I only need 4 cents left to get my order on Temu free. I will do code for code.
Download Temu App and search the code below to accept my invitation! 243044258

I played on my ps4 when it first came out for a couple months I’ve downloaded the save date to my PlayStation cloud but I can’t find it. Is there a way I can transfer my save date from my ps4 to my ps5? When I downloaded it on my ps5 all my characters were level 1. I played way back when I where I’m eligible for the free battle pass but I can’t get my save data for it out.

Check this out for ExpressVPN 3 Months Free. Find the best deals for you by looking at the current promo codes and coupons on that page. You'll always find the newest coupons, promo codes, and deals on that page. Choose one to apply to your order and save money.

Hi! This is going to be a long one/rant and story because I really don’t know who to talk to about this in real life because I’m not in therapy and I’m so embarrassed to be feeling this way knowing I made all the choices to be here and people are already flying in from out of state to come to our wedding. Also I’m diagnosed adhd incase any of yall are wondering what’s wrong with me once I tell you all the decisions I made to get here. I am getting married in three months and have a son who is 15 months old. My now fiance 28m and I 27f met whenever we were thirteen years old in middle school and started a tumultuous up and down / on and off again relationship. We were together all the way up until junior year in high school and we broke up. I come from a broken home and he does not. Looking back I realize how much of me staying with him and trying to keep his attention stemmed from my abandonment issues that I must have had from my own parents. After we broke up he joined a gang in my local hometown and I was still in love with him so I decided to still be involved with him even though I was not in a relationship with him. I ended up losing my virginity to him while we were not together just because I wanted to be with him and we said we were friends with benefits but really I was just in love with him and thought by doing that maybe he would want to be with me again but he didn’t and continued to sleep with other girls and do drugs. I also started doing drugs like Xanax and smoking to fit in with him and be cool. I ended up getting a horrible tattoo because one of the other girls he was also seeing had a bunch of tattoos. I dropped out of my high school college courses and ended up going to jail for marijuana in high school and got kicked out of cheer and softball. I ended up on probation and having to be drug tested for a year. Within that year after being heart broken and realizing nothing I did would make him change into who he was before he got involved in our local gang or make him want to be with me… I ended up enrolling in college and getting accepted to a university where I would move about two hours away from our home town to live on campus and study to be a nurse. While on probation, so I couldn’t really party or anything in college which was good (even though I was never really addicted to anything and it wouldn’t be that hard for me) I wanted to save money for a car so I ended up getting a job at the hooters next to my college and was in college full time and working at hooters. My sister happened to go to that same college before I did and live in that town with her ex bf and they would give me rides to and from work back to campus. Low and behold after about two semesters of me being in college and finally feeling like I was moving on from him, he came back messaging me and telling me he missed me and wanted to be with me again. I was stupid and so excited that I agreed and asked him to come see me at college where he would stay for the weekend and we would have an amazing time. I felt so good about myself doing what I was doing and being able to show my growth. Despite all that he was still able to convince me to leave school and come back to be with him and live with him and go to the college near our hometown and work at the hooters near our hometown. I had already felt like I didn’t want to be a nurse at the time because my sister who was a nurse told me you could never leave the state as a nurse if you get your license there (which she didn’t know at the time that you could) and I knew I didn’t want to stay where I was from and wanted to eventually travel. So I decided to leave and move back with him in his bedroom at his parents house where I would work at the hooters close to our home town and never enroll in the college. He would eventually break up with me while I was at work one day even though I was living with him and since I didn’t have a car he continued to take me back in forth from work and I continued to live with him and continued to be in love with him while he committed to the fact that he didn’t want to be in a relationship but wanted to marry me one day and just wasn’t ready for anything right now and still wanted to have sex with me which I did. From working at hooters I had auditioned for the calendar and ended up being really liked by the photographer and started doing some modeling from that which was super exciting for me because I always was interested in that and the pictures we took would blow up and I started getting well known in my area for modeling even though they were just pictures and I wasn’t making any money off of it. Eventually a guy came into hooters telling me about working as an exotic dancer and how much they could make and I still needed a car really badly and was desperate to get out of my ex’s (now fiance) house. So I told him I would be waitressing and that I heard the waitresses make good money there and asked him to give me a ride there one day and so he started giving me a ride everyday. The money was so good to me and the most money I had ever seen. I ended up staying in a hotel closer to the club I worked at and sometimes he would come stay with me and I would just uber to work. Eventually I had gotten a car which I was so happy about. A couple of weeks after I got a car I ended up getting sucked into human trafficking with a friend where I would live in a house with multiple girls for 6 months and go to work at the club every day of the week except Saturday and Sundays. I wasn’t doing anything extra just dancing but the money was going to some random guy. It’s crazy I know. I was stupid and young and my family were not concerned for me at all or involved in my life. unfortunately my friend is just now leaving that situation. I got out without anything no car or nothing and had nowhere to go so back to my exes I went where I decided I was going to buy a cash car again and I worked everyday like I was used to saved money and got a car. Moved to my sisters and stayed with her for a little where i decided I didn’t want to dance anymore and I got a job as a bottle service girl and then waitressing at another waitress. I continued modeling because it made me happy and I never told anyone the truth about the deep things that were happening in my life except for my now fiance. So nobody had no idea about me dancing or the human trafficking or anything. Everyone just knew I modeled. I ended up getting an apartment with some friends and One day I got the urge to go to California randomly and at my waitressing job I was handed $800 and I took it as a sign and booked a flight the next day. Where I went by myself my first time ever on a flight with no plans at all. The day I got there I got asked to be in a commercial two days later. My roommate and her friends flew out there to get me and she ended up being able to be in the commercial with me which ended up on tbs but I had to go back home to my apartment and responsibilities and couldn’t leave my roommate stranded. Even though months later we would end up getting in an argument and I’d move out and move back with my ex (now fiance) where I would continue to work and model (for free) and went back to the club to dance and then my sister ended up going to California for a travel nursing assignment and her and her bf broke up and she asked me to move with her. I had nothing else here, my ex was still saying he didn’t want to be in a relationship, he was consistently sleeping with other girls while we lived together and expected relationship things from me. I was paying for everything for him. I paid for him while he was in school for audio engineer, his gas, lunch, school clothes, shopping, I helped him open his own studio and bought his equipment and Mac for it, even though his parents were very involved in his life. I got all his family bday gifts and Christmas gifts every year. He was honestly just using me but I was so in love and blind. He encouraged me to go to California too so I had nothing else there for me, if he had told me to stay and he wanted to be with me I would’ve. I flew out on my 21st birthday and met my sister and Vegas where we would have such a great time and my ex spent that day hanging out with a girl that tried to fight me and didn’t even tell me happy birthday, I was crying in the bathroom in Vegas until my sister shook me and told me to get it together we’re in Vegas. I was so heart broken to be leaving him but he didn’t care. I got to LA and I instantly started modeling on day one I booked a photo shoot where I met a guy that reminded me of my ex (I know) but we instantly clicked and he was 7 years older than me. We ended up talking for a little bit and pursuing something even though I wasn’t ready emotionally but he didn’t really care and I was kind of star struck a little because he was a music producer for a very famous musician and he was very persistent but that’s another story. I ended up booking a music video as a main girl for my ex’s (now fiance) favorite artist. When it came out it was crazy because I felt like the universe and God was just blessing me for leaving that situation and I knew he would see it because he was so obsessed with that artist and it shook up the whole small town I was from. After that I booked a lot of cool jobs like Sephora and worked with a lot of companies, and did some music videos for other super famous artists, and walked in fashion shows and modeled for clothing brands etc. I was working all the time as an extra to pay my bills and I was meeting cool people. I was always getting invited to celebrities parties and just having such a fun time. I decided to start getting into acting instead and started going to acting school where a lot of well known celebrities also went to and I started having meetings with very popular directors and I was being mentored by famous directors and another person that created an tv entertainment channel that I won’t say here also mentored me a lot and got me a lot of meetings with these people and would go to dinners and stuff etc with a list celebrities. I truly was living the life. And coming from where I can it was almost a dream. I had gotten in a relationship my first year there with that other guy I mentioned who ended up being super possessive of me but he treated me like a queen in the sense of paying for everything, giving me a safe space to tell my feelings, open up, the sex was amazing, he would take me on trips, took me out of the country for the first time. We ended up not working out due to lifestyle differences and just being at two different places and wanting different things. He wanted to move out of the country and have a farm and I wasn’t ready to do that as I wanted to focus on my career. (But I would die to move out of the country on a farm now ironically and he is doing just that now like he said he would haha) anyway, I ended up having my own studio apartment by myself that I loved so much and was so proud of. My sister had moved to Montana and it took a lot for me to get my apartment like staying in a house with other girls for a little to sleeping in my car and at a spa for a couple days. When I would fly home or drive home to see my family I would always see my ex, everytime. We kept a friendship and sometimes I would still help him out if needed, he was interning at a church through his school for audio engineering and recording people at his studio in our hometown. By this time I was going to New York and Miami also sometimes and doing work there. I wasn’t as stressed about bills anymore. I was seeing guys every now and then but not at all interested in a relationship, my heart was still healing from the past and both my exes but mainly my first (now fiance). I was super focused on my career and optimistic, I was used to the grind and in no way ever thinking of quitting. It just wasn’t an option because I knew I would make it wherever that would be because to me that is all I had for me and all I ever knew I wanted and the only thing that saved me. Skip to around October 2019 I had found out about a girl my ex was seeing and it crushed me. He was doing with her just like he was with me though. Just “friends with benefits” I was living in my apartment in LA still and my uncle that helped raise me was getting really sick back home and put on hospice so I decided to take a trip back to see him. I would go to restaurants in my state and near my home town and people would ask to take pictures with me, and at the little ceasars drive through someone asked if I was me and stuff it was crazy because I hadn’t been home in awhile and I felt like what I was doing was finally paying off and people were recognizing me. It was surreal. I ended up going to see my ex. I had such a fear of losing him to this other girl for some reason. I was so scared he would get her pregnant or get in a serious relationship since I was gone so far away and I would never be with him, I would end up sleeping with him again and the girl found out and drove by his house mad and cussing me out and throwing stuff at me. We ended up getting in a fight which is so embarrassing and beneath me. I ended up crying to him that I wanted to be with him and don’t know why he never wanted to be with me which at this time he honestly was not even in my playing field anymore. He told me if I wanted to be with him I had to move back to my hometown.. my heart dropped to my stomach and I knew it wasn’t what I was supposed to do but I said okay… all because this is what I had wanted all those years. I decided to stay where the next two years all I would think about everyday was I was making the wrong decision and needed to go back to my life. My hometown had nothing for me.. COVID hit a couple months after me being there and we were terrified. We ended up getting everything out of my apartment and moving into a house around the corner from his parents. I had to tell him how I liked to communicate now without yelling and stuff which I learned from the boyfriend I had in LA and that I wasn’t going to put up with that disrespect but he never listened. Eventually everything went back to normal. I ended up going back to the club again dancing because I didn’t want to go backward and model here. He never wanted me to go back to LA even for a little bit even though that’s where my career and heart was so I had no idea what to do with my life. I started waitressing as well and getting back on my adhd meds. People started pressuring us to get pregnant and we tried for a year and 6 months. The month I found out I was pregnant before I knew, I quit my job and decided I was going to move back and get my life back. Two days later I found out I was pregnant…. Finally after trying for over a year. Our relationship was toxic just like the past he always yelled, I could never talk to him about my feelings without him saying I was trying to fight, he spit in my face once, threatened me, put his hands on me, he would tell me he was going to take my baby away from me as soon as I had it. I started asking him about getting married while I was pregnant and the proposal wasn’t even that. He got mad at me for asking one day and walked in the room and handed me the ring. It didn’t fit because I was pregnant & it was $27 (not that that matters but the proposal sucked).. he drained both my bank accounts and they closed it, charged my credit card up and put me in debt, he has not let me do anything I want to do like school or anything. He is so bad with money. He has an action figure addiction and at one point was spending 3k on action figures every month and turned one of the rooms in our house into a collection room so I had to take everything out of my closet and put my sons crib in there for the first year of his life. we have good times and I feel comfortable with him. He knows everything about me but he doesn’t respect me and sometimes I feel like he is intimidated by me. The sex isn’t good at all we always just ask “do you want to have sex” he never gives oral or foreplay, I never get pleasure. He’s an amazing dad though and loves his son. We have the most sweet and beautiful little boy now who I love so much and he loves him also. He’s very attentive to his son. But I still feel unheard. I can’t talk about my feelings. If I do it doesn’t matter, it doesn’t change anything. He is so defensive and we never communicate for a solution it’s always just pointing fingers. I have started yelling again because I’m so used to it now and I hate it because I grew up like that and I finally grew out of it until I got back with him and recently started again and now he throws it in my face and knows I begged him not to do it forever but he never stopped and now I am too. I’ve asked him to take me to the movies and he hasn’t still. I just ask for more romance and stuff but it just feels like I have a roommate. I have nothing now. I had my car and we traded it in for a new car that he wanted. I always dreamed of the next car I’d get once I paid it off but he got it & it’s in his name now so I paid it off for nothing. I’m driving around his dream car. I’ve been planning our wedding since I birthed our son and everything is going good. Money is tight. He works at the church now full time and makes about 45k a year or so, my son has been waiting to start daycare for awhile so I have been home with him. I’ve tried starting jobs multiple times but he is against it unless it’s super fast money like going to the club which I am so repulsed by and absolutely hate it now. I tried going back to college but my old college won’t release my transcripts for fasfa because I owe them money. I started cosmetology school a few months ago which he was all for but two months in freaked out and him and his mom guilt tripped me that we can’t handle this right now and he was having a hard time doing the night time routine for the baby while I was at school so I had to leave and now owe that’s school for my kit unless I enroll again in 128 days. I also miss modeling so much and sometimes think I can start again but it’s been five years. My body is so different too after a baby. Everything I want is a no go. Especially moving out of our hometown. He says he wants to but I don’t think he does. We are constantly at his moms and dads and they tell us all the time we aren’t moving anywhere which is really hard for me as this place is super toxic for my soul. Anytime I get money he spends it. Anytime I save money he spends it. Even if it does go towards our bills. His action figure habit is almost nonexistent now and he has grown a lot in the past few months from that since I demanded my son have his own bedroom after his first bday and all his figures are in boxes now and told him he could turn the shed into his man cave. He says we can’t save because we have nothing to save after bills but I believe in saving anything even $5 a paycheck. It’s doable. I grew up poor so this is nothing to me but after living the lifestyle I lived in LA and going out with guys that respected me and cherished me it’s hard. I know nobody is perfect but we are about to get married and I’m scared… I have nothing though anymore. I’ve threatened to leave a couple times and he says he will take me to court and take my baby. I’m scared he might. I don’t want my son to be angry like him or not respect women how he does. In public he’s a saint. He also has a very supportive family that it’s almost toxic. They all blame me for his anger issues and say I make him that way. But he’s been punching walls since I met him in 8th grade. I know it’s not because of me. But I have nobody else and nowhere else to go. No money. No car. I’m at the bottom again where I was before. Only difference is now I have a son. And we are getting married in three months and I can’t call it off. I am older now and looking back on my life I realize he maybe truly never loved me and I was just so desperate for love. I got myself here nobody else. I accepted everything, even when my gut told me not to. ( he is not just horrible, he’s a great person just with some bad qualities like everyone but I’m tired of feeling stuck with someone that never truly wanted me and doesn’t care to grow in some ways or show me )
Please help.. what do I do?

I need shein new and existing puppy, 1 existing farm
I have available to trade temu:
Existing fish: 6
New fish: 2
Existing farm: 4
New farm: 4
Existing Hat trick: 8
Existing Cash redeem: 8
Existing 5g: 8
Lucky flip: 8
Shein:
Existing Puppy: 3
New puppy: 3
Magic: 0
Free gift: 4
Spin: 0
Lucky draw: 0
Money tree: 2
Happy draw: 2
Comment if interested in trading & be specific if you want new or existing clicks.
Don't randomly click my codes ask me to trade first

Hi just wondering going to give this a shot and try to detail cars for some extra cash on the side. Any tips and or ideas on how to execute this professionally and or smart I am open to critique. Been mainly curious on when I should detail the cars sense I live in FL where it is very hot throughout most of the day I wonder when I should look to detail the clients if I get any. Please feel free to state anything about this topic I am willing to learn and talk. (:

Hello, I have gone through the entire Avatar store on the UK Xbox 360 store and made a list of every free avatar item.
I will note that this is male avatar only as when I tried to update the store with a female avatar it just didn't work and may have taken hours of waiting to do.
Also if done on the console avatar store (what I did) the pages will break at weird points (for me page 73, 149, 185, 225, 261, 301 consistently broke). If you see the scrolling white wheels of death, just back out and back into the section then scroll back to where you were.
Final note: there are Xbox codes still out there for free items but I didn't put in any effort personally to find them (I've heard of a free black Bing t-shirt).
[] represent page number
() represent block (going vertically)
Avatar Items
In order from "All" on the Avatar Store
Tops
Joe Bang Avatar T-shirt Male Free [page 12] (block 4)
Hydration Pack [page 28] (block 2)
Marines T-shirt [page 28] (block 5)
Pop-Tarts T-Shirt [page 32] (block 8)
Blacks Spades Shuffle Hoodie [page 36] (block 3)
Black Spades Wildcard Shirt [page 36] (block 4)
Black Spades Tee [page 36] (block 7)
BOOMco Blast Better Tee [page 84] (block 6)
Certified MCP – Black [page 126] (block 1)
Certified MCP – White [page 126] (block 5)
Xbox One Avatar t-shirt [page 229] (block 5)
Chicago Game Jersey [page 251] (block 2)
Buffalo Jersey [page 275] (block 6)
Cell Thermal [page 377] (block 2)
Agency Tower Shirt [page 377] (block 3)
Ruffian Shirt [page 377] (block 4)
Agency Fist Shirt [page 377] (block 5)
Crackdown 2 Tee [page 377] (block 6)
Running Agent Shirt [page 377] (block 7)
Headwear
Season Eight hat [page 2] (block 6)
Simple Mobile Avatar Hat [page 5] (block 8)
Marine Smokey [page 6] (block 1)
Marine Boonie Hat [page 18] (block 3)
Communications Helmet [page 18] (block 6)
Snap Hat [page 20] (block 7)
Pop-Tarts Helmet [page 20] (block 8)
Toucan Sam Mascot Head [page 21] (block 1)
Pop Hat [page 21] (block 2)
Crackle Hat [page 21] (block 5)
Black Spades Bucket Hat [page 23] (block 4)
Porsche 918 Spyder Hat [page 23] (block 8)
Black Spades Snapback [page 24] (block 2)
Vintage Helmet [page 24] (block 3)
Welcome to Porsche Helmet [page 24] (block 4)
Crackdown 2 Hat [page 248] (block 4)
Freak Head [page 248] (block 8)
Accessories
There are no free Glasses, Wristwear, Gloves or Earrings.
Rings
Black Spades Championship Ring [page1] (block 1)
Props
Osprey [page 41] (block 8)
Marine Parachute [page 42] (block 1)
Venom [page 42] (block 5)
Tony the Tiger Shirt [page 44] (block 3)
Tony the Tiger Mascot Head [page 44] (block 6)
Porsche 918 Spyder [page 45] (block 8)
Windows 10 Ninjacat Skis [page 60] (block 1)
Yarny Avatar [page 70] (block 2)
Windows 10 Ninjacat [page 76] (block 8)
Windows 10 Ninjacat [page 77] (block 1)
BOOMco Rapid Madness Blaster [page 77] (block 8)
Gold Medal Ceremony [page 124] (block 2)
Renegade Orbs [page 246] (block 4)
Agency SUV [page 246] (block 8)
Bottoms
There are no free bottoms.
Shoes
Combat Boots [page 1] (block 7)
Agency Supercar Slippers [page 39] (block 2)
Dress Up
Ghillie Suit [page 16] (block 2)
Xbox One Onesie – Black [page 20] (block 4)
Xbox One Onesie – White [page 20] (block 8)
Origin Race Suit [page 23] (block 4)
Growing Excellence Race Suit [page 23] (block 8)
Evolution Race Suit [page 24] (block 1)
Cell Soldier [page 309] (block 2)
Peacekeeper Outfit [page 309] (block 3)
Level 5 Agent Suit [page 309] (block 6)
This is part 4 of 4
I hope this helps.

Recently, I've been working on implementing dynamic data structures in C with a focus to make it into a dynamically linked library I can port with and use in some other projects I am also doing in C. I implemented a generic dynamic array deque/ring buffer (which copies the data directly into the buffer itself, not storing a void * to it which is then returned later, similar to how Stroustrup discusses compact layout). Based on this structure, I can easily implement dynamically-sized FIFO queues and stacks. I mention all of this because I am seeking advice/guidance on multiple fronts:

• Any advice on making the data structures efficient when allocating/reallocating memory, especially to maximize cache hits, as well as prevent fragmentation. I'm also open to discussing alternative non-linked implementations, such as how C++'s STL deque works if there is a clear advantage to using that approach (I haven't found much discussion as to why it was implemented that way instead of using a dynamic ring buffer, though it probably has to do with memory costs for expanding the buffer). I plan at the very least to also add normal dynamic arrays (and consequently dynamically-sized priority queues).
• Any guidelines on how to structure and compile library source code in C. Specifically, code structure, as well as makefile tips to automate the build process as much as possible (or I just end up using CMake).
• Any advice on how to implement OOP concepts like abstraction and encapsulation. I've started looking into vtables briefly, and I want to figure out if there is a way I can define vtables as the "interface" and change behaviour of an underlying implementation/struct (like the deque in my case) into those defined by the interfaces of the other data types like queues and stacks, similar to Java's Queue myQueue = new ArrayDeque, where ArrayDeque is the implementation and Queue is the wrapping interface, which is what the programmer is allowed to use.
• (Possibly later down the line) advice on how to make these operations lock-free so that I can potentially use them for concurrency applications, though that comes with its own plethora of problems, especially when dealing with portability.

I know that many different forms of generative AI exist that might be able to assist me with some of this stuff but I want to avoid using them because of the obscene amount of data they collect, as well as the fact that they are sometimes just downright wrong.
Here is a link to my code. Feel free to take a look, and please don't hesitate to send any advice/feedback that you might have. I look forward to your comments.

​
Proof .
​
Album - more/closer pictures of everything are in here. Check for toning, condition, etc. Any hand written 'grades' are someone else's opinion. If you need more pictures than what's in here, Please let me know!
Chat please!
​
8x Indian Head penny different date starter lot #1 $20
7x Buffalo nickel different date low grade starter lot $7
8x Indian Head penny different date starter lot #2 $20
Bicentennial set $3
4 rolls of unopened rolls of modern dollars $93

• 3x $25 rolls and 1x ?? - guessing $10

1876 and 1882 shield nickels $40
Low grade Better date Buffalo nickels

• 1913 S Type 1 $13
• 1913 D Type 2 $30

1/4 oz gold $620 each

• 2023 Krugerrand
• 2021 Philharmonic

1g Gold ​

• 8x loose 1g Valcambi bars $84 each
• 10x carded 1g IGR bars $89.50 each

Foreign silver coins $19
5oz silver shot $160
11x Shield Nickels $75
1914 Penny $8
1951 D 'Cud' Wheat penny $7
1929 D Wheat penny (nice) $6
12x V nickels $6
8x Widow's Mite and Widow's Mite-like fragments $6 each or all for $40
​
**Chat please!** Please state preferred shipping option and payment method (both detailed below) ....after replying on here.
* More fee free payment options now available! Zelle, ApplePay, CashApp and Venmo work well for fee free payment options - no comments in remarks (emoji ok if the app requires it). Check ok for someone established - shipment once check clears on my end (ie funds are fully received into my account; not just 'pending'). *you can also take a picture of your check and I print/deposit it to save time mailing it to me. ~~PPFF ok only for someone well established.
Shipping to US only. $6 Ground Advantage with tracking - up to 8 total oz to the mainland USA (total package weight = coins, padded envelope, etc). I will ship to HI and AK but need to check rates for GA first. $10 for flat rate priority shipping anywhere in the US. (extras like signature confirmation and registered mail available at cost - make sure you ask if you want them; how it's shipped via USPS is up to you). I pack well so no worries about loose items rattling around and use plenty of tape so the package doesn't fall apart if it gets wet. Once it's in USPS' hands, it's out of my control/responsibility. If something happens I will do everything I can to help but will not provide a replacement or a refund. Any purchase made is subject to these terms.

Hi I want to show my support for Palestine by wearing a Keffiyeh. I already looked to see if it was ok to do so in the dress code and it is. It's more just the only reason I've been against it is because of the fact I work at a company that directly supports the genocide. I have the freedom to quit my job but Palestinians don't even have the luxury of a job(due to finical reasons it's not liable for me to do so at this time). I don't want to come off as hypocritical but I do want to show my support with more than just donations and reposts. I'd appreciate your opionon on the matter thankyou. Free Palestine Free Congo Free Hawaii Free Hati Free Sudan Nobody is Free til Everybody is Free.

Tommy and Timmy are buying turnips for 635 bells! I'm gonna open my island in about 10-15 min, for 2-3 hours, maybe more. Nook's Cranny is below Resident Services, at the other side of the park.
No tips necessary but if you have spare DIY recipes, I'd be very grateful!
Comment your favorite videogame and I'll send you the Dodo Code. Pls, don't shake the fruit trees of the villagers. Also, certain parts of the island are closed due to remodelling, sorry for the inconveniences. If you wanna explore the explorable part of the island, feel free. Be nice to the villagers! Leif is on the island ~
If you take pictures, pls share it to me!

Can you accept my invitation so that I can get a free gift? Download Temu App and search the code below to accept my invitation! 234944348
I am 4.5 cents away, I can't do it with out you. I have all my clicks for today and I might be able to do a couple of Shein ( new user)

Can you accept my invitation so that I can get a free gift? Download Temu App and search the code below to accept my invitation! 239376284 - for 5 0$ items
I'll help you if you help me!

Hi! This is going to be a long one/rant and story because I really don’t know who to talk to about this in real life because I’m not in therapy and I’m so embarrassed to be feeling this way knowing I made all the choices to be here and people are already flying in from out of state to come to our wedding. Also I’m diagnosed adhd incase any of yall are wondering what’s wrong with me once I tell you all the decisions I made to get here. I am getting married in three months and have a son who is 15 months old. My now fiance 28m and I 27f met whenever we were thirteen years old in middle school and started a tumultuous up and down / on and off again relationship. We were together all the way up until junior year in high school and we broke up. I come from a broken home and he does not. Looking back I realize how much of me staying with him and trying to keep his attention stemmed from my abandonment issues that I must have had from my own parents. After we broke up he joined a gang in my local hometown and I was still in love with him so I decided to still be involved with him even though I was not in a relationship with him. I ended up losing my virginity to him while we were not together just because I wanted to be with him and we said we were friends with benefits but really I was just in love with him and thought by doing that maybe he would want to be with me again but he didn’t and continued to sleep with other girls and do drugs. I also started doing drugs like Xanax and smoking to fit in with him and be cool. I ended up getting a horrible tattoo because one of the other girls he was also seeing had a bunch of tattoos. I dropped out of my high school college courses and ended up going to jail for marijuana in high school and got kicked out of cheer and softball. I ended up on probation and having to be drug tested for a year. Within that year after being heart broken and realizing nothing I did would make him change into who he was before he got involved in our local gang or make him want to be with me… I ended up enrolling in college and getting accepted to a university where I would move about two hours away from our home town to live on campus and study to be a nurse. While on probation, so I couldn’t really party or anything in college which was good (even though I was never really addicted to anything and it wouldn’t be that hard for me) I wanted to save money for a car so I ended up getting a job at the hooters next to my college and was in college full time and working at hooters. My sister happened to go to that same college before I did and live in that town with her ex bf and they would give me rides to and from work back to campus. Low and behold after about two semesters of me being in college and finally feeling like I was moving on from him, he came back messaging me and telling me he missed me and wanted to be with me again. I was stupid and so excited that I agreed and asked him to come see me at college where he would stay for the weekend and we would have an amazing time. I felt so good about myself doing what I was doing and being able to show my growth. Despite all that he was still able to convince me to leave school and come back to be with him and live with him and go to the college near our hometown and work at the hooters near our hometown. I had already felt like I didn’t want to be a nurse at the time because my sister who was a nurse told me you could never leave the state as a nurse if you get your license there (which she didn’t know at the time that you could) and I knew I didn’t want to stay where I was from and wanted to eventually travel. So I decided to leave and move back with him in his bedroom at his parents house where I would work at the hooters close to our home town and never enroll in the college. He would eventually break up with me while I was at work one day even though I was living with him and since I didn’t have a car he continued to take me back in forth from work and I continued to live with him and continued to be in love with him while he committed to the fact that he didn’t want to be in a relationship but wanted to marry me one day and just wasn’t ready for anything right now and still wanted to have sex with me which I did. From working at hooters I had auditioned for the calendar and ended up being really liked by the photographer and started doing some modeling from that which was super exciting for me because I always was interested in that and the pictures we took would blow up and I started getting well known in my area for modeling even though they were just pictures and I wasn’t making any money off of it. Eventually a guy came into hooters telling me about working as an exotic dancer and how much they could make and I still needed a car really badly and was desperate to get out of my ex’s (now fiance) house. So I told him I would be waitressing and that I heard the waitresses make good money there and asked him to give me a ride there one day and so he started giving me a ride everyday. The money was so good to me and the most money I had ever seen. I ended up staying in a hotel closer to the club I worked at and sometimes he would come stay with me and I would just uber to work. Eventually I had gotten a car which I was so happy about. A couple of weeks after I got a car I ended up getting sucked into human trafficking with a friend where I would live in a house with multiple girls for 6 months and go to work at the club every day of the week except Saturday and Sundays. I wasn’t doing anything extra just dancing but the money was going to some random guy. It’s crazy I know. I was stupid and young and my family were not concerned for me at all or involved in my life. unfortunately my friend is just now leaving that situation. I got out without anything no car or nothing and had nowhere to go so back to my exes I went where I decided I was going to buy a cash car again and I worked everyday like I was used to saved money and got a car. Moved to my sisters and stayed with her for a little where i decided I didn’t want to dance anymore and I got a job as a bottle service girl and then waitressing at another waitress. I continued modeling because it made me happy and I never told anyone the truth about the deep things that were happening in my life except for my now fiance. So nobody had no idea about me dancing or the human trafficking or anything. Everyone just knew I modeled. I ended up getting an apartment with some friends and One day I got the urge to go to California randomly and at my waitressing job I was handed $800 and I took it as a sign and booked a flight the next day. Where I went by myself my first time ever on a flight with no plans at all. The day I got there I got asked to be in a commercial two days later. My roommate and her friends flew out there to get me and she ended up being able to be in the commercial with me which ended up on tbs but I had to go back home to my apartment and responsibilities and couldn’t leave my roommate stranded. Even though months later we would end up getting in an argument and I’d move out and move back with my ex (now fiance) where I would continue to work and model (for free) and went back to the club to dance and then my sister ended up going to California for a travel nursing assignment and her and her bf broke up and she asked me to move with her. I had nothing else here, my ex was still saying he didn’t want to be in a relationship, he was consistently sleeping with other girls while we lived together and expected relationship things from me. I was paying for everything for him. I paid for him while he was in school for audio engineer, his gas, lunch, school clothes, shopping, I helped him open his own studio and bought his equipment and Mac for it, even though his parents were very involved in his life. I got all his family bday gifts and Christmas gifts every year. He was honestly just using me but I was so in love and blind. He encouraged me to go to California too so I had nothing else there for me, if he had told me to stay and he wanted to be with me I would’ve. I flew out on my 21st birthday and met my sister and Vegas where we would have such a great time and my ex spent that day hanging out with a girl that tried to fight me and didn’t even tell me happy birthday, I was crying in the bathroom in Vegas until my sister shook me and told me to get it together we’re in Vegas. I was so heart broken to be leaving him but he didn’t care. I got to LA and I instantly started modeling on day one I booked a photo shoot where I met a guy that reminded me of my ex (I know) but we instantly clicked and he was 7 years older than me. We ended up talking for a little bit and pursuing something even though I wasn’t ready emotionally but he didn’t really care and I was kind of star struck a little because he was a music producer for a very famous musician and he was very persistent but that’s another story. I ended up booking a music video as a main girl for my ex’s (now fiance) favorite artist. When it came out it was crazy because I felt like the universe and God was just blessing me for leaving that situation and I knew he would see it because he was so obsessed with that artist and it shook up the whole small town I was from. After that I booked a lot of cool jobs like Sephora and worked with a lot of companies, and did some music videos for other super famous artists, and walked in fashion shows and modeled for clothing brands etc. I was working all the time as an extra to pay my bills and I was meeting cool people. I was always getting invited to celebrities parties and just having such a fun time. I decided to start getting into acting instead and started going to acting school where a lot of well known celebrities also went to and I started having meetings with very popular directors and I was being mentored by famous directors and another person that created an tv entertainment channel that I won’t say here also mentored me a lot and got me a lot of meetings with these people and would go to dinners and stuff etc with a list celebrities. I truly was living the life. And coming from where I can it was almost a dream. I had gotten in a relationship my first year there with that other guy I mentioned who ended up being super possessive of me but he treated me like a queen in the sense of paying for everything, giving me a safe space to tell my feelings, open up, the sex was amazing, he would take me on trips, took me out of the country for the first time. We ended up not working out due to lifestyle differences and just being at two different places and wanting different things. He wanted to move out of the country and have a farm and I wasn’t ready to do that as I wanted to focus on my career. (But I would die to move out of the country on a farm now ironically and he is doing just that now like he said he would haha) anyway, I ended up having my own studio apartment by myself that I loved so much and was so proud of. My sister had moved to Montana and it took a lot for me to get my apartment like staying in a house with other girls for a little to sleeping in my car and at a spa for a couple days. When I would fly home or drive home to see my family I would always see my ex, everytime. We kept a friendship and sometimes I would still help him out if needed, he was interning at a church through his school for audio engineering and recording people at his studio in our hometown. By this time I was going to New York and Miami also sometimes and doing work there. I wasn’t as stressed about bills anymore. I was seeing guys every now and then but not at all interested in a relationship, my heart was still healing from the past and both my exes but mainly my first (now fiance). I was super focused on my career and optimistic, I was used to the grind and in no way ever thinking of quitting. It just wasn’t an option because I knew I would make it wherever that would be because to me that is all I had for me and all I ever knew I wanted and the only thing that saved me. Skip to around October 2019 I had found out about a girl my ex was seeing and it crushed me. He was doing with her just like he was with me though. Just “friends with benefits” I was living in my apartment in LA still and my uncle that helped raise me was getting really sick back home and put on hospice so I decided to take a trip back to see him. I would go to restaurants in my state and near my home town and people would ask to take pictures with me, and at the little ceasars drive through someone asked if I was me and stuff it was crazy because I hadn’t been home in awhile and I felt like what I was doing was finally paying off and people were recognizing me. It was surreal. I ended up going to see my ex. I had such a fear of losing him to this other girl for some reason. I was so scared he would get her pregnant or get in a serious relationship since I was gone so far away and I would never be with him, I would end up sleeping with him again and the girl found out and drove by his house mad and cussing me out and throwing stuff at me. We ended up getting in a fight which is so embarrassing and beneath me. I ended up crying to him that I wanted to be with him and don’t know why he never wanted to be with me which at this time he honestly was not even in my playing field anymore. He told me if I wanted to be with him I had to move back to my hometown.. my heart dropped to my stomach and I knew it wasn’t what I was supposed to do but I said okay… all because this is what I had wanted all those years. I decided to stay where the next two years all I would think about everyday was I was making the wrong decision and needed to go back to my life. My hometown had nothing for me.. COVID hit a couple months after me being there and we were terrified. We ended up getting everything out of my apartment and moving into a house around the corner from his parents. I had to tell him how I liked to communicate now without yelling and stuff which I learned from the boyfriend I had in LA and that I wasn’t going to put up with that disrespect but he never listened. Eventually everything went back to normal. I ended up going back to the club again dancing because I didn’t want to go backward and model here. He never wanted me to go back to LA even for a little bit even though that’s where my career and heart was so I had no idea what to do with my life. I started waitressing as well and getting back on my adhd meds. People started pressuring us to get pregnant and we tried for a year and 6 months. The month I found out I was pregnant before I knew, I quit my job and decided I was going to move back and get my life back. Two days later I found out I was pregnant…. Finally after trying for over a year. Our relationship was toxic just like the past he always yelled, I could never talk to him about my feelings without him saying I was trying to fight, he spit in my face once, threatened me, put his hands on me, he would tell me he was going to take my baby away from me as soon as I had it. I started asking him about getting married while I was pregnant and the proposal wasn’t even that. He got mad at me for asking one day and walked in the room and handed me the ring. It didn’t fit because I was pregnant & it was $27 (not that that matters but the proposal sucked).. he drained both my bank accounts and they closed it, charged my credit card up and put me in debt, he has not let me do anything I want to do like school or anything. He is so bad with money. He has an action figure addiction and at one point was spending 3k on action figures every month and turned one of the rooms in our house into a collection room so I had to take everything out of my closet and put my sons crib in there for the first year of his life. we have good times and I feel comfortable with him. He knows everything about me but he doesn’t respect me and sometimes I feel like he is intimidated by me. The sex isn’t good at all we always just ask “do you want to have sex” he never gives oral or foreplay, I never get pleasure. He’s an amazing dad though and loves his son. We have the most sweet and beautiful little boy now who I love so much and he loves him also. He’s very attentive to his son. But I still feel unheard. I can’t talk about my feelings. If I do it doesn’t matter, it doesn’t change anything. He is so defensive and we never communicate for a solution it’s always just pointing fingers. I have started yelling again because I’m so used to it now and I hate it because I grew up like that and I finally grew out of it until I got back with him and recently started again and now he throws it in my face and knows I begged him not to do it forever but he never stopped and now I am too. I’ve asked him to take me to the movies and he hasn’t still. I just ask for more romance and stuff but it just feels like I have a roommate. I have nothing now. I had my car and we traded it in for a new car that he wanted. I always dreamed of the next car I’d get once I paid it off but he got it & it’s in his name now so I paid it off for nothing. I’m driving around his dream car. I’ve been planning our wedding since I birthed our son and everything is going good. Money is tight. He works at the church now full time and makes about 45k a year or so, my son has been waiting to start daycare for awhile so I have been home with him. I’ve tried starting jobs multiple times but he is against it unless it’s super fast money like going to the club which I am so repulsed by and absolutely hate it now. I tried going back to college but my old college won’t release my transcripts for fasfa because I owe them money. I started cosmetology school a few months ago which he was all for but two months in freaked out and him and his mom guilt tripped me that we can’t handle this right now and he was having a hard time doing the night time routine for the baby while I was at school so I had to leave and now owe that’s school for my kit unless I enroll again in 128 days. I also miss modeling so much and sometimes think I can start again but it’s been five years. My body is so different too after a baby. Everything I want is a no go. Especially moving out of our hometown. He says he wants to but I don’t think he does. We are constantly at his moms and dads and they tell us all the time we aren’t moving anywhere which is really hard for me as this place is super toxic for my soul. Anytime I get money he spends it. Anytime I save money he spends it. Even if it does go towards our bills. His action figure habit is almost nonexistent now and he has grown a lot in the past few months from that since I demanded my son have his own bedroom after his first bday and all his figures are in boxes now and told him he could turn the shed into his man cave. He says we can’t save because we have nothing to save after bills but I believe in saving anything even $5 a paycheck. It’s doable. I grew up poor so this is nothing to me but after living the lifestyle I lived in LA and going out with guys that respected me and cherished me it’s hard. I know nobody is perfect but we are about to get married and I’m scared… I have nothing though anymore. I’ve threatened to leave a couple times and he says he will take me to court and take my baby. I’m scared he might. I don’t want my son to be angry like him or not respect women how he does. In public he’s a saint. He also has a very supportive family that it’s almost toxic. They all blame me for his anger issues and say I make him that way. But he’s been punching walls since I met him in 8th grade. I know it’s not because of me. But I have nobody else and nowhere else to go. No money. No car. I’m at the bottom again where I was before. Only difference is now I have a son. And we are getting married in three months and I can’t call it off. I am older now and looking back on my life I realize he maybe truly never loved me and I was just so desperate for love. I got myself here nobody else. I accepted everything, even when my gut told me not to. ( he is not just horrible, he’s a great person just with some bad qualities like everyone but I’m tired of feeling stuck with someone that never truly wanted me and doesn’t care to grow in some ways or show me )
Please help.. what do I do?

You know how some credit cards offer 0% interest for X number of months when you join?
What is to stop you from opening the card, liquidating $20k in cash advances (if they don't allow that, then say we'll buy gold bars on the card and just resell them for cash), put the cash in something low-ish risk for 12 months (CD etc) and earn 5% = $21k and then go pay back the credit card before any interest comes due?
True it's only 1k over the course of a year but it's free money. Can this be done? Why not?

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
​

Was told by app to get free gifts all I had to do was invite one new user. Sent the code to my friend who is sitting next to me who does not have the app. Magically their invite was REJECTED for not BEING IN THE SAME AREA.
Contacted Temu support and after a lengthy back and forth they revealed
“ , Invite new using the required to complete the event, However the total number of invitee is cannot predict the exact number of friends to invite”
So basically it does not matter how many invite codes you send. THERE ARE NO FREE GIFTS.
I provided screen shots of my friend connected to my home wifi and their TEMU app trying to get a phone verification code that magically NEVER came.
It’s a scam people.

Play Star Citizen for Free until May 29th. (Free Fly May 17th to May 29th).

Referral Code: STAR-C2GJ-XSSS
Use the following links Create an account - https://robertsspaceindustries.com/enlist?referral=STAR-C2GJ-XSSS
As an experienced player, I can help answer any questions regarding 3.23, ship sales, how CCU’s work, NPC Bounties, in-game mining, and how to save some money via warbonds on internet spaceships. Just send me a DM and Thanks