DAILY UPDATE: Walmart, Women’s Health Month, UnitedHealth and the Mixed Stock Markets

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Here’s where the major stock market benchmarks ended:

  • The S&P 500® index (SPX) fell 17.30 points (0.3%) to 5,018.39; the Dow Jones Industrial Average® ($DJI) gained 87.37 points (0.2%) to 37,903.29; the NASDAQ Composite® ($COMP) lost 52.34 points (0.3%) to 15,605.48.
  • The 10-year Treasury note yield (TNX) dropped more than 5 basis points to 4.63%.
  • The CBOE Volatility Index® (VIX) decreased 0.28 to 15.37.

Banks and other financial shares led the market’s afternoon upswing, reflecting renewed optimism over the outlook for interest rates. The KBW Regional Bank Index (KRX) jumped 2.4% and posted its first gain in five days. Biotechnology and communication services were also strong.

Energy shares were among the weakest performers as WTI Crude Oil (/CL) futures extended a week-long nosedive and dropped under $80 per barrel for the first time since mid-March. Crude futures sank over 3% after the Energy Information Administration reported U.S. oil inventories surged 1.6% last week. 

Among top companies, Amazon (AMZN) gained 2.2% after reporting stronger-than-expected earnings and revenue late Tuesday. Starbucks (SBUX) tumbled 16% following unexpectedly soft quarterly results. Apple (AAPL) eased 0.6% ahead of its quarterly results, expected after Thursday’s close.

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

Speaking of stock companies, however big you think UnitedHealth is, it’s bigger than that. For example:

  • With a market cap of nearly $450 billion, it’s the fourth-largest company in the US by revenue this year, beating out Alphabet and Microsoft.
  • The company is eyeing a $24.7 billion profit in 2024.
  • One analyst estimated that more than 5% of US GDP flows through UnitedHealth’s systems daily.

And so, lawmakers in Washington are prepared to grill UnitedHealth CEO Andrew Witty in two congressional hearings today, months after a cyberattack on a subsidiary of the healthcare giant, Change Healthcare, rattled the industry and left pharmacies, doctors, and hospitals in the dark. Change processes roughly half of all Americans’ medical claims. Congress wants Witty to clarify how UnitedHealth handled the breach of patient data. But beyond that, it wants to investigate whether the company—the nation’s largest private health insurer—has grown too big and taken on too much risk.

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Retailer Walmart announced plans Tuesday to shutter its network of 51 health clinics in five states, along with its telehealth business. The impending closures signify that Walmart is scuttling its initial plans to expand the services, citing escalating operation costs and “challenging reimbursement environment,” the company said in a news release.

Finally – Happy Women’s Health Month! Women and people assigned female at birth are disproportionately affected by a range of health conditions, including autoimmune diseases, chronic pain, and dementia. The month of May is intended to raise awareness of these disparities and educate women on steps they can take to improve their health, such as getting annual breast exams. For all our woman-identifying readers, take some time to prioritize your health this month!

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What is a Hospital CHARGE MASTER?

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By Dr. David Edward Marcinko MBA MEd CMP

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According to George Washington University, a hospital chargemaster is a comprehensive list of a hospital’s products, procedures, and services. Everything from prescription drugs to supplies for diagnostic tests has a unique price listing in the chargemaster, making it a go-to document for hospital administrators such as CFOs, clinical documentation improvement specialists, and revenue directors.

Chargemaster usage dates back to the mid-20th century. At that time, fee-for-service (FFS) health insurance plans, which allow patients to direct their medical care by choosing physicians and facilities and paying a portion of the billed total, had just emerged in the U.S. healthcare system.

The chargemaster originally served as something akin to an FFS dictionary, with an entry for virtually anything billable under that economic model of healthcare.

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

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Over time, FFS itself has evolved and been challenged by alternatives like value-based care (VBC). Chargemasters built for FFS have changed accordingly, and they remain fixtures of the modern hospital revenue cycle. A standard chargemaster is a large electronic file containing multiple elements for each entry. These attributes usually include:

  • The charge for a single unit of the service in question
  • A Current Procedural Terminology (CPT) code; CPT is the official medical code set of the American Medical Association
  • Potentially, a Healthcare Common Practice Coding System (HCPCS) code; HCPCS is based on CPT
  • Alternative CPT and HCPCS codes if needed, e.g. one corresponding only to specific payers
  • A revenue code associated with the charge
  • Flag(s) indicating if the entry is scheduled for deletion, active or inactive
  • An internal reference number within the ledger for accounting purposes

LINK: https://revcycleintelligence.com/features/the-role-of-the-hospital-chargemaster-in-revenue-cycle-management

MORE: https://medicalexecutivepost.com/2013/09/26/some-modern-issues-impacting-hospital-revenue-cycles/

RCC: https://medicalexecutivepost.com/2013/03/06/a-better-approach-to-hospital-cost-estimation/

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FINANCE: 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

BUSINESS: 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

HEALTH INSURANCE: 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: Cash Flow, Revenue & Entrepreneurial Leadership in Healthcare Business

THE ENTREPRENEURIAL M.D.

In this episode we are joined by Dr. Brent Jackson, Chief Medical Officer for Mercy General in Sacramento, CA to discuss the physician life-cycle, burnout, and transitioning into leadership within healthcare.

Play EpisodeDownload (40.4 MB)

Summary: Dr Brent Jackson discusses the flow of revenue throughout the medical industry.

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DAILY UPDATE: The CHIPS and Science Act & the FOMC as Stocks Edge Higher

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It’ll be a big week for hot takes on the US economy, after the Federal Reserve meeting Tuesday and Wednesday and the April jobs report dropping Friday. Because inflation has been sticking around, the FOMC is expected to hold interest rates steady at this meeting and for the foreseeable future. On the jobs front, economists are projecting another strong month for employment growth.

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

In 2022, with bipartisan support, Congress passed the CHIPS and Science Act, an ambitious plan to juice domestic manufacturing of a product vital to national security: semiconductors. Two years later, the government has doled out more than half of the CHIPS Act’s $39 billion in incentives. According to the Financial Times

  • Chip companies and their suppliers have announced US investments of $327 billion over the next 10 years, per the Semiconductor Industry Association.
  • Construction of manufacturing facilities for computing and electronics devices has jumped 15x, government data shows.
  • By 2030, the US will likely produce around 20% of the world’s most advanced chips, according to USCommerce Secretary Gina Raimondo. Right now, it’s making 0%.

The proposed factories are massive and could transform regional economies. Micron, which received $6.1 billion in federal grants last week, plans to invest $100 billion in a manufacturing campus near Syracuse.

CITE: https://tinyurl.com/2h47urt5

Here’s where the major benchmarks ended:

  • The S&P 500® index (SPX) rose 16.21 points (0.3%) to 5,116.17, its highest close in over two weeks; the Dow Jones Industrial Average® ($DJI) gained 146.43 points (0.4%) to 38,386.09, the NASDAQ Composite® ($COMP) advanced 55.18 points (0.4%) to 15,983.08.
  • The 10-year Treasury note yield (TNX) fell more than 5 basis points to 4.616%.
  • The CBOE Volatility Index® (VIX) declined 0.36 to  14.67.

Communication services shares were among the market’s weakest performers Monday, reversing last Friday’s upswing as Alphabet (GOOGL) dropped more than 3% and Meta Platforms (META) lost 2.4%. Banks and retailers were also soft. The Philadelphia Semiconductor Index (SOX) climbed for the sixth-straight day and ended near a three-week high even though its biggest member, Nvidia (NVDA), ended little changed.

In other markets, the U.S. Dollar Index ($DXY) faded from early gains but is still up about 1% in April, driven by expectations domestic rates will remain high. “The U.S. dollar’s strength continues to reflect the relative strength of the economy and the wide interest rate differentials between the United States and other major developed markets,” Schwab Center for Financial Research analysts said in a report.

Despite last week’s strength, the S&P 500 index and the NASAQ Composite are still down 2.6% and 2.4%, respectively, for April and on track to break five-month winning streaks.

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Humana expects to exit Medicare Advantage (MA) markets in 2025, company executives told investors. The company reported its first quarter earnings April 24th. Humana posted $741 million in net income in the first quarter of 2024, beating investor expectations, but pulled its 2025 earnings guidance. 

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Modern Portfolio Theory and Asset Allocation [Not Correlation]

THE CORRELATION HOT TOPIC

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By Dr. David Edward Marcinko MBA CMP©

SPONSOR: http://www.CertifiedMedicalPlanner.org

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Modern Portfolio Theory approaches investing by examining the complete market and the full economy. MPT places a great emphasis on the correlation between investments. 

DEFINITION:

Correlation is a measure of how frequently one event tends to happen when another event happens. High positive correlation means two events usually happen together – high SAT scores and getting through college for instance. High negative correlation means two events tend not to happen together – high SATs and a poor grade record.

No correlation means the two events are independent of one another. In statistical terms two events that are perfectly correlated have a “correlation coefficient” of 1; two events that are perfectly negatively correlated have a correlation coefficient of -1; and two events that have zero correlation have a coefficient of 0.

Correlation has been used over the past twenty years by institutions and financial advisors to assemble portfolios of moderate risk.  In calculating correlation, a statistician would examine the possibility of two events happening together, namely:

  • If the probability of A happening is 1/X;
  • And the probability of B happening is 1/Y; then
  • The probability of A and B happening together is (1/X) times (1/Y), or 1/(X times Y).

There are several laws of correlation including;

  1. Combining assets with a perfect positive correlation offers no reduction in portfolio risk.  These two assets will simply move in tandem with each other.
  2. Combining assets with zero correlation (statistically independent) reduces the risk of the portfolio.  If more assets with uncorrelated returns are added to the portfolio, significant risk reduction can be achieved.
  3. Combing assets with a perfect negative correlation could eliminate risk entirely.   This is the principle with “hedging strategies”.  These strategies are discussed later in the book.

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

BUT – CORRELATION IS NOT CAUSATION

https://medicalexecutivepost.com/2021/02/05/correlation-is-not-causation/

In the real world, negative correlations are very rare 

Most assets maintain a positive correlation with each other.  The goal of a prudent investor is to assemble a portfolio that contains uncorrelated assets.  When a portfolio contains assets that possess low correlations, the upward movement of one asset class will help offset the downward movement of another.  This is especially important when economic and market conditions change.

As a result, including assets in your portfolio that are not highly correlated will reduce the overall volatility (as measured by standard deviation) and may also increase long-term investment returns. This is the primary argument for including dissimilar asset classes in your portfolio. Keep in mind that this type of diversification does not guarantee you will avoid a loss.  It simply minimizes the chance of loss. 

In the table provided by Ibbotson, the average correlation between the five major asset classes is displayed. The lowest correlation is between the U.S. Treasury Bonds and the EAFE (international stocks).  The highest correlation is between the S&P 500 and the EAFE; 0.77 or 77 percent. This signifies a prominent level of correlation that has grown even larger during this decade.   Low correlations within the table appear most with U.S. Treasury Bills.

Historical Correlation of Asset Classes

Benchmark                             1          2          3         4         5         6            

1 U.S. Treasury Bill                  1.00    

2 U.S. Bonds                          0.73     1.00    

3 S&P 500                               0.03     0.34     1.00    

4 Commodities                         0.15     0.04     0.08      1.00      

5 International Stocks              -0.13    -0.31    0.77      0.14    1.00       

6 Real Estate                           0.11      0.43    0.81     -0.02    0.66     1.00

Table Source: Ibbotson 1980-2012

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

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HOSPITALS: “Weighted Average Cost of Capital”

By Dr. David Edward Marcinko MBA CMP

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SPONSOR: http://www.MARCINKOASSOCIATES.com

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The Cost of Hospital Capital Is “WACC”

It is critical for physician executives to understand and to measure the total cost of hospital capital. Lack of understanding and appreciation of the total cost of capital is widespread, particularly among not-for-profit hospital and physician executives. The capital structure includes long-term debt and equity; total capital is the sum of these two, and, each of these components has cost associated with it.

For the long-term debt portion, this cost is explicit—it is the interest rate plus associated costs of placement and servicing. For the equity portion, the cost is not explicit and is widely misunderstood. In many cases, hospital capital structures include significant amounts of equity that has accumulated over many years of favorable operations.

Far too many executives wrongly attribute zero cost to the equity portion of their capital structure. Although it is correct that generally accepted accounting principles continue to assign a zero cost to equity, there is opportunity cost associated with equity that needs to be considered. This cost is the opportunity available to utilize that capital in alternative ways.

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In general, the cost attributed to equity is the return expected by the equity markets on hospital equity. This can be observed by evaluating the equity prices of hospital companies whose equity is traded on public stock exchanges. Usually, the equity prices will imply cost of equity in the range of 10%–14%. Almost always, the cost of equity implied by hospital equity prices traded on public stock exchanges will substantially exceed the cost of long-term debt. Thus, while many hospital executives will view the cost of equity to be substantially less than the cost of debt (i.e., to be zero) in nearly all cases, the appropriate cost of equity will be substantially greater than the cost of debt.

Hospitals need to measure their weighted average cost of capital (WACC). WACC is the cost of long-term debt multiplied by the ratio of long-term debt to total capital plus the cost of equity multiplied by the ratio of equity to total capital (where total capital is the sum of long-term debt and equity).

WACC is then used as the basis for capital charges associated with all capital investments. Capital investments should be expected to generate positive returns after applying this capital charge based on the WACC. Capital investments that do not generate returns exceeding the WACC consume enterprise value; those that generate returns exceeding WACC increase enterprise value. Therefore, physician and hospital executives need to be rewarded for increasing enterprise value.

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DAILY UPDATE: Cannabis, Healthcare and the Stock Market Rally!

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Here’s where the major stock market benchmarks ended:

  • The S&P 500 index gained 51.54 points (1.0%) to 5,099.96, up 2.7% for the week; the Dow Jones Industrial Average® ($DJI) increased 153.86 points (0.4%) to 38,239.66, up 0.7% for the week; the NASDAQ Composite jumped 316.14 points (2.0%) to 15,927.90, up 4.2% for the week.
  • The 10-year Treasury note yield (TNX) lost about 4 basis points to 4.665%.
  • The CBOE Volatility Index® (VIX) fell 0.34 to 15.03.

Alphabet’s rally helped communication services reverse Thursday’s downturn, which was driven by disappointing quarterly results from Meta Platforms (META). The S&P 500 Communication Services index ($SP500#50) surged 4.7% Friday and ended the week with a 2.7% gain. Semiconductor shares were also strong, led by a 6% gain in Nvidia (NVDA). The Russell 2000® Index (RUT) added 1.1% Friday and posted a 2.8% advance for the week.

In other markets, WTI Crude Oil (/CL) futures rose slightly Friday, ending around $83.65 per barrel and shutting down a three-week losing streak.

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

  • Midi Health, a health clinic geared toward women in midlife, raised $60 million in Series B funding to expand its network to 150 clinicians by the end of the year, among other efforts. (MobiHealthNews)
  • “We’re fooling ourselves if we think that’s cheap or can be done less expensively.”—Carmela Coyle, president and CEO of the California Hospital Association, on hospital finances and cutting costs (AP)
  • The federal government implemented new staffing rules to improve patient care, but most nursing homes won’t be able to meet that demand. (KFF Health News/NPR)

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The Biden administration is considering a change that would downgrade cannabis from a Schedule I drug to a Schedule III drug this year. The reclassification would have major effects on the business of cannabis, but for that to happen, the Drug Enforcement Agency needs proof of medical effectiveness.

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DAILY UPDATE: GDP Worries as Markets Stumble with Meta but other Technology Stocks are Good

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New GDP numbers out yesterday show a worrying combo of stubborn inflation + waning growth that dampens hopes for a potential interest rate cut. Per the latest data from the Bureau of Economic Analysis, the first quarter of 2024 was a confounding one:

  • GDP increased at a 1.6% annualized rate, far below projections of 2.4% and notably down from 3.4% at the end of 2023.
  • While slow growth would typically signal that the Fed could cut rates, another metric complicates matters: Consumer prices (excluding volatile categories), a solid indicator of inflation, shot up to a much higher than anticipated 3.7%.

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Meta reported record Q1 revenue yesterday, but it was overshadowed by the billions of dollars the company is spending in its efforts to win the Artificial Intelligence race and make the Metaverse happen. Investors were unhappy with the company’s forecast that its spending will rise by $10 billion dollars to support Artificial Intelligence development, sending Meta’s stock price down 15% after hours.

Here’s where the major benchmarks ended:

  • The S&P 500 index fell 23.21 points (0.5%) to 5,048.42; the Dow Jones Industrial Average lost 375.12 points (1.0%) to 38,085.80; the NASDAQ Composite® ($COMP) shed 100.99 points (0.6%) to 15,611.76.
  • The 10-year Treasury note yield (TNX) rose about 5 basis points to 4.704%.
  • The CBOE Volatility Index® (VIX) fell 0.64 to 15.33.

Communication services shares were the weakest S&P 500 sector Thursday behind the plunge in Meta Platforms. Late Wednesday, the Facebook parent provided lighter-than-expected second-quarter revenue guidance, while CEO Mark Zuckerberg discussed spending in currently unprofitable pursuits such as artificial intelligence (AI) and mixed reality. Meta’s first-quarter earnings and revenue both came above analysts ‘ estimates, however.

Meta’s slump helped send the S&P 500 Communication Services index ($SP500#50) down 4%. Banks were also particularly soft amid concern that persistently high interest rates may compress lender margins. Semiconductor and transportation shares were among the few pockets of strength.

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

But, Alphabet, Microsoft, and Snap reported Q1 earnings yesterday, and were generally good. Alphabet issued its first-ever dividend and authorized $70 billion in stock buybacks, after it beat Wall Street’s revenue expectations. Microsoft also beat revenue forecasts on the strength of its cloud services. And Snap shares soared after it topped estimates and impressed investors with its 422 million global daily active users. It was a much-needed boost for the sector after Meta spooked the market with how much it’s spending on AI.

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DAILY UPDATE: Retirement Security Rule, National Drug Take Back Day, Spotify, Cleveland Clinic, NAR and the Mixed Stock Markets

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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants

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Otherwise known as “National Prescription Drug Take Back Day,” National Drug Take Back Day on April 25th is sponsored by the Drug Enforcement Agency. Its goal is to keep the public aware of the dangers of prescription drug use and misuse. Many Americans don’t know how to safely dispose of the prescription drugs that have been sitting in the medicine cabinet past their prime. Using these expired drugs, or using someone else’s, is dangerous and puts both the public and the environment at risk.

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Spotify made money in Q1. According to Morning Brew, the streaming music giant grew its revenue last quarter by 20% to $3.8 billion on a record $180 million in profit, it announced yesterday. The smash report comes after Spotify cut costs last year, which included laying off more than a quarter of its workforce. The company also raised prices in 2023 for the first time in a decade as it further expanded beyond music into audio books and other categories. Spotify shares soared ~11% following the news.

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Here’s where the major benchmarks ended:

  • The S&P 500 index® (SPX) rose 1.08 points (0.02%) to 5,071.63; the Dow Jones Industrial Average® ($DJI) fell 42.77 points (0.1%) to 38,460.92; the NASDAQ Composite® ($COMP) added 16.11 points (0.1%) to 15,712.75.
  • The 10-year Treasury note yield rose more than 4 basis points to 4.644%.
  • The CBOE Volatility Index® (VIX) rose 0.28 to 15.97.

Transportation shares were among the market’s weakest performers Wednesday behind a drop of more than 10% in Old Dominion Freight Line (ODFL), which reported lighter-than-expected quarterly revenue. The shipper’s nosedive helped send the Dow Jones Transportation Average ($DJT) down 2.3%. Consumer staples, semiconductors, and utilities posted moderate advances. The Dow Jones Utility Index ($DJU) gained for the sixth straight day and ended at a three-and-a-half-month high.

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The National Association of Realtors’ $418 million settlement over an alleged conspiracy to inflate commissions received preliminary approval yesterday. It’s a new world order: Sellers won’t have to pay buyers’ agents anymore. There’s been talk of a metaphorical death of real estate agents, or a mass extinction; the jury is still out, but RE/MAX cofounder and chairman Dave Liniger doesn’t seem too concerned. 

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The Labor Department announced it has finalized its Retirement Security Rule, which aims to protect American workers who are saving for retirement and relying on advice from fiduciaries for it. The new rule will update the definition of an investment advice fiduciary under the Employee Retirement Income Security Act and the Internal Revenue Code.

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Clinicians don’t always get it right, and their mistakes can be costly: Studies show misdiagnoses lead to roughly 800,000 patient deaths or permanent disabilities each year in the US and cost the healthcare system an estimated $20 billion annually. Cleveland Clinic is using telehealth to try to combat misdiagnoses via its virtual second opinions program, which has saved an average of $8,705 per patient by avoiding unnecessary treatments, according to an analysis released in March.

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DAILY UPDATE: Nike Lay-Offs & Retirement “Rule of 55” as Stock Markets Zoom Upward

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Stat: 740. That’s how many employees Nike will lay off at its Oregon HQ before the end of June. In February, Nike CEO John Donahoe informed employees of the company’s plan to reduce 2% of its workforce, which would mean around 1,600 employees in total. (USA Today)

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Let’s say you leave your job at any time during or after the calendar year you turn 55 (or age 50 if you’re a public safety employee with a government defined-benefit plan). Under a little-known separation-of-service provision, often referred to as the “rule of 55,” you may be able take distributions (though some plans may allow only one lump-sum withdrawal) from your 401(k), 403(b), or other qualified retirement plan free of the usual 10% early-withdrawal penalties. However, be aware that you’ll still owe ordinary income taxes on the amount distributed.  This exception applies only to the plan (including any consolidated accounts) that you were contributing to when you separated from service. It does not extend to IRAs.

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Here’s where the major benchmarks ended:

  • The S&P 500 index rose 59.95 points (1.2%) to 5,070.55; the Dow Jones Industrial Average gained 263.71 points (0.7%) to 38,503.69; the NASDAQ Composite® ($COMP) surged 245.33 points (1.6%) to 15,696.64.
  • The 10-year Treasury note yield (TNX) decreased about 2 basis points to 4.602%.
  • The CBOE Volatility Index® (VIX) fell 1.25 to 15.69.

Similar to Monday, chipmakers were among the market’s strongest areas, carrying the Philadelphia Semiconductor Index (SOX) to a 2.2% advance. Retailers and communication services shares were also strong. The Dow Jones Utility Index ($DJU) gained for the fifth straight day and ended at its highest level in over three months. The Russell 2000® Index (RUT) surged nearly 2%. 

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DAILY UPDATE: BoA “De-Banks”, Hospitals Merge and Walmart Health Grows as the NASDAQ Dives

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A group of 15 financial officers representing 13 states issued a warning to Bank of America over its alleged practices of “politicized de-banking” targeting conservatives. In a letter to Bank of America CEO Brian Moynihan, the officials said the bank’s practices threaten its own financial health and reputation with customers while simultaneously harming the U.S. economy and Americans’ civil liberties. They pointed to examples of Bank of America shuttering the accounts belonging to Christian groups and leaders and joining a net-zero climate alliance in addition to its poor viewpoint diversity rating.

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Texas and Missouri will soon have about two dozen Walmart health centers, the retail giant announced this month, adding to its 50-site roster. The company plans to open eight clinics in the Houston metro area, 10 sites in the Dallas-Fort Worth area, and four facilities in Kansas City by the end of 2024, Modern Healthcare reported.

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Hospitals reported the strongest quarter of mergers and acquisitions since 2020, according to consulting firm Kaufman Hall. Four of the 20 announced transactions in the first quarter of 2024 were “megamergers” and brought in $12 billion in revenue in that time period, per the firm’s analysis. The era of consolidation is here.

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Here’s where the major benchmarks ended:

  • The S&P 500 index fell 43.89 points (0.9%) to 4,967.23, down 3% for the week; the Dow Jones Industrial Average gained 211.02 points (0.6%) to 37,986.40, little changed for the week; the NASDAQ Composite lost 319.49 points (2.1%) to 15,282.01, down 5.5% for the week.
  • The 10-year Treasury note yield (TNX) dropped more than 2 basis points to 4.623%, still up about 10 basis points for the week.
  • The CBOE Volatility Index® (VIX) rose 0.71 to 18.71.

Nvidia (NVDA) plunged 10% to lead the chip sector lower, sending the Philadelphia Semiconductor Index (SOX) down 4.1% to a two-and-a-half-month low. Communication Services shares were also among the weakest sectors, fueled by Netflix weakness. There were several pockets of strength, however. Banking shares posted firm gains Friday behind stronger-than-expected quarterly results from some regional lenders. Utilities also advanced.

The S&P 500 has fallen 5.5% from a record close March 28, more than halfway to the 10% threshold that’s traditionally viewed as a correction. The NASDAQ Composite is down 7.1% from a record close on April 11th.

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DAILY UPDATE: Stark Laws & 23andMe as Wall Street Pulls Back

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If the practice makes a reasonable effort to collect from a patient who is experiencing financial hardship (e.g., job loss due to COVID-19), providers may be able to offer a discount (e.g., settle for 70% of the amount owed) without violating Stark Law, says Reed Tinsley, CPA, healthcare consultant in Houston, Texas. “But remember that just because even if someone doesn’t have a job, they could still have money,” he adds. “There are a lot of people out there with big savings accounts.”

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Source: Lisa A. Eramo, MA, Keith A. Reynolds, Physicians Practice [4/3/24]

  • 23andMe cofounder and CEO Anne Wojcicki wants to take the once-hot DNA company private. 23andMe said a Special Committee would evaluate the proposal in light of other options. The company’s valuation has tumbled since its stock market debut in 2021. The struggling DNA company once valued in the billions — was essentially worthless as of Wednesday.
  • But,shares soared Thursday less than three years after it began selling shares. Wojcicki told board members she is proposing to acquire the company in a potential go-private transaction, according to a filing with the Securities and Exchange Commission.

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Here’s where the major benchmarks ended:

  • The S&P 500 index fell 11.09 points (0.2%) to 5,011.12; the Dow Jones Industrial Average® ($DJI) rose 22.07 points (0.1%) to 37,775.38; the NASDAQ Composite lost 81.88 points (0.5%) to 15,601.50.
  • The 10-year Treasury note yield (TNX) gained almost 5 basis points to 4.633%.
  • The CBOE Volatility Index® (VIX) dropped 0.22 to 17.99.

Weakness in chip maker shares pushed the Philadelphia Semiconductor Index (SOX) down 1.7% to a two-month low. Biotechnology and consumer discretionary shares were also among the weakest sectors. Energy companies eroded as WTI Crude Oil (/CL) futures dropped for a third straight trading day and closed at a three-week low. 

The S&P 500 is on track for its third consecutive weekly decline, its weakest stretch since September, while the NASDAQ Composite appears headed for a fourth straight weekly slide.

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DAILY UPDATE: PBM Pricing Structure and UnitedHealth Cyber Fury as Stock Markets Tumble

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Pharmacy Benefits Managers often need more transparency regarding their pricing structures and the rebates they negotiate with drug manufacturers. Some argue that PBMs might receive hidden fees or undisclosed profits from drug manufacturers in exchange for favorable positioning on their formularies (lists of covered medications). This can be seen as a form of kickback, which is illegal.

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Lawmakers Express Fury Toward UnitedHealth in Change Attack Hearing on the fallout surrounding the unprecedented cyberattack on Change Healthcare in late February. Individuals representing the American Hospital Association, private cybersecurity groups and providers testified before members of the House Energy and Commerce Committee on April 16th to discuss the healthcare industry’s response to the attack and how the federal government should act.

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In March, the cyber criminal organization received $22 million in bitcoins, though UnitedHealth Group has not addressed whether the company paid the ransom. On April 15th, ransomware group RansomHub posted files on its dark web leak site comprising of personal and protected health information on patients whose data was taken in the hack. The files also include contracts and agreements between Change and its clients, marking the first time hackers have posted data from the attack.

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Source: Jakob Emerson, Becker’s Hospital Review

Stocks started the day strong yesterday but ended up slumping before the market closed as investors pulled back on tech stocks, including Nvidia. United Airlines took off after releasing a strong forecast for the year despite saying it took a $200 million hit because of Boeing’s troubles.

Here’s where the major benchmarks ended:

  • The S&P 500 index lost 29.20 points (0.6%) to 5,022.21; the Dow Jones Industrial Average declined 45.66 points (0.1%) to 37,753.31; the NASDAQ Composite dropped 181.88 points (1.2%) to 15,683.37.
  • The 10-year Treasury note yield (TNX) decreased more than 7 basis points to 4.585%.
  • The CBOE Volatility Index® (VIX) fell 0.20 to 18.20.

ASML’s slump helped send the Philadelphia Semiconductor Index (SOX) down 3.3% to its lowest level since late February. Transportation shares were also under pressure after trucking company J.B. Hunt Transport Services (JBHT) dropped 8.1% in the wake of disappointing quarterly numbers. Energy shares slipped as WTI Crude Oil (/CL) futures fell 3% to a three-week low. 

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CERTIFIED MEDICAL PLANNER™ Niche Financial Advisor Professional Designation

Think Different – Be Different  – Thrive

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Dear Physician Focused Financial Advisors

Did you know that desperate doctors of all ages are turning to knowledgeable financial advisors and medical management consultants for help? Symbiotically too, generalist advisors are finding that the mutual need for knowledge and extreme niche synergy is obvious.

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So, if you are looking to supplement your knowledge, income and designations; and find other qualified professionals you may want to consider the CMP® program.

Enter the Certified Medical Planner™ charter professional designation. And, CMPs™ are FIDUCIARIES, 24/7.

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FINANCIAL ADVISORS: Finally Website Posting Their Fees?

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Many financial planning websites mention fees, as required, but still remain opaque to potential clients because the advisor wants to control the discussion and understandably wishes to avoid the website shopper phenomenon.

But, physicians and all investors can still control the discussion, and still provide transparency, because posting up front pricing information doesn’t mean presenting information in a vacuum!

For example, a 1%/year fee doesn’t have to just be 1%; it can be 1%, compared to an industry average cost of X%, where the average cost of an actively managed mutual fund is Y%.

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Similarly, it doesn’t have to be a retainer fee of $1,000/year; it can be a retainer fee for less than the cost of a monthly cable bill! And, a financial plan doesn’t cost $1,500; it costs 8-12 hours of staff time to craft extensive, customized solutions; but saves the doctor-client so much more!

And, if services have a range of potential prices, they might be provided with some insight into the factors that impact the price. Modern young and internet savvy doctors expect this sort of information.

ASSESSMENT: Your thoughts are appreciated.

LINK: https://medicalexecutivepost.com/2015/04/06/understanding-the-failure-to-recognize-mutual-fund-fees/

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INVESTMENT BANKING UPDATE: Rules, securities markets, brokerage accounts, margin and debt review

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A Primer for Investors and Entrepreneurial Medical Professionals

Dr. David Edward Marcinko; MBA, CMP™

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Investment banking is so back. All of the biggest banks have reported their first-quarter 2024 results, and their earnings have been as good as, if not better than, expected. Higher interest rates ate into the spoils—Bank of America reported yesterday that its profit dropped 18% compared to the same period last year—but investment banking arms did well, especially since many banks increased their fees, and deal making and IPOs started to pick up again. But despite perking up, investment banking activity is still below where it used to be. Strong consumer spending also helped banks out, with credit card income rising and people and businesses continuing to need loans.

[PART 1 OF 8]

BC Dr. Marcinko

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

Introduction

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

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

INVESTMENT BANKING AND SECURITIES UNDERWRITING

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

Introduction

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

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

Fundamentals of the Investment Banking Industry

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

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

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

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

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

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

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

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

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

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

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

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

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

The Securities Act of 1933 (Act of Full Disclosure)

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

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

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

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

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

###

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

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

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

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

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

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

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

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DAILY UPDATE: Tesla Lay Offs, Mammograms, Physician Pay, UnitedHealth and Tele-Health as Stock Markets Close Mixed

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Stat: 10%. That’s the percentage of Tesla employees that will be impacted by its global workforce reduction. Elon Musk sent an email to employees on Monday informing them of the layoffs, which he said were made to “reduce costs and increase productivity,” according to the WSJ. The move comes as the electric vehicle maker deals with a wider slowdown in EV sales. (the Wall Street Journal)

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UnitedHealth Group, reeling from the Change cyberattack, recorded a loss of $1.4 billion in the first quarter. Still, its EPS exceeded expectations and the stock is trading up.


The Florida Medicaid market is a big prize for insurers. Just three plans earned statewide contracts, starting in October.


And … physicians made steady pay gains last year, but increases were undercut by inflation rates. See how other specialties fared, according to a report from Medscape.

The social determinants of health can impact a woman’s chance of being up to date with her mammogram, according to a recent Centers for Disease Control and Prevention report. Women are less likely to get a mammogram if they feel socially isolated, have lost a job or don’t have reliable transportation.


And…A major House subcommittee is considering whether to issue another short-term extension on telehealth flexibilities as they continue to evaluate cost and quality issues or to enact permanent changes to virtual care reimbursement.  The American Telemedicine Association is pushing Congress to make permanent the Medicare telehealth flexibilities implemented during the COVID-19 pandemic.

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Here’s where the major benchmarks ended:

  • The S&P 500® index (SPX) declined 10.41 points (0.2%) to 5,051.41, its lowest close in almost two months; the Dow Jones Industrial Average® ($DJI) advanced 63.86 points (0.2%) to 37,798.97; the NASDAQ Composite® ($COMP) eased 19.77 points (0.1%) to 15,865.25.
  • The 10-year Treasury note yield gained almost 4 basis points to 4.667%.
  • The CBOE Volatility Index® (VIX) fell 0.83 to 18.40.

Scaled-back expectations for Fed rate cuts continued to burden interest-rate-sensitive sectors, such as banks and utilities. The KBW Regional Bank Index (KRX) lost 1.4% and ended near a five-month low. The small-cap Russell 2000® Index (RUT) dropped 0.4% and ended at a two-month low.

In other markets, the U.S. dollar index (DXY) strengthened for the fifth consecutive trading day and hit its highest level since late October, reflecting expectations rates will stay elevated. 

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WHAT IS A “CLOSED-END” MUTUAL FUND

REVIEW OF OPEN AND CLOSED MUTUAL FUNDS

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By staff reporters

A closed-end fund (CEF) or closed-ended fund is a collective investment model based on issuing a fixed number of shares which are not redeemable from the fund.

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Unlike open-end funds, new shares in a closed-end fund are not created by managers to meet demand from investors. Instead, the shares can be purchased and sold only in the market, which is the original design of the mutual fund, which predates open-end mutual funds but offers the same actively-managed pooled investments.

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DAILY UPDATE: Dental and Digital Health Start-Ups as Stock Markets Collapse Again!

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Here’s where the major stock market benchmarks ended:

  • The S&P 500 index fell 61.59 points (1.2%) to 5,061.82; the Dow Jones Industrial Average lost 248.13 points (0.7%) to 37,735.11; the NASDAQ Composite® ($COMP) dropped 290.08 points (1.8%) to 15,885.02.
  • The 10-year Treasury note yield (TNX) surged almost 12 basis points to 4.618%.
  • The CBOE Volatility Index® (VIX) rose 1.92 to 19.23.

Interest-rate-sensitive sectors like real estate and utilities were among the weakest performers Monday. Technology shares were also under pressure. The small-cap Russell 2000® Index (RUT) shed 1.4% and ended at a two-month low.

In other markets, the U.S. dollar index (DXY) strengthened for the fourth consecutive trading day and hit its highest level since early November, reflecting expectations rates will stay elevated. Volatility based on the VIX jumped near 19.50, its highest level since late October.

Monday’s session also produced technical damage on the charts of benchmarks like the S&P 500, which closed under its 50-day simple moving average, currently around 5,114, for the first time since early November. The S&P 500 has dropped almost 4% from a record intraday high posted March 28th.

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And, after a tough funding year for digital health startups, the first quarter of 2024 saw a flurry of deals announced—a “positive signal” that the funding landscape is looking up, according to Adriana Krasniansky, head of research at digital health strategy group and venture fund Rock Health’s advisory arm. Overall, the number of digital health funding deals (133) that closed in Q1 was the highest in six quarters, though the average deal size ($20.6 million) was smaller, according to a Rock Health report. Total funding for digital health startups was $2.7 billion, the lowest level since 2019. An increase in the frequency of deals—even if they’re smaller—is a good sign, according to Krasniansky.

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Dental startup Tend aims to simplify the patient billing process via a partnership with health tech startup Cedar, the companies announced on April 11th, 2024. The US spends roughly $165 billion per year on dental services as of 2022, according to professional organization the American Dental Association—but the payment experience can be “opaque” and “confusing,” Matthew Fitzgerald, chief marketing officer at Tend, told Healthcare Brew. “From the outset, Tend has sought to innovate the dental experience by leveraging technology and hospitality to build a company around the patient,” Tend CEO Troy Bage said in a statement. “By partnering with Cedar, we’ll be able to streamline and simplify the payment process for all our members—further enhancing their overall experience with Tend, while unlocking new ways for us to elevate engagement.”

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Understanding the Failure to Recognize Mutual Fund Fees

 Going Granular and Deep with Obligatory “Fund Facts”

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[By Dr. David Edward Marcinko MBA CMP™]

DEM blueAn attractive investment and a polished sales pitch can often hide the underlying costs of the investment, leading some medical professionals to give up a significant portion of the long-term growth of their assets to fees. Fees absolutely matter.

In a good market investors have a propensity to ignore them and in challenging markets they are scrutinized, but in the end no matter what type of market we are in fees do make a substantial difference in your long-term investment returns.

Assessing the Worth of the Investment

The first step in assessing the worth of the investment under consideration is figuring out what the fees actually are.  If a medical professional is investing in a mutual fund, these costs are found in mutual fund company’s now obligatory “Fund Facts”.

This manuscript clearly outlines all the fees paid – including upfront fees (or commissions/loads), deferred sales charges, and any switching fees.  Fund management expense ratios are also part of the overall cost of ownership. Trading costs within the mutual fund can also impact performance.

The List of Fees Keep Coming … and Coming!

Here is a list of the traditional fees from investing in a mutual fund:

  • Front end load: It is the commission charged to purchase the fund through a broker or financial advisor. The commission reduces the amount you have available to invest. Thus if you start with $100,000 to invest and the advisor charges a 5 percent front end load, you end up actually investing $95,000.
  • Deferred Sales Charge (DSC) or back end load: Charge imposed if you sell your position in the mutual fund within a pre-specified period of time (normally five years). It is initiated at a higher start percentage (i.e. as high as 10 percent) and declines over a specific period of time.
  • Operating Fees: These are costs charged by the mutual fund including the management fee rewarded to the manager for investment services. It also includes legal, custodial, auditing and marketing.
  • Annual Administration Fee: Many mutual fund companies also charge an additional fee just for administering the account – usually under $150 per year. A 1 percent disparity in fees for a medical professional may not seem like a lot. But fees do make a considerable impact over a longer time period. [For example, a $100,000 portfolio that earns 8 percent before fees, grows to $320,714 after 20 years if the client pays a 2 percent operating fee. In comparison, if the investor opted for a fund that charges a more reasonable 1 percent fee, after 20 years, the portfolio grows to be $386,968 – a divergence of over $66,000! For many investors, this is the value of passive or index investing. In the case of an index fund, fees are generally under 0.5 percent, thus offering even more fee savings over an elongated period of time].

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  fd9dd41a78cfc9c81d890534ddf26cce

[The Carousel of Fees]

Assessment

Fees and expenses can have significant impact on the performance of your investments. Always monitor the costs of an investment program to ensure that fees and expenses are reasonable for the services provided and are not consuming a disproportionate amount of the investment returns.

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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DAILY UPDATE: Medicaid and Government Employee Health Insurance Changes as Stocks Tank

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Texas Governor Greg Abbott has issued a sharp warning about proposed changes to Medicaid, claiming they could “strip millions of Americans” from access to healthcare. In February 2023, the Centers for Medicare & Medicaid Services (CMS) issued a new proposed rule that would change long-standing practices for how states fund the non-federal share of Medicaid payments. In particular, the CMS is pushing for greater oversight of how states use of healthcare provider taxes to help fund their programs.

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Democratic lawmakers Sen. Richard Blumenthal and Rep. Andy Kim have partnered up with Republican Rep. Jen Kiggans to introduce legislation aiming to give army reservists and members of the National Guard that also work for the federal government options on the type of health care plans they can receive. The bill, which could impact thousands of federal employees that are also in the U.S. Army, plans to give this group of Americans the ability to decide whether they want military or civilian health care. The lawmakers said in a shared statement that their proposal will fix current regulations that limit service members who also work for the government to enroll in the cheaper Tricare Reserve Select (TRS) health plan when they also qualify for federal health plans.

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Stocks tanked last Friday after the big banks reported underwhelming earnings and the sheen from the Magnificent Seven’s AI-driven surge earlier this week wore off. Meanwhile, oil prices continue to rise near six-month highs as concern grows over geopolitical tensions in the Middle East. The tech sector was highlighted in this market, particularly due to the exceptional performance of a group of mega-cap tech giants last year nicknamed the “Magnificent Seven.” This elite group includes Apple (AAPL), Amazon (AMZN), Alphabet (GOOGL), Meta Platforms (META), Microsoft (MSFT), Nvidia (NVDA) and Tesla (TSLA).

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Invite Dr. Marcinko to Speak at your Next Seminar, Webcast or Big Event in 2024?

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

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

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Interest Rates and the Money Commodity

Medial Office Equipment Interest Rate Costs

David Edward Marcinko

Dr. David E. Marcinko; MBA, MEd, CMP™

[Publisher in Chief]

Physicians, administrators and healthcare entrepreneurs are aware of the compounding effect of interest. However, since interest is deductible as a medical office business expense, many seem to forget about it despite the fact that it must be continually paid until the asset is either purchased or otherwise disposed. 

So, what are the various types of interest rates important to the medical practitioner and commodity – money?

[1] Simple Interest

Simple interest is merely the pro rata interest on a loan or deposit and represents the most basic interest rate type.

For example, for every $100 Dr. Bill borrows at 12 percent annual interest, he pays twelve dollars per year. The interest is calculated by multiplying the principal or original amount, by the interest rate in decimal form (100 x .12). 

[2] Add-On Interest

Add on interest immediately attaches the annual interest amount, to the principal amount, at the beginning of the payment period. Payments are then made according to the number of years required.

The following formula is useful: 

Add-on-Interest minus Payment  = Total Interest on Balance/Number of Payments

For example, if Dr. William Needy borrows $10,000 at 8 percent add-on interest, he will repay $10,000 plus $ 800 ($10,000 x 8%) or $10,800, divided by twelve months, for a total of $900 per month, since $ 900/month x 12 months equals $10,800.  

[3] Discounted Interest

When using the discounted interest method, the interest amount is deducted from the principal right up front. Notice that this is the opposite of add-on-interest that is applied up front.

For example, if Dr. Bill borrows the same $ 10,000 at a discounted interest rate of 8 percent, he will only receive a $9,200 loan, since $10,000 – $800 is $9,200.

Obviously, the discount method is the most expense way to borrow money.  

[4] Annual Percentage Rate

 Most financial institutions advertise an annual percentage rates (APR) for loans, deposits and investments.  The APR is the periodic interest rate multiplied by the number of periods a year. If the APR is 12 percent, and interest is compounded monthly, you receive (or pay) 1 percent of your balance each month, and the balance shifts with each compounding. 

For example, if Dr. Bill deposits $ 100 dollars at 12 percent APR compounded monthly, he receives $ 1 interest the first month (1% of $100), $1.10 the second month (1% of $101), and so forth. If compounding is daily, the interest accumulates at the rate of 1/365 of the APR each day.  

Unless interest is compounded annually, the APR will be lower than the effective annual interest rate, discussed below. 

[5] Effective Interest Rate

It is important to differentiate between the effective interest rate and the APR, which is often the most prominent figure in advertisements for medical business equipment, consumer goods and financial services (loans, annuities, IRAs, CDs, investment analysis, college funding or retirement planning).  Although the APR is the periodic interest rate multiplied by the number of periods per year, the effective annual interest rate is the periodic rate, compounded. 

In our case, if the APR is 12 percent, compounded monthly, the monthly interest rate is 1 percent and the effective annual rate is the monthly rate compounded for 12 periods.

Therefore, if your calculation is for a single year, you can treat the effective rate as simple interest. If you deposit (or borrow) $1,000 at 12 percent APR, the effective rate is 12.68 percent, and interest for the first year is about $126.80 (12.68% of $1,000).

For longer periods, you can use the effective interest rate as the periodic interest rate, compounded annually. 

[a] “Rule of 72” (Double your Money)

The number of periods required to double a lump sum of money can be quickly estimated by using what is known as the “Rule of 72”. To get the number of periods, usually years, just divide 72 by the periodic interest rate, expressed as a whole number (not a decimal).

For example, if the annual interest rate is 10 percent, it will take about 7.2 years (72/10) to double any lump cache of money. Conversely, you can also calculate the interest rate required to double your money in a given period by dividing 72 by the term.

Thus, to double your money in ten years, you need to earn about 7.2 percent annual interest (72/10) = 7.2%).  

[b] “Rule of 78”

According to this method, interest is front end loaded like a home mortgage, or office condominium, to discourage prepayment of a loan and consequently preserve the lender’s profit. In other words, it is a method of calculating installment loan interest rebates. 

The number 78 comes from an approved method of accelerated tax depreciation, known as the “Sum of the Years Digits” (SOYD) method (i.e., 12 + 11 + 10 + 9 . . . = 78). This fact is important because, throughout the period of a loan, even though the payments are all the same, the portions that are interest and principal are very different.

Using this method for a one year loan shows that, in the first payment, 15.38 percent of the interest due is paid off, and by the sixth month, 73.08 percent of the interest is paid off.  This means, that if a physician makes a one year equipment loan with a total interest charge of $ 100 and pays the loan off in full with the sixth payments, he or she will not get an interest rebate of $ 50, but only $ 26.92, since $ 73.08 of the interest has already been prepaid. 

Most ethical lenders use simple interest rates for loan rebates, and the Rule of 78 is unfair according to many authorities.  

[c] “Rule of 116”

A derivative of the Rule of 72 is the Rule of 116.  This determines the number of years it takes for a principal amount to be tripled and is calculated by dividing the annual interest rate into 116.

The Rules of 72 and 78 are very handy for figuring the amount of interest payments made or growth of funds invested. They can also be used in reverse to calculate at what rate of interest money must be invested to double or triple in a certain number of years.     

[6] Medical Equipment Payback Cost Analysis

The payback period, expressed in years, is the length of time that it takes for the medical equipment investment to recoup its initial cost out of the cash receipts it generates. The basic premise is that the quicker the cost of an investment can be recovered, the better the investment is. It is most often used when considering equipment whose useful life is short and unpredictable.

When the same cash flow occurs every year, the formula is as follows: 

Investment Required / Net Annual Cash Inflow = Payback Period 

Thus, in today’s tightening medical reimbursement atmosphere, practice cost control and expense reduction is the easiest method to increase medical office profitability.  Keeping the cost of the commodity money in the form of interest rate charges, as low as possible, will assist in this endeavor 

Assessment

And so, how have these rules affected your medical office borrowing costs; if at all? Does these principles apply to the medical student loan crisis, today? 

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

DAILY UPDATE: Mike Burry MD, Private Equity in Health Systems, Drug Shortages, United Health Stock Sale and the Change Healthcare Hack as the Stock Markets Re-Collapse!

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  • Medical colleague and our financial planning for physicians textbook contributor Michael Burry MD predicted a second inflation surge, and price growth re-accelerated in March,. 2024.
  • The “Big Short” investor first warned of inflation in April 2020, over two years before it peaked.
  • Burry expected a recession, rate cuts, and stimulus spending to reignite inflation.

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A growing number of drugs are in short supply around the U.S., according to pharmacists. 

In the first three months of the year, there were 323 active medication shortages, surpassing the previous high of 320 shortages in 2014, according to a survey by the American Society of Health-System Pharmacists (ASHP) and Utah Drug Information Service. It also amounts to the most shortages since the trade group started keeping track in 2001. “All drug classes are vulnerable to shortages. Some of the most worrying shortages involve generic sterile injectable medications, including cancer chemotherapy drugs and emergency medications stored in hospital crash carts and procedural areas,” ASHP said in a statement

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Scheduling an appointment with a primary care doctor who belongs to a large health system might cause an increase in health care spending, according to a recent study. Such physicians tend to make more referrals to specialists, and emergency room visits and hospitalizations sometimes increase, according to the research out of Harvard T.H. Chan School of Public Health.

In short, physicians who work for health care systems like hospitals are more likely to recommend that patients use other services within those systems, compared with independent physicians. For the study — which was published in JAMA Health Forum, a journal of the American Medical Association — researchers analyzed the experiences of more than 4 million patients in Massachusetts.

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UnitedHealth Chairman Stephen Hemsley and other executives sold $102 million in company stock months before a federal antitrust probe became public, Bloomberg reported.

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Small physician practices are still struggling in the wake of February’s Change Healthcare cyberattack, according to an American Medical Association (AMA) survey released Wednesday.

More than half of ~1,400 respondents (55%) reported that they’ve had to use personal funds to cover their practice’s expenses due to the cyberattack’s effects on cash flow. Practices across the country have been unable to fill prescriptions or process insurance claims as Change Healthcare systems went offline, Healthcare Brew previously reported. About two-thirds of respondents said they’ve experienced restrictions to core functions, such as suspending claim payments (36%), not being able to submit claims (32%), and not being able to obtain electronic remittance advice (39%), according to the survey.

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Here’s where the major benchmarks ended:

  • The S&P 500 index fell 75.65 points (1.5%) to 5,123.41, down 1.6% for the week; the Dow Jones Industrial Averagelost 475.84 points (1.2%) to 37,983.24, down 2.4% for the week; the NASDAQ Composite® ($COMP) dropped 267.10 points (1.6%) to 16,175.09, down 0.5% for the week.
  • The 10-year Treasury note yield (TNX) fell more than 5 basis points to 4.52%, still up about 12 basis points for the week.
  • The CBOE Volatility Index® (VIX) rose 2.38 to 17.30.

Semiconductor shares were also among the weakest performers Friday as chip makers reversed Thursday’s sharp gains. The Philadelphia Semiconductor Index (SOX) dropped more than 3% and ended with its third straight weekly decline. Energy companies were also under pressure after crude oil prices retreated from the morning rally. Oil futures are still up 20% this year. The small-cap Russell 2000® Index (RUT) lost 1.9% and posted a 2.9% drop for the week.

In other markets, the U.S. dollar index (DXY) strengthened to a five-month high and gained 1.7% this week, reflecting beliefs the hotter-than-expected inflation readings earlier this week will keep interest rates elevated. Volatility based on the VIX jumped to its highest level since late October.

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The Medicare Cost-Control Efficiency Paradox

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

By Dr. David E. Marcinko MBA MEd CMP

[Editor-in-Chief]

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

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

On Getting What You Wish For

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

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

A Forehead-Palm Moment

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

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

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

Too Much Demand Elsewhere

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

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

Our Domestic World

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

Listen Up!

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

Assessment

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

Conclusion

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

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PODCAST: What is the “Paradox of Thrift”

The Opposite of Consumerism During the Corona Pandemic!

Dr. David Edward Marcinko MBA CMP©

Courtesy: www.CertifiedMedicalPlanner.org

The paradox of thrift (saving) states that an increase in autonomous saving leads to a decrease in aggregate demand and thus a decrease in gross output which will in turn lower total saving. The paradox is that total saving may fall because of individuals’ attempts to increase their saving, and, broadly speaking, that increase in saving may be harmful to an economy.

Both the narrow and broad claims are paradoxical within the assumption underlying the fallacy of composition, namely that which is true of the parts must be true of the whole. The narrow claim transparently contradicts this assumption, and the broad one does so by implication, because while individual thrift is generally averred to be good for the economy, the paradox of thrift holds that collective thrift may be bad for the economy.

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Assessment: Your thoughts and comments are appreciated.

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DAILY UPDATE: Costco Gold, CPI, US Stamps and the Mexican Peso as Technology Stocks Rise and Private Equity Takes on Medicine

MEDICAL EXECUTIVE-POST TODAY’S NEWSLETTER BRIEFING

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Costco started selling gold bars to its members last August, and Wells Fargo analysts believe that the product is now bringing in between $100 million and $200 million a month. The retailer doesn’t reveal the price of the 1-ounce bullion to nonmembers online, but it’s estimated to be ~2% above the spot price gold trades at, per CNBC—and that price has soared since Costco got into the gold game. The price of gold has gone up 13% this year and reached record highs as investors pile in amid inflation worries.

The big numbers from the Consumer Price Index data released on Thursday

  • In March, inflation rose 3.5% from the year before, up from 3.2% in February.
  • The “core” CPI reading, which excludes volatile food and fuel prices, came in even higher, rising 3.8% on an annual basis. That’s the same as in February, but this time it’s serious.
  • Half of the increases came from rising gas prices and housing.

After seeing inflation fall by 3% over the course of 2023, Fed officials believed that higher inflation readings in January and February 2024 represented a hiccup in an otherwise downward trajectory. However, with the March reading also coming in hotter than anticipated, analysts say this is more than a fluke. That means hopes for a June interest rate cut are dashed. Even the US Postal Service plans to raise the price of “forever” stamps to $0.73 in July. Get yours now. And the Mexican peso is on an absolute tear, leaving the US dollar behind.

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

Here’s where the major stock benchmarks ended:

  • The S&P 500® index (SPX) advanced 38.42 points (0.7%) to 5,199.06; the Dow Jones Industrial Average® ($DJI) lost 2.43 points to 38,459.08; the NASDAQ Composite gained 271.84 points (1.7%) to 16,442.20.
  • The 10-year Treasury note yield (TNX) rose nearly 2 basis points to 4.578%.
  • The CBOE Volatility Index® (VIX) fell 0.89 to 14.91.

Chip maker strength lifted the Philadelphia Semiconductor Index (SOX) more than 2% and extended the benchmark’s year-to-date gain to more than 17%. Communications services and transportation shares were also among the strongest sectors. Financial shares were mixed ahead of expected quarterly results Friday from some major banks including JPMorgan Chase (JPM), Citigroup (C), and Wells Fargo (WFC). 

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  • Big businesses such as hospital systems, insurers, and PE firms are gobbling up medical clinics.
  • Some doctors and industry experts fear corporate owners could prioritize profits ahead of patients.
  • The federal government is dialing up scrutiny of PE firms and other corporate owners in healthcare.

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QUESTION: Are Independent doctors almost a thing of the past?

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DAILY UPDATE: KPMG Fined, Aging Doctors, Water Fluoridation Outcries, Medicare Part C Down, CBO Deficit with Inflation Up as Stock Markets Crash!

MEDICAL EXECUTIVE-POST Today’s Newsletter

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NEW YORK (Reuters) -The U.S. accounting watchdog on Wednesday said it has hit KPMG Netherlands with a $25 million civil penalty, a record for the regulator, in response to “egregious” and widespread exam cheating at the foreign affiliate of the major audit firm.

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As millions of Americans approach age 66, they face the inevitable question, is it time to retire? The physician population is aging alongside the general population—more than 40% of physicians in the U.S. will be 65 years or older within the next decade. In the case of surgeons, there is little guidance on how to best ensure their competency throughout their career and at the same time maintain patient safety while preserving mature physician dignity.

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It is a scenario playing out nationwide. From Oregon to Pennsylvania, hundreds of communities have in recent years either stopped adding fluoride to their water supplies or voted to prevent its addition. Supporters of such bans argue that people should be given the freedom of choice. The broad availability of over-the-counter dental products containing the mineral makes it no longer necessary to add to public water supplies, they say. The Centers for Disease Control and Prevention says that while store-bought products reduce tooth decay, the greatest protection comes when they are used in combination with water fluoridation.

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More health systems are going to be opting out of Medicare Advantage (MA) plans, George Hill, a managing director at Deutsche Bank in Boston, predicted Monday at a “Wall Street Comes to Washington” webinar hosted by the Brookings Institution. “I think you’re going to see more large provider organizations threaten to opt out of networks, particularly as it relates to MA,” Hill said, adding that there are a number of reasons for this. “Prior authorizations are the problem, claims denials are a huge problem, delayed payments and rates are the problem — barriers in access to care in all varieties are the problem.”

CITE: https://tinyurl.com/tj8smmes

The latest budget update from the nonpartisan Congressional Budget Office (CBO) found that the federal government has spent more on paying interest on the national debt than on the military in fiscal year 2024. The CBO’s budget report for March showed that the U.S. has spent $412 billion on military programs at the Department of Defense through the first half of FY-2024, according to preliminary figures from CBO and the Treasury Department. 

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Consumer price increases remained high last month, boosted by gas, rents, and car insurance, the government said Wednesday in a report that will likely give pause to the Federal Reserve as it weighs when and by how much to cut interest rates this year. Prices outside the volatile food and energy categories rose 0.4% from February to March, the same accelerated pace as in the previous month. Measured from a year earlier, these core prices were up 3.8%, unchanged from the year-over-year rise in February. The Fed closely tracks core prices because they tend to provide a good read of where inflation is headed.

Here’s where the major benchmarks ended:

  • The S&P 500® index (SPX) dropped 49.27 points (1.0%) to 5,160.64; the Dow Jones Industrial Average lost 422.16 points (1.1%) to 38,461.51; the NASDAQ Composite® ($COMP) fell 136.28 points (0.8%) to 16,170.36.
  • The 10-year Treasury note yield (TNX) soared more than 18 basis points to 4.548%.
  • The CBOE Volatility Index® (VIX) jumped 0.82 to 15.80.

Interest-rate-sensitive sectors like banks, real estate, and utilities led Wednesday’s decliners. The KBW Regional Bank Index (KRX) tumbled 5% to its lowest point since late November. The small-cap Russell 2000® Index (RUT) lost 2.5%. Energy shares were among the few gainers as WTI Crude Oil (/CL) futures rebounded after three-straight losing sessions.

In other markets, the U.S. dollar index (DXY) jumped 1% to a five-month high amid expectations interest rates will remain elevated.

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Medical School Ethics VERSUS Business School Ethics

Is Business Finally Embracing Medical Values?

[By Render S. Davis MHA CHE]

[By David Edward Marcinko MBA MEd]

dr-david-marcinko

In the evolutionary shifts in models for medical care, physicians have been asked to embrace business values of efficiency and cost effectiveness, sometimes at the expense of their professional judgment and personal values.

While some of these changes have been inevitable as our society sought to rein in out-of-control costs, it is not unreasonable for physicians to call on payers, regulators and other business parties to the health care delivery system to raise their ethical bar.

Tit-for-Tat

Harvard University physician-ethicist Linda Emmanuel noted that “health professionals are now accountable to business values (such as efficiency and cost effectiveness), so business persons should be accountable to professional values including kindness and compassion.”

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face-off

[Medicine versus Business]

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Assessment

Within the framework of ethical principles, John La Puma, M.D., wrote in Managed Care Ethics, that “business’s ethical obligations are integrity and honesty.

Medicine’s are those plus altruism, beneficence, non-maleficence, respect, and fairness.”

About the Author

Render Davis was a Certified Healthcare Executive, now retired from Crawford Long Hospital at Emory University, in Atlanta, GA He served as Assistant Administrator for General Services, Policy Development, and Regulatory Affairs from 1977-95.  He is a founding board member of the Health Care Ethics Consortium of Georgia and served on the consortium’s Executive Committee, Advisory Board, Futility Task Force, Strategic Planning Committee, and chaired the Annual Conference Planning Committee, for many years.

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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.

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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

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VENTURE Capitals and Investment BANKERS

By Lon Jefferies MBA CFP® CMP®

By Dr. David Edward Marcinko MBA MEd CMP®

SPONSOR: http://www.CertifiedMedicalPlanner.org

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OUR TAKE ON PRIVATE EQUITY AND VENTURE CAPITAL

Private equity and venture capital investments typically involve ownership of shares in a company and represent title to a portion of the company’s future earnings. However, private equity is an equity interest in a company or venture whose stock is not yet traded on a stock exchange.

Venture capital is typically a special case of private equity in which the investment is in a company or venture that has little financial history or is embarking on a high risk/high potential reward business strategy.

Like real estate, private equity and venture capital investments generally share a general lack of liquidity and a lack of comparability across different individual investments. The lack of liquidity comes from the fact that private equity and venture capital investments are typically not tradable on a stock exchange until the company has an IPO.

The lack of comparability is due to the fact that most private equity and venture capital investments are the result of direct negotiation between the investor/venture capitalist and the existing owners of the company  /venture.

With widely divergent terms and provisions across different investments, it is difficult to make general claims regarding the characteristics of private equity and venture capital investments.

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Why Some Career Doctors Still DO NOT Get Rich?

SOME DIFFERENT REASONS WHY DOCTORS DON’T GET RICH

“Physicians have a significantly low propensity to accumulate substantial wealth.”

Thomas Stanley – Author “The Millionaire Next Door”

[New York Times]

How come doctors fail to get rich? Re-read the above!

http://www.MarcinkoAssociates.com

By Dr. David Edward Marcinko MBA CMP®

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SPONSOR: http://www.CertifiedMedicalPlanner.org

The Institute of Medical Business Advisors Inc identified several reasons based on observations working with medical professional and physician clients over the years.

A late start

By the time doctors finish medical school and residency they’re typically in their middle or late thirties. Many have families to feed, and substantial student loans to pay off. It will be years before they can even start accumulating wealth. Consider that physicians typically enter careers at later ages, often with larger debts from training. Some specialties may not lead a case until 10 years of practice, and many specialties have limited longevity. Peak earning years may also be shorter for health care providers than other professionals. Financial survival skills are paramount for converting the limited earnings time period to personal financial security.

Challenging socio-political environment

It is increasingly challenging to practice medicine. With the Medicare Trust Fund slated to go bust in 2019, the Center for Medicare and Medicare Service (CMS) is increasingly resorting to cutting physician reimbursements and implementing capitation and bundled value based medical payments models. The medical reimbursement effects of the PP-ACA are not yet fully discerned; but appear to continue the decline in compensation. And to illustrate this potential governmental control, in what other industry can participants debate the simple question, “who is the customer?”

Lifestyle expectations

Society expects a doctor to live like a doctor, dress like a doctor, and drive like a doctor. Meeting social expectations can be quite expensive.

Time and energy

A doctor can’t be just a doctor any more. S/he also has to deal with ever increasing regulatory mandates, paperwork requirements by state and federal agencies and capricious insurance companies. It is estimated that for every hour spent on patient care, and additional half-hour is spent on paperwork. To-date, the use of electronic medical records has exacerbated; not ameliorated this problem. The demand on their time is mind-boggling. A typical doctor works a ten- to twelve-hour day. After work and family, they simply don’t have time and energy left to do comprehensive financial planning.

Financially naïve

Doctors are smart. They’re highly trained in their area of expertise. But, that doesn’t translate into understanding about finance or economics. Because they are smart, it’s easy for them to think they can easily master and execute concepts of personal financial planning, as well. Often, they don’t.

Lack of trust and delegation

Many doctors don’t trust financial advisors working for major Wall Street banks. They have the good instinct to realize that their interests are not aligned. Not knowing there are independent advisors out there who observe a strict fiduciary standard, they tend to do everything by themselves.

In fact, Paul Larson CFP®, President-CEO of the firm LARSON Financial Group LLC, noted a disquieting trend among physician client in his firm [personal communication]. Almost 90% of them fail to take care of their own family finances in a comprehensive manner; while only 10% are succeeding.  The strategies in this chapter and book are common to their success.

Too Trusting

Another aspect of naivety, many physicians do not realize that the financial advisory industry lacks the same discipline and regulation that the average physician operates in. A primary care doctor would never even attempt a complicated surgery on a patient, but is trained to refer such patients to a specialist in the field with the proper training and experience. Financial Advisors often come from a sales background and are trained to keep a client in house even if the advisor is lacking in expertise. Also, many physicians are not trained to discern a qualified financial advisor from a sales person dressed up like a financial advisor. It is illegal to call yourself a physician in the United States unless you have the credentials to back it up; yet, anyone in the US can legally call themselves a financial advisor or a financial planner.

Your thoughts are appreciated.

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SPRING: Automobile Detailing Tips for Neurotic Docs

Use a Pro -or- DIY? By Dr. David E. Marcinko MBADr. David E. Marcinko MBA

It’s never a source of pride stepping out of a dirty car or truck, especially for image conscious doctors. But, keeping your vehicle looking like new, for the doctor’s parking lot, is tough work. Sure, you may take it through the drive-thru car wash every now and then, but that isn’t the deep cleaning that your car deserves.

All in the Details

Detailing, on the other hand, is promised to give your beloved vehicle that ‘new-car’ feeling all over again. It isn’t easy work, but the results are amazing. While you could detail your car at home, is it really worth it? Let’s take a look at why letting the pros detail your vehicle is the way to go – or – not!

Working at the Car Wash

When you wash your vehicle at a drive-thru car wash, you may be doing more harm than good. If the car wash has brushes or pieces of cloth that scrub your vehicle as it goes through, these components can easily scratch your car’s finish. All of the bits of dirt from cars before can be trapped in the cloth   and brushes, and as they scrub your vehicle, they act as sandpaper, permanently marring your paint.

One step better is hand washing your car at home, but even then, you must be careful to not just become a humanized version of the car wash. Using two buckets is a good start, with one bucket being a rinse bucket to remove the dirt from your sponge, and the other containing the soap.

car

SOAP Suds – Not SOAP Notes

Also, be careful of the type of soaps and car care products being used. The interior and exterior cleaners found at the local parts store are often of decent quality, but they aren’t always the best, and they must be used properly. Even then, for a normal car owner, detailing a car can become an all-day task, sometimes with less than perfect results.

Don’t forget to use a clay bar or brick followed by your favorite Carnuba wax, too.

XJ-V8-LWB

Jaguar front seat

My Jaguar's engine after a steam

The Pros

So, why should you let the pros handle your detailing needs? They should know exactly what specialty products are right for your vehicle to get the perfect results every time. And, they know the techniques that will yield showroom-finish results while you don’t have to even touch your car.

And, while you won’t want to clean out all the dried soda, coffee stains, or leftover cheeseburger wrappers from under your seat, they will gladly do it for you – for a price.

Imagine

Just picture getting into a blindingly shiny, clean vehicle with an interior that looks equally as pristine. No more purchasing all kinds of car care products that don’t deliver results. No more spending hours in the driveway getting soaked and frustrated. No more wasted time. Pros know what it takes to detail your vehicle to concourse standards.

But then, it is just a job for them. It is a labor of love for me. Am I neurotic or compulsive?

More:

Assessment

My near showroom and mint conditioned 2000 Jaguar XJ-V8-L is a full-size luxury sedan, offers sporting drive characteristics, mixed with a classic style and interior comfort. It was available in multiple trims which all came very well equipped with upscale amenities.

And, this extended wheelbase version offers much more rear seat leg room for long and winding Georgia road trips. The standard steel engine [not nikasil] in this XJ is a 4.0L V8 which produces 290 hp. The upper and lower timing chain tensioners are original, second generation metal, not plastic.

There is also a supercharged version of this vehicle which bumps output to an impressive 370 hp. Even with all of its power and weight, my XJ-8-L is still rated at over 20 mpg on the highway. Ammenities and upgrades include a mobile phone, Magellan GPS, LoJack theft recovery system, CD and MP-3 players, with internal and external cable antenna for satellite radio.

What a Cat? She is my third favorite female after my intelligent and beautiful wife, and smart and lovely daughter.

Conclusion

Are you a DIYer, like me? Nothing says you care more than doing it yourself.

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FINANCE: “Prudence” in Investment Management?

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ON “PRUDENCE” IN FINANCE AND INVESTMENT MANAGEMENT
Courtesy: http://www.CertifiedMedicalPlanner.org

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TERMS & DEFINITIONS FOR PHYSICIANS AND ALL INVESTORS:

PRUDENT BUYER: The efficient purchaser of market balance between value and cost.

PRUDENT MAN RULE: An 1830 court case stating that a person in a fiduciary capacity (a trustee, executor, custodian, etc) must conduct him/herself faithfully and exercise sound judgment when investing monies under care. “He is to observe how men of prudence, discretion and intelligence manage their own affairs, not in regard to speculation, but in regard to the permanent distribution of their funds, considering the probable income as well as the probable safety of the capital to be invested.” Allows for mutual funds and variable annuities.

PRUDENT INVESTOR RULE: A fiduciary is required to conduct him/herself faithfully and exercise sound judgment when investing monies and take measured and reasonable investment risks in return for potential future rewards. Allows for mutual funds, stocks, bonds, variable annuities asset allocation & Modern Portfolio Theory.

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

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UNIFORM PRUDENT INVESTOR ACT: https://medicalexecutivepost.com/2011/02/18/the-uniform-prudent-investor-act-versus-fiduciary-accountability/

EDITOR’S NOTE: We interviewed noted authority Ben Aikin AIF® on this topic more than a decade ago. He was ahead of his time regarding fiduciary accountability and we appreciate his insights.

Dr. David Edward Marcinko MBA CMP®

[Editor-in-Chief]

INTERVIEW: https://medicalexecutivepost.com/2009/03/01/an-interview-with-bennett-aikin-aif/

FIDUCIARY OATH: http://www.thefiduciarystandard.org/wp-content/uploads/2015/02/fiduciaryoath_individual.pdf

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A Brief Historical Review of Behavioral Finance and Economics

By Related Influential Thought-Leaders

  • Dr. Brad Klontz CSAC CFP®
  • Dr. Ted Klontz PsyD
  • Dr. Eugene Schmuckler MBA MEd CTS
  • Dr. Kenneth Shubin-Stein FACP CFA
  • Dr. David Edward Marcinko MEd MBA CMP™

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doctor

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James O. Prochaska PhD, Professor of Psychology and Director of the Cancer Prevention Research Center at the University of Rhode Island, developed the Trans-Theoretic Model of Behavior Change [TTM] which has been evolving since in 1977. Nominated as one of the five most influential authors in Psychology, by the Institute for Scientific Information and the American Psychological Society, Dr. Prochaska is author of more than 300 papers on behavior change for health promotion and disease prevention.

TTM Stages of Change

In his Trans-Theoretical Model, behavior change is a “process involving progress through a series of these stages:

  • Pre-Contemplation (Not Ready) – “People are not intending to take action in the foreseeable future, and can be unaware that their behavior is problematic”
  • Contemplation (Getting Ready) – “People are beginning to recognize that their behavior is problematic, and start to look at the pros and cons of their continued actions”
  • Preparation (Ready) – “People are intending to take action in the immediate future, and may begin taking small steps toward behavior change”
  • Action – “People have made specific overt modifications in changing their problem behavior or in acquiring new healthy behaviors”
  • Maintenance – “People have been able to sustain action for a while and are working to prevent relapse”
  • Termination – “Individuals have zero temptation and they are sure they will not return to their old unhealthy habit as a way of coping”

Relapse

In addition, researchers conceptualized “relapse” (recycling) which is not a stage in itself but rather the “return from Action or Maintenance to an earlier stage.” In medical care, these stages of behavior change have applicability to anti-hypertension and lipid lowering medication use, as well as depression prevention, weight control and smoking cessation.

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Psychology

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Uniting Psychology and Financial Behavior

More recently, validating the emerging alliance between psychology (human behavior) and finance (economics) are two Americans who won the Royal Swedish Academy of Science’s 2002 Nobel Memorial Prize in Economic Science. Their research was nothing short of an explanation for the idiosyncrasies incumbent in human financial decision-making outcomes.

Enter Kahneman and Smith

Daniel Kahneman, PhD, professor of psychology at Princeton University, and Vernon L. Smith, PhD, professor of economics at George Mason University in Fairfax, Va., shared the prize for work that provided insight on everything from stock market bubbles, to regulating utilities, and countless other economic activities. In several cases, the winners tried to explain apparent financial paradoxes.

For example, Professor Kahneman made the economically puzzling discovery that most of his subjects would make a 20-minute trip to buy a calculator for $10 instead of $15, but would not make the same trip to buy a jacket for $120 instead of $125, saving the same $5.

1608708312704

in vitro and in-vivo Economics

Initially, in the 1960’s, Smith set out to demonstrate how economic theory worked in the laboratory (in vitro), while Kahneman was more interested in the ways economic theory mis-predicted people in real-life (in-vivo). He tested the limits of standard economic choice theory in predicting the actions of real people, and his work formalized laboratory techniques for studying economic decision making, with a focus on trading and bargaining.

Later, Smith and Kahneman together were among the first economists to make experimental data a cornerstone of academic output. Their studies included people playing games of cooperation and trust, and simulating different types of markets in a laboratory setting. Their theories assumed that individuals make decisions systematically, based on preferences and available information, in a way that changes little over time, or in different contexts.

University of Chicago

By the late 1970’s, Richard H. Thaler, PhD, an economist at the University of Chicago also began to perform behavioral experiments further suggesting irrational wrinkles in standard financial theory and behavior, enhancing the still embryonic but increasingly popular theories of Kahneman and Smith.

Laboratory

Other economists’ laboratory experiments used ideas about competitive interactions pioneered by game theorists like John Forbes Nash Jr., PhD, who shared the Nobel in 1994, as points of reference.

Assessment

But, Kahneman and Smith often concentrated on cases where people’s actions departed from the systematic, rational strategies that Nash envisioned. Psychologically, this was all a precursor to the informal concept of life or holistic financial planning. Kahneman was awarded the Medal of Freedom, by President Barack Obama, on November 20, 2013.

READ: Behavioral Economics and Psychology DEM

e513455b-e924-451f-9132-d4bbbeb8e033-original

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Understanding Medical Cost Accounting

A Subset of Managerial Accounting

By Dr. David E. Marcinko MBA CMP®

http://www.MARCINKOASSOCIATES.com

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SPONSOR: http://www.CertifiedMedicalPlanner.org

Managerial and medical cost accounting is not governed by generally accepted accounting principles (GAAP) as promoted by the Financial Accounting Standards Board (FASB) for CPAs. Rather, a healthcare organization costing expert may be a Certified Cost Accountant (CCA) or Certified Managerial Accountant (CMA) designated by the Cost Accounting Standards Board (CASB), an independent board within the Office of Management and Budget’s (OMB) Office of Federal Procurement Policy (OFPP).

The Cost Accounting Standards Board

CASB consists of five members, including the OFPP Administrator who serves as chairman and four members with experience in government contract cost accounting (two from the federal government, one from industry, and one from the accounting profession). The Board has the exclusive authority to make, promulgate, and amend cost accounting standards and interpretations designed to achieve uniformity and consistency in the cost accounting practices governing the measurement, assignment, and allocation of costs to contracts with the United States.

Codified at 48 CFR

CASB’s regulations are codified at 48 CFR, Chapter 99.  The standards are mandatory for use by all executive agencies and by contractors and subcontractors in estimating, accumulating, and reporting costs in connection with pricing and administration of, and settlement of disputes concerning, all negotiated prime contract and subcontract procurement with the United States in excess of $500,000. The rules and regulations of the CASB appear in the federal acquisition regulations.

North American Industry Classification System (NAICS) codes are used to categorize data for the federal government.  In acquisition they are particularly critical for size standards.  The NAICS codes are revised every five years by the Census Bureau.  As of October 1, 2007, the federal acquisition community began using the 2007 version of the NAICS codes at www.census.gov/epcd/www/naics.html

Cost Accounting Standards

Healthcare organizations and consultants are obligated to comply with the following cost accounting standards (CAS) promulgated by federal agencies:

  • CAS 501 requires consistency in estimating, accumulating, and reporting costs.
  • CAS 502 requires consistency in allocating costs incurred for the same purpose.
  • CAS 505 requires proper treatment of unallowable costs.
  • CAS 506 requires consistency in the periods used for cost accounting.

The requirements of these standards are different from those of traditional financial accounting, which are concerned with providing static historical information to creditors, shareholders, and those outside the public or private healthcare organization.

AssessmentTwo Doctors

Functionally, most healthcare organizations also contain cost centers, which have no revenue budgets or mission to earn revenues for the organization.  Examples include human resources, administration, housekeeping, nursing, and the like.  These are known as responsibility centers with budgeting constraints but no earnings.  Furthermore, shadow cost centers include certain non-cash or cash expenses, such as amortization, depreciation and utilities, and rent. These non-centralized shadow centers are cost allocated for budgeting purposes and must be treated as costs http://www.CertifiedMedicalPlanner.org

MORE:  CASE MODEL EOQ 1

Conclusion

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CRM: Patient Relations Management and Concierge Medicine

Characteristics of a Retainer or Cash-Based Practice

By DeeVee Devarakonda; MBA [Former CMO of Quaero, Inc]

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

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A young concierge medical practice is a business with challenges in these Customer [Patient] Relationship Management’s [CRM] areas that are critical for success.

Areas of Most Challenge

Maturity of Processes:

Processes are often associated with bureaucracy or stuffy hierarchical healthcare systems that are anathema to emerging concierge medical practices. At small practices, doctors are often owners who fiercely pride themselves on flat structures, autonomy and flexibility. However, processes are imperative to conduct a streamlined practice that can be woven around a CM culture that still ensures practice business is conducted in a systematic manner.

Organization Structure:

Young concierge medical practices have challenges managing growth while grappling to incorporate an organization structure that promotes the elite private practice culture.

Multi-tasking, rapidly growing work places:

Young CM practices are often characterized by employees who multi-task and assume several roles to make their resources stretch farther. Especially in the current healthcare reform climate, young practice employees take up a broader set of responsibilities. In addition, as young private CM practices grow, they may become anguished with a growing office workplace that may not be equipped with an evolving infrastructure to cope. They have a fierce need to carefully control growth with tightly managed resources.

Changing business needs and strategy:

In an era after the golden age of traditional medicine, profitability is critical for emerging concierge practices. It is imperative to be nimble and change marketing strategies as socio-political and competitive climates dictate. A good C[P] RM system is tightly integrated, but loosely coupled, to allow CM practices to communicate appropriately with patients.

Little room for Slack:

Small concierge medical practices do not have as much established name-brand equity as larger, established practices of any model type, and patients are less willing to tolerate mistakes. Concierge practices have to run a much tighter ship and build impeccable patient experiences.

Fierce Competition:

The cash or retainer medicine landscape today looks very different from just five years ago. Competition is becoming fierce and practices are fighting for mindshare and patients. Young practices are competing with older concierge practices – large traditional practices, micro-practices, behemoth healthcare systems, enterprise-wide medical corporations and every other practice model in-between – to attract and retain patients with private resources.

Assessment

The above characteristics form the basis of a compelling strategy to embrace C[P]RM and streamline patient relationships and cash revenue opportunities. Concierge practices still need to build scalable marketing programs that can easily ramp up and down effortlessly as needs and economic environments demand. But, they do need to establish marketing metrics and processes that can demonstrate the Return on Investment (ROI) on their CRM, and marketing programs, and for getting critical cash-paying patient buy-in.

Related link: https://healthcarefinancials.wordpress.com/2009/04/28/defining-and-understanding-%e2%80%9cboutique-medicine%e2%80%9d/

MORE: https://medicalexecutivepost.com/2009/10/30/return-on-investment-calculations-for-concierge-medical-practice-marketing-initiatives/

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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MEDICAL SCHOOLS: Why They Don’t Teach Business and How it’s Costing Doctors?

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[THE MILLION DOLLAR MISTAKE]

By Curtis G. Graham MD

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The fact that every physician in private medical practice, without a business education, leaves approximately a million dollars on the table and is unaware of it is well known to business experts who work with medical doctors experiencing financial difficulties.

Business experts such as Dan S. Kennedy, Peter Drucker, Michael Gerber, Maxwell Maltz, Neil Baum, William Hanson, Huss and Coleman, Steven Hacker, Thomas Stanley, Chris Hurn, Napoleon Hill, and Dave Ramsey, among others, understand the financial problems faced by medical practices and how to solve them.

READ HERE: https://www.kevinmd.com/2023/01/the-million-dollar-mistake-why-medical-schools-dont-teach-business-and-how-its-costing-physicians.html

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WHAT IS THE “LUXURY PRODUCT” ECONOMIC PARADOX?

WHAT IS THE “LUXURY PRODUCT” ECONOMIC PARADOX?

By Dr. David Edward Marcinko MBA

Courtesy: http://www.CertifiedMedicalPlanner.org

The more expensive something is – the less likely you are to use it. This relationship between price and product utility is graphed as an “inverted U.”

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

So, super car Ferraris sit in garages; but Fords get driven.

ESSAY: https://medicalexecutivepost.com/2014/01/08/the-jaguar-touring-sedan-one-of-the-finest-luxury-cars-built-yesterday/

My own Jaguar touring sedan illustrates this paradox.

dem-jag

ESSAY: https://medicalexecutivepost.com/2018/09/02/my-jaguar-mechanic-vs-doctor-story/

This theory may even be valid for services; as well as products?

THINK: Plastic and cosmetic surgery?

Assessment: Your thoughts and comments are appreciated.

THANK YOU

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Me, Marcinko and Dr. Avatar [Metaverse?]

The Virtual Doctor Will See You Now!

By Dr. David Edward Marcinko MBA CMP™

[Publisher-in-Chief]

Recently, I was invited to speak at a regional convention. No surprise there as I have been doing so – around the world – for more than twenty years – webcasts included. And, I was asked to submit the usual paraphernalia; a formal CV, audio-visual needs, travel arrangements and times, PPE, and a personal photo which were all dutifully supplied.

Then, I was asked to supply something that flabbergasted me; I became slack-jawed, actually.

DEM’s Avatar 

Imagine my surprise when I was asked for an avatar; not just a digital photograph. So – having none – I had one made and now submit it for your review.

  Photograph of Dr. David Edward Marcinko @ home

 Avatar of Dr. David Edward Marcinko @ work

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Assessment

So, how do I virtually look – better or worse – glasses or contact lens? It seems as though some folks are more interested in the virtual me; than the real me. Go figure!

Conclusion

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

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

Our Other Print Books and Related Information Sources:

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

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Health Care Entity: Venture Capital Funding

http://www.MARCINKOASSOCIATES.com

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Venture capital funding in the digital health space cooled a bit in 2022 following a red-hot 2021. Overall, digital health companies raised $15.3 billion last year, down from the $29.1 billion raised in 2021—but still above the $14.1 billion raised in 2020, according to Rock Health a seed fund that supports digital health startups.

MORE: https://marcinkoassociates.com/fmv-appraisals/

Nevertheless, analysts predict VC investors and bankers will still put a good amount of money into digital health in 2024 and 2025, especially in alternative care, drug development, health information technology technology, EMRs and software that reduces physician workload.

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

Of course. an essential first part of attracting VC interest and money is the crafting and presentation of your formal business plan [“elevator pitch”]; as well as the needed technical and managerial experience. This is crucial for success and exactly where we can assist.

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READ MORE: https://marcinkoassociates.com/welcome-medical-colleagues/

CONTACT: MarcinkoAdvisors@msn.com

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FINANCIAL PLANNING: Next Generation for Physicians Only

By Dr. David Edward Marcinko MBA CMP™

SPONSOR: http://www.MARCINKOASSOCIATES.com

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SPONSOR: http://www.CertifiedMedicalPlanner.org

(“Informed Voice of a New Generation of Fiduciary Advisors for Healthcare”)

For most lay folks, personal financial planning typically involves creating a personal budget, planning for taxes, setting up a savings account and developing a debt management, retirement and insurance recovery plan. Medicare, Social Security and Required Minimal Distribution [RMD] analysis is typical for lay retirement. Of course, we can assist in all of these activities, but lay individuals can also create and establish their own financial plan to reach short and long-term savings and investment goals.

But, as fellow doctors, we understand better than most the more complex financial challenges doctors can face when it comes to their financial planning. Of course, most physicians ultimately make a good income, but it is the saving, asset and risk management tolerance and investing part that many of our colleagues’ struggle with. Far too often physicians receive terrible guidance, have no time to properly manage their own investments and set goals for that day when they no longer wish to practice medicine.

For the average doctor or healthcare professional, the feelings of pride and achievement at finally graduating are typically paired with the heavy burden of hundreds of thousands of dollars in student loan debt.

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

You dedicated countless hours to learning, studying, and training in your field. You missed birthdays and holidays, time with your families, and sacrificed vacations to provide compassionate and excellent care for your patients. Amidst all of that, there was no time to give your finances even a second thought.

Between undergraduate, medical school, and then internship and residency, most young physicians do not begin saving for retirement until late into their 20s, if not their 30s. You’ve missed an entire decade or more of allowing your money and investments to compound and work for you. When it comes to addressing your financial health and security, there’s no time to waste.

And you may be misled by unscrupulous “advisors”.

READ HERE: https://marcinkoassociates.com/financial-planning/

RELATED: https://medicalexecutivepost.com/2023/12/15/doctor-are-you-a-financial-advisors-customer-or-client/

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PODCAST: AMA to Teach Medical Students Health Economics?

AMA TO TEACH MEDICAL STUDENTS ABOUT HEALTH ECONOMICS?

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Dr. David Edward Marcinko MBA

Courtesy: www.CertifiedMedicalPlanner.org

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

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

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

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economic freedom

LINKS

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

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

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

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

MORE: https://medicalexecutivepost.com/wp-content/uploads/2019/01/big-data.pdf

PODCAST: https://vimeo.com/ihe

Your thoughts are appreciated.

BUSINESS, FINANCE, INVESTING AND INSURANCE TEXTS FOR DOCTORS:

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

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What is the Goodhart Economics Principle?

The Goodhart Principle, and related

[By staff reporters]

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Goodhart’s law is a sociological analogue of Heisenberg’s uncertainty principle in quantum mechanics. Measuring a system usually disturbs it. The more precise the measurement, and the shorter its timescale, the greater the energy of the disturbance and the greater the unpredictability of the outcome.
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CAMPBELL’S LAW:
“The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor.”

FINANCIAL PLANNING: Physician and Fiduciary Focused

(“Informed Voice of a New Generation of Fiduciary Advisors for Healthcare”)

By Dr. David Edward Marcinko MBA CMP

http://www.MarcinkoAssociates.com

As fellow doctors, we understand better than most the more complex financial challenges physicians can face when it comes to their financial planning. Of course, most physicians ultimately make a good income, but it is the saving, asset and risk management tolerance and investing part that many of our colleagues’ struggle with. Far too often physicians receive terrible guidance, have no time to properly manage their own investments and set goals for that day when they no longer wish to practice medicine.

For the average doctor or healthcare professional, the feelings of pride and achievement at finally graduating are typically paired with the heavy burden of hundreds of thousands of dollars in student loan debt.

You dedicated countless hours to learning, studying, and training in your field. You missed birthdays and holidays, time with your families, and sacrificed vacations to provide compassionate and excellent care for your patients. Amidst all of that, there was no time to give your finances even a second thought.

Between undergraduate, medical school, and then internship and residency, most young physicians do not begin saving for retirement until late into their 20s, if not their 30s. You’ve missed an entire decade or more of allowing your money and investments to compound and work for you. When it comes to addressing your financial health and security, there’s no time to waste.

And you may be misled by unscrupulous “advisors”.

For example:

Question: Do you know the difference between a “Fee-Only” and a “Fee-Based financial advisor? Not knowing may cost you tens of thousands of dollars, or more, in excessive advisory fees.

MORE: https://marcinkoassociates.com/financial-planning/

Of course, all of this compound’s physician stress and burnout related issues, as well.

MORE: https://marcinkoassociates.com/process-what-we-do/

COMMENTS APPRECIATED

Thank You

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The New Federal SAVE Act

BY DR. DAVID E. MARCINKO MBA

SPONSOR: http://www.MARCINKOASSOCIATES.com

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In a January 24th letter, AHA and other national hospital organizations voiced support for the Safety from Violence for Healthcare Employees (SAVE) Act (H.R. 2584/S. 2768), bipartisan legislation that would provide federal protections for health care workers similar to those that apply to aircraft and airport workers. 

“Although our members have for many years had protocols in place designed to protect their employees and promote a safe environment for patient care, the number of violent attacks against health care workers has increased markedly in recent years,” the letters to House and Senate sponsors note. “Recent studies indicate that 44% of nurses have reported being subjected to physical violence and 68% have reported verbal abuse. These experiences affect the individual provider, who may suffer from both physical and psychological trauma, and they can also interfere with care delivery when providers fear for their personal safety, are distracted by disruptive patients or family members, or are traumatized from prior violent interactions. These types of incidents also consume scarce hospital and health system resources, which in turn could impact the care available for other patients.”

Link: https://www.govtrack.us/congress/bills/117/hr7961

Link: https://www.congress.gov/bill/117th-congress/house-bill/7961/text?r=179&s=1

Guidelines: https://medicalexecutivepost.com/2024/02/05/medical-workplace-violence-prevention-guidelines/

Healthcare Violence: https://medicalexecutivepost.com/2024/02/19/assessment-of-workplace-violence-in-healthcare/

COMMENTS APPRECIATED

Thank You

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DECEPTION: Mis-Managed Medicare [Dis] Advantage [Part C] Plans?

SPONSOR: http://www.MarcinkoAssociates.com

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Managed care insurers have profited handsomely from Medicare Advantage plans, scoring billions in annual profits. They credit this financial wizardry to their use of sophisticated data analytics, preventative care, cost optimization, provider networks, evidence and value-based care and risk mitigation strategies. However, doctors, hospitals, and medical providers assert something else.

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

In fact, Medicare Advantage plans have been making headlines in 2024, but not in a positive light, at least for health insurance companies. Medicare is a government-sponsored health insurance benefit; generally for retired people aged 65 and older.

For most, the money for Medicare Part B medical insurance or Part C Medicare Advantage plans is withdrawn directly from Social Security benefits monthly, coupled with a relatively small monthly payment from the patient. Nearly half of the Medicare population is enrolled in Part C Medicare Advantage plans.

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However, there have been rumblings in the medical sector between medical providers and medical insurers coming to a head. So, where do you stand?

COMMENTS APPRECIATED

Thank You

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RESOURCES: Financial and Economic Essays for Doctors and Healthcare Professionals

https://marcinkoassociates.com

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Informational essays of most current interest to healthcare professionals. Check back periodically for practical updates. Our catalogue library of major books, texts, case models and dictionaries is suggested for additional financial, economic, business and medical practice management information and education.

READ HERE: https://marcinkoassociates.com/articles-essays/

UPDATE: Prior ME-P Topics:

1-The number of balance billing disputes reaching arbitration is far higher than federal projections suggested.


2-Experts worry ACOs could face lasting financial difficulties due to an alleged $2 billion Medicare urinary catheter fraud scheme. 

COMMENTS APPRECIATED

Thank You

INVITE DR. MARCINKO: https://medicalexecutivepost.com/2024/02/05/invite-dr-marcinko-to-speak-at-your-next-seminar-webcast-or-event-in-2024/

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