First Quarter Market Review

By: Bridgeworth Financial

Financial markets have not been boring in the last six months with each day appearing equally or even more volatile than the day before. Each piece of news seems to result in changing opinions, forecasts and reactions from a multitude of people with differing viewpoints and investment objectives. This volatility does begin to make more sense if we step back and look at the big drivers of risk and return in the capital markets over the long-term. JP Morgan’s Chief Global Strategist, Dr. David Kelly, regularly says, “the key to successful investing is not predicting the future, but looking at the present with clarity”. These are our current views on the present.

Source: Blackrock/Bloomberg

After all the dust has cleared from the first quarter of 2016, the U.S. stock market has ended roughly where it started. This was after the worst start to the stock market in history with large cap stocks (S&P 500) down -10.3% at the low point in mid- February, followed by a rally that ended the quarter up 1.35%. Smaller companies (Russell 2000) returned -1.52% for the same time period. It is not unusual for markets to dip 10% quite frequently. It just normally doesn’t happen in the early months of the year and grab headlines.

Three Main Drivers of Risk

In our year-end review, we discussed three main drivers of risk and return over the shorter and intermediate terms: China, low oil prices, and interest rates. These still remain dominant themes, but as we suggested might occur, the sentiment around these themes is changing. Over the last several months, the price of oil and U.S. stocks have been highly correlated. This decline and then subsequent rebound in stocks was heavily influenced by a decline and then recovery/ stabilizing in oil prices. While oil is still a wildcard, prices have rebounded a bit, and although prices remain low and inventories high, the demand-side of the equation seems fairly strong, and there is hope that the market will start to work through some of those inventories over time. The silver lining of low gas prices for consumers is rarely discussed, but it most certainly does exist. While many factors impact the prices of financial assets, we believe that market participants felt some comfort that oil prices might stabilize, eventually moving higher; the Federal Reserve might continue to exhibit patience with raising interest rates in 2016; and that emerging markets might also stabilize in the short-run to brighten long-term prospects. These factors may have felt like new revelations to some market participants and was a change in attitudes from January and early February. When sentiment changes, the prices of all “risk assets” like stocks and bonds change accordingly.

International, Emerging, and Bond Markets

International markets have remained somewhat troubled, but we feel still present opportunity. They, too, had a tough start to the year dropping 12.5%, followed by a rebound to finish the quarter down -3.01%. The European Central Bank (ECB) has been continuing its efforts to spur economic growth through negative interest rates (charging you to hold your money!). While we are skeptical of this new policy, bank lending does appear to be increasing, unemployment is declining slowly, and GDP growth is anemic, but positive. These modest positives, combined with relatively attractive valuations, make this still an area we want to stay invested.

Emerging markets returns have been dominated by news about China. This is a little tricky in the sense that many investors apparently don’t trust Chinese government data, but independent research and looking at neighboring economies such as Korea and Taiwan, does give us some comfort that China’s economy might be stabilizing and the extreme volatility seen in their markets might subside. Stability is a key goal for the second largest economy in the world and it is important to remember that a slowing economy does not necessarily mean a slow economy. Part of the maturing process for an economy like China is to slow to a sustainable growth rate which is good for them and the rest of the world. With China growing at double-digit rates, they consume every commodity on the globe and cause inflation and resource depletion. Slowing to a more modest 6% or even lower growth rate is really still strong enough to help global growth and achieve targets they have set. Emerging markets are up 5.71% in the first quarter - a welcome change.

Bond market performance is heavily influenced by central bank policy both in the U.S. and around the globe. These interest rate policies are influenced by inflation expectations and employment (proxy for economic health/growth). The U.S. does appear to be in a stable place with the employment picture brightening and inflation low, but stable. With this backdrop, the Federal Reserve could argue for higher interest rates in an effort to get back to a “normal” interest rate environment, but it has favored a more subdued approach and tone. The real complicating matter is that most of the world has gone to a ZIRP or NIRP (Zero Interest Rate Policy or Negative Interest Rate Policy) in an effort to spur economic growth. Since money flows globally to the best opportunity, these policies make it difficult for the Federal Reserve to raise interest rates without dramatically increasing the value of the dollar, which has already appreciated a great deal against other world currencies. As a result, we believe that we are likely to be in a low interest rate and low return environment for bonds for an extended period of time. While interest rate increases are not only possible, but probable, we think they will be very incremental over time and the risk to bond investors is fairly low. If interest rates stay low and thus bond returns low, this also has a secondary effect of keeping stock returns lower than the historical returns we have been accustomed to seeing. Lastly, the high yield bond market (lower credit quality company bonds) had a rocky 2015 due to fears primarily related to energy companies, but these have subsided as we had hoped and returned 3.32% this first quarter. The aggregate bond index was up 3.03%, and the short-term corporate bond index up 1.14%.

When to React, When to Ignore

The volatility experienced in the first quarter continues to reinforce our belief that emotions are rarely our friend when investing. Additionally, watching every tick of the tape or hanging on each economic report is rarely helpful either. Instead, we feel it is best to major on the majors and minor on the minors. We should seek to understand the big risks and return drivers of asset returns and resist the temptation to over-react based on short-term volatility. This should not be confused with “set it and forget it”, but rather pursues thoughtful adjustments to current conditions. I can remember as a child sitting on my Dad’s lap and learning to steer a car. (This seems very irresponsible today, but it was fine at the time). As a child, you have a tendency to not recognize veering early enough and then have a tendency to saw on the wheel to correct, then re-correct the course. An experienced driver rarely has to do this, but rather makes small adjustments both to the speed and direction of the car. Successful investors, likewise, should learn to see the current environment clearly and know what to react to, and what to ignore. This is the challenge, but it is a task that is made easier with a philosophy, process, and group of people who collaborate on your behalf to make these decisions. We thank you for your trust.


The opinions voiced in this material are for general information only and are not intended to provide specific advice or recommendations for any individual. To determine what is appropriate for you, consult a qualified professional.

No strategy assures success or protects against loss. Investing involves risk, including possible loss of principal. International and emerging market investing involves special risks such as currency fluctuations and political instability and may not be suitable for all investors.


BTN #1-487953.0416

It Gives Me Freedom

By: Harold E. Giles, M.D. with Nephrology Associates, P.C.


“It gives me freedom.”

“I tell people I'm a dialysis patient and they don't believe it.”

“It's like I'm living a normal life.”


These are quotes from my patients who do dialysis at home. Their sentiments are common amongst those who visit us every month for a checkup.

Home dialysis is in a resurgence right now. This move is a combination of two strong trends in medicine. Patients want and deserve more autonomy over their healthcare and dialysis done in a traditional center is incredibly expensive. Most of our dialysis patients are on Medicare and while they make up just one percent of Medicare enrollees they take up eight percent of the budget. Home therapy is a win for the patient and the overall community.

Right now there are two paths to doing dialysis in the home. Patients can choose to do peritoneal dialysis (PD) which involves the placement of a soft catheter in the abdomen. Most of our patients can do most, if not all, of their dialysis overnight with a cycling machine the size of a printer in one’s office. If you see a PD patient in the grocery store or at church you would never know they have their catheter coiled up and hidden under their blouse or shirt.

Do patients do hemodialysis at home? Absolutely they do. And recent outcomes data shows that these patients do as well as those who have received a kidney transplant from a deceased donor. If you have ever seen the small machines in the ICU that are used for continuous dialysis then you have an idea of the small platform that is deployed in a patient’s home for hemodialysis. Most of our patients do this four to five times a week. The increased frequency makes it easier on the patient and reduces the “wiped out” feeling that in center dialysis patients often report.

Our home patients, need to get labs drawn once a month and see our team shortly after that. Our team consists of a nephrologist, their RN, a dietician and a social worker. We work together and this approach offers deep resources for patient care. This stands in contrast to an average of thirteen in center treatments at a local dialysis unit. I think much of the satisfaction for patients lies in both ownership of their health and in a less burdensome interaction with the delivery of healthcare.

If you run across a patient, a friend or a family member who might be facing dialysis, rest assured that an opportunity for home therapy is strongly supported by the literature. And most importantly, it is a wonderful chance at preserving more of the normalcy of daily life that we all treasure even when faced with a chronic illness.

Old EHRs - New Problem

By: Ryan McGinty,  President / CEO at OCERIS, Inc.

With EHRs finally reaching a widespread adoption tipping point in the past few years, a new set of challenges has been introduced as a result. When adoption was first occurring, most offices were moving from a paper-based system of documentation and kept the paper around while the transition to the EHR proceeded. While some of the paper never fully made the transition, the charts were still locked in storage somewhere and available if need be.

Fast forward a few years and there is a new situation: the EHR-to-EHR transition. Some offices have transitioned, not only once, but many times to new EHRs as the industry evolves, products get bought and sold, while others simply shut down. Unlike the paper charts that are “always there”, now clinical data is spread across one or more previous systems. Maintaining these previous systems is one of the major unforeseen, and often neglected, trends on the rise as more and more EHR-hopping occurs.

There is a reason why this problem is becoming more apparent as time progresses. The industry went from paper-to-EHR being the predominant transition type to EHR-to-EHR transitions in just a few years. The infrastructure to run the previous EHRs, new at the time of installation, is now at an age where failure is becoming more and more imminent. Most offices seem to take the “out of sight, out of mind” or “that’s our old system” approach and think that past systems are unimportant. They only hold old data and “we rarely even reference it anymore.” That’s great until there is chart audit request or subpoena for a chart on the previous system and suddenly the server that holds it fails to turn on. Most people don’t want to spend money on a system they aren’t actively “using”, but that lack of attention could lead to permanent loss of important data.

This growing problem is further obscured because offices that transition are rarely coached on what to do with their old system. The new vendor has no control over the old system, the old vendor has no desire to continue supporting their system for free, and the office doesn’t really want to pay for something they aren’t using. This puts the previous EHR into a limbo/gray area where it “just runs” and everyone assumes it will continue running because it always has in the past. This is not a reliable assumption and risky for the long term – remember, as the hardware ages, operating system upgrades occur, and a myriad or other variables change, the chances of something going wrong increases significantly.

So, what options are available?

1. Continue Official Support

The easiest thing to do, but usually the least desirable, is to continue to pay the old EHR company to keep the system up and running. This may be a requirement if you’ve used a cloud-based system and have significant amounts of data in it since they can simply cut your access to it. Some cloud vendors will send you the data, but alone, the data is no good without a tech person to sift through it and make it accessible – which could cost more than just keeping the old system running.

If the system is on-premises, this may involve not only paying a monthly fee to the software company, but also having a hardware/IT person or group that understand the hardware should it fail. Some software companies require the same support as if you were using the system while others may agree to a simple hourly fee should you have any problems down the road. Make sure to ask what options are available, because a cheaper option might not be volunteered without asking.

2. Find a Contractor

Some EHR systems have third-party contractors that know how their systems work. These third-parties may have a more affordable rate and give you the “emergency” support needed, without having to pay for “usage/updates/etc.” support. This may also be the only option if the previous vendor has gone out of business.

3. Data Export or Data Conversion

A data export is where the software company provides a former client with a human-readable copy of all the data in the system. This may in the form of a large amount of PDFs, it could be print outs, or any number of things that could then be manually loaded into a new system. This option is appealing because it requires no special software or hardware to keep the records accessible.

Data conversion is a bit more complex and varies wildly from situation to situation. There are very, very few times when a new system can have 100% of the old data imported. The only time this can happen, it is usually when a vendor has purchased another company and has worked on a one-to-one conversion, but even then great care should be taken to understand exactly what data is getting converted. Most conversions are simply demographics and appointments. More expensive options might include some encounter information. Most will NOT include enough information for an office to completely disregard the previous EHR, leaving the office to choose one of the other alternatives to keep the old system maintained.


Regardless of the method, the goal should be to protect the old system’s availability or move all of the data from it in a reasonable timeframe. Obviously, having all the data in one system would be ideal, but it is also not feasible if there are thousands or records that have to be moved by hand and an office’s staff is already stretched thin with current day-to-day activities. Maintaining clinical records, even in an EHR not actively used day-to-day, is an important responsibility for an office. Any data in a previous EHR needs to be backed up, secured, available, and treated just as importantly as data in the new EHR until a time that all the data has been moved or the legal retention requirements have ended. This is a case of prevention being key – once something prevents access to your old system it is likely too late, or extremely expensive, to correct.

Preventative Medicine Screenings

By: Amita Chhabra M.D Hoover Primary Care

Cancer screening for many healthy individuals fall very low on the list of priorities. Preventative medicine and routine cancer screenings are important even for those without chronic conditions as it allows us to catch cancer earlier. And as the saying goes; “early detection is key”. There are so many preventative medicine screenings that your doctor preforms, unbeknownst to the patient and mentioned below are a few that may start a discussion in your home.

Depending on your provider and the guidelines they follow, cancer screening can vary. However primary care physicians are the foot soldiers in coordinating preventative medicine for their patients. Patients may not realize but a simple set of vitals can tell us so much about a patients overall health. Blood pressure screen, BMI, and weight. Your doctor will routinely run lab work with insight to your cholesterol, thyroid function, and anemia if necessary. All the above screenings and many more are preventative steps we take to recognize a disease process before it takes a toll on the body as a whole. It seems only fair that there are a few guidelines in which men and women are subject to the same intervals for certain cancer screening. One that perhaps is the most daunting; a colonoscopy.

It is recommended that men and women should be screened starting at 50 years of age unless there is family history or a previous indication. Colonoscopies should be performed every 10 years unless there is a finding that requires a shorter interval. However it’s important to ask your primary care provider for other options if the idea of a colonoscopy is too overwhelming. Flexible sigmoidoscopies, double contrast barium, CT colonography, and checking a fecal occult blood are all alternative options. However the gold standard of finding cancers, that can be biopsied, is a colonoscopy.

For women it’s worth mentioning that breast cancer screenings periodically change. However if you have a family history of breast cancer notify your health care provider. It could mean that you qualify for a baseline mammogram earlier than 40 years old. The American Cancer Society reveals women ages 40 to 44 should have the choice to start annual breast cancer screening with if they wish to do so. Women age 45 to 54 should get mammograms every year. Women 55 and older should switch to mammograms every 2 years or yearly. Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer. It’s not well known that pap smears are now recommended to start at 21 years to catch cervical cancer earlier. Cervical cancer screenings should start at age 21. Women between the ages of 21 and 29 should have a Pap test done every 3 years. HPV, the virus that causes cervical cancer, should not be used in this age group unless it’s needed after an abnormal Pap test result. Women between the ages of 30 and 65 should have a Pap test plus an HPV test (called “co-testing”) done every 5 years. Breast cancer and cervical screenings are important in maintaining women’s health.

For Men, prostate cancer screening can also have varying guidelines. The American Cancer Society agrees it should be a discussion between provider and patient at 50 years old. If the patient is willing to go for further testing or biopsy then it would be an appropriate option to screen. African Americans, who have a father or brother who had prostate cancer before age 65, should have the discussion earlier starting at 45 years old. Depending on several factors, your doctor may choose to do a PSA level. If it is elevated it will likely be checked yearly, if not every 2 years depending on exam and other factors. Low sex drive, erectile dysfunction, fatigue and depression can all be signs of low testosterone. This could be due to a lot of factors but oftentimes insurance companies will pay for a screening testosterone for men over 40 years of age. Testosterone replacement should be discussed with your doctor, however many people are unaware that their symptoms could be alleviated with a simple screen.

Obviously there are so many more preventative medicine screenings that can’t be mentioned in one discussion. It’s important to allow your primary care physician to see you once at least once a year to address the above measures for an old fashioned checkup. It would allow the opportunity to address many cancer screenings, adult immunizations and preventative medicine screens.

The Watchman Left Atrial Appendage Occlusion Device:The alternative to blood thinners

By: Anil Rajendra, MD, FACC Cardiac Electrophysiologist Alabama Cardiovascular Group Grandview Medical Center

Background


Atrial fibrillation (afib) is the most common arrhythmia and affects over 3 million Americans. It is an irregular, unorganized heart rhythm originating in the top chambers of the heart (atria). When people are in afib, there are electrical signals originating from numerous locations in the atria, causing the atria to fibrillate or “quiver” rather than contracting normally.

While afib is not a fatal arrhythmia, it does carry an increased risk of other issues, of which the most concerning may be strokes. Because the atria “quiver” rather than contracting normally, blood may pool in certain areas of the atria and form a clot. This clot can then dislodge or break and cause a stroke. Patients with afib have a 5 times increased risk of stroke. To minimize this risk, patients have traditionally been placed on anticoagulation (blood thinners) to prevent these blood clots from forming in the heart.

The overwhelming majority of these blood clots form in the left atrial appendage. The appendage is an outpouching in the left atrium and is a vestigial structure; i.e., it does not have a real purpose in normal heart function.


What is your risk of stroke?

As mentioned, the risk of stroke in patients with afib can be at least 5 times higher than patients without afib. The risk of stroke varies depending on other medical problems and risk factors. There are a few risk scores that are used to determine a patient’s risk of stroke. The most commonly used risk score is called the CHA2DS2-VASc score. 1 to 2 points are assigned to the following risk factors: congestive heart failure, hypertension, age > 75 (2 points), diabetes mellitus, previous stroke (2 points), vascular disease, age 65-74, female sex. According to current recommendations, patients with 2 or more points should be on anticoagulation (blood thinners) to lower the risk of stroke. The higher your risk score, the higher your risk of stroke.

How do we prevent strokes in these high risk patients?


The first line and most common modality to reduce the risk of stroke is the use of anticoagulation (blood thinners). Warfarin (Coumadin) is the oldest of the blood thinners, having been used for many years. Because warfarin has been around for a long time, it is relatively inexpensive. However, it does require frequent blood monitoring as well as diet restrictions.

More recently, newer anticoagulants have become commercially available, namely dabigatran (Pradaxa), rivoraxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). These newer drugs performed well in clinical trials comparing their efficacy against warfarin, and all gained FDA approval for stroke prevention in patients with afib.

However, many patients cannot take blood thinners due to high risk for bleeding or previous bleeding. In addition, some patients just do not want to take blood thinners long term. Until recently, there was not an option for stroke prevention in these patients. Now there is a device, called the Watchman left atrial appendage closure (LAAC) device that is an alternative to oral anticoagulation for stroke prevention.

The Watchman device


The Watchman LAAC device gained FDA approval in the spring of 2015 after being studied extensively in 2 separate clinical trials and 2 subsequent registries. As mentioned previously, the left atrial appendage is the location where the majority of clots form in the heart. This device is implanted in the opening of the left atrial appendage, with the heart muscle growing over the device and permanently sealing off the appendage. The Watchman device was studied against warfarin in 2 large studies and proved to be as good as warfarin at preventing strokes.

The Watchman is shaped like a parachute and has a nitinol frame with a mesh covering over it. Using a minimally invasive technique through access in the femoral vein in the groin area, the device is implanted in the left atrial appendage. Ultrasound and fluoroscopy (x-ray) are used to position the device in the proper location. After the procedure, patients remain in the hospital overnight and are discharged home the following day. Patients remain on blood thinners for 45 days after implant. At 45 days, they have another brief ultrasound to ensure the device is still in good location and a good seal has formed. If that ultrasound shows a good seal, then patients can discontinue blood thinners at that time.

My partners and I with Alabama Cardiovascular Group at Grandview Medical Center were the first to implant the device in the state of Alabama. We have successfully implanted the device in over 40 patients and have had outstanding results. Our patients who have undergone the procedure have been able to discontinue their blood thinners and still be protected against stroke.

Conclusion


Atrial fibrillation is a very common, complex arrhythmia that increased the risk of stroke in patients afflicted with the disorder. Traditionally, anticoagulation has been the only modality available to reduce the risk of stroke in those patients. For patients that cannot take anticoagulation, however, the Watchman LAAC device is a very viable and effective treatment option to reduce the risk of stroke without the need for long-term anticoagulation. If you have afib and cannot take blood thinners, inquire if you are a candidate for the Watchman device.

How to Recognize a Dangerous Phishing Email

By Thomas Kane, CEO Keep IT Simple

How do you know that that rogue email from American Express about an unpaid invoice is real? How about the email from BestBuy, Costco or FedEx? Or the slew of other unsolicited emails you receive daily? Individual consumers are not the only targets made by cybercriminals. Businesses and medical practices are very often targeted by hackers and cybercriminals with emails that are designed to look completely legitimate and real as a form of introducing ransomware, malware, viruses, and trojans to your computer and practice network. You are often asked to click a link, download an attachment, or provide some personal information or credit card information. This type of scam is called phishing, and is becoming a very real threat to your medical practice.

There are 5 things to look for when reviewing incoming email that can help keep your office and your data safe.

1. Real companies will use your name.

Legitimate emails from legitimate companies in which you have an actual account will always use your name. Emails that start with vague introductions such as “Dear Customer” or “To Whom it May Concern,” or similar context should immediately alert you to something suspicious.

2. Safe emails will come from a registered domain email address.

If you receive an email from a company such as American Express, it should specifically be from someone@americanexpress.com, which reflects a registered domain email address. Emails from non-registered domain email addresses, such as americanexpresscustomerservice@gmail.com, are almost always dangerous, should be highly avoided, and quickly deleted.

3. Spelling and Grammar

A real email, from a real company, for a real reason, will always be spelled correctly and use proper grammar. For example, if you receive an email from someone@support.americanexp.com that uses a subject line like “You have missed a invoice,” this is considered to be very suspicious and should be promptly deleted. Sometimes the spelling is correct, but the grammar doesn’t quite make sense. If the email seems off and you can’t put your finger on it, it is probably a phishing scam.

4. An actual company will never ask for sensitive information.

Companies that you do business with will never contact you via email to ask for billing information or personal information about you. Never send your credit card number to anyone via email or give any specific personal information about yourself. Once you click send, it’s out in cyberland and will be too late to stop a hacker. If an email you receive asks for any credit card, billing, or personal information without requiring you to sign in to an account you already have set up, stay far away.

5. Legitimate companies will never send you an unsolicited attachment.

Lots of medical practices are receiving emails that look and feel exactly like an email they would normally get, but may include an attachment. There usually isn’t an attachment from a legitimate company. Proper invoices and company information will always be available through a secure portal on a legitimate company website.


It is imperative that you and your office staff begin implementing these critical items into your daily email checks to prevent phishing attacks via email. The number one cause of dreaded ransomware, where your office data is encrypted and the only course of action is to reformat and restore from a backup, is a phishing email. The nastiest virus known to be circulating right now may be sitting in your email inbox waiting for you to mindlessly click that link. Once you click, there’s no turning back. Take the time to educate yourself and your team on how to identify these types of vulnerabilities. If you ever have a doubt or a question about an email, immediately delete it and call the company in question to inquire about the noted issue. If they have no idea what you’re talking about, congratulations, you just avoided what could have been the worst virus infection your office has ever seen.

Just 30 Minutes

By: Raymond Workman, MD, Cardiologist at Medical West UAB

Sometimes, when it comes to getting in shape, the hardest part just starting. There are so many different ways to exercise now (CrossFit, pilates, old-fashioned running, on and on…), that it can be overwhelming as we look for what is most appealing to our lifestyle - and what will give you results.

Whatever your plan - DO IT. (Consult with your doctor, of course.) Get over that hump of getting started - set a plan, make time for it, and be accountable.

And when I say plan - put it in your schedule, your calendar, your iPhone app… whatever it is use to organize your day. Thirty minutes is set aside for you to exercise, nothing else. And set aside this thirty minutes five to seven days each week. Maybe get a friend to jump in with you and help keep each other accountable.

Exercise is a catalyst for so much in our lives. Not only are you in better shape, losing excess weight, etc. - but it also makes you more productive. The chemicals released into your body when you exercise make you sharper mentally and you are more productive. You are also less stressed, and people who are less stressed are more rested and - believe it or not - not sick as often. (Stress is a big hit to the immune system.)

And of course, there are all the physical benefits of lowered blood pressure and lowered cholesterol, which roll over into so many reduced risks of more serious diseases and events.

In short, a moderate amount of exercise and a moderate diet can almost completely turn around most health issues for a person. Of course, there are the exceptions of conditions that may arise in some people, but if you play the numbers, your healthy will more than likely be better with a moderate amount of exercise.

A happier, healthier life - and all you need is thirty minutes a day.

Do it!! -

Ray Workman