ADVISOR MARKETING: Meaningful “Tchotchkes” for Doctor Prospects

HDS

SPONSOR: www.CertifiedMedicalPlanner.org

According to Wikipedia, a tchotchke is a small bauble, doodad, doohickey, gewgaw, gismo knickknack, swag, thingamabob, thingamajig, toy, trinket, whatchamacallit, whosie-whatsit, widget, etc. Drug representative, various trade vendors and even prospecting financial advisors that give such cheap souvenirs to potential clients are even sometimes called “tchotchke dukes.” This industry practice is well known and wide spread.

Value-Less

Depending on context, the term has a connotation of worthlessness or disposability as well as tackiness, and has long been used in the regional speech of New York City and elsewhere.

The word may also refer to swag, in the sense of the logo pens, key rings and FOBs, t-shirts, golf balls, and other promotional freebies dispensed at trade shows, conventions, and similar large events. Most are largely value-less promotional pieces.

Valuable

Medical professionals of all types are fertile prospects for pharmaceutical representatives, insurance agents, financial advisors and like minded vendors. Most of these commissioned salesmen offer tchotchkes to their doctor clients and prospects as a reminder of their wares.

Product DetailsProduct DetailsProduct Details

Assessment

And so, wouldn’t it be interesting for these vendors to offer their doctors something of real value?  How about one of our Dictionaries of Health … in our series of three non-clinical handbooks? Affordable, memorable and valuable!

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

Product Details

ADVISORY OPINION: Allows Nurse Practitioner Support in Hospitals

NURSE PRACTITIONERS [NPs]

By Health Capital Consultants, LLC

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Advisory Opinion Allows Nurse Practitioner Support in Hospitals

On December 19, 2022, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) published Advisory Opinion (AO) No. 22-20, analyzing the utilization of nurse practitioners (NPs) in lieu of attending physicians within medical units. The OIG concluded that the arrangement utilizing NPs in certain medical units, subject to several safeguards, presented a low risk for fraud or abuse.

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

As noted by legal experts, this AO deviates from OIG’s typical approach to limiting arrangements involving potential remuneration from a hospital to its referring physicians. (Read more…)

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ORDER: https://www.amazon.com/Business-Medical-Practice-Transformational-Doctors/dp/0826105750/ref=sr_1_9?ie=UTF8&qid=1448163039&sr=8-9&keywords=david+marcinko

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FINANCIAL PLANNING: Strategies for Doctors and their Advisors

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BY DR. DAVID E. MARCINKO MBA CMP®

SPONSOR: http://www.CertifiedMedicalPlanner.org

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REVIEWS:

Written by doctors and healthcare professionals, this textbook should be mandatory reading for all medical school students—highly recommended for both young and veteran physicians—and an eliminating factor for any financial advisor who has not read it. The book uses jargon like ‘innovative,’ ‘transformational,’ and ‘disruptive’—all rightly so! It is the type of definitive financial lifestyle planning book we often seek, but seldom find.
LeRoy Howard MA CMPTM,Candidate and Financial Advisor, Fayetteville, North Carolina

I taught diagnostic radiology for over a decade. The physician-focused niche information, balanced perspectives, and insider industry transparency in this book may help save your financial life.
Dr. William P. Scherer MS, Barry University, Ft. Lauderdale, Florida

This book was crafted in response to the frustration felt by doctors who dealt with top financial, brokerage, and accounting firms. These non-fiduciary behemoths often prescribed costly wholesale solutions that were applicable to all, but customized for few, despite ever-changing needs. It is a must-read to learn why brokerage sales pitches or Internet resources will never replace the knowledge and deep advice of a physician-focused financial advisor, medical consultant, or collegial Certified Medical Planner™ financial professional.
—Parin Khotari MBA,Whitman School of Management, Syracuse University, New York

In today’s healthcare environment, in order for providers to survive, they need to understand their current and future market trends, finances, operations, and impact of federal and state regulations. As a healthcare consulting professional for over 30 years supporting both the private and public sector, I recommend that providers understand and utilize the wealth of knowledge that is being conveyed in these chapters. Without this guidance providers will have a hard time navigating the supporting system which may impact their future revenue stream. I strongly endorse the contents of this book.
—Carol S. Miller BSN MBA PMP,President, Miller Consulting Group, ACT IAC Executive Committee Vice-Chair at-Large, HIMSS NCA Board Member

This is an excellent book on financial planning for physicians and health professionals. It is all inclusive yet very easy to read with much valuable information. And, I have been expanding my business knowledge with all of Dr. Marcinko’s prior books. I highly recommend this one, too. It is a fine educational tool for all doctors.
—Dr. David B. Lumsden MD MS MA,Orthopedic Surgeon, Baltimore, Maryland

There is no other comprehensive book like it to help doctors, nurses, and other medical providers accumulate and preserve the wealth that their years of education and hard work have earned them.
—Dr. Jason Dyken MD MBA,Dyken Wealth Strategies, Gulf Shores, Alabama

I plan to give a copy of this book written
by doctors and for doctors’ to all my prospects, physician, and nurse clients. It may be the definitive text on this important topic.
—Alexander Naruska CPA,Orlando, Florida

Health professionals are small business owners who need to apply their self-discipline tactics in establishing and operating successful practices. Talented trainees are leaving the medical profession because they fail to balance the cost of attendance against a realistic business and financial plan. Principles like budgeting, saving, and living below one’s means, in order to make future investments for future growth, asset protection, and retirement possible are often lacking. This textbook guides the medical professional in his/her financial planning life journey from start to finish. It ranks a place in all medical school libraries and on each of our bookshelves.
—Dr. Thomas M. DeLauro DPM,Professor and Chairman – Division of Medical Sciences, New York College of Podiatric Medicine

Physicians are notoriously excellent at diagnosing and treating medical conditions. However, they are also notoriously deficient in managing the business aspects of their medical practices. Most will earn $20-30 million in their medical lifetime, but few know how to create wealth for themselves and their families. This book will help fill the void in physicians’ financial education. I have two recommendations: 1) every physician, young and old, should read this book; and 2) read it a second time!
—Dr. Neil Baum MD,Clinical Associate Professor of Urology, Tulane Medical School, New Orleans, Louisiana

I worked with a Certified Medical Planner™ on several occasions in the past, and will do so again in the future. This book codified the vast body of knowledge that helped in all facets of my financial life and professional medical practice.
Dr. James E. Williams DABPS, Foot and Ankle Surgeon, Conyers, Georgia

This is a constantly changing field for rules, regulations, taxes, insurance, compliance, and investments. This book assists readers, and their financial advisors, in keeping up with what’s going on in the healthcare field that all doctors need to know.
Patricia Raskob CFP® EA ATA, Raskob Kambourian Financial Advisors, Tucson, Arizona

I particularly enjoyed reading the specific examples in this book which pointed out the perils of risk … something with which I am too familiar and have learned (the hard way) to avoid like the Black Death. It is a pleasure to come across this kind of wisdom, in print, that other colleagues may learn before it’s too late— many, many years down the road.
Dr. Robert S. Park MD, Robert Park and Associates Insurance, Seattle, Washington

Although this book targets physicians, I was pleased to see that it also addressed the financial planning and employment benefit needs of nurses; physical, respiratory, and occupational therapists; CRNAs, hospitalists, and other members of the health care team….highly readable, practical, and understandable.
Nurse Cecelia T. Perez RN, Hospital Operating Room Manager, Ellicott City, Maryland

Personal financial success in the PP-ACA era will be more difficult to achieve than ever before. It requires the next generation of doctors to rethink frugality, delay gratification, and redefine the very definition of success and work–life balance. And, they will surely need the subject matter medical specificity and new-wave professional guidance offered in this book. This book is a ‘must-read’ for all health care professionals, and their financial advisors, who wish to take an active role in creating a new subset of informed and pioneering professionals known as Certified Medical Planners™.
—Dr. Mark D. Dollard FACFAS, Private Practice, Tyson Corner, Virginia

As healthcare professionals, it is our Hippocratic duty to avoid preventable harm by paying attention. On the other hand, some of us are guilty of being reckless with our own financial health—delaying serious consideration of investments, taxation, retirement income, estate planning, and inheritances until the worry keeps one awake at night. So, if you have avoided planning for the future for far too long, perhaps it is time to take that first step toward preparedness. This in-depth textbook is an excellent starting point—not only because of its readability, but because of his team’s expertise and thoroughness in addressing the intricacies of modern investments—and from the point of view of not only gifted financial experts, but as healthcare providers, as well … a rare combination.
Dr. Darrell K. Pruitt DDS, Private Practice Dentist, Fort Worth, Texas

This text should be on the bookshelf of all contemporary physicians. The book is physician-focused with unique topics applicable to all medical professionals. But, it also offers helpful insights into the new tax and estate laws, fiduciary accountability for advisors and insurance agents, with investing, asset protection and risk management, and retirement planning strategies with updates for the brave new world of global payments of the Patient Protection and Affordable Care Act. Starting out by encouraging readers to examine their personal ‘money blueprint’ beliefs and habits, the book is divided into four sections offering holistic life cycle financial information and economic education directed to new, mid-career, and mature physicians.

This structure permits one to dip into the book based on personal need to find relief, rather than to overwhelm. Given the complexity of modern domestic healthcare, and the daunting challenges faced by physicians who try to stay abreast of clinical medicine and the ever-evolving laws of personal finance, this textbook could not have come at a better time.
—Dr. Philippa Kennealy MD MPH, The Entrepreneurial MD, Los Angeles, California

Physicians have economic concerns unmatched by any other profession, arriving ten years late to the start of their earning years. This textbook goes to the core of how to level the playing field quickly, and efficaciously, by a new breed of dedicated Certified Medical Planners™. With physician-focused financial advice, each chapter is a building block to your financial fortress.
Thomas McKeon, MBA, Pharmaceutical Representative, Philadelphia, Pennsylvania

An excellent resource … this textbook is written in a manner that provides physician practice owners with a comprehensive guide to financial planning and related topics for their professional practice in a way that is easily comprehended. The style in which it breaks down the intricacies of the current physician practice landscape makes it a ‘must-read’ for those physicians (and their advisors) practicing in the volatile era of healthcare reform.
—Robert James Cimasi, MHA ASA FRICS MCBA CVA CM&AA CMP™, CEO-Health Capital Consultants, LLC, St. Louis, Missouri

Rarely can one find a full compendium of information within a single source or text, but this book communicates the new financial realities we are forced to confront; it is full of opportunities for minimizing tax liability and maximizing income potential. We’re recommending it to all our medical practice management clients across the entire healthcare spectrum.
Alan Guinn, The Guinn Consultancy Group, Inc., Cookeville, Tennessee

Dr. David Edward Marcinko MBA CMP™ and his team take a seemingly endless stream of disparate concepts and integrate them into a simple, straightforward, and understandable path to success. And, he codifies them all into a step-by-step algorithm to more efficient investing, risk management, taxation, and enhanced retirement planning for doctors and nurses. His text is a vital read—and must execute—book for all healthcare professionals and physician-focused financial advisors.
Dr. O. Kent Mercado, JD, Private Practitioner and Attorney, Naperville, Illinois

Kudos. The editors and contributing authors have compiled the most comprehensive reference book for the medical community that has ever been attempted. As you review the chapters of interest and hone in on the most important concerns you may have, realize that the best minds have been harvested for you to plan well… Live well.
Martha J. Schilling; AAMS® CRPC® ETSC CSA, Shilling Group Advisors, LLC, Philadelphia, Pennsylvania

I recommend this book to any physician or medical professional that desires an honest no-sales approach to understanding the financial planning and investing world. It is worthwhile to any financial advisor interested in this space, as well.
David K. Luke, MIM MS-PFP CMP™, Net Worth Advisory Group, Sandy, Utah

Although not a substitute for a formal business education, this book will help physicians navigate effectively through the hurdles of day-to-day financial decisions with the help of an accountant, financial and legal advisor. I highly recommend it and commend Dr. Marcinko and the Institute of Medical Business Advisors, Inc. on a job well done.
Ken Yeung MBA CMP™, Tseung Kwan O Hospital, Hong Kong

I’ve seen many ghost-written handbooks, paperbacks, and vanity-published manuals on this topic throughout my career in mental healthcare. Most were poorly written, opinionated, and cheaply produced self-aggrandizing marketing drivel for those agents selling commission-based financial products and expensive advisory services. So, I was pleasantly surprised with this comprehensive peer-reviewed academic textbook, complete with citations, case examples, and real-life integrated strategies by and for medical professionals. Although a bit late for my career, I recommend it highly to all my younger colleagues … It’s credibility and specificity stand alone.
Dr. Clarice Montgomery PhD MA,Retired Clinical Psychologist

In an industry known for one-size-fits-all templates and massively customized books, products, advice, and services, the extreme healthcare specificity of this text is both refreshing and comprehensive.
Dr. James Joseph Bartley, Columbus, Georgia

My brother was my office administrator and accountant. We both feel this is the most comprehensive textbook available on financial planning for healthcare providers.
Dr. Anthony Robert Naruska DC,Winter Park, Florida

MORE: tps://www.amazon.com/Comprehensive-Financial-Planning-Strategies-Advisors/dp/1482240289/ref=sr_1_1?ie=UTF8&qid=1418580820&sr=8-1&keywords=david+marcinko

INVITE DR. MARCINKO: https://medicalexecutivepost.com/dr-david-marcinkos-bookings/

Thank You

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RECESSION: Healthcare Industry Layoffs

Not even the healthcare industry is recession-proof

By Staff Reporters

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According to Kristine White of Healthcare Brew, New York City-based Memorial Sloan Kettering Cancer Center (MSK), one of the country’s top cancer treatment facilities, laid off 337 employees on Jan. 17 in response to ongoing financial challenges, according to a New York State Department of Labor filing.

The 337 employees, who worked across 14 sites and in multiple departments, represent about 1.5% of MSK’s 22,500 employees. This is a slight decrease from the expected 3% of layoffs announced in November 2022.

“This reduction was necessary to ensure that MSK can continue to invest in the future of cancer care, research, and education for the benefit of generations to come, and every effort has been made to ensure that patient care is not impacted,” spokesperson John Connolly said in a statement shared with Healthcare Brew.

The institution’s operating losses totaled $116.1 million for Q3 of 2022, compared to a loss of $8.7 million during the same period in 2021, according to a quarterly financial report released in November last year.

Factors such as increased patient activity, wages, and supply costs from inflation pushed the system’s operating expenses up by 7.5% from Q3 of 2021 to Q3 of 2022. The cancer center hired more staff in 2022 with the expectation that patient volume would increase, according to the financial report.

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

Health systems like MSK often reevaluate their biggest expense (workers) when business is down, Lori Kalic, a healthcare senior analyst at consulting firm RSM, told Healthcare Brew.

Just this year, multiple hospitals and health systems have also announced layoffs, including Tufts Medicine in Boston and Integris Health in Oklahoma, according to White.

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ORDER: https://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_4?ie=UTF8&s=books&qid=1275315485&sr=1-4

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INVITE: Professor Marcinko to Your Next Seminar or Event

See You Soon

CMP logo

SPONSOR: http://www.CertifiedMedicalPlanner.org

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

Avatar of Dr. Marcinko Speaking as MSL

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

LIVE or PODCAST enabled, as well.

Topics Link: imba-inc-firm-services

Teleconference: https://medicalexecutivepost.com/2020/10/14/me-marcinko-and-my-avatar/

My Fond Farewell to Tuskegee University

And so, we appreciate your consideration.

Invite Dr. Marcinko

CONTACT: ANN MILLER RN MHA CMP®

[ME-P Executive-Director]

PH: 770-448-0769

EM: MarcinkoAdvisors@msn.com

THANK YOU

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Medical CBD: No FDA Advocacy

By Staff Reporters

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The Food and Drug Administration said it can’t vouch for the safety of cannabidiol (CBD)—a nonpsychoactive compound found in marijuana and hemp plants—and because of that, it can’t regulate it. Instead, it’s calling on lawmakers to help supervise $12 CBD lavender sodas.The FDA said that CBD doesn’t fit the mold of the dietary supplements and food additives it typically monitors, such as ginseng and caffeine.

POT: https://contrarianedge.com/should-you-invest-in-marijuana-stocks/?uid=5f78aa3cd815b&utm_source=IMA++-+Main+Articles&utm_campaign=b43e790647-MARIJUANA_STOCKS_RESEND&utm_medium=email&utm_term=0_f1c90406d1-b43e790647-55139025

The agency claims the science is lacking on the safety of long-term CBD use, let alone on any potential perks—like preventing diabetes or aiding sleep.

No-2-Drugs: https://medicalexecutivepost.com/2022/04/20/just-say-no-to-drugs/

Derived from Hemp

Congress legalized hemp four years ago, and most CBD is derived from hemp, not marijuana. As a result, CBD got kicked off the controlled substances list and got lobbed from the Drug Enforcement Administration’s desk to the FDA’s.

Mental Health Drugs: https://medicalexecutivepost.com/2022/10/07/drugs-and-county-mental-health-programs/

Since then, the FDA’s been less active in regulating CBD than a teen in a ’90s anti-marijuana ad. That’s resulted in a chaotic and confusing marketplace, and CBD industry players were hoping the FDA would soon start reining it in.

Drug Middlemen: https://medicalexecutivepost.com/2022/03/14/drugs-money-and-the-middleman/

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INDUSTRY STATURE: Certified Medical Planner®

SPONSOR: http://www.CertifiedMedicalPlanner.org

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OUR OEUVRE’ OF TEXT BOOKS IS GROWING WITH OUR INDUSTRY STATURE

We believe that by writing and sharing our experiences in standard textbook, white-paper and new media electronic format, our experts are able to address most areas of physician-focused financial planning, business or medical practice management needs in an understandable and unbiased manner.

But, we recognize that some consultants and financial advisors may appreciate reading current medical business management theory, healthcare economics, technology or financial planning information privately, prior to becoming a Certified Medical Planner® professional.

However, there is a virtual information overload out there, little of which addresses the pragmatic concerns of the modern medical provider or healthcare industry. None imparts the wisdom to become a better financial advisor or medical management consultant. All motivate the purchase of products.

Therefore, as part of the iMBA Research Library for the Certified Medical Planner® program, we highly recommend the following in-house produced books. You may even recognize some of our nationally known contributing authors and CMPs®.

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

TEXT BOOKS AND HAND BOOKS

iMBA Inc offers links to these publications, to members, and non-members, alike:

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ENJOY THEM ALL

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COVID PANDEMIC: Official National Emergency Ending

By Staff Reporters

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President Biden plans to end both the public health and national emergencies originally declared to address the Covid pandemic in 2020 (and extended several times since) on May 11th 2023.

The White House just disclosed the plan while opposing efforts by Republican lawmakers to end the emergency declarations immediately with a bill called the Pandemic Is Over Act. The end of the emergencies will mean that many Americans will have to start paying for COVID tests, treatments, and vaccines.

It also signals a shift in how serious the government considers the pandemic to be. But, is this wise?

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ORDER: https://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_4?ie=UTF8&s=books&qid=1275315485&sr=1-4

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PODCAST: How Doctors are Really Paid?

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.”

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MORE: https://medicalexecutivepost.com/2020/09/19/what-doctors-must-do-to-file-an-aetna-claim-to-get-paid/?preview_id=237387&preview_nonce=44f9028974&preview=true

RELATED: https://medicalexecutivepost.com/2008/09/12/how-doctors-get-paid/

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BUSINESS MEDICINE: https://www.amazon.com/Business-Medical-Practice-Transformational-Doctors/dp/0826105750/ref=sr_1_9?ie=UTF8&qid=1448163039&sr=8-9&keywords=david+marcinko

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HOSPITALS: https://www.amazon.com/Financial-Management-Strategies-Healthcare-Organizations/dp/1466558733/ref=sr_1_3?ie=UTF8&qid=1380743521&sr=8-3&keywords=david+marcinko

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FAs & CPAs Wanted -BUT- Certified Medical Planners® Needed?

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Career Development, Products and Services for Medical Specificity

“The informed voice of a new generation of fiduciary advisors for healthcare”

SPONSOR: http://www.CertifiedMedicalPlanner.org 

CMP

FINANCIAL ADVISER WANTED: New York’s Belfer family, which gained riches from oil, is racking up quite an investing losing streak. They lost billions in Enron’s collapse and were clients of Bernie Madoff, and now it’s come to light that they were shareholders in FTX.

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CPAs WANTED: Just as tax season kicks off, US firms are facing a national shortage of accountants, forcing them to look overseas for workers to look over your W-2. More than 300k accountants and auditors have quit in the last two years, per the WSJ.

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CMPs NEEDED: The Certified Medical Planner® program was created in response to the frustration felt by doctors in small and mid-sized practices that dealt with top financial, brokerage and accounting firms. These non-fiduciary behemoths often prescribed costly wholesale solutions that were applicable to all, but customized to few, despite ever changing needs.

Enter the CMPs

Learn why brokerage sales-pitches and/or internet resources will never replace the knowledge and deep advice of a collegial Certified Medical Planner® professional.

Letterhead CMP

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ORDER: https://www.routledge.com/Comprehensive-Financial-Planning-Strategies-for-Doctors-and-Advisors-Best/Marcinko-Hetico/p/book/9781482240283

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PRIVATE EQUITY: Ownership in Physician Practices

By NIHCM

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Private equity acquisition of physician practices continues to grow nationwide. New research focused on specialists in dermatology, gastroenterology, and ophthalmology shows the impact of the trend.

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

Novel evidence by NIHCM grantee Jane Zhu, MD, and her team, reveals shifts in workforce composition and hiring patterns after private equity firms obtain physician practices. The researchers’ findings are particularly important for policymakers and practices considering selling to private equity firms. Highlights include:

  • A significant yearly increase in the number of advanced practice providers at private equity-acquired practices, specifically nurse practitioners and physician assistants. 
  • In acquired practices, entering clinicians replaced exiting clinicians at a higher rate than at non-private equity-acquired practices.

This work adds to the research team’s previous findings, including the geographic variations in private equity ownership across six medical specialties, and the impact of private equity on health care costs and utilization.

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ORDER: https://www.routledge.com/Comprehensive-Financial-Planning-Strategies-for-Doctors-and-Advisors-Best/Marcinko-Hetico/p/book/9781482240283

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AMAZON: Launches “RxPass” Generic Drug Subscription Program

PRIME MEMBERSHIP

By Staff Reporters

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Yesterday, Amazon announced the launch of RxPass: an add-on to Prime memberships that provides subscribers with access to 50 generic prescription drugs for a $5 monthly fee.

RxPass will launch immediately in most states (though not California and Texas, the most populous ones) and include generic drugs that treat common conditions like high blood pressure, anxiety, acid reflux, and hair loss. About 150 million US residents have a prescription for one of the drugs included in RxPass, according to Amazon.

But the service is not available to people on Medicare or Medicaid, and it doesn’t offer insulin.

RxPass is Amazon’s answer to the Mark Cuban Cost Plus Drug Company (which offers significantly more medications—1,100 of them) and is likely part of an effort to attract more users to Amazon Pharmacy. Amazon Pharmacy could use the boost—it launched in 2020 but ranked at the bottom of a list of which Prime perks drew members to the service, a Morgan Stanley survey found last summer.

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PODCAST: Medicare Advantage Plan Over Payments

A SYNOPSIS

By Eric Bricker

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PODCAST: Government Overpayments to Medicare Advantage Plans are a major problem.

CMS pays Medicare Advantage Plans per member based on a risk score. The more chronic conditions the person has, the larger the payments CMS makes to the Medicare Advantage Plan.

Medicare Advantage Plans may be overexaggerating how sick their members are in order to increase their payments from CMS.

The Department of Justice is currently suing Cigna and Elevance (Anthem) for such over exaggerations.

However there is a deeper problem… CMS itself had performed its own audits, but has not done so in 10 years. CMS identified $650M in overpayments and did nothing about them.

When the Kaiser Family Foundation (KFF) requested information on the audits, CMS refused. KFF had to sue CMS to obtain the audit information and it took 3 years for KFF to win the case.

Perhaps it is incompetence on the part of CMS or perhaps CMS does not want to reveal the audits or do anything about them due to political pressure.

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ORDER: https://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_4?ie=UTF8&s=books& qid=1275315485&sr=1-4

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PODCAST: Medicare Traditional [A and B] v. Advantage [C] v. Part [D] v. Supplements

By Eric Bricker MD

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

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ORDER: https://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_4?ie=UTF8&s=books&qid=1275315485&sr=1-4

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JANUARY: Cervical Cancer Awareness Month

By Staff Reporters

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Cervical Health Awareness Month

The United States Congress designated January as Cervical Health Awareness Month. More than 14,000 women in the United States are diagnosed with invasive cervical cancer each year, but the disease is preventable with vaccination and appropriate screening.

During January, NCCC and its many local chapters across the country highlight issues related to cervical cancer, HPV disease and the importance of early detection. While NCCC chapters host events throughout the year, January is a month with a special focus as chapters celebrate Cervical Health Awareness Month and work to spread the word in their communities.

NCCC and the American Sexual Health Association (ASHA) also offer a range of resources (listed below) to educate the public and healthcare providers about cervical health, from fact sheets to episodes of ASHA’s Sex+Health podcast.

READ: https://www.nccc-online.org/cervical-health-awareness-month/

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HEALTHCARE FRAUD: Predatory Senior Medicare Scams

By Staff Reporters

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As you likely know, the US spends much on healthcare ($4.3 trillion in 2021, to be exact). But did you also know that healthcare fraud makes up a not-so-small piece of that pie?

The National Health Care Anti-Fraud Association (NHCAA), a national organization that works to prevent health insurance fraud, conservatively estimates that 3% of the US’s total annual healthcare spend—a hearty $129 billion—is lost to healthcare fraud. Some government agencies estimate that percentage to be as high as 10% (that’s $430 billion), according to the NHCAA.

Overall, Medicare fraud costs the US about $60 billion each year, Nicole Liebau, national resource center director for Senior Medicare Patrol, a government-funded organization designed to help prevent Medicare fraud, told Healthcare Brew, though she added that “the exact figure is impossible to measure.”

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

While Medicare fraud isn’t new, the US saw a rise in one particular tactic during the pandemic: a durable medical equipment (DME) scheme.

How the schemes work.

In a DME scheme, scammers target Medicare patients—often after a procedure or an injury—and cold-call them to offer free equipment, said Jennifer Stewart, senior associate general counsel and senior director of fraud prevention and investigation at Blue Cross Blue Shield of Massachusetts. The scammers offer consumers items like lidocaine, wheelchairs, walkers, or braces.

The scammers have roped in doctors—who are often unaware they’re working with scammers instead of legitimate medical companies—to sign off on prescriptions that are then used to bill Medicare for the equipment, Stewart said. Sometimes patients actually receive the products, and sometimes they don’t.

“It’s really dangerous because [a prescription like lidocaine] could have reactions with other medications. The durable medical equipment isn’t sized for them, and certainly the doctor who treated their injury didn’t prescribe it […] There is a lot of patient harm involved,” Stewart said. Keep reading here.

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PODCAST: “Sage Transparency” on Hospital Prices

EMPLOYER SPONSORED HEALTH INSURANCE PLANS

By Eric Bricker MD

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

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PODCAST: Employee Engagement and Health Plans

By Eric Bricker MD

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

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MEDICARE SUPPLEMENT INSURANCE: Part G

What is it and How Does it Work?

By Staff Reporters

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Did you know that Medicare Plan G is the most popular Medicare Supplement with Baby Boomer clients? Everyone has heard of Plan F, but what is Medicare Supplement Plan G? What does Plan G cover?

Medicare Plan G coverage is very similar to Plan F, which is no longer available for people new to Medicare on or after January 1st, 2020. Plan G offers great value for beneficiaries willing to pay a small annual deductible. After that, Plan G provides full coverage for all of the gaps in Medicare. It pays for your Medicare Part A hospital deductible, co-pays, and coinsurance. It also covers the 20% that Medicare Part B doesn’t cover. Doctors and other healthcare providers must accept a Medigap Plan G if they accept Original Medicare. Plan G policies can be used across the U.S. since they do not have network limitations, and the premium costs can be very reasonable for the coverage you receive.

As you can see below, Supplement Plan G covers almost everything that F does, except for the Part B deductible.

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Medicare Plan G, also called Medigap Plan G, is an increasingly popular Supplement

Reasons:

First, Plan G covers each of the gaps in Medicare except for the annual Part B deductible. This deductible is only $226 in 2023. In fact, if you have a Plan F that has been in place for years, it can probably help you on premiums by looking at Plan G. When you shop for benefits, you can often find a Supplement Plan G that saves quite a bit in premiums over Plan F, usually substantially more than the $226 deductible that you’ll pay out.

Second, it has great coverage. For hospital stays, it covers all your hospital expenses. Most importantly, it pays the hospital deductible, which is over $1,600 in 2023. It also covers the expensive daily co-pays that you might encounter for a hospital stay that runs longer than 60 days. It provides an additional 365 days in the hospital after your Medicare benefits run out, and it covers your skilled nursing facility co-insurance, too.

What Other Medical Services Does Plan G Cover?

Medicare Supplement Plan G covers your percentage of any medical benefit that Original Medicare covers, except for the outpatient deductible. So, it helps to pay for inpatient hospital costs, such as the first three pints of blood, skilled nursing facility care, and hospice care. It also covers outpatient medical services such as doctor visits, lab work, diabetes supplies, cancer treatment, durable medical equipment, x-rays, ambulance, surgeries and much more. This means Plan G covers the coverage gaps with Original Medicare and all Plan G products must provide you with the exact same coverage.

Medicare pays first, then Plan G pays the remaining amount after you pay the once annual deductible. In addition, Plan G Medicare Supplements offer up to $50,000 in foreign travel emergency benefits (up to plan limits).

Related Article: Medicare Costs for 2023

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

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BEWARE: Ransomware Attacks in Healthcare

HHS CYBER SECURITY PROGRAM

By Staff Reporters

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According to Healthcare Brew, the rising tide of ransomware attacks in healthcare is exacting a hefty price from hospitals and other medical providers who’ve had their data locked up by cyberattacks.

Healthcare providers face potential costs arising from more than just the initial ransom; targeted systems have seen lost patient revenue, the need for remediation, and additional recovery costs. And even the largest health systems in the country aren’t immune to the costly ripple effects, such as delayed patient care, including surgeries, that can linger even after an initial attack.

“Not only is the frequency [of ransomware attack] picking up, but I’d say the magnitude or the size is also getting bigger,” said Brian Tanquilut, a healthcare services analyst at Jefferies.

CommonSpirit Health, one of the nation’s largest hospital chains, was hit with a high-profile cyberattack in October. The system has not publicly disclosed the financial fallout, but a Dec. 1 update published on the company’s website said that the cyberattackers gained access to personal information for some patients and that an investigation is ongoing. Chad Burns, a spokesperson for CommonSpirit, declined requests for an interview.

A report from the cybersecurity firm Sophos determined that “the average remediation cost [from a ransomware attack] went up from $1.27 million in 2020 to $1.85 million in 2021.” For others, it’s much more costly.

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

Tenet Healthcare, a Dallas-based healthcare company, reported a loss of about $100 million attributed to a ransomware attack in April, according to its second-quarter earnings report. San Diego-based Scripps Health said a ransomware attack cost it nearly $113 million in May and June 2021 primarily due to lost revenue, along with recovery costs. Keep reading here.

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AFFORDABILITY: Healthcare on Notice for Patients

By Staff Reporters

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People living in the US are finding it increasingly difficult to afford needed health services—even with employer-sponsored health insurance, a new analysis suggests.

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

Researchers at the NYU School of Global Public Health (GPH) examined data from the National Health Interview Survey—an annual CDC survey—that was collected from 2000 to 2020 for 230,000+ adults who received health insurance through an employer or union. Both men and women found most healthcare services to be less affordable now compared to the early 2000s, according to the finding of the NYU analysis reported in a December 2022 JAMA abstract. Women, in particular, found all types of health services to be less affordable than men.

From a nationally representative survey which is conducted annually, researchers included data from 5,545 women and 5,353 men sampled in 2020, and found that about 6% of women reported they couldn’t afford needed medical care. This compares to just 3% of slightly larger sample groups from 2000, per the analysis. By contrast, about 3% of men gave that response in 2020, compared to 2% in 2000.

Avni Gupta, a doctoral student in the public health policy and management department at NYU GPH and the lead author of the analysis, offered that “lower incomes and higher healthcare needs among women could be driving these differences in reported affordability.”

And, José Pagán, the department chair and co-author of the JAMA analysis, said people with employer-sponsored coverage—the largest source of health insurance for people living in the US—“generally think they are protected.”

“[B]ut our findings show that health-related benefits have been eroding over time,” he said; according to Healthcare Brew

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PODCASTS: The Physician-Patient Population Health Mis-Match

By Eric Bricker MD

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PODCAST: https://medicalexecutivepost.com/2022/10/23/podcast-help-your-medical-practice-embrace-population-health/

Population Health: https://medicalexecutivepost.com/2022/07/12/enter-population-health-management/

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

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PODCAST: History Applied to Health Economics

Divining the Future?

By Eric Bricker MD

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

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The State of COVID-19 in the USA

UPDATE

By Staff Reporters

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Johns Hopkins University: https://publichealth.jhu.edu/2023/what-you-need-to-know-about-xbb15-the-latest-omicron-variant

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METAVERSE: Expert Consensus in Medicine?

By Staff Reporters

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A multi-disciplinary panel of doctors and IT experts from Asia, the United States, and Europe analyzed published articles regarding expert consensus on the Medical Internet of Things, with reference to study results in the field of metaverse technology.

READ HERE: https://reader.elsevier.com/reader/sd/pii/S2588914122000016?token=4509ACBB9748F76769BCB6562B7413EAFAA5D83509412E53E17AC36F08A581B66B0F4E7B2D31A444F80A603E8FF22792&originRegion=us-east-1&originCreation=20221015174759

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MEDICINE: https://www.amazon.com/Business-Medical-Practice-Transformational-Doctors/dp/0826105750/ref=sr_1_9?s=books&ie=UTF8&qid=1287563112&sr=1-9

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

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

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RIGHTS: Mental Health in America [Georgia]

MENTAL HEATH AMERICA

By Staff Reporters

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MENTAL HEALTH PARITY ACT

Atlanta, GA – Governor Brian P. Kemp, joined by First Lady Marty Kemp and their three daughters, Lt. Governor Geoff Duncan, Speaker David Ralston, members of the House and Senate, and mental health advocates, today signed the Mental Health Parity Act (HB1013) into law. You may view his remarks from the bill signing ceremony below, and you can watch the full ceremony here.

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Mental Health Rights

People living with mental health conditions are people. They have people they love, activities they enjoy, and dreams for their lives. As people, they deserve to be treated with dignity, and under the law they have rights and protections. 

GA MENTAL HEALTH PARITY LAW: https://gov.georgia.gov/press-releases/2022-04-04/gov-kemp-provides-remarks-and-signs-mental-health-parity-act

Unfortunately, it has long been the case that individuals with mental health conditions are among the most abused and discriminated against in our country. From leaving people to languish in overcrowded state hospitals to lobotomies and forced sterilization, the treatment of those with mental health conditions is a dark stain on our history as a nation.

While we have come a long way, abuse and discrimination continue to be serious problems today. The shackling or restraining of children, keeping people out of work, and denying access to services are just a few examples of the way we continue to fail the 1 in 5 Americans that has a diagnosable mental health disorder.

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

This is not just a small issue for a small group of people: half of all Americans will experience a diagnosable mental health condition in their lifetime. If it is not us being directly impacted, it is likely that it will be our family members, friends, or loved ones– whether we know it or not. Beyond struggles in education or employment, we see the loss of human dignity and even human life for the people we love and care about when we do not work to address abuses in the system.

For Mental Health America, the fight against abuse and discrimination is essential to our history and continues to guide our work. MHA’s symbol, which sits in our national office, is the Bell of Hope cast from the chains and shackles that were used to restrain individuals in old state hospitals. As an organization, MHA is committed to the principles of human and civil rights inherent to the concept of equal justice under the law.

PROVIDERS: https://medicalexecutivepost.com/2022/10/05/a-review-of-mental-healthcare-provider-types/

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MEDICAL PROVIDERS: Hobson’s Choice in Medicine

CITE: https://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_4?ie=UTF8&s=books&qid=1275315485&sr=1-4

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TUCSON, Ariz., Dec. 06, 2022 (GLOBE NEWSWIRE) — Sheila Page, D.O., a family physician in Aledo, Texas, and president of the Association of American Physicians and Surgeons (AAPS), is featured in the winter issue of the of the Journal of American Physicians and Surgeons. She writes:  “Today physicians often feel constrained to pick from among options that are not in the best interest of patients but are ‘covered’ by insurance or approved by officials.”

“An apparently free choice when there is no real alternative is a Hobson’s Choice, and physicians must understand the political structure in which this type of ‘choice’ is embedded,” Dr. Page explains.

“During the COVID pandemic, people often faced a Hobson’s Choice of taking a shot that they believed put their life, health, or fertility at risk, or be barred from their education or career,” she noted.

“Voters generally believe that they have two choices, Republican or Democrat, and that they represent extremes of political ideology. However, when they are in office, politicians behave as if they belong to the same club,” she writes.

“Physicians have accepted the Hobson’s Choice of either abiding by ridiculous regulatory burdens or refusing to treat the senior population,” she explains. They “accept the Hobson’s Choice of either standing against the oppression or keeping their ‘place at the table.'” 

“The phrase ‘we need to keep our place at the table to avoid being on the menu’ entirely misses the point,” she states. “The profession is on the table already being carved up. How many times have we been told we must choose the lesser of two evils? Either choice is still evil!”

“We must identify the enemy within,” Dr. Page writes. “The medical profession must grasp the extent to which it has been manipulated by pharmaceutical, insurance, and other systems tied to medicine. We have been burdened with regulations and threats to our licenses by the same people who are selling us the solutions.”

“There is tremendous profit in the existing system, but we must nevertheless offer healing and hope, learn how to fight back effectively, and reject the Hobson’s Choice,” she concludes.

CITE: The Journal of American Physicians and Surgeons is published by the Association of American Physicians and Surgeons (AAPS), a national organization representing physicians in all specialties since 1943.

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

Contact Information:
Jane Orient
Executive Director
janeorientmd@gmail.com
(520)323-3110

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PODCAST: “All OR Nothing” Hospital Contracts

By Eric Bricker MD

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

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PODCAST: Value Based Healthcare Delivery by Dr. Michael Porter PhD

HARVARD BUSINESS SCHOOL

By Staff Reporters

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

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CENTENE CORPORATION: Medicaid Over-Billing?

By Staff Reporters

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Centene Corporation showers politicians with millions as it courts contracts and settles over-billing allegations by Samantha Young, Andy Miller, and Rebecca Grapevine (Kaiser Health News)

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Somehow KHN made Medicaid over-billing sound sexy.

This deep dive into Centene, “the nation’s largest private managed-care provider for Medicaid,” shows how the company has maintained good relationships with politicians as it looked to keep its market share and settle over-billing allegations.

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

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PODCAST: https://medicalexecutivepost.com/2021/11/12/podcast-centene-giant-medicaid-hmo/

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Omicron Sub-Variant XBB Rapidly Gaining Ground in the U.S.A.

By Staff Reporters

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he emerging Omicron subvariant XBB contributes to an increasingly high number of COVID-19 cases in the U.S., rivaling the sister strains BQ.1.1 and BQ.1, according to the latest estimates from the Centers for Disease Control and Prevention (CDC).

Recent studies have indicated that the updated bivalent COVID-19 booster performed poorly against BQ.1.1, with even a weaker antibody response against XBB.

In late November, citing its poor neutralization effect on BQ.1 and BQ.1.1., the FDA pulled the emergency use authorization granted for bebtelovimab, a COVID-19 antibody therapy developed by Eli Lilly (LLY) and AbCellera Biologics (ABCL).

The CDC estimates for the week ending Dec. 24 show that XBB has made up ~18% of COVID cases in the U.S. compared to ~11% a week ago. Meanwhile, BQ.1.1 has led to ~36% of cases unchanged from a week ago, and BQ.1 caused ~27% of cases, a decline from ~29% last week.  

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HOSPITAL FORMS: Be Aware BEFORE You Sign

By Staff Reporters

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You don’t have to sign all the forms to be treated

Part of being a patient is signing stacks of forms, most of which you barely read much less understood. This is a mistake, Charlotte O’Leary says. Look for any “blank check” clauses on intake forms—it’s the part that reads, “I will be responsible for all costs not covered by insurance.”

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

Instead, Charlotte Hilton Andersen, MS recommends crossing it out and writing, “I will be responsible for all costs that are medically necessary, that are not the responsibility of my insurer, are competitively priced, and that I am made aware of prior to treatment if they are not part of standard operating procedures.”

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Digital Health Insurance Tracking Devices

By Staff Reporters

Blue Cross Blue Shield has deployed several trackers on its website, according to the web extension Ghostery, a tool that can tell you what kind of technology web pages are using.

  • Ghostery returned a list of trackers from Twitter, Google, and LinkedIn.

Though we don’t know specifically what kind of data is being transferred, these pixels are usually installed to help marketing departments. Tracking pixels, for the uninitiated, are hidden or embedded graphics that can give a more complete picture of a customer’s journey: what they’ve clicked on, if they’ve searched for something specific, if they’ve put something in a shopping cart, or whether an advertisement drove them to, say, Blue Cross Blue Shield’s homepage. For example, if an insurer wants to show that its ads are working, it can use a pixel to determine that it was their ad that got someone to finally sign up for health insurance, not Susan in HR.

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

Trackers are ubiquitous, but experts and consumers have raised serious questions about the data that’s shared between companies. For example, investigative reporting outlet The Markup found that hospitals shared sensitive information with Facebook through the Meta pixel. And just this month, Indianapolis-based Community Health Network reported that pixels may have affected 1.5 million of its patients.

For more, read Marketing Brew’s interview with sociologist Mary F.E. Ebeling, who wrote a book about the collection of sensitive health data.

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DAILY UPDATE: Sovereign Wealth Funds, Mortgages and the Dimming U.S. Markets

By Staff Reporters

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Sovereign wealth funds could be selling roughly $29 billion in equities by the end of December. Meanwhile, U.S. defined benefit pension plans would need to shift up to $70 billion from equities to bonds to hit their targets, reports Bloomberg quoting the JPMorgan estimates. “The recent equity market correction and bond rally are consistent with the rebalancing hypothesis,” Bloomberg quoted Vincent Deluard, a macro strategist at StoneX. 

DEFINITION: A sovereign wealth fund, sovereign investment fund, or social wealth fund is a state-owned investment fund that invests in real and financial assets such as stocks, bonds, real estate, precious metals, or in alternative investments such as private equity fund or hedge funds. Sovereign wealth funds invest globally.

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

And, in a recent interview with CNN, Bank of America CEO Brian Moynihan said he’s concerned the housing market will continue to challenge buyers in the coming years. Moynihan pointed to sky-high mortgage rates as a big reason buyers might continue to struggle — especially first-time buyers with more limited financial resources. Moynihan also said there could be two more years of pain in the housing market before things cool off and homes become more available and affordable. And that’s a tough pill to swallow.

Finally, U.S. stocks were lower, adding to last week’s declines, as the global markets continued to grapple with the ultimate impact of aggressive monetary policy tightening around the world. Last week, the Fed, European Central Bank, Bank of England, and Swiss National Bank all increased their benchmark interest rates by 50 basis points, fostering recession concerns.

Treasury yields traded higher, and the U.S. dollar was unchanged, while crude oil gained ground, and gold was lower.

Other equity news was light, as L3Harris Technologies announced an agreement to acquire Aerojet Rocketdyne with an enterprise value of $4.7 billion, while shares of Madrigal Pharmaceuticals surged after positive trial results for its NASH and liver fibrosis treatment.

A busy week of housing data commenced, as the NAHB’s December Housing Market Index unexpectedly deteriorated.

Asia finished mostly lower as China’s COVID concerns weighed on sentiment, though European stocks were mostly higher, rebounding from last week’s decline as the global markets digest the recent rate hikes on both sides of the pond.

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HEALTH GORILLA: A New Health Data Interoperability Start-Up

By Staff Reporters

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Health Gorilla is in the business of health data interoperability and the double-backflip this startup is doing to both make clinical data an easily accessible commodity – while also making sure that access to that data adheres to the privacy rules established by the US government – takes a minute to understand, but is critically important for the future of many health tech businesses.

LINK http://www.HealthGorilla.com

And, it’s not often that 10,000-plus like-minded individuals come together for a common cause. Luckily in the healthcare space, we have HLTH – bringing together the entire health ecosystem to focus on innovation and transformation.

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

So for Health Gorilla, last month’s four-day event in Las Vegas was a most successful conference.

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

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TURQUOISE HEALTH? Compare Prices Before Receiving Medical Care

By Staff Reporters

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Last year, all hospitals were required to list their prices for elective services on an annual basis. Whether you have insurance or plan to pay cash – find and compare prices.

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

So, just like you wouldn’t buy a car, rent an apartment or even order food without knowing the cost, you shouldn’t pay blindly for healthcare.

Now you can compare prices before showing up for treatment.

READ MORE: https://turquoise.health/

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MEDICARE: Part “C” Plans = Double Standard

By Anonymous

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The HHS OIG Fall 2022 report was recently released to Congress. On page 20, there are many referrals to seven inappropriate payments to a variety of Medicare “Advantage” Plans. Topping the list is Humana. The OIG claims that Humana in the time period studied falsified records to receive $34.4M worth of payments they received from CMS for risk diagnosis code risk assessments. If even half this amount is true, it is unconscionable that Humana is not severely fined, their executives terminated and subjected to criminal proceedings, and they should be banned from the Medicare program for ten years. This is no different from how other healthcare providers are criminalized, so the question is, why is the insurance industry treated different and preferentially when they commit fraud?

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

These OIG studies are great reads, but up until now, they have done nothing to stop the insurance industry’s abusive practices of denying “clean claims”, denying claims after prior authorization, ignoring CCI edits, “losing” charts sent for review and then claiming higher error rates to Congress, paying providers often less than 50% of Medicare, and this the last draw… falsifying data so they can be paid more from CMS. When will this madness stop? When will providers have the gumption to actually act out the famous quote, “I’m mad as hell and I’m not going take it anymore!” (from the movie Network), and Peter Finch it!

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PODCAST: Industrial Revolution – Healthcare Revolution

SEE THE FUTURE BY LOOKING BACK

By Eric Bricer MD

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

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RISK MANAGEMENT & LIABILITY PROTECTION FOR PHYSICIANS

And … Their Insurance Agents and Financial Advisors

INVITE DR. MARCINKO: https://medicalexecutivepost.com/dr-david-marcinkos-

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By DR. DAVID EDWARD MARCINKO MBA CMP®

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SPONSOR: http://www.CertifiedMedicalPlanner.org

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BOOK REVIEW

It is not uncommon for practicing physicians to have more than a dozen separate insurance policies to protect their medical practice and personal assets. Yet, most doctors understand very little about their policies.BOOK REVIR

Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™explains to physicians and insurance professionals the background, theory, and practicalities of medical risk management, asset protection methods, and insurance planning.

The book presents information in a manner that is convenient and highly useful for busy medical practitioners. It discusses the medical records revolution and addresses concerns regarding cloud computing, data security, and technological threats.

The book covers modern health law and policy, including fraud and abuse, workplace-violence, Medicare compliance, HIPAA regulations, AR protection strategies with internal controls, P4P and value based care, insurance and reputation management, and how the ARA legislation is impacting physician practices. It also includes case models and examples that provide you with a real-world understanding of how to recognize and reduce personal and medical practice risks.

With time at a premium for all, and so much information packed into one well-organized resource, this book is a must-read for every physician and financial advisor that serves the health care sector. The book will help physicians make better decisions about the risks they face and will help financial advisors improve the value they provide to their clients who are doctors.

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

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PODCAST: Financial Deception in Healthcare

THIRTY EXAMPLES

By Eric Bricker MD

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

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ELIXIR: Rite Aid’s New PBM [mail order pharmacy]

By Staff Reporters

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When Rite Aid dropped roughly $2 billion in 2015 to buy its pharmacy benefit management (PBM) subsidiary now known as Elixir, the company had framed the investment as a strategic move to compete in the healthcare marketplace among rivals like CVS and Walgreens.

The deal quickly helped make Rite Aid $4.1 billion in its newly formed pharmacy services segment—including Elixir and other pharmacy services, according to the company—bolstering its financial standing the next fiscal year. Maybe it would no longer be the ugly duckling next to the cooler, sleeker swans.

It seemed to be working—for a while at least. But by 2018, analysts were recommending Rite Aid sell off Elixir to reduce the parent company’s debt. Still, Rite Aid stuck with Elixir in hopes of boosting its competitiveness in the retail pharmacy scene.

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

This year, Rite Aid President and CEO Heyward Donigan was still painting a rosy picture of Elixir, saying in earnings calls that the PBM was gaining more members and Elixir’s operating margins were improving.

But a month after its latest earnings call in September, Rite Aid was hit with a class-action lawsuit accusing the company of making “false and/or misleading statements” to investors about Elixir’s status between April and September of this year.

READ: https://www.healthcare-brew.com/stories/2022/12/09/rite-aid-faces-a-class-action-lawsuit-over-its-pharmacy-benefits-subsidiary

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PODCAST: Medical Utilization Management [UM]

By Eric Bricker MD

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PODCAST: Doctor’s Don’t Disclose Conflicts of Interest

C.O.I.

By Eric Bricker MD

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MORE: https://medicalexecutivepost.com/2022/10/05/video-on-doctors-money-and-conflicts-of-interest/

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

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Product Details

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RBP: The Rise of Reference Based Pricing & The Future of Health Care 

By Bill Rusteberg

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The New Payer You Never Heard Of 

For 35 years we have lived in the world of managed care. Consumers have been conditioned to believe networks of “preferred” providers ensure better access, better benefits, lower cost and convenient claim settlement.  

In the beginning managed care worked. Not all hospitals and physician groups were in networks and competition helped create cost savings for consumers and their employers. But over time consumers demanded more access and eventually almost all providers were “preferred” and in-network. Today less than 5% of all claims are out-of-network yet medical costs have increased. While professional providers are typically paid using managed care fee schedules, hospitals and other facilities are usually paid a percentage of whatever they charge, and over time, those charges have continued to increase.  

As a result, we are seeing the rise of Reference Based Pricing (RBP) claim reimbursement strategies. RBP strategies are gaining popularity with self-funded employer plans particularly as a way to bring more transparency and accountability to health care pricing. 

The new payer you never heard of are local employers breaking away from the status quo.  You will not see recognizable logos or insurance company names on their health insurance I.D. cards. You may wonder “what kind of insurance is this?” 

What is Reference Based Pricing? 

RBP sets uniform provider payments relative to a benchmark. The most commonly used benchmark is the Medicare Fee Schedule, a widely known payment methodology. Because Medicare fee schedules are on the low end of provider reimbursement, RBP health plans typically add a margin to ensure fair and equitable payment and profits for medical care givers.  Margins can range from 120% to 150% of Medicare and more.  

PPO networks, on the other hand, set opaque pricing at an arbitrary number to which an arbitrary discount is applied. Instead of this top down approach, RBP health plans utilize a bottom up approach.  

In addition, employers are not privy to negotiated PPO rates while reimbursement allowances are transparent and clearly disclosed in RBP plans. This is one of several important distinctions between managed care pricing strategies and RBP.  

An extension of RBP may include detailed claim audit protocols to facility claims prior to claim settlement. These audits typically produce savings of 5 – 7%. Managed care contracts, on the other hand, typically prohibit or severely limit an employer’s right to audit claims, another important difference.  

The Growth of Reference Based Pricing 

While many readers may view this as something new, it’s simply another form of the indemnity plans that were common prior to the advent of managed care in the early 80’s.  

The first RBP health plan in Texas was established in 2008 in San Antonio. Since then the concept has gained national momentum and is growing most rapidly among mid-size self-funded employers. However, we are beginning to see larger employers such as the state of Montana adopting this strategy for their employee benefit program. The Oklahoma State Medical Association adopted RBP strategies for their member health plans several years ago and has since expanded their program offering to Texas medical providers. 

Medical Community Reaction 

Since inception of Reference Based Pricing plans (RBP) in San Antonio fifteen years ago, professional providers have generally accepted patients insured through these plans.  Professional providers, particularly primary care physicians, may earn more under this payment methodology than earned under many managed care contracts. In addition, RBP plans do not intrude on the physician-patient relationship as there are no contractual terms and conditions providers are bound to accept.  

Hospitals have generally remained opposed to RBP plans, yet few patients are turned away for care because reimbursement levels are fair and reasonable. In those rare instances a patient is turned away RBP plans often arrange a bundled cash payment at mutually agreed reimbursement levels that are often less than what the plan would have otherwise paid.    

Action Plan for Physicians and Their Administrators 

With the explosive grown of RBP plans, physicians and their administrators should establish an action plan for RBP patients or potential patients seeking their services. What transpires at the point of contact with a patient can be critical. A knowledgeable staff insures adequate controls in determining patient financial responsibility. Turning away patients is not always a good business practice and is unnecessary in cases where RBP payment parameters are within a practice’s normal scope of acceptance.  

Always check for network logos on the members’ I.D. card. When calling an unfamiliar health plan or TPA to verify eligibility and benefits, ask what provider network(s) the plan uses for physicians and hospitals.  

If the customer service representative says that there is no hospital or professional network or that the plan is “open access”, ask whether the plan pays hospitals and/or physicians based on a standard reference price or a fixed % of Medicare.  

Staff administration should pre-determine the minimum level of acceptable payment based on a % of Medicare. This will empower intake clerks, at the point of contact, to determine if a plan’s reimbursement level is adequate and approved by administration. This will also assist intake clerks in determining each patient’s responsibility. Some RBP plans clearly indicate the basis of claim payment on member’s I.D. cards, i.e., “Plan Pays XXX% of Medicare.” 

If procedures are regularly performed in a facility setting and there is a choice of hospitals or ambulatory surgery centers, staff should ask whether the plan has any direct contracts or has a good working relationship with any of the local facilities. Most RBP plans have established direct agreements with certain local providers or are interested in doing so.  

It takes very little effort to certify a patient’s financial ability to pay for services. Verification is a phone call away. Intake clerks should be trained to ask the right questions, applying the answers against pre-determined parameters of acceptance rather than reliance upon a list of “approved insurance plans.” Turning patients away at the front desk when their insurance coverage pays as much as or more than “approved” plans is poor business.  

Partnering With Employer Health Plans 

A professional provider would be wise to reach out directly to local employers adopting RBP plans to arrange direct agreements, especially when it is discovered an employer important to the practice has adopted RBP. A direct agreement with an employer sponsored health plan would eliminate balance billing and provide steerage. Typically direct RBP agreements are no more than one page in length and contain a 30 day out clause. There are no third party intermediaries involved. 

Some RBP plans allow professionals to name their price. A sharing arrangement between the health plan and plan member assures full payment based on a mutually agreed pricing benchmark. For example, a plan may set its claim exposure at 120% of Medicare. A professional provider may agree to accept 150% of Medicare. The 30% differential would be borne by the plan member in the form of a pre-set co-pay amount. There would be no co-pay through providers who have agreed to accept the plans benchmark pricing, in this example 120% of Medicare. A tiered co-pay strategy solves provider access issues, benefiting providers, patients and employer health plan budgetary constraints.  

The Future of Reference Based Pricing 

RBP strategies are a transitory phenomenon, a bridge serving as a basis for more change to come in a dynamic market.  

RBP health plans will continue to gain market share in the next several years as more independent third party administrators (TPAs) and insurance companies are offering RBP options with new entrants into the market almost monthly. 

Professional providers should understand that RBP is yet another way to pay health care claims and would be wise to acclimate to this kind of pricing. As the Medicare eligible population of the United States increases from 17% in 2015 to 23% in 2023, professional providers will see more patients at Medicare rates than ever before. The good news for professional providers is RBP plans generally pay more. 

There is good news for employers too. RBP plans give self-funded employers a powerful cost containment tool that can make health care more affordable for their employees.  

You can expect to see a growing number of patients insured through RBP plans seeking your services. It would be good business to understand this growing trend now in order to accommodate them. RBP will create opportunities for physician-led bundles and other direct contracting strategies that benefit local employers, giving you more control and save money for your patients.  

The Future 

Reference Based Pricing is a transitory phenomenon leading to something better for all stakeholders. We are seeing a new trend rising in health care financing that removes third party barriers between patients and their physicians. 

Removing third party intermediaries between providers and the patients they serve is the foundation on which to provide better benefits at a lower cost for health care consumers. Cash pay settlements at the point of service, in real time, will be a major component of that, getting back to the way care and doctor-patient relationships once were, without the intervention of an insurance company. 

Plan members will pay cash at the time of service through plan sponsored funding. Physicians will receive cash payment by way of pre-negotiated electronic super bill at the time of service. No claims filing and no chasing patient share required, saving providers both time and expense. Hospitals will be paid in full on day of service too, saving time and expense filing claims and chasing patient share. 

Community based health plans will adopt a cash pay network of medical caregivers. Access and delivery of care on a local, collaborative basis by mutually controlling costs in a direct relationship with one another as opposed to the indirect relationships we find in our current carrier-driven dynamic will be key to providing community members with responsive and affordable access to care.  

Community health plans will adopt Direct Primary Care as a key focal point for all subsequent care. Capitated rates will replace fee-for-service fee schedules. Primary care physicians will, for the first time in their careers, devote 100% of their working hours to treating patients, not burdened with EMR’s and other administrative functions at the beck and call of third party intermediaries.  

One example of a Community Health Plan is currently under development in central Texas. It will incorporate ER, Lab & Radiology, and direct primary care at a capitated rate of less than $125. A cash based reimbursement wrap for all other covered services through a cash pay provider network will cover remaining covered medical services.  

The reader may find this to be a pipe dream that will never happen. On the contrary, it’s happening now and it’s growing faster than a melting raspa on a scorching August afternoon in deep South Texas. It’s the new payer you’ve never heard of. 

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

MORE: https://medicalexecutivepost.com/2022/09/26/podcast-reference-based-pricing-for-medical-facility-fees/

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PODCAST: Never Pay Your First Medical Bill?

Marshall Allen Has a New Healthcare Book Out Called Never Pay the First Bill.”

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PODCAST: Healthcare is Great for People with Medicare.

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Greater than 90% of Medicare Beneficiaries Are Satisfied with Their Care

By Eric Bricker MD

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ORGANIZATIONS: https://www.amazon.com/Financial-Management-Strategies-Healthcare-Organizations/dp/1466558733/ref=sr_1_3?ie=UTF8&qid=1380743521&sr=8-3&keywords=david+marcinko

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ON THE RISE: Healthcare Consumerism!

By Staff Reporters

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As technology continues to rapidly evolve, a corresponding transformation in the healthcare industry is occurring. One of the most significant changes is the shift from traditional healthcare to healthcare consumerism. Patients now have more information available to them than ever before, and they are using this information to make more informed healthcare decisions. Patients are no longer passively accepting the care that is provided to them.

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

Instead, they are actively choosing the care that they receive, and are more selective about the providers that they use. As a result, healthcare providers must now focus on providing a better patient experience to attract and retain patients.

Source: Hari Prasad, Physicians Practice [12/8/22]

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