The Leading Business Education Network for Doctors, Financial Advisors and Health Industry Consultants

By Dr. David Edward Marcinko MBA

[Editor-in-Chief]

We have a healthcare crisis . . . and the crisis is now. Costs are soaring out of control, threatening the physical and financial health of individuals and our nation. Quality of care is deteriorating, in spite of “world class care” signs seemingly on every corner. And physicians are checking out and burning out. I believe it’s one of the greatest societal issues of our day – Kent Mercado

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ME-P readers, you may be wondering: How in the heck did we get ourselves into such a healthcare mess? The USA is the greatest country in the world. We spend the most money on healthcare and regularly boast about how great it is. Yet, our average citizen longevity span is only 49th in the world in 2023? Only 77 years old for males.

What happened?  Middle-income countries made enough gains in life expectancy to catch up and then surpass the U.S. during times when the country’s acceleration slowed. By 2019, the U.S. ranked 40th among populous countries – lower than the countries of Lebanon and Albania.

Fortunately, I recently had the opportunity to sit down and speak with DR Kent Mercado JD, a friend and colleague from Illinois’s 11th District for several decades. His thoughts on healthcare policy in the USA, from the medical trenches to courtroom proceedings, is both insightful, pragmatic and politically centrist. It is the first of what I hope are several more interviews on other political hot topics in the future.

So, here is my brief interview synopsis and summation

PS: Feel free to subscribe to this ME-P for periodic updates on Dr. Kent Mercado JD as the election cycle progresses. It’s fast, free and secure! – DEM

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DR Kent Mercado JD on Public Healthcare Policy in the U.S.A.

JUNE 2023: FIRST ME-P PUBLIC INTERVIEW

A both a doctor and attorney, DR. KENT MERCADO JD believes that every American deserves access to quality and affordable healthcare. But, he knows that our nation’s current system is in need of repair. 

Considering the fact that the PP-ACA now has tendrils into all business sectors and communities, it cannot be repealed, so it must be repaired. For sure, there are positive aspects of the ACA, such as eliminating pre-existing medical conditions and allowing children to remain on their family’s health insurance plan until the age of 26. But, there are many problems inherent in the ACA as well.

For example, having a medical insurance card does not ensure access to quality healthcare, since so few medical and healthcare providers accept this form of skinny [narrow] network insurance. Promoting insurance policies that work, and revising the ones that do not, is the first step to achieving better access to healthcare for all. And DR KENT understands these skinny insurance networks, well. He explained:

DEFINITION: Narrow [skinny] health insurance network plans are similar to health maintenance organizations (HMOs). Like standard HMOs, these plans limit coverage to a select group of physicians, specialists and hospitals. However, narrow network plans can be even more restrictive than HMOs in the number of providers they include. Their providers also typically agree to lower reimbursements from insurers, which can mean financial difficulty for private practitioners staying in business. You’re more likely to see narrow networks — which include narrow pharmacy and restrictive drug formulary networks — if you shop for your own health insurance on HealthCare.gov or your state’s insurance exchange. Obviously, they’re less common in the plan options provided by private employers.  

CONS: As a medical practitioner DR KENT again emphasized that the biggest disadvantage to narrow and skinny network plans is less choice. Insurers keep these plans more affordable by negotiating lower reimbursements with health care providers. In return, those providers could see patient rosters grow, because smaller networks also mean less competition for those within the network. Smaller networks also can mean:

• A need to change physicians. Your current primary care physician and specialists might not be included in the plan. This can mean starting over with new doctors who aren’t familiar with your particular health concerns.
• Longer drives. With fewer choices, you may be forced into a longer commute to see an in-network physician. This could become a hardship for those in rural locations.
• Lack of specialty options. A smaller network might not include the broad range of specialists large networks typically include.

And, mandating universal healthcare for the USA is also not the answer either, according to Kent Mercado. Obviously, socialized medicine is not free, just prepaid (the average tax bracket is over 40% in many Illinois counties that sponsor socialized medicine). And any “Medicare for All” or single-payer program gets an “A” for passion, but an “F” in compassion. In fact, as a attorney, DR KENT knows the 2019 non-partisan Congressional Budget Office cautioned that any “Medicare for All” bill would create “a shortage of providers, longer wait times, and changes in the quality of care.” 

Now, as the Editor-in-Chief of this ME-P, a doctor and professor of health economics myself, I know that wait time Queuing is a commonly-used way to solve the rationing problem caused by “Medicare for All” designs. A queue is a long waiting line that solves the rationing problem on a “first-come, first-served” basis through longer and longer medical, X-ray and laboratory test waiting and physician appointment times. Although such price ceilings do limit the monetary cost that patient-buyers must pay so that equilibrium cannot be restored by higher prices; they Do Not limit the non-monetary cost of such queuing and very long waiting. Thus, M-4-A and related analogs are not the health insurance problem fix that advocates might suggest ……

Moving On ……

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information [PHI] from being disclosed without the patient’s consent or knowledge [covered entity]. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA. The HIPAA Security Rule protects a subset of information covered by the Privacy Rule. Attorney DR. KENT believes that patients and covered entities should rely less on professional ethics and best judgment when considering requests for permissive uses and accidental disclosures.

For example, in May 2023, the records of nearly 9 million dental patients were released online following a LockBit ransomware attack on Managed Care of North America Inc. The company, also known as MCNA Dental, is a leading provider of dental plans in the U.S., serving private employers, individuals and families through a range of Medicare, long-term and commercial plans. MCNA is also the largest dental insurer for government-sponsored Medicaid and Children’s Health Insurance Program [CHIPs] programs. The breach was first disclosed on May 26th with the Office of the Maine Attorney General. The breach occurred between February 26th and March 7th, with the breach discovered on May 3rd. The breach notice ticks the typical case in that MCNA hired a third-party out-sourced forensics team [ZeroFox Inc.-owned IDX]. It discovered that “a criminal was able to see and take copies of some information in rheir computer system.” The HHS Office for Civil Rights enforces HIPAA rules, and DR KENT, believes all complaints should be reported to that office. HIPAA violations may result in civil monetary or criminal penalties.

DR KENT also suggested that beyond the Health Insurance Portability and Accountability Act [HIPAA], Stark Laws and other related privacy rules for health care be re-evaluated as there has never been a bigger breach of confidential patient medical records since inter-operative electronic medical records [eMRs] and electronic health records [eHRs] became mandated. Old fashioned non-interoperable paper medical records were transferable by the patient-owner, and virtually never breached or accidentally disclosed. The recent COVID-19 pandemic illustrated this point thru a plethora of medical tele-conference breaches, too.

Of course, as we leave the month of May, also known as National Mental Health Month, DR KENT reminded me about some rules and regulations from federal, state, and county governments that have an impact the day-to-day operations, procedures and processes of a county mental health centers. Traditionally, there are three main types of regulations.

1. Federal Regulations — The United States healthcare system is guided by programs such as those established under the Centers for Medicare and Medicaid (in the case of county mental health programs, Medicaid is especially important), Americans with Disabilities Act (ADA), Occupational Safety and Health Administration (OSHA), Health Insurance Portability and Accountability Act (HIPAA), and others.
2. State Regulations — These include general legislative guidelines, state management of benefits and reimbursement of the Medicaid program, and state allocations of budgets, which impact the centers’ operations.
3. County Regulations — Each county defines its own County Mental Health Program and decides which services will be provided or excluded.

County facilities generally include outpatient clinics, county mental health programs, short-term psychiatric facilities, day-care centers, de-toxification centers, residential rehabilitation centers for substance abuse, long-term care psychiatric facilities, and Veterans Affairs (VA) psychiatric centers. The county centers may be co-located with other county services such as social services, occupational rehabilitation services, information technology services, human resources, maintenance services, and others or may be independently located. These must all be stabilized, enhance and promoted as Democratic Senator Chris Murphy and Republican Senator Bill Cassidy first teamed up six years ago to help update VA Hospital and related mental health legislation.

More specifically, rates of depression, mental health needs and anxiety among Asian Americans increased during the Covid-19 pandemic—a time that coincided with rising anti-Asian hate crimes. Stigma surrounding mental health is the “number one deterrent” keeping more Asian Americans from seeking care. Many Asian Americans just feel that they have to be self-sufficient and are not used to asking for help, DR KENT noted. This must change.

Now, as we begin the month of June, DR KENT reminded met that it is Alzheimer’s Disease and Brain Awareness Month. There are more than 5.5 million people in the world who are over 65 and have Alzheimer’s disease. Every 3 seconds someone else in the world develops some form of dementia. There are now more than 50 million people worldwide living with dementia. This number is expected to double every 20 years. Diet, exercise and social interactions are helpful; nursing homes are not.

Switching topics, and unfortunately in the wake of massive data breaches across the U.S. and the Department of Veterans Affairs, DR KENT reminded me that the VA has been largely silent on the measures it’s taking to protect veterans’ sensitive health information and eMRs, etc.

And, by way of contemporary breaking news, America’s youth are currently experiencing a mental health Social Media crisis. For example:

• The number of teens and young adults with clinical depression doubled between 2011 and 2021, according to a San Diego State University study.
• In 2021, the CDC found that nearly 25% of teenage girls made a suicide plan.

Far too many experts have pointed to some social media outlets as a potential cause since the deterioration of kids’ mental Health.

Unfortunately, another huge health care policy political issues is illicit drug abuse. Currently, Fentanyl abuse statistics indicate it is the world’s deadliest opioid, causing almost half of all overdose deaths nationwide. And, statistics indicate the overdose epidemic among opioid users is spreading geographically as well as across demographics in the USA. In fact, 52.7% of all overdose deaths (OD) involve fentanyl in 2022. This was up from March 2018 to February 2019, when 47% of drug overdoses involved fentanyl. This must end.

Even more, DR KENT believes the medical malpractice situation in the USA must also be addressed. For example, many countries that have the pre-paid universal health insurance that many American advocates love, do not realize the legal malpractice restrictions make is almost impossible to successfully sue physicians. Just look to the difficulty of suing a Veteran’s Administration physician! It all depends on whether the doctor is an employee or independent contractor for the VA. Some doctors who practice in the VA system are independent contractors. If the doctor is an independent contractor, you may be able to pursue him/her individually. But, if the doctor is an employee of the VA, then you must sue the VA or rather, the United States of America.

So, DR KENT rhetorically asked: Would it be this way in a national healthcare system for the USA? Voters must decide!

On top of all that, DR. KENT reminded me that June is Alzheimer’s Disease and Brain Awareness Month. More than 6 million people in the US received an Alzheimer’s diagnosis, a number that’s expected to rise to 13 million by 2050. And the disease is not cheap—it’s expected to cost the US $345 billion this year and $1 trillion by 2050.

Finally, as a doctor and private practitioner for more than two decades, DR KENT believes that any sort of physician payment reform, public option, single payer policy and/or Medicare reform must include slowing or reduced fee increases for medical specialists – and increased compensation for those doctors on the grass root front lines of public healthcare [primary care, obstetrics, gynecology, family medicine and general practitioners] for us all. For example,

◼ Family medicine, obstetrics and gynecology, ophthalmology and psychiatry had the lowest commercial health insurance markups relative to Medicare prices, averaging about 110 percent of Medicare rates or less.
◼ Nine specialties received commercial payments between 120 and 150 percent of Medicare rates, on average. These included gastroenterology, cardiology, general surgery, and orthopedics.
◼ Radiology and neurosurgery received commercial payment rates of 180 and 220 percent of Medicare rates, whereas emergency department and critical care specialties received commercial payment rates of 250 percent of Medicare rates. Anesthesia received the highest markup at 330 percent of Medicare rates.

In brief, primary care doctors and public health providers should receive additional compensation, while medical specialists a bit less.

Now, macro-economically, healthcare spending in the United States totaled 18.3 percent of gross domestic product (GDP) in 2021, according to the Centers for Medicare and Medicaid Services (CMS) most recent data update. That’s down from 19.7 percent of GDP in 2020, primarily due to an increase in economic growth as well as a decline in Federal COVID funds, However, healthcare costs in the United States remain above their pre-pandemic levels, and they remain a primary driver of our unsustainable national debt.

In his own words, DR KENT concluded our interview and opined: “Medicare Payment Reform must better align physician incentives for better patient care”.

NOTE: DR. KENT MERCADO JD is committed to ensuring digital accessibility for people with disabilities. He is continually improving the user experience for everyone, and applying the relevant accessibility standards.

THANK YOU DR. MERCADO AND BEST OF LUCK TO YOU.

The End

EDITORS NOTE:

Throughout my entire interview I felt assured that DR KENT’S main interest and passion was in pragmatic health policy and centrist legislation, particularly for the under-served (rural and urban) and historically disadvantaged communities. He certainly has much to offer through his thought leadership, regulatory, medical, legal and business acumen.

Fee free to comment on this Medical Executive-Post interview and/or to submit a question or concern to DR KENT. His job is to work for you!

Therefore, I am confident that DR KENT MERCADO JD can leverage his decades of medical and legal expertise to effectively promote major legislative health insurance initiatives that will benefit all his local constituents, most all US states, and perhaps even the entire country writ large?

FINIS

DR. KENT MERCADO JD

http://www.ElectDrKent.com

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