TEXT BOOK REVIEW: Comprehensive Financial Planning Strategies for Doctors

CYBER MONDAY

By Ann Miller; RN MHA CPHQ

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David Edward Marcinko’s Comprehensive Financial Planning Strategies for Doctors is a specialized text that addresses one of the most pressing challenges faced by medical professionals: managing the complexities of personal and professional finance in a demanding career. Physicians often devote years to mastering medicine, yet receive little formal training in financial literacy. Marcinko’s book seeks to bridge this gap by offering a structured, practical, and holistic approach to financial planning tailored specifically to the unique circumstances of doctors.

At its core, the book emphasizes the importance of integrating financial planning into the broader context of a physician’s life and career. Marcinko recognizes that doctors face distinctive financial pressures, including high student debt, delayed earnings due to lengthy training, and the need to balance practice management with personal financial goals. The book is not merely a manual on budgeting or investing; rather, it presents a comprehensive framework that encompasses wealth accumulation, risk management, tax strategies, retirement planning, and estate considerations. By situating financial planning within the realities of medical practice, Marcinko ensures that his advice resonates with the lived experiences of physicians.

One of the book’s strengths lies in its accessibility. Financial planning texts can often be dense, filled with jargon that alienates readers outside the financial sector. Marcinko avoids this pitfall by writing in a clear, structured manner that makes complex concepts digestible. He uses examples drawn from medical practice to illustrate financial principles, ensuring that readers can see the direct relevance of his strategies. For instance, discussions of liability insurance or practice valuation are framed in terms of the risks and opportunities doctors encounter daily. This contextualization makes the book not only informative but also practical.

Another notable aspect of Marcinko’s work is its emphasis on proactive planning. Rather than reacting to financial challenges as they arise, the book encourages physicians to adopt a forward‑looking mindset. Marcinko underscores the importance of setting long‑term goals early in one’s career, whether related to retirement, practice succession, or family wealth transfer. He argues that physicians, accustomed to evidence‑based decision making in medicine, should apply the same rigor to financial planning. This alignment between professional habits and personal finance is one of the book’s most persuasive insights.

The book also addresses the psychological dimensions of financial decision making. Marcinko acknowledges that physicians, despite their intelligence and training, are not immune to the emotional biases that affect all investors. Overconfidence, risk aversion, and the tendency to delay planning are explored as obstacles that can undermine financial success. By highlighting these behavioral pitfalls, Marcinko adds depth to his analysis and reminds readers that financial planning is not purely technical but also deeply human.

Critically, the book does not present financial planning as a one‑size‑fits‑all endeavor. Marcinko recognizes the diversity of medical careers and personal circumstances. A surgeon in private practice will face different challenges than a pediatrician employed by a hospital system, and the book provides strategies adaptable to these varied contexts. This flexibility enhances the book’s relevance and ensures that it can serve as a resource for physicians across specialties and career stages.

While the book is comprehensive, some readers may find its breadth overwhelming. Covering everything from investment vehicles to estate law, Marcinko’s text demands sustained engagement. Yet this density is also its strength: it reflects the complexity of financial planning for doctors and underscores the need for a holistic approach. For readers willing to invest the time, the book offers a roadmap that can significantly improve financial outcomes.

In conclusion, Comprehensive Financial Planning Strategies for Doctors is a valuable resource that combines clarity, practicality, and depth. Marcinko succeeds in translating financial principles into strategies that resonate with the realities of medical practice. By encouraging proactive planning, addressing psychological biases, and offering adaptable strategies, the book empowers physicians to take control of their financial futures. For doctors seeking to navigate the intersection of medicine and money, Marcinko’s work stands as a thoughtful and indispensable guide.

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PHYSICIAN: Car Repossessions Rise!

By Dr. David Edward Marcinko MBA MEd

SPONSOR: http://www.MarcinkoAssociates.com

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Physicians are increasingly facing car repossessions in 2025 due to rising debt, high vehicle prices, and economic pressures that are reshaping the financial landscape for medical professionals.

Traditionally viewed as financially secure, doctors are now among the growing number of Americans struggling to keep up with auto loan payments. The surge in car repossessions—expected to reach a record 10.5 million assignments by the end of 2025—has not spared the medical community. While physicians often earn higher-than-average incomes, they also carry significant financial burdens, including student loan debt, practice overhead, and personal expenses. These pressures are being amplified by macroeconomic forces such as inflation, high interest rates, and stagnant reimbursement rates.

One of the key contributors to this trend is the soaring cost of vehicles. In 2025, the average price of a new car in the U.S. surpassed $50,000, a dramatic increase from just a decade ago. For physicians who rely on vehicles for commuting between hospitals, clinics, and private practices, owning a reliable car is not a luxury—it’s a necessity. However, the combination of high sticker prices and elevated interest rates—averaging 7.3% for used cars and 11.5% for new cars—has made financing increasingly difficult.

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Even high-income professionals are not immune to the broader auto loan crisis. Subprime auto loan delinquencies reached 6.6% in early 2025, the highest rate in over 30 years.While physicians typically fall into the prime or super-prime credit categories, many are still affected by cash flow disruptions, especially those in private practice or rural areas where patient volumes and insurance reimbursements have declined. Additionally, younger doctors with substantial student debt may find themselves overleveraged, making it harder to keep up with car payments.

The emotional and professional toll of a car repossession can be significant. Beyond the embarrassment and logistical challenges, losing a vehicle can disrupt a physician’s ability to provide care, attend emergencies, or maintain a consistent work schedule. This can lead to further income loss, creating a vicious cycle of financial instability.

To combat this trend, some physicians are turning to financial advisors to restructure their debt, refinance auto loans, or downsize to more affordable vehicles. Others are advocating for systemic reforms, such as student loan forgiveness, higher Medicare reimbursements, and better financial literacy training during medical education.

In conclusion, the rise in car repossessions among doctors is a stark reminder that no profession is immune to economic volatility. As the cost of living continues to climb and financial pressures mount, even those in traditionally stable careers must adapt to protect their assets and livelihoods.

Addressing this issue requires both individual financial planning and broader policy changes to ensure that physicians can continue to serve their communities without the looming threat of personal financial collapse.

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EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit an RFP for speaking engagements: CONTACT: Ann Miller RN MHA at MarcinkoAdvisors@outlook.com -OR- http://www.MarcinkoAssociates.com

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DOCTORS: Early Investing Needed for Retirement

NEW FINANCIAL STRATEGIES?

By A.I. and Dr. David Edward Marcinko; MBA MEd CMP

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SPONSOR: http://www.CertifiedMedicalPlanner.org

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Starting early is key to saving for retirement

Although 97% of people aren’t yet millionaires, many could eventually meet that target if they start investing sooner rather than later; especially doctors [MD, DO, DPM, DDS or DMD].

BROKE DOCTORS: https://medicalexecutivepost.com/2025/08/02/doctors-going-broke-and-living-paycheck-to-paycheck/

A 20-year-old, for instance, needs to invest just $330 a month into an asset class that delivers a 7% to 8% annual return to reach $1.26 million by the time s/he turns 65 years old. The luxury of time significantly boosts your chances of becoming a millionaire.

This doesn’t mean it’s too late for middle-aged savers to reach that millionaire milestone, but it will take a significantly greater investment. If a 50-year-old doctor hasn’t started saving for retirement, s/he would need to invest $3,958 a month at a steady 7% return to reach $1.26 million by retirement.

MONEY ADDICTION: https://medicalexecutivepost.com/2025/08/07/moiney-addicted-physicians-the-investing-and-trading-personality-of-doctors/

However, according to one Goldman Sachs report, investors could expect the S&P 500 to deliver just 3% annualized nominal returns over the next 10 years.

After an average 13% yearly return for the past decade, a new strategy outside of the stock market may be needed for that level of outsized gain, especially if you’re late to investing.

RETIREMENT VISION: https://medicalexecutivepost.com/2025/08/04/physicians-determine-your-retirement-vision/

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EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit an RFP for speaking engagements: CONTACT: Ann Miller RN MHA at MarcinkoAdvisors@outlook.com -OR- http://www.MarcinkoAssociates.com

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

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ESSENTIALITY: Hospital Credit Analysis

By Dr. David Edward Marcinko MBA MEd

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SPONSOR: http://www.MarcinkoAssociates.com

Why Hospital Essentiality?

An important component of hospital credit analysis is essentiality. Hospitals are unusual businesses that many times possess some form of essentiality to their communities. Health care is important to the economic vitality of every community. Many hospitals have served their communities for many years; it is not uncommon to find hospitals that have been continuously operating for more than 100 years in the same community.

Most hospitals are not-for-profit. In not-for-profit hospitals, no private party actually “owns” the hospital; control is vested in various boards, but no one explicitly owns a not-for-profit hospital. In a broad sense, communities own not-for-profit hospitals. They are considered “charities” with a “charitable purpose.” Though a not-for-profit hospital may not have owners, it has many “stakehold-ers,” parties that have vested interests in the continuing success of the hospital.

HOSPITAL TYPES: https://medicalexecutivepost.com/2025/08/06/hospitals-understanding-different-types/

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Many hospitals have broad and vast webs of stakeholders. Stakeholders are why hospitals rarely close or are shut down. Too many stakeholders have interests in the continuing successful operation of hospitals.

Another dimension of the essentiality analysis is service analysis. How significant are the hospital’s services? If the hospital shuts down, what population segments would suffer? How significant is the population that would suffer? How much would they suffer?

HOSPITAL ROI: https://medicalexecutivepost.com/2024/10/09/the-dupont-decomposition-equation-for-roi/

Assessment

And so, hospital stakeholder relationships need to be considered in the analysis of essentiality. How strong are these relations? How many are there? How important is the continuing success of this hospital to these stakeholders?

Analysis of hospital’s stakeholders and services should provide a credible view of the degree of essentiality associated with a hospital. Higher degrees of essentiality suggest higher likelihoods that hospitals, one way or another, will meet their commitments, particularly their payment
commitments.

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EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit an RFP for speaking engagements: CONTACT: Ann Miller RN MHA at MarcinkoAdvisors@outlook.com -OR- http://www.MarcinkoAssociates.com

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DAILY UPDATE: Stocks, Commodities and Trade as Stock Markets End Mixed

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  • Stocks: Investors cheered the news of an EU & US trade deal over the weekend, pushing the S&P 500 above 6,400 for the first time ever. But the index gave up most of its gains late in the day as attention turned to a huge week of data ahead (more on that in a minute).
  • Trade: Today was the first day of discussions between US and Chinese negotiators in Stockholm to keep the trade war truce alive. Elsewhere, President Trump foresees a baseline 15% to 20% tariff rate for the rest of the world.
  • Commodities: Gold fell as trade deal hopes heightened investors’ risk appetite, while oil spiked higher after Trump gave Russia a 10- to 12-day deadline to sign a truce with Ukraine.

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

According to Bloomberg, 83% of the S&P 500 companies that have reported earnings have outpaced Wall Street’s estimates, putting the index on pace for its best season of beats since the second quarter of 2021.

CITE: https://tinyurl.com/tj8smmes

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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EMOTIONAL INTELLIGENCE & ORGANIZATIONAL BEHAVIOR: Economic Risk Management Classification for Medical Professionals

BY DR. DAVID EDWARD MARCINKO, MBA MEd CMP®

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SPONSOR: http://www.MarcinkoAssociates.com

ORGANIZATIONAL BEHAVIOR AND CLASSIFICATION OF RISKS

DEFINITION EMOTIONAL INTELLIGENCE: Emotional intelligence [EI] refers to the ability to identify and manage one’s own emotions, as well as the emotions of others. Emotional intelligence is generally said to include a few skills: namely emotional awareness, or the ability to identify and name one’s own emotions; the ability to harness those emotions and apply them to tasks like thinking and problem solving; and the ability to manage emotions, which includes both regulating one’s own emotions when necessary and helping others to do the same.

DEFINITIONAL ORGANIZATIONAL BEHAVIOR: Organizational behavior (OB) is the study of how individuals, groups, and organizations interact and influence one another. Though it is largely used within the field of business management as means to understand–and more effectively manage–groups of people. The reason businesses look to OB is because it can help organizations increase employee performance, while also creating a positive working environment.

CITE: Eugene Schmuckler; PhD MBA MEd CTS®

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And so, as we review the concept of Emotional Intelligence and Organizational Behavior, it is possible to set up five EI/OB risk classes, based on the economic consequences of the occurrence of specific individual risks:

1. Prevented risks: Risks whose cost of occurrence is higher than their cost of management and whose occurrence may invoke additional legal sanctions. This class would include intentional torts and injuries caused by gross negligence.

2. Normally prevented risks: Risks whose cost of occurrence is greater than the cost of their management but whose occurrence will be considered only as negligent. This class includes most negligent injuries
and most types of product liability actions.

3. Managed risks: Risks whose cost of occurrence is only slightly greater than their cost of management. The plaintiff usually has the burden of showing that the defendant owed the plaintiff a special duty to recover for one of these risks.

4. Un-Prevented risks: Risks whose cost of occurrence is less than their cost of management. The classic example of this class is the cost of railroad crossing barriers compared to the cost of people being hit by
trains.

5. Un-Preventable risks: Risks whose occurrence is unmanageable. The assignment of a risk to one of these classes is a major problem in medical and healthcare quality control, because the class of a risk determines how much effort must be expended to prevent the risk. The misclassification of a prevented or normally prevented risk as a managed or un-prevented risk can result in large financial losses.

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For example: A medical clinic that does not update obsolete equipment, such as inaccurate oxygen monitors, would be liable for any injuries attributable to the obsolete equipment. The classifications of risk must be reviewed periodically to determine if the cost of the risk-taking behavior has changed, thereby altering the classification.

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For example: A small hospital in a rural area would not be expected to have the sophisticated equipment as a major hospital in a city. If an accident victim is brought into the rural facility, the hospital’s duty may be to transfer the patient to a better-equipped facility. The patient will face the risk of dying because of the delay in treatment, but the risk of insufficient treatments outweighs the risk of transfer. If the same victim were brought into a hospital in a major metropolitan center, the duty would be to treat the patient without a transfer. The risk of transfer has not changed, but the risk of insufficient treatment has disappeared.

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EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit an RFP for speaking engagements: CONTACT: Ann Miller RN MHA at MarcinkoAdvisors@outlook.com -OR- http://www.MarcinkoAssociates.com

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DOCTORS AND LAWYERS: Often Aren’t Millionaires

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DAILY UPDATE: Measles Cases Up as Stock Markets Rise

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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

Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily

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US measles cases have reached a 33-year high. A little more than halfway into 2025, the US has reported 1,288 measles cases, marking the highest yearly total since 1992, according to data from the Centers for Disease Control and Prevention.

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

Stocks up

  • Cereal legend WK Kellogg popped 30.57% after chocolate giant Ferrero agreed to acquire it for north of $3 billion.
  • Tesla (+4.73%) continued to rebound from its plunge on Monday. Elon Musk said that Tesla’s robotaxi service would expand into the Bay Area “probably in a month or two” and that his AI chatbot Grok is coming to Tesla vehicles by next week.
  • Estée Lauder gained 6.32% after Bank of America slapped a buy rating on the stock, implying a 27% upside from Wednesday’s closing price. 
  • ProKidney continued its remarkable rally, rising another 19.35%, after the biotech announced positive trial results for its diabetes treatment. It’s gone from a penny stock to a $1.55 billion market cap in the past four days.
  • Copper companies Freeport-McMoRan (+3.51%) and Southern Copper (+2.34%) gained thanks to Trump’s announcement that copper tariffs would begin on August 1.

Stocks down

  • Biotech partners Ultragenyx (-25.11%) and Mereo BioPharma Group (-42.52%) plunged after issuing a disappointing update on their trial of a treatment for a rare genetic bone condition.
  • Vertiv, the maker of liquid cooling equipment, declined 5.96% when Amazon said it was rolling out a new liquid cooling system for its AI servers.
  • Hydro Flask owner Helen of Troy tumbled 22.71% after reporting a $450 million loss in its fiscal first quarter. CEO Brian Grass said “tariff-related impacts” were its Achilles heel.
  • Autodesk fell 6.89% after Bloomberg reported on Wednesday it was weighing a takeover of rival engineering software company PTC.

CITE: https://tinyurl.com/tj8smmes

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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BRANDS & BRAND MANAGEMENT: Defined and Explored for Doctors and Advisors

By A.I.

SPONSOR: http://www.CertifiedMedicalPlanner.org

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What Is a Marketing Brand

A brand is a name, term, design, symbol or any other feature that distinguishes one seller’s goods or service from those of other sellers. Brands are used in business, marketing and advertising for recognition and, importantly, to create and store value as brand equity for the object identified, to the benefit of the brand’s clients, patients, customers, its owners and shareholders. Brand names are sometimes distinguished from generic or store brands.

BRANDING: https://medicalexecutivepost.com/2023/02/02/podcast-personal-branding-for-doctors/

What is Brand Management?

Brand management, also known as Marketing, is responsible for the overall management of a brand. This includes everything from product or service development and marketing to advertising and public relations. All of these aspects work together to create a particular image or reputation for a brand. The goal of brand management is to create a robust and positive reputation for a brand that will result in increased sales and market share.This process helps companies create a unique identity for their products or services in the marketplace. A successful brand management strategy can build client, patient and customer loyalty .

BRANDS: https://medicalexecutivepost.com/2021/06/03/physician-branding-post-pandemic/

Branding is essential for financial advisors, doctors and businesses because it involves creating a unique identity for a company’s products, offerings and services. It can also help build customer, client and patient loyalty and emotionally connect with the practitioner. Branding can be complex, but it is essential to understand the basics before starting a brand strategy.

Thus, doctors, podiatrists, dentists, CPAs, insurance agents, financial advisors and their practices need to understand the different aspects of branding and brand management to create a strong brand identity.

SELF BRANDING: https://medicalexecutivepost.com/wp-content/uploads/2011/03/leadership-self-branding-marcinko.pdf

EDUCATION: Books

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DAILY UPDATE: Stock Markets Struggle

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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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  • Stocks: Markets sagged as fighting between Israel and Iran continued, with investors worried about escalation after President Trump called for the “unconditional surrender” of Iran’s Supreme Leader ​​Ali Khamenei. The Wall Street Journal reported that he is considering a potential US strike against Iran.
  • Commodities: Oil prices popped this morning after Trump warned that Tehran should be evacuated.
  • Bonds: Yields sank after US retail sales came in much lower than anticipated, raising fears of an economic slowdown.

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

🟢 What’s up

  • Verve Therapeutics exploded 81.50% on the news that the gene-editing company will be acquired by Eli Lilly in a $1.3 billion deal.
  • Reddit popped 6.06% after the social media site rolled out new AI-powered tools for advertisers.
  • BGSF surged 34.25% after the staffing company announced it is selling its professional division to INSPYR Solutions for $99 million.
  • Jabil gained 8.80% thanks to a strong earnings report for the electronics parts supplier.
  • Oil stocks climbed as the conflict between Israel and Iran threatens to grow. Valero Energy rose 2.89%, Chevron gained 1.93%, and Hess added 1.79%.

What’s down

  • Microsoft fell 0.23% after the Wall Street Journal reported that its partnership with OpenAI is falling apart.
  • JetBlue Airways lost 7.88% on the news that it’s cutting costs, including reducing its number of flights, due to softer-than-expected travel demand.
  • Lennar sank 4.42% after the homebuilder beat revenue estimates last quarter but missed profit forecasts.
  • T-Mobile tumbled 4.14% on the news that major shareholder Softbank sold 21.5 million shares of the telecommunications company.
  • Airline stocks sank as the price of oil rose throughout the day. United Airlines lost 6.18%, while Delta Air Lines fell 4.33%.

CITE: https://tinyurl.com/tj8smmes

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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DAILY UPDATE: Medicaid Payments as Stock Markets Collapse

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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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Read: Are “improper” Medicaid payments really that big of an issue? (KFF)

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🟢 What’s up

  • Gold stocks gained as investors pushed the price of the safe-haven commodity higher. Newmont climbed 3.54%, Barrick Mining added 2.81%, and SSR Mining rose 2.25%.
  • Tesla gained 1.94% on reports that the Trump Administration will lower the bar for regulations on self-driving cars.
  • Circle surged 25.54% a day after Shopify announced it will accept USDC stablecoin payments on its e-commerce platform.
  • RH popped 6.90% after the home furnishings retailer reported far better earnings than Wall Street predicted, even though revenue fell last quarter.
  • JBS rose 4.69% the day the world’s largest meatpacker made its NYSE debut.

What’s down

  • DraftKings fell 3.90% thanks to the gambling app’s decision to add a $0.50 surcharge to every bet made on its platform in Illinois to offset a new state tax.
  • Adobe tumbled 5.32% despite the software company’s solid earnings report and higher fiscal forecast.
  • Archer Aviation plunged 14.89% after announcing it will sell $850 million worth of new shares to raise money.
  • Boeing lost another 1.62% as the fallout from a 787 Dreamliner crash in India continues.
  • US Steel sank 3.03% on reports that Nippon Steel is balking at taking over the company if it can’t retain operational control of the domestic steelmaker.

CITE: https://tinyurl.com/tj8smmes

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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DAILY UPDATE: Bristol Myers Squibb Pays BioNTech as Stock Markets End Mixed

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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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A Partner of the Institute of Medical Business Advisors , Inc.

http://www.MedicalBusinessAdvisors.com

SPONSORED BY: Marcinko & Associates, Inc.

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Stat: $11.1 million. That’s how much Bristol Myers Squibb is paying biotech company BioNTech to license a new cancer drug. (MarketWatch)

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🟢 What’s up

  • Reddit climbed 6.63% after it announced it’s suing AI startup Anthropic for using the social media site’s content without permission.
  • ON Semiconductor rose 6.14% after its CEO touted a recovery in demand for its chips.
  • Guidewire Software popped 16.41% thanks to strong earnings for the insurance provider last quarter, including a 22% increase in revenue.
  • Thor Industries climbed 4.25% on better-than-expected earnings from the world’s biggest RV manufacturer.
  • HealthEquity jumped 8.96% after the health savings account custodian boosted its fiscal guidance for the year ahead.

What’s down

  • Tesla tumbled 3.55% on weak sales data from China and Germany.
  • Apple fell 0.22% thanks to a downgrade from Needham analysts, who think the company’s valuation is way too high.
  • Wells Fargo lost 0.36% after the Federal Reserve lifted its 2018 cap on the bank’s assets.
  • What goes up must come down: Constellation Energy sank 4.31% after Citigroup downgraded the nuclear power provider, warning it’s not getting its money’s worth with Meta Platforms.
  • Asana plunged 20.47% after the work management software maker announced fiscal forecasts that came in below Wall Street’s expectations.
  • Flowserve lost 6.27% and Chart Industries dropped 9.46% after the two industrial manufacturers agreed to an all-stock merger of equals.

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Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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DAILY UPDATE: Gold, VIX and Stock Markets Up as 23andMe is Sold

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  • When S&P downgraded the US’ credit rating in August 2011, it sparked the worst one-day decline in US stocks since the Great Financial Crisis. Today was the first day of trading after Moody’s downgraded the US’ credit rating, and while stocks sank at the open, they recovered a lot of lost ground after investors decided to buy the dip.
  • The downgrade pushed yields on 30-year Treasury bonds above 5% at the open, while 10-year yields rose to 4.55% at one point. But yields on both notes fell throughout the afternoon as buyers crept back into the bond market.
  • Gold was the big winner today as investors sought safety, while the CBOE Volatility Index, or VIX, popped higher.

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

🟢 What’s up

  • Investors largely shrugged at Nvidia’s many announcements today, including the ability for customers to use non-Nvidia chips in Nvidia products. Shares rose just 0.13%.
  • UnitedHealth Group posted a 8.18% gain as investors turned their attention to the suddenly cheap health insurance giant.
  • Novavax exploded 15.01% higher thanks to the FDA’s approval of its new Covid-19 vaccine.
  • TXNM Energy popped 6.98% to an all-time high on the announcement that Blackstone will acquire the power provider for $11.5 billion.

What’s down

  • Tesla tumbled 2.25% after Chinese tech giant Xiaomi announced it will debut its Yu7 sports utility vehicle, a clear Tesla challenger in a key market, on Thursday.
  • Walmart lost 0.12% after Treasury Secretary Scott Bessent met with company leadership to discuss how the retailer could “eat the tariffs.”
  • Bath & Body Works sank 0.56% after the retailer named former Nike exec Daniel Heaf as its new CEO effective immediately.
  • Reddit fell 4.63% due to a downgrade from Wells Fargo analysts who think the social media platform will lose search traffic to Google AI.
  • Diageo is down 0.69% after the maker of Johnnie Walker whiskey said it will take an annual tariff hit of $150 million.
  • Alibaba dropped 0.40% on a New York Times report that the Trump Administration is concerned with Apple’s plan to use Alibaba AI on its iPhones.
  • JPMorgan fell 1% as shareholders at the bank’s investment division grapple with CEO Jamie Dimon’s departure.
  • Solar stocks sank after the Republican tax and spending bill moved forward with a commitment to end clean energy tax credits earlier than planned. First Solar fell 7.59%, SunRun lost 7.84%, and AES lost 4.10%.

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Regeneron Pharmaceuticals will buy 23andMe for $256 million.

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DAILY UPDATE: PBMs, Cable Companies Merge as Stock Markets Rise

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Arkansas just passed a first-if-its-kind law banning vertical integration between pharmacy benefit managers (PBMs) and pharmacies. Arkansas Governor Sarah Huckabee Sanders on April 16th signed a law prohibiting any company that owns a PBM from also owning or operating pharmacies in the state. The goal of the law is to eliminate “conflicts of interest” that lead to higher drug prices and care delays, according to a press release.

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

🟢 What’s up

  • Nvidia climbed 0.42% on reports that the US and United Arab Emirates are nearing a deal that would allow the UAE to import 500,000 chips per year. But shares lost some ground after the company denied reports that it will build a new R&D center in Shanghai.
  • Galaxy Digital made its long-awaited debut on the Nasdaq today, with the crypto/data center company climbing 4.06%. The company is reportedly in conversation with the SEC to tokenize its stock.
  • Virgin Galactic rocketed 43.28% higher on the space tourism company’s announcement that it will restart commercial spaceflights.
  • Coinbase climbed 9.01% after Oppenheimer analysts said the market’s reaction to recent news of a hack and an SEC probe were “overblown.”
  • CoreWeave soared 22.09% after Nvidia disclosed a larger stake in the data center provider than expected.
  • Quantum computing stocks popped on news that the company Quantum Computing has finished laying the groundwork for a quantum chip foundry. Shares of Quantum Computing rose 39.29%, while D-Wave Quantum gained 11.06%.
  • Archer Aviation soared 9.11% after being named the Official Air Taxi Provider of the 2028 Los Angeles Olympic and Paralympic Games, which sounds made up but is apparently very impressive.
  • Vistra Corp popped 3.06% on the news that it has acquired seven natural gas facilities from Lotus Infrastructure Partners for $1.9 billion.

What’s down

  • Novo Nordisk slipped 2.69% on the news that its CEO is stepping down after eight years at the helm, due to the pharma giant’s recent challenges.
  • Applied Materials sank 5.25% after the semiconductor maker’s revenue last quarter came in under analyst estimates.
  • Cava crumbled 2.27% thanks to financial forecasts of slower growth for the salad bowl chain in the coming year.
  • Take-Two Interactive Software lost 2.41% due to weaker-than-expected projections for net bookings this quarter and this year.
  • Doximity plunged 10.08% after the healthcare platform issued fiscal guidance for the current quarter and full year that came in below analyst expectations.

CITE: https://tinyurl.com/tj8smmes

Two of the biggest cable companies in the United States have agreed to merge, marking a major milestone in consolidation as cord-cutters continue to ditch their pricey TV packages, thus forcing companies to adjust to their dwindling futures. Charter Communications, which operates under the Spectrum branding, is combining with its privately held rival Cox Communications, which it values at $34.5 billion including debt, the two companies announced Friday.

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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DAILY UPDATE: Rite Aid and MSFT Down as Markets End Mixed

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Rite Aid has announced that it is set to close 115 stores as part of the Chapter 11 bankruptcy proceedings it began earlier this month. The company published a slate of 47 closing stores in an initial filing in the U.S. Bankruptcy Court for the District of New Jersey and added 68 more locations in a May 9th filing. 

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

🟢 What’s up

  • Nvidia climbed 3.97% on CEO Jensen Huang’s announcement of a partnership with Saudi Arabia-backed Humain to build a 500 megawatt data center.
  • Advanced Micro Devices popped 4.18% after it, too, revealed it’s helping Humain out. The chipmaker’s board also authorized a $6 billion stock buyback program.
  • Super Micro Computer continued to rally, soaring another 15.69% on the back of Raymond James analysts’ initiating their coverage with an “outperform” rating.
  • Boeing climbed 0.59% thanks to a $96 billion deal with Qatar Airlines to buy up to 210 aircraft.
  • Oklo jumped 14.12% after the nuclear power startup revealed a smaller-than-expected loss last quarter.
  • Exelixis soared 19.70% after the oncology company reported a shockingly strong beat-and-raise quarter.
  • Septerna exploded 28.97% on the news that Novo Nordisk will license its oral obesity pill candidate for $2.2 billion.

What’s down

  • Airline stocks were down across the board after the FAA met with executives to discuss cutting flights in and out of Newark Airport. Delta Air Lines lost 4.32%, and United Airlines sank 3.51%.
  • American Eagle Outfitters tumbled 5.93% after the retailer cut its fiscal guidance, announced it’s writing down $75 million in merchandise, and forecast a decline in next quarter’s sales.
  • Grail plummeted 23.48% after the biotech’s revenue last quarter failed to meet Wall Street’s expectations.
  • Aurora Innovation fell 7.58% thanks to an announcement from Uber that it’s offering $1 billion in convertible notes that can be exchanged for Aurora shares.
  • JD.com lost 4.24% after the Chinese online retailer beat earnings expectations yesterday but still saw its price target cut by Morgan Stanley analysts.

CITE: https://tinyurl.com/tj8smmes

Inflation rose by 2.3% in April, less than economists feared, though the rate likely still doesn’t show the full effect of tariffs.

Microsoft is cutting 3% of its workforce, or about 6,000 employees, in order to reduce layers of management, a spokesperson told CNBC.

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DAILY UPDATE: Inflation Down, Wage Garnishments Up but Stocks Finish Mixed

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Inflation fell by one tenth of a percentage point to 2.3% for the year ending in April, the Bureau of Labor Statistics reported Tuesday in an update to the consumer price index. Forecasters had expected inflation to hold at 2.4%. 

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

What’s up

  • Coinbase exploded 23.97% on the news that the crypto trading platform will be added to the S&P 500 next week.
  • Nvidia climbed back into the elite $3 trillion market cap club today, rising 5.63% on the announcement that it will send 18,000 AI chips to Saudi Arabia.
  • Solar stocks soared after early drafts of a Republican tax and spending bill revealed renewable energy cuts weren’t as bad as feared. First Solar climbed 22.66%, while SunRun popped 8.58%.
  • Super Micro Computer climbed 16.02% thanks to Raymond James analysts initiating their coverage of the server maker with an “outperform” rating.
  • Boeing rose 2.46% now that the Chinese government has removed its ban on domestic airlines accepting orders from the plane manufacturer.
  • Rising sentiment powered popular momentum stocks higher today: Palantir rose 8.14%, AppLovin climbed 6.38%, Robinhood Markets jumped 8.95%, and Hims & Hers Health gained 15.92%.

What’s down

  • Honda Motor fell 4.20% after the company warned that tariffs will ding its bottom line and postponed its plans to build an EV plant in Canada.
  • Hertz Global plunged 16.93% after it missed analyst estimates across the board and announced it will offer fewer cars for rentals this year.
  • Enphase Energy lost 4.82% on a downgrade from Barclays analysts, who foresee slower demand for residential solar power products.
  • Rigetti Computing dropped 14.59% after the quantum computing company failed to live up to the high expectations that strong results from its competitors had given shareholders.

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Wage garnishment for defaulted student loans to begin this summer.

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DAILY UPDATE: Fed Holds Interest Rates Steady as Stock Markets Rise

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The Federal Reserve is still firmly in wait-and-see mode.

The Fed left its key interest rate unchanged again Wednesday and gave no hint it plans to lower it soon as President Donald Trump’s sweeping tariffs raise the risks of both another inflation spike and recession. But officials signaled they’re growing increasingly concerned about both hazards.

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What’s up

  • Netflix rose 1.56% after the streamer revamped its homepage and rolled out new AI search tools.
  • Nvidia popped 3.10% on news that President Trump will rescind Biden-era global chip curbs.
  • Advanced Micro Devices rose just 1.76% despite the chipmaker beating earnings and forecasting solid growth ahead.
  • Lions Gate Entertainment soared 20.77% after it finalized the separation of its studio and STARZ business segments into two distinct companies.
  • Logitech rose 1.46% thanks to an upgrade from UBS analysts who say the device maker is well-positioned to capitalize on Gen Alpha, 94% of whom play video games.
  • Charles River Laboratories popped 18.81% after the pharmaceutical company raised its full-year guidance above Wall Street’s expectations.
  • Rockwell Automation gained 11.90% on a beat-and-raise quarter thanks to higher demand for domestic manufacturing.

What’s down

  • Super Micro Computer fell 1.40% after the AI server maker missed on revenue last quarter and forecast slower revenue growth this quarter.
  • WW International, better known as Weight Watchers, plummeted 43.04% on the news that the company is going bankrupt.
  • Marvell Technology plunged 8.02% after the data storage manufacturer postponed its investor day—never a good sign.
  • Rivian Automotive tumbled 5.78% on management’s forecast that vehicle deliveries will be lower than expected this year.
  • Arista Networks beat Wall Street’s estimates but fell 4.76% after it warned that its margins will be squeezed in the coming quarters.
  • Sarepta Therapeutics plummeted 21.45% after posting a bigger-than-expected loss last quarter and projecting slower revenue growth this quarter.

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DAILY UPDATE: Sutter Heath & Medicare as Stock End Up Mixed

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🟢 What’s up

  • Seagate Technology popped 11.56% thanks to a beat-and-raise quarter and promises from management that tariff disruption would be minimal.
  • WingStop can’t stop, won’t stop: The purveyor of fried chicken rose 14.48% after posting an incredible earnings report.
  • Humana climbed 0.92% after the health insurer beat earnings expectations and kept its fiscal guidance intact.
  • GE HealthCare Technologies managed to rise 3.29% despite cutting its forward guidance.
  • Caterpillar eked out a 0.54% gain after raising its fiscal 2025 revenue forecast, but the construction giant warned that it will eat about $350 million in extra tariff-related costs.

What’s down

  • Super Micro Computer plunged 11.50% after reporting terrible preliminary earnings and warned of weaker results still to come.
  • Nvidia was pulled down just 0.09% by its very first “sell” rating from Wall Street analysts.
  • Etsy beat revenue expectations last quarter, but fell 5.74% after missing profit forecasts as the number of buyers and sellers using its platform continued to fall.
  • Snap tumbled 12.43% after the social media stock warned that economic uncertainty could hurt its advertising business and refused to issue a fiscal forecast.
  • Chili’s parent company Brinker International fell 1.89% despite posting solid earnings as investors worry about slowing consumer spending.
  • Norwegian Cruise Line sank 7.77% after missing earnings and warning of a slowdown in demand.

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Stat: $228 million. That’s how much Sacramento-based Sutter Health—one of the largest health systems in the US—agreed to pay to settle allegations of inflating insurance premiums. (Reuters)

Read: Here’s what some say the new Medicare director, a former tech CEO, is likely to focus on. (Stat)

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DAILY UPDATE: Coca-Cola and Pfizer as Stock Markets Rise

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Coca-Cola rose 0.84% after the beverage behemoth beat earnings expectations. Not only that, it also doubled down on its forward-looking guidance, saying that revenue will grow 5% to 6% while comparable earnings per share will jump 2% to 3% in 2025. Tariff mania may raise some costs, but the company said it would be “manageable,” putting it a step ahead of arch-rival PepsiCo.

Pfizer jumped 3.28% today after the pharma giant announced that it expects to cut costs by about $7.7 billion by the end of 2027 thanks to advances in AI and automation. Despite lower sales in Q1, the company managed to keep its 2025 revenue guidance of $61 billion to $64 billion intact. While that forecast takes into account the $150 million blow from tariffs, it does not include any future tariffs (which President Trump has threatened to slap on the pharma industry).—LB

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

What’s up

  • Meta Platforms gained 0.85% after the social media giant announced it will launch a standalone AI app to compete with ChatGPT. Expect more details in its earnings call tomorrow.
  • JetBlue Airways may have pulled guidance, but investors like the airline’s lower-than-expected loss last quarter so pushed shares 2.70% higher.
  • SoFi Technologies rose 0.53% after it crushed analyst expectations on both the top and bottom line.
  • Speaking of fintech, PayPal climbed 2.14% thanks in no small part to a 20% pop in Venmo revenue.
  • Honeywell International gained 5.40% thanks to strong earnings and sales for the manufacturing conglomerate.
  • Deutsche Bank climbed 4.08% after Germany’s largest lender reported a 39% increase in profit last quarter.
  • Sherwin-Williams may have missed on revenue last quarter, but the paint company beat earnings estimates and kept its forward guidance intact, so shareholders pushed it up 4.80%.
  • Royal Caribbean eked out a 0.02% despite reporting record bookings and boosting its profit outlook, a rare move these days amid tariff uncertainty.
  • Leggett & Platt may not be a household name, but it sells household goods—and the bedding company’s solid earnings and strong fiscal guidance sent shares 31.73% higher.

What’s down

  • General Motors fell 0.64% after the automaker beat on top and bottom line estimates but warned that it will have to pull its forward guidance and suspend stock buybacks.
  • Spotify dropped 3.04% despite active monthly users rising 10% last quarter. The problem, believe it or not, was lower guidance.
  • Regeneron lost 6.87% thanks to disappointing sales for its hit eye drug Eylea.
  • NXP Semiconductors may have beaten analyst estimates last quarter, but management’s lower-than-expected earnings guidance disappointed investors, and pushed shares 6.94% lower.
  • Wolfspeed tumbled 15.98% after the chipmaker’s impressive short squeeze rally fizzled out.

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ECONOMIC COMPETITION MODELS: In Medicine and Health Care

By Staff Reporters

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HEALTH CARE ECONOMIC COMPETITION MODELS

In a discussion of competitive healthcare economic models, assumptions must include normal demand quantities, many fully informed patients and the fact that physicians cannot directly influence demand for medical care. These assumptions, although fluid, also preclude that patient buyers are large enough to have any influence over price and result in the following”:

  • In a “pure monopoly”, there is only one provider with a unique service. The doctor   is a “price maker” and charges whatever s/he wishes.
  • In an “oligopoly”, there are a few physicians who provide similar services. For example, when it becomes clear to Dr. Smith and Dr. Jones that neither can win their price war, oli-gopolists return prices to prior, but still inflated levels!  
  • In “monopolistic competition”, there are many providers with differentiated services. For example, should Dr. Jones decide to have evening hours, she may charge a premium for her fees if Dr. Jones doe not follow suit.
  • Finally, when “pure competition” occurs, there are many physicians, providing providing similar and substitutable services. Marketing and advertising does not affect fees, and prices are determined by supply and demand. The doctors become “price takers” by accepting fees arrived at by practicing competitively.

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SEX: Bereavement Style

By Staff Reporters

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According to colleague Dan Ariely PhD, Bereavement Sex is one of those coping mechanisms that sounds strange but makes sense when you think about it. In the face of loss, our brains crave connection and comfort.

Engaging in sex after a significant loss can be a way to feel alive and regain a sense of control. It’s a testament to our complex emotional wiring, where grief and intimacy intertwine.

Psychology Today: https://www.psychologytoday.com/us/blog/all-about-sex/201911/myths-and-the-truth-about-sex-after-grieving?msockid=2d99b4712dfb6dde0d66a1522c226c4e

So, while it might seem odd, it’s just another way our brains handle the roller coaster of emotions.

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DAILY UPDATE: VA EHR Snafu and Stock Market Volatility

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e Department of Veterans Affairs announced plans last week to accelerate the rollout of its embattled electronic health records system. Lawmakers, meanwhile, continue to call for oversight despite concerns over the future of the modernization program. The VA added nine new medical facilities in Ohio, Kentucky, Indiana, and Alaska to the deployment schedule, along with four sites in Michigan that will launch in 2026 after the program expansion has largely been on hold since April 2023, when the agency acknowledged glitches in the system had contributed to at least four veterans’ deaths and “catastrophic harm” to others.

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After a roller coaster day, the Dow closed lower by 349 points, or 0.91%. The broader S&P 500 fell 0.23%. The NASDAQ Composite was 0.1% higher after fluctuating between gains and losses. Wall Street’s fear gauge, the CBOE Volatility Index, or VIX, on Monday closed at the highest level since the Covid pandemic as investors fretted over the market’s next move. The VIX surpassed an intraday level of 50 points midday Monday, a rare level associated with extreme volatility.

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EMOTIONAL INTELLIGENCE: How EQ Can Make You a Better Investor

By Vitaliy Katsenelson CFA

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How Emotional Intelligence Can Make You a Better Investor. You can also listen to a professional narration of this article on iTunes & online.
Your knee hurts, so you pay a visit to your favorite orthopedist. He smiles, maybe even gives you a hug, and then tells you: “I feel your pain. Really, I do. But I don’t treat left knees, only right ones. I find I am so much better with the right ones. Last time I worked on a left knee, I didn’t do so well.”

Though many professionals — doctors as well as lawyers, architects and engineers — get to choose their specializations, they rarely get to choose the problems they solve. Problems choose them. Investors enjoy the unique luxury of choosing problems that let them maximize the use of not just their IQ but also their EQ — emotional intelligence.

Let’s start with IQ. Our intellectual capacity to analyze problems will vary with the problem in front of us. Just as we breezed through some subjects in college and struggled with others, our ability to understand the current and future dynamics of various companies and industries will fluctuate as well. This is why we buy stocks that fall within our sphere of competence. We tend to stick with ones where our IQ is the highest.

Though we usually think about our capacity to analyze problems as being dependable and stable over time, it isn’t. It might be if we were characters from Star Trek, with complete control over our emotions, like Mr. Spock, or who lacked emotions, like Lieutenant Commander Data. This is where our EQ comes in.

I am not a licensed psychologist, but I have huge experience treating a very difficult patient: me. And what I have found is that emotions have two troublesome effects on me. First, they distort probabilities; so even if my intellectual capacity to analyze a problem is not impacted, my brain may be solving a distorted problem. Second, my IQ is not constant, and my ability to process information effectively declines under stress. I either lose the big picture or overlook important details. This dilemma is not unique to me; I’m sure it affects all of us to various degrees.

The higher my EQ with regard to a particular company, the more likely that my IQ will not degrade when things go wrong (or even when they go right). There is a good reason why doctors don’t treat their own children: Their ability to be rational (properly weighing probabilities) may be severely compromised by their emotions.

A friend of mine who is a terrific investor, and who will remain nameless though his name is George, once told me that he never invests in grocery store stocks because he can’t be rational when he holds them. If we spent some Freudian time with him, we’d probably discover that he had a traumatic childhood event at the grocery store (he may have been caught shoplifting a candy bar when he was eight), or he may have had a bad experience with a grocery stock early in his career. The reason for his problem is irrelevant; what is important is that he has realized that his high IQ will be impaired by his low EQ if he owns grocery stocks.

There is no cure for emotions, but we can dramatically minimize the impact they have on us as investors by adjusting our investment process. First and foremost, investors have the incredible advantage of picking domains where they can remain rational.

To be a successful investor, you don’t need Albert Einstein’s IQ (though sometimes I wish I had Spock’s EQ). Warren Buffett undoubtedly has a very high IQ, but even the Oracle of Omaha chooses carefully his battles; for instance, he doesn’t invest in technology stocks.

Investors have the luxury of investing only in stocks for which both their IQ and EQ are maximized, because there are tens of thousands of stocks out there to choose from, and they need just a few dozen.

Meanwhile, I hope when I go see the doctor, he will tell me, “I don’t do left knees,” because the best result will come from a doctor who while treating me will utilize both IQ and EQ.

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DAILY UPDATE: Microsoft Tempers A.I. as Hershey Buys LesserEvil and Stock Markets Crater!

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Microsoft is reportedly pulling back on data center projects around the world as it reexamines its AI plans. Hershey reportedly bought the popcorn brand LesserEvil for $750 million.

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US stocks cratered on Friday with the Dow Jones Industrial Average (^DJI) plunging more than 2,200 points after China stoked trade-war fears and Fed Chair Jerome Powell warned of higher inflation and slower growth stemming from tariffs.

The Dow pulled back 5.5% to enter into correction territory. Meanwhile, the S&P 500 (^GSPC) sank nearly 6%, as the broad-based benchmark capped its worst week since 2020. The tech-heavy NASDAQ Composite (^IXIC) dropped 5.8% to close in bear market territory.

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DAILY UPDATE: DJIA Plummets 1,700 Points While NASDAQ & S&P 500 Plunge for Biggest Drop Since 2025

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Roughly $2.5 trillion was erased from the S&P 500 Index on Thursday amid worries that President Donald Trump’s sweeping new round of tariffs could plunge the economy into a recession. The damage was heaviest in companies whose supply chains are most dependent on overseas manufacturing. Apple Inc., which makes the majority of its US-sold devices in China, fell 9.3%. Lululemon Athletica Inc. and Nike Inc., among companies with manufacturing ties to Vietnam, were both down more than 9%. Target Corp. and Dollar Tree Inc., retailers whose stores are filled with products sourced outside of the US, dropped more than 10%.

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The tech-heavy NASDAQ Composite (^IXIC) led the sell-off, plummeting 6%. The S&P 500 (^GSPC) sank nearly 5%, while the Dow Jones Industrial Average (^DJI) tumbled 4%. The Dow’s 1,700-point drop was the fifth-worst in its history.

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DAILY UPDATE: Superior HealthPlan, Larry Fink and the Mixed Stock Markets

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The CEO of a Texas health insurance company was fired after admitting before a DOGE panel of state lawmakers that he hired private investigators to spy on customers and obtain sensitive details about their lives. Mark Sanders was dismissed from his duties as chief executive of Austin-based Superior HealthPlan after he testified before the Texas House Delivery of Government Efficiency Committee in a hearing on Medicaid procurement last week.

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US stocks closed mixed on Tuesday as investors cautiously counted down to President Trump’s highly anticipated “Liberation Day” rollout of sweeping new reciprocal tariffs. The S&P 500 (^GSPC) rose about 0.4%, extending the gains the benchmark index secured on Monday, while the Dow Jones Industrial Average (^DJI) fell just below the flatline. The tech-heavy NASDAQ Composite (^IXIC) rebounded to close up around 0.9%.

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BlackRock CEO Larry Fink said private markets should be open to all investors, not just the wealthy few in his annual letter to investors (here.)

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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MEDICAL PRACTICE SALES: Contracting for Succession Planning

[Reviewing Terms, Conditions and Selling Agreements]

By Dr. Charles F. Fenton III JD

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Dealing with many issues concerning the actual contract that affect the purchase or sale of a medical practice can be daunting. For example, this chapter will not deal with issue of determining whether or not a physician should retire. Nor will it determine the proper Fair Market Value [FMV] of the practice. However, physicians may be assisted in both instances by a medically focused financial advisor, or valuation specialist. [AVA, CPA-CVA, Certified Medical Planner™; etc] working in conjunction with an experience  health care contract attorney to act as an advocate and determine certain contingencies that might occur, and protect him/her from them.

THE PARTIES

The first determination is whether the party at interest is an individual, group of individuals, or an entity (such as a partnership, limited liability partnership, limited partnership, limited liability company, or corporation – whether an S corporation, C corporation or a professional corporation). In many instances, even if the party at interest is an individual is an entity, the individual or individuals behind the entity should be made parties to the agreement.

From the buyer’s perspective, the purchase of a medical practice is a highly person-oriented business. The practice value depends much upon the personality of the current treating physicians. If the current treating physicians are also the owners of the entity, then binding those individuals (especially as applies to the restrictive covenant) is of primary importance.

If the current treating physicians are not owners of the entity, but rather employees, then a determination of whether they will continue in their same positions or whether the buyer will be taking over the treatment of patients becomes the prime focus. If the current treating physicians will be continuing in their same positions, then their current employment contract must be reviewed to determine whether the rights of the seller will accrue to the buyer.

If the rights of the seller will not accrue to the buyer, then the Purchase and Sale Agreement must have a provision that makes the continued employment of those current-treating physicians a condition to consummation of the sale. In such instances, the new employment agreement might be an exhibit to the main agreement and executed contemporaneously with the main agreement.

If the current treating physicians will not be continuing in their same position and if the purchaser will be assuming treatment of the patients, then the main agreement must provide for the dissolution of the employment agreement and provision must be made for restricting the ability of those physicians from competing with the buyer. If the employment contract with the seller contains a restrictive covenant, then the buyer must ensure that such covenants will accrue to the buyers benefit. Otherwise, the buyer should insist that those physicians sign restrictive covenants. In such an instance, a portion of the purchase price may need to be allocated towards the consideration for those restrictive covenants and paid directly to those physicians.

DATE OF AGREEMENT AND CLOSING DATE

In general, it usually does not matter when the agreement is dated. It should usually be dated once all the terms are agreed to and the parties desire to bind each other and to be bound. In certain instance, the parties may have reached an agreement, but certain issues (such as the obtaining of a state license to practice medicine) may be outstanding. In such a case, then an option can be given by either the seller or the buyer to bind the other to sell or buy the practice upon exercise of the option. Giving an option can also push the agreement date into the future. The option will usually be given with token consideration (e.g., one hundred dollars) and will have a fixed expiration date (e.g., thirty to ninety days).

The determination of the closing date is more important than the date that the agreement is dated. Just like in the purchase of a house where certain issues (such as obtaining a mortgage and home inspection) must occur before closing, in the purchase of a practice, there may be certain issues which require time to undertake before the actual transfer can be consummated. For example, the buyer may still need to obtain financing or the landlord may need to approve the assignment of the lease.

RECITALS

The recitals – or “whereas” clauses – traditionally enunciate the reasons the parties are entering into the agreement. In the sale of the practice the recitals may simply state that the buyer wishes to buy the practice and the seller wishes to sell the practice. Yet, there is a modern growing tendency among contract attorneys to eliminate the “whereas” clauses as some attorneys feel that such language is antiquated. In such instances, the agreement will simply have a paragraph or two delineation of the “Purpose” of the agreement.

ARTICLES, SECTIONS, AND PARAGRAPHS

The agreement will often be divided and numbered in some logical fashion, either into articles, sections, paragraphs, or a combination of these. The reason for doing so is twofold. First, it allows ready reference to the numbered paragraph, and secondly it allows the agreement to be divided and grouped in logical associations.

BINDING THE PARTIES

The first paragraph of the first article will often bind the seller to sell and the buyer to buy the practice under the terms of the agreement. The rest of the agreement simply spells out those terms.

WHAT IS PURCHASED?

The agreement must disclose the items which are being transferred and the items which are not considered part of the agreement. This section should be crystal clear, so that anybody reading the contract (and hence a court which may be called upon to enforce the contract) and not privy to the preliminary negotiations will know what is part of the agreement and what is not part of the agreement.

[1] Sale of Stock vs. Sale of Assets

In most cases, well-informed financial advisors [FAs] will recommend that the buyer solely purchase the assets of the practice and not the stock of the practice. By purchasing selected assets, the buyer is ensured that he will not become responsible for the known or unknown liabilities of the corporation. In prior days, avoiding purchasing the stock of the corporation was a wise recommendation.

However, with the advent of managed care, the purchase of the stock of the corporation can provide the new practitioner with certain competitive advantages. It may take a new practitioner three to nine months to get onto enough managed care panels to make the practice profitable. Purchase of the stock of the corporation ensures the new practitioner of acquiring the Federal Tax Identification Number [TIN], Personal Identification Number [PIN], Drug Enforcement Agency [DEA], Centers for Medicare and Medicaid [CMS], Global Location Number [GLN] , National Provider Identifier [NPI], HIE-Form 834 transmission number, Durable Medical Equipment Number [DME]  etc, of the corporate entity. Since most managed care corporations identify providers by the Federal TIN, purchase of the stock of the corporation should allow the new practitioner to be enrolled on managed care panels in a shorter period of time.

[2] Items Purchased

Items purchased often lists the tangible and intangible property of the seller which will be transferred to the buyer. Such items often include:

  1. A detailed inventory of the tangible assets to be purchased;
  2. A detailed listing of the inventory of the practice;
  3. The names and addresses of all of the patients of record treated by the seller;
  4. The patient medical records maintained by seller;
  5. The computer records maintained by seller;
  6. All licenses, permits, accreditation and franchises issued by any federal, state, municipal, or quasi-government authority relating to the use, maintenance or operation of the practice, running to or in favor of seller, but only to the extent that they are accepted by buyer;
  7. All of sellers’ right, title, and interest in and to all real estate and equipment leases, if any, services agreements, employment and professional service contracts relating to the practice but only to the extent that the foregoing are accepted by buyer;
  8. Assignment of lease should be attached and be incorporated to the agreement;
  9. All existing telephone numbers used in connection with the operation of the practice and all yellow page advertising of the practice; and
  10. The goodwill of the practice, which includes seller’s assistance and cooperation in transfer of all sellers’ rights and interests in the practice to buyer and any other intangible assets of the practice not listed in any other category.

Certain items purchased, such as [paper or electronic] medical records, governmental licenses, fax, email, website and telephone numbers have special considerations as discussed below.

[3] Medical Records

The seller should protect its future need to use the transferred patient medical records. In the current managed care environment, providers are subject to strict scrutiny. Even after leaving practice the provider may find himself subject to a government or third party audit or subject to a medical malpractice lawsuit. Therefore, the provider should ensure that the contract allows for him to take future possession of the specific medical record(s) of the practice in order to mount an appropriate defense.

[4] Governmental Licenses

Certain government licenses and permits may be nontransferable. These would include items such as the federal and state employer identification numbers, as these are unique to seller as a corporate entity. Likewise, other items unique to seller include Medicare identification numbers, Medicaid identification numbers, NPIs and UPINs. The buyer would have to purchase the stock of the corporation order to acquire such items, which is another advantage of a stock transaction versus an asset transaction. Likewise, some local business licenses may or may not be transferable.

[5] Telephone and Fax Numbers, Website URLs and Twitter [X] Accounts, etc

Transference of the telephone numbers often requires that a special local telephone company form authorizing transfer of the telephone numbers to the buyer. Often the new owner of the telephone number will also become liable for any current yellow page advertisement monthly fees. It is the same with an URL or website or e-mail address or office Twitter X account, etc.

[6] Items Not Purchased

Items not purchased or “excluded items” often list the personal items of the parties or of the employees of the parties. Such items would often include:

  1. All cash on hand or on deposit;
  2. All accounts receivable generated prior to the closing date;
  3. All prepaid expenses, utility deposits, tax rebates, insurance claims, credits due from suppliers and other allowances after Closing Date;
  4. The personal effects, including but not limited to photographs, diplomas, uniforms, books, mementos, memorabilia, personally owned art and any personal property owned by them;
  5. Life insurance, disability insurance, and disability buy-out insurance on seller;
  6. Motor vehicles used in connection with the practice;
  7. Any or all tangible-intangible assets used in conjunction with another practice of seller; and
  8. All other assets owned by seller other than those specifically described as items purchased.

The exact items transferred will often depend upon the prior negotiations of the parties. For example, the parties may have agreed that the accounts receivable will be transferred with the practice. In such an instance, the accounts receivable will be listed as an item to be purchased.

PURCHASE PRICE AND TERMS

The price of the transaction (or the value of the practice) is often the one item that is aggressively negotiated between the parties. That is because both the buyer and the seller are overly concerned with “how much?” As this chapter demonstrates, there are a lot more details that go into the negotiation and final contract than just the price. The buyer or seller would be doing themselves a disservice to consider the other factors simply “lawyer details.” Many additional terms of the agreement should be considered by one side or the other as “walk-way” conditions. The party that fully adheres to their additional terms is likely to find the other party capitulating to them. This is because the other party will most likely be fixated on the price.

The purchase price should be delineated in the agreement. Furthermore, the method of payment of the purchase price should be delineated. Although the usual method of payment would be cash, there are other methods available as well.

Cash payment can be made by an official bank cashier’s check, by a certified check, by deposit of funds into an escrow account, or by other method agreed upon by the parties.

Non-cash type transactions include loan agreements and exchanges. Exchanges can provide certain tax benefits if the exchange is a “like kind” exchange. A like kind exchange would occur when parties swap practices. For example, a group practice might have several offices. As part of the breakup of the group, the parties might exchange their stock of one office for all of the stock of another office. Like kind exchanges have strict guidelines that must be adhered to or the tax advantages will disappear. The reader is cautioned to get current legal and financial advice prior to the time of exchange.

It is in the seller’s best interest to get all cash at the time of closing. Then the seller can walk away and not worry about the success or failure of his predecessor. The seller will not have to worry about collecting periodic payments. The seller will not have to worry about placing the buyer in default or about eventually having to repossess the practice and begin to practice medicine at that office again. If a seller repossesses a practice, the buyer may have driven the patients away or lost the managed care contracts (why else would the buyer not be able to honor the loan agreement?). So the repossessed practice will have a significantly lower market value – if it is even marketable at that time.

On the opposite end of the spectrum, it is in the buyer’s best interest to get long and lean loan terms. First, by getting loan terms, the buyer will often have to come up with much less initial capital. Second, because of the discussion in the preceding paragraph, the seller has a vested interest in ensuring that the buyer succeeds once the practice changes hands.

If the transaction involves a seller-financed loan, then the agreement should specify the terms. Additionally, a separate loan agreement and security agreement should be attached as exhibits to the agreement. Finally, in order to perfect the security agreement, the lien should be recorded at the local courthouse in accordance to local rules and customs.

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ALLOCATION OF PURCHASE PRICE

The final purchase price will actually be the amalgamation of various assets of the practice. Those assets include the tangible and intangible assets. The tangible assets include the hard assets (such as computers, treatment tables, chairs and furniture, DME and x-ray machines, etc) and the soft assets (such as Q-tips, paper and cotton balls). The intangible assets will include going concern value, goodwill, and the value of any restrictive covenant.

The parties should delineate the allocation of the purchase price amongst those various categories to reach a mutual best fit with the potential tax obligations. The buyer is the one who should strive to make the allocation fit his needs as best as possible.

Generally, the sale of the assets will be ordinary income to the seller and taxed at the seller’s usual rate. The buyer will be able to depreciate the purchased items. However, the characterization of those assets and the allocated portion of the purchase price will determine how much can be depreciated and over what time period the items can be depreciated.

As a general rule, soft assets can be depreciated fully in the year of purchase. Generally, hard assets can be depreciated over a three to seven year time period, depending upon the class of the asset. Also, under Section §179, a certain dollar amount can be “expensed” or deducted in the year of purchase. The sooner and the faster that the assets can be deducted the less current taxes that the buyer will be required to pay. However, intangible assets generally must be deducted over a 15-year period. This prolongs the tax benefits of any payments characterized as such.

Nonetheless, purchase of the assets results in better tax consequences that purchase of the stock of the practice. When stock is purchased, there is no depreciation allowance allocated in the current or subsequent years. Instead, the cost of the stock becomes the “basis” of the buyer in the practice. Any gain or loss from that basis will only have tax benefits or tax consequences in the year that the stock is sold or becomes worthless.

Because of the tax consequences of the characterization of the allocations of the purchase price, it is important that the agreement delineate the portion of the practice price which is allocated to each category.  Each party should further agree never to claim a different allocation in any future tax filings. Generally, the soft and hard assets will be valued at their current actual cash value. In no event should the purchase price allocated to the soft and hard assets exceed the actual initial cost that the seller paid for the item. The only exception to the foregoing would be if the sale involved the transfer of an appreciable asset.

LEASE ASSIGNMENT

The agreement should provide that upon closing that the seller will assign the lease to the buyer. The buyer then acquires possession of the premises and assumes responsibility for the lease payments.

Sellers often do not understand that even though they do not practice at the leased premises and even though the buyer is making the lease payments, that the seller still remains liable to the landlord under the original lease. Usually this does not present a problem for the seller. But if the buyer abandons the premises or stops making the lease payments, then the landlord will look to the seller for the lease payments through the expiration of the lease.

If the seller has signed a restrictive covenant, then the seller may find himself in the unenviable position of making lease payments for the premises and prohibited from practicing at the premises. The seller should protect himself from this possibility. Therefore, the seller should ensure that the original agreement contains a provision that if the seller becomes liable under the lease that the seller can enter onto the premises, take possession of the practice and the practice assets and can practice medicine at the location until the seller’s liabilities are extinguished.

INDEMNIFICATION AND EXCLUSION/INCLUSION OF LIABILITIES

During the sale of a medical practice, each party will have certain liabilities that the other party should not assume and should not be required to assume. A mutual indemnification clause will act to ensure that each party remains liable for its own liabilities.

In a medical practice, the most common liability is a claim of medical malpractice against the provider. The seller has an interest in insuring that he is not liable for any claim brought by a patient that resulted after he leaves the practice and the buyer has an interest in insuring that she is not liable for any claim brought by a patient that resulted before she acquired the practice.

There are other areas of liability in the sale of a medical practice that may not be readily apparent. These include premise liability (e.g., slip and fall claims), employment claims (e.g., unemployment liability, sexual harassment, discrimination, and wrongful termination claims), tax claims (e.g., unpaid employment taxes and income or sales tax liabilities), and third party payer claims (e.g., Medicare recoupment claims). Consult your insurance agent to determine whether you can obtain insurance coverage to limit your liability under these clauses.

Medical practitioners should understand the full risk of signing an indemnification or hold harmless clause. If a claim is brought against the other party, then the party giving indemnification can be forced to pay any judgment or settlement incurred by that other party. The party giving indemnification can even be required to pay the other party’s attorney bills. This is an important point that the reader should consider carefully: Even if the other party successfully defends a claim, the indemnifying party can be held liable for the other party’s attorney’s fees. Since attorney fees can mount up rapidly, the indemnifying party can find itself responsible for thousands or even tens or thousands of dollars of attorneys’ fees.

If at all possible, one should never sign an indemnification agreement, whether in the sale of a medical practice, a managed care contract, or even a home security monitoring contract. Sometimes, one has no choice but to assume the risk and sign the contract. If at all possible, one should strive to sign such clauses in a corporate capacity and not in an individual capacity. If that is not possible, then seek insurance to minimize the risk. Indemnification clauses and the potential unlimited risk that they pose is one reason why the professional should undertake a carefully planned asset protection program.

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OTHER FACTORS AND CLAUSES 

[A] Integration

As a general rule, once parties have seen fit to put their agreement in writing, then no prior oral agreement regarding the same subject is binding. A paragraph stating that the written agreement contains the entire understanding of the parties simply reflects this rule of contract construction. Such a paragraph also places the parties on notice that any oral representation of the other party that has not been placed in the contract will be worthless.

[B] Construction

At times a court may hold any ambiguities in a contract against the party that prepared the agreement or that had the agreement prepared for them. If the party on the other side of the contract is an individual that was not represented by counsel and especially if that party has had very little business experience (such as a physician or medical provider recently in practice), courts are much more likely to hold ambiguities against the drafter of the agreement.

A paragraph regarding the construction of the agreement and stating that the agreement was formed from negotiation (as opposed to a “take-it-or-leave-it” proposition) can identify for any court constructing the contract that the court should not hold any ambiguities against the drafter. After all, even with negotiated contracts, one party or the other draws up the agreement.

[C] Choice of Law

In the United States today, it is common for parties in different states to have business dealings with each other. Likewise, in the sale of a medical practice, the buyer may begin negotiations in one state and then move to the practice state after consummation of the sale. In a similar vein, following the sale the buyer may move to another state.

In most cases, the various state laws should be similar on the contractual issues involved in the sale of a medical practice. However, a statement in the contract identifying the state whose laws will govern the contract will eliminate one possible source of dispute involving a side issue to the contract. In the vast majority of contracts, the laws of the state where the practice is physically located should be chosen by the parties to govern the contract

[D] Choice of Venue

Just like providing for choice of law, a side issue to the contract can be eliminated by choosing ahead of time the venue to resolve any conflicts that may arise. The venue is simply the place where the conflict will be decided. In most cases, the parties should choose the trial court of the county in which the practice is located.

[E] Survival of Obligations

An agreement to purchase a medical practice contains two aspects. First is the transference of the practice assets in exchange for the purchase price. Second are the various other terms, such as preservation of the medical records. By providing that these obligations survive the closing, each party is assured that the other party will not claim that the actual closing of the agreement extinguished the rights of the parties under the agreement.

 [F] No Waiver Clause

A provision providing that a party does not waive its rights unless such a waiver is committed to writing allows a party to be a “nice guy” without risking its future rights. In some instances, if a party does not insist upon full compliance by the other party, then the first party may be considered to have waived its rights and may have no recourse against the other party.

There may be instances when the forbearance to exercise a right under the contract will benefit both parties. For example, if the buyer cannot pay the seller an installment on time, the seller may agree to extend the time for payment of that installment. The no waiver clause allows the seller to refuse to extend the time for payment of a future installment. Without the clause the buyer might be able to argue that the seller had waived its future rights to timely payments.

[G] Notices

There may be various reasons under the contract why one party may need to give a notice to the other party. Most often such notice will be that a party is claiming that the other is in breach of some provision of the agreement.

By specifying the address and method of delivery of any notice, the sending party can be assured that a court will rule that the receiver had actual or constructive notice.

Such a provision should also provide that one type of notice would be a change of address. Such a change of address notification would then supersede the address delineated in the agreement.

In most cases, the agreement should provide that the counsel to the party would receive a copy of any notice. This accomplishes two goals. First, there is a greater likelihood that the receiving party would receive actual notice. If the receiving party had moved and had failed to provide notice of the change of address, then the party’s counsel would have received the notice. Secondly, the party’s counsel would have received the notice in a timely manner and could take any immediate action that may be necessary.

[H] Severability Clause

A severability clause helps to ensure that if one provision is held by a court to be illegal or unenforceable, then the offending clause will be stricken from the agreement and the parties will be held to the agreement without the clause.

Without a severability clause, if a court finds that one provision of the agreement illegal or unenforceable, then the court has the power to strike down the entire agreement. Although even with a severability clause a court could strike down the entire agreement, the severability clause tells the court that the intent of the parties was that only the offending clause be stricken and essentially asks the court to honor the parties’ intent.

[I] Further Assurances Clause

After execution of the agreement, the parties may discover that certain other documents are necessary to complete the transaction. Unless such documents materially change the meaning and purpose of the agreement, a further assurance clause requires the party of parties to execute and deliver the document.

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CLOSING – SETTLEMENT

The closing or settlement date should be chosen for a mutually time and place. Generally the date will be between 30 and 90 days from the execution of the agreement. This will allow the buyer and the seller adequate time to complete any conditions precedent to closing. At closing, the buyer will tender to the seller the agreed upon funds and will execute any loan and security agreements required under the purchase and sale agreement. If the restrictive covenant also contains a buyer’s covenant, then the buyer will execute that document. The seller will deliver to the buyer a bill of sale for the assets of the practice, will execute the restrictive covenant, will deliver the keys to the practice, and will surrender the assets and the premises to the buyer. Both the buyer and the seller will execute the lease assignment.

Many of the provisions of the agreement will survive the closing. This includes any agreement to prorate expenses not allocated in at the closing, the restrictive covenant agreement, the indemnifications, and any seller’s right maintained in the medical records.

TRANSITION

Both the seller and the buyer have certain interests to protect after the closing which would require the seller to stay with the practice for a period of time following the closing. The seller may have ongoing treatment plans with certain patients (such as post-operative follow-up treatment). The agreement should specify that the seller be allowed to continue at the practice location for the purpose of finishing such treatment plans. Although the buyer may be fully capable of completing such treatment plans, both the buyer and seller should be cognizant that the patient may claim abandonment. Allowing the seller to complete treatment plans in progress will mitigate against any perceived or actual claims of abandonment.

The buyer will want to require the seller to stay with the practice for a certain period of time, usually between three to six months. During that time, the seller will act to introduce the buyer to the current patients and the buyer will begin treatment of any new patients to the practice. In this way, the transition will appear smooth and natural to the current patients.

Of course, during the transition period, the seller will have the right to be paid by the buyer. To avoid misunderstanding, the method of payment should be reduced to writing. Usually the rate of compensation will be the profit margin percentage of the practice allocated to all income collected from the seller’s efforts during the time period in question. An astute negotiator might be able to require the seller to function during the transition period as an implicit condition for the payment of the practice price.

RESTRICTIVE COVENANTS

As part of the purchase price the buyer is paying for intangible assets of the practice. A medical practice is a highly individual based business. The practice depends in large part upon the reputation of the selling physician. For that reason, the buyer must ensure that the seller cannot use that highly individualized asset to compete against the practice for which she has just paid a high sum. The restrictive covenant protects this interest of the buyer.

A restrictive covenant actually contains several covenants to protect the buyer’s interests. These include not only the obvious covenant not to compete, but also a covenant regarding financial interests, a covenant regarding solicitations, and a covenant regarding proprietary information.

The first covenant is the covenant not to compete. In this covenant, the seller agrees not to compete with the practice in the geographic area during the time term of the agreement. This covenant prohibits the seller from actually practicing or from practicing indirectly. For example, the seller could not set up a clinic within the geographic area during the time period and employ a nurse practitioner to treat patients under his medical license.

The next covenant would be the covenant regarding financial interests. In this covenant, the seller is prohibited from investing in a competing business (i.e., medical practice), within the geographic area during the time period. This provision prevents the seller from investing in such a medical practice, even if he does not directly treat patients at that location.

The third covenant would be the covenant regarding solicitation. In this covenant the seller agrees not only to refrain from contacting patients of the practice during the time period, but also to refrain from contacting employees of the practice. If the seller maintains another office location which will not be sold, then the seller should ensure that the agreement provides that the seller is allowed to treat patients which find themselves to that practice location. Otherwise, the seller may be liable for patient abandonment and may also violate managed care contracts.

A final covenant would be a covenant regarding proprietary information. Simply by the fact of operating the practice, the seller has obtained certain proprietary information about the practice. This includes patient lists, accounting information, managed care contracts, and forms and handbooks. The seller should be prohibited from using such knowledge to the detriment of the practice.

 [A] Time and Distance

The time and distance covered by the restrictive covenants must be reasonable. If either the time or distance is unreasonable, then a court might strike down the entire restrictive covenant.

A reasonable time is usually between two to five years. A two-year time period should be the minimum that the buyer should insist upon. The purpose of the time period is to allow sufficient time for the practice patients to consider the buyer as their “doctor” and to lose confidence in the selling doctor. For that reason, any time period over five years is likely to be considered an unreasonable restraint.

On the other hand, a reasonable distance depends upon many individual factors. A reasonable distance in an urban area like New York City would most likely be completely unreasonable in rural areas, such as rural Iowa. In most metropolitan areas, a five to ten mile radius from the practice location is likely to be considered reasonable. In rural areas, an entire county or even several contiguous counties may be considered reasonable. The main determination of the reasonableness of the distance factor is the total area from which the practice draws its patients.

Most practice management software programs allow for delineation of the practice patient base determined by zip code. That will provide the parties a starting point from which to negotiate the distance factor of the restrictive covenant.

[B] Buyer’s Covenants

The restrictive covenant should also contain buyer’s covenants, although it may seem counterintuitive that the buyer, having paid the seller tens of thousands of dollars for the practice, should be required to sign buyer’s covenants. However, a buyer’s covenant is an important part of the restrictive covenant. Under the purchase agreement, the seller might retain the right to repossess the practice, the practice assets, and the premises. This is most likely to happen when the seller finances the purchase price and the buyer defaults on the payments. It can also happen when the seller assigns the lease to the buyer and the buyer either abandons the premises or otherwise causes a default under the lease. The seller then remains liable as principle under the lease.

For those reasons, the restrictive covenant should provide that if the seller is required to enter onto the premises and take possession of the practice, then the Seller is relieved of his obligations under the restrictive covenants and the buyer now becomes bound by those same obligations. Such buyer’s covenants will prevent the buyer from abandoning the practice and then setting up a nearby competing practice.

CORPORATE RESOLUTION

Most medical practices being sold are corporate entities. If the transaction is a sale for stock, then the transaction is between private parties – the buyer paying cash and the seller transferring the stock.

However, in those cases where the buyer is purchasing the assets of the corporate practice, then the corporation must take certain prerequisite steps. Generally, a corporation, through its officers and directors, is prohibited from selling significant assets without permission of the shareholders.

For that reason, a shareholder meeting must be held and the shareholders at that meeting must approve a resolution allowing the officers and directors to sell significant assets of the corporation.

ASSESSMENT

The contract regarding the sale of a medical practice is the final agreement of the parties. Such a contract should only be executed after sufficient investigation into the practice and upon consultation with proficient professionals, including attorneys, accountants, FAs and practice management consultants. Understanding the basic terms and conditions of a contract regarding the sale of a medical practice is the first step in successfully negotiating the best agreement possible. Before one can negotiate for a certain provision, one must first be aware of the possibility of such a provision and its possible ramifications.

So, what else can FAs and consultants do to help plan properly for the sale of a medical practice, physician succession planning, and this major life liquidity event? Some experience FAs suggest constructing a “dry run template analysis” so the doctor can envision what life will be like after the sale, and what their corresponding financial needs might be. When the practice is sold, life is very different because many expenses that the practice paid become expenses the doctor now must pay.  And so, the use of an astute financial advisor, practice valuation specialist, and healthcare contract attorney is highly advised.

CONCLUSION

As we have seen, the purchase price of a medical practice, although am important part of any sale, should only be considered one element of the negotiations. There are many clauses and provisions of a contract regarding the sale of the medical practice, which if not negotiated favorably should be considered factors to initiate the party to walk away from the sale.

EDUCATION: Books

References and Readings:

  • Boundy, Charles: Business Contracts Handbook Gower Pub, NY 2010
  • Fenton, CF: Contracts Regarding the Sales of a Medical Practice. Financial Planning for Physicians and Healthcare Professionals; Aspen Publishers, New York, NY, 2003.
  • Hekman, K: Buying, Selling & Merging a Medical Practice. Keneth Hekman, New York 2008.
  • Katz, D: Psychic Income, Financial Advisor, page 36, 2014.
  • Walker, Lewis: The Ultimate Transition. Financial Advisor, page 33, 2014.
  • Schatzki, M: Negotiation Speak: Winning Words and Phrases for Sales, Purchasing, Contract and Other Business Negotiations – All the Dialogue and Skills You Need to Come Out Ahead, Dynamic Negotiations, Chicago, IL 2009.
  • UCC, Commercial Contracts and Business Law Blog:  LexisNexis 2010.
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DAILY UPDATE: DJIA, S&P 500 & NASDAQ Futures Rise in Search of Bounce-Back Week

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US stock futures rose yesterday Sunday, as the major indexes looked for another week of gains toward the end of a rough month and quarter.

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Futures attached to the benchmark S&P 500 (ES=F) rose 0.6%, with NASDAQ 100 (NQ=F) futures up 0.7%. Futures tied to the Dow Jones Industrial Average (YM=F) advanced around 0.4%.

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The Missing Piece in America’s Health Care Debate

By Rick Kahler CFP™

http://www.KahlerFinancial.com

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The recent horrifying murder of UnitedHealthcare Group CEO Brian Thompson has called attention to the anger many Americans feel about our health care system. This tragedy has thrust the very real issue of health care costs back into the headlines.

One article on the topic, from Ken Alltucker for USA Today, offered seven reasons why Americans pay so much for health care with such poor results. When I saw the headline, I thought, “Finally, someone’s going to bring up the elephant in the room: taxes.”

The seven reasons included bloated administrative costs, lack of price transparency, overpaid specialists, higher prescription drug prices, and more. But I didn’t see a word about how, compared to other developed nations with “cheaper” health care, Americans pay far lower taxes. That omission feels like leaving a critical piece of the puzzle off the table.

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In reality, countries with universal health care are not pulling off some magic trick of efficiency. They are simply collecting the money differently—through significantly higher taxes. Americans, on the other hand, pay for health care more directly, through out-of-pocket costs and insurance premiums.

In a column last year, I did the math. Americans spend about 17.8% of GDP on health care, plus 27.7% of GDP in taxes. That’s a total of 45.5%. Now compare that to twelve European countries with universal health care. They spend a median of 11.5% of GDP on health care and collect 41.9% of GDP in taxes. Total? 53.4%. In other words, Americans are spending 7.9% less overall on healthcare and taxes combined.

The saving isn’t what it appears, though. A fair comparison of healthcare costs and taxes needs to account for the fact that universal healthcare systems cover 100% of their populations, while the U.S. system currently leaves about 8% uninsured. If you factor in the cost of covering our uninsured residents, the U.S. likely spends a comparable percentage of income on healthcare as European countries with universal systems.

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Our system is far from perfect. As the USA Today article points out, administrative costs are bloated. Harvard’s David Cutler estimates up to 25% of our health spending goes toward paperwork, phone calls, and processing. Price transparency is practically nonexistent. The cost of a diagnostic test might vary from $300 to $3,000 depending on where you go. We pay much more for prescription drugs and many procedures than those same treatments cost in other developed nations. Another issue is the fee-for-service model that rewards doctors for ordering more tests and procedures, whether or not patients get better.

We can do better. Innovations like value-based care, where providers are paid for outcomes rather than procedures, could help shift the system toward real results. Greater price transparency would empower patients to make informed choices and force providers to compete. And addressing administrative inefficiencies could save billions.

Yet fixing the system requires being honest about trade-offs. If we want universal health care at European price rates, we need to accept European tax rates. That’s the part of the conversation that often gets left out. It’s easy to be angry at hospitals, insurance companies, and drug manufacturers—and yes, they all have plenty to answer for. But we also need to face the reality that we’ve chosen a system that prioritizes lower taxes over centralized health care.

Anger may have put the flaws in our health care system in the spotlight. Finding genuine solutions will require moving beyond expressions of anger and frustration. It will demand thoughtful discussions about what kind of health care system, as individuals and as a nation, that we want and how we are willing to fund it.

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DAILY UPDATE: US Stock Markets Retreat

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U.S. stock indexes edged lower Thursday following another reminder that big, unsettling policy changes are underway because of President Donald Trump, along with more signals suggesting the U.S. economy remains solid for now.

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The S&P 500 slipped 0.2% after flipping between modest gains and losses through the day. The Dow Jones Industrial Average dipped by 11 points, or less than 0.1 %, and the NASDAQ composite fell 0.3%.

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DAILY UPDATE: Scripps Health & WHO as US Stock Markets Rise

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FIRST DAY OF SPRING

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Stat: $1.2 billion. That’s how much San Diego-based Scripps Health plans to spend building a new hospital in San Marcos, California. (Becker’s Hospital Review)

Read: What WHO Director-General Tedros Adhanom Ghebreyesus said about USAID cuts. (Stat)

Pharm fresh: Check out in-depth strategies designed to help increase engagement between pharma reps and primary care clinicians. It’s all right here in Pri-Med’s research. Read the report.

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Shares of Charles Schwab Corp. SCHW+1.51% rallied 1.51% to $78.73 Wednesday, on what proved to be an all-around favorable trading session for the stock market, with the S&P 500 Index SPX+1.08% rising 1.08% to 5,675.29 and the Dow Jones Industrial Average DJIA+0.92% rising 0.92% to 41,964.63.

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DAILY UPDATE: US Stock Markets Routed

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US stocks pulled back on Tuesday, led by a nearly 2% decline in the NASDAQ, following two days of gains as investors concerned about an economic slowdown looked to the Federal Reserve’s policy meeting for insights.

The tech-heavy NASDAQ Composite (^IXIC) plummeted about 1.7% as Nvidia (NVDA) shares fell roughly 3% as its annual GTC event failed to impress investors. Other “Magnificent Seven” names also dragged down the tech-heavy index. Notably, those stocks are having their worst quarter in more than two years.

The Dow Jones Industrial Average (^DJI) and S&P 500 (^GSPC) also moved to the downside on Tuesday, dropping about 0.6% and 1.1%, respectively.

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Uncertainty still dogs markets as investors debate whether the sell-off that pushed the S&P 500 into correction territory is over. Traders now turn their attention to the Fed’s two-day policy meeting, which kicked off on Tuesday, for clues on the health of the economy and potential tariff risks.

Policymakers are largely expected to hold rates steady in their decision on Wednesday.

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MALTA: A Hedge Fund Haven?

By Dr. David E. Marcinko MEd MBA CMP

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OVER HEARD IN THE DOCTOR’S LOUNGE

“Malta has quietly leveraged the rising tide of the financial transparency imperative to attract hedge funds.

There was a time when the quaint island sought to play on the traditional terrain, offering anonymity and a “laissez-faire regulatory regime,” not to mention very low taxes, as in no capital gains taxes and no taxes on dividends; all while English speaking and USD currency denominated.

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While many leading domiciles for offshore hedge funds remain in the Caribbean – notably the Cayman Islands, the British Virgin Islands, Bermuda, and the Bahamas – the island of Malta is drawing attention, especially from European funds.

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DAILY UPDATE: JPMorgan Chase Lawsuit as DJIA Gains 350 Points and Stocks Climb for 2nd Day After S&P 500 Enters Correction Territory

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A group of current and former employees of JPMorgan Chase (NYSE:JPM) has filed a lawsuit alleging that the company, through its prescription drug plan run by CVS Health (NYSE:CVS), overpaid for medicines, resulting in higher expenses for its workers, according to Bloomberg News.

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The S&P 500 (^GSPC) gained about 0.6% to rebound for a second day in row, while the Dow Jones Industrial Average (^DJI) gained more than 350 points, or more than 0.8%. The tech-heavy NASDAQ Composite (^IXIC) rose 0.3% as “Magnificent 7” stocks, including Nvidia (NVDA) and Tesla (TSLA), faltered.

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DAILY UPDATE: Bayer Executive Arson, Pi Day, Ides of March as Stock Markets Lift Off!

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At least eight agencies are investigating a recent fire at a Bayer executive’s New Jersey home as a possible arson, authorities said. The fire happened around 7:30 a.m. March 4th “at an occupied residence on East Lane in Madison,” the Morris County Prosecutor’s Office told CNN yesterday.

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US stocks bounced back sharply on Friday to cap a volatile week on Wall Street as the risk of a government shutdown eased while investors stayed on watch for the next move in an escalating trade war. The S&P 500 (^GSPC) climbed more than 2.1% after the benchmark index sank on Thursday to close in correction territory. The NASDAQ Composite (^IXIC) jumped over 2.6% as tech stocks soared. The Dow Jones Industrial Average (^DJI) moved up more than 600 points, or 1.6%.

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Yesterday March 14th was Pi Day! (Yes, the mathematical constant, although we fully support celebrating with actual pie.) Put simply, Pi—aka π—is the ratio of a circle’s circumference to its diameter. It also sneaks its way into medicine. For one, it’s part of Poiseuille’s Law, an equation that helps explain how fluid flows through tubes, including arteries and IV lines. So, whether you’re crunching numbers or crunching on a slice, Pi is definitely worth celebrating

And, today is the Ides of March!

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DAILY UPDATE: US Stocks Advance

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Stock markets mostly rose Wednesday on both sides of the Atlantic as investors shrugged off Washington’s latest tariffs to focus on cooling US inflation and a Ukraine ceasefire plan.

Markets have worried that the tariffs could spark a surge in US inflation and drive a stake into the chances that the Federal Reserve cuts interest rates further. But government data released Wednesday showed US consumer inflation had slowed slightly to 2.8 percent in February — the first full month of Trump’s White House return.

That was slightly better than analysts expected. Core inflation, which excludes volatile food and energy prices, dipped to an annual rate of 3.1 percent. “The inflation data are a bright spot in the Federal Reserve’s battle against rising prices. They reinforce the expectation of three rate cuts later in 2025,” said Jochen Stanzl, chief market analyst at CMC Markets.

“Sentiment on Wall Street is so negative that these positive inflation figures could spark a broader recovery in stock prices,” he added.

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

Wall Street’s main stock indices mostly closed higher with the tech-heavy NASDAQ Composite rising 1.2 percent. But the Dow dipped into the red, losing 0.2 percent.

CITE: https://tinyurl.com/tj8smmes

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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DAILY UPDATE: Mayo Clinic Operating Margin Up as Domestic Stocks Crushed Down!

MEDICAL EXECUTIVE-POST TODAY’S NEWSLETTER BRIEFING

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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

Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily

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

Stat: 6.5%. That was the size of Mayo Clinic’s operating margin in 2024, with an operating income of $1.3 billion. (Becker’s Hospital CFO Report)

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

US stocks plunged on Monday as investors processed growing concerns about the health of the US economy after President Trump and his top economic officials acknowledged the possibility of a potential rough patch.

The Dow Jones Industrial Average (^DJI) fell nearly 900 points, or over 2%, while the benchmark S&P 500 (^GSPC) dropped around 2.7% after the index posted its worst week since September. The tech-heavy NASDAQ Composite (^IXIC) fell 4% in its worst day since 2022, as the “Magnificent Seven” stocks led the sell-off. Tesla’s (TSLA) rout continued, plunging 15% and officially wiping out the gains it had made in the wake of Trump’s election win. Nvidia (NVDA), Apple (AAPL), Google parent Alphabet (GOOG), and Meta (META) all each lost more than 4%.

Key inflation data includes the Consumer Price Index (CPI) and Producer Price Index (PPI) on Wednesday and Thursday could help set the tone, though economic growth concerns seem to have replaced inflation as the prime concern. The S&P 500 index (SPX) dropped more than 3% last week, the worst performance since September.

However, the U.S. economy “is in a good place” despite recent policy uncertainty, Federal Reserve Chairman Jerome Powell said Friday. He sees no need to hurry rate cuts until there’s more policy clarity, Bloomberg reported. Stocks rallied on Powell’s words late Friday, but Monday’s early action indicates that rallies continue being sold, and the Cboe Volatility Index (VIX) rose above 26 as investors piled into risk-off assets like bonds. The 200-day moving average of 5,734 for the SPX remains a key technical support area, and the SPX was on pace to open below that Monday, now more than 6% off of all-time highs but not yet in –10% correction territory.

CITE: https://tinyurl.com/tj8smmes

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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ABBREVIATIONS GLOSSARY: Risk Management, Insurance and Asset Protection for Physicians

By Staff Reporters

SPONSOR: http://www.HealthDictionarySeries.org

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RISK MANAGEMENT, LIABILITY INSURANCE AND ASSET PROTECTION ABBREVIATIONS

[Glossary of Important Acronyms]

Much has been written and much has been opined on the topic of medical risk management, insurance, asset protection and professional liability for physicians and healthcare providers in this textbook; and elsewhere.

But occasionally, we all still get lost in a wide array of abbreviations, acronyms, and initialisms that are constantly changing in this ecosystem.

And so, this glossary serves as a ready reference for those who want to know about these medical risk management definitions in a quick and ready fashion.

Acronyms and Abbreviations

AAASC             American Association of Ambulatory Surgery Centers

AAHP                American Association of Health Plans

ABN                  advance beneficiary notice

ABQAUR          American Board of Quality Assurance and Utilization Review

ACE                   acute care episode

ACHCE             American College of Health Care Executives

ACS                   American College of Surgeons

ADA                  Americans with Disabilities Act

ADC                  average daily census

ADL                  activities of daily living

ADT                  Admission/Discharge/Transfer

AHA                  American Hospital Association

AHIMA             American Health Information Management Association

AHRQ               Agency for Healthcare Research and Quality

AI                      average inventory

AIMR                Association for Investment Management and Research

AIR                    assumed interest rate

ALE                   annualized loss expectancy

ALF                   assisted living facility

ALOS                average length of stay

AMA                 American Medical Association

AMBAC            AMBAC Indemnity Corporation

AMGA               American Medical Group Association

ANSI                 American National Standards Institute

AP                     accounts payable

APA                  American Psychiatric Association

APC                   ambulatory payment classification

APG                   ambulatory payment group

APR                   annual percentage rate

AR                     accounts receivable

ASA                   American Society of Appraisers

ASC                   ambulatory surgery centers; also Accredited Standards Committee

ASHA                American Surgical Hospital Association

ASO                   administrative services only

ASTC                 ancillary service technical component

ATM                  asynchronous transfer mode

AVG                  ambulatory visit group

BANTA             best alternative to negotiated agreement

BBA                  Balanced Budget Act of 1997

BBRA                Balanced Budget Refinement Act [1999]

BCP                   business continuity planning

BEA                   break-even analysis

BEP                   break-even point

BIPA                 Benefits Improvement and Protection Act [2000]

BLS                   Bureau of Labor Statistics

BPD                   border protection device

BS                      balance sheet

BSA                   Bank Secrecy Act

BVS                   business valuation standard

CA                     certificate authority

CAC                  Carrier Advisory Committee

CAS                   cost accounting standards

CASB                Cost Accounting Standards Board

CC                     common criteria [for IT Security Evaluation —ISO/IEC 15408];
complication or comorbidity [for MS-DRGs]

CCA                  certified cost accountant

CCC                   cash conversion cycle

CCEVS              common criteria evaluation and validation scheme

CCHIT               Certification Commission for Healthcare Information Technology

CCU                  critical care unit

CDC                  Centers for Disease Control and Prevention

CDH                  consumer-directed healthcare

CDHP                consumer-directed healthcare plan

CDPM               Clinical Data Project Manager

CDSS                 clinical decision support system

CEO                   Chief Executive Officer

CF                      conversion factor

CFA                   Chartered Financial Analyst

CFO                   Chief Financial Officer

CFR                   Code of Federal Regulations

CHAMP             Children’s Health and Medicare Protection Act of 2007

CHAMPUS        Civilian Health and Medical Program of the Uniformed Services

CHE                   Certified Healthcare Executive

CHIPS               Center for Healthcare Industry Performance Studies

CIA                    Corporate Integrity Agreement

CIO                    Chief Information Officer

CIP                    Customer Identification Program

CIS                    computer information systems

CLIA                 Clinical Laboratory Improvement Act

CLT                   capitation liability theory

CME                  continuing medical education

CMI                   case mix index

CMIO                Chief Medical Information Officer

CMIS                 contribution margin income statement

CMN                  Certificate of Medical Necessity

CMP                  Certified Medical Planner ™

CMS                  Centers for Medicare and Medicaid Services [formerly HCFA]

COD                  cash on delivery

COGME             Council of Graduate Medical Education

COH                  cash on hand

COLA                cost of living allowance

CON                  Certificate of Need

COO                  Chief Operating Officer

COSO                Committee of Sponsoring Organizations

COTS                 commercial off-the-shelf

CPHQ                Certified Physician in Healthcare Quality

CPIM                 Certificate in Production and Inventory Management

CPI-U                Consumer Price Index—urban

CPM                  critical (clinical) path method

CPOE                computerized physician order entry [system]

CPR                   computer-based patient record

CPT                   current procedural terminology

CQI                    continuous quality improvement

CRL                   Certification Revocation List

CRM                  customer relationship management

CRVS                California Relative Value Studies

CSO                   Chief Security Officer

CT scan              computed tomography scan [also called CAT scan]

CUSIP               Committee on Uniform Security Identification Procedures

CVE                   common vulnerabilities and exposures

CVPA                cost-volume-profit analysis

CY                     calendar year

DAC                  discretionary access control

DBMS                database management system

DCF                   discounted [net] cash flow

DEA                  Drug Enforcement Agency

DHHS                Department of Health and Human Services

DHMR               Designated Healthcare Management Representative

DIO                   days inventory outstanding

DLH                  doctor labor hours

DME                  durable medical equipment

DNFB                discharged, not finally billed

D&O                  directors and officers

DO                     Doctor of Osteopathy

DOA                  dead on arrival

DoD                   Department of Defense

DOJ                   Department of Justice

DOT                  Department of Transportation

DPH                  Department of Public Health

DPM                  Doctor of Podiatric Medicine

DPO                  days payable outstanding

DPP                   direct participation program

DRA                  Deficit Reduction Act of 2005

DRG                  diagnosis-related group

DES                   disease-specific care

DSH                   disproportionate share hospital [adjustment]

DSO                   days sales outstanding

DSS                   decision support system

DVP                  delivery versus payment

DWC                 days working capital

EAP                   Employee Assistance Program

EBDIT               earnings before depreciation, interest and taxes

EBM                  evidence-based medicine

ECP                   Exposure Control Plan

ED                     emergency department

EDI                    Electronic Data Interchange

EDSS                 Executive Decision Support System

EEOC                Equal Employment Opportunity Commission

EHCR                Efficient Healthcare Consumer Response Report

EHO                  emerging healthcare organization

EHR                   electronic health record

EIN                    employer identification number

E&M                  evaluation and management

EMR                  electronic medical record(s)

EMTALA           Emergency Medical Treatment and Active Labor Act

EOB                   explanation of benefits

EOMB               Explanation of Medicare Benefits

EOQ                  economic order quantity

EOQC                economic order quantity cost [analysis]

EPA                   Environmental Protection Agency

ePHI                  electronic personal health information

EPO                   exclusive provider organization

EPR                   electronic patient record

EPRI                  Emergency Preparedness Resource Inventory

ERISA               Employee Retirement Income Security Act

ERP                   enterprise resource planning

FACT Act          Fair and Accurate Credit Transactions Act of 2003

FAR                   federal acquisition regulation

FASB                 Financial Accounting Standards Board

FBCA                Federal Bridge Certification Authority

FC                      fixed cost

FCA                   False Claims Act

FDA                   Food and Drug Administration

FEHBP              federal employees health benefits program

FF&E                 furniture, fixtures and equipment

FFS                    fee-for-service

FGIC                  Financial Guaranty Insurance Company

FHA                   Federal Housing Administration

FIFO                  first in first out

FIPS                   Federal Information Processing Standard

FMAP                Federal Medical Assistance Percentage

FMLA                Family Medical Leave Act

FMV                  fair market value                                                                                                                                                                                                                    

FTP                    file transfer protocol

FV                     fair value

  • FY                     fiscal year

GAAP                generally accepted accounting principles

GAO                  [U.S.] Government Accountability Office (name changed in 2004 from General Accounting Office)

GDP                   gross domestic product

GIGO                 garbage in, garbage out

GMC                  guaranteed mortgage certificate

GNMA               Government National Mortgage Association

GNP                   gross national product

GPWW              Group Practice Without Walls

GSA                   General Services Administration

HARA               Healthcare Accounts Receivable Analysis [report]

HCCM               Hierarchical Condition Category Management

HCFA                [former] Health Care Financing Administration

HCFAC              Healthcare Fraud and Abuse Control [program]

HCFMA             Health Care Financial Management Association

HCPCS              healthcare common procedure coding system

HCSS                 Health Care Staffing Services

HD-HCP            high deductible healthcare plan

HEDIS               Health Plan Employer Data and Information Set

HFMA               Healthcare Financial Management Association

HH                     home health

HHA                  home health agency

HHCA               home healthcare agency

HHRG                home health resource group

[D]HHS             [Department of] Health and Human Services

HIM                   health information management

HIMSS               Health Information and Management Systems Society

HIPAA              Health Insurance Portability and Accountability Act [of 1996]

HIPDB               Healthcare Integrity and Protection Data Bank

HIPPS                health insurance prospective payment system

HIS                    hospital information system

HISAC               Healthcare Information Sharing and Analysis Center

HIT                    healthcare information technology

HMMIS              hospital materials management information system

HMO                 health maintenance organization

HOPPS              hospital outpatient prospective payment system

HR                     Human Resources

HSA                   health systems agency; also health savings account

HSG                   hospital service group

HSRV                hospital-specific relative value

I&A                   identification and authentication

IBA                    Institute of Business Appraisers

IBNR                 incurred but not reported [expenses]

ICD-9-CM          International Classification of Diseases, Ninth Revision, Clinical Modification [10-CM]

ICP                    inventory conversion period

ICSI                   Institute for Clinical Systems Improvement

IDS                    integrated delivery system; also intrusion detection system

IDTF                  independent diagnostic testing facilities

IHS                    Indian Health Services

IME                   indirect medical education [adjustment]

IOM                   Institute of Medicine

IPA                    Independent Physician Association; also Independent Practice Association

IPPS                  [Medicare] inpatient prospective payment system

IRB                    Institutional Review Boards

IRC                    Internal Revenue Code

IRR                    internal rate of return

IRS                    Internal Revenue Service

ISAC                  Information Sharing and Analysis Center

ISMS                  information security management system

ISO                    International Standards Organization

ISP                     Internet service provider

I-SPY Act          Internet Spyware Prevention Act

IT                       information technology

ITL                    Information Technology Laboratory

ITR                    inventory turnover ratio

JAMA                 Journal of the American Medical Association

JCAHO              [former] Joint Commission on Accreditation of Healthcare Organizations

[now known as the The Joint Commission-TJC]

JIT                     just-in-time

[inventory management]

LAN                  local area network

LCC                   life-cycle cost

LEP                   limited English proficiency

LIFO                  last in, first out

LIS                     Laboratory Information Systems

LISW                 Licensed Independent Social Worker

LLC                   Limited Liability Company

LLP                   Limited Liability Partnership

LMFT                Licensed Marriage and Family Therapist

LPCC                 Licensed Professional Clinical [Mental Health] Counselor

LOS                   length of stay

LVN                  licensed vocational nurse

LPN                   licensed practical nurse

LRAC                long-range average cost

LRRA                Liability Risk Retention Act

LSP                    limited service provider

LTCPP               long-term care pharmacy provider

MABC               medical activity-based costing

MAC                  monitored anesthesia care; also mandatory access control

MB                    marginal benefit

MBT                  Mechanical Biological Treatment [organization]

MC                    marginal cost

MCC                  major complication or co-morbidity

MCM                 mixed cost method

MCO                  managed care organization

MCS                  Monte Carlo Simulation

MD                    medical doctor

MDC                  major diagnostic category

MEC                  modified endowment contract

MedPAC            Medicare Payment Advisory Commission

MGMA              Medical Group Management Association

MI                      Medical Informatics

MIS                    management information services

MLIC                 malpractice liability insurance component

MMA                 Medicare Prescription Drug, Modernization, and Improvement Act of 2003

MMCO              Medicare Managed Care Organizations

MOE                  maximum office efficiency

MPCA               medical practice cost analysis

MPT                  Modern Portfolio Theory

MR                    medical records, marginal revenue

MSA                  medical savings account

MSCI                 Metals Service Center Institute

MS-DRG            Medicare Severity DRG

MSDS                material safety data sheet

MSO                  management services organization

MUD                 medically unnecessary days

MVO                 mean variance optimization

NACVA             National Association of Certified Valuation Analysts

NAICS               North American Industry Classification System

NAIP                 National Association of Inpatient Physicians

NAHC               National Association of Healthcare Consultants

NASD                National Association of Securities Dealers

NASDAQ          National Association of Securities Dealers Automated Quotations

NAT                  network address translation

NAV                  net asset value

NBER                National Bureau of Economic Research

NCFFR              National Commission on Fraudulent Financial Reporting

NCPDP              National Council for Prescription Drug Programs

NCQA               National Committee for Quality Assurance

NCUA               National Credit Union Administration

NCVHS             National Committee on Vital and Health Statistics

NDC                  National Drug Code

NEJM                New England Journal of Medicine

NGC                  National Guideline Clearinghouse

NIAP                 National Information Assurance Partnership

NIC                    net interest cost

NIOSH               National Institute of Occupational Safety and Health

NIS                    net income statement

NISAC               National Infrastructure Simulation and Analysis Center

NIST                  National Institute of Standards and Technology

NOW account     negotiable order of withdrawal account

NPDB                National Practitioner Data Bank

NPI                    National Provider Identification [number]

NPP                   Notice of Privacy Practices

NPS                   national provider system

NPV                  net present value

NQF                   National Quality Forum

NRC                  National Research Council

NRV                  net-realized accounts receivable value

NSA                   National Security Agency

NTFS                 new technology file system

NTPA                net target profit analysis

NYSE                New York Stock Exchange

OBO                  order book official

OBRA                Omnibus Budget Reconciliation Act [of 1989]

OCC                  Option Clearing Corporation

OCR                  optical character recognition; also Office of Civil Rights

OFAC                Office of Foreign Assets Control

OFPP                 Office of Federal Procurement Policy

OID                   original issue discount

OIG                    Office of the Inspector General [U.S. Department of Health and Human Services]

OMB                  Office of Management and Budget

OPHC                Office of Prepaid Health Care

OPIM                 other potentially infectious material

OPPS                 outpatient prospective payment system

OS                     operating system

OSI                    open systems interconnect

OR                     operating room

OSHA                Occupational Safety and Health Administration

OSJ                    Office of Supervisory Jurisdiction

OTC                   over-the-counter

P4P                    pay-for-performance

P/E                     price to earnings [ratio]

P/R                    price to revenue [ratio]

PAC                   planned amortization certificate

PAY                  post-acquisition year

PC                     [mortgage] participation certificate; also personal computer

PCC                   project cost of capital

PCMCIA            Personal Computer Memory Card International Association

PCP                   primary care physician

PDA                  personal digital assistant

PDX                   Patient Data Exchange

PE[C]                 practice expense [component]

PEO                   professional employer organization

PFS                    patient financial services

PG                     purchasing group

PHA                  public housing authority

PHI                    protected health information

PHN                  Private Health Network

PHO                  physician-hospital organization

PHR                   patient health record

PIN                    personal identification number

PIO                    public information office

PKI                    public/private key informatics/infrastructure

PKIX                 public key infrastructure for X.509 certificates

PLIC                  [mal]practice liability insurance component

PMG                  primary medical group

PM/PM              per member per month

PO                     purchase order

POC                   point-of-care

POL                   physician office laboratory

POS                   point-of-service

POSP                 point of service plan

PP                      projection profile

PP&E                property, plant, and equipment

PPE                   personal protective equipment

PPMC                physician practice management company

PPO                   preferred provider organization

PPS                    [Medicare] prospective payment system

PR                     pregnancy and related conditions

PROM               programmable read-only memory

PSI                     patient safety indicator

PSN                   provider-sponsored network

PSO                   provider-sponsored organization

Pt                       patient

PTO                   paid time off

PWC                  physician work component

PY                     projected year

QA                     quality assurance

QI                      quality improvement

RA                     registration authority

RADIUS            remote authentication dial-in user service

RAN                  Revenue Anticipation Note

RBAC                role-based access control

RBRVG             resource-based relative value group

RBRVS              resource-based relative value scale

RBRVU             resource-based relative value unit

RDBMS             regional database management system

REIT                  real estate investment trust

RERVU             resource-based relative value unit

REV/PP             revenue per patient

RFI                    request for information

RFID                  radio frequency identification device [scanner]

RFP                   request for payment

RHIO                 Regional Health Information Organization

RN                     Registered Nurse

RNANS             Registered Nurses Association of Nova Scotia

ROE                   return on equity

ROI                    return on investment

ROM                  read-only memory

ROP                   re-order point

RRG                   risk-retention group

RSNA                Radiological Society of North America

RUG-III             resource utilization group III

RVS                   relative value scale

RVUm               relative value unit – malpractice

RVUpe               relative value unit – practice expenses

RVUw               relative value unit – work

rWACC              relative weighted average cost of capital

S&P                   Standard and Poor’s

SaaS                   Software-as-a-Service

SAMHSA           Substance Abuse and Mental Health Services Administration

SAN                   storage area network

SARS                 Sever Acute Respiratory Syndrome

SBBI                  Stocks, Bonds, Bills and Inflation [Yearbook]

SCIM                 supply chain inventory management

SCF                    statement of cash flows

SCM                  supply chain management

SCP                   standard cost profile

SD                     standard deviation

SDLC                 system development life cycle

SDN                   specially designated nationals

SDO                   standards development organization

SEC                   Securities and Exchange Commission

SERP                 supplemental extended reporting policy

SESIP                sharps with engineered sharps injury protection

SHM                  Society of Hospital Medicine

SIC                    Standard Industrial Code

SIPC                  Securities Investor Protection Corporation

SLA                   service level agreement

SMA                  special miscellaneous account

SMD                  Society of Medical Dental Management Consultants

SMS                   socioeconomic monitoring system

SMTP                simple mail transfer protocol

SNF                   skilled nursing facility

SNMP                simple network management protocol

SP                      special publication

SSH                   single-specialty hospitals

SSL                    secure socket layer

STP                    standard treatment protocol

SVPN                secure virtual private network

TEL                   Terror Exclusion List

TFC                   total fixed cost

TIC                    true interest cost

TIN                    tax identification number

TLS                    transport layer security

TPA                   third party administrator

TQIM                 total quality and improvement management

TQM                  total quality management

UCC                  Uniform Commercial Code

UCSF                 University of California at San Francisco

UDP                  user datagram protocol

UFS                   unix file system

UIIRC                University of Iowa Injury Prevention Research Center

UM                    utilization management

UPIN                 Unique Provider Identification Number

UR                     utilization review

USPAP              Uniform Standards of Professional Appraisal Practices

v                        variance

VA                     Veterans Affairs

VAR                  value at risk

VC                     variable cost

VOC                  volatile organic chemicals

VPN                  virtual private network

WACC               weighted average cost of capital

WAN                 wide area network

WHO                 World Health Organization

WIA                   weighted industry average

WORM              wrote once-read many

READINGS

  • Marcinko, DE and Hetico, RN: Dictionary of Health Insurance and Managed Care. Springer Publishing, New York, NY 2007
  • Marcinko, DE and Hetico, RN: Dictionary of Health Information Technology and Security. Springer Publishing, New York, NY 2009
  • Marcinko, DE and Hetico, RN: Dictionary of Health Economics and Finance. Springer Publishing, New York, NY 2008

EDUCATION: Books

HEALTHCARE ADMINISTRATION BLOGS 

  • Candid CIO: Will Weider, CIO of Ministry Health Care and Affinity Health System, offers his perspectives on administration issues in this blog.
  • Christina’s Considerations: Christina Thielst is a hospital and healthcare administrator and entrepreneur with a deep desire for continually improving the health of the community being served. This is her blog.
  • Healing Hospitals — Formerly Ask a Hospital President: F. Nicholas “Nick” Jacobs has more than 20 years experience in hospital management, with an acknowledged reputation for innovation and consumer-centered leadership.
  • Hospital Impact: Part of the Fierce network of health sites, this site is becoming popular among healthcare administrators for its news updates, tips and opinions on health care matters.
  • Leading the Way to Medical Excellence: the president of McLeod Health non-profit institutions provides weekly insights into his facilities and health care in general.
  • Let’s Talk Health Care: Bruce Bullen, Interim Chief Executive Officer at Harvard Pilgrim in Massachusetts, provides and open and ongoing conversation about health care administration.
  • Life as a Healthcare CIO: Dr. John Halamka records his experiences with infrastructure, applications, policies, management, and governance as he supports 3,000 doctors, 18,000 faculty and about three million patients.
  • Managed Care Matters: Joe Paduda shares his knowledge on managed care for group health, health policy, health research, and medical news for insurers, employers, and healthcare providers.
  • More than Medicine: Tom Quinn, president and CEO of Community General Hospital in Syracuse, New York, began his career as a hospital kitchen worker. His perspective on administration reflects his knowledge on how hospitals work from every angle.
  • Regis University Health Services Administration Blog: Learn more about a college health service through the blog provided by its health administrator, Michael Jackson.
  • Running a Hospital: A CEO of a large Boston hospital shares thoughts on hospitals, medicine and health care issues.
  • St. Joseph Medical Center: Chief Executive Officer at St. Joseph Medical Center in Missouri, Mr. Kashman, provides personal insight into administrative matters and general topics.
  • Todd’s Perspective: Todd Linden, president and CEO of Grinnell Regional Medical Center, offers insights into medical administration and guest bloggers provide insight into various departments.
  • Wachter’s World: This blog focuses on hospitals, hospitalists, quality, safety, policy and much more from Robert M. Wachter, MD, Professor and Associate Chairman of the Department of Medicine at the University of California, San Francisco.

                 Legal Matters

  • Drug and Device Law: This blog contains an attorney’s personal views (and those of several other Dechert attorneys) on topics that arise in the defense of pharmaceutical and medical device product liability litigation.
  • Drug Injury Watch: Learn more about drug injury lawsuits from an attorney who represents patients and their families.
  • FDA Law Blog: Hyman, Phelps & McNamara, P.C. is the largest dedicated food and drug law firm in the country. Their knowledge about laws and regulations governing drugs, medical devices, foods, dietary supplements, and cosmetics is helpful to anyone interested in these topics.
  • Health Care Law Blog: Bob Coffield’s expertise lies in helping businesses and health care providers weave through a variety of state and federal health care regulations and assisting them in business transactions.
  • Health Plan Law: This site contains information about group health plans, claims administration and related ERISA fiduciary issues. This site also contains tutorials.
  • HealthBlawg: this is David Harlow’s popular health care law blog, offering expert insights and easy-to-understand analysis.
  • Healthcare Law Blog: Holland & Hart’s healthcare practice provides insight into this arena, including HIPAA, Stark law, the Anti-kickback Statute and more.
  • HIPAA Blog: Join in on this discussion of medical privacy issues often buried in “political arcana.”
  • HIPAA, HiTech & HIT: This updated blog brings insight into legal issues, developments and other pertinent information that relates to the creation, use and exchange of electronic health records.
  • HIT Blawg: This blog is focused on national health information technology legal trends and current news on this topic.
  • Home Care Law Blog: Learn more about legal and policy issues in the home health care, private duty and hospice industries from Gilliland & Markette LLP.
  • Med Law Blog: This law blog focuses on topics that range from compliance to contracts and from employee benefits to HIPAA and HIT.
  • Physician Law: This blog provides and easy way to stay on top of current news, updates and useful tips relating to legal issues that affect physicians and non-institutional providers.

                 eHealth and Health IT

  • Chilmark Research: This blog provides perspectives on key IT trends in the healthcare sector.
  • davidrothman.net: David is the Information Services Specialist at the Community General Hospital Medical Library, but he also provides great ideas for 2.0 tools and tips for healthcare industry professionals on this blog.
  • e-CareManagement blog: Vince Kuraitis, owner of Better Health Technologies, LLC, has a passion for disease management and care coordination that dates back to 1995.
  • e-HealthExpert: A non-profit organization provides a free and open forum to support the development of expertise in the field of eHealth, Healthcare Information Systems, and Health IT (Clinical IT).
  • eHealth: John Sharp is an IT Manager for a major medical center in Northeast Ohio, with a focus on ehealth, personal health records, Web 2.0 technologies, Windows Sharepoint Services and project management.
  • Found In Cache: If you would prefer a professional’s take on social media matters, Web sites and all things technological, then follow Ed Bennett, a technology expert for a Maryland medical care system.
  • Future Health IT: A health IT and EPR advocate from the UK provides a format to discuss the future of health care and IT.
  • Informaticopia: This UK blogger provides eclectic news and views on health informatics and elearning.
  • MedGadget: Stay ahead of the gadget curve with this site, which offers information about the newest health care gadgets on the market as well as emerging medical technologies.
  • Neil Versel’s Healthcare IT Blog: A healthcare journalist’s provides his views on the major segment of the industry he covers — and, he provides a ton of links to other sites as well.
  • Schwartz Healthcare IT Blog: A variety of authors from Schwartz Communications provide insights into ways to use IT effectively within healthcare facilities.
  • The Health IT Channel: For a different perspective on IT and EHR as well as other health care issues, watch a few videos at this site.
  • The Healthcare IT Guy: The CEO of Netspective, a Java/.NET consultancy that specializes in healthcare IT with an emphasis on e-health, EMRs, data integration, and legacy modernization, supplies tips and information for physicians and healthcare administration.

ACKNOWLEDGEMENTS: To Mackenzie H. Marcinko PhD of iMBA Inc., Perry D’Alessio CPA CMP™ [Hon] New York, NY; and Daniel B.  Moisand CFP®, Principal for Moisand Fitzgerald Tamayo, Melbourne, FL.

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DAILY UPDATE: Endometriosis Awareness Week as Stock Markets Soar!

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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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Endometriosis Awareness Week, which brings attention to the chronic disease that affects about 10% of reproductive-age patients with uteruses worldwide. There’s still no known cure, due in part to research being underfunded—in 2022, the NIH allocated just $16 million, or $2 per patient, to endometriosis research, according to a 2024 study.

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US stocks rallied on Wednesday as President Trump provided a one-month auto tariff exemption on Mexico and Canada.

After sliding earlier in the session, the tech-heavy NASDAQ Composite (^IXIC) led the gains, rising more than 1.4%. Meanwhile, the Dow Jones Industrial Average (^DJI) and the S&P 500 (^GSPC) rose roughly 1.1%.

Stocks lifted higher after the White House delayed by one month auto tariffs that could significantly impact US automakers Ford (F), GM (GM), and Stellantis (STLA). Shares of all three automakers were at least 5% higher.

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DAILY UPDATE: High Flu Cases as Stock Markets Collapse

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Despite high flu cases, vaccine this season looks overall like a good match.  Early season laboratory testing by the CDC suggested this year’s flu vaccine was 100% match for the strain influenza A (H1N1)which accounts for 48% of cases this year, and a 100% match for influenza B, which accounts for just under 3% of cases so far. For targeting influenza A (H3N1), which makes up 49% of cases so far, the CDC said the vaccine is a 51% match.

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The Dow Jones Industrial Average (^DJI) fell about 1.5%, or over 650 points, as losses escalated into the close, while the benchmark S&P 500 dropped around 1.2%, hitting its lowest level in four months. The tech-heavy NASDAQ Composite (^IXIC), which traded in the green at one point of the trading day, closed down about 0.4% but was able to avoid entering correction territory.

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DAILY UPDATE: TeleHealth Coverage Act as Stock Markets Plummet

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A new bill could change Medicare coverage requirements for Americans across the country. With Medicare was set to run out of funding for telehealth coverage by the end of March, Democratic Representative Ro Khanna of California has introduced the Telehealth Coverage Act to continue the services.

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Stocks plummeted on Thursday as tech sold off following Nvidia’s (NVDA) latest earnings report while investors took stock of the economy amid President Trump’s latest tariff pledges.

The S&P 500 (^GSPC) fell more than 1.6%, while the tech-heavy NASDAQ Composite (^IXIC) dropped 2.8%. The Dow Jones Industrial Average (^DJI) dropped 0.4%.

Investors dug into Nvidia’s quarterly earnings beat, which signaled plenty of scope for growth as it eased worries about DeepSeek and faltering AI demand. The results initially met a muted response as its profit outlook raised doubts on Wall Street. Nvidia’s stock erased early morning gains to dropped more than 8%.

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DAILY UPDATE: Pfizer’s Conflict as NASDAQ and Bitcoin Sink along with Consumer Confidence

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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

Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily

A Partner of the Institute of Medical Business Advisors , Inc.

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Health experts have expressed conflict of interest concerns after the FDA‘s drug chief quit for a top job in Big Pharma. Pfizer announced this week that Dr. Patrizia Cavazzoni, former director of the FDA’s Center for Drug Evaluation and Research (CDER), will join the company as its chief medical officer.

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The tech-heavy NASDAQ Composite (^IXIC) finished the volatile trading day down around 1.3%, dragged down by shares of Magnificent Seven players like Nvidia (NVDA) and Tesla (TSLA). The benchmark S&P 500 (^GSPC) dropped roughly 0.4%, while the Dow Jones Industrial Average (^DJI) reversed earlier session declines to end the day in the green, up about 0.4%.

Some of the biggest market moves also came from the cryptocurrency space, where the price of bitcoin (BTC-USD) tumbled below $90,000 for the first time since November. Bitcoin touched a low closer to $86,000 in the early morning hours, its lowest level since early November. Prices stabilized to just around $88,000 at the market close.

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PATIENTS: Self Diagnostic Risks

PAGING DOCTOR GOOGLE

BY DR. DAVID EDWARD MARCINKO; MBA MEd CMP™

SPONSOR: http://www.MarcinkoAssociates.com

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While health care is not “do-it-yourself,” an informed patient can be an asset. A poorly informed patient, on the other hand, clearly complicates treatment. Assume the responsibility of being the primary information source and educator for your patient. To help deal with a self-diagnosing patient, consider the following as suggested by: David B. Troxel, MD, Medical Consultant to The Doctors Company:

  • Encourage patients to always check with you about the accuracy of information obtained from external sources. Use the intake time to find out what Internet information the patient has found.
  • Directly discuss what the patient has read, even if the patient’s external source is a good one in your professional opinion. The exchange enhances your relationship with the patient and can increase treatment compliance. Welcome questions, and help put the patient’s information in the appropriate context.
  • Provide your patient with a list of Web sites that provide accurate information, such as the Centers for Disease Control and Prevention (www.cdc.gov). Make sure the patient understands the limitations of the Internet.
  • Document in the patient’s chart your diagnosis, your treatment management plan, and medication prescribed, as well as the reasons behind your decisions.

EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit a RFP for speaking engagements: MarcinkoAdvisors@outlook.com 

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FEBRUARY: National Children’s Dental Health Month

AMERICAN DENTAL ASSOCIATION

By ADA and Staff Reporters

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Every day should be about children’s dental health

This is the message behind the ADA’s National Children’s Dental Health Month resources for 2025. Observed nationally each February, the recognition brings together thousands of dedicated professionals, health care providers and educators to promote the benefits of good oral health to children, their caregivers, teachers and many others.

The ADA is offering new materials to celebrate and promote the importance of children’s dental health, not only during the month of February, but all year.

Posters and flyers emphasizing the importance of brushing are available for free download in two kid-friendly, topical designs and two sizes, 8.5″x11″ and 11″x17″. Matching coloring sheets are offered in 8.5″x11″. All materials have instructions for proper brushing and are available in English and Spanish from ADA.org/NCDHM.

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In addition, the ADA’s 2025 Brushing Calendar is available for free download. This 12-month calendar is valuable year-round for promoting healthy behaviors like brushing twice a day with a fluoride toothpaste to help prevent dental disease. Kids can track their daily brushing and flossing routines and exercise their creativity by coloring the calendar image for each month.

Another tool, the NCDHM Program Planning Guide, provides resources for program coordinators, dental societies, teachers and parents to promote the benefits of good oral health to children. The guide includes easy-to-do activities, program planning tips, a sample NCDHM proclamation and more.

“The sooner children understand the value of good oral health habits, the more likely they are to continue these habits well into adulthood,” said ADA President Brett Kessler, D.D.S. “The ADA is proud that NCDHM will once again equip some of the most influential figures in kids’ lives — like parents, educators and health care providers — to help set our nation’s kids on the path to a lifetime of healthy smiles and healthier lives.”

National Children’s Dental Health Month observances began with a one-day event in Cleveland and a one-week celebration in Akron, Ohio, in February 1941. Since then, the concept has evolved into a nationwide program.

The ADA held the first national observance of Children’s Dental Health Day on February 8th, 1949. The one-day event became a week long event in 1955, and in 1981 the program was extended to a month long celebration known today as National Children’s Dental Health Month.

For questions about NCDHM resources, please email ncdhm@ada.org. For oral health resources, visit MouthHealthy.org.

EDUCATION: Books

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INHERITANCE: Disclaimers

DEFINITION

“Show Me the Money”

By Staff Reporters

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In some situations, an inheritance might complicate an estate and add to the estate tax burden.  If there are sufficient assets and income to accomplish financial goals, more assets are not needed. A disclaimer may be useful.  This is an unqualified refusal to accept a gift or inheritance, that is, when you “just say no”.  You have decided not to accept a sizable gift made under a will, trust or other document. 

When you disclaim the property, certain requirements must be met:

  • The disclaimer must be irrevocable;
  • The refusal must be in writing;
  • The refusal must be received within nine months;
  • You must not have accepted any interest in the property; and
  • As a result of the refusal, the property will pass to someone else.

The property passes under the terms of the decedents will, as if you had predeceased the decedent. If the filer of the disclaimer has control, the property will be included in the disclaimant’s estate and can only be passed to another as a gift for as an inheritance. The intent of the disclaimer is to renounce and never take control of the property.

EDUCATION: Books

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CES: Las Vegas Consumer Electronics Show

FULL ARTICLE WITH TAKE AWAY POINTS

By Vitaliy Katsenelson CFA

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Key Take Away Points

  • The Consumer Electronics Show revealed that robotaxis are expanding beyond just Waymo, with multiple players entering the market – this fragmentation could actually benefit Uber’s switchboard system and transform sectors like school transportation.
  • Chinese EV manufacturers have leapfrogged traditional auto manufacturing much like Africa skipped landlines for mobile phones – their fresh designs and cost advantages could seriously challenge Western incumbents if tariffs weren’t a factor.
  • Autonomous and remote-controlled equipment is set to revolutionize traditional industries like construction, mining, and farming – transforming physically demanding jobs into office work and potentially reshaping immigration policy needs.
  • The path to cracking the US market has fundamentally changed – companies no longer need traditional retail gatekeepers like Best Buy or Costco, just a product and Amazon advertising budget, as demonstrated by companies like Renpho.
  • Brand value remains crucial in an era of rapid technology commoditization – your observations of the 15 Oura ring competitors and the GoPro story demonstrate that without strong brand differentiation, even good products can’t command premium pricing in today’s market.

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Full Article

I wrote this from Las Vegas, where my son Jonah and I were at CES (the Consumer Electronics Show). 

In investing and life, it’s very easy to get tunnel vision – doing what works and staying in your comfort zone. I wanted to attend CES to shake myself out of this pattern.

It’s hard to describe how massive this event is. It sprawls through five enormous pavilions at the Las Vegas Convention Center and takes up two floors of the Venetian Hotel. It is attended by over one hundred thousand people. 

Here are my initial, off-the-cuff, somewhat random thoughts from CES. 

Robotaxis There were several robotaxi companies here, in addition to Alphabet’s Waymo. Multiple robotaxis are going to hit the market over the next few years; it won’t be just Waymo. Most will start geofenced (they’ll work in specific areas), just like Waymo did. 

This is good news for Uber: The more fragmented the robotaxi market, the more players are in this market, the more valuable is Uber’s switchboard system (which will bring higher utilization to robotaxi operators). 

This will also hugely transform public transportation. Think about school buses – that market is primed for disruption since most buses follow the same route every day in a relatively small area.

Chinese EVs Chinese electric cars are awesome. This reminds me of what happened in Africa. Most of Africa skipped phone landlines completely and went straight to wireless phones. Similarly, Chinese automakers weren’t great at making regular gas-powered cars (everyone else had dominated that space), so they just leapfrogged straight to electric cars. And leapfrog they did – they’ll make even Tesla work hard. 

I can’t speak for their reliability, but their designs are fresh; and without labor unions mandating how many workers need to screw in a single lightbulb, they’re much cheaper than Western alternatives.

If they hit the US market without tariffs, they would decimate the incumbents – similar to what Japanese carmakers did in the early 80s to the Big Three.

Machines on Autopilot Autonomous and remote-controlled equipment is going to change construction, mining, and farming completely. Imagine excavators digging dirt on a project in the middle of nowhere, operated remotely from air-conditioned urban offices – maybe even by experienced operators brought out of retirement. 

Jobs that were physically demanding and that pulled workers away from their families are going to become regular nine-to-five office jobs. This means workers can have normal family lives and work longer – way past when they’d normally have to retire due to the physical demands of the job.

Or picture a colony of Caterpillar trucks working autonomously 24/7 at a mine site. The efficiency and safety gains would be huge. You’ll still need workers, but different workers, and fewer of them.

Think about agriculture. All those jobs that “Americans don’t want to do” will be done by tractors or other farm equipment going through strawberry fields, using AI to spray pesticides only where needed and collecting apples and oranges.

Here’s an economic observation with slight policy overtones: The nature of the job market will change. This is one of those turning points in history where our immigration policy should be forward-thinking, adjusted for the world where AI will be playing a larger role in it (that is inevitable), not just focused on the past and today’s needs.

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Cracking the US Market China has a significant competitive advantage in manufacturing; it has a very robust ecosystem and well-oiled supply chain – nothing new here. Its labor is no longer the cheapest, but Chinese manufacturing is getting more automated. 

We talked to one of the chief designers of Renpho, a Hong Kong company that makes digital scales (among other gadgets) and is the number one seller of those scales on Amazon. They outsource all manufacturing to China, and the factory that manufactures their scales is completely automated. 

What’s also interesting is that in the past, to break into the US market, you had to have relationships with Best Buy and Costco. They were the gatekeepers and also the quality-control testers. Today, all you need is a product. You have direct access to the US consumer through Amazon – you just have to be willing to spend on Amazon advertising to promote your product.

Brand or Bust It’s incredible how fast technology gets commoditized. There are literally fifteen (!) companies selling Oura-like rings (sleep-tracking biometric devices worn as a ring; I’ve been wearing one for five years).

In technology, you need to keep moving all the time or you’ll be eaten by the competition (true in life in general), but you also need a strong brand. I couldn’t tell the difference between my Oura ring and the fifteen replicas, most of them sold at a fraction of Oura’s price. But I trust Oura, and that’s the power of the brand.

I remember researching GoPro stock after it got bombed out (down 80%). During our research, I found that GoPro was selling their cameras for $300-400, while Chinese-made, no-name replicas were sold on Amazon for $40. These replicas didn’t have GoPro’s brand, but they had tens of thousands of five-star (hard to fake) reviews on Amazon. GoPro may have been exceptional (loved by pros), and these no-name cameras were just okay, but they were 10 times cheaper.

I put GoPro stock into the “too hard” pile and moved on – thank God I did; after declining 80%, the stock fell another 80%.

This brings me back to the value of a brand. GoPro wasn’t worth 10x more to consumers than Chinese no-name alternatives. Can Oura command 10x pricing over its no-name competitors? I don’t know. That’s the beauty of investing – I don’t have to have an actionable opinion on everything. With time I have become very comfortable saying “I don’t know.” Investing is one of the few professions where you don’t have to have an answer for everything. “I don’t know” should be the default answer, unless you do know. Which isn’t that often.

Global Tech Showdown Korean companies are really dominating screen technology. LG and several other Korean companies showed off transparent, glass-like LCD screens at CES. Imagine sitting in your self-driving car, and your windows are both regular see-through glass and LCD screens at the same time. Our lives are slowly becoming what we used to see in sci-fi movies, and these screens are definitely a leap in that direction.

CES is a truly global show, with technology on display that spans every aspect of our future. There were a lot of companies from Asia (especially China). In certain pavilions focused on consumer or business hardware, China completely dominated the exhibits. There were quite a few large American companies and many American startups, mostly focused on software (though all their hardware was manufactured in Asia). America still dominates in software.

A few, mainly Chinese, companies were showcasing their humanoid robots. One robot was slowly but accurately moving and stacking boxes in a defined area. Others were roaming more freely and were good at avoiding objects. At this point, these robots have the IQ of a smart dog, an average cat (now cat lovers will love me), or Siri. I bet in a few years this will have changed.

I was only mildly surprised by how few European companies were at the show. It’s a very broad generalization, but Europe seems to be running on fumes of past glory. Western Europe has become a pro at regulation and mastered the redistribution of wealth (activities that don’t help innovation or economic growth), and not much else. Yes, there are exceptions, but that’s the point – they are exceptions. If Europe doesn’t change course, eventually it will run out of fumes.

The beauty of learning is that you don’t always know everything you’ve learned at the moment of learning. Often, you’re just depositing data points that will crystallize into insights at a much later date. I don’t know if CES will become an every-year tradition or something I do sporadically, but it’s definitely fertile ground for learning.

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NEWEST THOUGHTS: Physician Personal Emergency Fund Size is Getting Complicated

SPONSOR: http://www.MarcinkoAssociates.com

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By Dr. David Edward Marcinko MBA MEd

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It has been said that most ordinary people should have at least three to six months of living expenses (not including taxes) in a cash-equivalent reserve fund that is easily accessible (i.e., liquid).  The amount needed for a one-month reserve is equal to the amount of expenses for the month, rather than the amount of monthly income. This is because during no-income months there is no income tax.  

However, the situation might not be the same for physicians in today’s harsh economic climate. 

The New Realities

Now, some physician-focused financial advisors, financial planners and Certified Medical Planners™ suggest even more reserve fund savings; up to two years. That’s because many factors come into play when determining how much a particular doctor’s family should have.

For example: 

  • Does the family have one income or two? If the doctor is in a dual-income family with stable incomes and they live on a single income, the need for a liquid reserve is less.  
  • How stable is the doctor’s income source? If a sole provider with an unstable income who spends all of the income each month, the need for a liquid cash reserve is high. 
  • Does the doctor own the practice, work in a clinic, medical group, hospital or healthcare system? In other words – employee (less control) or employer (more control). 
  • What is the doctor’s medical specialty and how has managed care penetrated his locale, or affected her focus? What about a DO, DDS/DMD or DPM, etc.
  • How does the family use its income each month; does it have a saver, spender, or investor mentality?  
  • Does the family anticipate the possibility of large expenses occurring in the future (medical practice start-up costs or practice purchase; children, medical school student debts; auto or home loans; and/or liability suits, etc)?  
  • Pan physician lifestyle?

The Past 

In the ancient past, a doctor may have opted for a nine-twelve month reserve if the need for security was high – and a six-to-nine month reserve if the need for security was low. But today, even more may be needed.  How about 15-18 months, or more? Perhaps even 24 months!

So, the following questions may be helpful in determining the amount of reserve needed by the physician: 

1. How long would it take you to find another job in your medical specialty if you suddenly found yourself unemployed – same for your spouse?

2. Would you have to relocate – same for your spouse? 

3. How much do you spend each month on fixed or discretionary expenses and would you be willing to lower your monthly expenses if you were unemployed? 

Assessment

Once the amount of reserve is determined, the doctor should use the appropriate investment vehicles for the funds. 

At minimum, the reserve should be invested in a money market fund. For larger reserves, an ultra-short-term bond fund might be appropriate for amounts over three-six months. While even larger reserves might be kept in a short term bond fund depending on interest rates and trends. 

So, what do the initials M.D. really mean? … More Dough!

How much reserve do you have and where is it stashed?

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EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit a RFP for speaking engagements: MarcinkoAdvisors@outlook.com 

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INFINITE BANKING: Life Insurance Defined

By Staff Reporters

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Infinite banking is not a product or service offered by a specific institution. It’s a concept promoted as a way you can “be your own bank” to have more control over your money. 

Infinite banking is a strategy in which you buy a life insurance policy that accumulates interest-earning cash value and take out loans against it, “borrowing from yourself” as a source of capital. Then eventually pay back the loan and start the cycle all over again. To whit:

  1. Buy a cash value life insurance policy, which you own and control.
  2. Pay policy premiums, a portion of which builds cash value.
  3. Cash value earns compounding interest.
  4. Take a loan out against the policy’s cash value, tax-free.
  5. Repay loans with interest.
  6. Cash value accumulates again, and the cycle repeats.

If you use this concept as intended, you’re taking money out of your life insurance policy to purchase everything you’d need for the rest of your life. Cars. Houses. Airplane tickets. Netflix.

So, when you pay back the policy loan, just as you’d have to pay back any mortgage, auto loan, or credit card, you’re paying yourself back.

Nelson Nash popularized this concept in his book Becoming Your Own Banker.

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TRILEMMA Economics

By Staff Reporters

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What is a Trilemma?

A trilemma refers to a situation in which three options are available, but only two can be chosen at a time. It is a situation in economics and international finance in which all three possible options are difficult or nearly impossible to achieve. Unlike a dilemma, which has two options, a trilemma has three options, all of which cannot be selected at once.

Trilemma in Economics

The impossible trinity is an example of a trilemma in economics. In an impossible trinity, a country can’t have a fixed exchange rate, independent monetary policy, and free capital movement all at once. A country can achieve only two out of the three policy objectives.

The impossible trinity involves a third option as a trilemma constraint, which cannot be achieved with the selected two options. It means that the selection of any two options will make it necessary to sacrifice the third beneficial option. It is like a three-way trade-off.

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