Press Release: CY 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS 1809-FC)

View in browser | Distributed by Center for Medicaid and CHIP Services (CMCS)   CY 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS 1809-FC) On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) issued Medicare payment rates for hospital outpatient and Ambulatory Surgical Center (ASC) services for calendar year (CY 2025). The Hospital Outpatient Prospective Payment System (OPPS) and ASC Payment System final rule is published annually. In addition to finalizing payment rates, this year's rule includes policies that align with several key goals of the Biden-Harris Administration, including responding to the maternal health crisis, addressing health disparities, expanding access to behavioral health care, improving transparency in the health system, and promoting safe, effective, and patient-centered care. The final rule advances the agency's commitment to strengthening Medicare and uses the lessons learned from the COVID-19 public health emergency (PHE) to inform the approach to quality measurement, focusing on changes that would help address health inequities.  These payment policies affect approximately 3,500 hospitals and approximately 6,100 ASCs. CMS is publishing this final rule to meet the legal requirements to update Medicare payment policies for OPPS hospitals and ASCs annually. This fact sheet discusses the major provisions of the final rule (CMS-1809-FC), which can be downloaded at: https://www.federalregister.gov/public-inspection/2024-25521/medicare-and-medicaid-programs-hospital-outpatient-prospective-payment-and-ambulatory-surgical Updates to OPPS and ASC payment rates In accordance with Medicare law, CMS is finalizing an update to OPPS payment rates of 2.9% for hospitals that meet applicable quality reporting requirements. This update is based on the projected hospital market basket percentage increase of 3.4% reduced by a 0.5 percentage point productivity adjustment. In the CY 2019 OPPS/ASC final rule with comment period, CMS finalized a proposal to apply the hospital market basket update to ASC payment system rates for an interim period of five years (CY 2019 through CY 2023). The CY 2024 OPPS/ASC final rule with comment period extended the interim period for an additional two years (through CY 2024 and CY 2025). Accordingly, using the hospital market basket update, CMS is finalizing an update factor to the ASC payment rates for CY 2025 of 2.9%. The update applies to ASCs meeting relevant quality reporting requirements. This update is based on the projected hospital market basket percentage increase of 3.4% reduced by a 0.5 percentage point productivity adjustment. Intensive Outpatient Program Intensive Outpatient Program (IOP) Rate Setting The CY 2025 OPPS/ASC final rule updates Medicare payment rates for intensive outpatient program (IOP) services furnished in hospital outpatient departments and Community Mental Health Centers (CMHCs). The IOP is a distinct and organized outpatient program of psychiatric services provided for individuals who have an acute mental illness or substance use disorder, consisting of a specified group of behavioral health services paid on a per diem basis for a minimum of nine hours of IOP services per week under the OPPS, or another applicable payment system when furnished in Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs). IOP services may also be furnished in Opioid Treatment Programs (OTPs) for the treatment of opioid use disorder (OUD). Update to IOP Payment Rates in Hospital Outpatient Departments and CMHCs CMS is maintaining the existing rate structure, with two IOP APCs for each provider type: one for days with three services per day and one for days with four or more services per day. For this CY 2025 rate setting, CMS is using the CY 2023 claims data and the latest available cost information from cost reports beginning three fiscal years prior to the year that is the subject of the rulemaking. For CY 2025, CMS is maintaining the calculation of both hospital outpatient department and CMHC IOP payment rates for three services per day and four or more services per day based on cost per day using OPPS data that includes Partial Hospitalization Program (PHP) and non-PHP days. CMS believes continuing to use the OPPS data set will allow CMS to capture data from hospital claims that are not identified as PHP, but that include the service codes and intensity required for a PHP day. Partial Hospitalization Program Partial Hospitalization Program Rate Setting The CY 2025 OPPS/ASC final rule updates Medicare payment rates for partial hospitalization program services furnished in hospital outpatient departments and CMHCs. The PHP is an intensive, structured outpatient program provided as an alternative to psychiatric hospitalization, consisting of a specified group of mental health services paid on a per diem basis for a minimum of 20 hours of PHP services per week under the OPPS, based on PHP per diem costs. Update to PHP Per Diem Rates CMS is maintaining the existing rate structure, with two PHP APCs for each provider type: one for days with three services per day and one for days with four or more services per day. Consistent with the OPPS, for this CY 2025 rate setting, CMS is using the CY 2023 claims data and the latest available cost information from cost reports beginning three fiscal years prior to the year that is the subject of the rulemaking. For CY 2025, CMS is maintaining the calculation of both hospital outpatient and CMHC PHP payment rates for three services per day and four or more services per day based on cost per day using OPPS data that includes PHP and non-PHP days. CMS believes continuing to use the OPPS data set will allow CMS to capture data from hospital claims that are not identified as PHP but that include the service codes and intensity required for a PHP day. Access to Non-Opioid Treatments for Pain Relief CMS is finalizing the implementation of Section 4135 of the Consolidated Appropriations Act (CAA), 2023, which provides temporary additional payments for certain non-opioid treatments for pain relief in the hospital outpatient department (HOPD) and ASC settings from January 1, 2025, through December 31, 2027. This policy is implementing several statutory provisions, including evidence requirements for medical devices and the requirements for the FDA-approved indications. To implement the statutory payment limitation, under which the additional payment must not exceed the estimated average of 18% of the OPPS payment for OPPS service, or group of services, with which the non-opioid treatment for pain relief is furnished, CMS is finalizing our proposal to utilize the top five OPPS procedures by volume, for each non-opioid drug or device, to calculate the payment limitation.  CMS is finalizing the policy to include drugs and devices that qualify as non-opioid treatments for pain relief, and these products will be paid separately in both the HOPD and ASC settings starting in CY 2025. The qualifying drugs have FDA-approved indications to reduce post-operative pain or produce postsurgical analgesia, and the qualifying medical devices have demonstrated through evidence that they reduce opioid usage when used in the post-operative setting. Paying separately to encourage the uptake of these non-opioid products is part of the Biden-Harris Administration's commitment to reducing opioid use disorder and overdose.  All-Inclusive Rate (AIR) Add-On Payment for High-Cost Drugs Provided by Indian Health Service (IHS) and Tribal Hospitals Under current regulations, IHS and tribal hospitals are excluded from payment under the OPPS. Instead, IHS and tribal outpatient departments are paid the Medicare outpatient hospital AIR for each encounter that provides hospital outpatient services. On an annual basis, IHS calculates and publishes, in the Federal Register, calendar year payment rates. These rates are often referred to as the AIR, which is updated annually based on a review of yearly cost reports. For CY 2024, the outpatient AIR is $667 in the lower 48 states.  IHS and tribal hospitals have continued to expand the breadth of services that they provide to their communities, which has increased access to care. Increasingly, this has meant providing higher-cost drugs along with more complex and expensive services, such as cancer-related services. To improve the payments to IHS and tribal hospitals, and better account for the costs of high-cost drugs furnished to people with Medicare seeking care at these facilities, we are finalizing our proposal to pay an add-on to the AIR for all drugs, whose per day cost exceeds two times the Medicare Outpatient per Visit Rate for the lower 48 states' AIR ($1,334 in CY 2024), furnished to people with Medicare who receive care from IHS or tribal hospital outpatient departments. We believe this will increase access to high-cost drugs like certain chemotherapies in IHS and tribal hospital settings, and will help improve disparities in access to cancer-related care consistent with the goals of the Cancer Moonshot.  Request for Information: Paying all IHS and Tribally Operated Clinics the IHS Medicare Outpatient AIR In response to the CMS Tribal Technical Advisory Group (TTAG) request that CMS amend its Medicare regulations to make all IHS and tribal hospitals eligible for payment at the IHS Medicare outpatient AIR, we requested information on the types of clinics and costs of services in these settings. This was a follow-up to a similar request for information in the CY 2022 PFS proposed rule. CMS will continue to evaluate the comments for potential future rulemaking and collaborate with the TTAG on improving health outcomes for tribal populations.  Improving Payment for High-Cost Diagnostic Radiopharmaceuticals Under the OPPS, the payment for diagnostic radiopharmaceuticals is packaged into the payment for the nuclear medicine tests they are used with. While this payment approach generally works appropriately to support efficient care, we recognize that, in some specific circumstances, the payment amount for the nuclear medicine tests may not adequately account for the cost of certain high-cost diagnostic radiopharmaceuticals, even when those agents may be the most clinically appropriate. Consequently, we are finalizing refinements to the existing packaging policy to improve the accuracy of the overall payment amounts by paying separately for any diagnostic radiopharmaceutical with a per day cost greater than $630 and removing their costs from the payment amounts for the nuclear medicine APCs. All qualifying products will be paid separately at their mean unit cost (MUC), which is a payment rate derived from hospital claims data. Any diagnostic radiopharmaceutical with a per-day cost equal to or below that threshold will continue to be policy packaged, with payment for the nuclear medicine tests. This update should address challenges for patients in accessing these prescribed nuclear medicine tests with higher-cost radiopharmaceuticals.  Add-on Payment for Domestically Produced Technetium-99m (Tc-99m) Radioisotopes are widely used in modern medical imaging. Technetium-99m (Tc‑99m), the radioisotope used in most diagnostic imaging services, is historically derived from legacy reactors outside of the United States using highly enriched uranium (HEU). Beginning in CY 2013, we finalized a policy to provide an additional payment of $10 for the marginal cost of Tc-99m produced by non-HEU sources. CY 2025 is the final year of the add-on payment for Tc-99m when the Tc-99m is produced without the use of HEU, as the Secretaries of the U.S. Departments of Energy and of Health and Human Services have issued a certification that there is sufficient global supply of Tc-99m  without the use of HEU available to meet the needs of patients in the United States. However, the Department of Energy and other interested parties have identified another issue affecting the domestic supply chain for molybdenum-99 (Mo-99), the source material for Tc-99m, that could cause payment inequity among outpatient hospital providers. Foreign Mo-99 production has historically been subsidized by foreign governments, resulting in prices below the true cost of production. These artificially low, foreign government-subsidized prices have created a disincentive for domestic investments in Mo-99 production infrastructure and a barrier to entry for new producers. We are finalizing our proposal to address the payment inequity in this rule by establishing a new add-on payment, of $10 per dose, for radiopharmaceuticals that use Tc-99m derived from domestically produced Mo-99, starting on January 1, 2026. We believe the $10 add-on payment for domestically produced Tc-99m would ensure equitable payments, by paying providers who use domestically produced Tc-99m radiopharmaceuticals, when available, an amount that reflects the anticipated higher cost of these products. The $10 add-on payment will help to ensure access to domestically produced Tc-99m radiopharmaceuticals by addressing the additional cost of domestically produced Tc-99m radiopharmaceuticals.  Request for Information on Payment Adjustments for Additional Costs of Domestic Personal Protection Equipment (PPE)  Hospitals need to be able to access a reliable supply of PPE that are delivered on a timely basis in order to protect health care workers and their patients, and sustaining domestic production of these products is important for helping to maintain that assurance. Currently, CMS recognizes that hospitals may incur additional costs when purchasing domestically made NIOSH-approved surgical N95 respirators and makes additional hospital payments that would account for those costs. In the proposed rule, CMS sought information on potentially improving and expanding this policy. CMS greatly appreciates the many thoughtful and informative comments we received in response and intends to propose to expand the payment adjustments in 2026 rulemaking. Payment Policy for Devices in Category B Investigational Device Exemption Clinical Trials and Drugs, and Devices with a Medicare Coverage with Evidence Development (CED) Designation  In the CY 2023 OPPS final rule with comment period, we finalized a policy to make a single blended payment for devices and services in Category B Investigational Device Exemption (IDE) studies, in order to preserve the scientific validity of these studies by avoiding differences in Medicare payment methods that would otherwise reveal the group (treatment or control) to which a patient had been assigned. We proposed to extend our coding and payment policy to drugs and devices being studied in clinical trials under a Coverage with Evidence Development (CED) National Coverage Determination (NCD)[1], for which the trial includes a treatment and control arm. Based on commenter feedback, we are not finalizing our proposal at this time. We believe that there are broader policy implications that require further consideration prior to finalizing a policy; therefore, we are not finalizing our proposal. Individuals Formerly in the Custody of Penal Authorities  To support individuals returning to the community from incarceration and individuals who have been sentenced to probation or home detention without jail time, CMS is finalizing our proposal to narrow the definition of "custody" in Medicare's payment exclusion rule and to revise the Medicare special enrollment period (SEP) for formerly incarcerated individuals. These modifications remove real or perceived barriers to Medicare access by individuals who have recently been released from incarceration or are on parole, probation, or home detention. Medicare is prohibited by statute from paying for an item or service if the individual receiving the item or service has no legal obligation to pay for it. Under Medicare regulations, an individual who is in the custody of penal authorities (e.g., in prison or jail) is presumed to have no legal obligation to pay for his or her health care; therefore, Medicare is presumed to be prohibited from paying for health care items or services furnished to such individuals. Currently, the definition of "custody" is very broad, including not only individuals who are physically detained in prison or jail but also potentially individuals who are not physically confined in jail or prison, such as individuals on bail, parole, probation, or home detention and individuals residing in halfway houses. Thus, applying the current definition of "custody," there is a presumption that Medicare will not pay for health care items or services furnished to individuals who are on bail, parole, probation, or home detention, or who are required to reside in halfway houses. CMS is finalizing our proposal to narrow the definition of "custody" to no longer include individuals who are on bail, parole, probation, and home detention. In the final rule, CMS is also narrowing the definition of "custody" to no longer include individuals who are required to reside in halfway houses. The finalized definition of "custody" removes the presumption that Medicare is prohibited from paying for health care items or services furnished to individuals on bail, parole, probation, or home detention and individuals who are required to reside in halfway houses, thus facilitating access to Medicare payment. To facilitate access to Medicare coverage, CMS is finalizing our proposal to revise the eligibility criteria for the special enrollment period for formerly incarcerated individuals to include individuals who have been released from incarceration or on bail, parole, probation, or home detention and align more closely with the Social Security Administration's criteria for determining incarceration status. In addition, the eligibility criteria will be expanded to include individuals released from incarceration to residency in halfway houses. Obstetrical Services' Conditions of Participation  The United States is currently facing a maternal health crisis, which has not only led to a maternal mortality rate that is among the highest in high-income countries, but also disproportionately affects people of color. To address this crisis, CMS is finalizing new national health and safety standards, known as conditions of participation (CoPs), for hospitals and Critical Access Hospitals (CAHs) that offer obstetrical (OB) services as part of CMS' multi-pronged approach to improve maternal health outcomes. These CoPs include new requirements for maternal quality assessment and performance improvement (QAPI), baseline standards for the organization, staffing, and delivery of OB care, and staff training on evidence-based maternal health practices. These final requirements ensure that all Medicare and Medicaid participating hospitals and CAHs offering these services are held to a consistent standard of high-quality maternity care that protects the health and safety of pregnant, birthing, and postpartum patients. CMS is also finalizing revisions to the CoP related to emergency readiness for hospitals and CAHs that provide emergency services. Lastly, CMS is finalizing revisions to the Discharge Planning CoP for all hospitals related to transfer protocols. Given commenter feedback, CMS is finalizing a phased-in implementation for these new requirements in an effort to balance the need for improved maternal health outcomes, while addressing potential burden concerns raised and providing additional clarity on the standards, including flexibilities offered.  Provisions for OB Services' CoP Organization and Staffing CMS is finalizing a requirement that OB services be well organized and provided in accordance with nationally recognized acceptable standards of practice for the health care (including physical and behavioral health) of pregnant, birthing, and postpartum patients. We are also finalizing that the organization of the OB services be appropriate to the scope of services offered by the facility and be integrated with other departments in the facility. Additionally, we are finalizing a requirement that OB patient care units be supervised by an individual with the necessary education and training, such as an experienced registered nurse (RN), certified midwife, nurse practitioner, physician assistant, or Doctor of Medicine or osteopathy. Lastly, we are finalizing a requirement that OB privileges be granted subject to written criteria for all practitioners providing OB care in accordance with the current requirements for hospitals and CAHs. Delivery of service  CMS will require that that basic equipment for treating OB cases (including a call-in-system, cardiac monitor, and fetal doppler/monitor) be kept at the facility and be readily available for treating OB cases in order to meet the needs of patients in accordance with the scope, volume, and complexity of services offered by the facility. While CMS is finalizing the requirement that this basic set of equipment should be in place in hospitals and CAHs providing OB services to ensure efficient, effective delivery of care as well as a timely response to emergency situations, we recognize that low-volume facilities may not need the same level of equipment as high-volume facilities. Therefore, we are finalizing this requirement with revisions to clarify that hospitals and CAHs must have this obstetrical equipment readily available at a minimum within the facility. We note that hospitals and CAHs may maintain these and other obstetrical emergency supplies in "crash carts," "obstetrical emergency carts/bags/boxes/kits,"[2] "OB hemorrhage carts,"[3] or other readily accessible method for use when and where needed. We expect facilities to stock equipment in a manner that aligns with the facility's scope, volume, and complexity of OB services offered (that is, per facility, per unit, or per room in order to meet the needs of patients). Lastly, CMS is finalizing a requirement that the facility ensure that it has adequate, readily available provisions and protocols consistent with nationally recognized and evidence-based guidelines for OB emergencies, complications, immediate post-delivery care, and other patient health and safety events. Although we are not requiring specific items, examples of provisions would include equipment, supplies, and blood used in treating emergency cases. Staff Training CMS is finalizing a requirement that hospitals and CAHs develop policies and procedures to ensure that relevant staff are trained on certain topics aimed at improving the delivery of maternal care. CMS requires that these training topics reflect the scope and complexity of services offered, including, but not limited to, facility-identified, evidence-based, best practices and protocols to improve the delivery of maternal care within the facility. Additionally, CMS is finalizing a requirement that hospitals and CAHs use findings from their QAPI programs to inform staff training needs and any additions, revisions, or updates to training topics on an ongoing basis. While we proposed that each hospital and CAH must identify and document which staff must complete training on an annual basis, we are modifying our finalized policy based on public comment to require that: 1) relevant new staff receive initial training and 2) that the hospital and CAH identify which staff must complete training every two years instead of annually. Hospitals and CAHs must also document in staff personnel records that training was successfully completed and be able to demonstrate staff knowledge on the training topics identified. Quality Assessment and Performance Improvement (QAPI) Program CMS is finalizing requirements that hospitals or CAHs providing OB services must use their QAPI programs to assess and improve health outcomes and disparities among OB patients on an ongoing basis. This marks the first time that facilities must use their QAPI programs to address health disparities. Specifically, at a minimum, the facility will have to:  Analyze data and quality indicators collected for the QAPI program by diverse subpopulations as identified by the facility among OB patients.  Measure, analyze, and track data, measures, and quality indicators on patient outcomes and disparities in processes of care, services and operations, and outcomes among obstetrical patients. Analyze and prioritize patient health outcomes and disparities, develop and implement actions to improve patient health outcomes and disparities, measure results, and track performance to ensure improvements are sustained when disparities exist among obstetrical patients. Conduct at least one performance improvement project focused on improving health outcomes and disparities among the hospital's population(s) of obstetrical patients annually. We will also require that obstetrical services' leadership engage in OB QAPI activities. Lastly, CMS is finalizing a requirement that if a Maternal Mortality Review Committee (MMRC) is available at the state, Tribal, or local jurisdiction in which the facility is located, hospitals and CAHs that offer OB services must have a process for incorporating publicly available information and data from the MMRC into the hospital or CAH QAPI program. Emergency Services' Readiness CMS is finalizing a revised Emergency Services' CoP to improve facility readiness in caring for emergency services' patients, including pregnant, birthing, and postpartum women. These new requirements apply to all hospitals and CAHs offering emergency services, regardless of whether they provide specialty services, such as OB services. CMS will require that hospitals and CAHs with emergency services have adequate provisions and protocols to meet the emergency needs of patients. Specifically, hospitals and CAHs must have protocols consistent with nationally recognized and evidence-based guidelines for the care of patients with emergency conditions. Additionally, we are requiring that applicable staff be trained on these protocols and provisions annually, and documentation would be expected to show that staff have successfully completed such training and can demonstrate knowledge on these topics.  Lastly, CMS is finalizing, for hospitals only, a requirement that such facilities set aside provisions for emergencies. Such provisions include equipment, supplies, and medication used in treating emergency cases. Although we are not requiring specific items, the available provisions must include: Drugs, blood and blood products, and biologicals commonly used in lifesaving procedures. Equipment and supplies commonly used in lifesaving procedures. Call-in system for each patient in each emergency services' treatment area. Of note, the emergency supply requirements would not be necessary for CAHs and Rural Emergency Hospitals (REHs), as CAHs and REHs already have emergency supply requirements included in their CoPs. Transfer Protocols CMS is finalizing the requirement for a hospital to have written policies and procedures for transferring patients under its care, which will include intra-hospital transfers of hospital inpatients (for example, transfers from the emergency room to inpatient admissions, transfers between inpatient units in the same hospital, and transfers between inpatient units at different hospitals), to the appropriate level of care as needed to meet the patient's needs. Lastly, we are finalizing the proposed requirement that hospitals must provide training to the relevant staff regarding the hospital policies and procedures for transferring patients under its care, with the modification that the training must be done annually. This modification ensures that hospital staff are following the same procedures regarding patient transfers, that staff are informed about any changes in transfer protocols, and that staff conduct transfers safely and by minimizing errors. Implementation Phase-In CMS received many comments requesting sufficient time for hospitals and CAHs to meet these new requirements. CMS is, therefore, implementing these provisions in three phases over two years:  Phase 1 requires facilities to comply with the following requirements six months following the effective date of the final rule:  Emergency services' readiness for hospitals and CAHs. Transfer protocols for hospitals only. Phase 2 requires facilities to comply with the following requirements one year following the effective date of the final rule: Organization, staffing, and delivery of services for hospitals and CAHs.  Phase 3 requires facilities to comply with the following requirements two years following the effective date of the final rule: OB staff training in hospitals and CAHs.  QAPI program for OB services in hospitals and CAHs.  We believe this approach will balance the need to address the maternal health crisis and improve patient outcomes, while also addressing concerns about the burden and unintended consequences raised by commenters. Hospital Inpatient Quality Reporting (IQR) Program  The Hospital IQR Program is a pay-for-reporting quality program that reduces payments to hospitals that do not meet program requirements. Hospitals that do not submit quality data or do not meet all Hospital IQR Program requirements are subject to a one-fourth reduction in their Annual Payment Update under the Inpatient Prospective Payment System.  In the CY 2025 OPPS/ASC final rule, CMS is finalizing its proposal to continue voluntary reporting of the core clinical data elements (CCDEs) and linking variables for both the Hybrid Hospital-Wide Readmission and Hybrid Hospital-Wide Standardized Mortality measures, for the performance period of July 1, 2023, through June 30, 2024, impacting the FY 2026 payment determination for the Hospital IQR Program. After consideration of public comment and further analysis, CMS is also extending the voluntary reporting of the CCDEs and linking variables for the July 1, 2024, through June 30, 2025, performance period, which is associated with the FY 2027 payment determination. Hospital Outpatient Quality Reporting (OQR) Program The Hospital OQR Program is a pay-for-reporting quality program for hospital outpatient departments that requires hospitals to meet quality reporting requirements or receive a reduction of 2 percentage points to their Annual Payment Update under the OPPS if these requirements are not met. In the CY 2025 OPPS/ASC final rule, CMS is finalizing its proposals to adopt: (1) the Hospital Commitment to Health Equity measure beginning with the CY 2025 reporting period/CY 2027 payment determination; (2) the Screening for Social Drivers of Health measure beginning with voluntary reporting in the CY 2025 reporting period, followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination; (3) the Screen Positive Rate for Social Drivers of Health measure beginning with voluntary reporting in the CY 2025 reporting period, followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination; and (4) the Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance measure beginning with voluntary reporting in the CY 2026 reporting period, followed by mandatory reporting beginning with the CY 2027 reporting period/CY 2029 payment determination. In addition, CMS is finalizing its proposals to remove: (1) the MRI Lumbar Spine for Low Back Pain measure beginning with the CY 2025 reporting period/CY 2027 payment determination and (2) the Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac, Low-Risk Surgery measure beginning with the CY 2025 reporting period/CY 2027 payment determination.  CMS is also finalizing proposals to: (1) modify the immediate measure removal policy to an immediate measure suspension policy for adopted Hospital OQR Program measures; (2) require that electronic health record (EHR) technology be certified to all electronic clinical quality measures available to report in the Hospital OQR Program; and (3) publicly report the Median Time from Emergency Department (ED) Arrival to ED Departure for Discharged ED Patients measure-Psychiatric/Mental Health Patients strata on the Compare tool hosted by HHS, available at: https://www.medicare.gov/care-compare/. Rural Emergency Hospital Quality Reporting (REHQR) Program Section 125 of Division CC of the CAA, 2021 added section 1861(kkk) to the Social Security Act (the Act), which established a new Medicare provider type, Rural Emergency Hospitals (REHs). An REH is a facility that, in relevant part as of December 27, 2020, was a Critical Access Hospital (CAH) or a subsection (d) hospital with not more than 50 beds located in a county (or equivalent unit of local government) that is in a rural area (defined at section 1886(d)(2)(D) of the Act), or was a subsection (d) hospital with not more than 50 beds that was treated as being in a rural area (pursuant to section 1886(d)(8)(E) of the Act). An REH must submit quality measure data to the Secretary, and the Secretary shall establish procedures to make the data available to the public on a CMS website. In the CY 2025 OPPS/ASC final rule, CMS is finalizing its proposals to adopt: (1) the Hospital Commitment to Health Equity measure beginning with the CY 2025 reporting period/CY 2027 program determination; (2) the Screening for Social Drivers of Health measure beginning with voluntary reporting in the CY 2025 reporting period, followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 program determination; and (3) the Screen Positive Rate for Social Drivers of Health measure beginning with voluntary reporting in the CY 2025 reporting period, followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 program determination.  CMS is also finalizing its proposals to: (1) extend the reporting period for the Risk-Standardized Hospital Visits Within 7 Days After Hospital Outpatient Surgery measure from one year to two years beginning with the CY 2025 reporting period; and (2) establish when, after conversion to REH status, REHs would be required to report data under the REHQR Program, such that an REH would begin submitting data to the REHQR Program on the first day of the quarter following the date that a hospital has been designated as converted to an REH. Ambulatory Surgical Center Quality Reporting (ASCQR) Program The ASCQR Program is a pay-for-reporting quality program for ASCs that requires facilities to meet quality reporting requirements or receive a reduction of 2 percentage points to their Annual Payment Update under the ASC fee schedule if these requirements are not met. In the CY 2025 OPPS/ASC final rule, CMS is finalizing its proposals to adopt: (1) the Facility Commitment to Health Equity measure beginning with the CY 2025 reporting period/CY 2027 program determination; (2) the Screening for Social Drivers of Health measure beginning with voluntary reporting in the CY 2025 reporting period, followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination; and (3) the Screen Positive Rate for Social Drivers of Health measure beginning with voluntary reporting in the CY 2025 reporting period, followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination.  CMS is also finalizing its proposal to modify the immediate measure removal policy to an immediate measure suspension policy for adopted ASCQR Program measures. Additionally, CMS summarizes the comments it received in response to its Request for Information on the Development of Frameworks for Specialty Focused Reporting and Minimum Case Number for Required Reporting to achieve the following outcomes: (1) the addition of case minimums for measure reporting for specialty measures, defined as measures related to clinical procedures performed only by a subset of ASCs; (2) the removal of the zero case attestation requirement for specialty measures to decrease reporting burden; and (3) the verification of case counts using claims data to determine which specialty measures would be required for reporting for individual ASCs.  Overall Hospital Quality Star Rating Request for Information  The Overall Hospital Quality Star Rating provides a summary of certain existing hospital quality information on Medicare.gov based on publicly available quality measure results reported through CMS' hospital quality measurement programs, by assigning hospitals between one and five stars, in a way that is simple and easy for patients to understand. Measures reported on the provider comparison tool on Medicare.gov (https://www.medicare.gov/care-compare/) that meet the criteria for inclusion in the Overall Hospital Quality Star Rating are organized into five conceptually coherent measure groups: Safety of Care, Mortality, Readmission, and Patient Experience (all of which include outcome measures), and Timely and Effective Care (which includes a selection of process measures). As part of the national commitment to improving patient safety, we sought feedback on whether hospitals that performed in the bottom quartile (lowest-performing 25%) in the Safety of Care measure group should be eligible to receive the highest 5-star rating. We are considering modifying the Overall Hospital Quality Star Rating methodology, specifically the Safety of Care measure group, to reinforce our dedication to emphasize patient safety across CMS.  We sought comments on potential modifications to the Safety of Care measure group in the Overall Hospital Quality Star Rating methodology. We requested input from interested parties on the following options: (1) reweighting the Safety of Care measure group; (2) applying a policy-based adjustment that reduces the Star Rating of any hospital in the lowest quartile of Safety of Care (based on at least three measures in the group) by one star; and (3) reweighting the Safety of Care measure group combined with a policy-based 4-star rating maximum on the Star Rating of any hospital in the lowest quartile of Safety of Care. In this final rule, we summarize the comments CMS received.  Medicaid and CHIP Continuous Eligibility Section 5112 of Title V, subtitle B of the Consolidated Appropriations Act, 2023 (CAA, 2023) amended section 1902(e)(12) of the Act and added a new paragraph (K) to section 2107(e)(1) of the Act to make the previously optional, continuous eligibility policy a requirement under the state plan or a waiver of the state plan for children enrolled in Medicaid and CHIP, effective January 1, 2024. In this final rule, CMS has amended the Medicaid and CHIP regulations to codify the requirements of the CAA, 2023. Specifically, CMS is finalizing the requirement to provide 12 months of continuous eligibility for children under the age of 19 enrolled in Medicaid and CHIP. CMS is also finalizing a policy removing the previous options of applying continuous eligibility to a subgroup of enrollees or limiting continuous eligibility periods to less than 12 months. CMS is also removing failure to pay premiums as an optional exception to continuous eligibility in CHIP. Medicaid Clinic Services' Four Walls Exceptions CMS amended the Medicaid clinic services' regulation to authorize Medicaid coverage for clinic services furnished by IHS/Tribal clinics outside the "four walls" of their facility. In addition, states implementing the Medicaid clinic services' benefit can opt to cover clinic services furnished outside the "four walls" of behavioral health clinics or clinics located in rural areas. For clinics located in rural areas, based on comments received, CMS is finalizing an approach to defining "rural area" where states will select either a definition used by a federal agency for programmatic purposes, or a definition adopted by a state agency with a role in setting state rural health policy. ###   Stay connected with Medicaid.gov and CMS: Modify/Update Subscriber Preferences  |  Unsubscribe  |  Contact Us   Questions or problems? Please contact subscriberhelp.govdelivery.com. This e-mail was sent to edwardlorilla1986.paxforex@blogger.com using GovDelivery Communications Cloud on behalf of the Centers for Medicare & Medicaid Services (410-786-5473) · 7500 Security Boulevard · Baltimore MD 21244

The Unsinkable, Overextended Ship

Nobody keeps buying and buying forever... How to choose your capital allocation... The unsinkable, overextended ship... Historical patterns in margin... U.S. households are back in debt... The market's coiled spring... Get your finances in order...

Delivering World-Class Financial Research Since 1999 Nobody keeps buying and buying forever... How to choose your capital allocation... The unsinkable, overextended ship... Historical patterns in margin... U.S. households are back in debt... The market's coiled spring... Get your finances in order... I'll sing this song until the inevitable reckoning comes... Lower your expectations for stock market returns, especially if you're contributing to a 401(k) or other account that's investing in the S&P 500 Index, Nasdaq Composite Index, or something close to either one. The market is very expensive compared to history. I've shown you that in a number of ways. And here's the latest... Analyst Charlie Bilello posted Wednesday on the social platform X, where he pointed out that the S&P 500 is now trading at 25.8 times peak earnings. That's the highest valuation since 2000 – the year the dot-com bubble peaked. I've been telling you stocks were anywhere between expensive and egregiously overvalued for most of the past few years. During that time, we had an epic Melt Up that ended with a 25% bear market in the S&P 500 and a 36% drawdown in the Nasdaq. The bear market was then followed by... another epic Melt Up. Since the market bottomed about two years ago, the S&P 500 is up 60%. And the Nasdaq is up 77% off its December 2022 trough. Is this what we can expect from the stock market from now on...? Epic rallies into hyper-expensive valuations, followed by bear markets during which stocks never become attractively valued? To be fair, the S&P 500 is up more than 270% since the dot-com peak and more than 630% from its dot-com bottom. You could have kept buying and buying endlessly and you'd have made plenty of money. Problem is... nobody keeps buying and buying forever... They buy more and more as the market goes higher and higher. Their conviction is highest right when the risk is greatest. And they buy nothing when the market bottoms out. A lot of what I publish in the Digest, Extreme Value, and The Ferris Report is geared toward avoiding those tragic outcomes. I seriously doubt anybody can time the stock market consistently, especially at the top... but I also doubt you'll make serious money if you remain oblivious to the fact that this is the riskiest moment of your investing career, as I said last week. As for what to do about it... in his latest memo, investor/author Howard Marks of Oaktree Capital Management laid out the fundamental decision for deciding how to allocate your money... In my opinion, one decision matters more than – and should set the basis for – all the other decisions in the portfolio management process. It's the selection of a targeted "risk posture," or the desired balance between aggressiveness and defensiveness. The essential decision in investing is how much emphasis one should put on preserving capital and how much on growing it. These two things are mostly mutually exclusive: Insistence on preserving capital – or, secondarily, on limiting the portfolio's volatility – calls for an emphasis on defense, which precludes pursuing maximum growth. Correspondingly, a decision to strive to maximize growth requires an emphasis on offense, meaning preservation of capital and steadiness must be sacrificed to some degree. The first question you should ask when allocating every dollar you invest is whether your goal is capital preservation or capital appreciation. Once you decide what mix of those two you want, Marks divides the two priorities between the two asset classes he considers most important... Marks says ownership assets (like stocks) are best for offense and debt assets (like bonds) are best for defense... You must then decide for yourself what mix of the two priorities (and their corresponding assets) you want by consciously targeting "the absolute level of risk," as Marks puts it. Say you want an investment that returns 7% to 10% a year with minimal volatility and you're willing to forgo further upside potential... Marks suggests you do more research into bonds and start putting more money there. Marks points out that, historically, that's also about what you could expect to make in equities over the long term. Given the current equity-like return available, the added protection of investing in bonds and loans ought to be enticing to all investors who understand his point about risk and reward. Sure, his firm, Oaktree Capital, specializes in debt investing... with roughly 78% of the firm's client assets in loans, bonds, and other credit instruments. So he's talking his book. But he's a highly credible voice, and he makes a reasonable point in a balanced way. I tend to think of him as the Warren Buffett of debt investing. I've recommended bond funds in The Ferris Report, and my colleague Mike DiBiase focuses solely on bonds in his Stansberry's Credit Opportunities newsletter. It's a bit ironic that, as Marks describes it, debt is the less-volatile, safer alternative... It's ironic because leverage – the use of debt to increase portfolio returns – is many investors' undoing. During bubbles, leverage tends to build up and then get wiped out when the market finally collapses under its own weight. Generally speaking, owning debt instruments puts you on the side that gets paid even when equity holders get wiped out. All this talk of leverage comes on the heels of new information regarding this past summer's tragic death of Mike Lynch and six others, which I told you about in the August 23 Digest. Lynch was a tech entrepreneur and billionaire celebrating a legal victory with his wife, daughter, and several friends by cruising around the Mediterranean on his 184-foot superyacht, Bayesian. The Bayesian sank in a storm off the coast of Sicily on August 19, killing Lynch, his daughter, and five others. According to witnesses, the yacht disappeared from view surprisingly quickly. Folks were shocked that it sank at all. Giovanni Costantino, chief executive of the Italian Sea Group – which owns the Bayesian's builder, Perini Navi – told the New York Times recently... The ship was an unsinkable ship. I say it, I repeat it. It sank anyway... The main reason, according to engineers and other experts the Times spoke with, is its unusually tall single mast. That type of boat usually has two shorter masts, but the boat's original buyer (not Lynch) insisted on the single tall mast. At an astonishing 237 feet, it was one of the tallest masts in the world, with folks stopping to stare at it when it came into port. A passenger who'd ridden on the boat before its fateful cruise recalled that its ultrasmooth ride under sail made it feel like the Bayesian was gliding. The large, top-heavy mast also made it more likely for the ship to capsize. Other risk factors included large glass doors, a sunken forward deck, and air vents too close to the water line. The ship's retractable keel also was not fully extended when it sank. The same storm hit other similar boats moored near the Bayesian, but they didn't sink. Despite its other problems, it might not have tipped over and sunk if not for that gigantic mast. In other words, leverage sank the Bayesian the same way it sinks many investors who've used margin during the past few bull markets. Without that giant, heavy lever sticking out of it, Lynch and his family and friends might still be out there cruising the world right now. Likewise, without the use of portfolio leverage, many investors who left the market during crises might still be in it... compounding at relatively high rates and not worrying much about their portfolios from year to year. The amount of margin is getting back up to levels not seen since the fall of 2021 – right before the 2022 bear market... Data from the Financial Industry Regulatory Authority ("FINRA") shows that folks have currently borrowed $830 billion to buy securities. As the chart shows, that's not far below the record for margin of more than $900 billion, set in late 2021. On the other hand... some folks will say the absolute level of margin doesn't mean much, that you have to measure it in relation to the whole market's value. That metric shows you whether folks are continuing to use margin at the same rate when stocks change price. And indeed, if you run the numbers that way, you get quite a different picture... Margin peaked at just shy of 2.5% of total market cap in September 2008 – the month Lehman Brothers went bankrupt – in the depths of the financial crisis. Terror swept through the markets and margin declined until December 2009, when it bottomed out and rose again, remaining consistently at or above 2% of total market cap until early 2019. What I see here is the rising use of margin debt... with a potentially large runway to increase that usage as the market (potentially) melts up in the coming months. And there's another way to look at where we are right now, which indicates folks are more comfortable than they've been in years with having plenty of debt... That same period of deleveraging in the stock market corresponds with a wider trend in the economy... The folks at The Daily Shot published this chart recently, showing net household liabilities (liabilities minus cash and cash equivalents) as a percentage of disposable income... You can see the liabilities peaking just before the financial crisis, same as in the margin/market cap charts. Then you can see it just about touching zero around 2021 – meaning zero net liabilities, a complete deleveraging of households. Since then, liabilities have risen to around 10% of disposable income, inspiring The Daily Shot to caption the graph, "US household deleveraging has bottomed." It remains to be seen if the bottom for household liabilities is in, but we know that Americans have spent the $2.1 trillion they saved during the pandemic. They'd already burned through that by May of this year. It seems that, having finally burned up their excess cash, folks have started using more credit cards, home-equity lines, and other forms of consumer debt to keep spending. Total credit-card debt is more than $1.14 trillion now – the highest balance since the Federal Reserve began tracking it in 1999. And we also know they've been using credit in the form of "buy now, pay later" programs, which let you quickly break up a purchase into a series of monthly payments. If you shop online, you've no doubt seen these options on your screen. And folks aren't just using this credit for frivolous expenditures, either. Some 15 million Americans used these programs to buy groceries last year. You see? Folks are borrowing more and more to buy stocks... and more and more just keep their household spending at the same level… Sooner or later, these two trends of rising debt usage will overwhelm households... Remember, the government can print money. Households have to earn it. As they borrow more in their brokerage accounts, their risk of loss rises. And as debt rises relative to disposable income, the likelihood of default goes up. Many households are just a layoff away from financial disaster. All of it suggests to me that maybe we're about to see some fireworks in the stock market as folks recover from election uncertainty and start buying again... if they do start buying again. As usual, I won't make any predictions. I need to know where the data says we are right now and think about what it's reasonable to expect to happen next. I can't help mentioning that the rise in total margin aligns roughly with the period of the easiest monetary policy and the lowest interest rates in recorded history. Then the amount of margin debt soared to an all-time high of more than $900 billion just as inflation was ticking up toward new 40-plus-year highs. And now, just as households are running out of dollars to spend, margin is sitting near its lowest levels since before the 2008 crisis. Folks got used to the regime of easy money... which is just another way of saying they got comfortable with lots of inexpensive borrowing. The past two and a half years of higher inflation have only just begun to beat that old feeling of comfort out of them. I believe the beatings will intensify until folks start realizing they're too levered up, both in their household budgets and their brokerage accounts. It all feels like a coiled spring, with stocks ready to bounce higher and deeper into mega-bubble heights than ever before, enticing even more borrowing... before plunging to lower bear market crisis depths than they have in decades. A final note today... Household liabilities were on my mind after talking with our friend Austin Root on the current episode of the Stansberry Investor Hour podcast... Austin is the chief investment officer at Stansberry Asset Management ("SAM"). SAM is a U.S. Securities and Exchange Commission-registered investment adviser, completely separate from our Stansberry Research publishing business. But it uses our research, plus other sources, to help manage individual client portfolios. For more information on Stansberry Research's relationship with SAM, click here. At SAM, Austin encourages his clients to get their financial houses in order. Only after they pay down their high-interest debt should they think about what to do in the stock market. In other words, investing isn't just what you do in the stock market. It's what you do with all your money. You should have a good positive net worth if you're going to put money into stocks. You don't want to be in a position of needing to liquidate a sound long-term investment because your income is being overwhelmed by too much high-cost debt. Few of our guests delve into personal finance issues like that, and Investor Hour co-host Corey McLaughlin and I found it refreshing. You can watch our full interview with Austin here. I've occasionally said that the fundamental skill beneath every type of investing is saving – setting aside capital for the future. In the end, being rich means having a big pile of wealth you didn't spend. Whether it's in cash, gold, stocks, bonds, real estate, or other assets is secondary to that fundamental truth. As Austin spoke, I was reminded of the data on credit cards and net liabilities I shared above. The releveraging of households suggests they're headed in the wrong direction after heading in the right one for years. Inflation will do that. Four-decade-high inflation has left folks struggling to the point where their excess savings are gone, and they're using credit cards and "buy now, pay later" just to make ends meet. It's tragically ironic that the government's issuing of more than $800 billion in cash to Americans during the pandemic is one of the culprits contributing to the post-pandemic surge in inflation. So keep your debts under control, including high-interest consumer debt and margin in your brokerage accounts. There are times when you get away with that sort of behavior. But I don't believe this is one of them. Recommended Links: 'It Doesn't Matter Who Wins... Bitcoin Is Going to $100K' The U.S. government is currently working on a proposed federal initiative – one that would require them to buy millions of dollars' worth of cryptocurrency in the months ahead. Bitcoin is already rallying in anticipation, increasing by more than $4,000 in just a week. But according to crypto expert Eric Wade, this is just the start. Here's Eric's No. 1 crypto move today to profit. This Election Trade Is ALWAYS Right (According to History) There's one surprising election trade that history says has never been wrong, stretching all the way back to 1921. It paid off under Harding, Roosevelt, Kennedy, Nixon, Reagan, Clinton, and Obama... and it could have doubled your money twice already this election year. Now, with the election just days away, it's time to take advantage of it once again. Here's the ONLY election trade to make today. New 52-week highs (as of 10/31/24): AbbVie (ABBV), Sprouts Farmers Market (SFM), Summit Materials (SUM), Texas Pacific Land (TPL), and Twilio (TWLO). In today's mailbag, a question about GDP data, stemming from our Wednesday edition... Do you have a comment or question? As always, e-mail us at feedback@stansberryresearch.com. "Good morning Corey. The government likes to tout good GDP numbers, but I don't recall seeing both a gross GDP number and a GDP number net of inflation. If the economy 'grew' by 2.8%, but real inflation (not their cherry-picked numbers) was running at 1% (or higher) for the quarter, then we really can't say GDP expanded by 2.8% (with the implication it grew from increased productivity). Is there a thinktank that publishes real numbers that strip out increases solely from inflation so that we can measure the real productivity of the economy?" – Subscriber Scott P. Corey McLaughlin comment: Scott, thanks for the question. The short answer is the 2.8% third-quarter number you're referring to that we discussed the other day is "real" GDP growth, which does account for inflation... at least somewhat. The government uses what it calls the GDP Price Deflator to adjust for inflation, and in this third-quarter GDP estimate, its inflation estimate was 1.8%. Without that consideration, nominal GDP growth was 4.7%, according to Uncle Sam. Of course, these headline numbers that are quoted in the mainstream media don't tell the whole story, or even close to it... First off, we're skeptical about whether the government's inflation adjustment is "real" enough. Second, consumer spending, which makes up about two-thirds of economic activity in the U.S. and grew at a 3.7% pace, is an aggregate dollar measure... meaning it grows with higher prices. So GDP is essentially giving credit to inflation for "growth." Beyond that, barely any of the reported GDP during the third quarter was from private investment (0.3%), and a lot was from government spending, including a roughly 15% annualized gain in national defense spending – even after adjusting for inflation. Long story short... I agree that the headline numbers aren't what they are cracked up to be. If people are simply spending more dollars on the same goods and services that cost less before, and in large part because of government policies and spending, is that "real" production? I don't think so. And it's one big reason why I expect to be hedging inflation forever. Good investing, Dan Ferris Eagle Point, Oregon November 1, 2024 Stansberry Research Top 10 Open Recommendations Top 10 highest-returning open stock positions across all Stansberry Research portfolios. Returns represent the total return from the initial recommendation. Investment Buy Date Return Publication Analyst MSFT Microsoft 11/11/10 1,348.7% Retirement Millionaire Doc MSFT Microsoft 02/10/12 1,295.0% Stansberry's Investment Advisory Porter ADP Automatic Data Processing 10/09/08 1,043.6% Extreme Value Ferris BRK.B Berkshire Hathaway 04/01/09 699.5% Retirement Millionaire Doc WRB W.R. Berkley 03/15/12 504.1% Stansberry's Investment Advisory Porter TT Trane Technologies 04/12/18 490.9% Retirement Millionaire Doc AFG American Financial 10/11/12 453.7% Stansberry's Investment Advisory Porter HSY Hershey 12/07/07 442.5% Stansberry's Investment Advisory Porter TTD The Trade Desk 10/17/19 430.5% Stansberry Innovations Report Engel SFM Sprouts Farmers Market 04/08/21 394.3% Extreme Value Ferris Please note: Securities appearing in the Top 10 are not necessarily recommended buys at current prices. The list reflects the best-performing positions currently in the model portfolio of any Stansberry Research publication. The buy date reflects when the editor recommended the investment in the listed publication, and the return shows its performance since that date. To learn if a security is still a recommended buy today, you must be a subscriber to that publication and refer to the most recent portfolio. Top 10 Totals 4 Stansberry's Investment Advisory Porter 3 Retirement Millionaire Doc 2 Extreme Value Ferris 1 Stansberry Innovations Report Engel Top 5 Crypto Capital Open Recommendations Top 5 highest-returning open positions in the Crypto Capital model portfolio Investment Buy Date Return Publication Analyst wstETH Wrapped Staked Ethereum 12/07/18 2,291.8% Crypto Capital Wade BTC/USD Bitcoin 11/27/18 1,769.6% Crypto Capital Wade ONE/USD Harmony 12/16/19 1,126.5% Crypto Capital Wade POL/USD Polygon 02/25/21 704.1% Crypto Capital Wade CVC/USD Civic 01/21/20 314.0% Crypto Capital Wade Please note: Securities appearing in the Top 5 are not necessarily recommended buys at current prices. The list reflects the best-performing positions currently in the Crypto Capital model portfolio. The buy date reflects when the recommendation was made, and the return shows its performance since that date. To learn if it's still a recommended buy today, you must be a subscriber and refer to the most recent portfolio. Stansberry Research Hall of Fame Top 10 all-time, highest-returning closed positions across all Stansberry portfolios Investment Symbol Duration Gain Publication Analyst Nvidia^* NVDA 5.96 years 1,466% Venture Tech. Lashmet Microsoft^ MSFT 12.74 years 1,185% Retirement Millionaire Doc Inovio Pharma.^ INO 1.01 years 1,139% Venture Tech. Lashmet Seabridge Gold^ SA 4.20 years 995% Sjug Conf. Sjuggerud Nvidia^* NVDA 4.12 years 777% Venture Tech. Lashmet Intellia Therapeutics NTLA 1.95 years 775% Amer. Moonshots Root Rite Aid 8.5% bond 4.97 years 773% True Income Williams PNC Warrants PNC-WS 6.16 years 706% True Wealth Systems Sjuggerud Maxar Technologies^ MAXR 1.90 years 691% Venture Tech. Lashmet Silvergate Capital SI 1.95 years 681% Amer. Moonshots Root ^ These gains occurred with a partial position in the respective stocks. * The two partial positions in Nvidia were part of a single recommendation. Editor Dave Lashmet closed the first leg of the position in November 2016 for a gain of about 108%. Then, he closed the second leg in July 2020 for a 777% return. And finally, in May 2022, he booked a 1,466% return on the final leg. Subscribers who followed his advice on Nvidia could've recorded a total weighted average gain of more than 600%. Stansberry Research Crypto Hall of Fame Top 5 highest-returning closed positions in the Crypto Capital model portfolio Investment Symbol Duration Gain Publication Analyst Band Protocol BAND/USD 0.31 years 1,169% Crypto Capital Wade Terra LUNA/USD 0.41 years 1,166% Crypto Capital Wade Polymesh POLYX/USD 3.84 years 1,157% Crypto Capital Wade Frontier FRONT/USD 0.09 years 979% Crypto Capital Wade Binance Coin BNB/USD 1.78 years 963% Crypto Capital Wade You have received this e-mail as part of your subscription to Stansberry Digest. If you no longer want to receive e-mails from Stansberry Digest click here. Published by Stansberry Research. You're receiving this e-mail at edwardlorilla1986.paxforex@blogger.com. Stansberry Research welcomes comments or suggestions at feedback@stansberryresearch.com. This address is for feedback only. 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