DAILY UPDATE: D-Day, Digital Health, Stock Companies as Markets Zoom Up!

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Today is the 80th anniversary of D-Day: More than 60 World War II veterans flew to Paris over the weekend to take part in what organizers believe could be the final major WWII commemoration involving living veterans. American veterans will be joined by President Joe Biden and other heads of state in Normandy.

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The digital health market has had a tough year, with no IPOs in all of 2023. Comparatively, the industry saw roughly 20 public exits in 2021. The recent slowdown in the broader IPO market is linked to several trends, including high interest rates and some high-profile bankruptcies, according to Adriana Krasniansky, head of research at digital health strategy group and venture fund Rock Health’s advisory arm.

Here’s where the major benchmarks ended:

  • The S&P 500 index rose 62.69 points (1.2%) to 5,354.03; the Dow Jones Industrial Average® ($DJI) gained 96.04 points (0.3%) to 38,807.33; the NASDAQ Composite rallied 330.86 points (2.0%) to 17,187.90.
  • The 10-year Treasury note yield (TNX) fell more than 5 basis points to 4.283%, its lowest level since April 1.
  • The CBOE Volatility Index® (VIX) declined 0.53 to 12.63.

What’s up

  • Nvidia only rose 5.16% today, but it was enough to surpass Apple’s market cap, making the high-flying semiconductor stock the second most valuable public company in the US.
  • Crowdstrike rose 11.98% today after reporting better than expected fiscal first quarter earnings yesterday afternoon.
  • Guidewire Software rose 17.63% today after its beat & raise quarterly report late yesterday.
  • Stitch Fix rose 29.40% after a red-hot earnings report, completely turning around the stock’s slow slide downward this year.
  • SweetGreen popped 12.76% this afternoon after revealing that its new automated kitchens can actually save on costs and cut time for orders in the long run.

What’s down

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

In case you needed more proof that we’re living in the strangest timeline: Morgan Stanley, which owns E*Trade, is contemplating kicking stock influencer Roaring Kitty off the platform. It’s concerned he manipulated GameStop stocks by…posting a meme on X. (the Wall Street Journal)

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What Kind of [Physician] Entrepreneur Are You?

More Doctors are Joining the Ranks

http://www.MarcinkoAssociates.com

Marcnko & Associates

[Medical] entrepreneurs, doctors and nurses, clinics and small-to-medium size healthcare business are on the forefront of  job creation in the United States because of the Affordable Care Act [ACA] of 2010.

And so, we now preview this infographic to celebrate the entrepreneur, their styles, and to investigate the data behind startup growth. Hopefully, it will encourage the next generation of physician-entrepreneurs.

Who knows, there just may be the next Steve Jobs MD out there!

Source: BizSugar

Conclusion

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DAILY UPDATE: The Peso, Health Company News with Firmer Stock Markets

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Sword Health, a virtual provider of musculoskeletal care, banked a financing round of $130 million after nearly tripling its revenue in the past year.


Blue Cross and Blue Shield of Kansas City is leaving the Medicare Advantage market, citing increased regulatory demands and a relatively small MA membership.


And … Cigna laid off 261 employees from its Evernorth Care Group division in Arizona. Keep up to date with all workforce updates with Fierce Healthcare’s ongoing layoff tracker.

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

On Monday, the largest U.S.-traded, Mexico-focused fund — the iShares MSCI Mexico ETF which has more than $2 billion under management — slid 10.7% to book its largest daily percentage decrease since March 16th, 2020. Meanwhile, the Franklin FTSE Mexico ETF was off 10%, also logging its worst day in over four years, according to Dow Jones Market Data. The two funds, which traded at $57.93 and $28.78, respectively, on Monday afternoon, closed at their lowest levels since early November, according to Dow Jones Market Data. 

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June got off to a rough start on Monday when a glitch at the NYSE incorrectly made it appear that some stocks suffered steep plunges—including a 99% dip in Berkshire Hathaway. Trading in the affected stocks was quickly halted and the errors were fixed.

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What’s up

What’s down

  • Stanley Black & Decker fell 3.69% after it was downgraded at Barclays. A slowdown in consumer spending plus a slow housing market means not many people are buying fancy drills at the moment.
  • Bath & Body Works fell 12.60% after beating analyst expectations this quarter but announcing that next quarter will bring lower lower earnings.
  • Designer Brands fell 20.27% after it beat revenue expectations but missed on earnings as its turnaround continues.

Here’s where the major benchmarks ended:

  • The S&P 500 index gained 7.94 points (0.2%) to 5,291.34; the Dow Jones Industrial Average® ($DJI) added 140.26 points (0.4%) to 38,711.29; the NASDAQ Composite® ($COMP) rose 28.38 points (0.2%) to 16,857.05.
  • The 10-year Treasury note yield (TNX) fell more than 7 basis points to 4.328%.
  • The CBOE Volatility Index® (VIX) rose 0.05 to 13.16.

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DAILY UPDATE: Cyber Health Hacks, DocGo, Public Companies and Mixed Stock Markets

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Dollar General has ended a pilot program with mobile care provider DocGo, becoming the latest retailer to wind down primary care operations, spokespeople from both companies confirmed to Healthcare Brew on May 31st. The retail giant—the largest in the US by number of stores—began the healthcare partnership in 2023 after announcing ambitions to establish itself as a “health destination” two years prior. DocGo and Dollar General offered mobile health clinics with basic, preventive, and urgent care services at three stores in Tennessee. Dollar General executives previously said in a June 2023 press release that they would expand the DocGo pilot program to more stores.

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

Here’s where the major benchmarks ended:

  • The S&P 500® index (SPX) rose 5.89 points (0.1%) to 5,283.40; the Dow Jones Industrial Average® ($DJI) lost 115.29 points (0.3%) to 38,571.03; the NASDAQ Composite® ($COMP) advanced 93.65 points (0.6%) to 16,828.67.
  • The 10-year Treasury note yield (TNX) declined more than 11 basis points to 4.40%, near a two-week low.
  • The CBOE Volatility Index® (VIX) rose 0.19 to 13.11.

🟢 What’s up?

What’s down?

  • GSK dropped 8.65% on the news that a Delaware court will allow scientific evidence to be heard in a series of lawsuits regarding the discontinued heartburn drug Zantac.
  • Boston Beer fell 3.25% after shareholders decided to take their winnings and run following Friday’s big pop after news of its apparent acquisition by Suntory.
  • Tractor Supply shares toppled 6.21%, likely on poor manufacturing news from the ISM Index, while Halliburton shares fell 5.34%, likely on poor oil news from OPEC+.
  • Dozens of Mexican stocks and ETFs tumbled today on the election of a new president. The steepest decline was seen by Grupo Financiero Banorte, SAB, which fell 11.38%.

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

Cyberattacks around the country are wreaking havoc on the ground at targeted hospitals, but a new study shows that security breaches hurt surrounding providers, too. The research published in JAMA on May 29 found that cyberattacks led to a decrease in emergency department (ED) visits at attacked hospitals and an increase in ED patients at nearby hospitals.

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PODCAST: What is a Quality-Adjusted Life Year?

NOT A Generic Obscure Measure

By Dr. David E. Marcinko MBA MEd CMP

http://www.CertifiedMedicalPlanner.org

The quality-adjusted life year or quality-adjusted life-year (QALY) is a generic measure of disease burden, including both the quality and the quantity of life lived.

It is used in economic evaluation to assess the value for money of medical interventions. One QALY equates to one year in perfect health. If an individual’s health is below this maximum, QALYs are accrued at a rate of less than 1 per year.

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

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ASSESSMENT: To be dead is associated with 0 QALYs. QALYs can be used to inform personal decisions, to evaluate programs, and to set priorities for future programs

VIDEO: https://www.youtube.com/watch?v=OTmXnv2RAHw

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

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DAILY UPDATE: Jobs, Chips, Banks and Tax Refunds

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Stat: 4.6%. That’s how much the average income tax refund increased YoY, from $2,878 in April 2023 to $3,011 as of April 5th. (Axios)

Quote: “Wall Street has never been known for high character and high values. Is there a willingness to support Trump if it looks like he’s on the right track? Yes. I’m not proud of that, and I’m not part of that either.”—Dan Lufkin, co-founder of investment bank Donaldson, Lufkin & Jenrette (Bloomberg)

Read: Bank of America’s CEO sees an overall cautiousness on display in the current spending choices of consumers and businesses. (CNBC)

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The May jobs report will drop on Friday: Little change is expected from April, when the unemployment rate ticked up to 3.9% and fewer jobs were added than expected (175,000). This jobs report will be one of the final pieces of economic data to drop before the Fed meets on June 11th and 12th. The central bank is unlikely to announce an interest rate cut.

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

Software is no longer eating the world. For the first time, chip stocks now account for the heaviest weighting in the S&P 500, taking the top spot away from software companies last week. Salesforce and other enterprise software giants are getting crushed as companies prioritize generative AI investments (chips and servers) over SaaS products.

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PODCAST: What is Epistemic Ambivalence?

Epistemic Ambivalence!

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

[By staff reporters]

Epistemic Ambivalence is almost the opposite idea of what ambivalence means because to be epistemic means you know, you are sure.

Epistemic ambivalence is when you may know the truth of a situation but cannot say which truth it is, because there is more than one option.

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MORE: Schrödinger’s cat is a thought experiment, sometimes described as a paradox, devised by Austrian physicist Erwin Schrödinger in 1935. It illustrates what he saw as the problem of the Copenhagen interpretation of quantum mechanics applied to everyday objects. The scenario presents a hypothetical cat that may be simultaneously both alive and dead, a state known as a quantum superposition, as a result of being linked to a random subatomic event that may or may not occur. The thought experiment is also often featured in theoretical discussions of the interpretations of quantum mechanics. Schrödinger coined the term Verschränkung (entanglement) in the course of developing the thought experiment.
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Assessment: Your thoughts are appreciated.
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Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners(TM)
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Invite Dr. Marcinko

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What is “COMPASSION FADE?”

A Cognitive Bias of the Post Corona Virus Pandemic Era

Courtesy: www.CertifiedMedicalPlanner.org

By Dr. David E. Marcinko MBA MEd CMP

Compassion Fade is a cognitive bias that predisposes people to behave more compassionately towards a small number of identifiable victims than to a large number of anonymous ones.

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

It is the psychological explanation to the known phenomenon alluded to by Joseph Stalin in his famous quote “The death of one man is a tragedy; the death of millions is a statistic”.

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LINK: https://www.publichealthpost.org/research/compassion-fade/

Assessment: Your thoughts and comments are appreciated.

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BUSINESS, FINANCE, INVESTING AND INSURANCE TEXTS FOR DOCTORS:

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DAILY UPDATE: Mixed Stock Markets with DJIA Up

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Here’s where the major benchmarks ended:

  • The S&P 500 index added 42.03 points (0.8%) to 5,277.51, down 0.5% for the week; the Dow Jones Industrial Average® ($DJI) gained 574.84 points (1.5%) to 38,686.32, down 1.0% for the week; the NASDAQ Composite® ($COMP) declined 2.06 points (0.01%) to 16,735.02, down 1.1% for the week. 
  • The 10-year Treasury note yield (TNX) fell more than 6 basis points to 4.491%.
  • The CBOE Volatility Index® (VIX) declined 1.55 to 12.92.

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

🟢 What’s up

  • Gap popped 27% after the retail conglomerate raised its guidance for the year and sales for all four of its brands beat earnings expectations.
  • Caesars jumped 12% because of the Carl Icahn effect: The investor reportedly acquired a “sizeable stake” in the casino company, per Bloomberg.
  • The Boston Beer Company shares gained 21% on reports that the company may sell itself to Suntory.
  • Ambarella leapt 20% after better-than-expected earnings for the semiconductor company.
  • PENN Entertainment jumped 20% today after an activist investor called for a sale of the company.

What’s down

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Private equity and consolidation are leading to a rise in hospital costs for patients. (the Wall Street Journal)

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DAILY UPDATE: Hospital Charges, Cannabis and Stocks as Markets Slump

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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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http://www.MedicalBusinessAdvisors.com

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The prices hospitals charge for their services have long been opaque, but thanks to a 2021 hospital price transparency law, the picture is starting to come slightly into focus. And it turns out, there are some huge disparities in the prices hospitals charge that can’t be attributed to quality of care, according to a recent study from research institute Rand Corporation.

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

🟢 What’s up

What’s down

  • Salesforce is down 19.73% after the cloud computing company missed revenue estimates for the first time since 2006 and projected slower sales in the coming quarter. Turns out not even commercials featuring hunky Matthew McConaughey could save the company’s quarter.
  • UIPath shares plummeted 34.06% after announcing disappointing results and lower forward guidance, and to add insult to injury got hit with an analyst downgrade from Bank of America.
  • Build-A-Bear Workshop got the stuffing knocked out of it, dropping 13.92% after it missed estimates on both the top and bottom lines.
  • Hormel sank 9.69% after missing earnings thanks to slower retail sales offsetting higher meat prices, leaving shareholders stuck eating bologna sandwiches for lunch.
  • Kohl’s dropped 22.88% in its worst day ever after the company announced a terrible quarter and forecast more issues ahead due to customers contending with inflation.

Here’s where the major benchmarks ended:

  • The S&P 500® index (SPX) fell 31.47 points (0.6%) to 5,235.48; the Dow Jones Industrial Averagedropped 330.06 points (0.9%) to 38,111.48; the NASDAQ Composite® ($COMP) declined 183.50 points (1.1%) to 16,737.08.
  • The 10-year Treasury note yield (TNX) lost more than 7 basis points to 4.548%.
  • The CBOE Volatility Index® (VIX) rose 0.19 to 14.47.

Interest-rate-sensitive sectors including banks and utilities were among the stronger performers Thursday, boosted by a pullback in Treasury yields from four-week highs posted earlier in the week. Stocks are still heading for a down week, with the S&P 500 on track for its first weekly decline out of the past six.

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

Legal cannabis is a booming industry: An estimated $38.4 billion in medical and recreational cannabis was sold in the US in 2023, and that figure is projected to rise to $56.9 billion by 2028. The industry has grown an average of 29.1% per year between 2018 and 2023, according to IBISWorld.

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What is the “DeMark” Investing Indicator?

A TECHNICAL ANALYSIS STOCK TRADING SIGNAL?

By Dr. David Edward Marcinko MBA, MEd CMP

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DEFINITION: The DeMark indicator (DeM) is a technical analysis oscillator that compares the most recent and previous prices of an asset to measure the demand and the directional trend of the market. It is based on principles promoted by technical analyst Thomas DeMark, who developed it over his nearly 50-year career. It aims to identify potential price reversals and inflection points before the market responds. It can be applied to any asset class, region, time interval, and data set.

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

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See the source image

READ: https://www.tradingview.com/scripts/demark/

TECHNICAL ANALYSIS: https://medicalexecutivepost.com/2007/12/03/the-technicians/

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DAILY UPDATE: Physician Salary, Consumer Confidence, Company Stocks and Slumping Markets

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Doctors Saw a 6% Boost in Pay in 2023

After several years of modest or declining growth, the average pay for doctors jumped 5.9% in 2023, rebounding from a decline of 2.4% in 2022. Most medical specialties experienced positive growth in 2023, with the top 10 seeing annual growth rates exceeding 7%, according to the 2024 Physician Compensation Report from professional medical network Doximity.

However, inflationary pressures continue to impact physicians’ real income. According to the American Medical Association, when adjusted for inflation, Medicare physician payment has dropped 26% since 2001. Doximity’s compensation data draw from nearly 150,000 survey responses over five years, including responses from more than 33,000 U.S. physicians in 2023 alone.

Source: Heather Landi, Fierce Healthcare [5/23/24]

Economic Summary

  • The S&P 500 has risen 23 of the last 30 weeks, according to Deutsche Bank, and rose slightly today as well. Meanwhile, the NASDAQ closed at a record high yesterday after tech companies across the board rose, while the Dow dropped over 200 points.
  • Treasury prices fell and yields rose after two weaker-than-expected auctions saw soft sales of 2-year and 5-year bonds.
  • Gold prices slipped 5% last week after falling four days in a row, but the key commodity kicked off this week with a win. With key PCE data coming out on Friday that could send the market soaring or tanking, investors are hedging their bets with the shiny yellow metal.
  • Bitcoin fell as Mt. Gox made good with its creditors a decade after being hacked, while ethereum sank as traders continued to lock in gains from the SEC’s dramatic ruling last week.
  • The S&P 500® index (SPX) fell 39.09 points (0.7%) to 5,266.95; the Dow Jones Industrial Average lost 411.32 points (1.1%) to 38,441.54; the NASDAQ Composite® ($COMP) shed 99.30 points (0.6%) to 16,920.58.
  • The 10-year Treasury note yield climbed more than 7 basis points to 4.614%.
  • The CBOE Volatility Index® (VIX) rose 1.38 to 14.30.

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

Consumer confidence rose for the first time in four months

Americans are unexpectedly feeling better about the economy this month: Per the Conference Board’s monthly index, US consumer sentiment rose from 97.5 in April to 102 in May, smashing economists’ estimates. Meanwhile, the expectations index, which measures the short-term outlook for income and other labor market conditions, increased the most since July. However, the report showed that Americans remain worried about inflation and interest rates. Despite their mixed feelings about the economy, Americans continue to spend vigorously on travel. The TSA set a record for most travelers screened in a single day last Friday.

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

STOCKS UP:

Dick’s Sporting Goods rose 15.86% to a new all-time high today after the company reported impressive earnings and a strong outlook.

STOCKS DOWN:

American Airlines shares fell 13.54% after the company cut its guidance for the second quarter. Southwest Airlines fell 3.83%, and Delta Air Lines fell 0.74%.

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DAILY UPDATE: Citigroup, CBO, CFPB, Spiked Treasury Yields and the Mixed Stock Markets

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Stat: $78 million. That’s the fine levied against Citigroup for an accidental, “fat finger” trade that momentarily erased $322 billion in market value in the European stock markets. (Business Insider)

Quote: “The CFPB wants to make sure that these new competitive offerings are not gaining an advantage by sidestepping the rights and responsibilities enshrined under the law.”Rohit Chopra, director of the Consumer Financial Protection Bureau, on the CFPB’s decision to treat “buy now, pay later” apps as credit cards.

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Here’s where the major benchmarks ended yesterday:

  • The S&P 500® index (SPX) rose 1.32 points (0.02%) to 5,306.04; the Dow Jones Industrial Average® ($DJI) lost 216.73 points (0.6%) to 38,852.86; the NASDAQ Composite gained 99.09 points (0.6%) to 17,019.88.
  • The 10-year Treasury note yield jumped almost 7 basis points to 4.54%.
  • The CBOE Volatility Index® (VIX) rose 0.55 to 12.91.

Financial shares were among Tuesday’s weakest performers, reflecting ideas elevated interest rates could burden bank margins. The KBW Regional Bank Index (KRX) sank 1% to its lowest close since April 30. Biotechnology and health care sectors were also under pressure.

In other markets, WTI Crude Oil (/CL) futures jumped more than 3% and ended at a four-week high above $80 per barrel ahead of next weekend’s OPEC meeting, which is expected to end with no change to the cartel’s production levels.

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House Committee Chair Jodey Arrington (R-Texas) said that site-neutral payment policy is the “most obvious” solution amid supportive testimonies from partisan think-tanks, the Congressional Budget Office and a practicing independent physician. 

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What is OBSERVATIONAL BIAS?

EVIDENCE BASED MEDICINE

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Observer bias occurs in research when the beliefs or expectations of an observer (or investigator) can influence the data that’s collected in a study.

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Supporting Teachers: Reducing Observational Bias - TeacherToolkit

This causes the results of a study to be unreliable and hard to reproduce in other research settings.

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DAILY UPDATE: Post Memorial Day Tuesday

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US markets were closed for Memorial Day in what will be a quiet few days until the latter half of the week, when a slew of economic reports get filed. The highlights include the Fed’s Beige Book on Wednesday, initial jobless claims and Q1 GDP on Thursday, and both the April personal income & spending report and the all-important PCE read on Friday.

PCE, or the Personal Consumption Expenditures Price Index, will dictate market moves more than any of the other readings next week, since the Fed places a lot of importance on the measure—particularly core PCE, which excludes ever-changing food and gas prices. April’s CPI report was better than expected, but recent FOMC minutes revealed the Fed is still hesitant to cut interest rates without more data—which makes this PCE reading all the more significant.

And don’t forget, the US isn’t the only country fending off high inflation. Germany reports preliminary May CPI on Wednesday, while readings for France, Italy, and the entire Eurozone will be released on Friday. Tokyo CPI, economic activity, and job market data will also come out on Friday, in what is turning out to be a key day in determining where markets are heading as the second half of the year kicks off.

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  • Stock spotlight: One to watch this week is Dell, which reports its quarterly earnings on Thursday. Investors will be seeking news on its AI-server business. The company hit a record high last week as Nvidia’s red-hot revenue numbers boosted AI-related stocks.

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DAILY UPDATE: Memorial Day as Stocks Recover

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Here’s where the major stock market benchmarks ended:

  • The S&P 500 index added 36.9 points (0.7%) to 5,304.72, basically flat on the week; the Dow Jones Industrial Average gained 4.3 points (0.0%) to 39,069.59, down 2.3% for the week; the NASDAQ Composite® ($COMP) rallied 184.8 points (1.1%) to 16,920.79, up 1.4% for the week.
  • The 10-year Treasury note yield (TNX) was little changed at 4.46%, up about four basis points for the week.
  • The CBOE Volatility Index® (VIX) fell 0.86 to 11.91 and finished a roller-coaster week roughly where it started.

Some of the mega cap names saw notable strength Friday. Nvidia added another 2.6% to Thursday’s 9.3% post-earnings rally. Apple (AAPL) gained 1.7%, Meta Platforms (META) added 2.7%, and Tesla (TSLA) rose 3.2%

The small cap Russell 2000® Index (RUT) also outperformed, gaining nearly 1% Friday. However, for the week, the index lost 1.3%.

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Craig Venter Unveils Synthetic Life

Some Positive News on Memorial Weekend 2024

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

Was Artificial Life Created A Decade Ago?

According to Craig Venter “synthetic life” was created. Venter is the American biologist and entrepreneur most famous for his role in being one of the first to sequence the human genome. He has now reportedly synthesized the first artificial cell.

I don’t know about you, but this is huge news – regardless of whether you call it “life” or not.

An Arm Chair Philosopher

Now, I am not speaking as a doctor or scientist; but rather as an armchair economist and philosopher recalling my undergraduate days at Loyola University Maryland, under the tutelage of the late Aldo Tassi PhD. So, I repeat, this was huge news and an interesting piece of science. It is historic, and has large implications for the future and even the economy. Why?

The Invisible Hand

Much of our time here at the ME-P is spent integrating the hard and soft sciences of practice management, economics and financial planning for a medical audience. But occasionally, negative situations, political cycles and pessimistic opinions on our topic channels are expressed. These disparaging political remarks even indirectly target the USA and our very survival as a free nation and self-governing people.

IOW: Contrary to innovations, and innovators, like Craig Venter.

Nevertheless, there an “invisible hand” – call it economics or capitalism – that keeps us moving in the direction of survival. And, we are conscious beings capable of controlling the rate of that progression in all fields of human endeavor.

What it Is

A chromosome was designed in digital code on a computer and then transplanted into a bacterial cell, transforming that cell into a new bacterial species. Apart from the usual blueprint for proteins, the DNA also carried the names of the key contributors and even its own email address.

How it Works

As reported according to Venter, “This is the first self-replicating species on the planet, whose parent is a computer.”

And, he has already mentioned some potential practical applications for his discovery: a vaccine for HIV and a new strain of algae that can significantly decrease CO2-levels and provide a source for gasoline.

Assessment

And so, on this Memorial Weekend – a day for remembering death and sacrifice – let us celebrate life and achievement instead by stating that we are not apologists for the USA.

As the last best hope for this planet, we are not always right or politically correct, but this country offers the greatest opportunity on earth for human advancement, capitalism and success through conscientious work effort.

We do not believe America has seen better days. Those who fought did not die in vain. Better days are still in our future. We are optimistic about the long-term future of our country when looking at our progression to ameliorate the planet’s ills, to-date. We have come out of hard times before – like the current recession – by taking innovative steps forwards, not backwards. While we are likely to go through a period of adjustment in the near-term, the end result will be further individual, national and private progress in the USA. God Bless America.

Rest assured, we will continue to lead and create the world, much like Crag Venter created artificial life. Candor – Intelligence – Goodwill to all

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. What do you think of this development? What economic discoveries, medical cures, life enhancing inventions and/or break-thru innovations will this creation open up?

Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe. It is fast, free and secure.

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Conclusion

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DAILY UPDATE: Sunday Stock Market Weekend Recap

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  • A tough week just ended with the Dow Jones just barely in the green, though the index snapped its 5-week winning streak thanks in large part to its worst day of trading this year on Thursday. The NASDAQ hit a new all-time high on the back of Nvidia’s strong earnings, while the S&P 500 rose but ended the week flat.
  • Bond yields rose this week as investors came to terms with the idea that the Federal Reserve may not cut rates more than once in 2024, fleeing to the safety of Treasuries. Gold ended the week down overall.
  • The market turned on copper selling off for a third straight day. And oil finally snapped its losing streak, rising on the hopes of a travel-heavy Memorial Day weekend, though crude still ended the week lower than where it started.
  • The big winner was ethereum thanks to the approval of a spot ethereum ETF by the SEC.

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The U.S. Markets were closed on Monday, May 27th, 2024. Please be aware that, transactions made after 4 p.m. EST on Friday, May 24th, 2024, will receive the closing price as of Tuesday, May 28th, 2024.

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Activity-Based-Medical-Cost Accounting and Management

A Non-Traditional Accounting System

[By Dr. David Marcinko MBA MEd CMP]CPA

Sooner or later you will want to ascertain and then demonstrate the cost effectiveness of your medical care. By using the process of Activity Based Cost (ABC) management, you will be able to do so.  But, if you’re using a traditional accounting system, you won’t know a thing about your activity costs. Here’s how. 

Traditional Cost Accounting Methods 

In a traditional medical practice cost accounting system, costs are assigned to different procedures and services based on volume.  In others words, office costs are spread over the entire office’s product line and you may not know the true profitability of any single medical activity. So, if the office is doing more “procedures” than general medicine, for example, more indirect office overhead costs will be allocated to the procedural portion of the practice. 

ABC management, on the other hand, determines the actual costs of the resources that each service consumes. Because general medicine requires more human resources than “technical procedures,” ABC management will assign more costs to the general medical portion of the practice. 

Accordingly, most physicians, office managers, and their accountants are surprised that a prior notion of office profitability is different than previously thought. ABC management is just more accurate in measuring medical service profitability than traditional accounting methods. 

Medical Activity Cost Drivers 

Examples of medical activities that are office cost drivers include such items as monitoring vital signs, taking radiographic images, removing dressings or casts, performing laboratory tests or veni-punctures, surgical set-ups or operative procedures; etc.  

However, in the office setting, the most economically important activities are listed as specific CPT codes for each medical specialty.  The most important end result of ABC management is the shift of general overhead costs to low volume services from high volume services. These effects are not symmetrical as there is a bigger dollar effect on the per-unit costs of the low volume service.  

ABC Managerial Accounting Improvements 

ABC management improves office managerial cost accounting systems in three ways: 

  1. It increases the number of cost pools used to accumulate general overhead office costs. Rather than accumulate overhead costs in a single office-wide pool, costs are accumulated by activity, service or procedure.
  2. It changes the base used to assign general overhead costs to services or patients. Rather than assigning costs on the basis of a measure of volume (employee or doctor hours), costs are assigned on the basis of medical services or activities that generated those costs.
  3. It changes the nature of many overhead costs in that those formerly considered indirect, are now traced to specific activities or services. The office service mix may then be adjusted accordingly, for additional profit.   

Methodology 

In order to perform an ABC analysis for your medical office, calculate the cost of delivering a single unit of medical or surgical activity using only the work component of the resource based relative value scale (RBRVS).

Do this by adding up your office’s average variable expenses for the prior 1-3 years.  Now, count the number of work resource based relative value units (RBRVUs) delivered for each CPT code for the same time period, using the latest edition of the Federal Register to obtain the latest list of RVUs by CPT code. Then divide total variable expenses by the total number of work RVUs in order to arrive at the marginal cost of a single unit of service for the time period being evaluated.

For example, if your office had variable expenses of $480,000, and produced 80,000 work RVUs last year, it cost $6, on top of the office’s fixed expenses, to deliver one unit of work product. So, if an HMO plan offers to reimburse you at a rate of $11 per member, per month, and you can expect to reasonably deliver on average of one RVU pm/pm, you’ll earn enough on the contract to cover your marginal costs and some of your fixed and direct expenses. 

CASE MODELs: CVPA 4 and CVPA 3

dhimc-bookAssessment

Remember, this method assumes that you have the excess operating capacity and time slots, available and unused, to see the additional patients of the new plan without adding extra overhead expenses to service the contract.

If not, or if you plan for capitation to become a major portion of your practice, you might want the capitated contract(s) to cover all your office expenses, so be sure to include both the fixed and other direct costs to your variable cost calculations. ABC determines the actual costs of resources rendered for each activity and represents a real measure of practice profitability. Office service mix can then be changed to either maximize revenues or better suit your practice personality.

A Caveat

Suppose however, that a medical service is competitively priced but still shows that the CPT code is unprofitable. For example, the costs of special requests can adversely affect office profits. Yet, special patient requests are one of the biggest reasons that a CPT code or procedure isn’t profitable.

In this case, look closely at activity costs and determine which ones are being performed inefficiently. Improving the efficiency of those kinds of medical services, or referring them out or abandoning them all together, will increase office profitability.

MORE: ABCM

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MEMORIAL DAY: Weekend Origination Thoughts 2024

“Decoration Day”

By Dr. David E. Marcinko MBA MEd CMP

”Memorial Day (Decoration Day) is a federal holiday in the United States for honoring and mourning the military personnel who died while serving in the United States Armed Forces.

The holiday is now observed on the last Monday of May, having been observed on May 30th from 1868 to 1970.

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DAILY UPDATE: Friday Before Memorial Day Weekend and the Stock Market Collapse

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The Friday before Memorial Day is never action packed, and this year is no exception as earnings season begins to wrap up and economic readings slow down. Two reports to watch for tomorrow: April Durable Goods Orders and University of Michigan’s May sentiment report.

Durable Goods Orders are big-ticket items with a shelf life of three or more years—think appliances and furniture for consumers, or machinery, equipment, and vehicles for businesses. More durable goods orders indicate a healthy economy, as consumers and companies alike wouldn’t spend as much if they weren’t confident they could afford it, and also provides insight into how strong the manufacturing industry is.

The University of Michigan’s consumer sentiment index is a survey of consumers via telephone to better understand how they feel about the economy, what they’re spending their money on, etc. The preliminary findings earlier this month weren’t great thanks to sticky inflation, and tomorrow’s finalized readings won’t change much. But with the latest CPI reading indicating inflation might yet be tamed, next month’s report could be much more illuminating.

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Here’s where the major benchmarks ended:

  • The S&P 500® index (SPX) fell 39.17 points (0.7%) to 5,267.84; the Dow Jones Industrial Average lost 605.78 points (1.5%) to 39,065.26; the NASDAQ Composite® ($COMP) shed 65.51 points (0.4%) to 16,736.03.
  • The 10-year Treasury note yield rose more than 4 basis points to 4.479%.
  • The CBOE Volatility Index® (VIX) rose 0.48 to 12.77.

Financial shares were among Thursday’s weakest performers amid ideas a “higher-for-longer” Fed rate outlook could pressure bank margins. The KBW Regional Bank Index (KRX) dropped almost 3% to a three-week low. Other interest-rate-sensitive sectors, including real estate and utilities, took pressure.

In other markets, WTI Crude Oil (/CL) futures fell for the fourth straight trading day and closed at a three-month low under $76 per barrel.

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Spot Ethereum ETFs were approved by the SEC in another big win for crypto, following the approval of spot bitcoin ETFs earlier this year.

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DAILY UPDATE: Uber Health, Lyft Healthcare, HHS Cyber Attacks as Markets Swoon

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Here’s where the major benchmarks ended:

  • The S&P 500 index lost 14.40 points (0.3%) to 5,307.01; the Dow Jones Industrial Average® ($DJI) declined 201.95 points (0.5%) to 39,671.04; the NASDAQ Composite® ($COMP) slipped 31.08 points (0.2%) to 16,801.54.
  • The 10-year Treasury note yield (TNX) rose more than 1 basis point to 4.426%.
  • The CBOE Volatility Index® (VIX) increased 0.43 to 12.29.

Retailer shares were among the market’s weakest performers after Target’s (TGT) quarterly results, released before Wednesday’s open, fell short of expectations. Target shares tumbled 8% after the company reported revenue fell 3% in the first quarter from the year-earlier period. During the company’s earnings call, Target CEO Brian Cornell noted “continued soft trends in discretionary categories” contributed to the revenue decline.

Energy companies were also under pressure after WTI Crude Oil (/CL) futures closed at a three-month low just above $77 per barrel.

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Following a series of high-profileand costlycyberattacks against the healthcare industry, the federal government is stepping in with a $50+ million initiative intended to boost hospital cybersecurity, a division of the Department of Health and Human Services (HHS) announced on May 20th.

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Uber Health will begin rolling out a new solution designed for caregivers this summer, allowing individuals to add a caregiver to their Uber profile. That caregiver can then see and spend that person’s health benefits on eligible services, request rides to doctors’ appointments or order groceries. In the coming months, Uber Health will be working with Medicare Advantage, Medicaid and commercial plans to offer the solution.


U.S. Sens. Sheldon Whitehouse and Bill Cassidy, M.D., want to reform how primary care providers get paid through Medicare, and they also want to hear from the healthcare industry about the best way to do it. Together, they introduced a bipartisan bill, the Pay PCPs Act (S. 4338), last week to better support and improve pay for high-quality primary care providers. 


And… digital maternal health company Babyscripts announced a partnership with Lyft Healthcare to offer sponsored rides for people who are pregnant or postpartum and face barriers to transportation. The Lyft partnership will identify transportation-insecure patients and offer free rides to in-person appointments in traditional care settings and community-based healthcare services and programs.

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DAILY UPDATE: Hims & Hers, MSFT-AI, Neuralink, FDIC and New Market Highs

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Microsoft unveiled new PCs with AI-powered features.

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Hims & Hers stock soared as much as 38% on the news that it’ll provide GLP-1 injections with the same active ingredient as Ozempic or Wegovy for just $199/month—an 85% discount compared to Wegovy’s ~$1,350 monthly price tag (without insurance).

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FDIC Chair Martin Gruenberg will resign after an investigation found widespread sexual harassment at the agency. But he won’t step down until a successor is named.

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The FDA granted Elon Musk’s neurotech company Neuralink, approval to place its brain chip into a second human test subject using a new method designed to correct issues that arose after its inaugural insertion in January, per the Wall Street Journal.

And, Optum Rx is shaking up its pharmacy model. The business says it will make drug costs more predictable and transparent for clients.

CITE: https://tinyurl.com/tj8smmes

  • All three indexes ended the day higher after Fed Governor Christopher Waller stopped by CNBC and mentioned he doesn’t think raising interest rates is in the cards, even if the Fed is waiting for more data before making cuts. The NASDAQ continued to hit new all-time highs today as investors place their bets before Nvidia’s earnings announcement tomorrow afternoon, and the S&P 500 hit yet another record.
  • Copper continued to rise as the market comes to terms with the metal’s importance, while oil fell on the news that the Biden administration will release 1 million barrels of gasoline this summer from the Northeast reserve. Meanwhile, ethereum continued to climb on the news that a new ETF may be joining the fray.

Here’s where the major benchmarks ended:

  • The S&P 500 index rose 13.28 points (0.3%) to 5,321.41; the Dow Jones Industrial Average® ($DJI) gained 66.22 points (0.2%) to 39,872.99; the NASDAQ Composite advanced 37.75 points (0.2%) to 16,832.62.
  • The 10-year Treasury note yield (TNX) lost more than 2 basis points to 4.414%.
  • The CBOE Volatility Index® (VIX) fell 0.29 to 11.86.

Banking and consumer staples were among the market’s strongest performers Tuesday, while utility shares extended a sharp upswing over the past month. The Dow Jones Utility Average® ($DJU) added 0.5% and closed at a 12-month high. Transportation companies were among the weakest performers.

In other markets, Gold (/GC) futures slipped from Monday’s record high above $2,454 per ounce, while Silver (/SI) futures ended near a 12-year high around $32.21. Gold futures are still up 17% this year due to several factors, including reports of China’s central bank buying actual gold as well as escalating conflict in the Middle East. Gold is viewed by some as a safe-haven asset during periods of heightened geopolitical tension.

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PHYSICIANS & DENTISTS: Financial Consulting & Planning

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EXPLAINED: Medical “Bottle Neck” Accounting

VARIANCE AND BOTTLE-NECK ACCOUNTING

DR. DAVID E. MARCINKO MBA MEd CMP

Any healthcare organization usually has several processes involved in the utilization of its patient services. Unfortunately, bottlenecks may arise which constrain the amount of services any given healthcare entity can deliver. 

Accounting Definition 

An accounting “bottleneck” is a process that has a low output and limits total healthcare entity revenues. If a medical business entity wants to increase sales or revenues, it has to solve its bottleneck [ie., access management] problems. 

Traditional Variance Analysis Dilemma 

With traditional variance analysis [VA], managers and administrators analyze the difference between budgeted patient revenues and actual revenues. Typically, differences between budgeted revenues and actual revenues are analyzed as seen in the example below.

Initially postulated by Horngren and Foster for manufacturing processes, VA can now be modified for medical business entity use. 

Example: 

  Patient Service Units   Contract/UCR Fee    
Budgeted sales revenues 10,000,000 * 1,23 = $ 12,300,000
Actual sales revenues 9,000,000 * 1,21 = $ 10,890,000
          -/- —————-
Total variance         $ 1,410,000
Traditional Assessment
Actual patient revenues were lower than budgeted; and the unfavorable patient sales volume variance was (9,000,000 – 10,000,000) * $ 1,23 = – $ 1,230,000. 

  

The actual patient revenue price was lower than budgeted as the unfavorable price variance was: ($ 1,21 – $ 1,23) * 9,000,000 = – 180,000.

Traditional variance analysis however does not point out which of the processes were bottlenecks, which caused the negative volume variance.Thus, a normal variance analysis can’t be used to solve bottlenecks in a clinic, hospital or medical practice.

Enter B-N Accounting

In bottleneck accounting however, managers and healthcare administrators determine the bottlenecks in a medical organization.And, a bottleneck accounting report shows which process were bottlenecks occur and how much money is lost in each bottleneck.

Example:

Bottleneck Patient Sales Revenues $ 800,000
Bottleneck Dep. II $ 350,000
Other Bottlenecks $ 80,000
  + —————-
Total Volume Variance $ 1,230,000

Conclusion: 

The managerial accounting modification for “bottlenecks” not only points out the bottlenecks to solve, it also shows which bottleneck is to be handled first.

And so, what are your thoughts on this accounting machination? Please comment.

References: Horngren, C. T. and G. Foster, ‘Cost Accounting, A Managerial Emphasis’, Prentice-Hall, Inc. 1987. 

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

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“ACTIVE” INVESTMENT STRATEGIES: For Physicians

And … why doctors are different?

By Dr. David Edward Marcinko MBA MEd CMP

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By Dr. David Edward Marcinko MBA CMP

There are two distinct forms of financial analysis investment strategies often used by medical colleague investors who desire to pursue an active investment strategy.

Technical Analysis: Technical analysts, sometimes referred to as chartists, use historical price data and transaction volume data to identify mis-priced securities. A key belief shared by technical analysts is that stock prices follow recurring patterns and that once these historical patterns are identified, they can be used to identify future security prices. The heart of technical analysis is identifying significant shifts in the macro/micro economic supply and demand factors for a particular securities investment.

Skeptics of technical analysis generally subscribe to the notion that the markets efficiently and accurately price securities. In fact, the weak form of the Efficient Market Hypothesis [EMH] is based on the view that investors cannot consistently earn superior returns using historical data and technical analysis alone.

Fundamental Analysis: In contrast to technical analysis – which relies on historical market returns / transactions data – fundamental analysis focuses on the underlying company’s assets, earnings, risks, dividends and intrinsic security factors to identify mis-priced securities.

Furthermore, investors using fundamental analysis can use either a top-down or bottom-up approach:

  • The top-down investor starts with global economics, including both international and national economic indicators. These may include GDP growth rates, inflation, interest rates, exchange rates, productivity and energy prices. They subsequently narrow their search to regional / industry analysis of total sales, price levels, the effects of competing products, foreign competition and entry or exit from the industry. Often they refine their search to the best business in the area being studied.
  • The bottom-up investor starts with specific businesses, regardless of their industry / region, and proceeds in reverse of the top-down approach. Bottom-up investing is an approach that focuses on analyzing individual stocks and de-emphasizes the significance of macroeconomic and market cycles. In other words, bottom-up investing typically involves focusing on a specific company’s fundamentals, such as revenue or earnings, versus the industry or the overall economy. The bottom-up investing approach assumes individual companies can perform well even in an industry that is under performing, at least on a relative basis.

And so, a medical professional utilizing fundamental analysis is attempting to find securities that are trading at market prices below their intrinsic value. Skeptics suggest this is difficult or almost impossible to achieve.

Thus, while technical analysis focuses on market price history, a security’s intrinsic fundamental analysis is determined independent of the security’s market value. Of course, a combination of both fundamental and technical analysis can also be considered.

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DAILY UPDATE: Abbvie, Treasuries, Gold, Copper and the NASDAQ Rally

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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The yield on the 10-year Treasury rose as investors wait for word from the FOMC on Wednesday, while oil initially rose on the news of the death of the president of Iran, though it fell back down to end the day lower after succession of the presidency was settled. But investors were clearly still feeling jittery as gold hit new highs on the back of geopolitical concerns. Copper also rose to a new all-time high.

Here’s where the major benchmarks ended:

  • The S&P 500 index gained 4.86 points (0.1%) to 5,308.13; the Dow Jones Industrial Average® ($DJI) lost 196.82 points (0.5%) to 39,806.77; the NASDAQ Composite rallied 108.91 points (0.7%) to 16,794.87.
  • The 10-year Treasury note yield (TNX) increased more than 2 basis points to 4.443%.
  • The CBOE Volatility Index® (VIX) rose 0.15 to 12.14.

Nvidia’s gain helped push the PHLX Semiconductor Index (SOX) more than 2% to a two-and-a-half-month high and just under a record close posted in early March. The small-cap Russell 2000® Index (RUT) added 0.3% and ended slightly below a six-week high posted last Wednesday. 

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JPMorgan shares fell 4.5% as investors realized that they won’t have Jamie Dimon around forever—he told shareholders at a meeting today that his 5-year timetable for leaving the company no longer applies.

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After AbbVie’s Humira, the best-selling drug in the world, lost patent exclusivity in 2023, company executives placed their bets on two other AbbVie drugs, Skyrizi and Rinvoq, to make up for an anticipated steep decline in revenue.

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What’s Your Business [Medical Practice] Start Up Style?

Entrepreneurs, their Styles and the Drive Behind Them!

[By staff reporters]

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It goes without saying that it takes a special kind of person to become a doctor, and an entrepreneur.

Driven, motivated, innovative – these are just a few of the many ways to describe individuals who risk everything to transform their vision into reality; or to save lives.

We created this infographic to celebrate the entrepreneur, not only for their individual, quirky styles, but also for their contributions to the global economy.

Source: bizsugar.com

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Assessment

Are medical professionals the same or different today -OR- in the health 2.0 future?

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Conclusion

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

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DAILY UPDATE: Fiduciary Rule with Stock Market Earnings Week

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For last the week, the NASDAQ Composite (^IXIC) rose more than 2% while the S&P 500 (^GSPC) popped more than 1.5%. The Dow Jones Industrial Average (^DJI) rose more than 1%, closing above 40,000 for the first time ever on Friday.

In the week ahead, highly anticipated earnings results from Nvidia (NVDA) are expected to be the key catalyst for markets. Results from Target (TGT), Palo Alto Networks (PANW), and Lowe’s (LOW) will also be closely tracked by investors.

The week is also expected to be quieter on the economic front, with updates on activity in the manufacturing and services sectors as well as the final reading of consumer sentiment for May on tap. Minutes from the Fed’s May meeting are also expected on Wednesday afternoon.

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The rule, finalized last month by the Labor Department, requires investment advisers to provide “prudent, loyal, honest advice free from overcharges” and avoid recommendations that favor their interests at the expense of their clients. It also updates the definition of an investment advice fiduciary under the Employee Retirement Income Security Act (ERISA) and Internal Revenue Code. 

Under the new definition, a fiduciary includes any financial services provider who offers investment advice to a retirement investor for a fee and who claims to be acting as a fiduciary or who a reasonable investor understands to be a trusted adviser acting in their best interest. The update removes the requirement that fiduciaries provide advice on a regular basis, bringing one-time advice under the rule. The Biden administration has argued that the previous definition, which was written in 1975, is outdated and has not kept pace with changes to the retirement landscape. 

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And, confidence in the U.S. dollar has waned, as forecasts suggest that a dip in inflation might allow the Federal Reserve to slash interest rates. With a notable 5% climb earlier this year, the dollar is now bracing for its first loss of 2024, triggered by a promising inflation report.

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Finally, fourteen of the world’s 20 largest stock markets have hit all-time highs recently, including England, Japan, Brazil, India, and Canada, according to Bloomberg. In the USA, the S&P 500 (also at a record) hasn’t dropped more than 2% in a trading session in 311 days, the longest streak in five years.

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DAILY UPDATE: Jerome Powell, DJIA, Reddit and Life Insurance

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Young adults are delaying life insurance purchases due to financial constraints and a preference for spending on immediate experiences. The insurance industry is responding with digital-first strategies and more flexible products.

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The DJIA closed above 40,000 for the first time after briefly crossing the milestone the day before and clinching its fifth winning week. Reddit shot up after announcing a partnership with OpenAI that lets the AI train on your posts and gives Reddit advertising dollars and the ability to use the tech to make new tools.

But, GameStop stock plunged after the recently reinvigorated meme stock filed to sell 45 million new shares and revealed that sales were down last quarter.

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Jerome Powell, chair of the Federal Reserve has tested positive for Covid. But the economy needn’t worry because he’s working from home.

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RE-BROADCAST: An Interview with Fiduciary Bennett Aikin AIF®

On Financial Fiduciary Accountability

[By Dr. David E. Marcinko MBA MEd CMP™]

[By Ann Miller; RN, MHA]

Currently, there is a growing dilemma in the financial sales and services industry. It goes something like this:

  • What is a financial fiduciary?
  • Who is a financial fiduciary?
  • How can I tell if my financial advisor is a fiduciary?

Now, in as much as this controversy affects laymen and physician-investors alike, we went right to the source for up-to-date information regarding this often contentious topic, for an email interview and Q-A session, with Ben Aikin.ben-aikin

About Bennett Aikin AIF® and fi360.com

Bennett [Ben] Aikin is the Communications Coordinator for fi360.com. He oversees all communications for fi360. His responsibilities include messaging, brand management, copyrights and trademarks, and publications. Mr. Aikin received his BA in English from Virginia Tech in 2003 and is currently an MS candidate in Journalism from Ohio University.

Q. Medical Executive Post 

You have been very helpful and gracious to us. So, let’s get right to it, Ben. In the view of many; attorneys, doctors, CPAs and the clergy are fiduciaries; most all others who retain this title seem poseurs; sans documentation otherwise.

A. Mr. Aikin

You are correct. Attorneys, doctors and clergy are the prototype fiduciaries. They have a clear duty to put the best interests of their clients, patients, congregation, etc., above their own. [The duty of a CPA isn’t as clear to me, although I believe you are correct]. Furthermore, this is one of the first topics we address in our AIF training programs, and what we call the difference between a profession and an industry.  The three professions you name have three common characteristics that elevate them from an industry to a profession:

  1. Recognized body of knowledge
  2. Society depends upon practitioners to provide trustworthy advice
  3. Code of conduct that places the clients’ best interests first

Q. Medical Executive Post 

It seems that Certified Financial Planner®, Chartered Financial Analysts, Registered Investment Advisors and their representatives, Registered Representative [stock-brokers] and AIF® holders, etc, are not really financial fiduciaries, either by legal statute or organizational charter. Are we correct, or not? Of course, we are not talking ethics or morality here. That’s for the theologians to discuss.

A. Mr. Aikin

One of the reasons for the “alphabet soup”, as you put it in one of your white papers [books, dictionaries and posts] on financial designations, is that while there is a large body of knowledge, there is no one recognized body of knowledge that one must acquire to enter the financial services industry.  The different designations serve to provide a distinguisher for how much and what parts of that body of knowledge you do possess.  However, being a fiduciary is exclusively a matter of function. 

In other words, regardless of what designations are held, there are five things that will make one a fiduciary in a given relationship:

  1. You are “named” in plan or trust documents; the appointment can be by “name” or by “title,” such as CFO or Head of Human Resources
  2. You are serving as a trustee; often times this applies to directed trustees as well
  3. Your function or role equates to a professional providing comprehensive and continuous investment advice
  4. You have discretion to buy or sell investable assets
  5. You are a corporate officer or director who has authority to appoint other fiduciaries

So, if you are a fiduciary according to one of these definitions, you can be held accountable for a breach in fiduciary duty, regardless of any expertise you do, or do not have. This underscores the critical nature of understanding the fiduciary standard and delegating certain duties to qualified “professionals” who can fulfill the parts of the process that a non-qualified fiduciary cannot.

Q. Medical Executive Post 

How about some of the specific designations mentioned on our site, and elsewhere. I believe that you may be familiar with the well-known financial planner, Ed Morrow, who often opines that there are more than 98 of these “designations”? In fact, he is the founder of the Registered Financial Consultants [RFC] designation. And, he wrote a Foreword for one of our e-books; back-in-the-day. His son, an attorney, also wrote as a tax expert for us, as well. So, what gives?

A. Mr. Aikin

As for the specific designations you list above, and elsewhere, they each signify something different that may, or may not, lend itself to being a fiduciary: For example:

• CFP®: The act of financial planning does very much imply fiduciary responsibility.  And, the recently updated CFP® rules of conduct does now include a fiduciary mandate:

• 1.4 A certificant shall at all times place the interest of the client ahead of his or her own. When the certificant provides financial planning or material elements of the financial planning process, the certificant owes to the client the duty of care of a fiduciary as defined by CFP Board. [from http://www.cfp.net/Downloads/2008Standards.pdf]

•  CFA: Very dependent on what work the individual is doing.  Their code of ethics does have a provision to place the interests of clients above their own and their Standards of Practice handbook makes clear that when they are working in a fiduciary capacity that they understand and abide by the legally mandated fiduciary standard.

• FA [Financial Advisor]: This is a generic term that you may find being used by a non-fiduciary, such as a broker, or a fiduciary, such as an RIA.

• RIA: Are fiduciaries.  Registered Investment Advisors are registered with the SEC and have obligations under the Investment Advisers Act of 1940 to provide services that meet a fiduciary standard of care.

• RR: Registered Reps, or stock-brokers, are not fiduciaries if they are doing what they are supposed to be doing.  If they give investment advice that crosses the line into “comprehensive and continuous investment advice” (see above), their function would make them a fiduciary and they would be subject to meeting a fiduciary standard in that advice (even though they may not be properly registered to give advice as an RIA).

• AIF designees: Have received training on a process that meets, and in some places exceeds, the fiduciary standard of care.  We do not require an AIF® to always function as a fiduciary. For example, we allow registered reps to gain and use the AIF® designation. In many cases, AIF designees are acting as fiduciaries, and the designation is an indicator that they have the full understanding of what that really means in terms of the level of service they provide.  We do expect our designees to clearly disclose whether they accept fiduciary responsibility for their services or not and advocate such disclosure for all financial service representatives.

Q. Medical Executive Post 

Your website, http://www.fi360.com, seems to suggest, for example, that banks/bankers are fiduciaries. We have found this not to be the case, of course, as they work for the best interests of the bank and stockholders. What definitional understanding are we missing?

A. Mr. Aikin

Banks cannot generally be considered fiduciaries.  Again, it is a matter of function. A bank may be a named trustee, in which case a fiduciary standard would generally apply.  Banks that sell products are doing so according to their governing regulations and are “prudent experts” under ERISA, but not necessarily held to a fiduciary standard in any broader sense.

Q. Medical Executive Post 

And so, how do we rectify the [seemingly intentional] industry obfuscation on this topic. We mean, our readers, subscribers, book and dictionary purchasers, clients and colleagues are all confused on this topic. The recent financial meltdown only stresses the importance of understanding same.

For example, everyone in the industry seems to say they are the “f” word. But, our outreach efforts to contact traditional “financial services” industry pundits, CFP® practitioners and other certification organizations are continually met with resounding silence; or worse yet; they offer an abundance of parsed words and obfuscation but no confirming paperwork, or deep subject-matter knowledge as you have kindly done. We get the impression that some FAs honesty do-not have a clue; while others are intentionally vague.

A. Mr. Aikin

All of the evidence you cite is correct.  But that does not mean it is impossible to find an investment advisor who will manage to a fiduciary standard of care and acknowledge the same. The best way to rectify confusion as it pertains to choosing appropriate investment professionals is to get fiduciary status acknowledged in writing and go over with them all of the necessary steps in a fiduciary process to ensure they are being fulfilled. There also are great resources out there for understanding the fiduciary process and for choosing professionals, such as the Department of Labor, the SEC, FINRA, the AICPA’s Personal Financial Planning division, the Financial Planning Association, and, of course, Fiduciary360.

We realize the confusion this must cause to those coming from the health care arena, where MD/DO clearly defines the individual in question; as do other degrees [optometrist, clinical psychologist, podiatrist, etc] and medical designations [fellow, board certification, etc.]. But, unfortunately, it is the state of the financial services industry as it stands now.

Q. Medical Executive Post 

It is as confusing for the medical community, as it is for the lay community. And, after some research, we believe retail financial services industry participants are also confused. So, what is the bottom line?

A. Mr. Aikin

The bottom line is that lay, physician and all clients have a right to expect and demand a fiduciary standard of care in the managing of investments. And, there are qualified professionals out there who are providing those services.  Again, the best way to ensure you are getting it is to have fiduciary status acknowledged in writing, and go over the necessary steps in a fiduciary process with them to ensure it is being fulfilled.

Q. Medical Executive Post 

The “parole-evidence” rule, of contract law, applies, right? In dealing with medical liability situations, the medics and malpractice attorneys have a rule: “if it wasn’t written down, it didn’t happen.”  

A. Mr. Aikin

An engagement contract accepting fiduciary status should trump a subsequent attempt to claim the fiduciary standard didn’t apply. But, to reiterate an earlier point, if someone acts in one of the five functional fiduciary roles, they are a fiduciary whether they choose to acknowledge it or not.  I have attached a sample acknowledgement of fiduciary status letter with copies of our handbook, which details the fiduciary process we instruct in our programs, and our SAFE, which is basically a checklist that a fiduciary should be able to answer “Yes” to every question to ensure the entire fiduciary process is being covered.

Q. Medical Executive Post 

It is curious that you mention checklists. We have a post arguing that very theme for doctors and hospitals as they pursue their medial error reduction, and quality improvement, endeavors. And, we applaud your integrity, and wish only for clarification on this simple fiduciary query?

A. Mr. Aikin

Simple definition: A fiduciary is someone who is managing the assets of another person and stands in a special relationship of trust, confidence, and/or legal responsibility.

Q. Medical Executive Post 

Who is a financial fiduciary and what, if any, financial designation indicates same?

A. Mr. Aikin

Functional definition: See above for the five items that make you a fiduciary.

Financial designations that unequivocally indicate fiduciary duty: Short answer is none, only function can determine who is a fiduciary. 

Q. Medical Executive Post 

Please repeat that?

A. Mr. Aikin

Financial designations that indicate fiduciary duty: none. It is the function that determines who is a fiduciary.  Now, having said that, the CFP® certification comes close by demanding their certificants who are engaged in financial planning do so to a fiduciary standard. Similarly, other designations may certify the holder’s ability to perform a role that would be held to a fiduciary standard of care.  The point is that you are owed a fiduciary standard of care when you engage a professional to fill that role or they functionally become one.  And, if you engage a professional to fill a non-fiduciary role, they will not be held to a fiduciary standard simply because they have a particular designation.  One of the purposes the designations serve is to inform you what roles the designation holder is capable of fulfilling.

It is also worth keeping in mind that just being a fiduciary doesn’t equate to a full knowledge of the fiduciary standard. The AIF® designation indicates having been fully trained on the standard.

Q. Medical Executive Post 

Yes, your website mentions something about fiduciaries that are not aware of same! How can this be? Since our business model mimics a medical model, isn’t that like saying “the doctor doesn’t know he is doctor?” Very specious, with all due respect!

A. Mr. Aikin

I think it is first important to note that this statement is referring not just to investment professionals.  Part of the audience fi360 serves is investment stewards, the non-professionals who, due to facts and circumstances, still owe a fiduciary duty to another.  Examples of this include investment committee members, trustees to a foundation, small business owners who start 401k plans, etc.  This is a group of non-sophisticated investors who may not be aware of the full array of responsibilities they have. 

However, even on the professional side I believe the statement isn’t as absurd as it sounds.  This is basically a protection from both ignorant and unscrupulous professionals.  Imagine a registered representative who, either through ignorance or design, begins offering comprehensive and continuous investment advice.  Though they may deny or be unaware of the fact, they have opened themselves up to fiduciary liability. 

Q. Medical Executive Post 

Please clarify the use of arbitration clauses in brokerage account contracts for us. Do these disclaim fiduciary responsibility? If so, does the client even know same?

A. Mr. Aikin

By definition, an engagement with a broker is a non-fiduciary relationship.  So, unless other services beyond the scope of a typical brokerage account contract are specified, fiduciary responsibility is inherently not applicable.  Unfortunately, I do imagine there are clients who don’t understand this. Furthermore, AIF® designees are not prohibited from signing such an agreement and there are some important points to understand the reasoning.

First, by definition, if you are entering into such an agreement, you are entering into a non-fiduciary relationship. So, any fiduciary requirement wouldn’t apply in this scenario.

Second, if this same question were applied into a scenario of a fiduciary relationship, such as with an RIA, this would be a method of dispute resolution, not a practice method. So, in the event of dispute, the advisor and investor would be free to agree to the method of resolution of their choosing. In this scenario, however, typically the method would not be discussed until the dispute itself arose.

Finally, it is important to know that AIF/AIFA designees are not required to be a fiduciary. It is symbolic of the individuals training, knowledge and ongoing development in fiduciary processes, but does not mean they will always be acting as a fiduciary.

Q. Medical Executive Post 

Don’t the vast majority of arbitration hearings find in favor of the FA; as the arbitrators are insiders, often paid by the very same industry itself?

A. Mr. Aikin

Actual percentages are reported here: http://www.finra.org/ArbitrationMediation/AboutFINRADR/Statistics/index.htm However, brokerage arbitration agreements are a dispute resolution method for disputes that arise within the context of the securities brokerage industry and are not the only means of resolving differences for all types of financial advisors.  Investment advisers, for example, are subject to respond to disputes in a variety of forums including state and federal courts.  Clients should look at their brokerage or advisory agreement to see what they have agreed to. If you wanted to go into further depth on this question, we would recommend contacting Brian Hamburger, who is a lawyer with experience in this area and an AIFA designee. Bio page: http://www.hamburgerlaw.com/attorneys/BSH.htm.

Q. Medical Executive Post 

What about our related Certified Medical Planner® designation, and online educational program for financial advisors and medical management consultants? Is it a good idea – reasonable – for the sponsor to demand fiduciary accountability of these charter-holders? Cleary, this would not only be a strategic competitive advantage, but advance the CMP™ mission to put medical colleagues first and champion their cause www.CertifiedMedicalPlanner.org above all else. 

A. Mr. Aikin

I think it is a good idea for any plan sponsor to demand fiduciary status be acknowledged from anyone engaged to provide comprehensive and continuous investment advice.  I also think it is a good idea to be proactive in verifying that the fiduciary process is being followed.

Q. Medical Executive Post 

Is there anything else that we should know about this topic?

A. Mr. Aikin

Yes, a further note about fi360’s standards. I wrote generically about the fiduciary standard, because there is one that is defined by multiple sources of regulation, legislation and case law.  The process defined in our handbooks, we call a Fiduciary Standard of Excellence, because it covers that minimum standard and also best practice standards that go above and beyond.  All of our Practices, which comprise that standard, are legally substantiated in our Legal Memoranda handbook, which was written by Fred Reish’s law firm, who is considered a leading ERISA attorney.

Additional resources:

Q. Medical Executive Post 

Thank you so much for your knowledge and willingness to frankly share it with the Medical-Executive-Post.

Assessment

All are invited to continue the conversation with Mr. Aikin, asynchronously online, or thru this contact information:

fi360.com
438 Division Street
Sewickley, PA 15143
412-741-8140 Phone
866-390-5080 Toll-free phone
412-741-8142 Fax

Conclusion

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DAILY UPDATE: Top Causes of Death, Narcan Saves Lives but Scientific Research Fraudulent as DJIA Tops 40,000

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Walgreens has released its own brand of naloxone, a medication that reverses the effects of an opioid overdose. Available online now, Walgreens Brand Naloxone HCl Nasal Spray comes with two doses for $34.99, about $10 cheaper than the name-brand version, Narcan. The over-the-counter medication will also be available in stores by the end of May in the pain aisle, according to a press release, making the life-saving nasal spray more accessible.

***

Here’s where the major benchmarks ended:

  • The S&P 500 index rose 6.17 points (0.1%) to 5,303.27, up 1.5% for the week; the Dow Jones Industrial Average gained 134.21 points (0.3%) to 40,003.59, up 1.2% for the week; the NASDAQ Composite® ($COMP) lost 12.35 points (0.1%) to 16,685.97, up 2.1% for the week.
  • The 10-year Treasury note yield (TNX) rose more than 4 basis points to 4.42%, down about 8 basis points for the week.
  • The CBOE Volatility Index® (VIX) fell 0.43 to 11.99.

Among major companies, Nvidia (NVDA) dropped 2% Friday but still posted a 2.9% advance for the week ahead of the semiconductor leader’s quarterly earnings Wednesday. Among sectors, energy shares led gainers behind a 1% jump in WTI Crude Oil (/CL) futures. The small-cap Russell 2000® Index (RUT) ended little changed but still gained 1.7% for the week.

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

Fraudulent research papers have cost scientific journal publishers millions in lost revenue. (the Wall Street Journal)

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The 10 Top Causes of Adult Death in the U.S.A.

1.  Heart disease 267.2* 2.  Cancer 142.3 3.  Unintentional injuries 64.0 4.  COVID-19 44.5 5.  Stroke 39.5 6.  Chronic lower respiratory disease 34.3 7.  Alzheimer disease 28.9 8.  Diabetes 24.1  9   Kidney disease 13.8 10. Chronic liver disease and cirrhosis 13.8 Deaths per 100,000 population.

Source: Jeffrey Bendix, Medical Economics [5/15/24]

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SUBMITTED ESSAYS: Economics, Management and Finance from Advisors to Physicians

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Finance, economics and management essays of most current interest to all physicians and healthcare professionals

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PHYSICIANS BEWARE: Traditional Financial Planning “Rules of Thumb”

DOCTORS AND MEDICAL PROFESSIONALS BEWARE?

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  • While financial planning rules of thumbs are useful to people as general guidelines, they may be too oversimplified in many situations, leading to underestimating or overestimating an individual’s needs. This may be especially true for physicians and many medical professionals. Rules of thumb do not account for specific circumstances or factors occurring at a particular time, or that could change over time, which should be considered for making sound financial decisions.
  • Great Health Industry Resignation: https://medicalexecutivepost.com/2021/12/12/healthcare-industry-hit-with-the-great-resignation-retirement/

For example, in a tight job market, an emergency fund amounting to six months of household expenses does not consider the possibility of extended unemployment. I’ve always suggested 2-3 years for doctors. Venture capitalist lay-offs of physicians during the pandemic confirm this often criticized benchmark opinion of mine.

As another example, buying life insurance based on a multiple of income does not account for the specific needs of the surviving family, which include a mortgage, the need for college funding and an extended survivor income for a non-working spouse. Again a huge home mortgage, or several children or dependents, may be the financial bane of physician colleagues and life insurance.

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

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EXAMPLES: Old/New Rules

  • A home purchase should cost less than an amount equal to two and a half years of your annual income. I think physicians in practice for 3-5 years might go up to 3.5X annual income; ceteras paribus.
  • Save at least 10-15% of your take-home income for retirement. Seek to save 20% or more.
  • Have at least five times your gross salary in life insurance death benefit. Consider 10X this amount in term insurance if young, and/or with several children or other special circumstances.
  • Pay off your highest-interest credit cards first. Agreed.
  • The stock market has a long-term average return of 10%. Agreed, but appreciated risk adjusted rates of return..
  • You should have an emergency fund equal to six months’ worth of household expenses. Doctors should seek 2-3 years.
  • Your age represents the percentage of bonds you should have in your portfolio. Risk tolerance and assets may be more vital.
  • Your age subtracted from 100 represents the percentage of stocks you should have in your portfolio. Risk tolerance and assets may still be more vital.
  • A balanced portfolio is 60% stocks, 40% bonds. With historic low interest rates, cash may be a more flexible alternative than bonds; also avoid most bond mutual funds as they usually never mature.

There are also rules of thumb for determining how much net worth you will need to retire comfortably at a normal retirement age. Here is the calculation that Investopedia uses to determine your net worth:

Compensation in the Physician Specialties: Mostly Stable - NEJM  CareerCenter Resources

RULES 72, 78 and 115: https://medicalexecutivepost.com/2022/01/30/the-rules-of-72-78-and-115/

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DAILY UPDATE: Core CPI and ERISA while Markets Remain High with Walmart Up

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Here’s where the major benchmarks ended:

America’s oldest popular stock index, the Dow Jones Industrial Average, hit a brief record high yesterday morning when it traded above 40,000, reflecting renewed hope for the market’s health after Wednesday’s promising inflation report.

  • The S&P 500® index (SPX) fell 11.05 points (0.2%) to 5,297.10; the Dow Jones Industrial Average declined 38.62 points (0.1%) to 39,869.38; the NASDAQ Composite® ($COMP) shed 44.07 points (0.3%) to 16,698.32.
  • The 10-year Treasury note yield (TNX) rose more than 2 basis points to 4.381%.
  • The CBOE Volatility Index® (VIX) dropped 0.03 to 12.42.

Walmart’s strength fueled a strong day for consumer staples shares. The S&P 500 Consumer Staples ($SP500#30), which includes Walmart as well as companies like Coca-Cola (KO) and Procter & Gamble (PG), surged 1.5% to its highest level in over two years. 

Among other companies, Applied Materials (AMAT) fell 1.6% ahead of the semiconductor industry supplier’s quarterly earnings report, which is expected after Thursday’s close.

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

And, Core CPI, which tracks the price of goods and services excluding volatile food and energy prices and is closely watched as an inflation indicator, rose 3.6% from the same period last year. That’s the smallest annual increase since April 2021. On a monthly basis, core CPI rose 0.3%, marking the first time in six months that its growth slowed from the prior month. Other good signs include:

  • Grocery prices dropped 0.2% from March, the first decrease in a year.
  • Health insurance and car insurance increased more slowly in April than in March.
  • A separate report released yesterday showed consumer spending stayed steady last month.

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

Finally, Joe Manchin (D-W.Va.) and a group of Republican senators are moving to overturn a retirement investment planning rule that was finalized by the Labor Department last month. The Labor Department unveiled the new rule last month that would update the definition of an investment advice fiduciary under the Employee Retirement Income Security Act. Manchin and 15 Republican senators joined in co-sponsoring a Congressional Review Act (CRA) resolution that would overturn this new rule.

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DAILY UPDATE: Healthcare Monopolies, Ark Invest and the Stock Markets Mega Rally

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More people are interested in determining their “heart age” using new tests and tech tools, but some skeptics say it’s not a healthy data point to focus on. (the Wall Street Journal)

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The Cathie Wood-led Ark Invest just made some significant trades. The most prominent among them were the increased stakes in Palantir Technologies Inc (NYSE:PLTR) and the reduced holdings in Coinbase Global Inc (NASDAQ: COIN).

Here’s where the major benchmarks ended:

  • The S&P 500 index rose 61.47 points (1.2%) to 5,308.15; the Dow Jones Industrial Average added 349.89 points (0.9%) to 39,908.00; the NASDAQ Composite rallied 231.21 points (1.4%) to 16,742.39.
  • The 10-year Treasury note yield fell almost 10 basis points to 4.348%.
  • The CBOE Volatility Index® (VIX) dropped 0.97 to 12.45.

Chipmaker shares led the way higher Wednesday, lifting the Philadelphia Semiconductor Index (SOX) almost 3% to a 10-week high. Interest-rate-sensitive sectors like real estate and utilities were also strong. The small-cap Russell 2000® Index (RUT) advanced 1.1% to a seven-week high. The U.S. Dollar Index ($DXY) slumped to its weakest level in five weeks, reflecting expectations for lower interest rates that may reduce the appeal of U.S. fixed income assets.

Among companies, Cisco Systems (CSC) surged 1.5% ahead of its quarterly results expected after Wednesday’s close. Dow member Walmart (WMT) is expected to release results Thursday morning as the unofficial retail earnings season accelerates. 

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And The U.S. Department of Justice (DOJ) announced it has established a new task force to take on healthcare monopolies and collusion. The task force, made up of prosecutors, economists, healthcare industry experts and others, will guide the division’s enforcement strategy and policy approach in healthcare, including by facilitating policy advocacy, investigations and, where warranted, civil and criminal enforcement in healthcare markets.

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CUSTOMIZABLE e-PODIATRY CONSENT FORMS Now Available for 2024

Electronically CUSTOMIZABLE FOR EVERY FOOT / ANKLE / LEG SURGEON

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CUSTOMIZABLE CMS & AGENCY FOR HEALTHCARE RESEARCH AND QUALITY STYLED PROTOCOLS, CHECKLISTS AND TEMPLATES

.… Specifically for Podiatrists ….   

e-Podiatry Consent Forms™ is an innovative new suite of software programs from the Institute of Medical Business Advisors [iMBA, Inc]. Our products solve your informed consent problems and enhance the education, discussion and documentation of the informed consent process for all podiatrists performing foot, ankle and leg reconstructive surgical procedures.

THE PROBLEM

All podiatrists are being pressured by the Centers for Medicare and Medicaid Services [CMS], the Joint Commission on Accreditation of Healthcare Organizations [JCAHO], liability carriers and private insurance payers to make their consent process more patient-friendly, informed and easily understood. And, the pressure to standardize and comply is great.

Most recently, based on the need to make healthcare even safer, the Agency for Healthcare Research and Quality (AHRQ) undertook a major study to identify patient safety issues and develop recommendations for “best practices”.

The AHRQ Evidence Report

The AHRQ report identified the challenge of addressing shortcomings such as missed, incomplete or not fully comprehended informed consent, as a significant patient safety issue and opportunity for improvement.

The authors of the AHRQ report hypothesized that better informed patients:

“are less likely to experience errors by acting as another layer of protection.”

And, the AHRQ study ranked a “more interactive informed consent process” among the top 11 practices supporting more widespread implementation; especially for surgical consent forms.

THE SOLUTION

Why Us: https://epodiatryconsentforms.com/why-us/

One answer to the modern risk-management problem of “informed consent interactivity” may be e-Podiatry Consent Forms™  We license two core interactive surgical products, and a reference library, with related concepts and products in development:

  • Forefoot, Mid-Foot and Simple Rear-Foot Version
  • Complex Rear-Foot, Ankle and Lower Leg Version
  • Comprehensive content library for extreme customization.

Each e-Podiatry Consent Forms™ CD-ROM [secure email delivery is now available] is increasingly trusted as the simple solution to standardized communications across the entire office-enterprise; from managing-risk, informing-patients and complying with modern regulatory requirements through enhanced patient-centric informed consent encounters.

Thus, by improving the consistency, details, documentation and effectiveness of the informed consent process, e-Podiatry Consent Forms™ equips all podiatric surgeons with the tools needed to augment quality standards, reduce litigation potential and improve patient outcomes and safety.

http://www.ePodiatryConsentForms.com

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DAILY UPDATE: Squarespace, Ark Invest & Hospitals as the Markets Rebound

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Here’s where the major benchmarks ended:

  • The S&P 500® index (SPX) rose 25.26 points (0.5%) to 5,246.68, the highest since a record close March 28; the Dow Jones Industrial Average® ($DJI) gained 126.60 points (0.3%) to 39,558.11; the NASDAQ Composite climbed 122.94 points (0.8%) to 16,511.18.
  • The 10-year Treasury note yield (TNX) fell more than 3 basis points to 4.449%.
  • The CBOE Volatility Index® (VIX) decreased 0.18 to  13.42.

Among companies, Home Depot’s (HD) quarterly results reported earlier Tuesday kicked off the unofficial start of the retail earnings season. The home improvement retailer’s earnings topped expectations, but revenue missed forecasts, initially sending the company’s shares down sharply. 

Home Depot also reaffirmed its full-year guidance for a 1% decline in comparable-store sales and a 1% increase in total sales. The company’s shares bounced back to end with a 0.1% loss.

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

And, the Cathie Wood-led Ark Invest just made some significant trades. The most prominent among them were the increased stakes in Palantir Technologies Inc (NYSE PLTR) and the reduced holdings in Coinbase Global Inc (NASDAQ: COIN).

Moreover, the website-building platform Squarespace is to go private, which it announced it’ll be doing in an all-cash deal with Permira, a private equity firm. Squarespace, which was public for nearly three years, joins a group of other smaller tech companies like Qualtrics that have recently pulled themselves off the public market. (CNBC)

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Employers and private insurers are paying hospitals more for inpatient and outpatient services than in previous years, a study from RAND Corporation finds. The American Hospital Association dismissed the report saying it offers a “skewed and incomplete picture.”


And finally … Kaiser Permanente began its 2024 earnings season with more than $2.7 billion in net income and $935 million in operating income, just months after sharing plans to lay off workers.

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DAILY UPDATE: Moderna Down with Mixed Markets

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Here’s where the major benchmarks ended:

  • The S&P 500® index (SPX) fell 1.26 points (0.02%) to 5,221.42; the Dow Jones Industrial Average lost 81.33 points (0.2%) to 39,431.51; the NASDAQ Composite® ($COMP) gained 47.37 points (0.3%) to 16,388.24.
  • The 10-year Treasury note yield (TNX) dropped almost 2 basis points to 4.487%.
  • The CBOE Volatility Index® (VIX) surged 1.05 to 13.60.

Biotechnology and food and beverage shares were among the market’s strongest sectors Monday, while communication services stocks were among the biggest laggards. Energy shares took pressure despite a jump of 1.2% in WTI Crude Oil (/CL) futures, which ended above $79 per barrel after slumping last week to two-month lows.

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

Moderna is “bleeding money” as its forthcoming RSV vaccine doesn’t appear to deliver better results than other RSV shots already on the market. (Bloomberg)

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It’s ChatGPT-4o’s time to shine. The “o” stands for omni, and it’s the latest iteration of OpenAI’s signature chatbot. According to the company, it’s much faster with enhanced “capabilities across text, vision, and audio.”

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23% is the average portion of the bill hospitals collected from patients before treatment in Q1 of this year, up 3% YoY. (the Wall Street Journal)

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About Tombstone Securities Advertising and the “New Issue” Propsectus

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A Primer for Physician Investors and Medical Professionals

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

[Editor-in-Chief]

[PART 2 OF 8]

BU Dr. Marcinko

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

Introduction

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

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

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

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

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

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

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

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

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

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

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

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

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Syndication Among Underwriters

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

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

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

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

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

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

Underwriter Compensation Hierarchy

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

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

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

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

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

PART ONE:

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

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DAILY UPDATE: Ark Invest, Dell and “Buy Now-Pay Later”

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While Buy Now-Pay Later (BNPL) reduces friction when purchasing, it’s giving some economy watchers unease. As Americans’ budgets buckle under the weight of inflation and higher interest payments, some worry BNPL is more of an invisible burden than a boon, Bloomberg reports. Beware the “phantom debt,” a Wells Fargo economist recently warned, referring to the BNPL industry’s short-term loans, which go largely unaccounted for by those tracking Americans’ debt load. That’s because, unlike credit cards and auto loan providers, Afterpay, Affirm, Klarna, and other BNPL providers don’t usually report transactions to credit scoring agencies.

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The Cathie Wood-led Ark Invest just made some significant trades. The most prominent among them were the increased stakes in Palantir Technologies Inc (NYSE: PLTR) and her reduced holdings in Coinbase Global Inc (NASDAQ: COIN).

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Dell has recently seen a decline in its revenue. In its most recent earnings report, it revealed that its net revenue shrunk by 11% year-over-year during its fiscal 2024 fourth quarter. For full year 2023, the company’s revenue was down by 14% to $88.4 billion. Partly that was due to a weak personal-computer market and the costs associated with more than 6,000 layoffs. But investors are excited by Dell’s growth potential for its server and computer businesses because of artificial intelligence, the Motley Fool reported.

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DAILY UPDATE: National Nurses Week, Multiplan Lawsuit, Rite Aid and Fatburger Down

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HAPPY MOTHER’S DAY 2024

Fat Brands is the parent company of Fatburger, Johnny Rockets, and a few other restaurant chains. Last year, former CEO Andy Wiederhorn stepped down after the Los Angeles Times reported that the federal government was investigating him for fraud. He has since stayed on as the company’s chairman, but on Friday the Justice Department charged him with perpetuating a $47 million fraud against his own shareholders.

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In a recent Becker’s Health Care Newsletter, it is reported that a large multi-state hospital system is suing Multiplan for illegal price fixing and automatic significant price reductions, in particular, for out-of-network providers. The story states that Multiplan, by bombarding healthcare providers with automatic reductions in pricing, has made it impossible for providers to deliver healthcare.

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National Nurses Week, which ends today on May 12th, Florence Nightingale’s birthday

Rite Aid has announced that 39 stores are set to close their doors for good, this follows the decision to declare Chapter 11 bankruptcy back in October, 2023.    

The strategy? Reduce the total number of stores to 1,600 nationwide. 

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DAILY UPDATE: Mortgage Rates, Ascension Healthcare Network Security Event with Mixed Markets

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Novavax, the Covid vaccine-maker’s value doubled after it announced a $1.2 billion deal to develop new shots with Sanofi.

And, Mortgage rates fell for the first time since March, to just over 7%.

Here’s where the major stock market benchmarks ended:

  • The S&P 500 index rose 8.60 points (0.2%) to 5,222.68, up 1.9% for the week; the Dow Jones Industrial Average® ($DJI) advanced 125.08 points (0.3%) to 39,512.84, up 2.2% for the week and its eighth straight daily gain; the NASDAQ Composite® ($COMP) fell 5.40 points (0.03%) to 16,340.87, up 1.1% for the week.
  • The 10-year Treasury note yield (TNX) increased more than 5 basis points to 4.50%.
  • The CBOE Volatility Index® (VIX) fell 0.14 to 12.55.

Chip makers ranked among top gainers Friday after Taiwan Semiconductor Manufacturing (TSM) shares surged 4.5% after the company said its April revenue soared 60% behind AI-driven demand. The Philadelphia Semiconductor Index (SOX) climbed 1% and posted a 1.9% gain for the week. Consumer staples and transportation shares were also strong. Energy shares slipped behind a 1.2% drop in WTI Crude Oil (/CL) futures, though oil still ended slightly higher for the week.

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National hospital operator Ascension said a “cyber security event” has disrupted some of its clinical operations, according to a news release. Ascension, a St. Louis-based nonprofit and Catholic healthcare network, announced it had detected “unusual activity” on some of its systems. In response, the company kicked off an investigation and remediation efforts—including turning to outside cybersecurity firm Mandiant for help, as well as notifying the “appropriate authorities,” per the release.

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Planet Fitness to raise membership price for the first time since 1998. It’s going to take more than $10/month to join a gym once Planet Fitness raises the price of a basic membership for new members to $15 per month this summer. The $10 amount, which has held steady for 26 years, was considered a sweet spot where people were happy to sign up and wouldn’t bother to cancel once they gave up on their fitness goals. But after posting weaker-than-expected Q1 results, the gym chain decided it’s time to change, even though execs acknowledged that customers are looking to save rather than spend.

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DAILY UPDATE: Uber, Lyft and MSFT as the Stock Markets Rally

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Here’s where the major benchmarks ended:

  • The S&P 500 index gained 26.41 points (0.5%) to 5,214.08; the Dow Jones Industrial Average rose 331.37 points (0.9%) to 39,387.76; the NASDAQ Composite® ($COMP) advanced 43.51 points (0.3%) to 16,346.26.
  • The 10-year Treasury note yield (TNX) lost more than 2 basis points to 4.459%.
  • The CBOE Volatility Index® (VIX) fell 0.31 to 12.69.

Interest-rate-sensitive sectors, such as real estate and utilities, were among the strongest performers Thursday. Energy shares were also strong after WTI Crude Oil (/CL) futures rose for a second straight day after sinking to a two-month low earlier this week. Semiconductor shares were under pressure after disappointing revenue guidance from chip designer Arm Holdings (ARM) sent its shares down 2.3%.

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The Dow jumped for the seventh straight day while the S&P 500 closed above 5,200 for the first time in a month as stocks climbed across the board, possibly a reaction to data showing that the cooling labor market could translate into a Federal Reserve interest rate cut in a few months. But, Roblox, tanked 22% yesterday after the company cut its annual bookings forecast. The rough patch suggests that the game’s pandemic-induced popularity has likely peaked.

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Last year, Uber boasted its first full-year profit since going public. But yesterday, the company reported a surprise loss for the first quarter of 2024, dashing investors’ hopes for steady profits and sending its stock way down.

Meanwhile, Uber’s smaller rival Lyft appears to have its foot on the gas pedal. It posted better-than-expected quarterly results on Tuesday and saw a stock bump yesterday.

Microsoft plans to put the cash toward creating an AI data center. President Biden was on hand in Wisconsin to help announce the news—and not just to tout a big investment that’s expected to create jobs.

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BUDGETING: For Physicians

Personal Physician Budgeting Thoughts

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Although some doctors might view a budget as unnecessarily restrictive, sticking to a spending plan can be a useful tool in enhancing the wealth of a practice. And so, I will emphasize keys to smart budgeting and how to track spending and savings in these tough economic times; like today with the stock market busts, venture capitalists invading health care, corona virus the pandemic, aging baby boomer physicians and the great resignation; etc.

   There is an aphorism that suggests, “Money cannot buy happiness.” Well, this may be true enough but there is also a corollary that states, “Having a little money can sure reduces the unhappiness.”

   Unfortunately, today there is still more than a little financial unhappiness in all medical specialties. The challenges range from the commoditization of medicine, aging demographics, Medicare reimbursement cutbacks, ACA, and increased competition to floundering equity markets, the squeeze on credit and declines in the value of a practice. Few doctors seem immune to this “perfect storm” of economic woes. And then Covid-19, corona, and covid.

   Far too many physicians are hurting and it is not limited to above-average earning professionals. However, one can strive to reduce the pain by following some basic budgeting principles. By adhering to these principles, physicians can eliminate the “too many days at the end of the month” syndrome and instead develop a foundation for building real wealth and security, even in difficult economic climates like we face today.

   There are three major budget types. A flexible budget is an expenditure cap that adjusts for changes in the volume of expense items. A fixed budget does not. Advancing to the next level of rigor, a zero-based budget starts with essential expenses and adds items until the money is gone. Regardless of type, budgets can be extremely effective if one uses them at home or the office in order to spot money troubles before they develop.

   For the purpose of wealth building, doctors may think of this budget as a quantitative expression of an action plan. It is an integral part of the overall cost-control process for the individual, his or her family unit or one’s medical practice.1

How To Prepare A Personal Cash Flow Budget

   Preparing a net income statement (lifestyle cash flow budget) is often difficult because many doctors perceive it as punitive. Most doctors do not live a disciplined spending lifestyle and they view a budget as a compromise to it. However, a cash flow budget is designed to provide comfort when there is surplus income that can be diverted for other future needs. For example, if you treat retirement savings as just another periodic bill, you are more likely to save for it.

   You may construct a personal cash budget by recording each cash receipt and cash disbursement on a spreadsheet. Only the date, amount and a brief description of the transaction are necessary. The cash budget is a simple tool that even doctors who lack accounting acumen can use. Since it is possible to track the cash-in and cash-out in the same format used for a standard check register, most doctors find that the process takes very little time. Such a budget will provide a helpful look at how well you are staying within available resources for a given period.

   We then continue with an analysis of your operating checkbook and a review of various source documents such as one’s tax return, credit card statements, pay stubs and insurance policies. A typical statement will show all cash transactions that occur within one year. It is helpful to establish a monthly equivalent to all items of income and expense. For the purposes of getting started, note items of income and expense by the frequency you are accustomed to receiving or spending them.

What You Should Know About The ‘Action Plan’ Cash Budget

   For a medial office, the first operations budget item might be salary for the doctor and staff. Operating assets and other big ticket items come next. Some doctors/clients review their office P&L statements monthly, line by line, in an effort to reduce expenses. Then they add back those discretionary business expenses they have some control over.

   Now, do you still run out of money before the end of the month? If so, you had better cut back on entertainment, eating dinner out or that fancy, new but unproven piece of medical equipment. This sounds draconian until you remind yourself that your choice is either: live frugally later or live a simpler lifestyle now and invest the difference.

   As a young doctor, it may be a difficult trade-off. By mid-life, however, you are staring retirement in the face. That is why the action plan depends on your actions concerning monetary scarcity, a plan that one can implement and measure using simple benchmarks or budgeting ratios. By using these statistics, perhaps on an annual basis, the podiatrist can spot problems, correct them and continue planning actively toward stated goals like building long-term wealth.2

Useful Calculations To Assess Your Budgeting Success

   In the past, generic budgeting ratios would emphasize not spending more than 15 to 20 percent of your net salary on food or 8 percent on medical care. Now these estimates have given way to more rigorous numbers. Personal budget ratios, much like medical practice financial ratios, represent comparable benchmarks for parameters such as debt, income growth and net worth. Although these ratios are still broad, the following represent some useful personal budgeting ratios for physicians.

   • Basic liquidity ratio = liquid assets / average monthly expenses. Cash-on-hand should approach 12 to 24 months or more in the case of a doctor employed by a financially insecure HMO or fragile medical group practice. Yes, chances are you have heard of the standard notion of setting enough cash aside to cover three months in a rainy day scenario. However, we have decried this older laymen standard for many years in our textbooks, white papers and speaking engagements as being wholly insufficient for the competitively unstable environment of modern healthcare.

   • Debt to assets ratio = total debt / total assets. This percentage is high initially but should decrease with age as the doctor approaches a debt-free existence

   • Debt to gross income ratio = annual debt repayments / annual gross income. This represents the adequacy of current income for existing debt repayments. Doctors should try to keep this below 20 to 25 percent.

   • Debt service ratio = annual debt repayment / annual take-home pay. Physicians should aim to keep this ratio below 25 to 30 percent or face difficulty paying down debt.

   • Investment assets to net worth ratio = investment assets / net worth. This budget ratio should increase over time as retirement approaches.

   • Savings to income ratio = savings / annual income. This ratio should also increase over time as one retires major obligations like medical school debt, a practice loan or a home mortgage.

   • Real growth ratio = (income this year – income last year) / (income last year – inflation rate). This budget ratio should grow faster than the core rate of inflation.

   • Growth of net worth ratio = (net worth this year – net worth last year) / net worth last year – inflation rate). Again, this budgeting ratio should stay ahead of the specter of rising inflation.

   In other words, these ratios will help answer the question: “How am I doing?”

Pearls For Sticking To A Budget

   Far from the burden that most doctors consider it to be, budgeting in one form or another is probably one of the greatest tools for building wealth. However, it is also one of the greatest weaknesses among physicians who tend to live a certain lifestyle.3

   In fact, I have found that less than one in 10 medical professionals have a personal budget. Fear, or a lack of knowledge, is a major cause of procrastination. Fortunately, the following guidelines assist in reversing this microeconomic disaster.

   1. Set reasonable goals and estimate annual income. Do not keep large amounts of cash at home or office. Deposit it in an FDIC insured money-market account for safety. Do not deposit it in a money market mutual fund with net asset value (NAV) that may “break the buck” and fall below the one-dollar level. The new limit is $250,000. Track actual bills and expenses.

   2. Do not pay bills early, do not have more taxes withheld from your salary than needed and develop spending estimates to pay fixed expenses first. Fixed expenses are usually contractual and usually include housing, utilities, food, Social Security, medical, debt repayments, homeowner’s or renter’s insurance, auto, life and disability insurance, etc. Reduce fixed expenses when possible. Ultimately, all expenses get paid and become variable in the long run.

   3. Make it a priority to reduce variable expenses. Variable expenses are not contractual and may include clothing, education, recreational, travel, vacation, gas, cable TV, entertainment, gifts, furnishings, savings, investments, etc. Trim variable expenses by 5 to 20 percent.

   4. Use “carve-outs or “set-asides” for big ticket items and differentiate true wants from frivolous needs.

   5. Calculate both income and expenses as a percentage of your total budget. Determine if there is a better way to allocate resources. Review the budget on a monthly basis to notice any variance. Determine if the variance was avoidable, unavoidable or a result of inaccurate assumptions. Take corrective action as needed.

   6. Know the difference between saving and investing. Savers tend to be risk adverse while investors understand risk and take steps to mitigate it. Watch mutual fund commissions and investment advisory fees, which cut into return-rates. Keep investments simple and diversified (stocks, bonds, cash, index, no-load mutual and exchange traded funds, etc.).4

How To Budget In The Midst Of A [Corona] Crisis

   Sooner or later, despite the best of budgeting intentions, something will go awry. A doctor will be terminated or may be the victim of a reduction-in-force (RIF) because of cost containment initiatives of the corona pandemic. A medical practice partnership may dissolve or a local hospital or surgery center may close, hurting your practice and livelihood. Someone may file a malpractice lawsuit against you, a working spouse may be laid off or you may get divorced. Regardless of the cause, budgeting crisis management encompasses two different perspectives: awareness and execution.

   First, if you become aware that you may lose your job, the following proactive steps will be helpful to your budget and overall financial condition.

   • Decrease retirement contributions to the required minimum for company/practice match.
   • Place retirement contribution differences in an after-tax emergency fund.
   • Eliminate unnecessary payroll deductions and deposit the difference to cash.
   • Replace group term life insurance with personal term or universal life insurance.
   • Take your old group term life insurance policy with you if possible.
   • Establish a home equity line of credit to verify employment.
   • Borrow against your pension plan only as a last resort.

   If you have lost your job or your salary has been depressed, negotiate your departure and get an attorney if you believe you lost your position through breach of contract or discrimination. Then execute the following steps to recalculate your budget and boost your wealth rebuilding activities.

   • Prioritize fixed monthly bills in the following order: rent or mortgage; car payments; utility bills; minimum credit card payments; and restructured long-term debt.

   • Consider liquidating assets to pay off debts in this order: emergency fund, checking accounts, investment accounts or assets held in your children’s names.

   • Review insurance coverage and increase deductibles on homeowner’s and automobile insurance for needed cash.

   • Then sell appreciated stocks or mutual funds; personal valuables such as furnishings, jewelry and real estate; and finally, assets not in pension or annuities if necessary.

   • Keep or rollover any lump sum pension or savings plan distribution directly to a similar savings plan at your new employer, if possible, when you get rehired.

   • Apply for unemployment insurance.

   • Review your medical insurance and COBRA coverage after a “qualifying event” such as job loss, firing or even after quitting. It is a bit expensive due to a 2 percent administrative fee surcharge but this may be well worth it for those with preexisting conditions or who are otherwise difficult to insure. One may continue COBRA for up to 18 months.

   • Consider a high deductible Health Savings Account (HSA), which allows tax-deferred dollars like a medical IRA, for a variety of costs not normally covered under traditional heath insurance plans. Self-employed doctors deduct both the cost of the premiums and the amount contributed to the HSA. Unused funds roll over until the age of 59½, when one can use the money as a supplemental retirement benefit.

   • Eliminate unnecessary variable, charitable and/or discretionary expenses, and become very frugal.

Final Notes

   The behavioral psychologist, Gene Schmuckler, PhD, MBA, sometimes asks exasperated doctors to recall the story of the old man who spent a day watching his physician son treating HMO patients in the office. The doctor had been working at his usual feverish pace all morning. Although he was working hard, he bitterly complained to his dad that he was not making as much money as he used to make. Finally, the old man interrupted him and said, “Son, why don’t you just treat the sick patients?” The doctor-son looked at his father with an annoyed expression and responded, “Dad, can’t you see, I do not have time to treat just the sick ones.”5

   Always remember to add a bit of emotional sanity into your budgeting and economic endeavors.6

   Regardless of one’s age or lifestyle, the insightful doctor realizes that it is never too late to take control of a lost financial destiny through prudent wealth building activities. Personal and practice budgeting is always a good way to start the journey.7

The Author:

Dr. Marcinko is a former university endowed chairman and professor, former certified financial planner and has been a medical management advisor for more than two decades. He is the CEO of www.MedicalBusinessAdvisors.com, a health economics and business finance consulting firm.

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References:

1. Marcinko DE (Ed). The Business of Medical Practice (Advanced Profit Maximizing Techniques for Savvy Doctors). Springer Publishers, New York, NY, 2000 and 2004 2. Marcinko DE (Ed). Financial Planning for Physicians and Advisors, Jones and Bartlett Publishers, Sudbury, MA, 2005 3. Marcinko DE (Ed). Risk Management and Insurance Panning for Physicians and Advisors, Jones and Bartlett Publishers, Sudbury, MA, 2006. 4. Marcinko DE, Hetico HR. The Dictionary of Health Insurance and Managed Care. Springer Publishing, New York, 2007. 5. Marcinko DE, Hetico HR. The Dictionary of Health Economics and Finance. Springer Publishing, New York, 2008. 6. Marcinko DE, Hetico HR. Healthcare Organizations (Financial Management Strategies). Standard Technical Publishers, Blaine, WA, 2009. Additional Reference 7. Schmuckler E. Bridging Financial Planning and Human and Human Psychology. In, Marcinko DE (Ed): Financial Planning for Physicians and Healthcare Professionals. Aspen Publications, New York, NY, 2001, 2002 and 2003.