SURVEY: Affordable ACA Family Coverage

By MCOL

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Families USA: Uninsured Rate by Quarter •  Q4 2020: 10.3%
 •  Q1 2021: 9.5%
 •  Q2 2021: 9.7%
 •  Q3 2021: 8.9%

Source: Families USA, “ACA’s Promise of Affordable Health Coverage for Families Across America Is at Risk as Pandemic-Era Policies Expire,” March 2022

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Understanding investment banking rules, securities markets, brokerage accounts, margin and debt

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A Primer for Investors and Entrepreneurial Medical Professionals

Dr. David Edward Marcinko; MBA, CMP™

SPONSOR: http://www.CertifiedMedicalPlanner.org

[PART 1 OF 8]

BC Dr. Marcinko

NOTE: This is an eight part ME-P series based on a weekend lecture I gave more than a decade ago to an interested group of graduate, business and medical school students. The material is a bit dated and some facts and specifics may have changed since then. But, the overall thought-leadership information of the essay remains interesting and informative. We trust you will enjoy it.

Introduction

The history, function and processes of the investment banking industry, and the rules and regulations of the securities industry and their respective markets, as well as the use of  brokerage accounts, margin and debt, will be briefly reviewed in this ME-P series.

An understanding of these concepts is required of all doctors and medical professionals as they pursue a personal investment strategy.

INVESTMENT BANKING AND SECURITIES UNDERWRITING

New economy corporate events of the past several years have provided many financial signs and symptoms that indicate a creeping securitization of the for-profit healthcare industrial complex. Similarly, fixed income medical investors should understand how Federal and State regulations impact upon personal and public debt needs. For, without investment banking firms, it would be almost impossible for private industry, medical corporations and government to raise needed capital.

Introduction

When a corporation such as a physician practice management company (PPMC), or similar entity needs, to raise capital for growth or expansion, there are two methods. Raising debt or equity. If equity is used, the corporation can market securities directly to the public by contacting its current stockholders and asking them to purchase the new securities in a  rights offering, by advertising or by hiring salespeople. Although this last example is somewhat exaggerated, it illustrates that there is a cost to selling new securities, which may be considerable if the firm itself undertakes the task.

For this reason, most corporations employ help in marketing new securities by using the services of investment bankers who sell new securities to the general public.  Although the investment banking is an exciting and vital industry, many SEC rules regulating it are not. Nevertheless, it is important for all physician executives to understand basic concepts of the industry if raising public money is ever a possibility or anticipated goal. It is also important for individual healthcare investors  to understand something about securities underwriting to reduce the likelihood of fraudulent investment schemes or ill-conceived transactions which ultimately result in monetary loss.

Fundamentals of the Investment Banking Industry

Investment bankers are not really bankers at all. The fact that the word banker appears in the name is partially responsible for the  false impressions that exist in the medical community regarding the functions they perform.

For example, they are not permitted to accept deposit, provide checking accounts, or perform other activities normally construed to be commercial banking activities. An investment bank is simply a firm that specializes in helping other corporations obtain the money they need under the most advantageous terms possible.

When it comes to the actual process of having securities issued, the corporation approaches an investment banking firm, either directly, or through a competitive selection process and asks it to act as adviser and distributor.  Investment bankers, or under writers, as they are sometimes called, are middlemen in the capital markets for corporate securities.

The medical corporation requiring the funds discuss the amount, type of security to be issued, price and other features of the security, as well as the cost to issuing the securities. All of these factors are negotiated in a process known as known as negotiated underwriting. If mutually acceptable terms are reached, the investment banking firm will be the middle man through which the securities are sold to the general public. Since such firms have many customers, they are able to sell new securities, without the costly search that individual corporations may require to sell its own security. Thus, although the firm in need of  additional capital must pay for the service, it is usually able to raise the additional capital at less expense through the use of an investment banker, than by selling the securities itself.

The agreement between the investment banker and the corporation may be one of two types. The investment bank may agree to purchase, or underwrite, the entire issue of securities and to re-offer them to the general public. This is  known as a firm commitment.

When an investment banker agrees to underwrite such a sale,  it  agrees to supply the corporation with a specified amount of money. The firm buys the securities with the intention to resell them. If it fails to sell the securities, the investment banker must still pay the agreed upon sum. Thus, the risk of selling rests with the underwriter and not with the company issuing the securities.

The alternative agreement is a best efforts agreement in which the investment banker makes his best effort to sell the securities acting on behalf of the issuer, but does not guarantee a specified amount of money will be raised.

When a corporation raises new capital through a public offering of stock, on might inquire from where does the stock come? The only source the corporation has is authorized, but previously un-issued stock. Anytime authorized, but previously un-issued stock (new stock) is issued to the public, it is known as a primary offering. If it’s the very first time the corporation is making the offering, it’s also known as the Initial Public Offering (IPO). Anytime there is a primary offering of stock, the issuing corporation is raising additional equity capital.

A secondary offering, or distribution, on the other hand, is defied as an offering of a large block of outstanding stock. Most frequently, a secondary offering is the sale of a large block of stock owned by one or more stockholders. It is stock that has previously been issued and is now being re-sold by investors. Another case would be when a corporation re-sells its treasury stock.

Prior to any further discussions of investment banking, there are several industry terms that’s should  be defined.

For example, an agent buys or sells securities for the account and risk of another party, and charges a commission. In the securities business, the terms broker and agent are used synonymously. This is not true of the insurance industry.

On the other hand, a principal is one who acts as a dealer rather than an agent or broker. A dealer buys and sells for his own account Finally, the dealer makes money by buying at one price and selling at a higher price. Thus, it is easy to understand how an investment banking firm earns money handling a best efforts offering; they make a commission on every share they sell.

  Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

The Securities Act of 1933 (Act of Full Disclosure)

When a corporation makes a public offering of its stock, it is bound by the provisions of the Securities Act of 1933, which is also known as the Act of Full Disclosure. The primary requirement of  the Act is that the corporation must file a registration statement (full disclosure) with the Securities and Exchange Commission (SEC); containing some of the following items:

  • Description of the business entity raising the money.
  • Biographical data regarding officers and directors of the issuer.
  • Listing of share holdings of officers, directors, and holders of more than 10% of the issuer’s securities (insiders).
  • Financial statements including a breakdown of existing capitalization (existing debt and equity structure).
  • Intended use of offering proceeds.
  • Legal proceedings involving the issuer, such as suits, antitrust actions or strikes.

Acting in its capacity as an adviser to the corporation, the investment banking firm files out the registration statement with the SEC. It then takes the SEC a period of time to review the information in the registration statement. This is the “cooling off period” and the issue is said to be “in registration” during this time. When the Act written in 1933, Congress thought that 20 days would be enough time from the filing date, until the effective date the sale of  securities is permitted.

In reality, it frequently takes much longer than 20 days for the SEC to complete its review. But, regardless of how long it lasts, it’s known as the cooling off period. At the end of the cooling off period, the SEC will either accept the issue or they will send a letter back to the issuer, and the underwriter, explaining that there is incomplete information in the registration statement. This letter is known as a deficiency letter. It will postpone the effectiveness of the registration statement until the deficiency is remedied. Even if initially, or eventually approved, an effective registration does not mean that the SEC has approved the issue.

For example, the following well known disclaimer statement written in bold red ink, is required to be placed in capital letters on the front cover page of every prospectus:

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THESE SECURITIES HAVE NOT BEEN APPROVED OR DISAPPROVED BY THE SECURITIES AND EXCHANGE COMMISSION NOR HAS THE COMMISSION PASSED UPON THE ACCURACY OR ADEQUACY OF THIS PROSPECTUS. ANY REPRESENTATION TO THE CONTRARY IS A CRIMINAL OFFENSE.

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During the cooling off period, the investment bank tries to create interest in the market place for the issue. In order to do that, it distributes a preliminary prospectus, more commonly known as a “red herring”. It is known as a red herring because of the red lettering on the front page.  The statement on the very top with the date is printed in red as well as the statements on the left hand margin of the preliminary prospectus.

The cost of printing the red herring is borne by the investment bank, since they are  trying to market it.. The red herring includes information from the registration statement that will be most helpful for potential medical investors trying to make a decision. It describes the company and the securities to be issued; includes the firm’s financial statements; its current activities; the regulatory bodies to which it is subject; the nature of its competition; the management of the corporation, and what the expected proceeds will be used for. Two very important items  missing from the red herring are the public offering price and the effective date of the issue, as neither are known for certain at this point in time.

The public offering price is generally determined on the date that the securities become effective for sale (effective date). Waiting until the last minute enables the investment bankers to price the new issue in line with current market conditions. Since the investment banker uses the red herring to try to create interest in the market place, stock brokers [aka: Registered Representatives (RRs) with a Series # 7 general securities license –  After a 2 hour multiple-choice computerize test, I held this license for a decade ) will send copies of the red herring to their clients for whom they feel the issue is a suitable investment. The SEC is very strict on what can be said about an issue, in registration.

In fact, during the pre-filing period (the time when the negotiations are going on between the issuer\and underwriter), absolutely nothing can be said about it to anyone.  For example, if the regulators find out that your stock broker discussed with you  the fact that his firm was negotiating with an issuer for a possible public offering, he could be fined, or jailed.

During the cooling off period (the time when the red herring is being distributed), nothing may be sent to you; not a research report, nor a recommendation from another firm, or even the sales literature. The only thing you are permitted to receive is the red herring. The red herring is used to acquaint prospects with essential information about the offering. If you are interested in purchasing the security, then you will receive an “indication of interest”, but you can still not make a purchase or send money.

No sales may be made until the effective date; all that can be used to generate interest is the red herring.

Conclusion

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My Academic “Chair” and “Teaching Philosophy”

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Sooth My Academic Teaching and Classroom Withdrawal Pangs!


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I’m screening for my next university Dean, Chair or teaching Professorship opportunity.

Currently, an endowed Resident-Scholar completing a text book production assignment complete with aligned case models, tests, quizzes, rubrics, curriculum teaching portfolio, and accreditation review.

Two-decades of domestic and international teaching experience and credentials in health economics, finance, investing, business, policy, risk management, IT and administration. Hundreds of peer-reviewed and trade publications [TNTC] with 30 major textbooks redacted in more than a thousand university libraries [NIH, Library of Congress and National Institute Health, etc]. Public and population health global speaker and thought leader. Wall Street experience as start-up founder, entrepreneur and CXO.

Ideal mentor for under graduate thru post-doctoral and fellowship students [PhD, DBA, MD/DO, MHA and MBA, etc].

Compensation important, but fit is paramount as servant-leader.
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FINANCIAL INVESTING RISKS DOCTORS SHOULD KNOW

Types & Definitions

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Financial Investing risk is any of various types of risk associated with financing, including financial transactions that include company loans in risk of default. Often it is understood to include only downside risk, meaning the potential for financial loss and uncertainty about its extent.

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BY DR. DAVID E. MARCINKO MBA CMP®

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SPONSOR: http://www.CertifiedMedicalPlanner.org

Understanding Financial Risk

Although broad investing risks can be quickly summarized as “the failure to achieve spending and inflation-adjusted growth goals,” individual assets may face any number of other subsidiary risks:

  • Call risk – The risk, faced by a holder of a callable bond that a bond issuer will take advantage of the callable bond feature and redeem the issue prior to maturity. This means the bondholder will receive payment on the value of the bond and, in most cases, will be reinvesting in a less favorable environment (one with a lower interest rate)
  • Capital risk – The risk an investor faces that he or she may lose all or part of the principal amount invested.
  • Commodity risk – The threat that a change in the price of a production input will adversely impact a producer who uses that input.
  • Company risk – The risk that certain factors affecting a specific company may cause its stock to change in price in a different way from stocks as a whole.
  • Concentration risk – Probability of loss arising from heavily lopsided exposure to a particular group of counterparties
  • Counterparty risk – The risk that the other party to an agreement will default.
  • Credit risk – The risk of loss of principal or loss of a financial reward stemming from a borrower’s failure to repay a loan or otherwise meet a contractual obligation.
  • Currency risk – A form of risk that arises from the change in price of one currency against another.
  • Deflation risk – A general decline in prices, often caused by a reduction in the supply of money or credit.
  • Economic risk – the likelihood that an investment will be affected by macroeconomic conditions such as government regulation, exchange rates, or political stability.
  • Hedging risk – Making an investment to reduce the risk of adverse price movements in an asset.
  • Inflation risk – The uncertainty over the future real value (after inflation) of your investment.
  • Interest rate risk – Risk to the earnings or market value of a portfolio due to uncertain future interest rates.
  • Legal risk – risk from uncertainty due to legal actions or uncertainty in the applicability or interpretation of contracts, laws or regulations.
  • Liquidity risk – The risks stemming from the lack of marketability of an investment that cannot be bought or sold quickly enough to prevent or minimize a loss.

CITE: https://www.r2library.com/Resource/Title/0826102549

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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About Tombstone Securities Advertising and the “New Issue” Propsectus

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A Primer for Physician Investors and Medical Professionals

By: Dr. David Edward Marcinko; MBA, CMP™

[Editor-in-Chief]

[PART 2 OF 8]

BU Dr. Marcinko

NOTE: This is an eight part ME-P series based on a weekend lecture I gave more than a decade ago to an interested group of graduate, business and medical school students. The material is a bit dated and some facts and specifics may have changed since then. But, the overall thought-leadership information of the essay remains interesting and informative. We trust you will enjoy it.

Introduction

Despite the SEC restrictions, noted in Part I of this series, some idea of potential demand for a new security issue can be gauged and have a bearing on  pricing decisions.

For example, as CEO of a medical instrument company, or interested investor, would you rather see a great deal of interest in a potential new issue or not very much interest?  There is however, one kind of advertisement that the underwriter can publish during the cooling off period. It’s known as a tombstone ad.  The ad makes it clear that it is only an announcement and does not constitute an offer to sell or  solicit the issue, and that such an offering can only be made by  prospectus.  SEC Rule 134 of the 1933 Act  itself, refers to a tombstone ad as “communication not deemed a prospectus”  because it makes reference to the prospectus in the ad. Tombstones have received their name because of the sparse nature of details found in them.

However, the most popular use of the tombstone ad is to announce the effectiveness of a new issue, after it has been successfully issued. This promotes the success of  both he underwriter, as well as the company.

Since distributing securities involves potential liability to the investment bank, it will do everything possible to protect itself.  So, near the end of the cooling off period, a meeting is held between the underwriter and the corporation. It is known as a due diligence meeting. At this meeting they both discuss amendments that are going to be necessary to make the registration statement complete and accurate. The corporate officers, and the underwriters sign, the final registration statement. They have civil liability for damages that result from omissions of material facts or

Mis-statements of fact. They also have criminal liability if the distribution is done by use of fraudulent, manipulative, or deceptive means. Due diligence takes on a whole new meaning when  incarceration from a half-hearted effort underwriting efforts can occur. The investment bank strives to ensure that there have been no material changes to the issuer or the terms of the issue since the registration statement was filed.

Again, as a physician, how would you feel if you were an investment banker raising capital for a new pharmaceutical company that had developed a drug product that was highly marketable. But, on the day after the issue was effective, there was a major news story indicating that the company was being sued for patent infringement? What effect do you think that would have on the market price of this new issue? It would probably plunge. How could this situation have been prevented? The due diligence meeting is more than a cocktail party or a gathering in a smoke filled room. Otherwise, the company would require specially trained people, to do a patent search lessening the likelihood of this scenario. At the due diligence meeting, work is done on the preparation of the final prospectus, but the investment bank does not set the public offering price or the effective date at this meeting. The SEC will eventually set the effective date for the registration and it is on that date that the final offering price will be determined.

Once the SEC sets the effective date, sales may be executed and money can be accepted by the investment bank. It is at this time that the final prospectus, similar to the red herring but without the red ink and with the missing numbers, is issued. A prospectus is an abbreviated form of the registration statement, distributed to purchasers, on and after the effective date of  the registration. It is not the same as the registration statement. A typical registration statement consists of papers that stand more than a foot high; rarely does a prospectus go beyond 40 or 50 pages. All purchasers will receive a final prospectus and then it becomes permissible for the underwriter to provide sales literature.

In addition to the requirement that a prospectus must be delivered to a purchaser of new issues no later than with confirmation of the trade, there are two other requirements that healthcare executives investors should know.

90-day: When an issuer has an initial public offering (IPO), there is generally a lack of publicly available material relating to the operations of that issuer.  Because of this, the SEC requires that all members of the underwriting group make available a prospectus on an IPO for a period of 90 days after the effective date.

4O-day: Once an issuer has gone public, there are a number of routine filings that must be made with the SEC so there is publicly available information regarding the financial condition of that issuer. Since additional information is now available, the SEC requires that, on all issues other than IPOs, any member of the underwriting group must make available a prospectus for a period of 40 days after the effective date.

In the event that the investment bankers misgauged the marketplace, and the issue moves quite slowly, it is possible that information contained in the prospectus would be rendered obsolete by the SEC. Specifically, the SEC requires that any prospectus used more than 9 months after the effective date, may not have any financial information more than 16 months old. It can however, be amended or stickered, with updated information, as needed.

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  Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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Syndication Among Underwriters

Because the investment banking firm may be underwriting (distributing) a rather large dollar amount of securities, to spread its risk exposure, it may form a group made up of other investment bankers or underwriters, known as a syndicate. The syndicate is headed by a syndicate manager, or lead underwriter, and it is his job to decide whether to participate in the offering. If so, the managing underwriter will sign a non-binding agreement called a letter of intent. .

If all has gone well and the market place is sufficiently interested in the security, and the SEC has been satisfied with respect to the registration statement, it is time for all parties to the offering to formalize their relationships with a contract including the basic understandings reflected in the letter of intent. Three principal underwriting contracts are involved in the usual public offering, each serving a distinct purpose. These are the: Agreement among Underwriters, Underwriting Agreement, and the Dealer Agreement.

In the Agreement Among Underwriters (AAU), the underwriters committing to a portion of the issue, enter into an agreement establishing the nature and terms of their relationship with each other. It designates the syndicate manager to act on their behalf, particularly to enter into an Underwriting Agreement with the issuer, and to conduct the offering on behalf of each  of them. The AAU will designate the managing underwriter’s compensation (management fee) for managing the offering.

The authority to manage the offering includes the authority to: agree with the issuer as to the public offering price; decide when to commence the offering; modify the offering price and selling commission; control all advertising; and, control the timing and effectiveness of the registration statement by quickly responding to deficiency letters. Each underwriter agrees to purchase a portion of the underwritten securities, which is known as each under-writer’s allotment (allocation).  It is normally signed severally, but not jointly, meaning each underwriter is obligated to sell his allocation but bears no financial obligation for any unsold allotment of another underwriter. This is referred to as a divided account or a Western account. Much less frequently, an undivided or Eastern account, will be used. Each underwriter is responsible for unsold allotments of others, based upon a  proportionate share of the offering.

The above comments referred to firm commitment underwriting. Another type of underwriting commitment  however, is known as best efforts underwriting. Under the terms of  best efforts underwriting, the underwriters make no commitment to buy or sell the issue, they simply do the best they can, acting as an agent for the issuer, and having no liability to the issuer if none of the securities are sold. There is no syndicate formed with a best efforts underwriting. The investment bankers form a selling group, with each member doing his best to sell his allotment. Two variations of a best efforts underwriting are: the all-or-none, and the mini-max (part-or-none) underwriting. Under the provisions of an all-or-none offering, unless all of the shares can be distributed within a specified period of time, the offering will terminate and no subscriptions or orders will be accepted or filled. Under mini-max, unless a set minimum amount is sold, the offering will be terminated.

SEC Rule 15c2-4 requires the underwriter to set up an escrow account for any money received before the closing date, in the event that it is necessary to return the money to prospective purchasers. If the “minimum”, or the “all” contingencies are met, the monies in escrow go to the issuer with the underwriters retaining their appropriate compensation. In order to make sure that investors are properly protected, the escrow account must be maintained at a bank for the benefit of the investors until every appropriate event or contingency has occurred. Then, the funds are properly returned to the investors. If the money is to be placed into an interest bearing account, it must have a maturity date no later than the closing date of the offering, or the account must be redeemable at face with no prepayment penalty as regards principal.

Underwriter Compensation Hierarchy

As we have seen, in a firm commitment the underwriter buys the entire issue from the issuer and then attempts to resell it to the public. The price at which the syndicate offers the securities to the public is known as the public offering price. It is the price printed on the front page of the prospectus.

However, the managing underwriter pays the issuer a lower price than this for the securities. The difference between that lower price and the public offering price is known as the spread or underwriting discount. Everyone involved in the sale of a new issue is compensated by receiving part of the spread. The amount of the spread is the subject of negotiations between the issuer and the managing underwriter, but usually is within a range established by similar transactions between comparable issuers and underwriters. The spread is also subject to NASD [now FINRA] review and approval before sales may commence. The spread is broken down by the underwriters so that a portion of it is paid to the managing underwriter for finding and packaging the issue and managing the offering (usually called the manager’s fee); and a portion is retained by each underwriter (called the underwriting or syndicate allowance) to compensate the syndicate members for their expenses, use of money, and assuming the risk of the underwriting. The remaining portion is allocated to the selling group and is called selling concession. It is often useful to remember the compensation hierarchy pecking order in the following way:

  • Spread (syndicate manager).
  • Underwriters allowance (syndicate members)
  • Selling concession (selling group members)
  • Re-allowance (any other firm)

While the above deal with corporate equity, the only other significant item with respect to corporate debt is the Trust Indenture Act of 1939. This Federal law applies to public issues of debt securities in excess of $5,000,000. The thrust of this act is to require an indenture with an independent trustee (usually a bank or trust company) who will report to the holders of the debt securities on a regular basis.

Successful marketing of a new issue is a marriage between somewhat alien factors: compliance and numerous Federal, state, and self-regulatory rules and statutes; along with finely honed and profit-motivated sales techniques. It’s not too hard to see that there could be a real, or apparent, conflict of interest here. Most successful investment bankers have built their excellent reputations upon their ability to properly balance these two objectives consistently, year after year.

PART ONE:

Understanding investment banking rules, securities markets, brokerage accounts, margin and debt

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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.

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

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On New Issues and Securities Stabilization

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A Primer for Physician Investors and Medical Professionals

By: Dr. David Edward Marcinko; MBA, CMP™

[Editor-in-Chief] http://www.CertifiedMedicalPlanner.org

[PART 3 OF 8]

NEU Dr. Marcinko

NOTE: This is an eight part ME-P series based on a weekend lecture I gave more than a decade ago to an interested group of graduate, business and medical school students. The material is a bit dated and some facts and specifics may have changed since then. But, the overall thought-leadership information of the essay remains interesting and informative. We trust you will enjoy it.

Introduction

Some securities issues move very well, like traditional blue chips stocks (ie., Wallgreen). Some are dogs, like smaller dot.com companies (iixl.com). Then, there are issues that are former darling, but are now ice cold; like PPMCs (i.e., Phycor) and internet stocks (i.e., Dr. Koop).  How far can an underwriting manager go in nudging along an issue that’s not selling well? SEC rules do permit a certain amount of help by the manager, even if this takes on the appearance of price-fixing. This help is called stabilizing the issue.

Simply put, if shortly after a new offering begins, supply exceeds demand, there will be downward pressure on the price. But, the law requires that all purchasers of the new issue pay the official offering price on the prospectus. If public holders of the stock become willing to bail out and accept a low selling price, the investor looking to buy will find he is able to buy stock of the issuer cheaper in the open market than buying it new from the syndicate members.

To prevent such a decline in the price of a security during a public offering, SEC rules permit the manager to offer to buy shares in \ the open market at a bid price at, or just below, the official offering price of the new issue. This is referred to as stabilizing and his bid price is called the stabilizing bid. There is always the risk, in a firm commitment underwriting, that the underwriters will have difficulty selling the new issue. What they can’t sell, they’re “stuck” with. That’s where the term “sticky issue” comes from.

As a physician executive, or potential investor in a new issue, be aware that the best way to get an issue to sell is to increase the compensation to the sales force (i.e., stock broker or Registered Rep).

Another choice is through stabilization. Stabilizing is a permitted form of market manipulation which tends to protect underwriters against loss. It allows the underwriting syndicate (usually through the efforts of the syndicate manager) to stabilize (peg or fix) the secondary market trading price in a new issue at the published public offering price. It works something like this.

When a new issue is selling slowly, some of the investors who initially purchased, may be dissatisfied with the performance of the stock (if it is selling slowly and the underwriters have plenty to sell at the public offering price, this is anything but a hot issue and the security price will not have risen).

This dissatisfaction with performance leads to these investors desiring to sell the securities they have just purchased. If the underwriters are unable to sell at the public offering price, certainly an individual investor will have to take less when bailing out. As market makers begin to trade the stock in the secondary market, they would only be able to compete with the underwriters by offering the stock at a lower price than the public offering  price. This would make it difficult (if not impossible) for the underwriters to distribute the remaining new shares.

In order to prevent this from happening, the managing underwriter (who is usually the one to assume the role of stabilizing underwriter), agrees to purchase back any of the new shares at or just slightly below the public offering price. That is a higher price than any market maker could, in all practicality, bid for the shares. When the shares are repurchased by the stabilizing underwriter, it is as if the initial trade were annulled and never took place so that these new shares are now placed back into the distribution and are sold as new shares at the public offering price. SEC rules do, however, require disclosure of this practice.

Therefore, no syndicate manager may engage in stabilizing unless the following phrase appears in bold print on the inside front cover page of the prospectus:

IN CONNECTION WITH THIS OFFERING, THE UNDERWRITERS MAY OVER ALLOT OR EFFECT TRANSACTIONS WHICH STABILIZE OR MAINTAIN THE MARKET PRICE OF (XYZ COMPANY) AT A LEVEL ABOVE THAT WHICH MIGHT OTHERWISE PREVAIL IN THE OPEN MARKET. SUCH TRANSACTIONS MAY BE EFFECTED ON (NYSE) STABILIZING, IF COMMENCED, MAY BE DISCONTINUED AT ANY TIME.

Of course, it would be manipulation and, therefore, a violation of law, if this “price-pegging” activity continued after the entire new issue was sold out. This activity costs the syndicate manager money which is recouped by levying a syndicate penalty bid against those members of the syndicate whose clients turn shares in on a stabilizing bid.

One way to avoid stabilization is to over allot  to each of the syndicate members. This is the same concept as “over booking” that’s done by the airlines. Most airlines typically sell 5% to 10% more seats than the airplane has knowing that there will be last minute cancellations and no shows. This tends to ensure that the plan will fly full. In the same manner, managing under-writers frequently over allot an additional 10% to each of their syndicate members so that last minute cancellations should still leave the syndicate with sell orders for 100% of the issue. If there are no “drop outs”, one of two things may happen.

  1. The issuer will issue the additional shares (which results in it raising more money).
  2. The issuer will not issue the additional shares and the syndicate will have to go short. Any losses suffered by the syndicate through taking of this short position are shared proportionately by the syndicate members.

Now, what if market conditions and the fervor surrounding a new issue like e-commerce company Ariba,  in 1999, remain so that the issue doesn’t cool down during the cooling off period? Such hot issues are a mixed blessing to be sure.

On the one hand, the issue is a sure sell-out. On the other hand, just how many healthcare investors are going to be told by brokers that additional shares can not be obtained.

Furthermore, the SEC and the NASD/FINRA are vigorous [or should be] in their scrutiny of  proper distribution channels for hot issues. Just what is a “proper” distribution?  It can be summed up in one sentence. Member firms have an obligation to make a “bona fide” public distribution of all the shares at the public offering price. The key to this rule lies within the definition of bona fide public distribution.

While the underwriting procedures for corporate bonds are almost identical to corporate stock, there are significant differences in the underwriting of municipal securities. Municipal securities are exempt from the registration filing requirements or the Securities Act of 1933. A state or local government, in the issuance of municipal securities, is not required to register the offering with the SEC, so there is no filing of a registration statement and there is no prospectus which would otherwise have to be given to investors.

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  Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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Municipal Underwriting

There are two main methods of financing when it comes to municipal securities. One method is known as negotiated. In the case of a negotiated sale, the municipality looking to borrow money would approach an investment bank and negotiate the terms of the offering directly with the firm. This is really not very different from the above equity discussions.

The other type of municipal underwriting is known as competitive bidding. Under the terms of competitive bidding, an issuer announces that it wishes to borrow money and is looking for syndicates to submit competitive bids. The issue will then be sold to the syndicate which submits the best bid, resulting in the municipality having the lowest net interest cost (lowest expense to the issuer).

If the issue is to be done by a competitive bid, the municipality will use a Notice of Sale to announce that fact. The notice of sale will generally include most or all of the following information.

  • Date, time, and place. This does not mean when the bonds will be sold to the public, but when the issue will be awarded (sold) to the syndicate issuing the bid.
  • Description of the issue and the manner in which the bid is to be made (sealed bid or oral). Type of bond (general obligation, revenue, etc.)
  • Semi-annual interest payment dates and the denominations in which the bonds will be printed.
  • Amount of good faith deposit required, if any.
  • Name of the law firm providing the legal opinion and where to acquire a bid form.
  • The basis upon which the bid will  e awarded, generally the lowest net interest cost.

Since municipal securities are not registered with the SEC, the municipality must hire a law firm in order to make sure that they are issuing the securities in compliance with all state, local and federal laws. This is known as the bond attorney, or independent bond counsel. Some functions are included below:

    1. Establishes the exemption from federal income tax by verifying  requirements for the exemption.
    2. Determines proper authority for the bond issuance.
    3. Identifies and monitors proper issuance procedures.
    4. Examines the physical bond  ertificates to make sure that they are proper
    5. Issues the debt and a legal opinion, since municipal bonds are the only securities that require an opinion.
    6. Does not prepare the official statement.

When medical investors purchase new issue municipal securities from syndicate or selling group members, there is no prospectus to be delivered to investors, but there is a document which is provided to purchasers very similar in nature to a prospectus. It is known as an Official Statement. The Official Statement contains all of the information an investor needs to make a prudent decision regarding a proposed municipal bond purchase.

The formation of a municipal underwriting syndicate is very similar to that for a corporate  issue. When there is a negotiated underwriting, an Agreement Among Underwriters (AAU) is used. When the issue is competitive bid, the agreement is known as a Syndicate Letter. In the syndicate letter, the managing underwriter details all of the underwriting agreements among members of the syndicate. Eastern (undivided) and Western (divided) accounts are also used, but there are  several different types of orders in a municipal underwriting. The traditional types of orders, in priority order, are:

Pre-Sale Order: Made before the syndicate actually offers the bonds. They have first priority over any other order turned in.

Syndicate (group net) Order: Made once the offering is under way at the public offering price. The purchase is credited to each syndicate member in proportion to its allotment. An institutional buyer will frequently purchase” group net”, since many of the firms in the syndicate may consider this buyer to be their client and he wishes to please all of them.

Designated Order: Sales to medical investors (usually healthcare institutions) at the public offering price where the investor designates which member or members of the syndicate are to be given credit.

Member Orders: Purchased  by members of  the syndicate at the take-down price (spread). The syndicate member keeps the full take-down if the bonds are sold to investors, or earns the take-down less the concession if the sale is made to a member of the selling group. Should the offering be over-subscribed, and the demand for the new bonds exceeds the supply, the first orders to be filled are the pre-sale orders. Those are followed by the syndicate (sometimes called group net) orders, the designated orders, and the last orders filled are the member’s.

Finally, be aware that the term bond scale, is a listing of coupon rates, maturity dates, and yield or price at which the syndicate is re-offering the bonds to the public. The scale is usually found in the center of a tombstone ad and on the front cover of the official statement.

One of the reasons why the word “scale” is used is, that like the scale on a piano, it normally goes up. A regular or positive scale is one in which the yield to maturity is lowest on the near term maturities and highest on the long term maturities. This is also known as a positive yield curve, since the longer the maturity, the higher the yield. In times of very tight money, such as in 1980-81, one might find a bond offering with a negative scale.

A negative (sometimes called inverted) scale is just the opposite of a positive one, with, yields on the short term maturities are higher than those on the long term maturities.

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About Securities “Shelf Registration”

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A Primer for Physician Investors and Medical Professionals

By: Dr. David Edward Marcinko; MBA, CMP™ http://www.CertifiedMedicalPlanner.org

[Editor-in-Chief]

[PART 5 OF 8]

Dr. Marcinko with ME-P Fans

NOTE: This is an eight part ME-P series based on a weekend lecture I gave more than a decade ago to an interested group of graduate, business and medical school students. The material is a bit dated and some facts and specifics may have changed since then. But, the overall thought-leadership information of the essay remains interesting and informative. We trust you will enjoy it.

Introduction

A relatively new method of registration under the Act of ’33 is known as shelf registration. Under this rule, an issuer may register any amount of securities that, at the time the registration statement becomes effective, is reasonably expected to be offered and sold within two years of the initial effective date of the registration. Once registered, the securities may be sold continuously or periodically within 2 years without any waiting period for a registration to clear issuers generally like shelf registration because of the flexibility it gives them to take advantage of changing market conditions.

In addition, the legal, accounting, and printing costs involved in issuance are reduced, since a single registration statement suffices for multiple offerings within the 2 year period. In effect, what the issuer does is register securities that will meet its financing needs for the next 2  years. It issues what it needs at the current time, and puts the balance on the shelf” to be taken off the shelf as needed.

SECURITIES MARKETS 

The purchase of common stock in an IPO (initial public offering) is facilitated through of the members an investment bank underwriting syndicate or selling group. This is known as the primary market and the proceeds of sale go directly to the issuing company. Six months later however, if a doctor wants to sell his shares, this would be accomplished in the secondary market. The term secondary market refers to trading in outstanding issues as the proceeds do not go to the issuer, but to the current owner of the securities, such as the physician investor.

Therefore, the secondary market provides liquidity to doctors who acquired securities in the primary market. After a doctor has acquired securities in the primary market, he wants to be able to sell the securities at some point in the future in order to acquire other securities, buy a house, or go on a vacation. Such a sale takes place in the secondary market. The medical investor’s ability to convert the asset (securities) into cash is heavily dependent upon the secondary market. All investors would be hesitant to acquire new securities if they felt they would not subsequently have the ability to sell the securities quickly at a fair price in the secondary market.

Securities Act of 1934

Every trade of stocks and bonds that is not a purchase of a new issue is a trade that takes place in the secondary market. The market place for secondary trading is the stock exchanges and the over-the-counter (OTC) market, and is governed by the Securities Act of 1934, which actually created the Securities and Exchange Commission (SEC) and outlines the powers of the SEC to interpret, supervise, and enforce the securities laws of the United States. The Act of 34 is very broad and governs the sales of securities, including the regulation of securities markets exchanges, OTC markets, broker/dealers, their employees, the conduct of secondary markets, the extension of credit in the purchase and sale of securities, and the conduct of corporate insiders (officers and directors and holders of more than 10% of the outstanding stock). The Act also prohibits fraud and manipulative and deceptive activities in securities transactions

The Stock Exchanges

A stock exchange is a private association of brokers. The main purpose of an exchange is to provide a central meeting place for its member-brokers. This central meeting place is called the floor. It is on the floor that the members trade in securities. It is important to remember that a stock exchange itself does not own any of the securities that are traded on its floor. Nor does it buy or sell any of the securities traded on the exchange. Instead, the securities are owned by member firms, customers, or perhaps, by the exchange member firm itself.

It is also important to remember that a stock exchange does not establish or fix the price at which any security is traded on the exchange. The price is determined in a free and open auction type of trading. It depends on the supply and  demand relationship of that security at a particular time. In other words, if sellers of a stock are offering to sell more shares of that stock than buyers want to buy, the price of that stock will tend to go down. On the other hand, if buyers want to buy more shares of a stock than the sellers are offering to sell, the price of that stock will tend to go higher because of the strong demand.

Any discussion of stock exchanges has to focus on the NYSE, which is by far the largest and most important of the exchanges. There are two exchanges referred to as national stock exchanges, the NYSE and the American Stock Exchange (AMEX). In addition to these two national exchanges, there are several regional stock exchanges including the Philadelphia Exchange, the Chicago Exchange (formerly Midwest), the Pacific Exchange, the Boston Exchange, and the Cincinnati Exchange. Stocks that are traded on an exchange are referred to as listed stocks. The term “listed on an exchange” means that the issue is eligible for trading on the floor of the exchange.

How does a stock become listed? The issuing company, having decided that they wish the prestige and broad visibility of being listed on the NYSE, applies to the exchange for listing. A critical condition for listing is that the issuer agrees to solicit proxies from those common stock shareholders unable to attend shareholder meetings. Once the securities have been accepted for listing (trading) on an exchange, the issuer must continue to meet certain requirements which are not quite as stringent as the original listing requirements, and may be de-listed if the firm ceases to solicit proxies on its existing voting stock, or meet other minimal requirements.

Physically, the exchange brings together buyers and sellers on a trading floor. The NYSE floor is larger than several football fields and is divided into 19 trading posts. Eighteen of the posts are horseshoe or U-shaped stations 100 square feet in area. The nineteenth post (post number 30) is in the northwest corer and really isn’t a post at all; it’s just an area where the inactive stocks trade.

The Specialist

Specialists are experts in trading one or more specific stocks at their particular post on the exchange floor. Their activity is vital to the maintenance of a free and continuous market in the specific issues they represent. They are responsible for conducting the auction at the post. Everyone interested in buying the stock calls out a price and the shares go to the highest bidder. The buyers compete, but there is only one seller. Unlike the usual auction market, the auction on the floor of the exchange is a two way auction with some brokers seeking to buy at the lowest possible price for their doctor clients and other brokers trying to sell at the highest possible price for their doctor clients. When two brokers, one representing a buyer and one a seller, agree on a price, a sale is made. The specialist functions in a dual capacity as a dealer and as a broker. As a dealer or principal, he buys and sells for his own account and risk to maintain a fair and orderly market in the stocks in which he specializes.

For example, if a commission broker approaches the specialist at the post with a buy or sell order, and there are no other brokers in the crowd, that is currently interested in buying or selling the stock, the specialist will buy the stock from that commission broker (if it’s a sell order) for his own account or sell the stock from his inventory (if it’s a buy order). Perhaps, he may even be able to fill the order from his specialist’s book?

Stock_Market

Specialist’s Book

This is done by using the specialist’s book of buy orders (bids), marked on the left hand page, or sell orders (offers) on the right. There is a book for each stock in which the specialist specializes. The pages are ruled and are usually printed with fractional stock points at regular intervals to permit easy insertion of orders. The orders are entered in the book by the specialist according to price and in the sequence in which they are received at the post. He notes the number of shares, putting down 1 for 100 shares, 2 for 200 shares, etc. He also notes the name of the member firm placing the order and if the order is Good Till Cancelled (GTC), or not. When orders are executed, they are executed in the same order recorded in the book at that particular price.

The specialist’s book also keeps track of all orders “away from the market ” (limit orders and stop orders) in his book. The book is organized with all buy orders on the left hand side of the page and all sell orders on the right hand side. In the absence of bids and offers from the “trading crowd” on the floor, the specialist can quote the best available market for the security by announcing the highest bid and the lowest offer (ask). The best bid is always the highest buy limit order on his book and the best offer (ask) is always the lowest sell limit on his book. In addition to quoting the best price, he will also give the “size of the market ” which is determined by the number of shares being bid for and offered at the respective best bid and best ask prices. The quote is price and size. When asked to quote the market for a security, the specialist disregards any stop orders on his book since those orders do not become activated until triggered by another trade. One thing to remember is that since most doctors place stop orders to hedge (protect) against a price movement adverse to their interests, most stop orders are entered with the fervent wish that they never be executed.

On stop and limit orders placed below the market, the specialist is required to reduce the price of those orders on the ex-dividend (ex-split, ex-rights) date. The two critical things to remember are: what types of orders are reduced and by how much? The specialist will reduce all GTC (open) buy limit and sell stop orders on an ex-date. You may remember this with the acronym BLISS where the BL equals buy limit and the SS equals sell stop. The only time either of these orders will not be reduced is if the medical client turned in DNR (do not reduce) instructions.

The price of the order is then reduced by enough to equal or exceed the amount of the dividend.

If we go back to the example approaching the specialist to buy or sell stock and there is no one in the “crowd”, the specialist will first give the commission broker a quote from his book. That quote will be the highest bid price (the highest priced limit order to buy on his books) and the best asked price {the lowest priced sell limit on his books). If the commission broker is willing to buy at the lowest ask or offering price on the specialist’s book, then a trade will take place; if the commission broker is looking to sell and is willing to accept the highest bid price on the specialist’s book then, again, a trade will take place. It is the responsibility of the specialist to maintain an orderly market and to keep the spread between the bid and asked prices as narrow as possible. If the spread between bid and asked is too wide to generate market activity, the specialist will act on his own account.

If the specialist is presented with sell orders at the post and he has no buyers, he must bid at least 1/8 of a point higher than the best bid on his books. If he has buyers and no sellers, then he must offer stock from his inventory at a price at least, 1/8 of a point below the lowest offer on his book.

Why? It’s because the specialist cannot “compete” with public orders and if his bid matched a customer’s bid or his offer matched a customer’s offering or ask price, he would be considered to be ” competing”.  Since the specialist is required to bid higher and ask lower than the best public orders on his book, the spread is narrowed. That is why it is said that the specialist acts in a dual capacity, as a dealer and as a broker. When buying and selling for his own account, he is acting as a dealer. The specialist acts as a broker when he executes limit orders left with him by commission brokers. When these limit orders are executed out of the specialist’s book (the doctor’s limit price is reached), the specialist uses a priority, parity, and precedence system, as to which order is executed first. These rules, like most others, are designed to give preference to the general public, not to members of the exchange, on a first come first served basis.

Walking Through a Trade

To see how the transactions are actually handled on the floor of an exchange, let us assume that an order to buy 100 shares of General Electric has been given by a doctor customer to the registered representative (stock broker), of a member firm in Atlanta. The order is a market order (an order to buy at the lowest possible price at the time the order reaches the floor of the exchange). This order is telephoned by direct wire, or computer, to the New York office of the member firm, which in turn telephones its order to its clerk on the floor of the exchange.

Each member firm has at least one member of the exchange representing them making trades on the floor. Each one of these members is assigned a number for identification. When the floor clerk receives the order to purchase the General Electric, he causes his member’s call number to appear on 3 large boards situated so that one is always in view. These boards are constantly watched brokers so that they will know when wanted at the phone, since there’s too much noise on the floor to use a paging system. Seeing his number on the board, the broker hurries to his telephone station or cell phone and receives the order to buy 100 shares of G.E. “at the market”. Acting as a commission broker, he immediately goes to the post where G.E. is traded and asks “how’s G.E”, of the specialist?

Part 4: Underwriting US Government Securities Issues

Conclusion

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New Medical Practice Entrepreneurial Business Rules for Young Physicians [circa 2022]

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Go “Out-of-Box” – OR – Go Employee

By Dr. David Edward Marcinko MBA CMP™ www.CertifiedMedicalPlanner.org

There are more than 950,000 physicians in the United States. Yet, the brutal supply and demand, and demographic calculus of the matter is that there are just too many aging patients chasing too few doctors. Compensation and reimbursement is plummeting as Uncle Sam becomes the payer-of-choice for more than 52% of us. More so, going forward with the PP-ACA OR, perhaps not so much after the Trump election.

Furthermore, many large health care corporations, hospitals, and clinical and medical practices have not been market responsive to this change. Some physicians with top-down business models did not recognize the changing health care ecosystem or participatory medicine climate. Change is not inherent in the DNA of traditionalists. These entities and practitioners represented a rigid or “used-to-be” mentality, not a flexible or “want-to-be” mindset.

Yet today’s physicians and emerging Health 2.0 initiatives must possess a market nimbleness that cannot be recreated in a command-controlled or collectivist environment. Going forward, it is not difficult to imagine the following rules for the new virtual medical culture, and young physicians of the modern era.

A. Rule 1

Forget about large office suites, surgery centers, fancy equipment, larger hospitals, and the bricks and mortar that comprised traditional medical practices. One doctor with a great idea, good bedside manners, or competitive advantage can outfox a slew of insurance companies, Certified Public Accountants, or the Associate Management Accountant, while still serving patients and making money. It is now a unit-of-one economy where “ME Inc.,” is the standard. Physicians must maneuver for advantages that boost their standing and credibility among patients, peers, and payers.

Examples include patient satisfaction surveys, outcomes research analysis, evidence-based-medicine, direct reimbursement compensation, physician economic credentialing, and true patient-centric medicine. Physicians should realize the power of networking, vertical integration, and the establishment of virtual offices that come together to treat a patient and then disband when a successful outcome is achieved. Job security is earned with more successful outcomes; not a magnificent office suite or onsite presence.

B. Rule 2

Challenge conventional wisdom, think outside the traditional box, recapture your dreams and ambitions, disregard conventional gurus, and work harder than you have ever worked before. Remember the old saying, “if everyone is thinking alike, then nobody is thinking.” Do traditionalists or collective health care reform advocates react rationally or irrationally?

For example, some health care competition and career thought-leaders, such as Shirley Svorny, PhD, a professor of economics and chair of the Department of Economics at California State University, Northridge, wonder if a medical degree is a barrier—rather than enabler—of affordable health care. An expert on the regulation of health care professionals, including medical professional licensing, she has participated in health policy summits organized by Cato and the Texas Public Policy Foundation. She argues that licensure not only fails to protect consumers from incompetent physicians, but, by raising barriers to entry, makes health care more expensive and less accessible.

Institutional oversight and a sophisticated network of private accrediting and certification organizations, all motivated by the need to protect reputations and avoid legal liability, offer whatever consumer protections exist today.

C. Rule 3

Differentiate yourself among your health care peers. Do or learn something new and unknown by your competitors. Market your accomplishments and let the world know. Be a non-conformist. Conformity is an operational standard and a straitjacket on creativity. Doctors must create and innovate, not blindly follow entrenched medical societies into oblivion.

For example, the establishment of virtual medical schools and hospitals, where students, nurses, and doctors learn and practice their art on cyber entities that look and feel like real patients, can be generated electronically through the wonders of virtual reality units.

D. Rule 4

Realize that the present situation is not necessarily the future. Attempt to see the future and discern your place in it. Master the art of quick change with fast, but informed decision making. Do what you love, disregard what you do not, and let the fates have their way with you.

Assessment

I receive a couple of phone calls each month from young doctors on this topic. I ask them to decide if they are of the philosophical ilk to adhere to the above rules; or become another conformist and go along … to get along? In other words, get fly!

Or, become an employed, or government doctor.  Just remember … the entity that gives you a job, can also take it away.

Sample fly: http://crossoverhealth.com/

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UPDATE: Memorial Day 2022

By Dr. David Edward Marcinko MBA

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MORE: https://medicalexecutivepost.com/2021/05/30/some-memorial-day-thoughts-2021/

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COMMENTS APPRECIATED

Thank You

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PODCASTS: AMA to Teach Medical Students Health Economics?

AMA TO TEACH MEDICAL STUDENTS ABOUT HEALTH ECONOMICS?

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Courtesy: www.CertifiedMedicalPlanner.org

DICTIONARY: https://medicalexecutivepost.com/2009/06/08/dictionary-of-health-economics-and-finance/

Did you know that the American Medical Association is calling on medical schools and residency programs to include specific information about healthcare economics and financing in their curricula.

But, is health economics heterodoxic, or not? And; what about demand-derived economics in medicine?

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economic freedom

LINKS

ESSAY: https://medicalexecutivepost.com/2019/08/31/is-health-economics-heterodoxic-or-not/

ESSAY: https://www.modernhealthcare.com/education/ama-adopts-new-policy-training-physicians-healthcare-economics

MORE: https://medicalexecutivepost.com/2019/11/10/ricardian-derived-demand-economics-in-medicine/

MORE: https://medicalexecutivepost.com/2014/08/27/financial-and-health-economics-benchmarking/

MORE: https://healthcarefinancials.files.wordpress.com/2019/01/big-data.pdf

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Your thoughts are appreciated.

BUSINESS, FINANCE, INVESTING AND INSURANCE TEXTS FOR DOCTORS:

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Necessary Pillars to Expand the Free Medical Markets

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 By Jay Kempton

[Free Market Medical Association]

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Conclusion

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The TOP 100 Economics Blogs of 2022

INTELLIGENT ECONOMIST

Last Updated: February 3rd, 2022

By Prateek Agarwal

Welcome, and thank you for joining us for the 5th annual Top Economics Blogs list! We are happy, once again, to introduce you to a freshly updated list of economics blogs for 2022. As always, our winners list provides blogs for many different audiences, ranging from the budding economic enthusiast to the seasoned academic. The list also covers a variety of economics topics, whether it be traditional economic theory or the application of economics to current events and issues. In this meticulously curated list, we’ve condensed the most unique elements of each blog into short descriptions, so that you can see which ones catch your eye.

CITE: https://www.r2library.com/Resource/Title/0826102549

For 2022, a few newcomers have emerged, while many mainstays from previous years are present as well. Like previous years, we’ve done our best to capture the blogs which stand out for their quality rather than their popularity. As such, the list is an eclectic group that represents a wide range of tastes and perspectives.

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What is an economist? Definition and examples - Market Business News

Regardless of your school of thought or political affiliation, you can find valuable new content in this list of engaging, high-quality economics blogs.

LINK: https://www.intelligenteconomist.com/economics-blogs/

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“MINNOVATION” for Physician Entrepreneurs

And … Disruptive Healthcare Innovators

[By Dr. David E. Marcinko MBA]

We all seem to be fascinated by our endless capacity to invent new words, and Yes, I am a non-clinical healthcare linguist.

LINK: https://www.amazon.com/Dictionary-Health-Information-Technology-Security/dp/0826149952/ref=sr_1_5?ie=UTF8&s=books&qid=1254413315&sr=1-5

So, the word “minnovation” caught my eye a few days ago while browsing old articles from Harvard Business Review.

LINK: https://hbr.org/2019/08/before-you-start-a-business-decide-what-success-looks-like

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INN

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The “Next Big Thing”

According to one colleague, Philippa Kennealy MD MPH, her take on this article is that for most of us, the notion of coming up with “The Next Big Thing” is simply over whelming. So, rather than pursuing an enticing but unreachable entrepreneurial path, we give up, despairing of ever being able to break out of our ruts.

Example:

For example, we imagine that the only way to get away from a traditional insurance-based practice is to go all out for a full-blown high-fee concierge practice.

  • OR, we feel compelled to invent, develop and successfully market the next Medical Device of the Year.
  • OR, maybe the pressure of needing to reinvent healthcare delivery entirely, in this rapidly changing world, is keeping us awake at night. So, we procrastinate, plagued by our perfectionism!

However, here is the excuse you can no longer avoid:

In reality, the vast majority of real-life entrepreneurs around the world aren’t innovators. They’re minnovators — mixing small parts of novelty and creativity with huge helpings of flexibility scrappiness and a generous portion of hard-driving execution.

Outing the Rut

So, if you yearn to break out of your traditional-but-tiresome medical practice, or merely exercise your emerging entrepreneurial physician muscle, here are a few ways to think about your next move:

  • what business or practice process can you tweak, or radically redesign?
  • what new spin can you put on the valuable information or education you provide?
  • what obstacles do your patients face regularly that they would love to surmount?
  • what product would work a whole lot better with a minor (or even major) adaptation?
  • what leadership and creativity could you provide to a team or group that is already executing an idea, and doing it poorly, or not well?

 Assessment

How can you become a scrappy, bootstrapping, quick-to-adapt physician “minnovator”?

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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.

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.

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“Fiduciary Financial Planning for Physicians” https://tinyurl.com/y7f5pnox

“Business of Medical Practice 2.0” https://tinyurl.com/yb3x6wr8

HOSPITALS:

“Financial Management Strategies for Hospitals” https://tinyurl.com/yagu567d

“Operational Strategies for Clinics and Hospitals” https://tinyurl.com/y9avbrq5

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About Healthcare Marketing Plan Revisions?

By MM+M

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Cause of Healthcare Marketing Plan Revisions

A recent survey asked “Have you revised, relaunched or otherwise altered an existing healthcare marketing campaign for any reason?” The survey shows:

 •  Pandemic-related disruption: 70.0%
 •  New competitive entrant: 36.7%
 •  Access issues: 36.7%
 •  Under-performance: 36.7%
 •  New brand leadership: 33.3%
 •  New indication/label change: 30.0%
 •  Drug shortage: 13.3%
 •  Other external market shift: 6.7%

Source: MM+M, “Healthcare Marketers Trend Report 2022: The Reset,” March 8, 2022

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Crafting a Medical Practice Strategic Marketing Plan

Necessary Today – Not So In the Past

dem

[By Dr. David Edward Marcinko; MBA, CMP™]

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Marketing plays a vital role in successful practice ventures. How well you market your practice, along with a few other considerations, will ultimately determine your degree of success or failure. 

The key element of a successful marketing plan is to know your patients – their likes, dislikes and expectations. By identifying these factors, you can develop a strategy that will allow you to arouse and fulfill their wants and needs. 

The Beginning

Identify your patients by their age, sex, income/educational level and residence. At first, target only those patients who are more likely to want or need your medical services. As your patient base expands, you may need to consider modifying the marketing plan to include other patient types or medical services. 

Your marketing plan should be included in your medical business plan and contain answers to the questions asked below:

·Who are your patients; define your target market(s)?

·Are your markets growing; steady; or declining?

·How is the practice unique?

·What is its market position?

·Where will we implement the marketing strategy?

·How much revenue, expense and profit will the practice achieve?

·Are your markets large enough to expand?

·How will you attract, hold, increase your market share?

·If a franchise, how is your market segmented?

·How will you promote your practice and services?

Practice Competition

Competition is a way of life. We compete for jobs, promotions, scholarships to institutions of higher learning, medical school, residency and fellowship programs, and in almost every aspect of our lives. 

When considering these and other factors, we can conclude that medical practice is a highly competitive, volatile arena. Because of this volatility and competitiveness, it is important to know your medical competitors. Questions like these can help you determine:

·Who are your five nearest direct physician competitors?

·Who are your indirect physician competitors?

·How are their practices: steady; increasing; or decreasing?

·What have you learned from their operations or advertising?

·What are their strengths and weaknesses?

·How do their services differ from yours?

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Chief-Marketing-Officer

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Patient Targeting

Patient targeting generally describes the strategic competitive advantage and/or professional synergy that is specific and unique to the practice. Intuitively, it answers such questions as:

·Who is the target market?

·How is the practice unique?

·What is its market position?

·Where will we implement the marketing strategy?

· How much revenue, expense and profit will the practice achieve?  

The science of modern marketing however, is based on intense competition largely derived from the interplay of five forces, codified in the early 1980s, by Professor Michael F. Porter of Harvard Business School. They are placed in this section of the business plan and include the following:

Power of suppliers: The bargaining power of physicians has weakened markedly in the last managed care decade.  Reasons include demographics, technology, over/under supply and a lack of business acumen. 

Power of buyers: Corporate buyers of employee healthcare are demanding increased quality and decreased premium costs within the entire healthcare industry. The extents to which these conduits succeed in their bargaining efforts depend on several factors:

·Switching Costs: Notable emotional switching costs include the turmoil caused by uprooting a trusted medical provider relationship.

·Integration Level: The practitioner must decide early on whether or not he will horizontally integrate as a solo practitioner, or vertically integrate into a bigger medical healthcare complex.

·Product Importance: Increasingly, HMOs do not often strive to delight their clients and may be responsible for the beginning backlash these entities are starting to experience. Additionally, some medical specialties have more perceived value than others (i.e., neurosurgery v. dermatology)

· Concentration:  Insurance companies, not patients, represent buyers that can account for a large portion of practice revenue, thereby bringing about certain concessions.  A danger sign is noted when any particular entity encompasses more than 15-25% of a practice’s revenues.

Threat of new entrants: Some authorities argue that medical schools produce more graduates than needed, inducing a supply side shock. Others suggest that there too many patients? Regardless, this often can be mitigated by practicing in rural or remote locations, away from managed care entities, or in areas with under-served populations.

Current or existing competition: Heightened inter-professional competition has increased the intensity and volume of certain medical services and referrals may be correspondingly with-held.  Rivalry occurs because a competitor acts to improve his standing within the marketplace or to protect its position by reacting to moves made by other specialists.

Substitutions: Examples include: PAs for DOs, nurse practitioners for MDs, technicians for physical therapists, hygienists for dentists, cast technicians for orthopedists, nurse midwives for obstetricians, foot care extenders for podiatrists and even, hospital sanitation workers for medical and surgical care technicians.  Any strategy to ameliorate these conditions will augment the successful business practice plan. 

MORE: Healthcare Market.Tensions 2,0 MARCINKO

MORE: Strategic Management Improvement

Enter the Chief Marketing Officer [CMO]

A Chief Marketing Officer or marketing director is a corporate executive responsible for marketing activities in an organization.  The CMO leads brand management, marketing communications, market research, product management, distribution channel management, pricing, often times sales, and customer service, etc.

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Academic Metaphor?

Now, with all the competition today at the college and university level; notwithstanding the recent Hollywood Elite University acceptance debacle, can you see how these basic ideas might also be helpful in the academic and educational strategic marketing ecosystem?



The Emerging Role of University CHIEF STRATEGY OFFICER

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 The changing role of a college / university Chief Marketing Office [narrow focus] –versus–  Chief Strategy Officer [broader entity focus].

Assessment

A good way to accomplish and codify the above marketing plan concept is through a SWOT analysis. Mention the Strengths, Weaknesses, Opportunities and Threats of your specialty specific practice and what you plan do to maximize the positive, and minimize the negative aspects of the analysis.

Conclusion

Only after the above forces have been considered, should you begin the process that many physicians mistake for crafting their marketing efforts; executing the actual marketing plan. 

If you are not going to the right audience, making the correct statements or delivering your message through the proper advertising channels, you might as well put your medical practice marketing plan into the trash can because it will not secure you funds, or benefit your practice. 

Do you have a marketing plan, and more importantly, how well do you execute it? 

More info: http://www.springerpub.com/prod.aspx?prod_id=23759

Speaker: If you need a moderator or a speaker for an upcoming event, Dr. David Edward Marcinko; MBA is available for speaking engagements. Contact him at: MarcinkoAdvisors@msn.com

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How to Buy Securities On Margin

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How It Works and What Physicians’ Must Watch Out For

 Dr. David Edward Marcinko MBA CMP

“Buying on margin” is borrowing money from your stock-broker to buy a stock and using your investment as collateral. Physician-investors generally use margin to increase their purchasing power so that they can own more stock without fully paying for it. But, margin exposes all investors to the potential for higher losses.

https://www.amazon.com/Dictionary-Health-Economics-Finance-Marcinko/dp/0826102549/ref=sr_1_6?ie=UTF8&s=books&qid=1254413315&sr=1-6

This ME-P discusses the basics of buying on margin, some of the pitfalls inherent in margin buying, whether this financial tool is for you and how you can best use it.

How Does Margin Work?

Let’s say you buy a stock for $50 and the price of the stock rises to $75. If you bought the stock in a cash account and paid for it in full, you’ll earn a 50 percent return on your investment. But, if you bought the stock on margin – paying $25 in cash and borrowing $25 from your broker – you’ll earn a 100 percent return on the money you invested. Of course, you’ll still owe your brokerage $25 plus interest.

The downside to using margin is that if the stock price decreases, substantial losses can mount quickly. For example, let’s say the stock you bought for $50 falls to $25. If you fully paid for the stock, you’ll lose 50% of your money. But if you bought on margin, you’ll lose 100%, and you still must come up with the interest you owe on the loan.

Caution: In volatile markets, investors who put up an initial margin payment for a stock may, from time to time, be required to provide additional cash if the price of the stock falls. Investors have been shocked to learn that a broker has the right to sell the securities that were bought on margin – without any notification, and at a potentially substantial loss to the investor.

Caution: If your broker sells your stock after the price has plummeted, then you’ve lost out on the chance to recoup your losses if the market bounces back.

The Risks

Margin accounts can be very risky and they are not for everyone. Before opening a margin account, be aware that:

  • You can lose more money than you have invested;
  • You may have to deposit additional cash or securities in your account on short notice to cover market losses;
  • You may be forced to sell some or all of your securities when falling stock prices reduce the value of your securities; and
  • Your brokerage firm may sell some or all of your securities without consulting you to pay off the loan it made to you.

You can protect yourself by knowing how a margin account works and what happens if the price of the stock purchased on margin declines.

Tip: Your broker charges you interest for borrowing money; take into account how that will affect the total return on your investments.

Tip: Ask your broker whether it makes sense for you to trade on margin in light of your financial resources, investment objectives, and tolerance for risk.

Read Your Margin Agreement

To open a margin account, you must sign a margin agreement. The agreement may either be part of your account agreement or separate. The margin agreement states that you must abide by the rules of the Federal Reserve Board, the New York Stock Exchange, the National Association of Securities Dealers, Inc., and the firm where you have set up your margin account.

Caution: Carefully review the agreement before signing.

As with most loans, the margin agreement explains the terms and conditions of the margin account. The agreement describes how the interest on the loan is calculated, how you are responsible for repaying the loan, and how the securities you purchase serve as collateral for the loan. Carefully review the agreement to determine what notice, if any, your firm must give you before selling your securities to collect the money you have borrowed.

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margin risk

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Know the Margin Rules

The Federal Reserve Board and many self-regulatory organizations (SROs), such as the NYSE and NASD, have rules that govern margin trading. Brokerage firms can establish their own requirements as long as they are at least as restrictive as the Federal Reserve Board and SRO rules.

Here are some of the key rules you should know:

Before You Trade – Minimum Margin. Before trading on margin, the NYSE and NASD, for example, require you to deposit with your brokerage firm a minimum of $2,000 or 100 percent of the purchase price, whichever is less. This is known as the “minimum margin.” Some firms may require you to deposit more than $2,000.

Amount You Can Borrow – Initial Margin. According to Regulation T of the Federal Reserve Board, you may borrow up to 50 percent of the purchase price of securities that can be purchased on margin. This is known as the “initial margin.” Some firms require you to deposit more than 50 percent of the purchase price.

Tip: Not all securities can be purchased on margin.

Amount You Need After You Trade – Maintenance Margin. After you buy stock on margin, the NYSE and NASD require you to keep a minimum amount of equity in your margin account. The equity in your account is the value of your securities less how much you owe to your brokerage firm. The rules require you to have at least 25 percent of the total market value of the securities in your margin account at all times. The 25 percent is called the “maintenance requirement.” In fact, many brokerage firms have higher maintenance requirements, typically between 30 to 40 percent and sometimes higher, depending on the type of stock purchased.

Example: You purchase $16,000 worth of securities by borrowing $8,000 from your firm and paying $8,000 in cash or securities. If the market value of the securities drops to $12,000, the equity in your account will fall to $4,000 ($12,000 – $8,000 = $4,000). If your firm has a 25 percent maintenance requirement, you must have $3,000 in equity in your account (25 percent of $12,000 = $3,000). In this case, you do have enough equity because the $4,000 in equity in your account is greater than the $3,000 maintenance requirement.

But, if your firm has a maintenance requirement of 40%, you would not have enough equity. The firm would require you to have $4,800 in equity (40% of $12,000 = $4,800). Your $4,000 in equity is less than the firm’s $4,800 maintenance requirement. As a result, the firm may issue you a “margin call,” since the equity in your account has fallen $800 below the firm’s maintenance requirement.

Margin Calls

If your account falls below the firm’s maintenance requirement, your broker generally will make a margin call to ask you to deposit more cash or securities into your account. If you are unable to meet the margin call, your firm will sell your securities to increase the equity in your account up to or above the firm’s maintenance requirement.

Tip: Your broker may not be required to make a margin call or otherwise tell you that your account has fallen below the firm’s maintenance requirement. Your broker may be able to sell your securities at any time without consulting you first. Under most margin agreements, even if your firm offers to give you time to increase the equity in your account, it can sell your securities without waiting for you to meet the margin call.

  • Margin accounts involve a great deal more risk than cash accounts, where you fully pay for the securities you purchase. You may lose more than your initial investment when buying on margin. If you cannot afford to do so, then margin buying is not for you.
  • Read the margin agreement, and ask your broker questions about how a margin account works and whether it’s appropriate for you to trade on margin. Your broker should explain the terms and conditions of the margin agreement.
  • Know how much you will be charged on money you borrow from your broker, and know how these costs affect your overall return.
  • Remember that your brokerage firm can sell your securities without notice to you when you don’t have sufficient equity in your margin account.

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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.

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

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

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REPORT: Digital Health Technology

By Staff Reporters and MCOL

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Digital Health Tech Report – 5 Key Findings

 •  48% of hospitals don’t have a strong digital health strategy.
 •  90% believe a strong digital health strategy is critical to improving outcomes, increasing productivity, and enhancing clinician satisfaction.
 •  55% receive more than 11 vendor calls and emails from digital health solution vendors per week.
 •  95% say it’s challenging to narrow down the list of digital health solutions to evaluate.
 •  25% are “very confident” that, after selecting a new digital health solution, it’s truly the best one for their unique needs.

Source: Panda Health, April 2022

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[Medical] Entrepreneurs Drawn to Starting Incubators?

INFORMATION FROM THE TRENCHES

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More Ideas to Help [Medical] Entrepreneurs

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David Cummings on Startups

Last week I was reading an article about a successful entrepreneur that had started an incubator to work on multiple startups simultaneously. Incubators, now called studios or labs, were popularized during the dot com boom, and most failed to work, leaving a negative connotation for many people. Now, the cost to start is 10x cheaper and there are millions of people with mobile broadband connections, making for a different dynamic compared to 15 years ago. While it is still expensive to scale, getting started is easy.

Here are a few ideas why entrepreneurs are drawn to incubators:

  • Timing a market is terribly difficult, so having multiple startups running simultaneously increases the chance of finding a fit
  • For many (most?) entrepreneurs, the starting part is more fun than the scaling part
  • Small, dedicated teams without a legacy customer base can innovate fast, making it more fun to see rapid progress
  • When…

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Mental Health Entrepreneurial Start-Up Companies

Top Ten [10] Venture Capital Backed

PRE and POST Texas School Shooting MEMORIUM

By Dr. David Edward Marcinko MBA

By Carol Miller RN MBA

By http://www.MCOL.com

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Mental Health White Paper:

FILE: https://healthcarefinancials.files.wordpress.com/2019/05/mental-health-dr.-marcinko.pdf

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

LINK: https://www.routledge.com/Risk-Management-Liability-Insurance-and-Asset-Protection-Strategies-for/Marcinko-Hetico/p/book/9781498725989

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About “Non-Profits” for Entrepreneurs

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David Cummings on Startups

Back in college I’d routinely jump in my old Jeep Wrangler and make the 10 mile drive down the Durham Freeway to RTP for events and programs at the Council for Entrepreneurial Development (CED). CED bills itself as “the network that helps Triangle entrepreneurs build successful companies” and has 700+ member companies with 4,000 members. In Atlanta, we have a number of strong entrepreneurial non-profits:

Only, we don’t have a central entrepreneur organization that encompasses both tech and non-tech startups. As expected, there are a tremendous number of non-tech entrepreneurs in town. EO has a strong Atlanta chapter with over 100 members, but that’s limited to companies with at least $1 million in revenue. Where do non-tech entrepreneurs go?

Last week I had the chance to learn…

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The Non-Medical “POISON PILL” Strategy is in the Investing News!

MUSK versus TWITTER

By Staff Reporters

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DEFINITION: A shareholder rights plan, colloquially known as a “poison pill“, is a type of defensive tactic used by a corporation‘s board of directors against a takeover. In the field of mergers and acquisitions, shareholder rights plans were devised in the early 1980s as a way to prevent takeover bids by taking away a shareholder’s right to negotiate a price for the sale of shares directly.

Typically, according to Wikipedia, such a plan gives shareholders the right to buy more shares at a discount if one shareholder buys a certain percentage or more of the company’s shares. The plan could be triggered, for instance, if any one shareholder buys 20% of the company’s shares, at which point every shareholder (except the one who possesses 20%) will have the right to buy a new issue of shares at a discount. If all other shareholders are able to buy more shares at a discount, such purchases would dilute the bidder’s interest, and the cost of the bid would rise substantially. Knowing that such a plan could be activated, the bidder could be disinclined to take over the corporation without the board’s approval, and would first negotiate with the board in order to revoke the plan.

CITE: https://www.r2library.com/Resource/Title/082610254

The plan can be issued by the board of directors as an “option” or a “warrant” attached to existing shares, and only be revoked at the discretion of the board.

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READ: https://www.msn.com/en-us/money/companies/twitter-adopts-poison-pill-plan-to-block-elon-musks-bid/ar-AAWfUaZ?li=BBnb7Kz

MUSK: https://www.cbsnews.com/news/twitter-poison-pill-elon-musk/

TWITTER: https://www.msn.com/en-us/money/companies/twitter-activates-poison-pill-to-thwart-musk-hostile-takeover-attempt/ar-AAWgmwW?li=BBnb7Kz

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TODAY’S INVESTMENT WORLD STRATEGIES

RICH HELPPIE: The COMMON BRIDGE

Featuring Beata Kirr

This is the first of a two part series with Rich’s special guest, Beata Kirr, the co-head of investment strategies and national managing director in the Chicago office of Bernstein. We think you’ll find this conversation very fascinating.

Exploring Today’s Investment World

Editor’s Note: We hope you enjoy the video above. If you’d rather just listen to the podcast, click this link to Apple Podcasts: The Common Bridge.

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What is a Stock Market Index IMPLIED OPEN?

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FINANCIAL TERMS AND DEFINITIONS FOR PHYSICIANS AND ALL INVESTORS

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By Dr. David E. Marcinko MBA CMP®

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SPONSOR: http://www.CertifiedMedicalPlanner.org

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The stock markets have been near all time highs, lately. Physician colleagues and clients are so excited that they are even checking the overnight status of favorite stocks and/or the domestic/overseas markets.

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Some colleagues are even becoming a bit OCD by checking the implied open of various markets the night before. But, what exactly is the Implied Open? How is it calculated?

DEFINITION: The Implied Open attempts to predict the prices at which various stock indexes will open, at 9:30am New York time. It is frequently shown on various cable television channels prior to the start of the next business day.

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CITE: https://www.r2library.com/Resource/Title/0826102549

EXAMPLE: Considering the DJIA as an example, the basis of calculating implied open is the price of a “DJX index option futures contract”. This is not the price of the DJIA itself but rather the current ticker price of an option issued by the Chicago Board Options Exchange.

CBOE: The Chicago Board Options Exchange, located at 400 South LaSalle Street in Chicago, is the largest U.S. options exchange with annual trading volume that hovered around 1.27 billion contracts at the end of 2014. CBOE offers options on over 2,200 companies, 22 stock indices, and 140 exchange-traded funds.

CALCULATION: https://www.quora.com/How-do-you-calculate-the-implied-open-from-futures

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NOTE: We would like to remind you that new amendments adopted by the U.S. Securities Exchange Commission (SEC) have gone into effect as of September 28, 2021. These amendments restrict the ability of market makers to publish OTC quotations for those companies that have not made required current financial and company information available to regulators and investors.

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For Entrepreneurs and Investors, Discovering Truth Takes Time

 

For Investors, Discovering Truth Takes Time

 CFA

 

The Roman philosopher, playwright, statesman and occasional satirist Lucius Annaeus Seneca wasn’t talking about the stock market when he wrote that “time discovers truth,” but he could have been. In the long run a stock price will reflect a company’s (true) intrinsic value. In the short run the pricing is basically random.

Here are two real-life examples:

Let’s say you had the smarts to buy Microsoft in November 1992. It would have been a brilliant decision in the long run — the software giant’s stock has gone up manyfold since. But nine months later, in August 1993, that call did not look so brilliant: Microsoft shares had declined 25 percent in less than a year. In fact, it would have taken you 18 months, until May 1994, for this purchase to break even. Eighteen months of dumbness?

In the early ’90s the PC industry was still in its infancy. Microsoft’s DOS and Windows operating systems were de facto standards. Outside of Macs and a tiny fraction of IBM computers, every computer came preinstalled with DOS and Windows. Microsoft had a pristine balance sheet and a brilliant co-founder and CEO who would turn mountains upside down to make sure the company succeeded. The above sentence is infested with hindsight — after all, that was almost 30 years ago. But Microsoft clearly had an incredible moat, which became wider with every new PC sold and every new software program written to run on Windows.

Here is another example. GoPro is a maker of video cameras used by surfers, skiers and other extreme sports enthusiasts. If you had bought the stock soon after it went public, in 2014, you would have paid $40 a share for a $5.5 billion–market-cap company earning about $100 million a year — a price-earnings ratio of about 55. Your impatience would, however, have been rewarded: The stock more than doubled in just a few short months, hitting $90.

Would it have been a good decision to buy GoPro? The company makes a great product — I own one. But GoPro has no moat. None. Most components that go into its cameras are commodities. There are no barriers to entry into the specialized video camera segment. Most important, there are no switching costs for consumers. Investors who bought GoPro after its IPO paid a huge premium for the promise of much higher earnings from a company that might or might not be around five years later.

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What is even more interesting is that some of those buyers were then selling to even bigger fools who bought at double the price a few months later. GoPro was a momentum stock that was riding a wave about to break. Fast-forward a year and GoPro sales are collapsing, so now the stock is trading in the low teens ($11.65 as of this writing).

These two examples bring us to the nontrivial topics of complex systems and nonlinearity. My favorite thinker, Nassim Taleb, wrote the following in his book Antifragile: Things That Gain from Disorder: “Complex systems are full of interdependencies — hard to detect — and nonlinear responses. ‘Nonlinear’ means that when you double the dose of, say, a medication, or when you double the number of employees in a factory, you don’t get twice the initial effect, but rather a lot more or a lot less.”

The stock market is a complex system where in the short term there are few if any interdependencies between decisions and outcomes. In the short run stock prices are driven by thousands of random variables. Stock market participants have different risk tolerances and emotional aptitudes, and diverse time horizons ranging from milliseconds (for high-speed traders) to years (for long-term investors).

Assessment

In other words, predicting where a stock price will be in a day, a month or even a year is not much different from prognosticating whether the ball on a roulette wheel will land on red or black. In the longer run, however, good decisions should pay off because fundamentals will shine through — just as was the case with buying Microsoft in 1992 and not buying GoPro in 2014. But in the short run there is no correlation between good decisions and results. None!

Whenever you look at your portfolio, think of the Microsoft and GoPro examples above. The performance of your stocks in the short run tells you absolutely nothing about what you own or about the quality of your decisions. You may own a portfolio of Microsofts, and its value is still going down because at this juncture the market doesn’t care about Microsofts. Or maybe you stuffed your retirement fund with overpriced fads that may not be around a year from now. But in the longer run, which always lies out there past the short run, time discovers truth, as Seneca said.

Conclusion

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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.

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“Financial Management Strategies for Hospitals” https://tinyurl.com/yagu567d

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

“ENTERPRISE METAVERSE” Innovation and Entrepreneurship

WHAT IS IT?

On an earnings call last year Microsoft CEO Satya Nadella said the term “enterprise metaverse.”

By Dr. David Edward Marcinko MBA

DEFINITION: The Metaverse is a collective virtual shared space, created by the convergence of virtually enhanced physical reality and physically persistent virtual space, including the sum of all virtual worlds, augmented reality, and the Internet.

The word “metaverse” is made up of the prefix “meta” (meaning beyond) and the stem “verse” (a back formation from “universe“); the term is typically used to describe the concept of a future iteration of the internet, made up of persistent, shared, 3D virtual spaces linked into a perceived virtual universe.

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PODCAST: Physician Entrepreneurial Tips on Opening Your Own Medical Practice

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By MEDICAL ECONOMICS

James Underberg, MD, discusses how he left a large health system to open his own practice, and provides tips for physicians considering the same move.

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Private Healthcare Equity: https://www.youtube.com/watch?v=tBwHu1uigoA

ME-P Business Plan: https://medicalexecutivepost.com/2022/04/05/get-your-free-medical-office-start-up-business-plan-from-imba-inc/

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Recognizing the Differences between Healthcare and Other Industries

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Why Hospitals, Clinics and Medical Offices are Not Hotels, or Manufacturing Plants or Production Assembly Lines, etc.

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

[Editor-in-Chief]

The rising cost of health insurance remains a major concern for business; despite the Affordable Care Act [ACA] of March 2010. Local and national news publications have trumpeted that healthcare costs are not just rising but are growing in proportion to the cost of other goods and services.

Many of these publications have expressed the widely held view that because of the “inflation gap,” the cost of medical expenses needs curbing.  Proponents of this viewpoint attribute the growth in the gross domestic product (GDP) devoted to personal medical services (from 5% in 1965 to approximately 14% in 2005 and 17% in 2012) to increases in both total national medical expenditures as well as prices for specific services, and then conclude that there is a need to rein in the growing costs of healthcare services for the average American, even if it be through a legislative mandate.

Healthcare Is the Economy

According to colleague Robert James Cimasi MHA, AVA, CMP™ of Health Capital Consultants LLC in St. Louis, MO, healthcare cannot be separated from the economy at large. Although economists have cited the aging population as the reason for the increase in healthcare’s share of the GDP, other voices assert that financial greed among HMOs, pharmaceutical companies, hospitals, and medical providers like doctors and nurses is responsible.  In reality, the rise in healthcare expenditures is, at least in large part, the result of a much deeper economic force.

www.CertifiedMedicalPlanner.org

As economist William J. Baumol of New York University explained in a November 1993 New Republic article: “the relative increase in healthcare costs compared with the rest of the economy is inevitable and an ineradicable part of a developed economy. The attempt [to control relative costs] may be as foolhardy as it is impossible”.

Baumol’s observation is based on documented and significant differences in productivity growth between the healthcare sector of the economy and the economy as a whole.

Low Productivity Growth

Healthcare services have experienced significantly lower productivity growth rates than other industry sectors for three reasons, according to Cimasi:

1) Healthcare services are inherently resistant to automation. Innovation in the form of technological advancement has not made the same impact on healthcare productivity as it has in other industry sectors of the economy.  The manufacturing process can be carried out on an assembly line where thousands of identical (or very similar) items can be produced under the supervision of a few humans utilizing robots and statistical sampling techniques (e.g., defects per 1,000 units). The robot increases assembly line productivity by accelerating the process and reducing labor input. In medicine, most technology is still applied in a patient-by-patient manner — a labor-intensive process. Patients are cared for one at a time. Hospitals and physician offices cannot (and, most would agree, should not) try to operate as factories because patients are each unique and disease is widely variable.

2) Healthcare is local. Unlike other labor-intensive industries (e.g., shoe making), healthcare services are essentially local in nature. They cannot regularly be delivered from Mexico, India or Malaysia.  They must be provided locally by local labor.  Healthcare organizations must compete within a local community with low or no unemployment among skilled workers for high quality and higher cost labor.

3) Healthcare quality is — or is believed to be — correlated with the amount of labor expended. For example, a 30-minute office visit with a physician is perceived to be of higher quality than a 10-minute office visit. In mass production, the number of work-hours per unit is not as important a predictor of product quality as the skills and talents of a small engineering team, which may quickly produce a single design element for thousands of products (e.g., a common car chassis).

Assessment

Healthcare suffers a number of serious consequences when its productivity grows at a slower rate than other industries, the most serious being higher relative costs for healthcare services. The situation is an inevitable and ineradicable part of a developed economy.

For example, as technological advancements increase productivity in the computer, and eHR, manufacturing industry, wages for computer industry labor likewise increase. However, the total cost per computer produced actually declines.  But in healthcare (where technological advancements do not currently have the same impact on productivity), wage increases that would be consistent with other sectors of the economy yield a problem: the cost per unit of healthcare produced increases.

Conclusion

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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

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FINANCE: Financial Planning for Physicians and Advisors

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Honoring Memorial Day 2022

NOT Just a Three Day Weekend

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Memorial day

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Healthcare LOGISTICS Survey

By MCOL

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4 Key Take-Aways

 •  87% of nurses said that medical courier deliveries—or lack thereof—impacted their work weekly.
 •  32% of nurses have created a “secret stash” of supplies.
 •  27% have personally transported an item to another facility in the past year to overcome courier issues.
 •  19% said that errors or delays impacted their ability to provide patient care five or more times per month.

Source: American Nurse Journal via Businesswire

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Percent of Hospitals That Provide Discounted Rx to Patients

By Staff Reporters

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% of Hospitals That Provide Discounted Rx to Patients

 •  Delayed access to a needed drug: 75%
 •  Caused financial hardship for patient and/or their families because that had to pay more for the drug: 69%
 •  Made it logistically harder for patient to obtain needed medications: 61%
 •  Caused patient to stop taking a drug or switch to a less effective therapeutic alternative: 50%
 •  Negatively impacted patient’s health/outcomes: 41%
 •  Led to preventable emergency department visits or hospital stays: 23%
 •  Other: 15%

Source: 340B Health, “Contract Pharmacy Restrictions Represent Growing Threat to 340B Hospitals and Patients,” March 2022

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Are MDs and FAs being Replaced by Robotic Technology?

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On Disruptive Innovation or Deus ex Machina

By Dr. David Edward Marcinko MBA CMP

[Editor-in-Chief]

Dr David E Marcinko MBAAccording to Wikipedia, a disruptive technology is an innovation that helps create a new market and value network, and eventually goes on to disrupt an existing market and value network (over a few years or decades), displacing an earlier technology.

The term is often used today used in business, healthcare and technology literature to describe innovations that improve a product or service in ways that the market does not expect, typically first by designing for a different set of consumers in a new market and later by lowering prices in the existing market.

For Doctors

You can feel it happening in the marketplace around us. Retail clinics, medical tourism, technology-enabled self care — disruptive innovations in the U.S. health care system challenge the status quo. These and other new phenomena zero in on unmet needs, leverage new technologies and business models, and deliver enhanced value throughout the health care supply chain.

So, along with consumerism, healthcare reform and technology, disruptive innovation is one of the three major themes we follow at the ME-P: www.CertifiedMedicalPlanner.org  and www.MedicalBusinessAdvisors.com

For Financial Advisors

According to Mike Kitces CFP, MTax, MSFS many of the things that financial advisors do can be implemented far more efficiently with technology, and overall it’s important to acknowledge that there are some things that humans do better but some things that really are done better by computers.

Which means in the end, the real winner may not be the robo-advisors, nor the human advisors, but the technology-augmented humans – the cyborg advisors – who blend human and technology together into an optimal financial advice solution for consumers.

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cyborg

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Assessment

And so, do these big changes create big value opportunities; or not? Of course they may … but only if you know where to look!

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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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

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

DICTIONARIES: http://www.springerpub.com/Search/marcinko
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PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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Medicare for All?

OR

Worse Care for All?

THE CBO OPINES

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Senate Budget Committee Chairman Bernie Sanders (I-Vt.) has announced that as early as next week, his committee will hold a hearing “on the need to pass a Medicare for All single-payer program.”  

Sanders gets an “A” for passion, but an “F” in compassion.  

But, the non-partisan Congressional Budget Office has cautioned that Sanders’ Medicare for All bill would create “a shortage of providers, longer wait times, and changes in the quality of care.” 

MORE: https://www.msn.com/en-us/news/politics/medicare-for-all-would-mean-worse-care-for-all/ar-AAWVDo6?li=BBnb7Kz

CITE: https://www.r2library.com/Resource/Title/0826102549

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FIVE CONDITIONS: Total 50% of Healthcare Financial Costs

By Staff Reporters

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5 Conditions Total 50% of Healthcare Costs

 •  Cancer makes up nearly 15% of all healthcare spending with employers in the study paying $533 million for nearly 103,000 cancer claims.
 •  Musculoskeletal conditions (including joint wear, knee injuries, hip pain, etc.) makes up 13% of healthcare spending with employers spending $477 million for 317,000 musculoskeletal claims.
 •  Cardiovascular conditions (including heart rhythm issues, stroke, heart attack, and heart failure) makes up 9% of healthcare spending with employers paying $357 million towards 169,000 claims.
 •  Gastrointestinal conditions (including colitis, irritable bowel system, celiac disease, etc.) makes up 7% of healthcare spending with employers paying $284 million for 136,000 claims.
 •  Neurological conditions (including Parkinson’s disease, migraines, epilepsy, etc.) makes up 6% of total health care spending with employers paying $225 million for 240,000 claims.

Source: HAC and UHC via ACDIS, April 14, 2022

CITE: https://www.r2library.com/Resource/Title/082610254

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Invite Dr. Marcinko to Mask-Up and Speak at your Next Seminar, Webcast or Event?

Invite Dr. Marcinko

The Choice is Up to You

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Colleagues know that I enjoy personal coaching and public speaking and give as many talks each year as possible, at a variety of medical society and financial services conferences around the country and world.

These include lectures and visiting professorships at major academic centers, keynote lectures for hospitals, economic seminars and health systems, keynote lectures at city and statewide financial coalitions, and annual keynote lectures for a variety of internal yearly meetings.

 Topics Link: imba-inc-firm-services

My Fond Farewell to Tuskegee University

And so, we appreciate your consideration.

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PODCAST: The Financial Cost of Medication Non-Adherence

Cost of Medication Non-Adherence: 33- 69% of Hospitalizations

By Eric Bricker MD

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CITE: https://www.r2library.com/Resource/Title/082610254

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SURVEY: Artificial Intelligence [A.I.] in Health Care

By AMA and MCOL

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JAMA: Public Views About Artificial Intelligence in Health Care

A recent JAMA survey asked “Overall, in the next 5 years, do you think AI will make health care in the United States?” The survey results were as follows:

 •  Much better: 10.9%
 •  Somewhat better: 44.5%
 •  Minimal change: 19.3%
 •  Somewhat worse: 4.3%
 •  Much worse: 1.9%
 •  Don’t know: 19%

Source: JAMA Network, May 4, 2022

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Clinic ‘Charged Patient $40 for Crying’

By Staff Reporters

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FULL REPRINT: A woman who visited doctors in the US was charged for an ’emotional and behavioral assessment’ simply for shedding a tear.

LINK: https://7news.com.au/news/world/us-patient-charged-extra-for-crying-during-doctors-appointment-c-6867615

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SURVEY: Medical Clinicians of the Future?

By Staff Reporters

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Clinician of the Future Study – 5 Key Findings

 •  62% of clinicians agreed the role of the clinician will change to be more of a partnership with the patient in 10 years’ timer.
 •  51% of clinicians agreed tele-health will negatively impact their ability to demonstrate empathy with patients.
 •  56% agreed patients will be more empowered to take care of their own health.
 •  77% of clinicians expect real-time patient analytics to be critical to personalized care in the future.
 •  43% expect every individual will have their genome sequenced to support illness prevention.

Source: Elsevier, Clinician of The Future, Report 2022

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UPDATE: Vitalik Buterin, Recession Risk the Euro and BOA

By Staff Reporters

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  • Vitalik Buterin tweeted Friday that he’s no longer a billionaire. Crypto has crashed in recent weeks amid a broad sell-off in traditional markets. Ethereum cofounder Vitalik Buterin tweeted Friday that he’s no longer a billionaire. Buterin, who cofounded the blockchain network in 2014, has seen its Ether token crash by 59% since hitting a high of around $4,800 in November 2021, when his holding was valued at around $1.5 billion.
  • Historically, the S&P 500 has fallen an average of 29% around recession (median of 24%). With the S&P 500 currently showing a peak-to-trough decline of almost 19%, the market is effectively already pricing in a 60%-75% chance of recession based on the average and median.
  • Thanks to a surging US dollar and a faltering Euro, many analysts expect that the two currencies could reach parity this year—meaning one dollar would fetch you one euro. The two currencies haven’t reached a 1:1 exchange rate since 2002, three years after the euro was introduced in an effort to bring stability to Europe. The euro closed at $1.057 against the dollar, just 5% above equal value with the US currency.
  • Finally, the current market plunge hasn’t yet scared investors like downturns in years past. Bank of America’s private clients are still dedicating 63% of their portfolios to stocks, compared to 39% after the 2008 financial crisis.

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SDOH = Social Determinants of Oral Health

By Staff Reporters

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Social determinants of oral health and tooth loss

A study led by investigators at the Harvard School of Dental Medicine suggested that “machine-learning algorithm models incorporating socioeconomic characteristics were better at predicting tooth loss than those relying on routine clinical dental indicators alone.”

CITE: https://www.r2library.com/Resource/Title/082610254

Furthermore, new research reported that

  • adults living in urban areas visited the dentist more than those in rural areas
  • women were more likely than men to visit the dentist in both rural and urban areas
  • the number of adult dental visits increased as family income increased
  • non-Hispanic white adults were more likely than Hispanic and non-Hispanic black adults to have a dental visit in urban areas.

Therefore, it is important to consider how disparities in access to and use of dental care impact not only tooth loss but also oral and overall health.

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COLLEAGUE: Dr. Mike Burry Opines on the Markets

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By Dr. David Edward Marcinko MBA

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Big Short’ investor Michael Burry MD warns stocks will crash and rallies won’t last.

  • “The Big Short” investor Michael Burry expects a far steeper decline in the stock market.
  • The Scion Asset Management chief’s view is based on how past crashes have played out.
  • Burry warned brief rallies were likely, and joked about his penchant for premature predictions.

Michael Burry, the hedge fund manager of “The Big Short” fame, rang the alarm on the “greatest speculative bubble of all time in all things” last summer. He warned the retail investors piling into meme stocks and cryptocurrencies that they were careening towards the “mother of all crashes.”

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Mike also wrote a popular chapter in our financial planning textbook for physician investors. With our appreciation and gratitude.

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