Welcome to Finance Insider, Business Insider's summary of the top stories of the past 24 hours. Wells Fargo CEO John Stumpf and Carrie Tolstedt, the executive who ran the bank's retail banking division, <a href="http://www.businessinsider.com/wells-fargo-ceo-will-forfeit-41-million-in-pay-after-banking-scandal-2016-9">will forfeit tens of millions of dollars in bonuses as the bank tries to stem a scandal over its sales practices</a>. Sen. Elizabeth Warren said the move is a "small step," but <a href="http://www.businessinsider.com/elizabeth-warren-tweetstorm-on-wells-fargo-ceo-john-stumpf-clawback-2016-9">doesn't think the bank has gone far enough</a>.The <a href="http://www.businessinsider.com/r-germany-denies-preparing-deutsche-bank-rescue-plan-2016-9">German government was forced to deny that it is working on a rescue of Deutsche Bank</a>, and we got the internal Deutsche Bank memo on its <a href="http://www.businessinsider.com/deutsche-bank-memo-to-staff-on-crashing-share-price-2016-9">bombed-out share price in which the bank says it doesn't need to raise money</a>.On Wall Street, UBS has <a href="http://www.businessinsider.com/ubs-names-foresman-vice-chair-of-investment-bank-2016-9">made a marquee hire in New York</a>, and JPMorgan <a href="http://www.businessinsider.com/jpmorgan-barry-sommers-brian-carlin-thasunda-duckett-new-roles-2016-9">promoted a rising star in its biggest business</a>. Ken Moelis, the CEO of the investment bank Moelis &amp; Company, <a href="http://www.businessinsider.com/ken-moelis-says-donald-trump-will-win-the-us-presidential-election-2016-9">expects Donald Trump to win the US presidential election in November</a>. And the Fed is thinking about <a href="http://www.businessinsider.com/yellen-testimony-says-fed-may-change-stress-tests-2016-9">making big changes to how it tests America's largest banks</a>.Julian Robertson, the legendary hedge fund manager behind Tiger Management, <a href="http://www.businessinsider.com/tiger-global-hedge-fund-julian-robertson-everything-is-in-a-bubble-2016-9">thinks central banks are fueling bubbles throughout financial markets</a>.In company news, Tempur Sealy, the maker of TempurPedic mattresses and other bedding products, <a href="http://www.businessinsider.com/tempur-sealy-tempurpedic-mattress-stock-crashing-2016-9">reported a dismal update on its business, sending its shares in a tailspin</a>. SABMiller shareholders backed the brewer's $100-billion-plus takeover by rival Anheuser-Busch InBev, <a href="http://www.businessinsider.com/sabmiller-shareholders-approve-takeover-by-anheuser-busch-inbev-2016-9">paving the way for one of the biggest corporate mergers in history</a>. In the tech industry, BlackBerry <a href="http://www.businessinsider.com/blackberry-stops-making-own-phones-quarterly-results-q2-2017-2016-9">is going to stop making its own smartphones</a>. <a href="http://www.businessinsider.com/uber-promoted-employee-new-cfo-january-2016-9">Uber has finally got a CFO</a>. And here are <a href="http://www.businessinsider.com/snapchat-top-executives-2016-9/#bobby-murphy-co-founded-the-company-and-is-now-cto-1">the secret power players who run Snapchat</a>.Lastly, here's a reminder that <a href="http://www.businessinsider.com/real-wage-growth-new-york-fed-research-2016-9">you really need to get as many raises as you can before you turn 40</a>.Here are the top Wall Street headlines at midday<a href="http://www.businessinsider.com/gop-congressman-says-janet-yellen-fed-cozy-obama-democrats-2016-9">A GOP congressman attacked Janet Yellen for looking 'cozy' with Obama and Democrats</a> - During testimony in front of the House Financial Services Committee, Federal Reserve Chair Janet Yellen was grilled by a member of Congress about whether the Fed and some of its members were favoring President Obama, the Democratic Party, and nominee Hillary Clinton.<a href="http://www.businessinsider.com/saudi-arabia-cut-bonus-payments-for-state-employees-and-that-has-long-term-consequences-2016-9">Saudi Arabia slashed worker pay and now its stocks are tanking</a> - Saudi Arabia announced several fiscal consolidation measures <a href="http://www.reuters.com/article/us-saudi-economy-idUSKCN11W1VS?il=0">on Tuesday</a> in an effort to help reduce the kingdom's record budget deficit as it contends with <a href="http://www.businessinsider.com/crude-oil-down-after-iran-and-saudi-arabia-2016-9">lower-for-longer oil prices</a> and<a href="http://www.businessinsider.com/saudi-arabia-oil-facilities-and-yemen-campaign-2016-9">costly regional conflicts</a>.<a href="http://www.businessinsider.com/credit-suisse-ceo-tidjane-thiam-at-bloomberg-event-2016-9">CREDIT SUISSE CEO: 'Only a fool would try to make a five-year prediction in a world that is so random'</a> - European investment banks are struggling to make money in a world of zero interest rates and tougher rules on capital.<a href="http://www.businessinsider.com/why-disney-should-not-buy-twitter-according-to-citi-2016-9">CITI TELLS DISNEY: Please don't buy Twitter</a> - Twitter is reportedly looking for a buyer.<a href="http://www.businessinsider.com/sears-demise-could-shut-down-another-200-shopping-malls-2016-9">Sears could kill hundreds of American shopping malls</a> - Sears' decline is threatening to kill off at least 200 shopping malls, according to a new report. <a href="http://www.businessinsider.com/the-feds-rate-hike-predictions-and-actual-rate-hikes-2016-9">Here's how bad the Fed is at predicting rate hikes</a> - In January, Fed Vice Chair <a href="http://www.reuters.com/article/us-usa-fed-fischer-idUSKBN0UK1OT20160106">Stanley Fischer predicted</a> that four rate hikes were "in the ballpark" for 2016. Of course here we are at the end of September, with only two Fed meetings remaining for the year, and the Fed has yet to hike rates even once. <a href="http://www.businessinsider.com/volkswagen-id-electric-concept-car-paris-motor-show-photos-2016-9">Volkswagen just unveiled its 'revolutionary' electric concept car - and it's hitting roads in 2020</a> - It's finally here, the Volkswagen I.D. electric concept car.<a href="http://www.businessinsider.com/inside-manhattans-diamond-district-2016-9">Go inside America's largest diamond factory, which is leading a revolution in the jewelry industry</a> - New York City's Diamond District - located on 47th Street between Fifth and Sixth Avenues - glitters and sparkles, the well-lit diamonds in shop windows immediately drawing the eyes in.

What you need to know on Wall Street right now

<img src="https://static-ssl.businessinsider.com/image/58786e0aee14b617038b8029-878/undefined" alt="Jamie Dimon" /><a href="http://www.gettyimages.com/photos/jamie-dimon?family=editorial&amp;phrase=jamie%20dimon&amp;excludenudity=true&amp;sort=best#license">Getty/Win McNamee</a>Jamie Dimon, Chairman and CEO of JPMorgan Chase &amp; Co., speaks at the Economic Club of Washington September 12, 2016 in Washington, DC.Welcome to Finance Insider, Business Insider's summary of the top stories of the past 24 hours. First quarter earnings season kicked off on Wall Street on Thursday, with JPMorgan, Citigroup and Wells Fargo all reporting. Here's what you need to know:<ul><li><a href="http://www.businessinsider.com/jpmorgan-q1-2017-earnings-2017-4">JPMorgan beats, investment bank has a record quarter</a></li><li><a href="http://www.businessinsider.com/citigroup-citi-earnings-q1-2017-2017-4">Citigroup beats on earnings as fixed income revenues rise to a three-year high</a></li><li><a href="http://www.businessinsider.com/wells-fargo-earnings-q1-2017-2017-4">Wells Fargo beats on earnings as lending falls</a></li><li><a href="http://www.businessinsider.com/bond-traders-strong-start-to-the-year-2017-4">Bond traders are crushing it</a></li><li><a href="http://www.businessinsider.com/jamie-dimon-on-mortgage-market-2017-4">Jamie Dimon says there's something shameful going on with the mortgage market</a></li></ul>Elsewhere in Wall Street news, Bridgewater founder Ray Dalio said going broke in 1982 was the <a href="http://www.businessinsider.com/bridgewater-ray-dalio-lesson-from-going-broke-2017-4">"best thing that ever happened" to him</a>. Wall Street legend Howard Marks said one phone call <a href="http://www.businessinsider.com/howards-marks-on-a-truth-about-investing-2017-4">changed his life.</a>Meanwhile, Lee Cooperman's Omega Advisors expects the rampant bull market to slow down. "<a href="http://www.businessinsider.com/lee-coopermans-omega-quarterly-investor-letter-2017-2017-4">It is time for the US equity market to rest</a>," Cooperman and Steve Einhorn, Omega's vice chairman, wrote in a letter to investors last week.Credit Suisse has its own "Fear Barometer," <a href="http://markets.businessinsider.com/news/stocks/credit-suisse-has-its-own-fear-barometer-and-its-flashing-red-2017-4-1001921106-1001921106">and it's flashing red</a>. And consumers have not been this <a href="http://www.businessinsider.com/umich-consumer-confidence-april-13-2017-2017-4">bullish about the US economy since 2000</a>. In President Trump news:<ul><li><a href="http://www.businessinsider.com/wall-street-gary-cohn-trump-steve-bannon-2017-4">Trump's Wall Street faction is starting to win him over</a></li><li><a href="http://www.businessinsider.com/trump-dollar-getting-too-strong-2017-4">TRUMP: The dollar is "getting too strong" partly because people have confidence in me</a></li><li><a href="http://www.businessinsider.com/dollar-rally-trump-strong-2017-4">Here's why the dollar could defy Trump and keep marching higher</a></li><li><a href="http://www.businessinsider.com/trump-yellen-could-be-fed-chair-after-2018-not-toast-2017-4">"NOT TOAST": Trump says Yellen may stay on as Fed chair after her term expires in 2018</a></li><li><a href="http://www.businessinsider.com/mulvnaey-trump-20-trillion-debt-promise-hyperbole-2017-4">BUDGET CHIEF: Trump's promise to eliminate America's $20 trillion problem was "hyperbole"</a></li></ul>A new video shows the moments before <a href="http://www.businessinsider.com/video-police-united-airlines-flight-passenger-removed-plane-2017-4">police dragged a man off a United flight</a>. The man is gearing up for <a href="http://www.businessinsider.com/man-dragged-from-united-airlines-flight-will-file-lawsuit-2017-4">a legal battle after saying he had a concussion and lost teeth</a>.Snapchat has set its first earnings call for May, <a href="http://www.businessinsider.com/snapchats-first-q1-earnings-report-2017-4">and investors only care about users, users, users</a>. In related news, Snap slipped below $20 <a href="http://markets.businessinsider.com/news/stocks/snap-stock-price-slides-below-20-after-instagram-clone-has-more-users-2017-4-1001921401">after Instagram said its Snapchat clone has more users</a>.Elon Musk just fired back at<a href="http://www.businessinsider.com/elon-musk-fires-back-at-investors-looking-for-tesla-board-shake-up-2017-4"> the investors who want Tesla to shake up its board</a>. Analysts are speculating <a href="http://www.businessinsider.com/rbc-analysts-speculate-apple-acquiring-disney-2017-4">about Apple buying Disney</a>. Netflix has a <a href="http://www.businessinsider.com/netflix-merchandise-revenue-2017-4">potential "billion dollar" opportunity that it's just starting to explore</a>.The founders of Warby Parker revealed how they run a <a href="http://www.businessinsider.com/warby-parker-ceo-and-founder-podcast-success-how-i-did-it-2017-4">billion-dollar glasses brand with two CEOs, and why Amazon won't crush them</a>.One company symbolizes <a href="http://www.businessinsider.com/opioid-crisis-and-insys-therapeutics-fentanyl-spray-2017-4">everything sickening about the opioid crisis</a>.Lastly, here are seven watches that are so classic, <a href="http://www.businessinsider.com/watches-that-will-never-go-out-of-style-2017-4">they'll never go out of style</a>.Here are the top Wall Street headlines from the past 24 hours.<a href="http://www.businessinsider.com/wall-street-should-bet-on-trump-killing-chinese-deals-2017-4">Wall Street should bet on Trump killing Chinese deals</a> - In his first US-China summit, President Donald Trump took a significant step toward making good on campaign promises aimed at resetting a broken relationship between the world's two largest economies.<a href="http://www.businessinsider.com/yext-stock-jumps-27-after-ipo-2017-4">Yext stock jumps 27% after IPO</a> - Yext, a 10-year-old enterprise tech business that manages "digital knowledge," started trading this morning on the New York Stock Exchange at $14 per share, up by more than 27 percent from its IPO price of $11 per share.<a href="http://www.businessinsider.com/kpmg-fires-6-people-over-unethical-leaks-of-audit-checks-2017-4">KPMG fired 6 people over "unethical" leaks of confidential information</a> - KPMG has fired six employees including its top US auditor for "unethical behaviour" relating to leaked information which gave them advance warning of which audits an accounting watchdog would inspect.<a href="http://www.businessinsider.com/blink-health-prescriptions-savings-app-raises-90-million-2017-4">A startup just raised another $90 million to help people save money on prescriptions</a> - Blink Health, a company that provides discounts to prescription drugs, just raised another $90 million.<a href="http://www.businessinsider.com/amazons-alexa-echo-revenue-estimate-by-2020-2017-4">The 3 ways Amazon's Alexa could snag $10 billion in revenue by 2020</a> - People love Amazon's Echo speaker, and the digital assistant Alexa who lives inside it - especially Amazon CEO Jeff Bezos.<a href="http://www.businessinsider.com/maserati-nerissimo-edition-revealed-2017-4">If you want an "extremely black" luxury car, Maserati has you covered</a> - On Wednesday, Maserati unveiled a new option for buyers of its Ghibli sedan: the "Nerissimo Edition," which translates as "extremely back."

What you need to know on Wall Street today

<div class="KonaFilter image-container display-table"><div><div class="image on-image"><img src="https://static-ssl.businessinsider.com/image/53f1e53e6bb3f784531c5fb9-1200-858/rtr2gi37.jpg" border="0" alt="bull cattle rodeo cowboy">REUTERS/Todd Korol</img></div></div></div>The S&amp;P 500 is up a whopping 200% from its March 2009 low. At 2,003, the S&amp;P has already exceeded many analysts forecasts.
Morgan Stanley strategist Adam Parker and economist Ellen Zentner believe that the conditions are just right for the bull market to keep going for years.
"Our best guess is that an S&amp;P500 peak of near 3000 is possible should the US expansion prove to have five or more years left to it, based on 6% per annum EPS growth through that time frame and a 17x price-to-earnings ratio," Parker writes.
Like many experts on Wall Street, Parker reminds us that our recent experience of crisis to recovery is not like most of history's boom and bust cycles. He also reminds us that bull markets and economic recoveries don't just end because they've gone on for a long time.
"We believe a prolonged period of deleveraging in the US, coupled with an uneven global recovery, are just two of the reasons why this could prove to be the longest US expansion - ever," he writes.
In a meaty 27-page research note titled "2020 Vision: Long Live the Expansion," Parker and Zenter argue that the U.S. economy is actually only in the early parts of its growth cycle. It's also uniquely positioned in the world, benefiting from low volatility, healthier balance sheets, and a lack of corporate exuberance.
Here's their bulleted summary (verbatim):
<ul>
<li>The world economy is not in sync. Major regional economies are at different points along the growth cycle. In general, DM is leading while EM is lagging.</li>
<li>Volatility in the US continues to trend lower, which can extend the life of expansions.</li>
<li>Deleveraging in the US is ongoing, albeit largely complete, and balance sheet priorities have shifted.</li>
<li>Interest payments on debt burdens are ultra-low, and household debt dynamics suggest there exists a sizable cushion protecting consumers in a rising interest rate environment.</li>
<li>Capital spending and inventories do not look stretched.</li>
<li>Corporate management hubris and other corporate metrics of overheating remain muted.</li>
<li>Several broad economic indicators in the US have only just reached "normal" expansionary levels and are far from looking unsustainable.</li>
</ul>
There are a couple things worth highlighting from the analysts' note.
<h2>The Capital Spending Comeback</h2>
First is their comment about capital expenditures, or business investment. The capex recovery has been one of the most highly-anticipated and controversial aspects of this recovery. And recent data show that <a href="http://www.businessinsider.com/capex-boom-is-happening-2014-8">it's finally happening</a>.
However, Parker notes that capex levels are still at reasonable levels when considered relative to sales. For Parker, this is a sign that "hubris" is absent.
<div class="KonaFilter image-container"><div class="image"><img src="https://static-ssl.businessinsider.com/image/540594edeab8ea9760f36178-598-401/screen shot 2014-09-02 at 5.51.38 am.png" border="0" alt="capital spending" width="850" height="576">Morgan Stanley</img></div></div>
<h2>The Debt Cushion</h2>
No one has forgotten the financial crisis, which was highlighted by a freeze in credit. This had even the most financially healthy companies struggling to meet their financial obligations.
However, that memory also had companies turning their balance sheets into fortress balance sheets.
Many companies engaged in aggressive amounts of refinancing, which pushed the maturies on their debt back by several years.
<div class="KonaFilter image-container"><div class="image"><img src="https://static-ssl.businessinsider.com/image/540596626bb3f7d17a44e2ef-823-551/screen shot 2014-09-02 at 6.00.07 am.png" border="0" alt="loan maturities" width="799" height="534">Morgan Stanley</img></div></div>
From an income statement perspective, a very high interest coverage ratio shows that companies have plenty of operating earnings to finance their current debt financing needs.
<div class="KonaFilter image-container"><div class="image"><img src="https://static-ssl.businessinsider.com/image/540596f6ecad04e12044e2fc-822-545/screen shot 2014-09-02 at 6.05.28 am.png" border="0" alt="interest coverage" width="794" height="525">Morgan Stanley</img></div></div>
<h2>Risk</h2>
Obviously, there's no guarantee that we're looking at five years of smooth sailing.
"There are a number of ways the current expansion could get derailed," Parker writes. "Europe and China are already slowing and near recession in some parts. Japan is highly dependent on the success of policy. US reforms on key issues like the budget, taxes and entitlements, and immigration seem a long way off and are likely to cause much angst in the coming years. And after a prolonged period of unprecedented monetary policy accommodation, we are on the cusp of removal of that accommodation - also in an unprecedented way."
But their base case remains quite bullish.
"As the prolonged expansion becomes more visible, we'd expect a materially higher US stock market."

MORGAN STANLEY: The Market Could Rally For Years, And The S&P Might Go To 3,000

<div class="KonaFilter image-container display-table"><div><div class="image"><img src="https://static-ssl.businessinsider.com/image/5c8693e526289874ea0dfee3-2400/0278-from-the-hip-photo.jpg" border="0" alt="A patient consulting with a medical professional at an Iora Health clinic." data-mce-source="Courtesy Iora Health" data-mce-caption="A patient consulting with a medical professional at an Iora Health clinic." /></div></div></div><ul class="summary-list"><li>Major health systems are rethinking their approach to primary care.</li><li>The goal is to give doctors more time with patients while simultaneously making them more responsible for their patients' health.</li><li>Rather than getting paid for each visit or procedure, health systems like Geisinger and Intermountain are working to get paid a large fixed sum each month to take care of all of a patient's health needs. </li><li>The shift to value-based care is catching on around the US.</li><li><a href="https://www.businessinsider.com/prime?module=article&amp;area=summary">Click here for more BI Prime stories.</a></li></ul>Major health systems are rethinking how they approach primary care, devoting more resources to keeping patients healthy, as they prepare for a future in which they won't make as much money on individual visits.Hospitals have been hiring up doctors in recent years and acquiring whole physician groups. They now employ <a href="http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/021919-Avalere-PAI-Physician-Employment-Trends-Study-2018-Update.pdf?ver=2019-02-19-162735-117">almost half of all physicians</a>, including a large number of primary care doctors.In some cases, hospitals are seeking <a href="https://www.fiercehealthcare.com/practices/healthcare-leaders-look-at-past-present-and-future-consolidation">to control more healthcare services</a> so that they can refer patients into their health systems. That's been <a href="https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.0472">linked with higher healthcare costs</a>, though in this case, the health systems are looking for new ways to use their doctors to make them more responsible for keeping patients healthy.It's part of a bet on an idea known as value-based care. Rather than getting paid for each visit or procedure that a patient needs, health systems are working to get paid a large fixed sum each month to take care of all of a patient's health needs.The contracts are built to motivate the health systems to keep patients healthier. Under these arrangements, if patients end up requiring more healthcare than expected, the hospitals bear some responsibility for the extra costs."They think they'd be better off if they took more risk and own the whole budget for care," Dr. Lisa Bielamowicz, the president of Gist Healthcare, which consults with health systems, told Business Insider. Primary care physicians are often on the front lines of these efforts. By putting more resources into taking care of patients in primary care clinics, the goal is to prevent more costly surgeries or hospital stays down the road.Health systems like Pennsylvania's Geisinger and Intermountain Healthcare in Utah are at the forefront of these efforts, in part because they run their own insurance plans and are used to taking on financial responsibility for patients.The goal is to give doctors more time with patients while simultaneously making them more responsible for their patients' health. To help, Geisinger and Intermountain are stationing additional caregivers at primary care clinics, so a pharmacist can be on hand to explain a new treatment regimen, or a mental health professional can be there to counsel on anxiety, for example. Patients don't pay extra for the additional care.Read more: <a href="https://www.businessinsider.com/providence-st-joseph-health-creates-ayin-for-population-health-management-2019-1">The $23 billion health system in Amazon's backyard just started a company to help hospitals avoid 'landmines' when they try to act like health insurers</a>As the population ages, <a href="https://batten.virginia.edu/school/people/carolyn-engelhard">Carolyn Long Engelhard</a>, a public-health expert and professor at the University of Virginia School of Medicine, noted, health systems are adapting their strategies. Older Americans have more healthcare needs, and the government - which pays for much of their care - is pushing health systems to take on more financial responsibility.<div class="KonaFilter image-container display-table"><div><div class="image"><img src="https://static-ssl.businessinsider.com/image/5d1a4da9a17d6c042a41c5b4-2400/holladay clinic03 1.jpg" border="0" alt="holladay clinic03 (1)" data-mce-source="Courtesy Intermountain" data-mce-caption="One of Intermountain's primary care clinics." /></div></div></div><h2>A new kind of primary care model that charges a monthly fee</h2>Doctors offices that are paid with a monthly fee are catching on around the US, not just within hospital systems. A growing group of private practices, <a href="https://www.businessinsider.com/direct-primary-care-a-no-insurance-healthcare-model-2017-3">known as direct primary care practices</a>, charge a monthly fee but don't take insurance.That amount, typically about $50 a month, covers average patient needs, including visits and discounts on some common drugs. It can either be paid for by <a href="https://www.businessinsider.com/how-employers-could-use-direct-primary-care-2018-3">patients or as a benefit from employers</a>. Similarly, large employers like LinkedIn and Comcast-NBCUniversal are paying companies <a href="https://www.businessinsider.com/crossover-health-buys-virtual-primary-care-startup-sherpaa-2019-2">like Crossover Health</a> on a monthly basis to help keep their employees healthy via onsite or near-site health clinics. Upstarts <a href="https://www.businessinsider.com/rushika-fernandopulle-iora-health-plan-to-change-the-way-you-see-your-doctor-2019-4">like Iora Health</a>, for their part, are working with employers and health insurers operating Medicare Advantage plans in a similar way.Medicare Advantage is the privately run version of the Medicare health insurance program for the elderly.For years, the administrations of both former President Barack Obama and President Donald Trump fueled the push to value-based care. The Obama administration started emphasizing <a href="https://khn.org/news/aco-accountable-care-organization-faq/">Accountable Care Organizations</a>, which group doctors and hospitals together and get paid more if they keep Medicare patients healthier at a lower cost.Both administrations have backed <a href="https://www.businessinsider.com/bringing-value-based-care-to-hospitals-and-radiology-2016-11">bundling payments for healthcare services</a> so that say, if a patient goes in for a knee replacement, the hospital is paid a set amount for the whole procedure. Should a complication arise, the hospital would be on the hook for covering the cost.In April, <a href="https://www.businessinsider.com/centers-for-medicare-and-medicaid-services-primary-care-initiative-2019-4">Department of Health and Human Services Secretary Alex Azar announced a new primary-care initiative</a> that aims to move from paying based on how much care is given to Medicare recipients (a model known as fee-for-service) to a model that pays doctors on a per-patient-per-month basis. That could free up medical practices to do more follow-up work and coaching sessions, and provide services that aim to keep patients on Medicare plans out of the hospital. The US has estimated that about 25% of Medicare participants, or nearly 11 million people, would be covered under the new model.Read more: <a href="https://www.businessinsider.com/centers-for-medicare-and-medicaid-services-primary-care-initiative-2019-4">The Trump administration just gave a big boost to a new kind of doctor's office that charges monthly fees and could be the future of medicine</a><h2>Reorganizing primary care clinics</h2>Intermountain's changes to primary care came with a shift in the way it viewed its business. On the one hand, it operates hospitals, geared at making sure people get better when they are sick. On the other, its primary care practices perform annual check-ups and dealing with cold and flu symptoms as they arise.Intermountain operates a health plan called Select Health, which had <a href="https://intermountainhealthcare.org/annual-report-2018/">870,000 members in 2018</a>, as well as 24 hospitals and southeastern Idaho.It decided to split its business essentially in two. Intermountain hired Rajesh Shrestha to serve as the associate chief operating officer of community-based care, and run the portion of the health system focused on keeping people well. He joined in 2018, after eight years at health insurer Cigna."We've created a tension between those two in a thoughtful way," Intermountain CEO Marc Harrison told Business Insider.<div class="KonaFilter image-container display-table float_right"><div><div class="image"><img src="https://static-ssl.businessinsider.com/image/5c48a41d2bdd7f5b77550ef2-2400/marc harrisonbusath76985-8806 hires.jpg" border="0" alt="Marc Harrison_Busath_76985 8806 hires" data-mce-source="Courtesy Intermountain Healthcare" data-mce-caption="Intermountain Healthcare CEO Marc Harrison" /></div></div></div>With Shrestha on board, Intermountain started the "reimagining primary care initiative," which the team had been planning since 2017. Intermountain decided to set up clinics where teams of caregivers, including social workers, mental health professionals, nurse practitioners and primary care doctors could work together.Similarly, Geisinger, a health system headquartered in Danville, Pennsylvania, and catering to people in the predominantly rural central areas of the state, is an integrated health system that oversees care for 3 million people and owns health plans that cover 580,000 members.Dr. Jaewon Ryu, CEO at Geisinger, said that the system has been looking at team approaches to primary care for years. That accelerated about three years ago when the health system introduced a program called "Primary Care Redesign." The new model applies to most of Geisinger's clinics today. That included defining panel sizes (keeping them between 1,900 and 2,000 patients per doctor), setting up care teams within practices, and giving doctors a longer time to meet with patients.Read more: <a href="https://www.businessinsider.com/unite-us-raises-35-million-led-by-oak-hcft-social-services-determinants-2019-3">Investors just made a $35 million bet on a startup that wants to help people find food and housing to keep them healthy</a>To be sure, some health systems have long emphasized primary care as a way to keep patients healthy at a lower cost. <a href="https://www.businessinsider.com/kaiser-permanente-ceo-tyson-on-future-of-healthcare-2018-8">Kaiser Permanente</a>, for instance, traces it roots to arrangements struck between industrial companies and hospitals in the 1930s and 1940s to cover care for workers at a set monthly rate. The company's strategy <a href="http://www.businessinsider.com/warren-buffett-jamie-dimon-jeff-bezos-healthcare-interest-2018-1">is a favorite of Berkshire Hathaway Vice Chairman Charlie Munger</a> and <a href="https://www.businessinsider.com/amazon-berkshire-hathaway-jpmorgan-and-employer-funded-healthcare-2018-1">others</a> who see it as a model for the future of healthcare in the US.<h2><div class="KonaFilter image-container display-table"><div><div class="image"><img src="https://static-ssl.businessinsider.com/image/5d1a72f7a17d6c0db65469a3-2000/mountpleasant4527.jpg" border="0" alt="Geisinger Health System's Mount Pleasant office in Scranton, Pennsylvania" data-mce-source="Courtesy Geisinger" data-mce-caption="Geisinger Health System's Mount Pleasant office in Scranton, Pennsylvania. The building houses some of Geisinger's primary care practices." /></div></div></div></h2><h2>Early results</h2>Since implementing the new program, Ryu said that Geisinger has experienced slightly less turnover among its primary care doctors. So far, the system's noticed that patients in the new model of primary care have been able to get appointments quicker and ended up using other more expensive parts of the health system less, he said. Geisinger hasn't published any results from the initiative yet"We've realized as we make investments, we almost always see that the care improves," Ryu said. <h2><div class="KonaFilter image-container display-table float_right"><div><div class="image"><img src="https://static-ssl.businessinsider.com/image/5d1a72efa17d6c0d8a12da1c-1663/9-27-18gcsomhegmeetingdsc2233original.jpg" border="0" alt="Geisinger Health CEO Jaewon Ryu" data-mce-source="Courtesy Geisinger" data-mce-caption="Geisinger Health CEO Jaewon Ryu" /></div></div></div></h2>The increasing focus on the preventive work that can be done through primary care has come as Geisinger's health insurer has enrolled more people in its Medicare and Medicaid plans.Geisinger had about 185,000 Medicaid members in 2017, up from 116,000 in 2013. Medicare Advantage enrollment rose to about 94,000 last year from 67,705 in 2013.Intermountain's primary care initiative started last year, and by this summer, the system expects to have 25,000 patients in the model. It plans to grow that to 100,000 by 2020. Intermountain provided Business Insider with a summary of some early results from its initiative, but hasn't published them. The health system said there's been a 60% reduction in hospital admissions among members of Intermountain's Medicare Advantage plan who took part in the new primary care model.For commercial plans, there were 25% fewer hospital admissions. Medical expenses for those on Medicare Advantage plans were reduced by 20%, the health system said.To fill the new practices, Intermountain has been shifting over patients who are part of its Select Health Medicare Advantage plan. The system plans to open up the clinic to Select Health members in Medicaid plans, as well as to people who get insurance at work or who buy it on the Affordable Care Act's exchanges.Doctors in the new practices are responsible for about 700 patients, down from the 2,000 or so they were previously taking care of. Intermountain is hiring additional healthcare providers and doctors to take care of patients."It's a satisfying way of practicing to actually be trying to keep people well teams let them practice at the top of their license," Intermountain CEO Marc Harrison said. Eventually, the hope is to expand this model beyond Intermountain, Shrestha said. That'd mean deploying Intermountain's primary care model within other health systems who might have an interest in initiating the approach to primary care but don't necessarily have the resources to do it themselves."We felt we would be able to provide a new differentiated care model that would benefit our patients and beyond," he said. <h2>Geisinger's plan to open primary care clinics for the elderly</h2>Starting this summer, Geisinger plans to open clinics geared toward members of its Medicare Advantage plans.The new clinics, called "65 Forward," are modeled on the concierge care models Ryu's seen in places like the Bay Area, but won't charge extra fees.The model is predicated on the fact that Geisinger operates the Medicare Advantage plan as well as the clinics. Because Geisinger's getting paid a set amount by the US government to manage the health of the patients, the system has a direct reason to try to keep those patients healthy and out of the hospital, investing in preventive services instead.The new clinics will cap panels at around 450 patients per doctor, a much smaller number than Geisinger's other clinics. They'll also serve as community centers for seniors, hosting educational sessions, bridge leagues, knitting groups, etc."We believe that when you do that people are healthier," Ryu said.Want to tell us about your healthcare experience? Email the author at lramsey@businessinsider.com. <a href="https://www.businessinsider.com/intelligence/digital-health?IR=T&amp;itm_source=businessinsider&amp;itm_medium=ctgr_bii&amp;itm_term=ctgr_subscription&amp;itm_content=health&amp;itm_campaign=digital-health"><img src="https://static.businessinsider.com/image/5cf6b11111e205471c5718a4" alt="Join Digital Health Pro" border="0" style="width: 100% !important" /></a>

Big hospital systems are borrowing an 80-year-old idea to keep patients healthy and cut costs, and it could be the future of healthcare

<div class="image-container" style="width:620px"><div class="image"><img src="http://static6.businessinsider.com/image/5141ec97eab8ea777800000a-3109-1554/shinzo-abe-7.jpg?maxX=620" border="0" alt="Shinzo Abe" width="620" /></div>AP</div>
There's a new government in <keyword id="6355311" type="COUNTRY" weightage="60" keywordseo="Japan">Japan</keyword>, and it appears determined to finally do "<a href="http://www.businessinsider.com/kuroda-says-he-will-do-whatever-it-takes-2013-3">whatever it takes</a>" to attempt to revive the moribund Japanese economy, which has struggled with deflation for a decade.
The plan – called "Abenomics," named after newly-elected Prime Minister Shinzo Abe – is three-fold. It involves a massive increase in fiscal stimulus through government spending, a massive increase in monetary stimulus through unconventional central bank policy, and a reform program aimed at making structural improvements to the Japanese economy.
In short, "Abenomics" amounts to one of the biggest economics experiments the modern world has ever seen.
Financial markets are loving it. The Japanese stock market is soaring. But what exactly is it, and how is it expected to work?
In a recent report, titled "Abenomics Handbook," Nomura economists led by Tomo Kinoshita break down the Japanese government's new plan and examine the challenges facing it.
Naturally, the first question is: How exactly are these policies supposed to boost the economy?
While fiscal stimulus and structural reform are essential components of the experiment, monetary policy is expected to do most of the heavy lifting in the short term. So, let's take a look at the monetary policy behind the plan first.
<h3>The monetary policy aspect of Abenomics</h3>
The goal of easy monetary policy is to reduce real interest rates. In Japan's case, it has a significant side effect of weakening the yen.
So, the yen is weakening – and it's beginning its journey downward from incredibly elevated levels. (In recent years, investors piled into yen as a safe-haven currency, helping to drive up its value.)
<div class="image-container click-to-enlarge" style="width:620px"><div class="image"><a title_source="Business Insider / Matthew Boesler, data from Bloomberg" title_caption="" class="zoomin" href="http://static4.businessinsider.com/image/5141eb536bb3f7c813000010-960/usdjpy-3.png"><img src="http://static4.businessinsider.com/image/5141eb536bb3f7c813000010-1502-752/usdjpy-3.png" border="0" alt="USDJPY dollar-yen exchange rate" width="620" /></a></div>Business Insider / Matthew Boesler, data from Bloomberg</div> 
A weaker yen could be virtuous for the Japanese economy. The currency has already devalued swiftly against the dollar since September, when the wheels of a new economic regime in Japan were set in motion.
This does a number of things. Most importantly, it boosts exports, because other currencies can now buy more Japanese-manufactured products. That means manufacturers are selling more, which feeds into corporate earnings and hopefully translates to increased business investment.
All of this should boost stock prices on a fundamental basis. At the same time, the weakening yen provides fuel for stocks. Since September, the Japanese government has verbally "talked down" the yen, and a big rally in the Nikkei materialized along with the decline of the currency.
"As for the specific effect of higher share prices on the economy," the Nomura team writes, "we think higher share prices invigorate corporate capex by (1) making it easier for companies to raise funds, and (2) making companies more likely to invest in business expansion. We estimate that a 10 percent rise in share prices boosts capex by 3.2 percentage points one year later."
And the wealth effect is a big part of the plan.
<div class="image-container click-to-enlarge" style="width:620px"><div class="image"><a title_source="Matthew Boesler / Business Insider, data from Bloomberg" title_caption="" class="zoomin" href="http://static2.businessinsider.com/image/5141eb93eab8ea2878000004-960/nikkei.png"><img src="http://static2.businessinsider.com/image/5141eb93eab8ea2878000004-1502-753/nikkei.png" border="0" alt="Nikkei 225" width="620" /></a></div>Matthew Boesler / Business Insider, data from Bloomberg</div> 
?"For households, we think higher share prices stimulate willingness to spend by boosting the value of shareholdings and giving an indication of the health of the economy," the Nomura economists continue. "We estimate that a 10 percent rise in share prices boosts consumer spending by 0.12 percentage points three months later."
All of this works to narrow the ¥16.5 trillion (~ $170 billion) gap between current GDP and potential GDP, thus working toward eliminating deflationary pressures.
However, the Japanese government has come under fire in the international community recently for its verbal interventions in the yen that have caused it to swiftly devalue against other currencies.
The Bank of Japan has a few other options.
Recently, it announced that it would double its target inflation rate to 2 percent, employing open-ended asset purchases (much like the Federal Reserve is doing in the United States) to get there.
This represents a shift from the conservatism that has characterized the Bank of Japan in recent years. Haruhiko Kuroda, a big dove on monetary policy (meaning he's usually in favor of more stimulus, not less), is set to take over at the helm of the central bank in April. The times are changing, and one can expect to see some experimentation in the months and years ahead.
(<a href="http://www.businessinsider.com/bank-of-japans-policy-options-2013-1">Click here for 23 things the Bank of Japan could do to weaken the yen even more</a>.)
<h3>The Abenomics approach to fiscal policy</h3>
The second part of the "Abenomics" game plan involves short-term fiscal stimulus. This aims to revive economic growth immediately through increased government consumption and public works investment.
Abe already introduced ¥5.3 trillion (~ $60 billion) in public works spending as part of its 2013 budget. That's up from an estimated ¥5 trillion (~ $50 billion) last year, according to Nomura, representing a change from the fiscal tightening that Japan has undergone in recent years.
"?Aside from the general account, the government plans to set aside spending for post-quake reconstruction efforts in special accounts," says Nomura. "The Abe government has decided to boost total spending on the five-year effort (through FY15) to about ¥25 trillion (~ $260 billion), from ¥19 trillion (~ $200 billion) previously."
The important point here is that the government is pledging to be flexible with regard to fiscal policy in the coming years, a stance in stark contrast to those in the United States (which is dealing with the effects of sequestration) and the euro area (where economic austerity is helping to deepen the economic contraction there).
<h3>Structural reforms – the most important aspect of Abenomics</h3>
Loose fiscal and monetary policy is supposed to facilitate expansionary economic conditions in the short term (although weakening the yen is arguably a longer-term goal as well).
Crucially, though, the success of "Abenomics" hinges on the third prong of the approach: structural reform.
The Nomura economists call this "the key to improving medium-term growth potential," details of which are expected to be unveiled to the public in June.
"With government debt having expanded to more than 200 percent of GDP, we think it will be difficult for Japan to boost the economy in the medium term via fiscal spending alone," they write. "As the effects of bold monetary easing are primarily transmitted via expectations on the financial and capital markets, any resultant move out of deflation is likely to be short lived unless economic growth can also be boosted via the government's growth strategy."
Below is a summary of the growth strategy currently under proposal.
<div class="image-container" style="width:620px"><div class="image"><img src="http://static3.businessinsider.com/image/5141deb5eab8ea8957000009-755-854/screen%20shot%202013-03-14%20at%2010.27.14%20am.png" border="0" alt="Key themes proposed by the Headquarters for Japan's Economic Revitalization" width="620" /></div>Nomura, based on Headquarters for Japan's Economic Revitalization data</div>
 There are several aspects to the regulatory reforms under proposal as well, outlined below.
<div class="image-container" style="width:620px"><div class="image"><img src="http://static6.businessinsider.com/image/5141df736bb3f7f17b00001e-728-854/screen%20shot%202013-03-14%20at%2010.31.36%20am.png" border="0" alt="Main areas of focus for regulatory reform panel" width="620" /></div>Nomura, based on regulatory reform panel (within Cabinet Office) data</div>
In short, there is a lot of work to do.
Will the Abe government be able to get it all done? There are some serious open questions about its ability to achieve success in putting the Japanese economy back on stronger footing.
<h3>Why Abenomics might not work</h3>
The first question is whether the Bank of Japan will be able to implement monetary policy to actually effect 2 percent inflation. After all, they've been operating with a 1 percent inflation target, and they haven't even been able to come close to that.
The Nomura economists write, "While we think attainment of the 2 percent inflation target will be problematic, we see the establishment of the 2 percent inflation target as meaningful because setting the bar high and bringing on board more powerful easing measures makes an end to deflation more likely."
Nomura also acknowledges the risks to financial stability that may arise from excessive monetary easing, warning that "if the BOJ were to sharply increase its purchases of financial assets, this could cause distortions in the markets for those financial assets, disrupting market mechanisms or producing unforeseen risks related to the accumulation of imbalances.
In other words, there could be bubble trouble.
The Abe government's fiscal approach is tricky, too. Good policy strives to be counter-cyclical, meaning that when the economy improves, the government should take the opportunity to tighten its belt.
There's a consumption tax hike scheduled for 2014, though. Nomura thinks the Abe government will boost spending to offset it.
<div class="image-container float_right click-to-enlarge" style="width:400px"><div class="image"><a title_source="Nomura" title_caption="Click to enlarge" class="zoomin" href="http://static1.businessinsider.com/image/5141e87b6bb3f73d11000003-960/screen%20shot%202013-03-14%20at%2011.09.53%20am.png"><img src="http://static1.businessinsider.com/image/5141e87b6bb3f73d11000003-849-755/screen%20shot%202013-03-14%20at%2011.09.53%20am.png" border="0" alt="Japan primary central and local government budget balances" width="400" style="color: #000000;" /></a></div>NomuraClick to enlarge</div>"The biggest challenge," the economists say, "is striking a balance with fiscal reconstruction." Abe's government says it wants to cut the budget deficit in half from 2010 levels by 2015 and flip the budget balance into outright surplus by 2020. Continued public spending could make that pretty difficult.
Finally, if the yen stops weakening, it really puts the brakes on the entire "Abenomics" project. The yen is expected to continue its decline – and <a href="http://www.businessinsider.com/the-comeback-of-the-us-dollar-2013-3">many expect the U.S. dollar to enter a new bull market</a> – but, as ever, the future is uncertain, and for Japan, it depends on implementation.
We should also note that this all assumes that the Abe government is committed to the task to begin with. There is at least one theory that ultimately calls this commitment into question. (<a href="http://www.businessinsider.com/abe-might-not-be-aggressive-about-easing-2012-12">Everybody Is Talking About The Japanese Yen's Collapse, But Nobody Understands The Prime Minister's True Motivations</a>.)
The Nomura economists come to the following conclusion:
Yen depreciation benefits exporters but it could also have an adverse effect on the economy via an expansion of the trade deficit or a deterioration in the terms of trade (export prices/import prices). Also, the benefits of fiscal expansion and monetary easing are not limitless. In particular, fiscal and monetary easing are not limitless. In particular, fiscal expansion could stimulate market concerns regarding problems securing funding and fiscal risk.
For Japan's economy to overcome these challenges and be revived, we think the key requirements are a change in ingrained expectations about deflation (ie, an improvement in growth expectations), a self-sustaining increase in private-sector economic activity (ie, growth without fiscal expansion), and fiscal reconstruction (ie easing of fiscal risk). If companies can pass higher import prices and other cost increases onto selling prices, we think restructuring pressures in Japan will lessen. If confidence in economic growth in Japan grows simultaneously with an improvement in Japan grows simultaneously with an improvement in corporate earnings, we think increases in employment and wages will be likely.
If real wages increase amid efforts to end deflation and put inflation on track, we think the Japanese economy will be more likely to return to self-sustaining growth.
The rest of the world will be watching closely.
<div class="image-container click-to-enlarge" style="width:620px"><div class="image"><a title_source="Nomura" title_caption="Click to enlarge" class="zoomin" href="http://static3.businessinsider.com/image/5141b92e6bb3f7533300000e-960/screen%20shot%202013-03-14%20at%207.47.37%20am.png"><img src="http://static3.businessinsider.com/image/5141b92e6bb3f7533300000e-1134-652/screen%20shot%202013-03-14%20at%207.47.37%20am.png" border="0" alt="Abenomics flow chart" width="620" /></a></div>NomuraClick to enlarge</div>

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