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Saturday, May 19, 2012
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Lyceum Newsletter Perspectives
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A Return to Long Horizons
02/01/2007
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| The information revolution slashed transaction costs and transformed investment strategy. |
“We do everything we can to get the best information.” It’s a common declaration of savvy money managers, and the information revolution has made this an extremely cost effective task for many. From strategic-minded business leaders to discerning consumers, the slogan ‘knowledge is power’ has become a self-evident precondition in financial success. But the real power of knowledge lies in how it’s applied, and that’s what separates winners from losers.
By empowering high-churn money managers in the late nineties, broadband Internet revolutionized the financial markets and the business of investing. Rapid-fire trading produced eye-popping results and a new breed of Wall Street leadership.
Market fortunes, however, once again favor the go-slow approach of Benjamin Graham, as pervasive information accessibility makes once scarce critical real-time information for one trader an easy achievement for thousands of his competitors. The benchmark is no longer the market index: It’s the performance of that newly minted billion-dollar fund downstairs on the fortieth floor, or the dozen in the building next door.
As prospective shareholders begin to rank money managers more by peer performance and risk-return conditions continue shifting against portfolio churning, margin-of-safety will replace absolute return as the buzz-phrase of the next five years.
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First introduced in Benjamin Graham’s and David Dodd’s seminal work Security Analysis (first published in 1934), margin-of-safety desribes the difference between a stock’s intrinsic worth and its market value. Seth Klarman borrowed the phrase for the title of his 1991 book, and added the notion of absolute return in addition to several wise observations on investing. Now out of print, Mr. Klarman’s book commands prices on Amazon.com of between $1,500 and $2,500 (speaking of good investments!). Rank and file value-investors dutifully covet both works, the majority of whom commit to multi-year time horizons.
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This article addresses transaction costs as a critical economic force. Whether software development or pharmacy claims adjudication (as discussed on these pages and in our various events), these costs have steadily declined, with significant benefit to the overall economy. Share trading provides one of the clearest examples of how this cost factor reflects an momentous period for the entire economy. Measuring in risk/return and time, we show a significant transition to more deliberate action.
☆ ☆ ☆
Momentum behind trading-driven investing began accelerating in the late 1990s, with Wall Street’s (and Main Street’s) full embrace of the Internet and its capacity to deliver relevant, instantaneous information. Broker-dealers (“B/Ds”) quickly invested billions of dollars in online trading systems and information delivery.
| Between 1995 and 2006, the total number of Internet users grew from 16 million to over one billion, and the number of Web sites with domain names and content from 18,000 to over 100 million. |
Latching onto the Web’s emergence, market centers such as alternative trading systems (“ATS”) or electronic communication networks (“ECNs”) became viable alternatives to traditional stock exchanges following the 1998 court decision against Nasdaq market-markers. They hastened price competition, and quickly gained market share (now over 60 percent of all over-the-counter stocks from just a few basis points in 1997).
More recently, crossing networks have appeared. By sidestepping the process routing an order to an exchange or market center, these systems allow institutional investors to trade directly and anonymously, often across international markets. Liquidity, however, can be problematic depending on the security. Examples include Liquidnet, Posit and Pipeline
Though a contributing factor too, expanding computer hardware and software capability has been much more anticipatory than the sudden surge in Internet-driven information. Computer systems, after all, are only as effective as the information available to analyze.
The result: extreme compression in investment horizons, with increasing numbers of money managers trading for sixteenths (decimal points from 2001) over days or even minutes.
The information revolution fundamentally altered the practice of money management, with commission reductions and the rise of absolute return investing becoming its consequences, rather than its drivers. Simultaneously connected, portfolio managers could better assess a data point’s validity, especially those who could act on its immediacy. Imagine a world without your Blackberry – now imagine it without any form of electronic communication.
Better performance on better information attracted shareholder dollars. Greater buy-side power, whether under the guise of alpha or absolute return, then augmented market liquidity: sell-side transparency rose and transaction (or trading) costs declined.
While the Internet unexpectedly advanced the quality and quantity of information, its success is now commoditizing information as access points proliferate and costs decline. Together with government regulation (fair disclosure and Sarbanes-Oxley), information’s evolutionary surge has turned to level the playing field – at least for those playing the trading game.
Churn and burn
Between 1995 and 2006, mutual fund turnover (the rate at which funds replace their portfolios, with 100 percent equaling a complete replacement over a twelve month period) slowed from 71 percent to 47 percent on an asset-weighted basis, while turnover on the New York Stock Exchange (“NYSE”) jumped from 59 percent to 102 percent, and over 110 percent in recent months.

Applying ownership levels and typical manager characteristics, we estimate an underlying turnover rate of 300 percent in today’s market. Mutual funds hold about 20 percent of corporate equity, according to the NYSE. Pension funds and insurance companies make up another 30 percent. Both represent longer holding periods than mutual funds, but we assume identical periods for this exercise. Households, bank personal trusts, foreign funds and alternative investment vehicles comprise the remainder. Assuming half of these match the mutual fund level and the NYSE turns over at its current 110 percent rate, 25 percent of market participants buys and sells its portfolio every four months.
If we use the same framework for the 1995 market, this segment then bought and sold its portfolio only once every four years. The eleven-year period, therefore, witnessed an impressive twelve-fold increase in turnover. Of course, there are several moving parts to this analysis, and we do not pretend to be precise, but the trend is patently obvious.
Trading costs
A byproduct of the shifting balance between buy-side and sell-side trading desks, declining trading costs (down more than 25 percent from 1998, according to an Elkins/McSherry study) have contributed significantly to rising market activity. [Elkins/McSherry is a leading trading cost consultant, monitoring costs for many of the world's largest pension plans, investment managers and broker/dealers.]

The chart above breaks down global trading costs as commissions (broker fees), fees (exchange fees) and market impact (the price change between the broker’s receipt of an order and its execution of that order). Key factors include market transparency (price discovery) and liquidity (number of participants).
Market impact as a percentage of total costs is down eight percent from 1998, 14 percent from the 2000 to 2002 period, and 20 percent from its 2000 peak – corresponding with a pronounced downshift in market volatility.
NYSE and Nasdaq trading costs have fallen by more than 40 percent – due in large part to market impact (see volatility section). [The 2001 and 2006 cost levels for NYSE and Nasdaq were 29.2 and 37.9, and 17.51 and 20.66, respectively. A fairer comparison would be between similar volatility periods (in this case, low to low), but we do not have the data.]
Elkins/McSherry described the shifting market relationship between the buy-side and sell-side in an August 2006 press release: “Brokers are slowly becoming technology and liquidity providers as buy-side desks are demonstrably adding greater value to the investment process. For the typical $10 billion dollar money manager with 100 percent turnover, a five basis point reduction in trading costs is equal to $5 million in increased returns to investors.”
Although we don’t anticipate commission rates rising, the rate of deceleration could abate if performance mean reversion persists, and trading-driven investing dissipates as a market force. During a frenzy of mass poor-performance, we would, not doubt, an outcry for lower rates, but this would moderate as the worst performers shut down. For slow turnover money, cost is a less factor, and therefore less of a bargaining chip with the sell-side (assuming execution, not research, is the dominant reason for interaction).
| Large low-turnover fund complexes with several hundred billions of dollars under management can exert their sheer size to force downward pressure on rates, although we expect this would vary depending on volume: A 60 percent turnover strategy, for example, would generate four times the commission volume of a 15 percent strategy on the same asset base – all things equal. |
The move toward unbundling (vendor cost transparency) has reinforced execution as a market force on commission rates. Prior to new soft dollar rules, investment firms could compensate B/Ds with commission dollars for a range of services beyond just trade execution – a practice now limited to research. The questions now become: What’s the value of research relative to execution? How much research value do executing (full-service) B/Ds generate? How much execution value do full-service B/Ds offer relative to execution-only services?
Price discovery, of course, varies by stock exchange or market center, with developing countries typically more sensitive to liquidity balances than developed ones (the ratio of foreign to domestic investors). Liquidity affects market impact, and the overall cost of trading – why investors require vastly higher risk compensation in Colombia than Japan, for example.
The table below illustrates how portfolio turnover affects investment performance, net of trading costs and management and performance fees typical for alternative investment strategies.
| Mutual fund fees may or may not include a load charge at entry or exit. This can be as high as 5.75 percent. Management fees range between 70 and 150 basis points. Performance fees are rare. This analysis does not include the effect of leverage or taxes. |

Trading costs vary not just by market, but also by broker-dealer, who negotiate rates based on several different factors including market-maker capability, order size, liquidity, and market information and communication (the relationship between broker and client). We assume an aggregate level of 20 basis points, including market impact and exchange fees – slightly higher than the current NYSE cost of 17.5.
For the purpose of comparison, we also assume that each fund produces a similar dollar volume of commissions. Broker rates would otherwise vary, normally favoring the higher volume client.
Risk-return payoff
As described in past issues, risk compensation – the rate at which the market rewards risk taking – varies over time. Shareholders can adjust their fund exposure according to the holding period, depending on underlying conditions. Although the market has favored high turnover strategies in recent years, the chart below shows long-term investors performing best over the ten-year period.

The chart’s values equal the compounded return of the daily four-year, one-year, and three-month moving average of risk compensation between January 1994 and January 2007, with a beginning level of one.
We define risk compensation as market return per unit of risk, and calculate it by dividing the daily level of the VIX index (closing prices) into the daily percentage change of the S&P 500. This metric captures market expectations of risk-return, and more accurately portrays market dynamics than either variable by itself. It also provides a means to anticipate shareholder money flows by estimating future performance, where those funds achieving higher risk compensation have a greater probability of outperforming.
Using the S&P 500 allows us to assume a generic money manager that reliably beats 70 percent of its competition. It also captures about two-thirds of total stock market capitalization.
| The majority of active managers underperform the blue chip benchmark on any given year, with even worse odds for mid- and small-cap investors. See Standard & Poor’s January 17, 2007 press release, “Year End Index Versus Active Scorecard.” In 2005, total US market capitalization was $17 trillion versus $11.2 trillion for the S&P 500 (sources: IMF, Standard & Poor’s). |
We assume too that turnover has a greater effect on performance than investment style (growth, value, GARP, etc.), which the dotcom mania proved arbitrary: Investment mandates can vary widely and be quite flexible.
That said, people typically associate shorter holding periods with growth and momentum. Performance levels in 2006, in fact, show value (generally perceived as long-term) outperforming, according to the fund intelligence company Lipper. Large-cap growth funds and diversified funds advanced six percent and 12.9 percent, respectively, while value funds achieved a resounding 18.5 percent return – against 15.6 percent for the S&P including dividends.
As we demonstrated in our January 2007 issue, the fourth quarter of 2006 finished with the third best risk compensation level in the last ten years. According to our analysis, the final quarter is normally the best performer, while the first is the worst.
The cost of money
Absolute return means not losing money, and the safest investment of all is cash, which we define as the 90-day Treasury bill. This serves as an investor’s basic hurdle. If you can’t beat cash, why bother? In the age of leverage, it also serves as the basic cost factor. The more expensive the cost of money, the higher an investor’s required risk-adjusted return.
This next chart illustrates how the simultaneous hurdle and cost basis varies by investment horizon – assuming, of course, identical transaction costs, credit quality, and reinvestment risk. By borrowing less frequently, the long-term strategy lags its competitors in cost exposure – now an advantage with short-term rates having only gradually risen over the past two-and-half years.

We calculate each value as the four-year, one-year, and three-month moving average of the three-month Treasury bill (constant maturity).
A history of volatility
Our own commentary notwithstanding, many pundits have wondered at the low level of market volatility in recent years. Our view holds that global capital market evolution and capital flow directions since 1990 explain the current environment, which various malignancies such as war and asset price fluctuations have failed to alter.
But how low in the cycle are we? Well, that depends on your time frame. The following chart dates back to 1950, and presents volatility as the annualized standard deviation of daily close-to-close percentage price changes for each month.
Except for an extreme spike in 1987 (the October market crash), volatility remained largely subdued throughout most of the two-decade bull-market that began in 1981, and was clearly lower on average in the 1990s until 1997. As we’ve argued in past issues, generational socio-economic events around the globe prompted elevated levels during the 1997 to 2003 period, making it not just aberrational, but also a critical contributing factor to our present state of low volatility: The average level for this period was 14.83 percent, in contrast to 9.48 percent for the 56-year period – 5.97 percent for the month of December (2006). [“Market Calm: Parts I & II” Perspectives July & July 2005, volume 1, issues 2 & 3]

| The Transaction Economy. A climate of voluminous liquidity and favorable risk compensation has swelled the coffers of both private and public market investors. Together with the added effect of low economic and market volatility, the quantity of market transactions, whether in terms of trading volume or company purchases, has exploded. In 2005, for example, the average daily volume of the NYSE reached 1.6 billion shares, more than three times the 1997 level, and in 2006 financial buyers made record-setting purchases: HCA and Equity Office Properties Trust for $33 billion and $36 billion each, for instance. “I can’t afford not to participate,” goes the parlance on the Street. Sensing a buyer always lining up, market participants have pushed for greater risk exposure – in many cases moving beyond core competencies in sectors and markets (what practitioners call style-drifting). |
Though indeed historically low, today’s volatility is by no means excessively low – and should be viewed in the evolution of capital market efficiency beginning in 1981.
It has also facilitated strong investment performance, by curbing trading costs. Should volatility suddenly elevate, narrowing performance differentiation among trading-driven strategies could result in sharply lower returns – as one moves so they all move together.
Going long
At the end of summer 2006, we noted a turning point between risk compensation and the cost of money for a 100 percent turnover strategy – reiterated in January. Again, this does not constitute an index level forecast (we’ll leave that to the experts), rather it’s an estimation of the ability of different investment strategies to achieve excess return. The market itself may rise or fall.
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We present again the 100 percent turnover strategy in this next chart as a baseline (see September 2006 and January 2007 newsletter issues). It shows the timeline of turning points (marked by circles). The green (jagged) line depicts risk compensation, and the blue (smooth) line the risk-free rate. |
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Stock selection will continue to separate the field over the short-term, but performance mean reversion will be more pronounced than previous periods, as risk compensation and risk-free rate converge and move in tandem.
Although – for the short-term strategy (400 percent turnover) – the gap between risk compensation and the risk-free rate widened considerably in the fourth quarter 2006, the general trend of its closing holds, so long as risk compensation normalizes after its eight-year peak and short-term rates do not suddenly drop.
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The picture, however, changes markedly for the long-term strategy (25 percent turnover). Currently, the hypothetical slow turn fund is best positioned, with risk compensation expanding relative to the cost of money.
Though vulnerable to negative performance, this strategy never actually suffers negative risk compensation as with higher turnover strategies even during a prolonged downturn, due to the smoothing effect of continuous buying over an extended period. Conversely, it also means a slower recovery period. |
The market’s tendency toward appreciation corresponds with the firmly entrenched adjustment capability of the broad economy, and should not falter, though whether it beats a cash return is another question. An aggressive, short-term trading strategy eying market contraction (chronic short-selling), therefore, seems precarious at best.
☆ ☆ ☆
Transaction costs have declined across many industries, not just equity trading. This reflects in an increasingly flexible economy, which has engendered strong growth often surpassing consensus forecasts. These costs represent the economic effect of not only a revolution in information delivery and availability, but also the explosive dynamic of Web-based communities – large numbers of people collaborating on common goals – and, consequently, the efficiencies of process innovation.
At what point, though, do risk/return profiles diminish? That depends on the size and scale of a particular business. More nimble players will adopt unforeseen technological breakthrough faster than those plagued by bureaucratic decision-making. In many cases this disrupts traditional business models. Over time, the playing field rebalances, as money flows alter – graph below.

The aftermath of the dotcom bust, however, instructs us that several traditional business practices hold fast, even strengthen. Has video-conferencing encouraged or discouraged the number of in-person meetings, for example? Record-high business air travel volumes would suggest more people spending more time in meetings than ever before.
In respect to equity trading, wide-scale distribution and affordable access has blunted the informational edge gained in recent years. The information revolution roused market liquidity, which contributed to reduced trading costs. Having flocked by the billions of dollars, short-term investors now risk crowding out their own opportunity for excess return.
Unless liquidity freezes, we would not expect trading costs to reflate, although broker-dealers may take advantage of firmer footing in client relationships. At their present course, market conditions are favoring long-term holding periods over rapid turnover.
Declining transaction costs have likewise benefited the overall economy, by widely spreading wealth, especially among the capital-hungry entrepreneurial class. Whether or not this represents the low point in the cycle depends on the economy’s flexibility. We reckon it to be historically high; but, as always, this assessment remains at the mercy of gatekeepers (politicians, regulators, central bankers) and their continued wisdom.
© Lyceum Associates, Inc. All rights reserved.
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These and other organizations have recently participated in Lyceum roundtables and events.
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AARP
Academy of Managed Care Pharmacy
Aetna
Altos Solutions
American Benefits Council
American Enterprise Institute
Amgen
Athenahealth
Beth Israel Hospital
Biotechnology Industry Organzation
BioCentury
Blue Cross & Blue Shield Illinois
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Cardinal Health
Carol
Carnegie Mellon University
Caterpillar
CBS Corp
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Centura
Colgate Palmolive
Colorado Business Group on Health
Colorado Health Foundation
Connecticut Oncology Association
Consortium Health Plans
CVS Caremark
Deloitte Consulting
EMC
Empire Blue Cross Blue Shield
Employee Benefit Research Institute
Engel & Novitt , LLP
Epstein Becker Green
Exigo
Foot Locker
Foundation for Managed Care Pharmacy
GE Company
General Mills
Genentech
Harmony Pharmacy
Harvard Business School
Harvard Kennedy School
Harvard Medical School
Harvard Pilgrim Health Care
Harvard School of Public Health
Hassard Bonnington
Health Care Service Corp.
HealthPass
Health Strategy LLC
Heritage Foundatioin
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Hogan & Hartson
HomePort
Horizon Blue Cross
Hospira
Hospitals Without Borders
HR Policy Assocation
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Imerica
Innovent Oncology
Inspire
Intellogy Health Designs
ITA Partners
Kaiser Permanente
Leavitt Partners
Manatt Health Solutions
Marriott International
Massachusetts Medical Society
Med Adherence
Medical Oncology Association of Southern California
Medsphere
Merrill Lynch Health Care Services
Microsoft Corporation
Milliman
MinuteClinic
Midwest Business Group on Health
Muir Medical Group IPA
National Business Coalition on Health
NaviNet
Neighborhood Diabetes
New Media Strategies
New York Business Group on Health
New York Clinical Informaton Exchange (NYCLIX)
Novartis Pharmaceutical Corporation
New York Presbyterian Hospital
NovoLogix
NPS Pharmaceuticals
Oncology Metrics
Oncure Medical Corp.
OneOncology
Pacific Surgical Partners
Park Avenue Health Care Management
Partners Transforming Health
Pfizer
Practice Fusion
Premier Inc.
PricewaterhouseCoopers
Protein Sciences
Ready Consultant
Rx Vitality
Salix Ventures
Sandoz
Sanofi Aventis
Silverlink
State of Colorado
SustainAbility
TIAA-CREF
United States Senate
UnitedHealth Group
University of Colorado
University of Pittsburgh
US Chamber of Commerce
Vantage Oncology
Verisk Health
Volo Healthcare
Wakely Consulting
Watson Wyatt
Weill Cornell Medical Center
WellPoint
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Drug Pricing Methodologies
Average Wholesale Price (“AWP”): The most commonly used price index in pharmaceutical transactions, AWP operates as a suggested list price. Buyers, typically, negotiate lower prices through the inclusion of discounts, rebates or free goods. Medicare uses it to calculate the cost of drug products administered in a physician’s office. PBMs, insurance carriers, and other managed care organizations use AWP to calculate payments to retail pharmacies for providing drug products to patients. Pharmacies often use AWP as a cost basis for pricing prescriptions.
Average Sales Price (“ASP”): The Medicare Modernization Act of 2003 established ASP as a drug payment system. The methodology uses quarterly drug pricing data, which drug manufacturers submit to the CMS. In calculating the ASP, the manufacturer must deduct various discounts, including prompt payment discounts. Like AWP, it serves as a baseline to determine Medicare reimbursement rates.
Average Acquisition Cost (“AAC”): The retailer’s cost to buy drugs from wholesalers: the final cost of the drug to the pharmacy after all discounts are subtracted.
Average Manufacturer’s Price (“AMP”): The average price retail pharmacies or wholesalers pay manufacturers. It is based on sales to the retail sector, which generally pays higher prices than other purchasing sectors. The federal government currently uses AMP to calculate rebates in the Medicaid outpatient prescription drug rebate program.
Wholesale Acquisition Cost (“WAC”): A manufacturer’s list price established for sales to wholesalers, and a basis for calculating rebates.
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MANUFACTURER TO PHARMACY (VIA WHOLESALER)
1. MANUFACTURER
↓ Wholesale Acquisition Cost (WAC) or ↓ Average Manufacturer's Price (AMP)
2. WHOLESALER
↓ Actual Acquisition Price (AAP)
3. PHARMACY
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MANUFACTURER TO PHARMACY
1. MANUFACTURER
↓ Average Manufacturer's Price (AMP)
2. PHARMACY
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PAYER TO PHARMACY
1. PAYER
↓ Reimbursement: Average Wholesale Price + Discount
2. PHARMACY
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PHARMACY TO PATIENT
1. PHARMACY
↓ Retail or Usual & Customary Price (U & C)
2. PATIENT/END-USER
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Drug Coding Procedures
Vendors use both the Health Care Common Procedure Coding System (“HCPCS”), devised by CMS, and Current Procedural Terminology (“CPT”), an AMA creation, to bill for drugs/products that are utilized in the physician’s office, clinic or home setting. These include drugs that are injected subcutaneously, intramuscularly, or intravenously, and drugs administered via nebulizers or other DME equipment.
The National Drug Code (“NDC”) serves as a universal product identifier for drugs and biologics. Although similar to NDC, J Codes contain less information, such as the name of the drug manufacturer. J Codes are administered under the HCPCS.
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The newsletter Perspectives features commentary and opinion on economic transition and business innovation across health care, financial systems and consumer business. Many contributions come from our participants, and reflect front-line experience.
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Maureen Bailey "Silent Epidemic" (volume 5, issue 2), "Nudging Temptation Aside: Behavioral Economics and Diabetes" (volume 5, issue 5)
Ms. Bailey is the author of the forthcoming book "The Diabetic Diva", a cookbook for diabetics with a foreword by Ron Rosedale, MD. Dr. Rosedale developed a nutritional protocol that has helped thousands of people reverse type 2 diabetes. Her work has also appeared in Barron's and The Economist. Read more about Maureen.
Tom Cronin "A Better Model for Disease Management" (volume 5, issue 11)
Mr. Cronin is CEO of Neighborhood Diabetes, where he and his partners on the Management Team have grown the company tenfold in the last five years. Prior to involvement in the acquisition of Neighborhood, Tom took a sabbatical from business and was a math teacher at an urban high school and high school varsity soccer coach. Prior to teaching, Tom was CEO and owner of CranBarry, Inc., an established manufacturer and distributor of women's sporting goods. Earlier, Tom was a consultant at Bain & Company, the international strategy consulting firm headquartered in Boston. Read more about Tom.
Bruce Cutter, MD "A New Oncology Business Model" (volume 5, issue 1)
Dr. Cutter is a practicing medical oncologist/hematologist at Cancer Care Northwest, a large integrated oncology group in Spokane, WA. As president and CEO from 2000 to 2007, Bruce lead the development of a comprehensive quality initiative called Foundations of Quality ("FOQ"). FOQ was developed six years ago, in close collaboration with Premera Blue Cross. This program, which includes a pay-for-performance contractual relationship, was founded on the quality principles promulgated by the Institute of Medicine, is physician-driven and collaborative, and based on a commitment by the practice to measurable quality and accountability. Read more about Bruce.
Steve Hyde "Personal Choice and Breast Cancer Screening" (volume 5, issue 12)
Mr. Hyde is the author two books: most recently, “Cured! An Insider's Handbook for Health Care Reform” (June 2009, Hobnob Publishing; read review) and, previously, “Prescription Drugs for Half Price or Less,” (2006, Bantam-Dell Division of Random House). He has been a public company CEO and chairman or board member of numerous companies. The former federal chief HMO financial regulator and a certified actuary, he started and grew Peak Health Care, Inc., into a highly successful public managed care company, recognized by Business Week Magazine as one of America’s Best Small Companies. He has extensive experience in managed care operations and strategy, health insurance, managed care regulation, consumer-driven health care, pharmacy benefits, disease management, medical information technology, medical group management, medical network and PPO operations, health benefit design & pricing, health insurance underwriting, community rating, and health service product development and marketing. Steve is CEO of Hyde Rx Services Corp., a health care management consultancy. Read more about Steve.
Wolfgang Klietmann, MD "Understanding H1N1 as a Pandemic Threat and Public Health Service Challenge" (volume 5, issue 11)
Dr. Klietmann is a clinical pathologist and medical microbiologist and serves at Harvard Medical School faculty as an appointed Lecturer on Pathology. Prior to his immigration to the United States in 1992, Klietmann founded and was president and physician-in-chief of a major Institute of Laboratory Medicine in Germany which he built into a peerless institution in its scientific standing and innovative diagnostic reputation among private laboratories in Germany. A prolific author and guest lecturer with over 200 publications and presentations delivered to audiences across the globe, the cornerstone of Klietmann’s career has centered on infectious diseases and bringing together individuals and organizations to share information, technology and resources. His work in biodefense includes a collaboration with MIT in a project for the Department of Defense. He serves as president on the board of directors of the Harvard Business School Health Industry Alumni Association and organized as co-chairman several major conferences held on the campus of Harvard Business School. His memberships in several scientific societies include a fellow of the College of American Pathologists. Read more about Wolfgang.
Tom McNulty, Pharm.D "New Strategies for Specialty Pharmacy" (volume 5, issue 12)
Dr. McNulty is co-founder and chief clinical officer of NovoLogix, Inc, a performance-based health care technology company delivering electronic claims re-pricing processes, prior authorization controls, and integrated patient care and pharmaceutical programs. His expertise includes medication adherence and compliance. Tom is a frequent speaker at industry events and conferences. Read more about Tom.
Kavita Nair, PhD "Value-Based Benefit Design: Getting It Right" (volume 5, issue 4)
Dr. Nair is an associate professor in the department of clinical pharmacy at the University of Colorado (Denver) School of Pharmacy. Her current area of research involves pharmacy benefit design in managed care and retail pharmacy including the structure, pricing and reimbursement of medications, factors affecting the reimbursement of medication in retail pharmacy, willingness to pay for retail pharmacists services and consumer attitudes regarding their pharmacy benefit plans and the impact of multi-tiered reimbursement mechanisms on medication utilization. She is currrently working with Anthem Blue Cross Blue Shield of Colorado to examine the impact of two and three tier co-pay pharmacy benefit plans on the drug utilization patterns of a commercially insured population and a Medicare managed care population. She is also working with various Pharmacy Benefit Managers to examine the impact of converting prescription Claritin to an over-the-counter status on medication utilization and reimbursement mechanisms. Read more about Kavita.
Susan Pantely "Benefit Design Strategies and Oral Anticancer Medications" (volume 6, issue 1)
Ms. Pantely is a principal and consulting actuary with Milliman. She works with a broad range of clients, including Blue Cross/Blue Shield plans, HMOs, commercial insurers, government agencies and healthcare providers. Her work includes rate development, provider contract review, reserve certification, capitation development, Medicare risk feasibility studies, HMO start-ups, HMO due diligence, and development of risk sharing and reimbursement arrangements for physician groups, PHOs, and other integrated delivery systems. In addition, Susan has extensive experience with the valuation, financial analysis, and projection of healthcare services for several state public health insurance (Medicaid) programs. Read more about Susan.
David Rose "Smart Packaging, Better Health Care" (volume 6, issue 1)
Mr. Rose is CEO of Vitality, inc. a company focused on connected-health devices and services. He teaches at the MIT Media Lab and speaks frequently on design and product innovation at conferences and corporate retreats. Previously, he was founder and CEO of Ambient Devices where he pioneered embedding Internet information in everyday objects like umbrellas, light bulbs, bathroom mirrors, and refrigerator doors, to make the physical environment an interface to digital information. Read more about David.
Robert Rowley, MD "Cloudburst: The New Frontier for Electronic Health Records" (volume 5, issue 11)
Dr. Rowley is a family practice physician and Practice Fusion’s Chief Medical Officer. Dr. Rowley has a first-hand perspective on the technology needs and challenges faced by healthcare practitioners from his 30 year career in the sector, including experience as a Medical Director with Hill Physicians Medical Group and as a developer of the early EMR system Medical ChartWizard. His family practice in Hayward , CA has functioned without paper charts since 2002. Read more about Robert.
David Willcutts "Are Expectations Too High for Health IT Vendors?" (volume 6, issue 2)
Mr. Willcutts is a long time health care services executive and entrepreneur focused on managed care, specialty pharmacy and home care services. He is currently the president and founder of Ready Consultant, LLC an early stage marketplace for healthcare consulting services created in response to the unprecedented level of health care initiatives underway in the US covering areas such as EHR, HIPAA, ICD10, and more. He previously founded Ancillary Care Management (now Novologix) in 1995 growing it to over $450 million in annual revenue before leaving in 2007. Read more about David.
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Selected Health Care Legislation
1965: Social Security Amendments authorized Medicare and Medicaid programs. The act created separate payment systems for in patient hospital care (Part A), and outpatient care, including home care and physician services (Part B). Read more here.
1983: Orphan Drug Act gave tax breaks, subsidies, and special exclusivity privileges to sponsors of drugs for rare diseases, defined as having fewer than two hundred thousand cases in the United States. The act implemented market exclusivity by granting protection for seven years against competition from any drug with a similar effect. Read more here.
1984: Hatch-Waxman “Generic Drug” Act required the FDA to accept bioequivalence as sufficient for approval and established the procedure for a generic drug approval called the Abbreviated New Drug Application (“ANDA”). The act extended patents for time lost during FDA review and for one-half the time lost during FDA-required clinical testing. The act capped the extension at a maximum of five years, and the total patent term at 14 years from the data of the FDA approval. Read more here.
1986: The Health Care Quality Improvement Act protected peer review bodies from private money damage liability, and prevented incompetent practitioners from moving state to state without disclosure or discovery of previous damaging or incompetent performance. Read more here.
1989: Omnibus Budget Reconciliation Act authorized resource-based, relative value scale reimbursement of physicians under Part B of Medicare. Read more here.
1990: Budget Reconciliation Act established Medi-Gap insurance regulation that limited exclusions for pre-existing conditions, requirements for uniformity in policies, civil penalties for duplicative services, mandatory rebates if policies failed to return specified percentages of each premium dollar, and rules for "simplification" and standardization of policies. The act also introduced a series of Medicare reforms that aimed to save $40 billion over five years. Read more here.
1992: Prescription Drug User Fee Act established for a five-year period a mandatory fee to be submitted by a pharmaceutical company along with its application to finance the hiring of new employees and reduce average processing time. Read more here.
1996: Health Insurance Portability and Accountability Act (“HIPAA”) allowed for the protection of health insurance coverage for workers and their families when changing jobs, and established national standards for electronic health care transactions and national identifiers for providers, insurance plans, and employers to promote electronic data interchange. The act also authorized tax-deductible medical savings accounts. Read more here.
1997: Balanced Budget Act added Part C to Medicare, which expanded options for enrollment in managed care plans. Read more here.
1997: FDA Modernization Act reauthorized user fees for another five years, and introduced new inducements to conduct pediatric studies that included granting a sponsor an additional six months of exclusive marketing privileges beyond any patent or other nonpatent rights for which the drug may already be eligible. Read more here.
2003: Medicare Modernization Act provided a new outpatient prescription drug benefit under Medicare beginning in 2006 (Part D). In the interim, it created a temporary prescription drug discount card and transitional assistance program. It also included a provision for establishing health savings accounts. Read more here.
2005: Patient Safety and Quality Improvement Act established a system of patient safety organizations and a national patient safety database, to encourage reporting and broad discussion of adverse events, near misses and dangerous conditions. The Agency for Healthcare Research and Quality oversees many of its provisions. Read more here.
2009: The American Recovery and Reinvestment Act included the Health Information Technology for Economic and Clinical Health ("HITECH") Act, which provisions $19.2 billion in incentive money for the implemention and use of electronic health records. It also legislatively mandated the Office of the National Coordinator for Health Information Technology ("HIT"), and the creation of the HIT policy and standards committees. Read more here.
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Perspectives features commentary and opinion on economic transition and business innovation. Articles often reflect front-line experience.
We award badges to the five contributors ranking highest in total number of views.
Whether you've published one article or several, we're counting the sum of all reader 'clicks'.
Submit your commentary today. You, too, could become a Top Five contributor!
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Our one-page summaries describe in general terms roundtable proceedings. Because each Lyceum event is exclusive to its participants, we do not publish complete details.
- February 3, 2011 "Payers, Providers and Corporate Strategy", New York
- February 24, 2011 "Health Reform, Public Policy and Corporate Strategy", Washington
- March 29, 2011 "Health Care & Risk Management: Design, Implementation and Market Impact", Boston
- April 5, 2011 "Pharmacy Benefit Design, Biosimilars, and Supply Chain Issues", New York
- April 18, 2011 "Provider Business Models: New Opportunities, New Risks", San Francisco
- May 4, 2011 "Risk Management, Public Policy and Industry Realignment", Washington
- May 31, 2011 "Provider Business Models", New York
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Are you an independent consultant or sole proprietor? Do you operate your own franchise within a larger organization?
What if you could interact more closely with prospective clients and win valuable industry advocates at the same time?
Lyceum's highly regarded roundtables connect diverse stakeholders on topics of industry transition and business innovation. Our members share a common goal of making the best possible business decisions.
Lyceum Associates is pleased to offer unaffiliated individuals the opportunity to join corporate participants as members in our exclusive service.
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Disciplined Approach
Step 1 - Planning
We create in partnership with the client an effective roundtable series design that matches content to strategic objectives and emphasizes insight and urgency.
Step 2 - Execution
We advance the roundtable agenda, recruit high-value participants, and rapidly achieve goals.
Step 3 - Reporting
We present key takeaways and essential information in summary reports, and promote follow-up communication among participants.
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Essential Discussions
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Business Innovation
- Payer/Provider Business Models
- Benefit Design/Employer Strategies
- Information Technology
- Risk Management
Industry Transition
- Health Policy & Reform
- FDA
- Consumer Engagement
Case Studies
- ACOs/Integrated Care Delivery
- Insurance Exchanges
- Biosimilars (Follow On Biologics)
- Drug Distribution/ Alternative Pharmacy Networks
- Oncology Business Practices
- Physician Leadership
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High Return Events
“Market Knowledge”
A large pharmaceutical company weighs investment in different medication adherence programs, but questions how provider consolidation may or may not affect that investment. The Lyceum team designs a series of roundtables addressing adherence issues concerning the company’s specific medication(s). The roundtable series encompasses payers, different vendors, relevant patient groups, and a cross-section of providers. At the series’ conclusion, the Lyceum team delivers its assessment of the landscape and proposes a best course of action.
“Corporate Action"
At the behest of its bankers and its own internal strategists, a health plan considers extending its corporate portfolio into the ownership of physician practices. Although financial models appear sensible, company management worries about hard-to-quantify cultural issues and marketplace uncertainty, from the response of patients to the emergence of alternative provider business models. Based on an interactive roundtable series including diverse provider organizations, employers and other market participants, the Lyceum team submits an independent analysis, allowing management to decide more confidently.
“New Product Development”
Anticipating increased demand for risk management tools addressing global payments, a health information services company plans to develop various proprietary solutions, but discovers that demand may not adequately materialize because of client uncertainty about how the marketplace is evolving. The Lyceum team coordinates a series of roundtables featuring the company, prospective users of its tools, and relevant market participants to provide immediate feedback on the marketplace and inspire greater confidence in the company’s offerings.
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Lyceum members occupy one seat at any event. Lyceum sponsors occupy multiple seats at one or more roundtable series. Members and sponsors qualify as GatherSmart® Executive participants. We expect other participants to pay a participation fee, and to become members or sponsors for continued involvement.
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Lyceum collaborates extensively with its participants on topic and event development.
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Lyceum pursues direct person-to-person contact, optimizing business development.
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Search hundreds of Lyceum roundtable and event participants. GatherSmart® Executive participants enjoy full access.
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The Lyceum Newsletter Perspectives dates back to June 2005, and encompasses more than three dozen discussion topics and over one thousand published pages.
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My GatherSmart is your starting point for dynamic group interaction. Connect to users across our community, search participants at past and future events, and more.
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ChatterSmart is a short-format news forum. Adding your thoughts is as easy as 1-2-3.
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View profile information on users across our entire community. GatherSmart® Executive participants enjoy full access.
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Read Sydney's Weblog Talking Transitions for related commentary and opinion.
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Lyceum Associates welcomes a variety of organizations as members in our service. Members represent diverse stakeholders, including for-profit and non-profit corporations, government agencies, academic institutions, consultancies, and financial service institutions.
User fees support our unique equal-participation, invitation-only format. These fees apply to individual business entities and cover multiple participants.
For enhanced client outreach and business development, we encourage series sponsorships.
Unaffiliated individuals may join Lyceum as contributors, and participate in roundtables and events.
View a checklist of our services.
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Gainful business development and investment require an ability to price future economic shifts within and across industries. Read "Talking Transitions" and learn more.
View the "Talking Transitions" Blog here.
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ACCESS TO THE LYCEUM NEWSLETTER "PERSPECTIVES" AND THE "PERSPECTIVES" ARCHIVES IS LIMITED ONLY TO AUTHORIZED SUBSCRIBERS WHO HAVE READ AND AGREED TO THE LYCEUM USER AGREEMENT, WHICH SOLELY GOVERNS THE CONDITIONS FOR USE OF ANY OF THESE SERVICES AND THE INFORMATION CONTAINED THEREIN. All contents Copyright © 2005-2012 Lyceum Associates, Inc. ALL RIGHTS RESERVED. These Services and the Content contained therein are protected under U.S. and foreign copyright and intellectual property laws, and may not be photocopied, reproduced or retransmitted in any form without the written consent of Lyceum Associates, which may be requested from info@lyceumassociates.com. The content and opinions expressed in "Perspectives" may change and do not constitute investment advice. Lyceum Associates is not responsible for the accuracy of information provided on third-party Web sites. GatherSmart@ is a registered trademark of Lyceum Associates, Inc.
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