BOARD CERTIFICATION EXAM STUDY GUIDES Lower Extremity Trauma
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Posted on July 6, 2022 by The D.E.A. ROGUE WARRIOR
ACCORDING TO AUSTRIAN ECONOMISTS
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BY PER BYLUND
Colleague Peter R. Quinones and Per Bylund return to the show to talk about the role of the entrepreneur not only in society, but according to the Austrian School of Economics. Medical perspectives are implied.
Posted on July 6, 2022 by The D.E.A. ROGUE WARRIOR
By Staff Reporters
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The Euro lost 10% versus the dollar this year and at $1.0238 EUR=EBS is close to the psychologically crucial parity point it last saw in mid-2002. It also hit new seven-year lows versus the Swiss franc and dropped against the sterling and the yen, but few observers are willing to call a bottom yet. Nomura’s analysts cut their euro/dollar target to $0.95 and said parity could be breached as soon as August. Citibank says a move to parity is “inevitable.” However, Nomura said that $0.95 was not that important historically, noting that the euro fell from $1.17 after its creation to $0.82 in October 2002. Extrapolating backwards using its legacy currencies, the euro traded as weak as $0.6444 in February 1985.
On the New York Mercantile Exchange, benchmark U.S. crude oil for August delivery fell $8.93 to $99.50 a barrel, its first dip below $100 since May 11th. Brent crude for September delivery fell $10.73 to $102.70 a barrel.
Finally, the Dow dropped 129.44 points, or 0.4%, to finish at 30,967.82; it had been down more than 700 points at its lows earlier in the session. The S&P 500 gained 6.06 points, or 0.2%, closing at 3,831.39. And, the NASDAQ Composite advanced 194.39 points, or 1.8%, to finish at 11,322.24.
The impact of medical workplace violence became widely exposed on November 6, 2009 when 39 year old Army psychiatrist Maj. Nidal M. Hasan MD, a 1997 graduate of Virginia Tech University who received a medical doctorate in psychiatry from the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and served as an intern, resident and fellow at the Walter Reed Army Medical Center in the District of Columbia, went on a savage 100 round shooting spree and rampage that killed 13 people and injured 32 others. In April 2010 he was transferred to Bell County Jail in Belton, Texas awaiting trial.
Federal Government Guidelines
The federal government and some states have developed guidelines to assist employers with workplace violence prevention. For instance, one of the earliest sets of guidelines for a comprehensive workplace violence prevention program was published in 1993 by California OSHA. This resulted from the murder of a state employee. In 1996, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers was published by OSHA.
In its guidelines, OSHA sets forth the following essential elements for developing a violence prevention program:
Management commitment — as seen by high-level management involvement and support for a written workplace violence prevention policy and its implementation.
Meaningful employee involvement — in policy development, joint management-worker violence prevention committees, post-assault counseling and debriefing, and follow-up are all critical program components.
Worksite analysis — includes regular walk-through surveys of all patient care areas and the collection and review of all reports of worker assault. A successful job hazard analysis must include strategies and policies for encouraging the reporting of all incidents of workplace violence, including verbal threats that do not result in physical injury.
Hazard prevention and control — includes the installation and maintenance of alarm systems in high-risk areas. It may also include the training and posting of security personnel in emergency departments. Adequate staffing is an essential hazard prevention measure, as is adequate lighting and control of access to staff offices and secluded work areas.
Pre-placement and periodic training and education — must include educationally appropriate information regarding the risk factors for violence in the healthcare environment and control measures available to prevent violent incidents. Training should include skills in aggressive behavior identification and management, especially for staff working in the mental health and emergency departments.
On May 17, 1999, Governor Gary Locke signed the New Workplace Violence Prevention Act for the state of Washington. This act mandates that each healthcare setting in the state implement a plan to reasonably prevent and protect employees from violence.
New Washington Workplace Violence Prevention Act
According to this act, prevention plans need to address security considerations related to:
physical attributes of the healthcare setting;
staffing, including security staffing;
personnel policies;
first aid and emergency procedures;
reporting of violent acts; and
employee education and training.
Prior to the development of an actual plan, a security and safety assessment needs to be conducted to identify existing or potential hazards. The training component of the plan must include the following topics:
general safety procedures;
personal safety procedures;
the violence escalation cycle;
violence-predicting factors;
means of obtaining a patient history form from a patient with violent behavior;
strategies to avoid physical harm;
restraining techniques;
appropriate use of medications as chemical restraints;
documenting and reporting incidents;
the process whereby employees affected by a violent act may debrief;
any resources available to employee for coping with violence; and
the healthcare setting’s workplace violence prevention plan.
Assessment
The act further mandates that any hospital operated and maintained by the State of Washington for the care of the mentally ill is required to provide violence prevention training to affected employees identified in the plan on a regular basis and prior.
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:
Posted on July 3, 2022 by The D.E.A. ROGUE WARRIOR
By Phil Taylor
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US digital health company investment financing experienced a dip in Q1 of 2022, dropping to $6 billion from the $6.7 billion invested in Q1 2021. In addition, the average size of each investment deal dropped from $46 million last year to just shy of $33 million. These declines come after a boom in investments in recent years. The Rock Health Digital health securities index also reflected this year’s trend, including special purpose acquisition company (SPAC) listings.
According to Phil Taylor of PharmaPhorum, “SPACs have been a popular route to public listing for digital health as well as many other sectors, but the deals have underperformed, with steep declines in share prices after they closed that has “exerted downwards pressure” on the Rock Health Digital Health Index (RHDHI).”
Posted on July 3, 2022 by The D.E.A. ROGUE WARRIOR
By Steve Febus
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Hospital Finance 101: Understanding the Cost of Full-Service Healthcare in Pullman, WA Program by: Steve Febus, Pullman Regional Hospital Chief Financial Officer.
Posted on July 1, 2022 by The D.E.A. ROGUE WARRIOR
By Vitaliy Katsenelson CFA
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Charter Communications (CHTR) is a significantly undervalued stock today. But are competition, 5G, and satellite internet significant threats to its business? How does its management compare to AT&T and Verizon? Read and/or listen to the analysis below.
Posted on June 30, 2022 by The D.E.A. ROGUE WARRIOR
By Jakob Emerson, beckerspayer.com
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The company formerly known as Anthem commemorated its official rebranding to Elevance Health on June 28th by ringing the opening bell at the New York Stock Exchange and beginning to trade under the new ticker symbol “ELV”. The former Anthem website now reflects the name change, which is a combination of the words elevate and advance to represent the company’s commitment to “elevating the importance of whole health and advancing health beyond healthcare for consumers.”
When it first announced the rebrand in March, the payer said Blue Cross Blue Shield health plan names would not change, though it planned to narrow the number of brands under its umbrella. The company owns BCBS plans in 14 states. On June 15, the company launched two new subsidiaries under the Elevance name: Carelon and Wellpoint.
Carelon, a healthcare services brand, will consolidate the company’s existing portfolio of capabilities and services businesses under a single name. The Wellpoint health plan brand will unify the company’s Medicare, Medicaid, and commercial health plans in select markets.
Posted on June 29, 2022 by The D.E.A. ROGUE WARRIOR
FOR TOP MANAGERS AND BODs
By Dr. Jeffery Funk
Did you know that far more MBAs and bachelor-degree holders were among top managers and board of directors among startups filing for IPOs between 1990 and 2018 than were other degree holders?
About 55% of them had an MBA for their highest degree vs. 20% for bachelors, 7% for PhD, 3% for MD, 12% for MS, and 3% for JD. The high percentage of MBAs and bachelor-degree holders reflects the move away from #science-based #technologies such as semiconductors, and electronic, communications, and medical equipment that once dominated Silicon Valley (hence the name), and towards Internet commerce, content, and services over last 25 years.
In fact, most PhDs among top managers and board of directors at IPO time studied life sciences and were employed in #biotech#startups, a sector that continues to thrive. Creating successful science-based startups in other sectors continues to be a big challenge, one that may be partially overcome by #AI in near future.
As for which #universities train these people, Harvard, Stanford, Berkeley and MIT had the most graduates in many categories, representing almost 20% of PhDs for instance.
“Most of my friends assume that business owners spend their money and time on cocaine and hookers.”
This jaw-dropping quote came from a young man I was talking with recently about money, investing, and running a business. I was shocked; this was a money script I had never heard.I asked if he was serious. He was. I asked if any of the friends with this belief were raised by a parent who owned a business. He thought for a moment and said, “No, not one.”
This conversation reminded me of a government employee who once told me, “Any person who succeeds in business had to do so illegally by embracing corruption and dishonesty.” He, too, was serious.
I was dumbfounded by both of these encounters. My experience of being raised by parents who owned a small business, and then going into business for myself, was quite different from these perceptions.
My father started his own business when I was four years old. I witnessed him working long hours. I remember the times when business was so bad he would have to borrow money to pay the bills and keep the doors open. Later in life I learned his business rarely made a profit and was just able to pay his salary.
He never shared with his employees how tight money was. When I went to work for him as a teenager, I remember listening to the talk around the water cooler. They all assumed he made far more money than what I knew was true.
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In the years since, I have discovered many misperceptions about people who own real estate, are in business, or who have accumulated wealth.
The first misperception is that someone who owns real estate or a business has actually accumulated wealth. My 40 years of experience in financial planning has taught me that many, if not most, business owners would make more money working for someone else. And real estate owners accumulate wealth slowly. Most of them, myself included, struggle through some lean years with short or even negative cash flow until they finally pay off their mortgages.
Certainly, real estate or business owners who persevere over the long term can become wealthy. Being wealthy, according to various studies, is defined as having a minimum net worth of somewhere between five million and twenty million dollars.
About 80% of millionaires own their own businesses. They put in long hours, often in careers they love enough so that work becomes play. The average business owner puts in about 70 hours a week. They are five times more likely than non-business owners to be “always available” via e-mail, four times more likely to work nights, and three times more likely to be in the office or store on weekends.
This is the way one successful business owner described it: “Our company will celebrate its 50th anniversary next year. Probably the first 30 years were spent working 70-100 hour weeks at below minimum wage and dumping every extra penny back into the business. I would say it’s only been the last 10 years that we have begun to reap the financial rewards that we spent 40 years striving to attain, still working 60-70 hour weeks. I acknowledge our work habits may in part be a result of being stubborn Norwegians that don’t think anyone else can do things right, but most successful small business owners I know have pretty much dedicated their life to become successful.”
Assessment
This focus and work ethic are what it takes to succeed at business ownership. It’s not a mindset that includes blowing money and time on cocaine and hookers.
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
Posted on June 27, 2022 by The D.E.A. ROGUE WARRIOR
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Dr. Bertalan Meskó, MD PhD
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The Medical Futurist
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Google in healthcare: The search giant has repeatedly successfully transferred its in-depth knowledge of algorithms in the field of medicine, particularly since it acquired DeepMind.
Apple in healthcare: Apple will keep on working on expanding the health features of its devices, Apple Watch and iPhones included.
Microsoft in healthcare: Microsoft’s cloud solutions provide integrated capabilities that make it easier to improve the healthcare experience.
Amazon in healthcare: Amazon will make further use of its vast knowledge of online shopping trends and behavior and will keep on providing what people need, from medicine to wearables.
IBM in healthcare: IBM has a lot to offer in federated learning, blockchain, and quantum computing
Nvidia in healthcare: NVIDIA seems incredibly focused on its approach to healthcare. We can expect NVIDIA to be a leader in the use of artificial intelligence in healthcare
Facebook in healthcare: The Metaverse developed by Facebook/Meta has incredible potential to revolutionize healthcare.
Posted on June 27, 2022 by The D.E.A. ROGUE WARRIOR
By Staff Reporters
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Predictions: The stock market could surge 7% this week as quarter-end re-balancing leads to a buying spree in equities, according to JPMorgan. The bank expects re-balancing trades to favor equities after a year-to-date decline of nearly 20%. “Next week’s re-balance is important since equity markets were down significantly over the past month, quarter and six-month time periods.”
Markets: With the S&P having plunged nearly 18% this year, expect W. Buffett to preach the value of value stocks (aka steady, non-flashy public companies). By one measure, they’re on track to beat growth stocks by the widest margin in more than two decades, according to the WSJ.
Global economy: Russia defaulted on its foreign-currency sovereign debt for the first time since the Bolshevik Revolution in 1918 after failing to pay bondholders $100 million worth of interest by the end of a 30-day grace period. The default marks the beginning of a complex legal journey for bondholders, but it’s not expected to have any major consequences for the Russian economy, which has already been battered by Western sanctions.
Posted on June 27, 2022 by The D.E.A. ROGUE WARRIOR
Or, NOT!
By Rick Kahler CFP®
How do you spot the investment opportunity that will become the next Apple, Facebook, or Microsoft? Certainly they are out there. Someone is going to discover them and be set for life, so why shouldn’t it be you?
Here’s why it shouldn’t
As with all Registered Investment Advisors, the amount of money I manage for clients is publicly disclosed information that anyone with an Internet connection can find.
Because of that, I am seen as the gatekeeper of a source of funding for every under funded business opportunity that is sure to become the next Apple. I get to see a lot of proposals. Many have promise at first glance. But the promise usually fades the more I dig into the proposal, ask questions, and do the math.
After hours and hours of investigation, every few years I see that one proposal that looks really good. One that calls to me to invest, that really has the promise of being a winner. When all the stars and the planets align, I know I now have a 90% chance of not making a dime on the venture.
That’s why I have learned to save my time and my money when I am approached with “the next big thing.” I just don’t have time to investigate every project and cull hundreds of opportunities down to the one that has a 10% chance of succeeding. I see it as looking for the proverbial needle in the haystack. Certainly, there’s a needle in there somewhere. But examining every piece of hay in order to find it has a significant monetary cost.
To succeed, I would need a lot of time, even more money, and exponentially more intuition and intellect. Not to mention a fair amount of luck. The probability that I will go bankrupt before I ever find the needle is staggering.
Most of the “next big things” are discovered by driven entrepreneurs who bank everything they have on an idea and find the financing to shoestring it together. It usually isn’t the armchair investor who cashes in.
My experience
Over my 40 years of real estate and investment experience, I have seen people lose millions investing in lumber mills, emu farms, highly leveraged real estate, futures contracts, day trading, restaurants, multi-level-marketing companies, rare earth minerals, Iraqi currency, and the newest ones—marijuana farms and crypto-currencies.
As a result, for my money and the money of my clients, I’ll play the odds for success by saying “no” to every opportunity that comes across my desk. I don’t take the time to investigate them. I don’t read the offering circulars. I don’t attend presentations. The answer is “no” to the great odds of losing my money and “yes” to the staggering odds of keeping money growing conservatively for me and for my clients.
What do I say “yes” to? I say yes to investing in mutual funds that own or loan money to 12,000 successful companies around the globe and thousands of real estate properties. I say yes to well-diversified portfolios. I say yes to proven investment strategies with 25-year track records. I say yes to having enough cash reserves to fund two to five years of retirement income.
Boring
I know, it’s not very sexy, is it? In fact, the way I invest my money and the money of those who have entrusted their investments to me is downright boring.
So here is my hot tip when it comes to finding investment opportunities to secure your future: forget about the “next big thing.” Instead, stay with the “next boring thing.” The odds are overwhelming that this will make you a long-term winner.
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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Posted on June 26, 2022 by The D.E.A. ROGUE WARRIOR
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By Darrell K. Pruitt DDS
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“We’re now truly in the era of ransomware as pure extortion without the encryption – Why screw around with cryptography and keys when just stealing the info is good enough”
Posted on June 24, 2022 by The D.E.A. ROGUE WARRIOR
By Eric Bricker MD
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Google Starts Stop Loss Company Called Coefficient
Coefficient Will be a Part of the Verily Healthcare Subsidiary Within Google. Coefficient Will Also Be in Partnership and Partly Owned by the Giant, International ReinsuranceCompany Swiss Re.
Some of the pioneers of behavioral finance are Drs. Kahneman, Twersky and Thaler. This short introduction to the subject is based on John Nofsinger’s little book entitled “Psychology of Investing” an excellent quick read for all medical professionals or anyone who is interested in learning more about behavioral finance.
Rational Decisions?
Much of modern finance is built on the assumption that investors “make rational decisions” and “are unbiased in their predictions about the future”, however this is not always the case.
Cognitive errors come from (1) prospect theory (people feel good/bad about gain/loss of $500, but not twice as good/bad about a gain/loss of $1,000; they feel worse about a $500 loss than feel good about a $500 gain); (2) mental accounting (meaning that people tend to create separate buckets which they examine individually), (3) Self-deception (e.g. overconfidence), (4) heuristic simplification (shortcuts) and (4) mood can affect ability to reach a logical conclusion.
John Nofsinger’s Book
The following are some of the major chapter headings in Nofsinger’s book, and represent some of the key behavioral finance concepts.
Overconfidence leads to: (1) excessive trading (which in turn results in lower returns due to costs incurred), (2) underestimation of risk (portfolios of decreasing risk were found for single men, married men, married women, and single women), (3) illusion of knowledge (you can get a lot more data nowadays on the internet) and (4) illusion of control (on-line trading).
Pride and Regret leads to: (1) disposition effect (not only selling winners and holding on to the losers, but selling winners too soon- confirming how smart I was, and losers to late- not admitting a bad call, even though selling losers increases one’s wealth due to the tax benefits), (2) reference points (the point from where one measures gains or losses is not necessarily the purchase price, but may perhaps be the most recent 52 week high and it is most likely changing continuously- clearly such a reference point will affect investor’s judgment by perhaps holding on to “loser” too long when in fact it was a winner.)
Considering the Past in decisions about the future, when future outcomes are independent of the past lead to a whole slew of more bad decisions, such as: (1) house money effect (willing to increase the level of risk taken after recent winnings- i.e. playing with house’s money), (2) risk aversion or snake-bite effect (becoming more risk averse after losing money), (3) trying to break-even (at times people will increase their willing to take higher risk to try to recover their losses- e.g. double or nothing), (4) endowment or status quo effect (often people are only prepared to sell something they own for more than they would be willing to buy it- i.e. for investments people tend to do nothing, just hold on to investments they already have) (5) memory and decision making ( decisions are affected by how long ago did the pain/pleasure occur or what was the sequence of pain and pleasure), (6) cognitive dissonance (people avoid important decisions or ignore negative information because of pain associated with circumstances).
Mental Accounting is the act of bucketizing investments and then reviewing the performance of the individual buckets separately (e.g. investing at low savings rate while paying high credit card interest rates).
Examples of mental accounting are: (1) matching costs to benefits (wanting to pay for vacation before taking it and getting paid for work after it was done, even though from perspective of time value of money the opposite should be preferred0, (2) aversion to debt (don’t like long-term debt for short-term benefit), (3) sunk-cost effect (illogically considering non-recoverable costs when making forward-going decisions). In investing, treating buckets separately and ignoring interaction (correlations) induces people not to sell losers (even though they get tax benefits), prevent them from investing in the stock market because it is too risky in isolation (however much less so when looked at as part of the complete portfolio including other asset classes and labor income and occupied real estate), thus they “do not maximize the return for a given level of risk taken).
In building portfolios, assets included should not be chosen on basis of risk and return only, but also correlation; even otherwise well educated individuals make the mistake of assuming that adding a risky asset to a portfolio will increase the overall risk, when in fact the opposite will occur depending on the correlation of the asset to be added with the portfolio (i.e. people misjudge or disregard interactions between buckets, which are key determinants of risk).
This can lead to: (1) building behavioral portfolios (i.e. safety, income, get rich, etc type sub-portfolios, resulting in goal diversification rather than asset diversification), (2) naïve diversification (when aiming for 50:50 stock:bond allocation implementing this as 50:50 in both tax-deferred (401(k)/RRSP) accounts and taxable accounts, rather than placing the bonds in the tax-deferred and stocks in taxable accounts respectively for tax advantages), (3) naïve diversification in retirement accounts (if five investment options are offered then investing 1/5th in each, thus getting an inappropriate level of diversification or no diversification depending on the available choices; or being too heavily invested in one’s employer’s stock).
Representativeness may lead investors to confusing a good company with a good investment (good company may already be overpriced in the market; extrapolating past returns or momentum investing), and familiarity to over-investment in one’s own employer (perhaps inappropriate as when stock tanks one’s job may also be at risk) or industry or country thus not having a properly diversified portfolio.
Emotions can affect investment decisions: mood/feelings/optimism will affect decision to buy or sell risky or conservative assets, even though the mood resulted from matters unrelated to investment. Social interactions such as friends/coworkers/clubs and the media (e.g. CNBC) can lead to herding effects like over (under) valuation.
Financial Strategies
Nofsinger finishes with a final chapter which includes strategies for:
(i) beating the biases: (1) Understand the biases, (2) define your investment objectives, (3) have quantitative investment criteria, i.e. understand why you are buying a specific investor (or even better invest in a passive fashion), (4) diversify among asset classes and within asset classes (and don’t over invest in your employer’s stock), and (5) control your investment environment (check on stock monthly, trade only monthly and review progress toward goals annually).
(ii) using biases for the good: (1) set new employee defaults for retirement plans to being enrolled, (2) get employees to commit some percent of future raises to automatically go toward retirement (save-more-tomorrow).
Assessment
Buy the book (you can get used copies at through Amazon for under $10). As indicated it is a quick read and occasionally you may even want to re-read it to insure you avoid the biases or use them for the good. Also, the book has long list of references for those inclined to delve into the subject more deeply.
You might even ask “How does all this Behavioral Finance coexist with Efficient Market theory?” and that’s a great question that I’ll leave for another time.
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:
Posted on June 22, 2022 by The D.E.A. ROGUE WARRIOR
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By Michael A. Gayed, CFA
Portfolio Manager of the ATAC Rotation Funds
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Bob Farrell is a legendary Wall Street trader and market analyst. He’s perhaps best-known for his “10 rules” of investing that he developed based on his 50-year career in the industry. One of the more popular rules says that “when all the experts and forecasts agree, something else is going to happen.”Right now, almost everyone is expecting a recession driven by high inflation, rising interest rates and geopolitical risks. The S&P 500 is still more than 10% off of its highs, while the NASDAQ 100 is down by more than 20%. Many feel as if more downside is ahead, but what if they’re wrong? What if the bottom is already in? What if the worst is over?
My take? I have no idea. I believe there’s still a bigger and more traditional classic “risk-off” period coming where stocks decline and Treasuries rally in price (which is what historically happens during periods of heightened equity volatility), but the path to get there is what drives investor sentiment. And like everyone else in this business, I can’t tell the future. All I can do is identify conditions in a rules-based fashion that favor an outcome.The important thing to remember here is that the market isn’t the economy. The financial markets are often leading indicators of where investors feel things are going. The actual data is only showing how conditions are or were.
Take the 2020 COVID recession, for example. Once the government announced its multi-trillion dollar stimulus program, stock prices shot higher even though the worst of the economic pain had yet to be experienced.Today, some of the data isn’t even indicating imminent danger.
High yield spreads tend to blow out ahead of a recession. They’re currently not at the levels reached during 2016, 2018 or 2020. Investors often view the 10-year/2-year Treasury yield spread as the “recession indicator”. This number did briefly turn negative earlier this year, but has remained in positive territory ever since. While both of these numbers have teased the idea of higher risk conditions ahead, neither has done so in convincing fashion yet.Also consider that the markets tend to be very sensitive to what the Fed does. If the central bank ever decides that recession risk is too high and it hits the pause button on the rate hiking cycle, it could be off to the races again for equity prices. Risk asset prices have the ability to react favorably to looser monetary conditions. Any pivot in that direction could give a big boost to investor sentiment.
If the bear market is over, the ATAC Rotation Fund (ATACX), the ATAC U.S. Rotation ETF (RORO) and the ATAC Credit Rotation ETF (JOJO) could be primed to benefit.We believe all three funds use proven market signals to determine whether they should be positioned either offensively or defensively. Since investors often flock to safety in times of market volatility, the three funds use Treasuries as the “risk-off” or defensive asset class. Admittedly, Treasuries haven’t acted as they historically do relative to equities when in high volatility states. But that doesn’t mean things won’t revert back to historical behavior in the small sample of the here and now.When the signals suggest that conditions are more favorable, the funds can go “risk-on”.
In the case of RORO and ATACX, that could include some combination of large-cap stocks, small-caps and emerging markets. JOJO remains in the fixed income markets and targets junk bonds in this scenario.RORO and ATACX also use leverage, which offers higher return potential. Why? Because leveraging equities when risk-on helps to, over time, counter the impact of being in Treasuries when stocks continue to move higher and with hindsight, risk-off positioning there wasn’t warranted.
Of course this is a double-edged sword, since in a year like this year, the leveraged risk-on position in stocks earlier in the year led to a sizeable decline for both ATACX and RORO. However, over multiple roll of the die, it is that leverage which gives investors the opportunity to capture above average returns in more traditional markets when combined with occasional risk-off periods where Treasuries perform well.High volatility markets don’t need to be feared.
We believe strategies that add and remove market risk based on what the market is telling us give investors the opportunity to earn superior risk-adjusted returns while lowering downside risk. If the markets are ready to begin the next leg higher, the ATAC funds stand ready to benefit while (hopefully) Treasuries get back to doing what they normally would in true risk-off periods .
Posted on June 20, 2022 by The D.E.A. ROGUE WARRIOR
Former: CEO and Founder Superior Consultant Company, Inc. [SUPC-NASD]
EDITOR’S NOTE:I first met Rich in B-school, when I was a student, back in the day. He was the Founder and CEO of Superior Consultant Holdings Corp. Rich graciously wrote the Foreword to one of my first textbooks on financial planning for physicians and healthcare professionals. Today, Rich is a successful entrepreneur in the technology, health and finance space.
-Dr. David E. Marcinko MBA CMP®
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By Richard Helppie
Today for your consideration – How to fix the healthcare financing methods in the United States?
I use the term “methods” because calling what we do now a “system” is inaccurate. I also focus on healthcare financing, because in terms of healthcare delivery, there is no better place in the world than the USA in terms of supply and innovation for medical diagnosis and treatment. Similarly, I use the term healthcare financing to differentiate from healthcare insurance – because insurance without supply is an empty promise.
This is a straightforward, 4-part plan. It is uniquely American and will at last extend coverage to every US citizen while not hampering the innovation and robust supply that we have today. As this is about a Common Bridge and not about ideology or dogma, there will no doubt be aspects of this proposal that every individual will have difficulty with. However, on balance, I believe it is the most fair and equitable way to resolve the impasse on healthcare funding . . . .
Let me start in an area sure to raise the ire of a few. And that is, we have to start with eliminating the methods that are in place today. The first is the outdated notion that healthcare insurance is tied to one’s work, and the second is that there are overlapping and competing tax-supported bureaucracies to administer that area of healthcare finance.
Step 1 is to break the link between employment and health insurance. Fastest way to do that is simply tax the cost of benefits for the compensation that it is. This is how company cars, big life insurance policies and other fringe benefits were trimmed. Eliminating the tax-favored treatment of employer-provided healthcare is the single most important change that should be made.
Yes, you will hear arguments that this is an efficient market with satisfied customers. However, upon examination, it is highly risky, unfair, and frankly out of step with today’s job market.
Employer provided health insurance is an artifact from the 1940’s as an answer to wage freezes – an employer could not give a wage increase, but could offer benefits that weren’t taxed. It makes no sense today for a variety of reasons. Here are a few:
1. Its patently unfair. Two people living in the same apartment building, each making the same income and each have employer provided health insurance. Chris in unit 21 has a generous health plan that would be worth $25,000 each year. Pays zero tax on that compensation. Pat, in unit 42 has a skimpy plan with a narrow network, big deductibles and hefty co-pays. The play is worth $9,000 each year. Pat pays zero tax.
3. The insurance pools kick out the aged. Once one becomes too old to work, they are out of the employer plan and on to the retirement plan or over to the taxpayers (Medicare).
4. The structure is a bad fit. Health insurance and healthy living are longitudinal needs over a long period of time. In a time when people change careers and jobs frequently, or are in the gig economy, they are not any one place long enough for the insurance to work like insurance.
5. Creates perverse incentives. The incentives are weighted to have employers not have their work force meet the standards of employees so they don’t have to pay for the health insurance. Witness latest news in California with Uber and Lyft.
6. Incentives to deny claims abound. There is little incentive to serve the subscriber/patient since the likelihood the employer will shop the plan or the employee will change jobs means that stringing out a claim approval is a profitable exercise.
7. Employers have difficulty as purchasers. An employer large enough to supply health insurance has a diverse set of health insurance needs in their work force. They pay a lot of money and their work force is still not 100% happy.
Net of it, health insurance tied to work has outlived its usefulness. Time to end the tax-favored treatment of employer-based insurance. If an employer wants to provide health insurance, they can do it, but the value of that insurance is reflected in the taxable W-2 wages – now Pat and Chris will be treated equally.
Step 2 is to consolidate the multiple tax-supported bureaus that supply healthcare. Relieve the citizens from having to prove they are old enough, disabled enough, impoverished enough, young enough. Combine Medicare, Medicaid, CHIP, Tricare and even possibly the VA into a single bureaucracy. Every American Citizen gets this broad coverage at some level. Everyone pays something into the system – start at $20 a year, and then perhaps an income-adjusted escalator that would charge the most wealthy up to $75,000. Collect the money with a line on Form 1040.
I have not done the exact math. However, removing the process to prove eligibility and having one versus many bureaucracies has to generate savings. Are you a US Citizen? Yes, then here is your base insurance. Like every other nationalized system, one can expect longer waits, fewer referrals to a specialist, and less innovation. These centralized systems all squeeze supply of healthcare services to keep their spend down. The reports extolling their efficiencies come from the people whose livelihoods depend on the centralized system. However, at least everyone gets something. And, for life threatening health conditions, by and large the centralized systems do a decent job. With everyone covered, the fear of medical bankruptcy evaporates. The fear of being out of work and losing healthcare when one needs it most is gone.
So if you are a free market absolutist, then the reduction of vast bureaucracies should be attractive – no need for eligibility requirements (old enough, etc.) and a single administration which is both more efficient, more equitable (everyone gets the same thing). And there remains a private market (more on this in step 3) For those who detest private insurance companies a portion of that market just went away. There is less incentive to purchase a private plan. And for everyone’s sense of fairness, the national plan is funded on ability to pay. Bearing in mind that everyone has to pay something. Less bureaucracies. Everyone in it together. Funded on ability to pay.
Step 3 is to allow and even encourage a robust market for health insurance above and beyond the national plan – If people want to purchase more health insurance, then they have the ability to do so. Which increases supply, relieves burden on the tax-supported system, aligns the US with other countries, provides an alternative to medical tourism (and the associated health spend in our country) and offers a bit of competition to the otherwise monopolistic government plan.
Its not a new concept, in many respects it is like the widely popular Medigap plans that supplement what Medicare does not cover.
No one is forced to make that purchase. Other counties’ experience shows that those who choose to purchase private coverage over and above a national plan often cite faster access, more choice, innovation, or services outside the universal system, e.g., a woman who chooses to have mammography at an early age or with more frequency than the national plan might allow. If the insurance provider can offer a good value to the price, then they will sell insurance. If they can deliver that value for more than their costs, then they create a profit. Owners of the company, who risk their capital in creating the business may earn a return.
For those of you who favor a free market, the choices are available. There will be necessary regulation to prevent discrimination on genetics, pre-existing conditions, and the like. Buy the type of plan that makes you feel secure – just as one purchases automobile and life insurance.For those who are supremely confident in the absolute performance of a centralized system to support 300+ million Americans in the way each would want, they should like this plan as well – because if the national plan is meeting all needs and no one wants perhaps faster services, then few will purchase the private insurance and the issuers will not have a business. Free choice. More health insurance for those who want it. Competition keeps both national and private plans seeking to better themselves.
Step 4 would be to Permit Access to Medicare Part D to every US Citizen, Immediately
One of the bright spots in the US Healthcare Financing Method is Medicare Part D, which provides prescription drug coverage to seniors. It is running at 95% subscriber satisfaction and about 40% below cost projections.
Subscribers choose from a wide variety of plans offered by private insurance companies. There are differences in formularies, co-pays, deductibles and premiums.
So there you have it, a four part plan that would maintain or increase the supply of healthcare services, universal insurance coverage, market competition, and lower costs. Its not perfect but I believe a vast improvement over what exists today. To recap:
1. Break the link between employment and healthcare insurance coverage, by taxing the benefits as the compensation they are.
2. Establish a single, universal plan that covers all US citizens paid for via personal income taxes on an ability-to-pay basis. Eliminate all the other tax-funded plans in favor of this new one.
3. For those who want it, private, supplemental insurance to the national system, ala major industrialized nations.
4. Open Medicare Part D (prescription drugs) to every US citizen. Today.
Posted on June 19, 2022 by The D.E.A. ROGUE WARRIOR
START-UPS AND INNOVATIONS
Health tech investment raced ahead in 2020. Join innovation insiders for a discussion on new health technologies, health-care’s digital transformation timeline, and what to expect for mid- to long-term health tech investment.
Posted on June 19, 2022 by The D.E.A. ROGUE WARRIOR
By Staff Reporters
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Recession fears overtook the S&P 500 a day after the Fed meeting, reversing gains seen midweek.
The S&P 500 has been higher only 43.5% of all trading days in 2022, a gloomy marker, according to Bespoke Investment Group.
Meanwhile, it said the Fed is facing a “policy error” in focusing on headline inflation that’s swayed by high gas prices.
This year’s dismal performance in US equities worsened this week as a post-Fed rally fizzled and investors cemented the S&P 500 to one of its shabbiest mid-year showings in decades, all taking place with poor economic data piling up.
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Goldman Sachs’ President John Waldron admitted at a June 2 conference that this is “among—if not the most—complex, dynamic environments” that he’s ever experienced. As a result, investment banks and economists are split on what the most likely outcome will be for the U.S. economy moving forward. Deutsche Bank has argued since April that we’re headed for a “major” recession, but Morgan Stanley’s CEO James Gorman said on Monday the odds of even a minor recession are more like 50-50.
Bank of America believes we will most likely avoid a recession altogether and instead face “extended weakness,” while the economist and Nobel laureate Paul Krugman appeared to side with more optimistic Fed officials arguing that we could be headed for a ”goldilocks” scenario, where economic growth slows enough to cool inflation without instigating a recession.
As a teacher educating is your job. It’s what you enjoy. There’s a fairly lax time schedule and resources are already built in the equation. Little accountability because the ultimate burden and measure of success is placed on the student to pass a test. If they don’t do well, it’s the student not directly the teacher who pays the price.
Now, I work with first year students who don’t know what a red blood cell looks like (biconcave disc, you thought I forgot, didn’t you) all the way to a chief resident who can probably do some surgeries better than me. It’s my job to take that first year student and turn them into a chief resident.
As an entrepreneur with limited resources, time, and energy, you don’t have the luxury to continuously teach, develop, and convince. You need people who simply get it especially in strategic positions. You don’t have the luxury of time or resources. You also are directly accountable if they don’t understand because you have a burn rate that probably just got worse. So how much “oxygen” do you allocate when trying to build your team?
Different story for Apple, Boeing and others that can create academies and educational tracks to teach and develop internally.
Operating as a startup company will present many challenges, but you should take heart in knowing that many of today’s biggest companies were once in your position. If you wish for your startup company to succeed, then employee engagement will be a crucial factor. Keep reading to learn more about the importance of employee engagement for startups. It should allow you to figure out the right path forward to find the success you desire.
It Makes Employees Loyal
When employees are engaged in the work they are doing, they will be more likely to be loyal to your company. Having loyal employees will benefit you in several different ways, but one of the most important ones is that they will work harder. When employees are engaged in the work that they’re doing, then that means that they truly care about it. They’re going to take things seriously, and you will…
Posted on June 18, 2022 by The D.E.A. ROGUE WARRIOR
By Free Market Medical Association
*** DEFINITION: Direct Primary Care (DPC) is an innovative alternative payment model improving access to high functioning healthcare with a simple, flat, affordable membership fee. No fee-for-service payments. No third party billing. The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider. Patients have extraordinary access to a physician of their choice, often for as little as $70 per month, and physicians are accountable first and foremost their patients. DPC is embraced by health policymakers on the left and right and creates happy patients and happy doctors all over the country!
Posted on June 18, 2022 by The D.E.A. ROGUE WARRIOR
By Ismail Sayeed, MD
We are joined by Dr Ismail Sayeed, pediatrician and physician entrepreneur to talk about his cross-border telehealth communications platform Vios, why he transitioned away from clinical practice and how his entrepreneurial journey could not have been possible without that clinical background.
Posted on June 18, 2022 by The D.E.A. ROGUE WARRIOR
Try (or learn about) Entrepreneurship
BY DR. DAVID EDWARD MARCINKO MBACMP®
One of the greatest things about the virtual economy is the expanded opportunity for people to branch out on their own and create something using their own expertise. Related to this is the growing societal desire to have more free time and a more balanced, efficient life overall.
In fact, years ago when I was in business school, I learned that during a recession when jobs were sparse – folks would either go back to school to re-engineer and re-educate OR start their own business.
Today – If the pandemic taught us anything, it’s that we need to be able to pivot when circumstances call for it. In the years ahead, there will be a premium on flexibility, portability, and improvisation; knowing how to earn income outside the traditional employer-employee relationship will continue to be an especially valuable skill.
ASSESSMENT: So, if you are a physician, nurse, medical professional or financial advisor in the healthcare space, think about what you’re naturally good at (or at least interested in), and determine if there’s an opportunity to monetize it in some way on your own. Your career might thank you for it!
Posted on June 17, 2022 by The D.E.A. ROGUE WARRIOR
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By Michael Accad MD
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In this article, I wish to introduce the reader to the theory of entrepreneurship advanced by Frank Knight (1885–1972), and show that the common, everyday work of the physician could be considered a form of entrepreneurial activity in the Knightian sense.
Posted on June 17, 2022 by The D.E.A. ROGUE WARRIOR
By Darrell K. Pruitt DDS
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Some say e-prescriptions are a swell idea for dentists!
“Over 70% of organizations suffered two or more ransomware attacks in the past 12 months – According to the data presented by the Atlas VPN team based on a Veeam 2022 Ransomware Trends Report, 73% of organizations suffered two or more ransomware attacks in the past 12 months. The majority — 44% of ransomware infections entered through phishing emails, links, and websites. In total, 35% of organizations experienced two ransomware attacks, nearly a quarter (24%) endured three, close to a fifth (9%) of companies had four, and 4% went through five. Meanwhile, 1% of organizations suffered six or more ransomware attacks in the past 12 months. The remaining 27% of organizations faced only one ransomware attack.” By Acrofan, June 15, 2022. https://us.acrofan.com/detail.php?number=679260
“Why Ransomware Extortion is a Threat – In a typical ransomware extortion scheme, files are not only encrypted, but are also copied and exfiltrated from the network. Then, when the time comes to demand payment, hackers also say that if the business doesn’t meet their ransom demands within a given timeframe, they will publish the stolen files, or undertake some other activity to harm the business, such as a DDoS attack. This is known as double, or even triple extortion, with threats to release confidential information to the public, disrupt internet access or inform customers, shareholders or other partners about the incident unless they pay the ransom. It puts more pressure on businesses to make a quick decision, boosts the odds of criminals getting a big payout and increases the number of risks firms are exposed to, so this type of ransomware is something every firm should be concerned about.” By Brenda Robb for Security Boulevard on June 15, 2022. https://securityboulevard.com/2022/06/why-ransomware-extortion-is-a-threat/
It is also worth noting that if a dentist suffers a ransomware attack, HIPAA demands that all affected patients be notified that their identities might have been breached and might show up on the internet. If the breach involves 500 or more records, a description of the incident must be reported in the local media. This could easily bankrupt a practice even before the ransom is paid. What’s more, from the increasing numbers of data breaches that are occurring, one can surmise that dentists are not obeying the law … not yet.
There is no way to eliminate all the risks associated with starting a medical practice, or launching any innovative concept in the health 2.0 ecosystem. However, entrepreneurial focused doctors can improve their chance of success with good planning and preparation. So, prior to starting your practice, merging, franchising or purchasing an existing one, ask yourself the following sobering questions. Hopefully, such reflection will enhance success, or at least prevent an unmitigated catastrophe. (www.sba.gov)
The Questions to Consider
1. Is medical practice ownership and physician entrepreneurship right for you?
It will be up to you, and your consultants; not someone else telling you to develop projects, organize your time or follow through on details. Your must be self motivated.
2. Do you like people and get along with different personality types?
Practice owners need to develop working relationships with a variety of people including patients, customers, vendors, staff, other physicians, and professionals like lawyers, accountants, consultants and bankers. Can you deal with a demanding patient, an unreliable vendor or cranky staff person in the best interest of your practice?
3. Can you make decisions and leave with ambiguity?
Practice owners are required to make independent decisions constantly; often quickly, under pressure and without all the facts. Ambiguity is a constant.
4. Do you have the physical and emotional stamina?
Practice ownership can be challenging, fun and exciting. But it’s also a lot of work. As a physician-owner, can you face twelve hour work days? As a doctor, can you offer advice, service, care and moral support 24/7?
5. How long can you live on your current savings?
Most small medical practice startups induce a declining bank balance in the early going. So, it’s wise to look at your expenses and determine how long you can live on your savings, and what personal costs you can temporarily eliminate. Emotionally, it’s easier to tighten expenses when you’re contemplating a new practice, than it is to cut back after you’ve started. Financial consultants and accountants that perform consolidated financial statement preparation and analysis are vital in this regard. A two to five year margin of safety is not unusual and may be needed
6. How deeply in debt can you go?
Medical practice business debt can be good. It can fund expansion, improve profit ratios and cash flow. For physician entrepreneurs, business debt is often personal debt. Many start a practice by deferring payments for their own labor. Although lenders may make loans to a practice, the physician-owner will often be required to personally guarantee the loan. So, although the debt is on the business’s books, is ultimately the doctors’ debt should the practice fail.
7. What about health insurance?
If your current residency, fellowship or job offers health insurance, and is subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA), you might be able to keep your coverage by paying the premiums, plus another 2% for administrative costs. You may keep your coverage under COBRA for up to 18 months and is a useful stopgap. For example, pay the premiums for six months or until another health insurance plan is obtained. Others suggestions are working spouse coverage with family benefits, or an HMO; or Medical or Health Savings Account (HSA/MSA).
8. Can you line up credit in advance?
Some new practice owners may set up a home equity line of credit that will let them borrow money at 1-2 percentage points over the prime rate or less. Lenders are more willing to make loans to someone who has a steady paycheck than to a new practice entrepreneur. If you have an excellent credit rating, you can probably get a home equity or other secured loan, but with more paperwork than in the recent past. Once you’re a self-employed practice owner, you’ll probably have to provide your most recent tax returns before getting approval. But, today, the biggest obstacle to a practice loan is a home mortgage. Domestic credit has been very tight since 2007, even for physicians.
9. What if you can’t manage the practice?
Disability insurance, unlike health insurance, usually cannot be transferred to an individual policy when you leave your job to start a new venture. So, get your own disability policy while you are still employed. Once you have the policy established and are paying the premiums, you should be able to keep the policy when you go out on your own. Remember, benefits received on a policy paid by you are free of federal income tax. Benefits on a policy paid for by a previous employer were taxable.
10. How well do you plan and organize?
Research indicates that many medical practice failures could have been avoided through better planning. Good organization of financials, inventory, schedules, information technology, medical services and human resources can help avoid many pitfalls.
11. Is your determination and drive strong enough to maintain your motivation?
Running a practice can wear you down. Some doctor-owners feel burned out by having to carry all the responsibility on their shoulders. Strong motivation can make the practice succeed and will help you survive slowdowns as well as periods of burnout.
12. How will the practice affect your family?
The first few years of practice startup can be hard on family life. The strain of an unsupportive spouse may be hard to balance against the demands of starting a medical business. There also may be financial difficulties until the business becomes profitable, which could take years. You may have to adjust to a lower standard of living or put family assets at risk.
13. How do you feel about the Patient Protection and Affordable Care Act of 2010?
Most provisions of the PPACA take effect over the next four to eight years, including expanding Medicaid eligibility, subsidizing insurance premiums, providing incentives for businesses to provide health care benefits, prohibiting denial of coverage/claims based on pre-existing conditions, establishing health insurance exchanges, and support for medical research. The expense of these provisions are offset by a variety of taxes, fees, and cost-saving measures, such as new Medicare taxes for high-income brackets, cuts to the Medicare Advantage program in favor of traditional Medicare, and fees on medical devices and pharmaceutical companies. There is also a tax penalty for citizens who do not obtain health insurance. Decreased physician reimbursement is a component, as well.
Are you a medical innovator or healthcare entrepreneur? I am available for queries – thanks again for your interest.
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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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Posted on June 15, 2022 by The D.E.A. ROGUE WARRIOR
THE COMMON BRIDGE
By Richard Helppie
The Federal Reserve just hiked interest rates by three quarters of a percentage point, its most aggressive move yet to try to control inflation, as it squeezes the U.S. economy.
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An Interview with the former Chairman, President, and CEO of Washington Mutual Bank, Kerry Killinger
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DEFINITION: In economics, inflation refers to a general progressive increase in prices of goods and services in an economy. When the general price level rises, each unit of currency buys fewer goods and services; consequently, inflation corresponds to a reduction in the purchasing power of money.
Editor’s Note: We hope you enjoy the podcast video below. If you’d rather just listen to the podcast, click this link to Apple Podcasts: The Common Bridge. It is also available on all podcast platforms. We have also included the transcript to this program below.
Posted on June 15, 2022 by The D.E.A. ROGUE WARRIOR
Yesterday versus Today?
The Great Depression is often compared to the 2001-08 Great Recession. There are some interesting facts when comparing the Great Depression to the Great Recession. It may even be considered scary when laid out directly in front of you.
The cause of the Great Depression was because people were borrowing too much money, unlike the Great Recession where the banks were lending too much money irresponsibly. Don’t forget that what was once a recession turned into the Great Depression because of unemployment rates reaching 25%, bank failures covering half of all banks, and more.
Both Roosevelt and Obama have used “wall street bankers” as a scapegoat.
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View more interesting facts about the Great Depression and Recession by viewing this infographic presented by Payday Loan.
Assessment
Do you think we are going into another Great Depression in 2022?
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:
The popularity of special purpose acquisition companies (SPACs) has been soaring in recent years. There are 35 times as many SPACs operating in 2020 as in 2010, and these companies seem poised for greater exponential growth in the future.
While many experts are predicting a continued, rapid increase in SPACs, this article will also examine the factors that could possibly slow SPAC growth and diminish their future prospects. SPACs span several market areas, including biotechnology and healthcare; this article will review SPAC trends generally as well as healthcare SPACs in particular. (Read more…)
On December 15, 2021, the Centers for Medicare & Medicaid Services (CMS) released a report detailing healthcare spending in the U.S. in 2020, which confirmed the outsized impact the COVID-19 pandemic has had on the nation’s healthcare industry and on federal spending. Overall, healthcare spending increased 9.7% in 2020 (to $4.1 trillion), double the 2019 increase of 4.3%. Healthcare spending also became a larger share of the U.S. gross domestic product (GDP) in 2020. This Health Capital Topics article will review the notable findings included in CMS’s report. (Read more…)
Posted on June 11, 2022 by The D.E.A. ROGUE WARRIOR
Learn the Incentives in Physician Compensation
BY ERIC BRICKER MD
RAND and Harvard University Researchers Recently Published a Study in the Journal of the American Medical Association Examining How Doctors are Paid by Hospital System-Owned Practices. The Study Found that only 9% of Primary Care Physician Compensation was Based on Value (Quality and Cost-Effectiveness) and only 5.3% of Specialist Compensation was Based on Value.
The Study Concluded: “The results of this cross-sectional study suggest that PCPs and specialists despite receiving value-based reimbursement incentives from payers, the compensation of health system PCPs and specialists was dominated by volume-based incentives designed to maximize health systems revenue.”
Posted on June 11, 2022 by The D.E.A. ROGUE WARRIOR
What is NEXT?
U.S. equities closed lower as losses in the Technology, Consumer Services and Financials sectors propelled shares lower. At the close, the Dow Jones Industrial Average fell 2.73%, while the S&P 500 index lost 2.91%, and the NASDAQ Composite index fell 3.52%.
Posted on June 10, 2022 by The D.E.A. ROGUE WARRIOR
More on Passive Investing
By Rick Kahler MS CFP®
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Need a car? Buy used. It’s what I always do. My sweet spot is a low-mileage vehicle two or three years old, which I routinely can find for 25% to 35% less than the original cost. I recommend this strategy to my clients, staff, and friends.
If everyone followed this advice, you’d think the approach would eventually fail dismally. After all, someone has to buy new cars. No worries, though; there are millions of people who will continue to buy new cars. Financial planners have recommended this strategy for decades, and nothing has changed in the supply of great deals on low-mileage cars.
The same applies to investors who invest “passively” in index mutual funds. Passive investors embrace a philosophy that extremely few investors can beat the average return of the stock market. Research by Dalbar, Inc. shows that over a 20-year-period, 97% of fund managers who tried to beat the market actually ended up doing worse than the market average. They suggest that, instead of paying a manager to try and beat the market, you pocket that money yourself and beat them by investing in low cost index mutual funds that simply earn average market returns.
As you might guess, those pushing the high-fee mutual funds that are actively trying to beat the market returns are the big Wall Street firms that need your money to keep their companies thriving. Not surprisingly, these firms regularly attempt to dissuade investors from passive investing.
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An article at ETF.com by Larry Swedroe, the director of research for The BAM Alliance, lists a few of these attempts. Representatives for two large brokerage firms call passive investing “worse than Marxism” and those that do it “parasites.” Another, however, gives a more reasoned warning that is worth exploring. Tim O’Neill, global co-head of Goldman Sach’s investment management division, says “if passive investing gets too big, the market won’t function.”
Up to a point, this idea has some validity. Swedroe says, “Active managers play an important societal role. Specifically, their actions determine security prices, which in turn determine how capital is allocated. And it is the competition for information that keeps markets highly efficient, both in terms of information and capital allocation.”
Passive investors get a free ride at the expense of active investors. As Swedroe notes, they receive all the benefits from the role that active managers play without having to pay their costs. Passive investors need active investors to continue to believe they can beat the markets, just as used car buyers need new car buyers to supply them with used cars.
Just how likely is it that all the people who invest with active investors will figure out that paying active managers is not in their best interests and will shift to passive investing? About the same chance everyone will stop buying new cars.
Consider this. A study by Vanguard, one of the largest passive fund managers, found that $10 trillion, or 20% of the global market equity, is invested in index funds. More importantly, this 20% accounted for only 5% of all the trading. It’s the trading that drives market prices and makes markets efficient and liquid. Swedroe says “we are nowhere near” the chance that passive investing will become so dominant that the efficiency of the markets would be threatened.
Just as there is no immediate threat of the used car supply drying up because no one is buying new cars, there is also little chance that the majority of investors will give up the delusional dream of beating the market. That means wise used-car buyers and wise passive investors can keep on following their wise wealth-building strategies.
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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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Posted on June 10, 2022 by The D.E.A. ROGUE WARRIOR
By MCOL
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EHIR was started nearly a decade ago out of a need for objective support in identifying and assessing emerging solutions to sift through the noise and stay ahead of the curve amid a rapidly changing competitive landscape. EHIR provides a streamlined and efficient innovation intake and evaluation process along with valuable insights to the world’s leading employers.
• The survey found that 59% indicated lowering costs was a very high, or high, priority – up from 52% prior to the pandemic. • Over half of the employers surveyed indicated that surgical costs were a significant issue, with surgery accounting for 34% of their total healthcare spend. About 75% noted that by controlling surgery costs, they can largely reduce their total spend.
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* Even though 69% of employers have a COE (Center of Excellence), the majority of them have been implemented within the past two years, and not with an eye to specifically reducing surgical costs. * Only 9% of respondents rely on carrier-sponsored COEs, which suggests that they are seeking out third-party vendors for this benefit, as either the sole COE provider or as a partner with the employer’s health plan carrier.
Posted on June 10, 2022 by The D.E.A. ROGUE WARRIOR
Millennial Investing
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By Vitaliy Katsenelson, CFA
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COVID, Inflation, and Value Investing: Millennial Investing
I was recently interviewed by Millennial Investors podcast. They sent me questions ahead of time that they wanted to ask me “on the air”. I found some of the questions very interesting and wanted to explore deeper. Thus, I ended up writing answers to them (I think through writing). You can listen to the podcast here.
By the way, I often get asked how I find time to write. Do I even do investment research? Considering how much content I’ve been spewing out lately, I can understand these questions. In short – I write two hours a day, early in the morning (usually from 5–7am), every single day. I don’t have time-draining hobbies like golf. I rarely watch sports. I have a great team at IMA, and I delegate a lot. I spend the bulk of my day on research because I love doing it.
This is not the first time I was asked these questions. If you’d like to adapt some of my daily hacks in your life, read this essay.
How has Covid-19 changed the game of value investing?
Value investing has not changed. Its fundamental principles, which I describe in “The Six Commandments of Value Investing,” (one-click sign up here to receive it in your inbox) have not changed one iota. The principles are alive and well. What has changed is the environment – the economy.
I learned this from my father and Stoic philosophers: You want to break up complex problems into smaller parts and study each part individually. That way you can engage in more-nuanced thinking.
Let’s start with what has not changed. Our desire for in-person human interaction has not changed. At the beginning of the pandemic, we (including yours truly) were concerned about that. We were questioning whether we were going to ever be able to shake hands and hug again. However, the pandemic has not changed millions of years of human evolution – we still crave human warmth and personal interaction. We need to keep this in mind as we think about the post-pandemic world.
What we learned in 2021 is that coronavirus mutations make predicting the end of the pandemic an impossible exercise. From today’s perch it is safe to assume that Covid-19 will become endemic, and we’ll learn how to live with it. I am optimistic on science.
Let’s take travel, for example. Our leisure travel is not going to change much – we are explorers at heart, and as we discovered during the pandemic, we crave a change in scenery. However, I can see business travel resetting to a lower base post-pandemic, as some business trips get resolved by simple Zoom calls. Business travel is about 12% of total airline tickets, but those revenues come with much higher profit margins for airlines.
Work from home. I am still struggling with this one. The norms of the 20th-century workplace have been shaken up by the pandemic. Add the availability of new digital tools and I don’t need to be a Nostradamus to see that the office environment will be different.
By how much?
The work from home genie is out of the bottle. It will be difficult to squeeze it back in. My theory right now is that customer support, on-the-phone types of jobs may disproportionately get decentralized. The whole idea of a call center is idiotic – you push a lot of people into a large warehouse-like office space, where they sit six feet apart from each other and spend eight hours a day on the phone talking to customers without really interacting with each other. Current technology allows all this work to be done remotely.
On another hand, I can see that if you have a company where creative ideas are sparked by people bumping into each other in hallways, then work from home is less ideal. But again, I don’t think about it in binary terms, but more like it’s a spectrum. Even for my company. Before the pandemic, half of our folks worked outside of the IMA main office in Denver. Most of our future hires will be local, as I believe it is important for our culture. However, we provide a certain number of days a year of remote work as a benefit to our in-office employees.
From an investment perspective, we are making nuanced bets on global travel normalizing. We don’t own airlines – never liked those businesses, never will. Most of their profitability comes from travel miles – they became mostly flying banks.
Office buildings I also put into a too-difficult-to-call pile. There was already plenty overcapacity in office real estate before the pandemic, and office buildings were priced for perfection. The pandemic did not make them more valuable. Maybe some of that overcapacity will get resolved through conversion of office buildings into apartments. By the way, this is the beauty of having a portfolio of 20–30 stocks: I don’t need to own anything I am not absolutely head over heels in love with.
What is the importance of developing a process to challenge your own beliefs?
My favorite quote from Seneca is “Time discovers truth.” My goal is to discover the truth before time does. I try to divorce our stock ownership from our feelings.
Let me give you this example. If you watch chess grandmasters study their past games, they look for mistakes they have made, moves they should have made, so in the future they won’t make the same mistake twice. I have also noticed they say “white” and “black,” not “I” and “the opponent.” This little trick removes them from the game so that they can look for the best move for each side. They say “This is the best move for white”; “This is the best move for black.”
You hear over and over again from people like Warren Buffett and other value investors that we should buy great companies at reasonable prices, and I’d like to dig deeper on that idea and its two key parts, great companies and reasonable prices. Could you tell us what it takes for a company to qualify as a “great” company?
This question touches on Buffett’s transformation away from Ben Graham’s “statistical” approach, i.e., buying crappy companies that look numerically cheap at a significant discount to their fair value, to buying companies that have a significant competitive advantage, a high return on capital, and a growth runway for their earnings.
The first type of companies often will not be high-quality businesses and will most likely not be growing earnings much. Let’s say the company is earning $1. Its earnings power will not change much in the future – it is a $5 stock trading at 5 times earnings. If its fair value is $10, trading at 10 times earnings, And if this reversion to fair value happens in one year, you’ll make 100%. If it takes 5 years then your return will be 20% a year (I am ignoring compounding here). So time is not on your side. If it takes 10 years to close the fair value gap, your return halves. Therefore you need a bigger discount to compensate for that. Maybe, instead of buying that stock at a 50% discount, you need to buy a company that is not growing at a 70% discount, at $3 instead of $5. This was pre-Charlie Munger, “Ben Graham Buffett.”
Then Charlie showed him there was value in growth. If you find a company that has a moat around its business, has a high return on capital, and can grow earnings for a long time, its statistical value may not stare you in the face. But time is on your side, and there is a lot of value in this growth. If a company earns $1 today and you are highly confident it will earn $2 in five years, then over five years, if it trades at 10 times earnings, a no-growth company may be a superior investment if the valuation gap closes in less than 5 years, while one with growing earnings is a superior investment past year 5.
Both stocks fall into the value investing framework of buying businesses at a discount to their fair value, looking for a margin of safety. With the second one, though, you have to look into the future and discount it back. With the first one, because the lack of growth in the future is not much different from the present, you don’t have to look far.
There is a place for both types of stocks in the portfolio – there are quality companies that can still grow and there are companies whose growth days are behind them. In our process we equalize them by always looking four to five years out.
What qualifies as a “reasonable price”?
We are looking for a discount to fair value where fair value always lies four to five years out. In our discounted cash flow models, we look a decade out. Our required rate of return and discount to fair value will vary by a company’s quality. There are more things that can go wrong with lower-quality companies than with the better ones. High-quality companies are more future-proof and thus require lower discount rates. We are incredibly process-driven. We have a matrix by which we rate all companies on their quality and guestimate their fair value five years out, and this is how we arrive at the price we want to pay today.
Why do you believe that buying great companies sometimes isn’t a great investing strategy?
Because that is first-level thinking, which only looks at what stares you in the face – things that are obvious even to untrained eyes and thus to everyone. First-level thinking ignores second-order effects. If everyone knows a company is great, then its stock price gets bid up and the great company stops being a great investment. With second-level thinking you need to ask an additional question, which in this case is, what is the expected return? Being a great company is not enough; it has to be undervalued to be a good stock.
We are looking for great companies that are temporarily (key word) misunderstood and thus the market has fallen out of love with them. Over the last decade, when interest rates only declined, first-level thinking was rewarded. It almost did not matter how much you paid for a stock. If it was a great company, its valuations got more and more inflated.
You’re a big advocate of having a balanced investment approach that is able to weather all storms. What investments have you found that you expect will be able to hold their buying power if inflation persists through 2022 and 2023?
There are many different ways to answer this question. In fact, every time I give an answer to this question I arrive at a new answer. You want to own companies that have fixed costs. You want assets that have a very long life. I am thinking about pipeline companies, for instance. They require little upkeep expense, and their contracts allow for CPI increases (no decreases); thus higher inflation will add to their revenue while their costs will mostly remain the same.
We own tobacco companies, too. I lived in Russia in the early ’90s when inflation was raging. I smoked. I was young and had little money. I remember one day I discovered that cigarette prices had doubled. I had sticker shock for about a day. I gave up going to movies but somehow scraped up the money for cigarettes.
Whatever answer I give you here will be incomplete. It’s a complex problem, and so each stock requires individual analysis. In all honesty, you have to approach it on a case-by-case basis.
With higher inflation, you’d expect bond yields to rise, since bond investors will demand a higher return to keep pace with inflation. However, CPI inflation is currently over 6%, and the 10-year Treasury is sitting at 1.5%. Why haven’t we seen Treasury yields rise more, and what does it mean for investors if a spread this wide persists?
I am guessing here. My best guess is that so far investors have bought into the Fed’s rhetoric that inflation is transitory due to the economy’s rough reopening and supply chain problems. I wrote a long article on this topic. To sum up, part of the inflation is transitory but not all of it.
I am somewhat puzzled by the labor market today. I’ve read a few dozen very logical explanations for the labor shortage, from early retirement of baby boomers to the pandemic triggering a search for the meaning of life and thus people quitting dead jobs and all becoming Uber drivers or starting their own businesses. Labor is the largest expense on the corporate income statement, and if it continues to be scarce then inflation will persist.
I read that employees are now demanding to work from home because they don’t want to commute. The labor shortages are shifting the balance of power to employees for the first time in decades. This will backfire in the long run, as employers will be looking at how to replace employees with capital, in other words, with automation. If you run a fast-food restaurant and your labor costs are up 20–30% or you simply cannot hire anyone, you’ll be looking for a burger flipping machine.
If we continue to run enormous fiscal deficits, then the US dollar will crack. The pandemic has accelerated a lot of trends that were in place. We were on our way to losing our reserve currency status. Let me clarify: That is going to be a very slow, very incremental process. It will be slow because currency pricing is not an absolute but a relative endeavor, and the alternatives out there are not great. But two decades ago the US dollar was a no-brainer decision and today it is not. So we’ll see countries slowly diversifying away from it. A weaker US dollar means higher, non transitory inflation.
You wrote The Little Book of Sideways Markets, in which you point out that history shows that a sideways market typically occurs after a secular bull market. With the role that the Federal Reserve plays in the financial markets, do you still anticipate that valuations will normalize in the coming years?
I say yes, in part because declining interest rates have pushed all assets into stratospheric valuations. Rising bond yields and valuations pushed heavenward are incompatible. Yes, I expect valuations to do what they’ve done every time in history: to mean revert. In big part this will depend on interest rates, but if rates stay low because the economy stutters, then valuations will decline – this is what happened in Japan following their early-1990s bubble. Interest rates went to zero or negative, but valuations declined.
The stock market today is very much driven by the Federal Reserve’s monetary policy. Is there a point at which they are able to take the gas off the pedal and allow markets to normalize?
I am really puzzled by this. We simply cannot afford higher interest rates. Going into the pandemic our debt-to-GDP was increasing steadily despite the growing economy. In fact, you could argue that most of our growth has come from the accumulation of debt (the wonders of being the world’s reserve currency). Our debt has roughly equaled our GDP, and all of our economic growth in some years equaled the growth in government debt.
During the pandemic we added 40% to our debt in less than two years. We have higher debt-to-GDP than we had during WWII. After the war we reduced our debt. Also, we were a different economy then – we were rebuilding both the US and Europe. As a society we had a high tolerance for pain.
Just like debt increases stimulate growth, deleveraging reduces growth. Also, I don’t think politicians or the public care about high debt levels. So far debt has only brought prosperity. However, higher interest rates would blow a huge hole in government budgets. If the 10-year Treasury rises a few percentage points, interest rates will increase by the amount we spend on national defense. One thing I am certain about is that our defense spending will not decline, so higher interest rates will lead to money printing and thus inflation.
I am also puzzled by the impact of higher interest rates on the housing market. Housing will simply become unaffordable if interest rates go up a few percentage points. Loan-to-income requirements will price a huge number of people out of the market, and housing prices will have to decline. This Higher rates will also reduce the number of transactions in the real estate market, because people will be locked into their 2.5% mortgages, and if they sell they’d have to get 4-5-6% mortgages. There are a lot of second-order effects that we are not seeing today that will be obvious in hindsight. Housing prices drive demand in adjacent sectors such as home improvement. And think of the impact of higher rates on any large purchase, for example a car.
We’re seeing the continuing rise of China has a big player in the global economy, and I know you like to invest internationally. As a value investor, how do you think about China’s rise as a global powerhouse and how it might affect the financial markets?
During the Cold War there were two gravitational centers, and as a country you had to choose one – you were either with the Soviets or with the West. Something similar will likely transpire here, too. I have to be careful using the Cold War analogy, because the Cold War was driven by ideology – it was communism vs. capitalism. Now the tension is driven by economic competition and our unwillingness to pass the mantle of global leader to another country.
We are drawing red lines in technology. Data is becoming the new oil. China is using data to control people, and we want to make sure they don’t have control over our data. Therefore, the West wants to make sure that our technology is China-free. The US, Europe, and India will likely be pursuing a path where Chinese technology and Chinese intellectual property are largely disallowed. We have already seen this happening with Huawei being banned from the US and Western Europe. Other countries, including Russia, will have to make a choice. Russia will go with China.
Also, we are concerned that most chip production is centered in Taiwan, which at some point may be grabbed by China. The technological ecosystem would then have to undergo a significant transformation. This has already started to happen as we begin to bring chip production back to the US and Europe.
The pandemic made us realize that globalization had made us reliant on the kindness of strangers, and we found we could not even get facemasks or ventilators.
Globalization was deflationary; deglobalization will be inflationary.
This increased tension between countries has led to your investing in the defense industry. Could you tell us how you think about this industry?
Despite the rise of international tensions, the global defense industry has been one of sectors that still had reasonable (sometimes unreasonably good) valuations. We have invested in half a dozen US and European defense companies. The US defense budget is unlikely to decline in the near future. There is a common misperception that Republicans love defense and Democrats hate it. Those may be party taglines, but history shows that defense spending has been driven by macro factors – it did not matter who was the occupant of the White House.
There are a lot of things to like about defense businesses. They are an extension of the US or European governments. Most of them are friendly monopolies or duopolies. They have strong balance sheets, good returns on capital, and predictable and growing (maybe even accelerating) demand. They are noncyclical. They have inflation escalators built into their contracts. I don’t have to worry about technological disruptions. They are also a good macro hedge.
We added to our European defense stocks recently for several reasons. Europe has underinvested in defense, relying on the US Yet we have shown time and again that we may not be as dependable as we once were.
Posted on June 9, 2022 by The D.E.A. ROGUE WARRIOR
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BY HEALTH CAPITAL CONSULTANTS, LLC.
DEFINITION: Vertical integration is an arrangement in which the supply chain of a company is integrated and owned by that company. Usually each member of the supply chain produces a different product or service, and the products combine to satisfy a common need.
A study released in the December 2021 issue of Health Affairs examined the correlation between hospital/health system ownership of physician practices and physician compensation. While a number of studies have analyzed the “rapidly growing trend” of vertical integration from the hospital/health system perspective, this is the first study to evaluate vertical integration from the physician practice perspective.
This Health Capital Topics article will discuss the study’s findings and potential implications. (Read more…)
Posted on June 9, 2022 by The D.E.A. ROGUE WARRIOR
By Darrell Pruitt DDS
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More reasons to stick with paper if you haven’t yet become paperless, Doc
“Paying Ransomware Paints Bigger Bullseye on Target’s Back – Ransomware attackers often strike targets twice, regardless of whether the ransom was paid. Paying ransomware attackers doesn’t pay off and often paints a bigger target on a victim’s back. Eighty percent of ransomware victims that paid their attackers were hit a second time by the malware scourge.”– Threatpost, June 8, 2022.
A dentist can avoid the second ransomware attack by returning to paper … What? Yeah. I said it.
“New ransomware numbers come from a Cybereason’s April ransomware survey of 1,456 cybersecurity professionals. According to the gated report (registration required), victims that were successfully extorted were not only targeted a second time, but frequently data encrypted by criminals later became unusable during the decryption process because of corruption issues.”
Posted on June 8, 2022 by The D.E.A. ROGUE WARRIOR
Health Insurance Job Options
By Eric Bricker MD
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DEFINITION: ICHRA (we pronounce it “ick-rah”) stands for “Individual Coverage Health Reimbursement Arrangement” (not the common misnomer of individual coverage health reimbursement accounts) and is available for employers to start using as of January 2020. ICHRA is an evolution of another type of HRA, called a QSEHRA, that was created in 2017. Both allow employers to reimburse employees tax-free for individual health insurance, but ICHRA represents a “super-charged” version of QSEHRA with higher limits and greater design flexibility that will appeal.
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