Long story here, tldr is at the end.
When I was around 5, i was sexually abused by my older brother. I kept it a secret and we didn’t mention it to anyone. The story my mom had told me when I grew older and asked about what happened was that my parents found out and reported it immediately. She told me that they separated us and didn’t let him near me whatsoever and were very careful.
She continued to say that I went to counseling (I want to clarify I have almost no memory of this time period except for the times I was harmed) and that my therapist said I wasn’t strongly affected by this and would be fine.
As I grew older, id have more questions and my mom would always be there to answer and listen. Once I turned 18, however, we were chatting and she proceeded to let it slip that her and my father had not reported it to the police like she said.
I was utterly confused to say the least and tried to not lose it and asked what she meant.
Apparently my parents both found out about the abuse and decided they were equipped to handle it themselves. They did their best to separate us and wouldn’t let him near me. This was how it was for many many months. (My parents are also conservative Christians who attend church quite frequently for context here.)
It wasn’t until the youth leader at our current church called my mother and told her that my brother had confessed about what he did to me that it was reported. Afterward, there was an entire court process and that was when police were involved as well as CPS.
After she explained this all to me, I felt completely blindsided. It felt like by not reporting it that they took his side and put me in more danger because they were “scared we were going to be taken away.” (Actual quote from her.)
I yelled at her and basically said that it wasn’t right that she didn’t report it. She got angry with me and basically told me that it was eventually reported anyways so I should be satisfied regardless. She also went on to say that my being a girl was the reason he almost was put on a sex offender list.
This happened a few nights back and I feel so hurt and confused. I don’t know what to do and how I can ever trust my parents again after this. I feel like they chose him over me and didn’t care enough to protect me.
TLDR: my parents lied about the fact that they were not the ones to report my sexual abuse at the hands of my brother for 13 years.

🎶 Discover the Transformative Power of "Bajo la Gracia" by Edu Calderon

🎤 What is "Bajo la Gracia"?

"Bajo la Gracia" is the latest single by Edu Calderon, a vibrant fusion of dancehall and religious music designed to bless your day from the first listen. This song is not just a hymn of gratitude and faith but also a powerful tool to start your day and week with the best possible energy.

📺 Watch the Official Video

Transform Your Week with "Bajo la Gracia" by Edu Calderon: A Musical Blessing

🎶 Discover the Transformative Power of "Bajo la Gracia" by Edu Calderon

🎤 What is "Bajo la Gracia"?

"Bajo la Gracia" is the latest single by Edu Calderon, a vibrant fusion of dancehall and religious music designed to bless your day from the first listen. This song is not just a hymn of gratitude and faith but also a powerful tool to start your day and week with the best possible energy.

📺 Watch the Official Video

https://www.youtube.com/watch?v=nX2NVFL9_hk

🌟 Who is Edu Calderon?

Edu Calderon, whose real name is Eduin Jimenez Calderon, is a versatile artist known for his ability to blend genres and convey deep messages through his music. With "Bajo la Gracia", Edu aims to connect with his audience on a spiritual level, offering them a musical experience that is both uplifting and inspiring.

💬 Highlighted Lyric

"Una gotera me acaba de mojar, suave lluvia que me moja. Bajo la gracia de Dios estoy."

🎵 History and Context

Edu Calderon has been an influential figure in urban music, recognized for his talent in combining catchy rhythms with meaningful lyrics. In "Bajo la Gracia", he uses his talent to offer a musical blessing that reflects his own life experience and his relationship with spirituality. This song is more than just a melody; it is an invitation to reflection and connection with the divine.

🎧 Song Analysis

"Bajo la Gracia" is a masterpiece that uses the metaphor of rain to symbolize divine grace. The gentle rain that soaks and refreshes represents the blessings and love of God, always present in the believer's life. Throughout the song, Edu Calderon expresses gratitude and joy for these blessings, encouraging his listeners to recognize and celebrate their own.

🎯 Audience Intent

Bless, forgive, thank, love, and start anew, even from scratch.

🌈 Inspirational Message

Each verse of "Bajo la Gracia" is designed to evoke a sense of peace and renewal. Edu Calderon reminds us of the importance of walking with joy and facing challenges with faith. The song is a constant reminder that, no matter the difficulties, there is always an opportunity to receive and share blessings. The rain and divine grace imagery in the lyrics are meant to touch the soul of the listener, providing comfort and motivation.

📜 Full Lyrics of "Bajo la Gracia" - Edu Calderon

Coro:

Una gotera me acaba de mojar, una gotera me acaba de mojar... Suave lluvia que me moja, bajo la gracia de Dios estoy. 

Verso 1:

Me moja la camisa, me humedece la piel. Feliz caminando, recibiendo bendición. Feliz caminando, recibiendo su bendición... 

Pre-Coro:

Como a ti se te eriza la piel, quien sabe nada le parece difícil. Nubes y viento favorecen, para que tus sueños se realicen. 

Coro:

Una gotera me acaba de mojar, una gotera me acaba de mojar... Suave lluvia que me moja, bajo la gracia de Dios estoy. 

Verso 2:

Caminante, encuentra tu propio yo. Orgulloso de ser, esa es tu bendición. Matizando recuerdos que te acompañan, galería de recuerdos, se cayó y se levantó. 

Pre-Coro:

Como a ti se te eriza la piel, quien sabe nada le parece difícil. Nubes y viento favorecen, para que tus sueños se realicen. 

Puente:

Gracias al Señor, gracias le voy a dar, gracias porque puedo cantar. 

Coro:

Una gotera me acaba de mojar, una gotera me acaba de mojar... Suave lluvia que me moja, bajo la gracia de Dios estoy. 

Despedida:

Suave lluvia que me moja, bajo la gracia de Dios estoy. Oye, oye, no temas estar solo, la soledad es tu compañía. 

Conclusión:

EL DIVINO, EL QUE SIEMPRE TE ACOMPAÑA dice E Jiménez Calderón ES ENSERIO... 

🚀 Listen and Share

👉 Watch the full video here: Bajo la Gracia - Edu Calderon

🌐 Connect with Edu Calderon

For more music and updates, visit: Edu Calderon WebsiteTransform Your Week with "Bajo la Gracia" by Edu Calderon: A Musical Blessing

🎶 Discover the Transformative Power of "Bajo la Gracia" by Edu Calderon

🎤 What is "Bajo la Gracia"?

"Bajo la Gracia" is the latest single by Edu Calderon, a vibrant fusion of dancehall and religious music designed to bless your day from the first listen. This song is not just a hymn of gratitude and faith but also a powerful tool to start your day and week with the best possible energy.

📺 Watch the Official Video

"Tell me how all this, and love too, will ruin us.
These, our bodies, possessed by light. Tell me we'll never get used to it." — Richard Siken, Scheherazade

I have so many stories to tell you, won't listen?
Presently, I'm seeking a fwb situation. Someone that is curious, attentive, charismatic and sharp; engaging with those and the world around you is something you excel at even if it tends to exhaust you, if it does.
The dull things: I am a plus size black woman. 5'6, short black hair, glasses. Full lips, some (but not many) curves, big thighs and a noticable tummy.
Spending late nights whispering about our woes, joys, loves and hates is an activity I greatly, greatly enjoy.
You? Your musical tastes are eclectic, you have some love of the arts—poetry and music—and bring your best self to put forward. You would be 30 or above (the least I'll accept is 28 as I would like to speak to people my own age) and in the same state at the very least—it would be waste of both our times to have us be in two different states and countries.
Share yourself with me, tell me something unusual; I, myself, am very curious and would be willing to risk all lives that I have for the information. My chats are open (highly preferred) but I'll take a message (which will eventually be moved to a chat.)
🖤

This is kinda a sequel to a post I made few days ago
Hello umm just some background for context
I’m 21 year old man
I have a long history of uhh loneliness and limerence and putting people on a pedestal especially woman I’m crushing on
I get attached to folks really easily
Actively working on myself exercise and diet so far I’m 304 down to 277lbs since January
Keep trying to tell myself that I’m doing this for me myself and my health but deep down I also know I’m doing to think to be a lil more attractive
Trying to get back into therapy just waiting for my insurance to kick in
Context and why I posted this
Without airing anyone’s dirty laundry
Basically met someone over in R4R and Forever alone dating. Talked sparingly she found someone in her home country which was cool happy for her
We continued to talk recently though she was in a crisis basically abandoned by her abuser and kicked out of her home
I’ve been trying my best to help being supportive sent a lil money. (I know it’s not a scam)
It was good I was really trying to do the right thing and uhh well my dumbass started crushing on her.
And I feel a lil gross cause she just got out of abusive relationship and I shouldn’t be thinking about dating her she’s focus’s on where she’s gonna eat and sleep.
This has all been going on for a week and a half
Friday I felt limerence kicking in I was at my desk and I realized as I was working I was day dreaming about me visiting and us visiting all the historical sites in her country
It scares the hell out of me I don’t wanna be limerent again and chasing people again
But I’ve still been helpful and supportive but today at work I had I think it might have been an anxiety attack but basically I just spilled my guts and told her how I have a huge crush on her
And I know it’s wrong but I can’t hold it in if I kept holding it in I was gonna start bawling my eyes out in work. I apologized
She got back to me she isn’t mad, at me
She was very forgiving and understanding and empathetic
She said she thinks I’ve got anxious attachment like her, she said she’d help me work through it.
So when I got home from work today. I went online and did some research and I know tests aren’t like certified or a diagnosis I guess but I took three different ones and got anxious attachment every time.
I feel like the hardest part of my self improvement is gonna be social stuff, I’ve always been awkward I catch feelings very easily
I’m a stupid romantic, I’m apparently to kind for my own good
I’ve always wanted the intimacy and the lovey dovey stuff of relationships the companionships more than any sex o
And look, I swear I’m not a nice guy, or a white knight
I genuinely went into helping her because it was the right thing to do. It’s just my brains is stupid cause people are nice to me and I get really attached I’m a sucker for compliments
I would just love any and all advice and resources maybe you notice something I don’t
I don’t hate myself I don’t think I’m fuck ugly
I used to think I was unlovable but I’ve had one relationship in my life and in therapy I learned that, I have the qualities to be a good boyfriend they just manifest in improper ways
My dream in life is I want a home, a sense of independence, I’d love to get married and I love her she loves me we support each other and help each other grow as human beings
*im not specifically talking about her in my dream in life
I know this is a lot and might sound like the ramblings of a mad man. But I’d really appreciate anything

Is New England the best part of the US in terms of QoL, education, crime rate, and other lifestyle or environmental factors?
Could it be seen as equal or superior to countries in Europe?

My daughter has always dreamed of living and working in South Korea as a clinical psychologist. From what I can glean, even if she becomes fluent in reading and writing she will not be able to have a career outside of being a teacher there. Does that sound correct? Would the best case scenario be to go to school here but then settle in her home country when she’s graduated and can begin her career?

Hey everyone, fresh college grad here. I am a little confused as to which MBA programs will be best suited for me and which industries I’ll have the best chances of breaking into post-MBA. I would appreciate if you fine folks could take some time to go over my profile, or at least what I expect it to be within 3 years.
Existing profile:
Engineering grad from Indian Institute of Technology, Kharagpur (Top 5 in the country, <1% acceptance, I guess good image among M7 and other adcomms given the number of interview calls my alums get) and masters in entrepreneurship from the same institute (5 year dual degree program).
GPA (scale of 10): 8.2 CFA Level 1, FRM Level 1 (gave level 2 yesterday) 1 research paper published (co-author) in the domain of climate finance 1 patent filing for a proprietary smart safety helmet for underground coal miners. Adequate involvements in extracurriculars, clubs, competitions, etc.
Did my recent summer internship in a risk team at Aladdin Financial Engineering, BlackRock. Worked in fixed income backtesting, performed well, got a PPO. Joining full time next month and will be working in portfolio optimisation, a brand new vertical for my team. Other experiences include research internships at a couple reputed Indian BSchools and some derivative valuation and risk assessment work for another MNC.
A lot of my batchmates were trying out for deferred MBA programs in their final year so I gave GMAT too, just to get a feel. Gave a couple mocks without practise (740/750) and then gave the exam and got 730. I wasn’t serious so I didn’t hire a counsellor, especially coz they cost a year of tuition+hostel/food worth of money for 10 applications. Applied at IESE and Booth then gave up as I ultimately decided that I didn’t want to go to the States due to personal reasons.
What I think I definitely will have within 3 years:
CFA and FRM charters 2-3 years of volunteering experience, hopefully even some PoRs, as I will be continuing my stint at the local chapter of the Rotary Club. (Have been involved since I was 14, absolutely love those folks and the work they do) And WorkEx lol
Of all the post MBA options, venture capital seems the most alluring to me. Syncs well imo with my postgrad and after talking to alumni in the industry, it seems I would enjoy the work. Personally IB is not for me and I absolutely despise management consulting. Geographically, I would love to work in Europe and the Middle East. Open to study anywhere except the Americas.
I would love to hear from you guys regarding my profile, how I can add to it and make it more structured over the next few years because let’s face it, it’s a hot mess right now. LBS/INSEAD have always been at the top of my list but I don’t know all the granular details about LBS and INSEAD seems to be an exclusive labour provider for MBB 😂. It is my first post here, so hope I’m not violating any rules. Thank you for taking time to read this mundane post, hope you have a blessed day!

My wife and I are moving to Langley from the US at the start of next year, and I'd love to get an idea of what you think we should know before we get there!
For context if useful, I moved to the states from the UK and my wife is American, I like a lot about the states but it isn't somewhere I'd feel particularly safe or comfortable forever, especially when looking to start a family, mostly due to the way the country approaches healthcare and firearms (if you have the choice to raise kids somewhere other than the school-shooting and maternal-mortality capital of the developed world, why wouldn't you? Is our main thinking).
We initially landed on VancouveSurrey/Surrounding areas as it's close enough to easily see US friends and family, while also being a tech hub/big city, making work hopefully accessible to us. After a few trips looking around a few areas (Guildford, White Pines, Coquitlam, Langley, Abbotsford) and talking to people in the different areas we think Langley is the best fit so we're planning our move and aiming for the start of the year! (Exciting!)
All of this is to say, as the people who'd best know, what would you recommend knowing or keeping in mind for a couple aiming to move there to start a family/lay down some roots! No feedback to harsh or honest!
Thanks all!

Demographics: Rising senior, Indian, Female, East Coast. Super competitive school, 13 got into Penn, 8 into Cornell, 5ish into Georgetown, etc.
Intended Major(s): BS/DMD (early assurance dental school) programs at schools that offer. Otherwise, biochemistry/biology.
SAT: 1550 (750 EBRW, 800 Math)
UW/W GPA and Rank: UW is 3.91/4, W is 6.88/7, rank about 20 something (because we have 17 valedictorians 😒)
Coursework:

• Completed so far: AP Seminar, APUSH, AP Bio, AP Psych, APES, AP Lang, AP Research
• Senior Year: AP Chem, AP Lit, AP Calc BC (my school doesn't have AB), AP Stats, AP Macro + Micro, Human Anatomy Honors

Extracurriculars (kind of vague so I don't doxx myself):

• Extern at a dental practice nearby - very hands on, I suction and such during procedures ranging from basic prophys to complex extractions or root canals - about 300 hours
• Research assistant at state uni's school of dentistry, working on a project dealing with constructive oral surgery and materials to be used - in the publishing process to top dental journals
• Research intern at local university, project on ALL growth using mice models
• Candidate for Leukemia Lymphoma Society's Student Visionaries of the Year Comp., raised over 38K in a 7 week period to go towards cancer research
• Leading a social-media based health-related (can't say specific topic bc of doxxing but it is a very niche topic and is helping fulfill a gap by reducing stigma) awareness campaign
• Wrote a review paper on cervical cancer and how it affects South Asian women specifically - in one of the final reviewing processes by The Lancet!
• Founder + Co-Pres of Operation Smile at my school (club focusing on cleft palates and helping kids with them in underprivileged countries)
• President of Biology Club (anticipating, not out yet - if I don't get it then I'll speak about being Vice President of Science National Honors Society)
• Job at Kumon for the past 4 years, work as the lead center assistant
• President of Indian Club, leading over 100 members in order to choreograph a 8 min dance for the school's International Day event as well as coordinating various cultural activities throughout the year

Essays/LORs: Definitely going to ask the dentist who owns the practice I extern at - she knows me super well, has been the one who sparked an interest in dentistry for me, and I also tutor her kids (11/10). In school, my math teacher (should be 10/10, we are quite literally best friends) and AP Bio teacher (8/10 - she likes my work and labs and uses them as examples, I just haven't participated the most in her class)
Other: The only thing keeping my GPA from being a perfect 4.0 is that I got 2 Bs in my freshman year (an 88 and an 87) in English and History. However, I've shown an upward trend, ending with all As for my sophomore and junior years, and my English grade improving up to a 99 final grade this year. So I hope it's not that much of a bad look?
Schools I'm Applying To: UPenn 7 Year BA/DMD (ED), Cornell, Barnard, Harvard for fun, UMich, NYU 7 Year BA/DMD, Case Western 7 Year BS/DMD, Boston University 8 Year BA/DMD, Tufts 8 Year BA/DMD, Carnegie Mellon, UNC Chapel Hill, Georgetown, and then some local safeties.

Weird title! Yep. Basically, I recently heard of the La Roche Posay uvmune 400 and it only came to my country recently (we don’t even have the pediatric version, or the body spray version, or the Loreal Paris cream version).
What differentiates that sunscreen from others is that it protects your skin from long uvA rays, which I don’t think any other current sunscreen does. However does it protect from all ray lengths (apologies if the question is not scientifically accurate)? And also this is a bit of a cosmetic ellegance problem, but it is a bit oily (scared of clogging my pores). Is there any sunscreen that offers the best of both worlds (ie not very oily, white cast is ok + good sun protection)?

I only just discovered that this was a thing so it's nice to see i'm not the only one.
I worked a remote job for many years and after long relationship ended i got curious and did a lot of travel and it was shocking the difference between the dynamic between the women in my home country of Australia and those abroad. Since then have exclusively dated women from abroad both while traveling for extended periods and at home. I am seeking a long term partner and have had a couple of great relationships that didn't pan out amongst other shorter but just as rewarding encounters.
I came back to Aus as the pandemic was kicking off and I don't know if this is frowned upon and not in the spirit of ppb but Australia has a huge migrant population and also a vast amount of people study here from abroad. I have met a lot of wonderful women from other places here who I felt were genuine and not visa hunting. A lot of them were also high achievers and intelligent but had excellent grounding / moral compass from their upbringings and were of course well traveled.
I still like to take extended trips but have found meeting foreign women at home just as rewarding for those who maybe have jobs that don't allow or other constraints. I like that they are here on their own merit too so i don't feel any obligation as far as their living arrangements if it gets serious.
I just wanted to mention the two recent experiences I have had this year. One was a Filipina and I also tried dating an Australian girl for first time in years...
So this filipina was cute as a button, highly educated completing a masters here and also working. Her attitude was so different to western girls and she always wanted to take care of me bringing food, affection and also sexually she did her best to ensure i was taken care of. The way she treated me made me want to step up to try my best to ensure she had everything she needed and treat her right with lots of love and care. It's all the small things I tell you! alot of it was very sweet cooking for each other and being lame. people think PPB just want a maid or to have some sort of power over their partner but I just loved how it was so reciprocal.
Then i should mentioned this Australian girl. Playing games with me from day one, saying things just to try and get reactions out of me, almost begging to be constantly complimented which was a turn on in itself. Her texts were also super passive aggressive and if i didn't play the game she'd mention oh some guy at work was flirting with me etc like i would be outraged. She was a perfectly lovely person to hang with but i got this feeling like it was a one way street. She wanted to be worshipped but she was so uncaring and cold why would i? She also seemed to think every guy she met or knew was madly in love with her but she was a pretty average person. I just thought her attitude stunk. really hot and cold.
I don't even know why i'm posting but there are so many great girls out there who aren't the spoilt brats we have here in Australia. Im not surprised when i see such i high number of interracial / international couples here in Melbourne. It makes me laugh because i have a lot of female friends and they are always the ones that comment on it when we are out with snide remarks. We are friends so obviously I think they are awesome company, funny and cool but they have the same attitude and wonder why they are single in their late 30's / early 40's now desperately trying to hunt down a man to shack up with or have kids.
I believe in equality for men and women 100% but i also think we are different creatures and theres nothing wrong with that. Being vilified by western women for being a straight white dude blows.
Finally I would say my favourite destinations have been in Asia by far due to the cost, food, proximity to Aus and wonderful people of both genders. Vietnam, Japan and Thailand are honourable mentions. Although with Thailand I stay clear of BKK or Resort towns.
My first post but i look forward to following the sub. I'm at the stage where i really hope to lock someone special I can marry and build something with so i like seeing so many genuine posts also.
Excuse the poorly written post i just typed my random thoughts on the matter. If i've made any blunders that aren't allowed here i'm sorry in advance!
Repost as last wasn't clear enough

A quick note about Karl Nell's SALT Conference audience today

There is zero possibility that Karl Nell gave his talk without express authorization of the United States Pentagon and White House, especially with the audience that attends the SALT Conference. Why? Read this post and his resume. You'll understand why.
Karl Nell, today, has four (4) bosses over him.

• You may have heard of the top of the reporting chain Karl Nell works under.

What do you reckon the average net worth of a SALT guest in the crowd is? Eight figures? Nine? A number of the cell phones in the crowd for Nell will have personal phone numbers of United States Senators and House members. Guaranteed.
We were not the audience for Karl Nell tonight. American industry and Congress were the audience.

Karl Nell endorsed two figures in "UFO" history tonight

Karl Nell is a step removed from the National Security Council. These people don't speak out of turn, and certainly not to tell the leaders of American industry that "aliens are real, NHI is real, and yeah, they've been here a long time," and... then name drop two foreign officials who flat out argued that we're covering up diplomatic relations with a "Galactic Federation".
But Karl Nell did exactly that in New York City today.
That would be Paul Hellyer and Haim Eshed. My jaw dropped how instantly and full-throated he was with the latter two as people to look toward:

• https://en.wikipedia.org/wiki/Paul_Hellyer
• https://en.wikipedia.org/wiki/Haim_Eshed

Again:

1. Karl Nell is an active Pentagon official four (4) steps removed from the United States PRESIDENT.
2. Nell just told the world to look to a Canadian minister of defense and the found of Israel's space program.
3. Who both say the world is secretly in contact with a Federation of outer space cultures.

A military leader four steps from Joe Biden said to look to Hellyer and Eshed.

What did Karl Nell have to say about David Grusch in 2023?

Source:

• https://thedebrief.org/intelligence-officials-say-u-s-has-retrieved-non-human-craft/

Quotes about Nell:

Karl E. Nell, a recently retired Army Colonel and current aerospace executive who was the Army’s liaison for the UAP Task Force from 2021 to 2022 and worked with Grusch there, characterizes Grusch as “beyond reproach.”
In a 2022 performance evaluation, Laura A. Potter, Deputy Chief of Staff for Intelligence, Headquarters, Department of the Army, described Nell as “an officer with the strongest possible moral compass.”

Karl Nell on David Grusch:

“His assertion concerning the existence of a terrestrial arms race occurring sub-rosa over the past eighty years focused on reverse engineering technologies of unknown origin is fundamentally correct, as is the indisputable realization that at least some of these technologies of unknown origin derive from non-human intelligence,” said Karl Nell, the retired Army Colonel who worked with Grusch on the UAP Task Force.

Who is Karl Nell?

He works here today:

• https://en.wikipedia.org/wiki/United_States_Army_Futures_Command

This is Karl Nell's boss:

• https://en.wikipedia.org/wiki/James_Rainey

The AFC reports directly to the Army Chief of Staff and the Secretary of the Army:

• https://en.wikipedia.org/wiki/Chief_of_Staff_of_the_United_States_Army
• https://en.wikipedia.org/wiki/Christine_Wormuth

Who do they report to?
United States Secretary of the Army reports to:

• https://en.wikipedia.org/wiki/United_States_Secretary_of_Defense

Which only reports to:

• https://en.wikipedia.org/wiki/President_of_the_United_States

So the chain of command for Nell today is:

1. Joe Biden
2. Lloyd Austin
3. Christine Wormuth
4. James Rainey
5. Karl Nell

Karl Nell's full (known, public) resume

His full resume:
Modernization Advisor to Vice Chief of Staff of the Army
Army Futures Command 2018 - Present · 6 yrs 5 mos Pentagon

Key contributor to the most significant Army reorganization since 1973. Entrepreneurial leader successful in conceiving, shaping, orchestrating, implementing transformative national security strategies, business process improvements, organizational designs, and talent development initiatives. Recommended technical, programmatic, funding actions accelerating the 32 highest-priority (of 800) Army acquisitions. Orchestrated, led cross-organization digital engineering study quantifying gaps and opportunities within the Army Modernization Enterprise resulting in creation of new #1 top priority program – $100(+)-million multi-year Project Convergence – delivering national-to-tactical, sensor-to-shooter integration. Led SE&I advancing JADC2 collaborating with OSD, DARPA, NRO, USAF Rapid Capabilities Office, Space Security Defense Program. Only space-qualified Army participant in joint. Subject matter expert for Army Science Board (ASB) studies and AI/ML whole-of-government forums.

Deputy COO / Director, Special Programs (Colonel)
U.S. Africa Command (AFRICOM) 2016 - 2018 · 2 yrs Stuttgart, Germany / National Capital Region

Managed daily business operations of a 2000-service member geographic Combatant Command headquarters including all strategic planning, human resources, logistics, finance, IT, legal, and public affairs departments. Represents Chief of Staff in his absence responsible for mediating and arbitrating all issues below flag officer-level. Responsible for orchestrating senior leader engagement process resulting in increased partnering agreements and longer-term stakeholder commitments with key influencers across the African continent. Selected by Presidentially-appointed officials at Assistant Secretary-level to serve in OSD. Provided key evidence-based policy recommendations in DoD Program Budget Review process identifying $3-billion in FYDP savings.

Vice President & General Manager (Corporate Officer)
ENSCO, Inc. 2015 - 2016 · 1 yr Falls Church, VA

Recruited by Board to rescue $100-million failing business; affected organizational transformation within complex portfolio (dozen contracts, multiple contract types, majority of IP creation) in less than two-years. Reporting to CEO, P&L leader of 100-employee, geographically-dispersed R&D division supporting AFC, AFTAC, DHS, DTRA, FBI, PFPA, and other elite NSS clients with disruptive technology solutions. Set conditions for sustained profitable growth (building leadership team, Shipley-based capture process, talent mobility, business strategy) winning all contracts during tenure following 2-years net losses under predecessor.

Chief Strategy Officer (CSO)
US Army Reserves 2013 - 2015 · 2 yrs Fort Knox, KY

Spearhead largest re-structuring of Army Reserve since 9/11 and inauguration of the "gold standard" for multi-echelon, multi-functional combat support training within the US Army. Led force modernization Task Force re-organizing and re-stationing dozens of units and thousands of personnel to build a two-star, 5000-soldier command across 23 states with annual budget of $32-million. Routinely briefed Army Reserve Executive Steering Committee (Board-level) forum.

Vice President, Solution Architecture, Capture, & BD
CACI International Inc 2011 - 2013 · 2 yrs Chantilly, VA

Led cross-company teams formulating campaigns winning critical $250(+)-million corporate bids; delivered support across a $4-billion, 15000-person enterprise successfully capturing new and re-compete business with tier one clients such as INSCOM, CECOM, DHS. Advised corporate officers in M&A review, championed digital engineering and space technology solutions, negotiated best-in-class cyber-security offerings. US Army Reserve: Served as Chief of Operations (G-3) for Army Reserve Counter-Terrorism Unit advising US Ambassadors abroad in whole-of-government preparations to overseas terrorist incidents.

Deputy CTO / Director, Systems Engineering & Integration
Northrop Grumman 1998 - 2011 · 13 yrs Chantilly, VA

Led Board strategic-thrusts developing, orchestrating, implementing: (1) operational excellence policy & process improvement, (2) digital engineering tools IR&D, (3) talent mobility & development for a $2-billion, 5000-person company rejuvenating TASC as a premier SE&I brand after corporate spin-off. Won >$100-million of new business with NRO through SE&I support to re-compete and take-away bids. Senior Program Manager responsible for all SE&I services required in $1-billion equity-backed, satellite & terrestrial, 4G-mobile start-up spanning multiple states encompassing over 70 multi-national sub-contractors. Spearheaded pursuit, capture, program management of >$25-million P&L within non-traditional markets – US Department of State Merida foreign assistance SATCOM SE&I (international) and TerreStar Networks (commercial) – the most significant new venture in company during that fiscal year.

TECHINT Operations Officer (C/J-2)
Defense Intelligence Agency 2001 - 2003 · 2 yrs Wasington, DC / Kuwait / Iraq

First person deployed from the DIA Directorate of Intelligence Production and Analysis to participate in multi-agency planning for Operation Iraqi Freedom as the Foreign Material Program command representative to USCENTCOM / CFLCC in Kuwait. Served as C/J-2 for the one-star Combined Joint Captured Materiel Exploitation Center (C/JCMEC) in Iraq. Enabled the safe and successful recovery of hundreds of conventional weapons systems of strategic value and successfully addressed the question of potential WMD-existence asked by the President of the United States while incurring zero mission fatalities.

Senior Systems Engineer / Lead SATCOM SRE
Lockheed Missiles and Space 1996 - 1998 · 2 yrs Newington, VA

Responsible for mission-critical operations of a sophisticated national satellite constellation; preserved unique capabilities by resolving satellite anomalous behavior in safest, most efficient, cost-effective manner. US Army Reserve: Commanded 80-soldier Special Operations Forces (SOF) PSYOP / MISO company training for possible USEUCOM peace operations to Bosnia-Herzegovina.

Member of Technical Staff (MTS)
AT&T Bell Telephone Laboratories 1994 - 1996 · 2 yrs Holmdel, NJ

Assembled and led teams of subject matter experts engineering new feature enhancements for improving AT&T's long distance switched network capabilities and services. Investigated alternate mechanisms for control of voice signal processing within the toll network. Published a benchmark study quantifying capacity over time of the primary AT&T network element – the 4ESS intertoll switch. Amended the AT&T Network Technology Development work process for certification under the ISO 9001 quality standard.

Commander / Operations Officer
U.S. Space Command 1990 - 1994 · 4 yrs US Army Space Command in Europe

Competitively selected for one of only three Army officer billets within US Space Command in Europe. Commanded a $14-million transportable Satellite Communications Control Central war-traced directly to the Joint Chiefs of Staff while serving as Operations Officer for a Defense Satellite Communications System Operations Center valued at over $38-million. Responsible for 63 soldiers.

I just graduated college and am moving to a different country. Over the four years of college I have had best friend who is a guy (I’m a girl). There weren’t feelings there (on my side) for a long time but over the past 6-9 months I began to see him in a different way. I ignored the feelings because I knew I was moving away and I didn’t want to ruin the friendship. And also (immaturely) I didn’t want to have everyone be right about us ending up together.
Now that I am moving away from him I am full of regret and feel that I missed my chance to be with him.
My question is, is it possible for us to get together in the future? Or did I royally miss my chance? I know we will stay friends and stay in contact.
(please don’t leave any other comments about what I should’ve done differently or if you have a different take. I just want to know if there’s still a chance for us, or if college was it.)

What's the verdict on things like Open door or similar we buy houses type things. I have a fixer upper, and we want to move cross country. I want a cash buyer, and Will roll those funds into my new house (also fixer upper, no mortgage). I don't have funds for repairs nor time to make them (we need moved before September).
What's the best way to do this? Do I actually need a realtor for selling or can I just compare offers from flippers?

We as a family have decided to move to Canada. Now I know this has been a hot topic. There will be some who will be discouraging me from moving. And others that will be supportive. Let me tell you that my circumstances have necessitated this move. Starting many threads like this to gather some info because you guys are the best.
Coming to the point, I need information on cheapest and convenient way to move my stuff. I got a quote of around 2400USD from Uhaul upack for VC and 3500 to move to Toronto. Any other competitors that you think can offer more competitive prices? This is basically we pack and fill the trailer , they move. Also want to understand if moving my 65 inch TV if well sealed is a good idea , or should i rather try to sell it off?I hardly have any furniture. so its going to be mainly 20 or so boxes. I dont want to rent a truck and do it myself.

1st post: https://www.reddit.com/AITAH/comments/1cmw03u/aita_for_snitching_on_my_sister_because_she_read/
Despite there just being a few of you who have read/commented on my post, this will be my update about everything that has happened throughout the past couple of weeks since my first post. I am in dire need of advice.
On the day we found out about what happened between my dad and my older sister, my sister called my mom to ask if it was true. My mom was silent at first, but later on said that she believes my older sister 100%. I just kept on crying because of the sheer absurdity of it all, and my sister went on asking questions about every detail.
I was immensely confused.
For context, we live in a third-world country, and my family isn't doing very well financially as of the moment. My father is a tricycle driver which doesn't earn much, and my mother is in millions of debt due to getting scammed by a friend (or at least she claims she got scammed by) and has been on the run; trying to make fast cash through money laundering in city casinos. Nonetheless, before she got scammed, there is no denying that my mother has been the bread winner on top of being a single-mom, while my dad went NC for a long time when they split up.
We still have my little sister (F 14) to take care of. My 2 older sisters have their own lives to worry about. Now that I have a job, I wouldn't be able to participate in doing housework and watching over my little sister either. So, I got my sister to come home since she just quit her job anyway, and was living with her boyfriend. I asked her to take care of the house, my mother's 4 dogs, and our little sister, to which she all agreed to. Should it happen that my sister cannot take care of our little sister anymore, we've planned (this including my mom) that we'll have our little sister live in with our dad.
Realizing that my mom knew what my dad did to my older sister, and then agreeing to have our little sister live with him, I snapped. I told her just why she thought that would be a good idea when she knew all about this, and she said that "he wouldn't do it to you guys". I told her that she doesn't know that, asked how she can be so sure, and yelled that she should just come home. She's been away for 2 months now, and from what I have heard from my sister, our mother has spent the rest of her savings on her living expenses in city hotels near casinos. She's been living like this for more than a year now.
My mother has been endlessly making hollow promises that we will make millions by "next week", that everything will be okay again, and that she can't come home because the house reminds her too much of her ex of 6 years (they broke up 2 months ago because we found out he made a mistress out of my mother). She insisted that nothing good will ever happen if she came home and salvaged what was left of our family business that she claims got fucked over because of her "scammer"-friend. From what I've seen, I would say that it was all because of her own mismanagement.
And I guess this is the part where I made it all about myself. After yelling at my mom, I walked out of the room and just started bawling my eyes out. I called my boyfriend, told him everything that's happened, and cried some more. My younger sisters were knocking on my door, asking if we could talk, and I told them that they should just give me some space. They tried opening my door, but they left me alone after my boyfriend messaged my sister to just leave me alone.
My sister went on to tell my boyfriend how I made it all about myself for texting my older sister about her snooping into the diary, yelling at my sister because she doesn't want to give the diary up, and raising my voice at my mother after finding out she knew all about this and was still insistent on having my little sister live with my dad. My boyfriend let my sister go on about her rant, to which he replied that he does not want to get too involved without my permission.
A couple of days later, I called my dad to ask if we could talk. I told him about what happened, and asked if he's got any idea of this history between him and my older sister.
Again, for context, throughout my mother's marriage with my dad, he and my older sister never spoke a word to each other. We grew up never seeing them even exchange greetings.
All I knew was that my dad did his best to raise my older sister as his own, but because of her father's relatives' influence on her, he claimed that my older sister was brainwashed to think that my father was a bad person. This is the same kind of argument my sister said about the abuse not being true too.
My dad wasn't the type to be serious upon confrontation either, so when I told him about it, he said, "well, that's new". He continued on to tell me that he doesn't blame my sister for feeling that way about him because she was brainwashed by her father's relatives ever since she was a little kid. I told him that I am having trouble believing him, because it is quite hard to believe that someone could brainwash a child into thinking that they got molested by their own step-father.
He said that although that argument does make sense, he said that he's got nothing to do with anything like that with my older sister. I made him swear that he's telling me the truth. I told him that if I do find out that he's lying, I will be going NC on him permanently.
I do not know who to believe anymore.
Thinking back on it, there was a time when by dad got so drunk during a family christmas party, that he opened up to me about how he also got molested by a man when he was young. He told me about it because I was also sexually abused by our neighbor as a kid, but that's a whole different can of worms. The point is, he wouldn't think if doing that to another person, especially my older sister, because he knows just how horrible that is... right?
I am so conflicted about everything. After my dad left my mom, my older sister did try her best to take care of us. However, she would also beat us up if we messed up our chores or just plainly fail to do what she wanted. Perhaps that was her way of coping with the frustrations she had on my father.
Everything is making sense, but at the same time, it doesn't. A lot of things have transpired since then, and I will be making a separate post about it soon.
But this is all I have for now. So Reddit, I know it's a lot to ask, but I would very much appreciate any help/criticism you may have on this.

Throwaway acc for obvious reasons but I have a special hatred for them as an immigrant woman myself. Committing horrific crimes in foreign countries and acting entitled which only serves to incite hatred against the native population to the point where they want nothing to do with us. While immigrant women commit virtually no crimes (at best petty theft) and go into universities and jobs, these men refuse to do anything. Yet, us immigrant women, bear the brunt of the crimes and the hate crimes that follow.

Ok, so this may sound crazy but I've had this song stuck in my head off and on for awhile, and have been searching for for the past 3 years. I think the first time I heard it was at a concert for Indie singers I went to with my mom about 13 years ago. We even go the album and I listened to it regularly. What bothers me is I have a pretty good memory when it comes to lyrics and remember most of the words especially because I played the song constantly in the car and my grandfather used his burner to help me download it on my ipod to listen to constantly. I've told a lot of my friends about the song and have sung it to them. The crazy thing is, the friends I told about it who grew up in Indianapolis knew the song and could sometimes even finish the lyrics. A lot of us remember it playing on the Smiley Morning radio show and around Broadripple.
The song had a female lead, old country-rock vibes, and when I look up the lyrics I can't find it at all.
Here's the lyrics I remember (I believe it's most of them tbh):
She threw a penny in the fountain and looked up at the sky. It was time for her to leave this town. Her enthusiasm gunning, She hit the pavement running, And she left nothing behind her, But a white wedding gown.
Oh, Carolina, girl you've got to come back home.
Oh, Carolina, so much has happened since you've been gone.
She didn't plan to be a mother, didn't wanna be a bride. Wasn't looking for no man only looking for a ride. When she heard that whistle blowing, Felt the rumble of the ground, And she saw that train a comin'- It was Indiana bound.
Oh, Carolina, girl you've got to come back home.
Oh, Carolina, so much has happened since you've been gone.
She was riding that rail, Thought it better to fail Then never to have tried at all. And though she tried to roam, Love kept pulling her back home, And so she answered that lonesome whistles call.
(Band solo)
She through a penny in the fountain, And thought of better days. She sat and watched the world turn round. She found solace in St. Patrick, And underneath she prayed, That the sun was shining on her side of town.
Oh, Carolina, girl you've got to come back home.
Oh, Carolina, so much has happened since you've been gone.
(Some of these lyrics could be wrong, but it's weird that so many people remember the same song with it seemingly not existing on the internet at all.)

Good evening Healthcare_anon members
I believe we are at the midpoint of the multi series DD on the paper:
Rooke-Ley H, Brown E, Grumbach K, Hoffman A, Ryan A, Roy V, Grogan C, Appelbaum E, Lipschutz D. Medicare Advantage and Vertical Consolidation in Health Care. American Economic Liberties Project, April 2024. Available: https://www.economicliberties.us/our-work/medicare-advantage-and-vertical-consolidation-in-health-care/#, accessed 05/19/24 (for this subreddit post).
Today's discussion will be centered around page 23-31. I will be collaborating with u/ Fabulous-airport-273 on the remainder of the paper, as I believe we should address the topic in a collaborative fashion after this midpoint. If you like, you may review the previous DD in the following links:
https://new.reddit.com/Healthcare_Anon/comments/1culz57/medicare_advantage_capitation_model_prio
https://new.reddit.com/Healthcare_Anon/comments/1cw50xp/vertical_integration_of_the_healthcare_insurance/
https://new.reddit.com/Healthcare_Anon/comments/1cwsavi/vertical_integration_of_the_healthcare_insurance/
I was thinking on also discussing Aetna and Humana within the model as well, however in the interest of time and effort, I may have to revisit those 2 creatures at a later time - not because they are particularly difficult, but that it would be a similar rehash of UNH and BHG. The minutiae of improper population model care and investment made by CVS/Aetna and Humana is in my personal belief the reason why their MCR exploded, and perhaps inadequate preparation for CMS V28 blend adjustment also played a role. Even though CVS/Aetna has an adequate service sector, Humana does not, and we may see further margin divergence of these 2 behemoths.
Without further digression, let us begin:
Vertical consolidation - what is currently happening
"Consolidation allows these vertical conglomerates to use capitated payment structures in ways that drive profits without creating value. As noted above, corporate consolidation in health care has existed for decades, largely driven by hospitals. The primary result: hospitals can negotiate higher prices in the commercial market, cut labor costs and demand more of clinicians, and exploit various loopholes in the fee-for-service Medicare system. In addition, private equity (PE) rollups in health care have risen dramatically over the decades, also exploiting fee-for-service reimbursement and threatening patient care."
We have certainly seen the damage from PE acquisition on practices, especially in emergency medicine, which I previously alluded to in: https://new.reddit.com/Healthcare_Anon/comments/1c0bi4u/the_healthcare_workforce_staffing_crisis_a/. The damage to physician morale is especially acute during this consolidation process.
We are also seeing widespread practice buyouts in the PCP arena now:
https://www.nytimes.com/2023/05/08/health/primary-care-doctors-consolidation.html
https://www.beckersasc.com/asc-transactions-and-valuation-issues/optum-s-multibillion-dollar-acquisition-spree-3-deals-to-know.html
https://www.hcinnovationgroup.com/finance-revenue-cycle/mergers-acquisitions/news/55000097/steward-health-care-plans-to-sell-physician-network-to-optum
https://radiologybusiness.com/topics/healthcare-management/healthcare-economics/unitedhealth-earns-emergency-order-buy-radiology-provider-placed-crisis-due-change-cyberattack
The last one from Corvallis is a particularly spicy acquisition - the change healthcare cyberattack created a cash flow crunch within Corvallis, creating the impetus for Corvallis to then sell itself to Optum. If I were to use cruder terminology, the analogy is this: Optum/Change groomed Corvallis to be dependent on its "service", and once Corvallis is dependent on Optum/Change, Optum/Change then "convinced" Corvallis that Corvallis needs to sell its body (clinics) to Optum for the couple to stay together after Optum/Change failed in its basic "pimp" duty on protecting the groomed subject. Absolutely disgusting analogy, and I hope it brings the message across - what Optum did was absolutely abhorrent and should have paid Corvallis interest and damages, but instead gets to steal the Damsel-in-distress. Who said pimping doesn't pay?
"Today, as policy moves away from fee-for-service, analogous patterns of corporate consolidation are emerging under capitation-based financing. While vertical conglomerates promise clinical integration, familiar harms are emerging, such as the push toward “productivity” medicine and the replacement or supplementation of physicians with less expensive advanced practice providers."
Ok, I am not sure if that last part was absolutely necessary. Advanced Practice Providers (APP) are Physician Assistants (PA), Advanced Nurse Practitioners (APRN), or in the case of Anesthesia, CRNA (Certified Nurse Anesthetist) who work under a supervision of an overall Medical Doctor (MD) for the practice. In the current labor shortage, there are not enough physicians to make up for lack of physician help. I would rather work with our APP colleagues on creating a more equitable platform, and this paper is not helping the cause in this manner. Vertical integration can bring plenty of harm, but having APP being part of the Team is NOT a problem. In fact, I have worked with many APP who are wonderful healthcare colleagues and we all want the same thing: equitable treatment of our patients in the most humane, effective, and medically appropriate way possible.
I. Gaming capitated benchmarks:
"Vertical conglomerates in capitation-based models are keen on controlling primary care physicians, who are essential for inflating risk-adjustment payments and quality bonuses. In MA alone, gaming of risk adjustment is responsible for at least $23 billion in annual overpayments to insurers, while quality payments amount to another $10 billion in subsidization without demonstrated value. In addition to increasing costs, the preoccupation with risk-coding and box-checking wastes scarce time with patients and contributes to dissatisfaction among clinicians."
Remember my CMS DD a month ago? If not, I will submit those links again:
https://new.reddit.com/Healthcare_Anon/comments/1c1n3tf/cms_finalizes_payment_updates_for_2025_medicare/
https://new.reddit.com/Healthcare_Anon/comments/1c1yg8q/cms_finalizes_payment_updates_for_2025_medicare/
We on the field AND CMS knows this is happening. In fact, CMS is attempting to stop this practice by the rollout of CMS V28 AND the April 1 2024 Contract Year 2025 Medicare Advantage and Part D Final Rule (CMS-4205-F). What CMS is attempting to do is to decrease the capitated payments on risk adjustment and quality bonus payments to elongate the Medicare Trust Fund depletion runway, which hopefully also will force the MA companies to take care of patients. As was seen in our 24Q1 DD, companies will instead retrench, retreat, and cut benefits instead. this indicate a potential market failure of the capitated model payment. We should readdress this point in a future post.
***"***The centrality of data in diagnosis coding puts vertical conglomerates in the driver’s seat. It helps contextualize UnitedHealth’s recent $13 billion acquisition of Change Healthcare, the nation’s largest billing clearinghouse, which, according to the Department of Justice, would give UnitedHealth a near monopoly (94% market share) over the clearinghouse market. Through the prism of risk coding, as well as other financial strategies discussed below, the business case was obvious: acquiring Change gives UnitedHealth visibility into the claims, diagnosis codes, and provider IDs of tens of millions of patients"
With the Change Cyberattack in February 2024, UNH unleashed the biggest cybersecurity threat on our patients' medical history in this nation's history, all because someone forgot 2 factor authentication on a whole server worth of data. Good job United. We thank you for proving the ineptitude of private enterprises. We no longer get to just make fun of the National Health System in UK for ineptitude, or that only government agencies suck, but a private enterprise that is a small nation state with a profit margin higher than the NSA's yearly budget can't figure out 2FA.
***"***As with risk adjustment, vertical conglomerates can inflate quality scores with greater control of clinicians. They can, for example, game medication adherence quality measures by pushing providers to put their patients on 90-day refills, mail-order prescriptions, and automatic refills, even if patients never take the medications. Similarly, they can discourage or prohibit clinicians from giving samples to patients and allowing them to use lower- cost alternatives. Further, Star Ratings and other quality programs require significant administrative efforts, placing small practices at a disadvantage."
I do take exception to the samples argument. Look, we just got out of the VERY SHADY stuff happening in the 90s with MD offices taking a HUGE backhand deal when giving out samples, I don't really want to see that stuff back in vogue again. Do you know how frustrating it was for a patient to say they are on a med that is from their doctor's office, they got it for free, and they must have it as an inpatient, when they don't even have it on the medication fill list or on the electronic medical record database? Who do I trust?
II. PATIENT STEERING AND “CAPTIVE” REVENUE:
This section is the reason why I did UNH and BHG as a DD - to pave the way for the discussion on this section. If you haven't read it, please see:
https://new.reddit.com/Healthcare_Anon/comments/1cw50xp/vertical_integration_of_the_healthcare_insurance/
https://new.reddit.com/Healthcare_Anon/comments/1cwsavi/vertical_integration_of_the_healthcare_insurance/
"UnitedHealth is increasingly relying on this captive revenue—or “intercompany eliminations”—with its growth of its provider subsidiary, Optum. UnitedHealth has increased intercompany eliminations by over 80% in five years, reaching $108 billion in 2022. It now sends over 25% of its medical claim revenue to its own subsidiaries. Its market presence shows why: UnitedHealth exists in 87% of insurance markets, only rivaled by Humana at 90%. 130 Further, UnitedHealth has over 50% share in more than 140 MA markets."
OK even though this paper is quoting another paper, my 10K/10Q analysis does match what this paper said, except it isn't 25%. Its 37.7% now. WHOA!
"These captive revenue strategies enable regulatory arbitrage. Medical Loss Ratios (MLRs) were established in the Affordable Care Act to cap insurance administrative costs and profits and to ensure that a minimum percentage of capitation payments and private insurance premiums were spent on medical care. However, insurance companies can circumvent this regulation by paying themselves, directing above-market payments and end-of-year bonuses to their own sister subsidiaries. This is referred to as “transfer pricing” and has been best documented with PBMs. For example, UnitedHealth can evade the MLR requirement by paying higher-than-cost fees to its Optum PBM, booking that fee as a medical cost. The same is possible with medical providers: insurers can increase fees to their sister primary care or post-acute providers to conceal profits as costs and to therefore evade the MLR constraint."
Is this how UNH continues to have high profits, and how the impact of CMS V28 somehow did not threaten UNH and Elevance the same way as Humana and CVS/Aetna? I think they may be onto something...
"In addition to increasing profits, steering squeezes independent providers and other competitors. In the prescription drug space, the gaming of medication adherence, explained above, diverts business away from unaffiliated pharmacies while gaming quality metrics. As another example, vertical conglomerates that own PBMs can devise formularies and copays that funnel patients to their own pharmacies, squeezing independent pharmacies. The proliferation of “specialty” pharmacies embeds these anti-competitive practices.".
Personal anecdote: I know of independent pharmacies who CANNOT compete anymore due to high PBM requirements, "clawback" penalties, quality metrics that is impossible to achieve, and "out of network" processing fees, that these pharmacies either have to be shut down, or acquired. "Specialty Pharmacies" are basically pharmacies who carry high dollar cost items that may have more stringent FDA counseling requirements, but because now the Marketplace is littered with PBM funnels, most independent pharmacies cannot "enter the foot in the door" of the PBM requirements. Guess who does though? Optum Rx!
"Vertical consolidation in the post-acute setting presents similar steering risks. MA insurers have increasingly been under scrutiny for limiting or denying care through narrow networks, “ghost networks,” and onerous prior authorization. Recent reporting revealed that UnitedHealth and Humana are using artificial intelligence with their conveners, specifically NaviHealth, to drive “clinical” prior authorization decisions and override clinical judgment."
I think I've beaten this dead horse many times already.
"Another way to steer patients in post-acute care is to effectively bring the prior authorization function “in house.” By directly employing physicians, the risk-bearing entity can cut costs by prohibiting or discouraging clinicians from authorizing expensive care. In a 2020 whistleblower lawsuit reported by The Prospect, Maxwell Ollivant, a UnitedHealth-employed nurse practitioner in a nursing home, alleged that his supervisor denied requests to transfer UnitedHealth-MA patients with exacerbations to the hospital. This, Ollivant alleged, was consistent with UnitedHealth’s compensation structure, which gave bonuses to their clinicians who kept patients in the nursing home and out of the hospitals."
Well holy shit Batman, that is more degenerate than a WSB 0-5DTE put taken on a Thursday afternoon.
III. PATIENT “FLIPPING” AND ENROLLMENT ARBITRAGE
" In MA, favorable selection is responsible for another 11%-14% of overspending, or as much as $56 billion annually. Selecting enrollees also allows insurers in MA to game county benchmark bonuses, which excessively rewards insurers with patients in areas of low Medicare spending, to the tune of another roughly $10 billion in excess MA payments. As vertical conglomerates increasingly own physicians and operate in ACOs, similar risks of selection may arise."
CMS is acutely aware of this gaming, however their model hasn't exactly been able to pinpoint how to address this yet. This was discussed in the CMS Final rule comments section.
"More direct than marketing, provider acquisitions allow conglomerates to “flip” patients into MA plans or ACOs by coordinating efforts with sister provider subsidiaries. Conglomerates can initiate the flipping strategy by using some of the steering tactics discussed above. In a recent lawsuit, UnitedHealth was accused of terminating contracts with unaffiliated physicians in order to force the patients to establish care at nearby Optum practices. In another suit, UnitedHealth, with 50% of the MA and commercial insurance markets, allegedly attempted to force the sale of local practices to Optum. UnitedHealth was accused of cutting insurance reimbursement and steering members away from the target practice, and as a condition of insurance contracting, forcing the target practice to give UnitedHealth the first right of refusal upon sale.
I inivite our physician colleagues to comment on this section. I have personally heard of such anecdotes, but further validation is always helpful and will also increase our membership engagement on such complicated subjects
And we now reach the end of page 31. This paper is extremely dense, and required basically a multi-layer DD on top of it to corroborate and create discussion points on the topic discussion.
We hope you enjoyed this half of the mini-series, and we hope to bring you the 2nd part of the mini-series soon as a collaborative post.
Thank you for taking the time to read through this. I hope this provides you with a better perspective on a glimpse of the landscape that I am personally aware. Please submit your comments below on your thoughts
Sincerely
Moocao
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