them regarding this.

Self-serving 3rd party payer manipulations pressing upon the clinical decision making of the doctor  patient relationship need to be exposed and seen for the garbage that they are! Indeed, 3rd party payers are a moral hazard!


R. Garth Kirkwood, MD  (doctork@equalhealthcare.org)

The New England Journal of Medicine and Its Editors: What Is Their Agenda?

Recently, the New England Journal of Medicine (NEJM) published the following article: Cents and Sensitivity–Teaching Physicians to Think about Costs.  http://www.nejm.org/doi/full/10.1056/NEJMp1205634 Please take a few minutes to read this article. You may not understand the medical lingo, but the message is clear enough.

I wrote the following letter to the editor regarding this article, which the editor politely declined:

Cents and Sensitivity—Teaching Physicians to Think about Costs by Drs. Rosenbaum and Lamas is Socialized Medicine[1]. Bringing dollars to mind while working up a patient conflicts the work-up. A doctor trying to save money is just as conflicted as a doctor doing procedures solely because he/she profits from them.

Costs are out of control largely because of greed:

  1. Multi-billion dollar insurance companies, whose sole function is clerical administration of payment of the bill,
  2. Thousands of not-for-profit hospitals, which garner hundreds of millions of dollars in revenue; pay administrators salaries of $500,000 to $1,000,000/year or more; and do not understand their own billing[2], have become independent business fiefdoms,
  3. Drug & Technology Companies,
  4. Lobbying politicians at state and federal levels,
  5. Malpractice lawsuits.

Capitalism and profit making are the essence of American culture. When capitalism becomes unbridled allowing open-ended greed to endanger the doctor—patient relationship, it’s time to bring the business of medicine under control, while concomitantly ensuring its negotiated profitability, not to scapegoat  the doctor—patient relationship.

R. Garth Kirkwood, MD






[1] R. Garth Kirkwood, Socialized Health Care Reform, 2010 http://equalhealthcare.org/books/

[2] Uwe E. Reinhardt, “The Pricing of U.S. Hospital Services: Chaos Behind a Veil of Secrecy,” Health Affairs, 25, no.1 (2006): 57-69  http://content.healthaffairs.org/content/25/1/57.full.html

The editor’s response to my letter:

 Dear Dr. Kirkwood,

I am sorry that we will not be able to print your recent letter to the editor regarding the Rosenbaum article of 12-Jul-2012.  The space available for correspondence is very limited, and we must use our judgment to present a representative selection of the material received.  Many worthwhile communications must be declined for lack of space.

Thank you for your interest in the Journal. 

I question, Why did they not publish my letter? It is correct information. Surely what they suggest is socialized medicine, not the economic definition of that term but rather the end result of that type of healthcare system: The payer, public or private, interfering with non-conflicted clinical decision making within individual doctor  patient relationships. They would make the doctor a vicarious administrator for 3rd party payers, which results in the following message to the patient: That test or therapy is just too expensive to use for your individual case. The clinical thinking of the doctor becomes conflicted with the dollar bill. This is exactly what formally socialized systems do either directly or indirectly. But here, the doctor becomes a substitute for the payer, which accomplishes that agenda.

The second part of my letter is also correct. For true healthcare reform, it is necessary to challenge all the mechanisms of greed embedded in the business of medicine and to recognize that scapegoating the doctor  patient relationship is not the answer.

So, why didn’t they publish my letter?

In the following paragraphs, I am going to dissect this article a little more to show how these authors use rhetoric, which I think is misleading, to accomplish this new way of operating for the doctor  patient relationship. I will italicize statements from the article and then respond to them in regular text. You should pay close attention to make sure that I have correctly transcribed the authors’ statements and that I have not taken them out of context.

First: Good care, we believe, cannot be codified in dollar signs. But with health care costs threatening to bankrupt our country, the financial implications of medical decision making have become part of the national conversation. This is true. But who is making this part of the national conversation? The answer is the 3rd party payers and their co-opted politicians  from both political parties, under the guise of the noble rhetoric, reducing healthcare spending. These authors suggest that now individual doctor  patient relationships should be co-opted by this business thinking. It is wrong, a thousand times over. When you start this modus operandi, the accumulation of medical information and knowledge for that individual patient becomes obstructed by the dollar bill.

Second: The fact that we can no longer ignore the financial implications of our decisions leaves the medical profession in a quandary. The operative word in this sentence is our. These decisions are not ours in the context that the authors employ this word. They belong to individual doctors and individual patients in the context of that unique, individual relationship. If you really want $$$$ to be part of that decision making, then delete the entire 3rd party payer system and tell individual patients that they will have to be first party payers. That’s the only way that financial considerations can be introduced into the doctor  patient relationship without conflicting the doctors’ clinical decision making. The patients would decide whether the expense is worth it. Why do we need 3rd party payers? This would greatly reduce annual healthcare spending because many patients would have to take out loans to pay the bill or forego the clinical evaluation. Nevertheless, annual healthcare spending would be greatly reduced. Such a noble end!

Third: Can a physician remain a patient advocate while serving as a “steward” of society’s resources? The operative word in this sentence is society’s. The word, society, is a circumlocution, which makes vague the fact that the resources, i.e., dollars, in our healthcare system come from the individuals living in America in the form of health insurance premiums, taxes, and out-of-pocket- spending. The first two of these sources go to 3rd party payers, who are supposed to administer payment of the bill. That’s why individuals send money to the two types of 3rd party payers. What we cannot allow is rhetoric from bioethicists, these authors, and others to regulate our health care by using poisoned language to do so. (See, Hayek, F.A. The Fatal Conceit The Errors of Socialism-Chapter 7 for discussion of our poisoned language). Using the words, society’s resources, gives cover to the underlying agendas of these 3rd party payers, which are not in the interests of the individuals who pay for their existence.

Fourth: There are several other examples of misleading rhetoric, which have been insinuated into our healthcare lexicon and which these authors utilize, such as, evidence-based medicine, cost-effectiveness, value-based purchasing etc. I have discussed these elsewhere in this blog. But the final sentence of this article deserves comment: Protecting our patients from financial ruin is fundamental to doing no harm. If the authors really believe this, then the place to focus their efforts is the greed-driven manipulations of the business of medicine, which I outlined for them in my letter to the editor. The doctor  patient relationship is sacrosanct. And this tradition must be maintained without compromise, not because it is a tradition but rather because it is the origin and ongoing source of accumulation of medical knowledge for individual patients and thus for our healthcare system.

R. Garth Kirkwood, MD


High Value, Cost-Conscious: Weasel Words of 3rd Party Payers and Their Sycophants

Weasel words are words or statements that are intentionally ambiguous or misleading (The New Oxford Dictionary of English, Oxford University Press 1998) and which can deprive of content any term to which they are prefixed while seemingly leaving them untouched (Hayek, F.A. The Fatal Conceit The Errors of Socialism).

Currently it seems the vogue to say, “High Value, Cost Conscious Care” (Do a Google search of this expression, and you will find a plethora of articles). My view is, when this adjective, high value, cost conscious, modifies the noun, care, it extinguishes thought about the noun’s meaning in the context in which it is being used and focuses attention on the dollar bill, $$$. I believe that is the intent of the people who use this expression.

Some of you may say, “Well, that’s not bad, we have to be focused on dollar expenditure in our healthcare system.” However, the people who foster this thinking want it to be part of the doctor’s thinking when he/she is seeing patients (http://www.nejm.org/doi/full/10.1056/NEJMp1205634 and many of the results from your Google search mentioned above).

Let’s look at the functioning of the doctor  patient relationship:

In the doctor  patient relationship there is an intersection or interchange which occurs and involves an exchange of information via the history, physical examination, laboratory tests, xrays, etc. This is how medicine is practiced and it is where clinical decision making regarding diagnosis, treatment, and follow up occurs. The dollar bill, $$$, is not part of this exchange of information. It cannot be because then the information exchange and clinical thinking & decision making resulting from it is muddied. When this happens, medical care will be suboptimal at best or destructive and/or non-existent at worst. No good outcome can occur from bringing the dollar bill and dollar thinking into this exchange of information. The dollar bill is a non-clinical agenda, whether the dollar thinking is intended to benefit the doctor’s income or that of the 3rd party payer under the guise of the noble sounding rhetoric, reduction in healthcare spending and cost control.

If the American public (not their 3rd party payers and their sycophant politicians and think tanks) insists on dollar thinking as part of their doctor  patient relationship, then they have to bring that dollar thinking themselves and not expect that their doctor should or can do it. Admittedly, they will be conflicting their own medical care, but that is their choice. And, of course, with this we enter Gingrich land, the home of his now bankrupt, Center for Health Transformation (http://www.bizjournals.com/atlanta/news/2012/04/05/newt-gingrich-think-tank-files.html?page=allhttp://www.kaiserhealthnews.org/Daily-Reports/2012/April/06/Gingrich-consulting-firm.aspx). You must have heard of this dollar-green quagmire, where the advocates of consumer-focused health care ply their rhetoric. It’s all the same poison: high value care, cost conscious care, cost-effective care, consumer focused care, etc., etc: Bring dollars or lack thereof into play within the doctor  patient relationship so that clinical thinking is disrupted. Why? Because that’s the proximate cause of dollar spending in our healthcare system. If you control that, you control a gold mine, a greater than 2 trillion dollar annual gold mine.

The question arises, Why should patients or the American public in general bring dollar thinking into their interchanges with their doctors, when they are already sending mega dollars, $$$$$, to 3rd party payers via private health insurance policies (individual or employer based; note the latter is not a gift from the employer but a defined part of the employees’ salary) and via taxes to the public payers, such as Medicare & Medicaid. Why should they do this? They can’t gain anything from it. All they can do is conflict their own medical care.

So, if the powers that be (unfortunately, this is not the American public, except for the bogus notion that the voting system gives individuals some sort of say) and their sycophants really desire Cents and Sensitivity (http://www.nejm.org/doi/full/10.1056/NEJMp1205634) as a modus operandi, then simply delete all 3rd party payers from our system and allow the American public to become lone first party payers (Lone, as opposed to this greed-driven mixture of cash-out-of-pocket spending via deductibles, co-pays, account management fees for high deductible insurance policies, pharmacy, and uncovered services all of which benefit the payer and its sycophants and disadvantage individual Americans). With the American public acting as lone first party payers, we would surely have what the purveyors of these weasel words want: Medical care conflicted by the dollar bill yet somehow also carrying the label, high value, cost-conscious care.

R. Garth Kirkwood,MD