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    Dr. Marcinko is originally from Loyola University MD, Temple University in Philadelphia and the Milton S. Hershey Medical Center in PA; as well as Oglethorpe University and Emory University in Georgia, the Atlanta Hospital & Medical Center; Kellogg-Keller Graduate School of Business and Management in Chicago, and the Aachen City University Hospital, Koln-Germany. He became one of the most innovative global thought leaders in medical business entrepreneurship today by leveraging and adding value with strategies to grow revenues and EBITDA while reducing non-essential expenditures and improving dated operational in-efficiencies.

    Professor David Marcinko was a board certified surgical fellow, hospital medical staff President, public and population health advocate, and Chief Executive & Education Officer with more than 425 published papers; 5,150 op-ed pieces and over 135+ domestic / international presentations to his credit; including the top ten [10] biggest drug, DME and pharmaceutical companies and financial services firms in the nation. He is also a best-selling Amazon author with 30 published academic text books in four languages [National Institute of Health, Library of Congress and Library of Medicine].

    Dr. David E. Marcinko is past Editor-in-Chief of the prestigious “Journal of Health Care Finance”, and a former Certified Financial Planner® who was named “Health Economist of the Year” in 2010. He is a Federal and State court approved expert witness featured in hundreds of peer reviewed medical, business, economics trade journals and publications [AMA, ADA, APMA, AAOS, Physicians Practice, Investment Advisor, Physician’s Money Digest and MD News] etc.

    Later, Dr. Marcinko was a vital and recruited BOD  member of several innovative companies like Physicians Nexus, First Global Financial Advisors and the Physician Services Group Inc; as well as mentor and coach for Deloitte-Touche and other start-up firms in Silicon Valley, CA.

    As a state licensed life, P&C and health insurance agent; and dual SEC registered investment advisor and representative, Marcinko was Founding Dean of the fiduciary and niche focused CERTIFIED MEDICAL PLANNER® chartered professional designation education program; as well as Chief Editor of the three print format HEALTH DICTIONARY SERIES® and online Wiki Project.

    Dr. David E. Marcinko’s professional memberships included: ASHE, AHIMA, ACHE, ACME, ACPE, MGMA, FMMA, FPA and HIMSS. He was a MSFT Beta tester, Google Scholar, “H” Index favorite and one of LinkedIn’s “Top Cited Voices”.

    Marcinko is “ex-officio” and R&D Scholar-on-Sabbatical for iMBA, Inc. who was recently appointed to the MedBlob® [military encrypted medical data warehouse and health information exchange] Advisory Board.

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Podcasts are Coming to the ME-P in 2011

Audio Casts, Too!

By Prof. Hope R. Hetico RN MHA CMP

[Managing Editor]

The Medical Executive-Post will soon be producing podcasts and audio-casts featuring interviews with interesting financial advisors, physicians, health economists, CXOs and management consultants leading successful and often innovative  financial planning and medical practices, clinics and hospitals, etc.

Call for the Spotlight

If you would like to be interviewed or want to recommend a physician, FA, consultant, administrator, CXO or practice to be spotlighted, please send your suggestions to us: MarcinkoAdvisors@msn.com

Testing … Testing

Link: http://gspn.tv/test.mp3

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com and http://www.springerpub.com/Search/marcinko

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Are Financial Services “Professional” Certifications Important? [A Poll]

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Often of Murky Respect – Usually Confusing to Clients

By Dr. David Edward Marcinko MBA, CMP™

http://www.CertifiedMedicalPlanner.org

[Editor-in-Chief]

There are more than 100 “certifications” which represent the often nebulous field of “financial advisory, or planning credentials” that presently exist in the market place today.

Some of these “professional” designations are awarded to individuals in the financial planning or financial “advisory” space after [some] diligent study, and [often not so] arduous testing; others not so.

And so, are such “credentials” more important to you, or your clients; pleas opine.

More:

Disclaimer: I am a reformed Certified Financial Planner®, Series 7 [stock-broker], 63 and 65 license holder, and RIA representative who also held all applicable insurance and security licenses.

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Social-Norms versus Market-Norms in Healthcare Reimbursement

Rogue Thoughts on Toppling the Current Payment System

By Dr. David Edward Marcinko MBA, CMP™

[ME-P Editor-in-Chief]

Recently, I reviewed a copy of “Predictably Irrational” by fellow blogger Dan Ariely, PhD. Dan is the James B. Duke Professor of Behavioral Economics at Duke University and a founding member of the Center for Advanced Hindsight.

In the book, he examines some of the positive effects that irrationality has in our lives and offers a new look on how irrational decisions might influence our personal lives and our workplace experiences. I found the chapter on social-norms v. market-norms particularly interesting and wondered about its’ applicability to healthcare economics and reimbursement.

Example:

Dan sites the example of various fund raising charitable goods that had been set at market prices [the norm in this country – little retail negotiating takes place in the USA], but that he recently chose to experiment and make them donation-based instead. 

The Difference

What a difference it made! He cites the case of one woman who bought a cupcake and reached for a dollar bill when asked about the price.  When told there was no set price, but donations-only were accepted, she put the one bill back in her wallet and pulled out a ten-spot. 

References and Research

Assessment

So, please allow me to use this trivial example and suggest a limited switch experiment to social-norms – instead of market-norms in some cases of healthcare reimbursement – perhaps starting with non-surgical, non-specialty, primary care providers [GPs, internists, FPs, DNPs, podiatrists, etc], or any “willing provider” for that matter. What do you think would happen?

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Is this idea too far out – or thought provoking enough for further consideration? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com and http://www.springerpub.com/Search/marcinko

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Tax Strategies for Retiring Medical Professionals

Some Valuable Tips for 2011

By Sean G. Todd, Esq., M. Tax, CFP©, CPA 

www.EMCAdvisors.com

We need to start this ME-P with the famous quote made by Benjamin Franklin almost 300 years ago and yet still rings true: 

Nothing in life is certain except death and taxes.”

I believe physicians and all individuals better be formulating a tax-efficient investment and distribution strategy. Here is why: as a physician retiree or planning-to-be retired, with an effective tax strategy, you will keep more of your hard-earned assets for yourself and your heirs. Here are a few items for consideration which just might help with your money management during your later years.

The General “Rules”

1.  Utilize Tax Efficient Investments

Municipal bonds or “munis” have long been appreciated by retirees seeking a haven from taxes and stock market volatility. In general, the interest paid on municipal bonds is exempt from federal taxes and sometimes state and local taxes as well. The higher your tax bracket, the more you may benefit from investing in munis. This is not the “silver bullet” to retirement income planning. Yet, we see unknowing investors being exposed to a significant downside risk which could result in significant losses of their assets.

2.  Utilize Tax Efficient Mutual Funds/Index Funds

A more acceptable point is that all mutual funds are not created equal. A prudent move might be to reallocate part of your portfolio to start investing in tax-managed mutual funds. Managers of these funds pursue tax efficiency by employing a number of strategies. For instance, they might limit the number of times they trade investments within a fund or sell securities at a loss to offset portfolio gains. Equity index funds may be even more tax-efficient than actively managed stock funds – having the ability to identify which index fund(s) are being more tax efficient is where we come in.

It’s also important to review which types of securities are held in taxable versus tax-deferred accounts. Why? Because in 2003, Congress reduced the maximum federal tax rate on some dividend-producing investments and long-term capital gains to 15%. In light of these changes, many financial experts recommend keeping real estate investment trusts (REITs), high-yield bonds, and high-turnover stock mutual funds in tax-deferred accounts. Low-turnover stock funds, municipal bonds, and growth or value stocks may be more appropriate for taxable accounts.

A Comparison Chart

Just for ease of comparison on a pure return basis, I thought the following chart would make a great reference.  Would a tax-free bond be a better investment for you than a taxable bond? Compare the yields to see. For instance, if you were in the 25% federal tax bracket, a taxable bond would need to earn a yield of 6.67% to equal a 5% tax-exempt municipal bond yield.

Federal Tax Rate 15% 25% 28% 33% 35%
Tax-Exempt Rate Taxable-Equivalent Yield
4% 4.71% 5.33% 5.56% 5.97% 6.15%
5% 5.88% 6.67% 6.94% 7.46% 7.69%
6% 7.06% 8% 8.33% 8.96% 9.23%
7% 8.24% 9.33% 9.72% 10.45% 10.77%
8% 9.41% 10.67% 11.11% 11.94% 12.31%

*The yields shown above are for illustrative purposes only and are not intended to reflect the actual yields of any investment. 

3.  A question we get frequently: Which Security to Tap First?

A successful retirement plan is largely based on a sustainable income stream. This type of financial planning requires a specific set of skills. To facilitate a consistent income stream, another major decision is when to liquidate various types of assets.  The advantage of holding on to tax-deferred investments is that they compound on a before-tax basis and therefore have a greater earning potential than their taxable counterparts.

Consideration must also be given to making qualified withdrawals from tax-deferred investments which are taxed at ordinary federal income tax rates up to 35%, while distribution, in the form of capital gains or dividends, from investment in taxable accounts are taxed at a maximum 15% [Capital gains on investments held for less than one year are taxed at regular income tax rates].

This reason makes it beneficial to hold securities in taxable accounts long enough to qualify for the 15% rate.  When the focus is on estate planning, long term capital gains are more attractive because the beneficiary will receive a step-up in basis on appreciated assets inherited at death.
Another consideration when developing the sustainable retirement income plan is the timeframe for tapping into tax-deferred accounts.  Keep in mind, the deadline for taking required annual minimum distributions (RMDs) and have you taken into account the possible impact of the proposed tax law changes on your retirement income distribution plan?

4.  The Ins and Outs of RMDs

The IRS mandates that you begin taking an annual RMD from traditional IRAs and employer-sponsored retirement plans after you reach age 70 1/2. The premise behind the RMD rule is simple — the longer you are expected to live, the less the IRS requires you to withdraw (and pay taxes on) each year. RMDs are now based on a uniform table, which takes into consideration the participant’s and beneficiary’s lifetimes, based on the participant’s age. Failure to take the RMD can result in a tax penalty equal to 50% of the required amount.

Inside Tip: Why you should not wait until you retire to develop a sustainable retirement income plan: If you’ll be pushed into a higher tax bracket at age 70 1/2 due to the RMD rule, it may pay to begin taking withdrawals during your sixties. Unlike traditional IRAs, Roth IRAs do not require you to begin taking distributions by age 70 1/2. In fact, you’re never required to take distributions from your Roth IRA, and qualified withdrawals are tax free. For this reason, you may wish to liquidate investments in a Roth IRA after you’ve exhausted other sources of income. Be aware, however, that your beneficiaries will be required to take RMDs after your death. 

Estate Planning and Gifting

Attaining proper investment counsel and advice has to answer the question—-“What happens when I die?”  Many strategies can be implemented by clients to address the various ways to make the tax payments on your assets easier for your heirs to handle. Who is the proper beneficiary of your money accounts?  If you do not name a beneficiary, your assets could end up in probate, and your beneficiaries could be taking distributions faster than they expected.

In most cases spousal beneficiaries are ideal, because they have several options that aren’t available to other beneficiaries, including the marital deduction for the federal estate tax, and the ability to transfer plan assets — in most cases — into a rollover IRA.

Also consider transferring assets into an irrevocable trust if you’re close to the threshold for owing estate taxes based on the sunset provisions.  Best estate tax avoidance plan today – die in 2010 as there is no limit on the amount you can pass to the next generation estate tax free.  Assets in this type of arrangement are passed on free of estate taxes, saving heirs tens of thousands of dollars.

Inside Tip: If you plan on moving assets from tax-deferred accounts do so before you reach age 70 1/2, when RMDs must begin.

Finally, if you have a taxable estate, you can give up to $13,000 per individual ($26,000 per married couple) each year to anyone tax free.  If you need my contact information, please let me know.  Also, consider making gifts to children over age 14 as dividends may be taxed — or gains tapped — at much lower tax rates than those that apply to adults.

Inside Tip: You may want to consider a transfer of appreciated securities to custodial accounts (UTMAs and UGMAs) to help save for a grandchild’s higher education expenses.

Market Focus

As individuals, especially doctors living in mini-mansions, come to grips with not being able to sell their homes for a value they once thought possible, we are apt to suggest that we might see increased activity in the home improvements sector as individuals just decide to make the upgrade to their existing home while they wait this whole real estate mess out. 

How can all this help you financially?  You are seeing exactly why you cannot base your investment decisions on the latest headline or try to time the market  Single and doubles in the investment world will score more runs than trying to to hit a home run (timing the market). What is your singles and doubles strategy? 

Summary

  • Formulating a tax-efficient investment and distribution strategy may allow you to keep more assets for you and your heirs.
  • Consider tax-efficient investments, such as municipal bonds and index funds, to help reduce exposure to taxes.  It’s what you keep that counts.
  • Tax-deferred investments compound on a before-tax basis and therefore have greater earning potential than their taxable counterparts. However, qualified withdrawals from tax-deferred investments are taxed at income tax rates up to 35%, whereas distributions from taxable investments held for more than 12 months are taxed at a maximum 15%.
  • You must begin taking an annual amount of money (known as a required minimum distribution) from some tax-deferred accounts after you reach age 70 1/2.
  • Review how your assets fit into a comprehensive estate plan to make the most of your money while you’re alive and to maximize the amount you’ll pass along to your heirs.
  • Before selling appreciated investment assets, be sure that you have owned them for at least one year. That way, you’ll qualify for lower capital gains taxes.
  • If you’re considering placing assets in a trust or custodial account, think carefully about which assets would be most appropriate to transfer.
  • Schedule a meeting with a financial professional to review your tax management strategies.
  • Remember to begin taking required minimum distributions from traditional IRAs and employer-sponsored retirement accounts after you reach age 70 1/2 in order to avoid costly penalties.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

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Join Our ME-P Partner Research Panel for 2011

Invitation to Respond

By Prof. Hope Rachel Hetico; RN MHA CPHQ CMP™

[Managing Editor]

Dear ME-P Readers and Subscribers,

On behalf of the Medical Executive-Post, I would like to invite you to become a member of the ME-P Partner Research Panel (MPRP) for 2011. This panel presents a chance for a limited number of M-E-P participants to have their voices heard through ongoing research studies with the www.MedicalBusinessAdvisors.com [iMBA, Inc].

The insights and suggestions of this vital partner community help shape products and programs which are critical to our mutual success.

The MPRP Panel

The MPRP panel is composed of ME-P readers and subscribers who have agreed to participate in a research program which asks their opinions via surveys typically once or twice a month. Most of your feedback would be submitted online, although there may be opportunities to participate in more in-depth types of research throughout the year. In all cases, it is up to you whether you choose to participate in the research request. All responses remain confidential and are reported only in aggregate.

Building Out the Process

As we continue to build out this process we are seeing greater internal iMBA Inc management participation and interest. External ME-P product development groups and business teams are asking for MPRP insights, as well. Complete studies have been developed around some topics, while at other times MPRP members have been asked to help with focus group activities and in-depth interviews. The help provided by the MPRP is not only appreciated by iMBA Inc, but has become vital to our work here at the ME-P.

Registration Required

I hope you will become a part of this new, vital component of the MPRP network. The registration process requires only a click on the “Join Us” tab, or confirmation-reply email to: MarcinkoAdvisors@msn.com Your membership will be a powerful way to present your thoughts and opinions to the management and staff of the ME-P. Please call us [770-448-0769] with queries, and/or “click” or email register now.

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Assessment

You’ve probably already noticed that we have asked two of our valued research partners and sponsors www.CertifiedMedicalPlanner.com to assist us in managing and maintaining the many details of the panel. The CMP™ program has been involved with partner research on an ongoing basis for more than five years. Over time, you will become familiar with both www.MedicalBusinessAdvisors.com and www.CertifiedMedicalPlanner.com as two of the primary contacts for the ME-P Partner Research Panel.

Conclusion

Thanks for your participation in the ME-P Partner Network. I look forward to hearing more from you in the future. And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com and http://www.springerpub.com/Search/marcinko

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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The Unique ME-P Advertising Model

Catch the Growing “ME-P Wave”

By Ann Miller RN, MHA

[Executive-Director]

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Readership for the ME-P is growing at a fast clip.  So, what better way to target those with a passion for the personal financial [financial advisors] and business side of medicine [doctors and nurses, medical executives and clinic managers]; as well as those who serve both arenas?

A Unique Advertising Model

We’ve taken a unique approach with our advertising model.  We don’t necessarily sell rotation banner ads.  We sell article sponsorship and content. What this means is that we will pair your product or company with an article we [or you] have written covering a topic that logically connects to your company or product.  Your ad is then embedded into the article for all time. The article, outfitted with your witty ad, will continue to exist indefinitely in our searchable archives. 

Generating Targeted Traffic

Your purchase of a single ad will continue to generate traffic every time a ME-P reader seeks out information on the topic we’ve tied to your product or company. Check out the example below of a massage company ad strategically paired and embedded within a heart article.

Sample Heart: https://medicalexecutivepost.com/2010/08/14/about-theheart-org/

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The Emerging Discipline of “Slow Medicine” and Professional Liability

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Examining the Heuristic Relationship between Face-Time and Medical Negligence Lawsuits 

By Dr. David Edward Marcinko MBA CMP™

www.BusinessofMedicalPractice.com

[Editor-in-Chief]

Our colleague and blogger Kent Bottles MD has been thinking and posting about the emerging philosophy of “slow medicine”. Of course, health economists realize how complex and difficult it is to transform American health care so that we will enjoy lower per-capita costs along with increased medical care quality in our lives. Unfortunately, grass root practitioners have done just the opposite these last two decades or so. In other words, practicing “faster medicine” with assembly line efficiency relegating office visits to 15, 10 or even 7 minute increments etc, in order to compensate for diminishing MCO/HMO reimbursement. And, this may have been a financially acute perspective for modernity until now!

Defining the Obvious

Slow medicine is practiced by a small, but growing subculture whose pioneer and spokesperson is Dr. Dennis McCullough, author of the book My Mother, Your Mother [Embracing “Slow Medicine,” The Compassionate Approach to Caring for Your Aging Loved Ones].

In other words, slow medicine is a philosophy and set of practices that believes in a conservative medical approach to both acute and chronic care. However, I believe there may be more to it than first perceived.

Link: http://www.thehealthcareblog.com/the_health_care_blog/2010/12/slow-medicine.html#comments

My Experiences

After serving as a medical expert witness in hundreds of malpractice cases [consulting, chart review, discovery depositions, trial appearances and sworn testimony] – both directly and indirectly and for both plaintiff and defendant doctors [predominately] – thru almost twenty year of private practice, my gut tells me the following:

“Patients do not sue doctors they personally like – they do sue doctors they do not like.”

In my opinion and experience, great clinical doctors are often sued while their lesser adept souls are not. Moreover, I believe this pleasing reduced liability relationships is enhanced by more patient face-time; not less. This is not a function of competency, but one of human relationships and “connectedness” with one’s caregiver. It will not be changed by eMRs, or more diagnostic tests [malpractice phobia] or procedures. It will be improved by intense physical examination, touching, eye contact, sympathy, empathy and time [aka: a TRUSTING relationship and pleasing bedside manner forged by TIME]. Period!

And so, for our business managers, CEOs and medical executive readers, let us compromise on terminology and call it “slower medicine.”

Assessment

Link: http://www.amazon.com/Insurance-Management-Strategies-Physicians-Advisors/dp/0763733423/ref=sr_1_3?ie=UTF8&s=books&qid=1275315795&sr=1-3

Conclusion

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eMR Privacy versus Healthcare Efficiency [A Voting Opinion Poll]

The Electronic Controversy Continues

By Anonymous

Medicine may be the last industry to resist the digital revolution as many doctors still use paper medical records.

Framing the Debate

Privacy advocates worry that if the move to eMRs is rushed, patient privacy will suffer. Supporters, on the other hand, argue that health information technologies have advanced to the point that such concerns are vastly overblown. Any loss of privacy will, they insist, be more than offset by efficiency gains. Who is right?

Link: http://www.economist.com/debate/debates/overview/189

Assessment

Will any privacy loss from eMRs be compensated for by commensurate welfare gains from increased medical delivery efficiency?

Conclusion

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What is Universal-Variable Life Insurance and How Does it Work?

 Insurance Basics for Medical Professionals

By By Jeffrey H. Rattiner, CPA, CFP®, MBA

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After determining the need for insurance and the amount to purchase, the doctor-client and financial planner’s next task is to match those needs to the client’s objectives to determine what type of policy the client should purchase. The life insurance industry features more products today than ever before. One reason for this change is that, clearly, the insurance industry has expanded its product base to become more competitive. Another reason is that clients’ needs are constantly changing and the insurance companies must keep up with those needs or run the risk of having funds withdrawn from their companies. New and different types of life insurance products are here to stay. Since life insurance represents a significant part of a doctor-client’s risk-management program, planners have to be versed in the specifics of the varied product base.

Definition

Universal variable life insurance is a hybrid of universal life and variable life insurance. It lets policyholders adjust premiums and reconfigure the death benefit level. The cost of this increased flexibility depends on the equities that are invested.

Similarity to Variable Life Insurance

Similar to the variable life contract, the policyholder gets to choose the investment medium under this contract, with no guaranteed cash value levels or growth. Policyowners are given the choice of option A death benefits (face amount only) or option B death benefits (face amount plus cash value). Because of the daily changes in cash value, however, option B is often not available. Premiums and death benefits are flexible and not guaranteed.

Assessment

Universal variable life policies are most appropriate for people with changing financial needs or long-term needs and for those who are willing to give up all guarantees in exchange for policy and investment flexibility.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. What kind of life insurance do you have doctor, and is it enough? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Musings on Sector Mutual Funds

A Historical Review

By Dr. David Edward Marcinko MBA, CMP™

www.CertifiedMedicalPlanner.org

[Publisher-in-Chief]

Although less than 5-10% of the total number of mutual funds are considered true sector funds, year after year, 40-50% or more of the top-performing funds have been sector funds. However, for some physician investors sold on a buy-and-hold strategy, sector funds may not be their cup of tea. But, sector funds do offer an opportunity to outperform the market indices, possibly even substantially, according to Marshall Schield in “Developing a Sector Funds Strategy” (Personal Financial Planning, November/December 1996, pp. 39–42, Warren, Gorham & Lamont, [800] 950-1205).

A Volatile Strategy

Typically sector funds are more volatile than the majority of growth funds. This volatility springs from: (1) the fact that the majority of stocks in a particular sector fund move together, thereby magnifying the fund’s movement; (2) the focus of the sector fund manager only on stocks in that sector, enabling him or her to target high potential stocks; and (3) the rotation of “in” and “out” sectors at particular times.

So – What’s a Doctor Investor to Do?

An investor in sector funds needs a strategy that will target sectors on the upswing and signal when to move out of declining funds. When selecting sector funds, Schield recommends building a list of funds that are manageable, full of choices in all types of markets, diversified (three to four funds for an aggressive portfolio or 10–12 for a less aggressive approach) and liquid.

The Balancing Act

Also, develop a healthy balance—not a “hit-or-miss” approach. Schield suggested using the “relative strength” approach for sector selection by computing the percent change in the price of funds over a certain number of days and then ranking them for short-term, intermediate, and long-term periods. With respect to determining the proper timing for buying or selling, the author suggests the use of an individual fund timing system, such as comparing the current NAV of the sector against a moving average for 50 or 75 days or combining both short- and long-term moving averages.

Simplicity Rules

In creating buy-and-sell signals:

  • Keep it simple and manageable.
  • Do not look for perfection.
  • Practice patience.
  • Cut losses and let profits run.
  • Stick with your relative strength.
  • Buy/sell signals consistently.

Assessment

Most of all; be prepared to spend and invest the time necessary to be successful. But, have you or your sector funds been successful in the last decade, or so? If so, which sectors? Please opine?’

Conclusion

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How I KISS My IRA [A Prudent Checklist]

Simplified Retirement Thoughts for Physicians in 2011

By Dr. David Edward Marcinko MBA CMP™

www.CertifiedMedicalPlanner.com

[Publisher-in-Chief]

As a reformed certified financial planner and stockbroker, and current CMP™ professional charter holder for more than a decade, I am always amazed at how complex and convoluted some medical colleages and other folks make IRAs and their retirement planning.

So, please allow me to offer this brief checklist of advice on how to KISS your IRA in 2011!

What to have in an IRA?

Assets that are expected to generate the greatest relative pretax returns, such as:

  • fixed-income investments expected to yield high returns
  • stocks with high dividend yields
  • stocks expected to be held short term
  • mutual funds that emphasize stocks paying high dividends
  • mutual funds that expect to hold stocks short term.

What not to have:

  • collectibles (e.g., art objects, antiques, and stamps)
  • tax-free, tax-deferred, or tax-sheltered vehicles (e.g., municipal bonds, Series EE U.S. savings bonds, or variable annuities)
  • investments in individual foreign securities or mutual funds that hold primarily foreign securities.

Activities to avoid:

  • borrowing from the account
  • creating unrelated business taxable income, which may result from ownership of an interest in a partnership or S corporation or from purchasing securities on margin or borrowing to acquire real estate.

Assessment

So, what’s in your IRA, doctor? Do you have a Keep It Simple and Sane [KISS] checklist? 

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Do you KISS your IRA like me? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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The Medicare Cost-Control Efficiency Paradox

Essay on the Eight-Hundred Pound Gorilla in the Medical Treatment Room

By Dr. David E. Marcinko MBA

[Editor-in-Chief]

According to economist Austin Frakt PhD, and others, there is a school of thought that says Congress is incapable of controlling costs in the Medicare and Medicaid System [CMS].

And, then there is the reality known by all practicing medical professionals regardless of specialty orientation or degree designation. That is to say, CMS really can control healthcare costs and with great ferocity and efficiency, and to non-public sectors as well …. PARADOXICAL?

On Getting What You Wish For

Blogger Ezra Klein opines that one of the dirty little secrets of the health-care system is that Medicare has done a much better job controlling costs than private health insurers.

http://voices.washingtonpost.com/ezra-klein/2010/11/what_happens_when_medicare_con.html

A Forehead-Palm Moment

Of course, we doctors know that the real problem is that Medicare seemingly [think Seinfeld’s character George Costanza] controls costs all too well; but not really. It is just that CMS pays doctors too little and thus it appears costs are controlled. What really is happening is that physician fees are being reduced carte’ blanche.

Nevertheless, and regardless of semantics, CMS will never control costs much more efficiently than private insurance companies or doctors will simply abandon Medicare for related payment models like direct reimbursement or concierge medicine. This is happening right now. Physicians, osteopaths and podiatrists etc, are opting out of Medicare in increasingly large numbers. In a world where there’s only Medicare and Medicare to control costs, doctors can either take the pay cut or stop seeing patients, and stop being doctors. “Taking what they are given – because they’re working for a livin.”

So sorry that this seems like a forehead-palm moment for Ezra, but not for healthcare practitioners or the ME-P!

Too Much Demand Elsewhere

And, as we see from other countries, many young bright folks want to be doctors, even if being a doctor doesn’t make one particularly wealthy [high demand and high eventual supply produces lower provider costs in the long term?]. Think medical tourism.

Not so much the case anymore in this country [lower demand and lower eventual supply produces higher reimbursement costs to the doctor survivors in the very long term?].

Our Domestic World

But, we are not elsewhere. In fact, in our present domestic healthcare ecosystem, when Medicare decides to control costs, many doctors can simply stop accepting Medicare patients, and the politicians will lose their jobs. One political party then declares that Medicare is rationing and will hurt senior citizens. The other party capitulates and pays MDs more [SGR]. Then, the federal budget looks bad as it does now. The circle is complete when one party asserts that Medicare actually can’t contain costs but the private insurance companies will.  It all fails, in an unending circular Boolean-like loop of illogic.

Listen Up!

So, listen up AARP, politicians, CMS and seniors as I admonish you to be careful what you wish for [medical cost controls]. It might just come true. As Ezra rightly says; rinse, repeat – rinse, repeat – ad nausea. You simply can’t have it both ways.  You either choose to spend less and offend certain cohorts, or spend more and offend different factions.  Either way, you’re going to piss someone off. A good healthcare reimbursement system would try to make that decision rationally [a-politically]. But, at least it would make an economics driven decision; wouldn’t it?

Assessment

Is CMS really the eight hundred pound cost-controlled gorilla in the increasingly large Medicare treatment room? Why or why not? Now, relative to the ACA of 2010, please read: The Case for Public Plan Choice in National Health Reform [Key to Cost Control and Quality Coverage], by Jacob S. Hacker, PhD. Link: Jacob Hacker Public Plan Choice

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Do we have a Medicare cost control efficiency paradox? Or, are the economists just reveling in the publication banal? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Hospitals and Healthcare Organizations [2 New Print Books]

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Healthcare Organization and Hospital Financial Management Strategies

All hospitals and healthcare organizations, both emerging and mature, face a daunting financial scenario in today’s volatile healthcare re-imbursement environment.

Decreasing revenues, increasing costs, and high consumer expectations present a complex challenge for CEOs, CFOs, physicians and nurse executives, administrators, financial advisors and department managers who must not only lead in today’s climate, but also position their organizations for tomorrow’s financial tumult and potential political changes of the Obama Administration and ACA, etc.

A National Team of Contributors

Produced by  economists, administrators – accountants, business leaders, MDs and IT consultants, among others; Hospitals and Healthcare Organizations [Financial Management Strategies] looks at ways to manage assets, costs, human resources and healthcare claims.  Everything – from inventory management to hybrid and activity based cost analysis in order to accelerate the cash conversion cycle – is scrutinized.  And, modern health economic themes like competitive strategy, workplace violence and financial benchmarks, for both public and private entities, are included.

Contemporaneous Health 2.0 Topics

We also examine contemporaneous topics such as the lessons learned from the corporate healthcare market competition and the PPMC imbroglio of the early 2000’s, and the domestic financial meltdown of 2009. This includes current methods for achieving hospital objectives, negotiating and analyzing cost-volume-profit contracts, and understanding the financial impact of regulatory requirements under HIPAA, STARK I-III, OSHA, the US Patriot Acts, the Deficit Reduction Act [DRA], the often contentious Sarbanes-Oxley Act, ARRA and HITECH Acts, and the Fair and Accurate Credit Transactions [FACT] Act. In addition, information technology issues like electronic medical records (eMRs), RFID controls, RSS feeds and blogs, Health 2.0 initiatives and computerized physician order entry (CPOE) systems are examined in detail. Virtually no operational, strategic business, health economics, or financial management topic is omitted.

Assessment

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Hospitals and Health Care Organizations [Financial Management Strategies] is dedicated to meeting the administrative needs of our nation’s healthcare organizations in order to help them maintain a competitive edge in the markets they serve; and to take advantage of emerging business opportunities. We therefore invite you to be the first health economics cynosure in your hospital, facility, or healthcare system to join us for the journey.

Channel Surfing the ME-P

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Conclusion

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Is Primary Care Medicine Toxic?

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Requesting Real-Life Examples of Professional Despair

By Dr. David Edward Marcinko MBA CMP™

www.BusinessofMedicalPractice.com

[Editor-in-Chief]

As you’ve probably heard – and experienced or know from our books, journal and this ME-P – there’s a primary care medical shortage out-there!  Maybe you’ve even read or heard about the Physician’s Foundation study describing the overwhelming number of PCPs who want out of this toxic environment. On one hand, we have patients desperately searching for a PCP, while on the other hand we have good caring doctors being forced out of the profession. Of course, NPs, ANPs, DNPs and other ancillaries are part of the solution; but not entirely.

Link: http://www.physiciansfoundation.org/

Human Anguish

And humanely, as stated by our medical colleague L. Gordon Moore MD, these statistics miss the very real pain and anguish of people who entered primary care to help patients when they find the environment for primary care toxic to the ethical practice of medicine. Even to the point of suicide!

Assessment

These voices need to be heard. And so, we are asking doctors and providers of all stripes to post in the comments section below personal examples of medical practitioners leaving primary, solo or small group practice because they just can’t stand the toxic environment any longer.

Conclusion

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Life and Death Choices as South Africans Ration Dialysis Care

Dialysis Unit at Tygerberg Academic Hospital – Near Cape

By Sheri Fink, Special to ProPublica Dec. 15, 2010, 3:18 pm

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Late last August, 41-year-old Amos Phillips arrived by ambulance at Tygerberg Academic Hospital near Cape Town, South Africa. His kidneys had failed. He was confused, struggling to breathe, and desperate enough to ask doctors to end his life.

The same month, a 43-year-old widow with three children was also treated at Tygerberg for kidney failure. The patient, Karen MacPherson, desperately wanted to live. She said she had been plagued by high blood pressure, a risk factor for kidney disease, since her children’s birth. “It’s because of the high blood [pressure] the kidneys don’t want to work anymore,” she said.

Kidney failure can come on suddenly and affect anyone. Some forms are partial or reversible. Others are permanent and fatal without treatment.

To live, both Amos Phillips and Karen MacPherson would need ongoing dialysis treatment to filter toxins from their blood, sustaining them until they received a kidney transplant. But needing treatment didn’t mean they would get it.

Public hospitals in South Africa strictly limit the number of expensive dialysis treatment slots for chronic kidney failure to save money for other pressing health priorities. It falls to the medical staff to do the rationing.

The situation in South Africa is strikingly similar to that of the United Sates in the 1960s, when dialysis first became available. Demand for the procedure was far greater than the supply, and hospital-based committees quietly rationed dialysis—much as they do in South Africa today.

In the United States, committees granted or denied dialysis in large part by judging how much a particular patient’s life was worth. A 1962 article in LIFE magazine exposed the selection process at one Seattle clinic, triggering public outcry. Lawmakers created a program that now entitles almost anyone diagnosed with kidney failure to dialysis treatment under Medicare.

A few kidney doctors have argued publicly that access in the United States has become too broad, including patients who are unlikely to benefit from the expensive therapy. They have called for limits on which types of patients should receive dialysis.

But where to draw the line? The scenes that unfold each week in Cape Town, South Africa, where committees meet to choose dialysis patients, are a reminder of how difficult any selection process can be.

I was granted access to closed dialysis selection committee meetings at the two hospitals that provide public dialysis services to adult kidney patients in the Cape Town Area. It is the first time a reporter has been allowed to attend a committee meeting at Tygerberg and report on the process.

An investigation by ProPublica [1] recently highlighted the high cost of the massive, rapidly expanding kidney disease program in the United States and the poor outcomes experienced by many dialysis patients.

The challenge for the United States is to address systemic flaws and achieve the superior results that patients in other wealthy countries, such as Italy, enjoy. In less-affluent countries like South Africa, the central question is a different one: How can these nations expand access to dialysis—and in the interim bring some modicum of consistency and transparency to the heartbreaking task of rationing lifesaving care.

Global inequities

When it comes to expensive, chronic therapies like dialysis, there is still a stark divide between wealthy nations and much of the rest of the world. In the United States, Western Europe and Japan, there is widespread access to dialysis care, most of it paid for publicly. But in many countries, the vast majority of patients with kidney disease don’t have access to dialysis [2].

In South Africa, only the roughly one out of five patients who have a form of health insurance or the small proportion of patients who can afford pay are able to get dialysis at private clinics or hospitals based on medical need alone. The cost of paying out of pocket—about $20,000 per year— is nearly double the gross domestic product per capita.

The remaining patients rely on an overburdened public health system in which an increasing number of chronic kidney disease patients are denied dialysis.

“Probably in the middle of the last decade we were turning away 50 percent of the patients,” said Dr. Rafique Moosa, a kidney specialist at Tygerberg Hospital and head of the Department of Medicine at the University of Stellenbosch. According to him, as of August they were turning away 80 percent, and in November, only two out of 20 patients were accepted. “We just don’t have the resources to deal with the patients,” Moosa said. But deciding to reject patients for the program can feel like issuing a “death sentence,” he said.

“In a court of law, you have courts of appeal and you have a higher court and all those kinds of processes before the death sentence is eventually applied,” Moosa said. “Here, essentially if we say no, the process is essentially terminated.”

So, the doctors have adopted a firing-squad-like approach to share the responsibility and the burden. “It’s a tough process having to decide who lives and who doesn’t,” Moosa said. “One of the ways of dispersing the guilt and the blame and all the badgering that goes with this is to do it as a group rather than an individual.”

The question of how groups of medical professionals choose who lives is particularly important given South Africa’s history. Tygerberg was built during the apartheid era, when the government mandated racial segregation. The vast hospital has hallways that stretch out east and west, in wings that are mirror images. One side used to treat white patients. The other treated nonwhites.

For decades, a committee at the hospital has decided who gets dialysis treatment. In a recent study of historical data from Tygerberg’s program, Moosa found that patient selection often fell along racial lines. “What we clearly discovered in that initial paper was that black patients were disadvantaged,” he said.

The apartheid era ended with the first multiracial, democratic elections of 1994. However, between 1988 and 2003, Moosa’s study found, white patients were nearly four times more likely to be accepted for dialysis treatment than nonwhites at Tygerberg. (In recent years, the vast majority of white kidney disease patients have shifted to the growing private dialysis sector for care, and their cases are no longer subject to review by Tygerberg’s dialysis selection committee.) During that period, there was little in the way of detailed guidance governing the selection process. That left patients and the public with limited insight into the basis for the committee’s decisions.

Several years ago, the government announced cutbacks that would further squeeze the dialysis program. At the same time, the number of new kidney patients was skyrocketing thanks to a growing rate of diabetes and other risk factors.

Moosa protested the budget cuts and sought to have government officials in charge of his hospital take more public responsibility for rationing.

“We were making these clinical decisions that would have economic benefit to the hospital, and the hospital managers played absolutely no role in this,” he said. “We felt that was blatantly unfair.”

Provincial officials agreed to work with the medical professionals to establish official guidelines [3] for patient selection—essentially a more standardized and explicit rationing system. Ethicists and several patients with kidney disease also provided input.

Participants differed somewhat over the criteria for allotting dialysis treatment—there are no universally accepted methods to ration health care. However, they worked to ensure that the selection guidelines were developed in a just way and that the selection process would be more accountable.

“The main thrust of this was to be fair and equitable and transparent,” Moosa said. The provincial government adopted the new system earlier this year. It calls for the dialysis selection committees at public hospitals to place patients into three prioritization categories based on a variety of medical and social factors.

This was the system that was in place when Amos Phillips and Karen MacPherson, two of the recent patients at Tygerberg, were considered.

The Committee

On a recent Tuesday morning, about a dozen medical professionals, stethoscopes dangling from their necks, gathered in a small conference room at the hospital. The committee meets weekly to decide who will be accepted into the dialysis treatment and transplant program.

The hospital’s longtime social worker for kidney patients, Marietjie Swart, presided. She projected a photo of Amos Phillips onto a large screen.

The image showed a man with closely cropped brown hair lying in his hospital bed.

Phillips’ doctor outlined his medical condition, and then Swart reviewed other aspects of his life that might have a bearing on the committee’s decision. She began with his age and where he lives. “He can read and write,” she added. “He speaks Afrikaans and Xhosa, as well.”

Phillips “never smoked, never used any drugs,” Swart continued. “He only drank over weekends with his wife, but they would only buy about four bottles, 750 ml, between the two of them.” Phillips was, Swart said, “not a party animal.”

That was a point in his favor. Under the guidelines, active substance abuse automatically excludes a patient from receiving dialysis.

Swart also discussed Phillips’ living conditions. “It’s a one-bedroom house, with a lounge, kitchen and a bathroom,” she said. The bathroom had a tub, sink and a toilet.

The guidelines call these “good home circumstances,” and they, too, improved Phillips’ chances of being chosen for dialysis. Running water, sanitation and electricity are important for performing a form of dialysis safely at home. However, these criteria can disadvantage the poorest South Africans, who often lack such utilities.

Swart offered more personal details. “He is employed on a farm,” she said. “His income is more or less 1,200-1,500 rand ($175-$220) a month.” He had “no criminal record” and was married to a 33-year-old woman. “They’ve got three children of 13, 9, and 4 years old, all three living with them.”

These factors—criminal and employment history, whether the patient is a parent—have little to do with the chances of benefiting medically from dialysis. They are, instead, measures of social worth.

Dr. Moosa said the committee used to weigh these factors heavily when considering patients for dialysis. “I suppose we used a utilitarian approach,” he said. “The question that we used to ask ourselves—you know, if we put this patient onto our program, of what benefit can he be to the society?”

According to the new guidelines, those factors are no longer considered. The ethicists who helped draw up the guidelines argued that medical practitioners should not judge which patients are the worthiest contributors to society.

Judgments are often wrong. For example, former prisoners might have been falsely convicted, especially during the apartheid years. Patients who lack their own children might be helping to raise others.

Most important, the ethicists said, are medical criteria. Is the patient healthy enough to undergo a kidney transplant? If so, he or she might someday no longer need dialysis, and that would free up a slot for a new patient.

The problem is, few actually are able to get transplants. There are far more good medical candidates than there are dialysis slots. Therefore, the committee falls back on subjective criteria—does the patient seem motivated? Does he or she have a good social support network?

The committee still discusses some social factors that are no longer included in the government-approved priority setting guidelines Moosa helped to develop for the province. For example, the checklist still used by the committee penalizes those who’ve been convicted of serious crimes and requires gainful employment for a patient to be accepted into “Category One,” the only category of patients guaranteed access to the dialysis program. Both of these “social worth” factors are missing from the new guidelines.

Moosa said in an interview that he had not had time to update the checklist tool to conform with the new guidelines, but that those factors are mentioned at committee meetings “more out of habit” and are “not something we pay a lot of attention to anymore.”

The assessment committee weighed the factors in Amos Phillips’ case, deciding whether he should be ranked “Category One” and guaranteed dialysis.

“I think he would almost be a Category One patient if it wasn’t for his late presentation,” Moosa said to his colleagues at the committee meeting.

By “late presentation,” Moosa meant that Phillips had arrived at the hospital after his kidneys had already failed. He needed to be put on life support, with a breathing tube and emergency dialysis, until he was stabilized. That bumped him to Category Two—not guaranteed a spot in the chronic dialysis program.

The Case for Karen MacPherson

The same day, the committee members also talked about Karen MacPherson, the widowed mother of three.

Her picture was projected on the screen. Her wide eyes peered at the camera through large plastic glasses. Dr. Yazid Chothia described her medical and social situation.

“She’s the only breadwinner,” he said, and she had been raising several children. Now other family members were caring for her. “Yesterday they brought her in here because she was nauseous, vomiting,” Chothia said. “It sounds like the family is struggling in terms of taking care of her.”

MacPherson’s case had come to the committee before. She had many characteristics that counted in her favor.

She was well below age 60, the cutoff for initiating dialysis under the government-approved guidelines used at the hospital. She didn’t have any other serious medical or psychiatric disorder, which could disqualify her. She had a home near the hospital with running water and electricity.

Before the new guidelines were adopted, the selection committee might have given great consideration to the fact that she was a mother with a steady job and no criminal history. But the committee had recently turned her down.

“We didn’t accept her for the program?” Moosa asked his colleagues. He had been on vacation when the case had come up before.

“It was mainly based on her BMI, prof,” Chothia said. “Her BMI was 39.”

BMI is body mass index. MacPherson’s was high. She was obese.

Although obese patients do better than average on dialysis, they have a poorer prognosis when it comes to a kidney transplant. That, according to the new rationing guidelines, takes precedence.

Moosa accepted the committee’s previous decision. MacPherson had been assigned to Category Three—automatically excluded from dialysis treatment. She was already very sick.

“It probably won’t be for very much longer,” Moosa said. “Shame.”

The committee members took some steps to help her. They agreed to provide a letter that could be used to relieve a debt. They also referred her to Eagle’s Rest, an inpatient hospice located on the grounds of an evangelical church.

Grasping for Hope

The next day, MacPherson lay in bed at the hospice beneath a pink blanket. She trembled when she sat up. She was too nauseated to keep down her food.

Her father came to visit, and she asked him about her prognosis. “Did the doctor tell you how much longer I’ve got to live?”

“You’re going to live long enough,” her father, Richard MacPherson, answered. “Don’t you worry about that. You just get well. That’s all.” He smiled at her. “There’s no limitation. The doctor can’t say that.”

With her family’s support and the nurses’ prayers, Karen MacPherson tried to stay hopeful.

“I want to get better, I want to get out of here, get my life back on track—get back to my kids,” she said. “My daughter needs me.”

As she spoke, she seemed unaware that she had been turned down for dialysis, or even that dialysis could help her. Her doctor later confirmed that he didn’t tell Karen MacPherson about the program, although he said he informed her father.

According to the prioritization guidelines, patients or their family membersare supposed to be fully informed of the committee’s decision and the reasons for denial and given the opportunity to appeal.

“It’s an ethical obligation to actually communicate openly, truthfully, and sincerely with one’s patients,” said Dr. Keymanthrie Moodley, a bioethics professor at Tygerberg and Stellenbosch University. Moodley said this can prevent the misconception that a patient was rejected for reasons of race or socioeconomic status. “To create a healthier society from both a physical and a mental and psychological perspective, an open line of communication is absolutely critical.”

Dr. Moosa said the guidelines require informing patients or their family members however challenging that may be.

“The reality is that it’s very difficult to go to a patient and inform them, well look, there is this particular form of therapy which is available to you which will help you live another reasonably healthy life for another five to 10 years, and then in the same breath say, well, unfortunately I can’t offer it to you,” he said. “I think it’s actually cruel to dangle that almost as a carrot in front of the patient.”

Pushing the Boundaries

South African physicians are looking to expand public dialysis programs by partnering with private clinics, campaigning for more funding and trying to cut costs. Still, any such plans will come too late for today’s kidney patients. Tygerberg Hospital has no free slots for dialysis.

Sometimes, however, room is made for exceptions.

Several months ago, one of the patients who had received a kidney transplant at Tygerberg in the mid-1990s experienced rejection of her organ and developed kidney failure again. She was brought before the committee to be reconsidered for dialysis. She was now 59 years old and experiencing heart failure­—no longer a candidate for kidney transplant under the guidelines, and therefore no longer a candidate for dialysis at the public hospital.

“If you look at the criteria, she should not be [accepted to] our program,” Swart said. But the woman had provided many years of service to the hospital’s patient-support group overseen by Swart. By this point, the woman had secured private health coverage, known as “medical aid,” but she wanted to continue being treated at Tygerberg, which no longer accepts such patients.

“I just said, ‘Guys, there’s no way that you’re going to turn down this lady,’ ” Swart recalled. “ ‘She’s my left and my right hand.’ ” The committee approved her, and she currently performs dialysis at home that is overseen by the clinic at Tygerberg. “She’s just a very, very special case,” Swart said.

She is not the only one for whom extraordinary efforts have been made.

The day after the recent committee meeting, Dr. André Nortje went to the bedside of kidney patient Amos Phillips. “Mr. Phillips, we discussed you yesterday in our meeting,” Nortje informed him.

The committee had classified Phillips as a Category Two patient— eligible for dialysis only “provided resources allow.”

The program was full, but Phillips was borderline. The committee members thought he had a good chance of benefitting from dialysis, and they hate turning anyone away. They had accepted him for dialysis.

“We decided at our meeting yesterday morning that we will support you in terms of that,” Nortje said. “What I mean by that is that we will offer you, in future, a kidney transplant.”

Phillips looked up at the doctor from his hospital bed. “Yes. I understand.”

“You understand?” Nortje asked.

“I understand and am very happy.”

Phillips began receiving regular dialysis and soon returned home to his family.

Karen MacPherson was buried two weeks after the committee meeting—on what would have been her 44th birthday.

Conclusion

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Musings on a Famous Portfolio Asset Allocation Study

Some Critics Claim Brinson, Hood, and Beebower Conclusions Wrong

[By Dr. David Edward Marcinko MBA CMP™]

http://www.CertifiedMedicalPlanner.org

[Publisher-in-Chief]

Frequently, we hear the axiom that asset allocation is the most important investment decision, explaining 93.6% of portfolio returns. The presumption has been that once the risk tolerance and time horizon have been established, investing is simply a matter of implementing a fixed mix of stocks, bonds, and cash using mutual funds selected for this purpose. This axiom is based on a famous study by Brinson, Hood, and Beebower (BHB) published in the Financial Analysts Journal in July/August 1986. It is the stuff of most modern business school and graduate students in economics and finance.

Enter the Critics

One critic claims that BHB’s conclusions and the interpretation of their conclusions are wrong, stating that because of several methodological problems, BHB needed to make certain assumptions for their analysis to go forward. They assumed that the average asset-class weights for the 10-year period studied are the same as the actual normal policy weights; that investments in foreign stocks, real estate, private placements, and venture capital can be proxied by a mix of stocks, bonds, and cash; and that the benchmarks for stocks, bonds, and cash against which fund performance was measured are appropriate. The author believes that each of these assumptions can lead to a faulty measurement of success or failure at market timing and stock selection.

The Jahnke Study

William Jahnke claims that BHB erred in their focus on explaining the variation of quarterly portfolio returns rather than portfolio returns over the 10-year period studied. According to the study, asset allocation policy explains only a small fraction of the range of 10-year portfolio returns earned by the pension funds reported in the study. The author concluded that this discrepancy is caused by the effect of compounding returns. He adds that BHB were wrong to use variance of quarterly returns rather than the standard deviation. Use of standard deviation would reduce the often cited 93.6% to about 79%. Moreover, BHB did not consider the cost of investing, such as operating expenses, management fees, brokerage commissions, and other trading costs, which are more significant for individual investors than for the pension plans studied. Jahnke claims that excessive costs can reduce wealth accumulation by 50%.

Note: (“The Asset Allocation Hoax,” William W. Jahnke, Journal of Financial Planning, February 1997, Institute of Certified Financial Planners [303] 759-4900).

Assessment

Finally, the author takes issue with establishing long-term fixed asset class weights. Asset allocation should be a dynamic process. Higher equity return expectations should in turn produce larger equity allocations, other things being equal.

Certified Medical Planner

Conclusion

Are doctors different than the average investor noted in this essay?

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Weak Laws and Lenient Enforcement Plague Missouri’s Oversight of Dangerous Doctors

Understanding the Faulty Oversight of Dangerous Doctors?

By Karen Weise
ProPublica, Dec. 13th, 2010, 11:36 am

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Patients in Missouri face a double whammy of the state’s faulty oversight of dangerous doctors — Missouri law limits the state medical board’s authority to disciple them, and the board doesn’t fully exercise the rights it does have.

St. Louis Post-Dispatch’s Series

These are latest [1] findings in the St. Louis Post-Dispatch’s series looking at the lack of information available to patients [2] about the doctors and hospitals that treat them. “Leniency and secrecy are the rule when it comes to policing Missouri’s 22,000 doctors,” the paper wrote.

The state’s Board of Registration for the Healing Arts makes public little information on doctors [3]. The board doesn’t release information on its own warning letters, on malpractice cases, on restrictions by hospitals or even where a doctor went to medical school. It seldom researches cases that challenge the quality of care, and it never uses its power to immediately suspend doctors, the paper found.

State laws also hamper the board’s oversight. It’s hard to discipline a doctor for one negligent incident, and unlike in most states, Missouri law does not give the board absolute authority over discipline. Instead, it must reach a settlement with a doctor or bring the case before commission in a litigious process that can drag on for years. Meanwhile, doctors continue to practice. Because the process is so long, the board often settles, the paper said.

A Longstanding Problem

This isn’t a new problem for Missouri. The paper wrote: A Post-Dispatch investigation 30 years ago found Missouri was lax in its policing of doctors. Soon after, the legislature changed the board’s makeup to include one non-physician — a “public” member — to represent patients’ interests. For a time, the board became more stringent, but the trend seems to have reversed, and the board is among the least active in the nation.

Assessment

No board members would comment to the Post-Dispatch, though board staff told the paper that it hands were generally tied by the state’s laws. The problematic oversight of doctors echoes much of what ProPublica found in our series looking at the lack of discipline of nurses [4] around the country.

Link: http://www.propublica.org/blog/item/weak-laws-and-lenient-enforcement-plague-missouris-oversight-of-dangerous-d

Conclusion

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Grading Texas Lawmakers on Patient Privacy

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Grade Spread Runs Gamut from F to A+

[By D. Kellus Pruitt DDS]

Are the interests of my dental patients in Fort Worth, Texas being adequately represented by their elected officials in Austin and Washington DC? Starting a few months ago, I’ve sent multiple emails concerning patient privacy and identity theft to my elected government officials on state and national levels; as a test of responsiveness.

The Elected Officials

These include:

  • Texas US Senators John Cornyn and Kay Bailey Hutchison
  • US Representatives Joe Barton and Michael Burgess
  • Texas State Senators Wendy Davis and Chris Harris
  • Texas State Representatives Diane Patrick and Marc Veasey.

Of the 8 lawmakers I contacted through their Websites, I received no response from state officials Davis, Harris, Patrick and Veasey. However, from my national representation, only Joe Barton failed to reply. I simply have to give those 5 a grade of F. I assumed my state representatives would be more patient-friendly than members of the US Congress. But, I was wrong.

Texas US Senators 

US Senator Cornyn has responded twice: Once in September and again on December 6. In both emails he says,

“Dear Darrell Pruitt,

Thank you for contacting my offices. Your correspondence has been received, and we will respond to you as quickly as possible.”

I suppose there’s still hope for a response, but he also failed. Cornyn also earned an F.

On the other hand, I’m more disappointed with Kay Bailey Hutchison’s staff than John Cornyn’s. In all 3 of her identical responses to my emails, she addresses me as “Dear Friend,” before wasting my time with a vanilla lecture about the origin and intention of the HITECH Act that I can get from HHS:

“The HITECH Act includes privacy and security provisions to expand current requirements under the Health Insurance Portability and Accountability Act (HIPAA) and strengthens the HIPAA privacy rule, blah, blah, blah.”

If Hutchison’s staff member had read the first paragraph of any of the three emails I sent before he or she assigned me the same canned response all three times, the bonehead would have recognized that an explanation of HIPAA was not what I needed from his or her boss. I’m pretty sure I know more about HIPAA than the Senator, and that is the reason I wrote her in the first place.

Senator Hutchison closed all three emails with,

“I appreciate hearing from you, and I hope that you will not hesitate to contact me on any issue that is important to you. Sincerely, United States Senator Kay Bailey Hutchison”

Then she added,

“PLEASE DO NOT REPLY to this message as this mailbox is only for the delivery of outbound messages, and is not monitored for replies.”

Although I should have known better, following her dead-end reply, I returned to her Website and complimented the Senator for being my patients’ first elected official to respond to my emails. I told Kay Bailey how special her personal attention made me feel as an American… which attracted the same response, which quickly stopped that special feeling. Compared to Hutchison’s predictable responses, Senator Cornyn’s thin promises of a meaningful response some day don’t look so bad. Hutchison gets an F, but I’ll upgrade Cornyn to a D for incomplete.

Enter Dr. Michael Burgess 

And then there is Michael C. Burgess. Compared to this man, everyone else is just a failing politician, in my opinion. Dr. Burgess gets an A+.

In response to both emails I sent to US Representative Michael Burgess MD in the last few weeks, I received sincere, personalized responses. This week, I sent Dr. Burgess a copy of the timely comment I posted Tuesday on this Medical Executive-Post, “Is ‘encryption of PHI’ discussed in dentistry?”

https://medicalexecutivepost.com/2010/12/07/%e2%80%9cthe-ada-practical-guide-to-hipaa-compliance%e2%80%9d/#comment-9242

While Senator Hutchison is unaware that her staff is asleep, and while I’ve been waiting for John Cornyn to get back in touch with me for months, Congressman Burgess’ meaningful and personalized response arrived within 48 hours on Thursday:

Dear Dr. Pruitt:

Thank you for your continued correspondence regarding your concerns for privacy as it relates to health information technologies (HIT). I appreciate hearing from you on this matter.

I assure you that I understand the concerns you have that the implementation of HIT will have harmful effects on patients’ privacy, specifically as it relates to dentistry. As problems arise, I will work closely with the Department of Health and Human Service as well as organized dentistry to make sure that these problems are dealt with quickly and efficiently so that patients continue to receive the rights guaranteed to them in HIPAA.

As one of the few Members of Congress who have run a medical practice and been required to meet HIPAA, I take your concerns to heart and will be vigilant in my oversight.

Again, thank you for taking the time to contact me. I appreciate having the opportunity to represent you in the U.S. House of Representatives. Please feel free to visit my website (www.house.gov/burgess) or contact me with any future concerns.

Sincerely,

Michael C. Burgess, MD

[Member of Congress]

—————————–

So of those 8 elected officials from the Dallas /Ft. Worth area, who you think, I should trust with my patients’ interests next time I vote?  As for my state representatives whom I could run into almost anywhere in my community, they never bothered responding at all.

For months, I’ve emailed Diane Patrick more times than any other lawmaker. Long ago, I assumed that since she is married to a dentist, she might have natural interest in the welfare of dental patients. I was wrong. Even though the Fort Worth District Dental Society supports her campaigns, I have to wonder why?

Assessment 

And as for Marc Veasey, I met the man once, but I don’t think he remembers me. His campaign office is four doors down the hall from me as I type Tip O’Neal’s quote. “All politics is local.”

Conclusion

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“A Guide to Sound Money”

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Where Are the Financial Crisis Prosecutions?

The White Collar Slump?

By Jesse Eisinger
ProPublica: jesse@propublica.org

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You may have noticed that prosecutors in this country are in something of a white-collar slump lately.

The stock options backdating prosecutions have largely been a bust [1], not because it wasn’t a true scandal. The Securities and Exchange Commission and the Justice Department investigated more than 100 companies. Over a hundred took accounting restatements. Yet only a handful of executives went to prison, with some high-profile cases fizzling out. Prosecutors also stumbled in other high priority corporate fraud prosecutions, like the KPMG [2] tax shelter and the stock-exchange specialists [3] cases.

Bear Sterns

The most spectacular prosecutorial flameout [4] was the case against the Bear Stearns hedge fund managers. The consequences of that disaster are still reverberating. The United States attorney’s office in Brooklyn rushed to haul low-level executives in front of a jury based on a few seemingly incriminating emails. The defense was easily able to convince jurors that these represented only out-of-context glimpses of fear as markets swooned, not a conspiracy to mislead. But, now we have a supposedly new push: the insider trading scandal.

Insider Trading

The United States attorney in Manhattan, Preet Bharara, and the United States Attorney, General Eric H. Holder Jr., are hyping their efforts. “Illegal insider trading is rampant and may even be on the rise,” Mr. Bharara dubiously pronounced in a speech [5] in October. The Feds are raiding [6] hedge funds and publicly celebrating their criminal investigations related to insider trading.

The storyline is that Wall Street now lives in fear. Hedge fund managers’ phones might be tapped, any stray remark is suspect, and old trades are being exhumed so that the entrails can be examined.

In fact, plenty of folks on Wall Street are happy about the investigation. A scant few — the ones with clean consciences — like the idea that the world of special access to favorable tips is being cleaned up.

But others are pleased for a different reason: They realize the investigation is a sideshow.

All the hype carries an air of defensiveness. Everyone is wondering: Where are the investigations related to the financial crisis?

Enron, Lehman, Merrill, Citigroup and Others

John Hueston, a former lead Enron prosecutor, wonders: “Have they committed the resources in the right place? Do these scandals warrant apparent national priority status?”

Nobody from Lehman, Merrill Lynch or Citigroup has been charged criminally with anything. No top executives at Bear Stearns have been indicted. All former American International Group executives are running free. No big mortgage company executive has had to face the law.

How about someone other than the Fabulous Fab [7] at Goldman Sachs? How could the Securities and Exchange Commission merely settle with Countrywide’s Angelo Mozilo [8] — and for a fraction of what he made as CEO?

The world was almost brought low by the American banking system and we are supposed to think that no one did anything wrong?

The most common explanation from lawyers for this bizarre state of affairs is that it’s hard work. It’s complicated to make criminal cases in corporate fraud. Getting a case that shows the wrong-doer acted with intent — and proving it to a jury — is difficult.

But, of course, Enron was complicated too, and prosecutors got the big boys. Ken Lay was found guilty (he died before he served his time). Jeff Skilling is in prison now, though the end result was bittersweet for prosecutors when much of his conviction was overturned by the Supreme Court. WorldCom’s Bernie Ebbers and Tyco’s Dennis Kozlowski are wearing stripes.

Complicated Cases

Sure, it takes time to investigate complicated cases. Many people think that the SEC, at the least, will bring some charges against top executives at Lehman Brothers. The huge, ground-breaking special examiner’s report [9] on Lehman Brothers laid bare problems with Lehman’s accounting. But that report came out back in March — on a bank that blew up more than two years ago. That seems awfully slow.

The most popular reason offered for the dearth of financial crisis prosecutions is the 100-year flood excuse: The banking system was hit by a systemic and unforeseeable disaster, which means that, as unpleasant as it may be to laymen, it’s unlikely that anyone committed any crimes.

Stupidity is No Crime

Or, barring that wildly implausible explanation (since, indeed, many people saw the crash coming and warned about it), the argument is that acting stupidly and recklessly is no crime.

As I ride the subway every morning, I often fantasize about criminalizing stupidity and fecklessness. But alas, it’s not to be.

Nevertheless, it’s hardly reassuring that bankers, out of necessity, have universally adopted the dumb-rather-than-venal justification. That doesn’t mean, however, that the rest of us need to buy it. It’s shocking how pervasive and triumphant this narrative of the financial crisis has been.

Link: http://www.propublica.org/thetrade/item/where-are-the-financial-crisis-prosecutions/

Assessment

Just as it’s clear that not all bankers were guilty of crimes in the lead-up to the crisis, it strains credulity to contend no one was. Corporate crime is usually the act of desperate people who have initially made relatively innocent mistakes and then seek to cover them up. Some banks went down innocently. Surely some housed bad actors who broke laws.

As a society, we have the bankers we deserve. Sadly, it’s looking like we have the regulators and prosecutors we deserve, too.

Conclusion

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Doctors – Are You Preparing for Retirement [A Voting Opinion Poll]?

ME-P Voting Poll with Survey

By Dr. David Edward Marcinko FACFAS,  MBA, CMP™

[Publisher-in-Chief]

www.CertifiedMedicalPlanner.com

As a physician-focused financial advisor, I know that for those medical professionals between the ages of 45 to 54, the thought of retirement should be popping up a few times these days.

And, for doctors between ages 55 and 64, the thought may be taking on urgent tones about now!

In fact, many of us are reconciling to the idea that it may be a fact that we have to either postpone our retirements or live a much simpler life during retirement. Whatever the thoughts may be, what’s driving them is our preparedness to retire.

And so, we’d appreciate your vote and comments, too!

Disclaimer: I am a reformed Certified Financial Planner®, Series 7 [stock-broker], 63 and 65 license holder, and RIA representative who also held all applicable insurance and security licenses.

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Dental Therapists [Emerging New Providers?]

Coming to a State Near You

By D. Kellus Pruitt DDS

The topic of the day in the dental industry concerns the recent WK Kellogg Foundation announcement of their $16 million initiative to help dentalcare stakeholders in five U.S. states, including Kansas and New Mexico, develop dental therapist programs similar to Alaska’s experiment in low cost – high risk dentalcare. The project is moving forward because of reportedly excellent results in a 2 year study following 5 therapists who are a couple of years out of high school with 400 hours of training and 300 Alaskan patients in hard to reach places. That’s risky even in the best of conditions in better climates. It doesn’t take many tragedies to eat up the savings from cheap.

A Balanced Article

DrBicuspid.com contributing writer Mary Otto posted a balanced article on the topic titled “More states moving forward with midlevel providers.”

http://www.drbicuspid.com/index.aspx?d=1&sec=sup&sub=pmt&pag=dis&ItemID=306190

In My Opinion

I am very pleased to see ADA President Dr. Raymond Gist making his presence known concerning the dental therapist controversy. At last count, his name has come out on the Internet four times since yesterday – even though the ADA had to pay a lot of money for the press releases. If dentists fail to represent the interests of dental patients, nobody else will.

Assessment

Paid advertisement is not as effective and not as cheap as an ADA Facebook would be, but press releases are certainly better than silence from ADA President Dr. Raymond Gist.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too! Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com and http://www.springerpub.com/Search/marcinko

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December is the Time to Advertise in the ME-P

And Post Job Openings, Too!

By Ann Miller RN MHA

[Executive Director]

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With the holiday season officially upon us, many BDs, RIAs, medical clinics, offices and hospital HR departments are going into stand-down mode when it comes to hiring, turning their attention instead to end-of-the-year concerns such as final budget numbers, performance reviews, and employee benefits analysis, to name just a few. The rationale from many is pretty much the same-scheduling interviews around the holidays are difficult, particularly with staggered vacation schedules and shortened workdays. And, here at the ME-P we completely understand that line of thinking. Here’s the thing, though.

Seeking Employment

In addition to braving the shopping mall crowds, imbibing too much eggnog, and standing under the mistletoe, can you guess what (both passive and active) job seekers with some extra down time tell me they plan to do over the holidays? Yep. Look for a new job.

Not only do I hear this directly from the candidates themselves, but job seekers are definitely looking for the gift of an exciting new opportunity during the month of December. But wait–it’s great that job seekers are looking during the holidays, but what about the staggered vacation schedules and shortened workday dilemma we just agreed existed? Here’s what I suggest. Post your current and upcoming job opportunities this month to take advantage of the increased attention span of potential candidates. And, then set up a friendly, “so glad you’re interested” auto-reply that lets the candidates know you’ll be reviewing applications when you return in January.

Job Link: https://medicalexecutivepost.com/2007/11/28/classified-advertisement-section/

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Benefits

The benefits to this approach are many, according to HR guru Gwen Dowling:

  1. You’ll get a jump-start on the 2011 hiring process returning to an Inbox full of eager applicants.
  2. You’ll get a broader candidate pool since both active and passive job seekers will have time to apply over the holidays.
  3. You’ll gain a competitive edge over the hiring team at the BD, RIA, clinic or hospital down the street, who didn’t read this blog post and plan to wait and post those jobs in January, 2011.

Conclusion

And while we’re on the topic, in order to attract the very best candidates, an effective job posting must be written with the candidate in mind, painting an attractive picture of your corporate environment and culture. This is your only chance to make a positive first impression, so take the time necessary to craft an enticing description.

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“The ADA Practical Guide to HIPAA Compliance”

Book Review – Dark, Dark Reading

By Darrell K. Pruitt DDS

Complying with HIPAA is an investment in the future of your dental practice. HIPAA Privacy sets forth requirements regarding the proper protection, use, and disclosure of patient information. HIPAA Security addresses using and protecting electronic patient information and the electronic technology that can save time, increase revenues, and improve workflow.” So are those evidence-based claims or an advertisement in the $250 ADA publication I purchased?

On Being Leary 

I’ve learned to be wary when dentalcare stakeholders like authors Ed Jones and Carolyn P. Hartley call HIPAA an “investment in the future of your practice” much like I would advise people to be wary of a dentist who sells cosmetic veneers by calling it an “investment in your smile!” All too often it turns out to be an investment in the dentist’s smile.

Unsupported Claims

Contrary to the authors’ unsupported claims in the Introduction of “The ADA Practical Guide to HIPAA Compliance,” there is no evidence that electronic technology saves time, increases revenues or improves workflow in dental offices. And even though Jones and Hartley mention “investment” numerous times in their HIPAA guide, how smart is it for a dentist to sink money into expensive electronic technology that demands mind-numbing documentation (even if it’s done on a computer); that exposes a practice to government inspections which carry liabilities up to $1.5 million even before state attorneys general get involved; that endangers the long-term welfare of both the dental practice as well as dental patients, and that promises no financial return? So just how smart is a HIPAA investment in the future of one’s practice?

Disaster Recovery 

I wasn’t far into Jones and Hartley’s imaginative guide to HIPAA compliance before reading other long-since rejected selling points that are so lame that even rookie eDR vendors know better than to attempt them. The authors’ naïve claim of the digital advantage of easier “disaster recovery” from a fire or hurricane is a good example of ADA-approved HIT fiction. Just ask yourself why disaster recovery was hardly a concern throughout the history of dentistry until the ADA leadership mindlessly bought in to promoting paperless practices and suddenly needed selling points in the worst way.

ADA Slogan

“Dentistry is healthcare that works”.

Beware

Any time dentalcare stakeholders trot out solutions, before asking the price, dentists should determine that there is indeed a corresponding problem that needs to be solved. Here is a simple marketplace test of Jones and Hartley’s disaster recovery claim: Which is cheaper: Disaster recovery insurance or data breach insurance? Common sense says that dentists’ offices are much more likely to be hit by burglars than fires and hurricanes. When burglars break into dentists’ offices, they don’t go for filing cabinets and ledger cards. They steal computers that can contain thousands of patients’ identities. As for the small percentage of US dentists whose offices are located in coastal cities and vulnerable to hurricanes, perhaps those dentists should maintain both digital and paper patient records. After all, which kind is easier to read during power failures that are common with hurricanes as well as ice storms – which occur much more frequently and throughout the nation?  What’s more, pegboards and ledger card boxes in a paper-based practice are not only hack-proof, but their use is unaffected when Internet servers go down, or are hacked. Confused yet? 

“You may decide to engage a technology consultant at some point, but after reading this book, you’ll have specific reasons for that engagement.”

Still Not a Fan

I’m not a fan of creative writers Ed Jones and Carolyn P. Hartley’s style of humor, but I needed a few continuing education credits and decided to pick up 8 easy hours through the ADA by purchasing their HIPAA guide and accompanying test. After finally conquering the first 2 bureaucratic-tedious chapters, it’s a pretty sure bet that I’ll try to wing it on the test long before getting through all 360 pages – many with footnotes even.

In the Minority 

I think studying for a CPA exam would be more riveting reading for me, as well as perhaps more meaningful for my dental patients – even if I were a HIPAA-covered entity. But since I’m one of the 4% of dentists in the nation who still doesn’t store or transmit patients’ protected health information (PHI) in slippery digital form, I never have to worry about attracting a subjective inspection because of my highly visible opinions about the absurdity of HIPAA in dentistry. Fines for being “willfully negligent” start at $50,000, and my transparent lack of respect for the Law would understandably trigger an inspection if I were a HIPAA-covered entity.

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HIPAA Flexibility 

On the other hand, since the HIPAA Rule is “flexible” by design, and HIPAA-covered dentists can be charged with huge fines – the other 96% of dentists in the nation who use computers in the business office have good reason to be careful about exercising their basic freedoms in the land of the free. It’s easy to see why covered entities aren’t complaining. Not to worry. As always, Proots has your six, good buddy. Are flexible laws really in American citizen’s best interest?

Although authors Jones and Hartley repeatedly point out that the HIPAA Rule’s flexibility is its beauty – even to the extent of allowing dentists to decide whether or not to notify their patients of a breach – dentists simply must be warned of the dangers that are inherent in vague laws: Flexibility for the dentist always means subjectivity for the inspector. History has shown us that subjectivity is dangerous in the hands of poorly-trained people with badges working on commission. The odds of fair treatment following even a self-reported data breach are not in a dentist’s favor. Even the simplest investigation by HHS representatives will cost a dentist at least $100 – even if the dentist is determined to be innocent of a baseless complaint – perhaps filed by a disappointed patient or employee.

Investigations and Violations 

“Violation Category (A) Did Not Know:  For a violation in which it is established that the Covered Entity did not know and, by exercising reasonable diligence, would not have known the Covered Entity violated such provision [$100-$50,000 per violation]. Chapter 2, page 20. HHS Secretary Kathleen Sebelius promised Congress that she intends to efficiently investigate every complaint against providers and vows to stop data breaches through stricter enforcement of the (hazy) HIPAA Rule – starting real soon. How is that not tyranny?

HITECH Subjectivity?

The ADA’s guide to HIPAA compliance has reaffirmed to me that HITECH HIPAA is a subjective law designed for abuse by those who created it. What’s more, eDRs provide NOTHING to dental care that has not been adequately and safely handled by conventional means of communication for decades at far lower costs. Sooner or later, the sudden news about HIPAA’s absurdity in dentistry is going to hit the HIT market like a brick. Following that flash of honesty, anyone who doesn’t agree that HIPAA is absurd in dentistry will do so at risk of snickers. So how complicated is compliance?

Chapter One: Dentist’s Obligations 

Chapter 1, page 1: “This book is concerned with only a portion of [Public Law 104-191]: Subtitle F — Administrative Simplification, hereinafter referred to as ‘HIPAA.’” Later in Chapter 1, Jones and Hartley use a paragraph to describe dentists’ obligations.

“Adopting Health IT presents challenges as well. For example, a dental practice must research and evaluate available systems, assess the current and foreseeable needs of the practice, negotiate the terms of the contract for the system and related services, including items such as the cost and availability of tech support, the number of licenses and authorized users that the contract will include, and the hardware and software features that enable HIPAA and HITECH compliance. Time and energy must be devoted to training staff to use the electronic health record system. A dental practice adopting an electronic health record should consult its attorney both with regard to the acquisition itself (including any contracts, licenses, and other legal documents) as well as with regard to the legal implications of using an electronic health record (for example, the dental practice should understand what will constitute the legal record and how the electronic health record would affect document retention requirements). A dental practice that intends to take advantage of the HITECH Act Medicare or Medicaid reimbursement incentives must understand and stay abreast of developments regarding the incentives, such as the qualifications of an “eligible provider,” how to demonstrate compliance with the “meaningful use” criteria,  how reimbursement incentives will be structured, and certification criteria of dental information systems.” 

Now do you see why the name “HIPAA” works better for stakeholders than “Administrative Simplification”?

HIT Rot 

As another illustration of how effectively stakeholders have hidden rot in HIT, the most common misspelling of HIPAA is “HIPPA,” and most consumers trustingly assume at least one of the Ps stands for “Privacy.” HIPAA hasn’t been about patient privacy since it was amended 8 years ago, and the P stands for “Portability.” And boy-howdy are digital records ever portable! HIPAA has ceased to be a benevolent law for Americans. It’s become instead a bi-partisan plan to take control of healthcare from healthcare principals and award it to healthcare stakeholders such as the HIT industry.

Assessment

You’ll spend a good amount of time implementing the Security Rule in your dental practice, but it’s the maintenance measures that will keep you in compliance.” This is a beautiful, meaningless point, Ed Jones and Carolyn P. Hartley.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Of WikiLeaks, Politics and eMRs [A Voting Opinion Poll]

Is Reporting for “Accidental” Political Downloads a HIT Security Game-Changer?

By Dr. David Edward Marcinko MBA CMP™

[Publisher-in-Chief]

Recently, I read in The New York Times that Federal workers are being told to avoid the website WikiLeaks and stay away from those classified cables leaked from the US State Department! Classified information, whether or not already posted on public websites or disclosed to the media, remains classified, and must be treated as such by federal employees and contractors”,  the Office of Management and Budget [OMB] said in a notice sent out last Friday.

Link: http://www.msnbc.msn.com/id/40512200/ns/us_news-wikileaks_in_security

Of Advice … Not Threats?

According the release, The New York Times was told by a White House official that it does not advise agencies to block WikiLeaks or other websites on government computer systems. Nor does it bar federal employees from reading news stories about the leaks! But – and this is a big one – if they “accidentally download” any leaked cables, they are being told to notify their “information security offices.”

Too Many Conflicting Questions 

  • Is document leaker PFC Bradley Manning a hero and a real patriot – not the mislabeling of an ACT as THE PATRIOT ACT – or traitor goat? What about Julian Assange – is he a full-disclosure hero or guilty of treason – should he be treated as an enemy combatant of the US Government?
  • How could a mere PFC download a quarter million classified documents without raising a red flag? Is the government incompetent? Has it just issued a not so thinly veiled threat to its own citizens with this admonishment? Are we becoming more like China in our use and restrictions of the Internet? Was the big brother prescience of George Orwell’s 1984, correct?
  • Is the admonishment of security officer notification following “accidental download” akin to the “don’t ask – don’t tell” policy on gays in the armed forces? So much for the transparency we were told our current administration wanted.
  • Should we forget about, or modify, the eMR privacy debate and/or should HIPAA be modernized?
  • Should Hillary Clinton resign?

Health Care Security Questions

  • Who exactly is a government employee anyway? And, does this include workers in the VA system, prison health system, Indian Health Service, postal workers, Medicare and Medicaid recipients, school kids with government meal subsidies and/or independent contractors and recipients of budgetary pork projects, US tax credits or federal unemployment benefits, etc?
  • Have these employed folks signed a HIPAA-like “business associate agreement” with Uncle Sam? Should government workers close their eyes and ears, too! And, with the expansion of federal government, does this mean that even more folks will have access to classified information [and more accidental downloads] than ever before? Who is left and allowed to read WikiLeaks and who is actually immune, or not?
  • If government can not protect its own data, records, confidential information or websites with certainty, how does it expect a solo medical professional [DPM, DO, DDS, DC, etc] to do the same with eMRs, and at what cost! HIPAA rules and regulations spell ou very specific health policy mandates and onerous legal punishments and fines for protected health information [PHI] data breach don’t they; not just the notification of a Chief Medical Information Security Officer [CMISO]. Is this a federal double standard?

Historical Re-Do

Federal employees were told to not read the Pentagon Papers. The leaker, economist Daniel Ellsberg PhD, precipitated a national controversy in 1971 when he released them. The right of the press to publish the papers was upheld in New York Times Co. v. United States. As a response, the Nixon administration began a campaign against further leaks – and  a smear campaign against Ellsberg personally – by creating the White House “plumbers”, which in turn led to the Watergate burglary of the LA office of Dr. Lewis Fielding MD [Ellsberg’s psychiatrist] in an effort to discredit him. According to Ellsberg;

“The public is lied to every day by the President, by his spokespeople, by his officers. If you can’t handle the thought that the President lies to the public for all kinds of reasons, you couldn’t stay in the government at that level, or you’re made aware of it, a week … The fact is Presidents rarely say the whole truth—essentially, never say the whole truth—of what they expect and what they’re doing and what they believe and why they’re doing it and rarely refrain from lying, actually, about these matters.”

Note: “Presidential Decisions and Public Dissent”, Conversations with History, July 29, 1998].

Now … Four Decades Later

Has anything changed since the above scandal? Almost forty years later, those with security clearance across the board were given this same directive about WikiLeaks. Will they comply; nope! Did little Johnny refrain when his mother told him not to read Playboy magazine; of course not! The surest way to perusal, or unwanted behavior, is prohibition. Just tell someone NOT to do something, and watch that activity increase.  Human nature is human nature. Recall, the 18th. amendment [1919-1933] was repealed by the 21st. amendment whose 77th. anniversary is celebrated just this week.  

Assessment

Look, like most traditional news organizations and journalists, we at the ME-P fiercely advocate for our First Amendment Rights. Anyone looking at classified information without clearance, while not necessarily illegal when posted by a media organization, is considered to be making an “ethics” violation of the rules of secrecy as established by the intelligence community. And, we always strive to be ethical as part of our Judeo-Christian heritage.

But, citizens and members of the fourth estate are not in the intelligence community. What does this mean for average citizens and private doctors … nothing at all. What a HIPAA breach means to a medical professional however, is another serious matter! Fear the government’s admonition: Do as I say – Not as I do. Use paper medical records; eschew eMRs?

Voting Poll and Survey

Conclusion

Is reporting for “accidental” downloads, or security breaches, an HIT security game-changer? Your thoughts and comments on this ME-P are appreciated. Is WikiLeaks like eMR security; more potentially legal and economically damaging to the leaker than the outed? What about Julian Assange and the need to revise the HIPAA statutes? Is there an analogy here; or not?Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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How to Monitor Hedge Funds

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Four Ways to Monitor after Purchase

By Dr. David Edward Marcinko MBA, CMP™

www.CertifiedMedicalPlanner.org

[Publisher-in-Chief]

Hedge funds (broadly defined as private investment vehicles that trade a variety of long and short equities, derivatives, futures contracts, and options in a variety of capital markets) have grown in size and importance in client portfolios because of superior performance, until of late [2008-09], and readily available investor capital.

Risk Factors

Physicians and clients often ask us to assess certain risk factors and a variety of investment entity structural characteristics associated with hedge funds. Accordingly, we must often be involved in discussing clients’ specific risk/return desires and expectations as they consider such investments.

Four Key Post-Investment Issues:

  1. A change in core investment strategies or risk postures from those which are documented in the investment policy statement—Among these are the specific markets to be traded, the degree of financial leverage to be employed or allowable, the underlying instruments or contracts to be used, and the investment strategies to be pursued under various conditions. Hence, there is no substitute for careful and regular assessment by the planner of changes in how and what an investment manager is trading and communication of such to the client.
  2. Use of financial leverage can dramatically increase returns just as poor performance can be accentuated—The key issue for the planner is whether a given investment manager’s use of leverage changes over the life of the hedge-fund investment, thereby possibly affecting the client’s initial desired risk/return profile.
  3. The composition of the performance return, particularly with respect to the long-term capital gain component.
  4. Asset growth—Regularly monitor and evaluate whether it is detrimental to performance and capable of causing an erosion of performance over a long-term horizon.

Assessment

www.CertifiedMedicalPlanner.org

Often, after a hedge-fund investment has been made, if performance over time is good (or even adequate), both the doctor client and the financial advisors or planner may assume that there has been no material changes in investment strategy or structural characteristics that warrant attention or concern. Such changes often occur subtly over time and, if performance erodes, and the client may feel that the planner did not adequately monitor the investment. Hence the necessity for the above warning post

Note: “Post investment Issues Regarding Hedge Funds,” by Richard L. Fisher, Personal Financial Planning, November/December 1996, pp. 14–19, Warren, Gorham & Lamont, 1-800-950-1205.)

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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About Our Newest Practice Management Book

MEDICAL PRACTICE MANAGEMENT EDUCATION:
The Business of Medical Practice [Transformational Health 2.0 Skills for Doctors]

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Front Matter BoMP – 3

David E. Marcinko; Hope Rachel Hetico
December 2010 – 750 pp Hardcover (C) 2011
ISBN: 9780826105752  – Price: $95.00 

Reach the Executive Decision-Makers!

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Why You’re Better off with Variable Annuities than Mutual Funds?

Investing Under the Umbrella

By Dr. David Edward Marcinko MBA, CMP™

[Editor-in-Chief]

http://www.CertifiedMedicalPlanner.org

While participation in savings programs such as 401(k), 403(b), IRAs, and SEPs were at record numbers before the “flash-crash” of 2008-09, each of these plans is subject to a contribution cap.

Consequently, investors are always looking for tax-efficient methods to save more for retirement; especially medical professionals as the economy improves as it has been doing of late. Many have turned, or continue to use, mutual funds. In fact approximately 47% of mutual fund assets are composed of nonqualified funds. And, investors tend to buy mutual funds on the basis of before-tax performance rankings.

Enter the VAs

But these folks might far better off with variable annuities [VAs] according to C. Michael Carty and Robert E. Skinner in the article “Variable Annuities vs. Mutual Funds” (Financial Planning, November 1996, pp. 75–84, Securities Data Publishing, Inc). In fact, they present a strong case for investing in variable annuities (said to operate under an umbrella that protects them from current taxation and inflation) as compared to mutual funds, which may continue today.

The Dickson-Shoven Study

Carty and Skinner refer to a 1993 study by Dickson and Shoven conducted at Stanford University in which mutual funds were ranked on an after-tax basis. The change in relative rankings was dramatic. Dickson and Shoven concluded that:

  • Investors should always use after-tax rankings to evaluate and select mutual funds.
  • Given two investments with similar pretax returns, an investor should select the one involving fewer taxes.
  • A variety of approaches to sheltering or deferring taxes should be considered.

And, in one of the first comparison of returns between variable annuities and mutual funds, Rodney Rhoda of Fidelity Investments demonstrated that the difference in expense charges between variable annuities and mutual funds are less than one would expect because of lower variable annuity trading costs and a more stable asset base, which is usually more fully invested.

Assessment

I am not a fan of VAs as several essays in this ME-P suggest. Fees, expenses, loads and commissions are just too darned high.  And, most are sold, not bought.

However, the authors demonstrated that under either lump-sum or gradual withdrawal assumptions, variable annuities consistently beat mutual funds, particularly for medium to high tax-bracket investors who achieve only median investment performance. Low tax-bracket investors who achieve average or lower investment performance benefit least from variable annuities. Also, variable annuities have been shown to be more likely to withstand the ravages of inflation.

And so, the conundrum continues.

Conclusion

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Settlement Reached with Temple University Health System

Diversion of Controlled Substances

By Anonymous

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NOV 01, 2010 — PHILADELPHIA – The Temple University Health System (“TUHS”), today, agreed to pay $130,000 to the U.S. government for failing to keep proper receiving, dispensing and inventory records of controlled substances, and failing to take effective precautions to prevent theft or loss of controlled substances, announced United States Attorney Zane David Memeger. In addition, TUHS agreed to implement a detailed Compliance Assessment Plan to review and monitor its policies and procedures relating to controlled substances.

“Hospitals must have effective controls to prevent and detect drug diversion, in order to
prevent people from suffering significant physical harm, addiction or death when they use controlled substances without appropriate supervision from their doctor”,
Memeger said.

Back to 2004

In 2004, Temple University Hospital’s lack of control over controlled substances allowed its then chief resident of anesthesiology to steal 107 vials of Ketamine and smaller amounts of Fentanyl, Midazolam and Morphine. The resident doctor, who attempted to sell the drugs to an undercover Drug Enforcement Administration (DEA) operative was charged and convicted. In addition, from January 2007 to February 2007, an anesthesiologist at Jeanes Hospital, a Temple University Health Systems facility, manipulated the computerized controlled substance distribution system to extract 35 vials of Fentanyl and five vials of Morphine for his own personal use. DEA Special Agent in Charge John J. Bryfonski stated:

“The public expects our health professionals to honor their oath and follow both regulations and the law to assure the health and safety of the people they treat. When these professionals depart from their oath and the law by diverting controlled substance-pharmaceuticals from legitimate medical uses to illegal uses, DEA will investigate and hold them accountable.”

The DEA Audits

Following these thefts, DEA audited five Temple University Health Systems facilities and found that the hospital failed to keep dispensing records for certain controlled substances; failed to note on the required DEA form the number of packages of controlled substances the pharmacy received and the date it received them; failed to verify the amount of controlled substances coming into the pharmacy on each invoice; and kept inaccurate inventory of certain controlled substances.

Stricter Future Controls

TUHS voluntarily initiated changes to their drug dispensing system, to provide stricter measures for accessing the medication and frequent counts of the facilities’ inventory. In addition to the monetary settlement, TUHS agreed to implement an innovative Compliance Assessment Plan whereby an independent consultant will survey the Temple facilities and recommend remedial changes as necessary. The agreement requires TUHS to report to DEA discrepancies revealed during these audits.

Assessment

This resolution is part of the Eastern District of Pennsylvania’s Special Focus team Health Care Fraud initiative. The case was investigated by DEA Philadelphia Division Diversion Group. The case was handled by Assistant United States Attorney Susan R. Becker, Auditor Allison Barnes and Healthcare Fraud Consultant Ray Uhlhorn.

Conclusion

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Is Medicine Still a Sovereign Profession? [A Voting Opinion Poll]

The Social Transformation of American Medicine

By Dr. David Edward Marcinko MBA CMP™

Historical Review, Book Excerpts and ME-P Survey for Modernity

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The Social Transformation of American Medicine [The rise of a sovereign profession and the making of a vast industry].

This classic book was written by Paul Starr in 1984. I first read it while in business school back in 1994-96. Here is an excerpt from pages 227 and 232. It is even more relevant for the healthcare industrial complex today.

Quoting Kenneth Arrow PhD

The structural features Arrow[*] discusses have a history. He writes that when the market fails, “society” will make adjustments. […] But, modern day economists like Austin Frakt PhD and others, have to ask: For whom did the market fail, and how did “society” make these adjustments?

Of Failed Markets

The competitive market was failing no one more than the medical profession, and it was the profession that organized to change it. […]. By the 1920s, the medical profession had successfully resolved the most difficult problems confronting it as late as 1900. It had […] won stronger licensing laws; turned hospitals, drug manufacturers and public health from threats to its position into bulwarks of support; and checked the entry into health services of corporations and mutual societies. It has succeeded in controlling the development of technology, organizational forms, and the division of labor. In short, it had helped shape the medical system so that its structure supported professional sovereignty instead of undermining it.

Master over Diseases

Over the next few decades, the advent of antibiotics and other advances gave physicians increased mastery of disease and confirmed confidence in their judgment and skill. The chief threat to the sovereignty of the profession was the result of this success. So valuable did medical care appear that to withhold it seemed deeply unjust. Yet as the felt need for medical care rose, so did its cost, beyond what many families could afford. Some agency to spread the cost was unavoidable. It would have to be a third party, and yet this was exactly what physicians feared. The struggle of the profession to maintain its autonomy then became a campaign of resistance not only to programs of reform but also to the very expectations and hopes that the progress of medicine was constantly arousing. To continue to escape the corporation and the state meant preserving a system that was at war with itself.

Notes: Arrow, Kenneth J. “Uncertainty and the Welfare Economics of Medical Care.” American Economic Review 53 (December 1963), pp. 941–73. Dr. Arrow is my favorite health economist and indeed father of the profession*.

Link: 1963Arrow_AER

The Opinion Poll [Please Vote]

Conclusion

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How Equity-Based Securities Affect a Physician’s Total Financial Plan

Equity Securities Provide a Portfolio Growth Engine

By Dr. David Edward Marcinko MBA, CMP™

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[Editor-in-Chief]

Equity securities provide growth. Theoretically, the amount of growth potential in an equity security is infinite. A stock’s price appreciation possibilities have no limit. However, a stock’s price can also go to zero and an investor can lose the entire amount invested. Therefore, while stocks contribute long-term growth to a portfolio, they also add risk.

Stock Diversification is Key

Diversification is the best defense against risk, so only a portion of every portfolio should be in stocks. Other investments—fixed income securities; cash equivalents that can be used to take advantage of opportunities or for emergencies; real estate; and even commodities (precious metals, for instance, or securities of companies whose businesses are commodity-based)—should all be considered by the responsible physician-investor or financial advisor as components of a well-rounded, balanced portfolio.

And So is Portfolio Diversification

The stock portfolio itself should also be diversified. Diversify among all types of equity securities such as some large capitalization stocks, some small capitalization stocks, some utilities, some cyclical stocks, some value stocks, some growth stocks, and some defensive stocks. Because it is difficult to adequately diversify an equity portfolio with a small amount of money, consider mutual funds or ETFs for some doctors or financial advisory clients. At least this is the philosophy of our Certified Medical Planner™ [CMP] online educational program.  

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Assessment

Always remember that, because the equity component of the portfolio can be expected to provide more than its proportionate share of the risk of a portfolio, it must be constantly monitored. Also remember that every physician-investor as a different level of risk tolerance, and some may be able to handle ownership of only the most solid and stable equity investments.

Conclusion

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Events Planner: December 2010

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Events-Planner: DECEMBER 2010

By Staff Writers

“Keeping track of important health economics and financial industry meetings, conferences and summits”

Welcome to this issue of the Medical Executive-Post and our Events-Planner. It contains the latest information on conferences, news, and relevant resources in healthcare finance, economics, research and development, business management, pharmaceutical pricing, and physician/entity reimbursement!  Watch for a new Events-Planner each month.

First, a little about us! The Medical Executive-Post is still a relative newcomer. But today, we have almost 175,000 visitors and readers each month from all over the country, in addition to our growing subscriber base. We have been a successful collaborative effort, thanks to your contributions.  As a result, we are adding new resources daily. And, we hope the website continues to provide the best place to go for journals, books, conferences, educational resources, tools, and other things you need to establish the value your healthcare consulting and financial advisory intervention.

So, enjoy the Medical Executive-Post and this monthly Events-Planner with our compliments. 

A Look Ahead this Month – And now, the important dates:

  • December 02-03: The New Face of Medicare Medical Management, New Orleans, LA.
  • December 05-08: National Forum on Healthcare Quality Improvement, Orlando, FL.
  • December 07-08: American Health Care Congress, Irvine, CA.

Please send in your meetings and dates for listing in the next issue of our Events-Planner.

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