Tzvi Doron, DO

Critical Issues in Healthcare that Everyone Should Know but Are Complicated (Explained as simply as possible) 1. Declining Reimbursements (Even Though the Dollar Amount Payments May Increase)   Declining reimbursements are probably the most urgent problem in healthcare right now. Reimbursements are a more technical term and represent revenue in healthcare (at least in the traditional model where healthcare organizations are being “reimbursed” for services by the insurance carriers) and as reimbursements decline, providers struggle to maintain profitability. Yes, healthcare is a business and without profits the medical practices will not survive.    How can there be “declining” reimbursement and the cash payment for some services still increase year-over-year?   Short answer: CMS (Center for Medicare and Medicaid Services) publish publicly the annual fee schedules (technical term for an organized table of reimbursement rates) that the commercial insurance carriers base their reimbursement rates on.    CMS uses a relative value unit formula to calculate the cash payments for each service. There are three components in the RVU model - Practice Expense RVU, Malpractice Liability Insurance Expense RVU, and Work RVU. The RVUs are adjusted for geographic price factors, essentially to factor in the cost of living differences between different regions, states, cities, etc., and then are multiplied by the Conversion Factor.    The formula: (PE RVU x GPCI) + (MP RVU x GPCI) + (wRVU x GPCI) x Conversion Factor   The Conversion Factor is arguably the most critical component of the formula and has decreased year-over-year for the past 20 years. This is why providers and healthcare experts keep ringing alarm bells on declining reimbursement. However, that does not always mean the actual dollar payment has decreased for each CPT code/service (though, many cash payments have decreased).    This is because CMS analyzes the actual historical revenues and expense of Medicare participating hospitals and medical practices at the CPT code level and assigns RVUs to each service based on these metrics. Overall, healthcare expenses have been increasing and based on the RVU allocations there are services that have still “increased” in total cash payment despite declining conversion factors.   The PROBLEM is at this point Medicare rates are basically breakeven points based on legislation that mandates CMS changes to meet certain federal budget requirements. The components of RVUs are based on expenses - actual expenses, so just because these increase they are just covering rising expenses. The conversion factor is the profitability component of the formula and has been shrinking for over 20 consecutive years.   

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Blue Health Intelligence, a data analytics and software company, undertook an evaluation of almost 170,000 unique GLP-1 users for weight loss, notes less than half of those prescribed stay on the medication for 12 weeks or more. Younger adults were less likely to continue the drug, whereas those who were prescribed the medication by an endocrinologist or obesity medicine specialist were more likely to continue for longer. Indeed, this data states 30% of patients dropped out of treatment after the first four weeks, and 58% at 12 weeks. Those who dropped out are unlikely to achieve clinically meaningful weight loss.  The likelihood of continuance was further exacerbated for those with health inequities or who lived in underserved health regions. The data comes from Blue Cross Blue Shield Association members participating in Plans that provided coverage of these products, from 2014 through to end of 2023. Razia Hashmi, vice president for clinical affairs at Blue Cross Blue Shield wants to ‘…paint a clearer picture of what makes somebody successful.’ The missing piece here is why the patients stopped – side effects, failure to achieve initial weight loss, stigma and discrimination, or coverage issues related to cost and access. My longtime friend, colleague and bariatric surgeon at Stanford University, Dr. Dan Azagury rightly states ‘…The goal is for patients to stay on this for a significant amount of time. Most likely… beyond 12 weeks.’ https://lnkd.in/ediQskQx

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What seems safe: joining a large health system What seems risky: betting on yourself The truth? The biggest risk is putting your future in someone else's hands Getting a "steady" paycheck Selling to a health system Selling to private equity All great until your line item on a spreadsheet starts dragging the bottom line Then come layoffs Then the clinic closes Then the service line shuts down The the hospital gets sold to someone else I'm not saying that any of it is easy But we all have the opportunity to choose which version of risk and difficulty we want P.S. If you want to see what the business of healthcare is doing to independence and how to take it back, then you'll love The Healthcare Breakdown, where we breakdown the business of healthcare so you can swing the pendulum of independence back Check it out here: https://buff.ly/47NeASx See you out there!

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CareMax and Steward Health Care are besties What is CareMax you ask? But of course a value based care provider that went public via SPAC in 2021 $297 open price at IPO $487 high price post IPO $3.00 current trading price Notably, CareMaxbought Steward's Medicare VBC business in 2022 for $135M As part of that transaction, double yacht owning Ralph de la Torre became a board member of CareMax Solid foreshadowing Here's what CareMax recently said in it's 10-Q related to its business: "These conditions raise substantial doubt regarding the Company’s ability to continue as a going concern..." Meaning, it may file for bankruptcy if it can't turn things around Some numbers from the quarter: $156M current assets $507M current liabilities $232M revenue ($21.7M) op loss ($23.8M) cash from ops 1:30 reverse stock split recently issued Translation, you had 30 shares and now you have 1 Some more numbers: 55 centers 218,000 covered members 99% under VBC arrangements And last interesting bit of info: "Our principal sources of liquidity have been cash generated by our centers and MSO operations, and borrowings under our credit facilities." When your third key source of liquidity is borrowing, that's an issue Sorry, sorry, one more thing... Apparently, after the acquisition of Steward's VBC business, Steward doctors continued to serve these patients, though they would then be paid from CareMax... which didn't happen What's going on at CareMax? P.S. If you liked this mystery breakdown, you'll love The Healthcare Breakdown, where I breakdown the business of healthcare and all these wheelings and dealings so you can see what's really going on Check it out here: https://buff.ly/47NeASx See you out there!

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“So... Apple is entering the hearing space!” For the past two weeks, I've been flooded with messages asking how Apple's latest announcement will impact Concha Labs. Another consumer tech giant is stepping into the hearing space, but what does this really mean? With over 1.5 billion people affected by hearing loss globally, this is a massive market. Yet, like mental health, hearing loss is something people don’t talk about much. If you ask anyone who’s tried hearing aids, you’ll likely hear stories of frustration—they’re often disliked because of impersonal sound quality. For me, they were always too loud or too quiet, and I could never find the “right” fit. This isn’t new. Apple, like Bose before them, will likely face similar challenges in replicating the status quo. Despite their audio expertise, Bose entered the hearing aid space but exited due to the same hurdles. Bluetooth earpieces, with their short battery life and social awkwardness, also highlight how hard it is to create a practical, long-term solution. But here’s the good news: more attention on hearing health, thanks to Apple’s announcement and the OTC Hearing Aid Act, is a win for everyone. It’s sparking conversations about hearing loss—something I kept hidden for decades. Concha Labs' hearing aids are nearly invisible, like contact lenses. When I tell people I’m wearing our product, they’re always shocked because they don’t notice them, even with my hair up! (And this goes for the guys who wear them, too!) What’s clear to me is that while awareness is growing, real innovation comes from solving actual user pain points. That’s where Concha Labs comes in: we offer a fully personalized hearing experience, much like how Spotify revolutionized music personalization beyond iTunes. Our solution is designed for real-world usability—comfortable, discreet, personalized, and customizable in multiple sizes and colors. Created by people who were tired of the status quo (like me!), our Concha Sol hearing aids are made for those who want something better. So, if you’re tired of the same old hearing aids, let Concha Labs empower you to hear clearly. We promise, you’ll notice the difference. 😉 Amy www.conchalabs.com #hearing #hearingaids #apple #conchalabs #invisible #otchearingaids #startup

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Semi-baked thought here. As so many employers/plan sponsors are strategizing ways to mitigate costs of GLP-1 drugs, perhaps it’s an opportunity to think bigger. Given the cost of these drugs, I posit we could provide a healthy meal service (three meals per day) to each member who qualifies, access to an exercise program, coaching, and a significant financial incentive/bonus if their biomarkers improve. I’d have to do the math, but seems it could be cost neutral (perhaps even a small savings) on an annual basis. Today’s innovators are reducing costs through various strategies like direct contracting, alternative drug sourcing, etc. This totally makes sense, as these strategies target the PRICING FAILURES of the current system. There is so much low hanging fruit there. The innovators of tomorrow will target the actual DRIVERS of cost through improving overall health and reducing prevalence of chronic diseases. The best way to reduce cost long term is to make the current sick-care system less relevant and less utilized. Chess not checkers. Peace and love, fam.

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CME - “I’ll take well intentioned, comical moneymaking schemes in healthcare for $200 Alex” Add continuing medical education (CME) to the long list of healthcare verticals that get it wrong. I’d love to share a story about how not understanding CME cost me $1000 plus a negative course of action on my national practitioners database record. In the state of Alabama, you must perform 25 hours of CME per year. I went to a conference that counted for 22 hours. Since I was a faculty member with a university, I mistakenly thought that medical school lectures that I had organized and legitimately given, counted for the other 3 hours. I was wrong. I was audited. I was asked for a certificate. I answered, “what certificate?” I was fined and reprimanded. I didn’t learn this crap in residency? How was I to know what counted as category 1 CME? Oh that’s right! It’s the stuff that makes someone else money that counts. I gotcha. Unless you spend thousands of dollars to go to some conference in San Antonio, or even worse, hundreds of dollars to take some online test that is useless, your educational activities “don’t count.“ Are there free CME activities? Absolutely. But you get what you pay for. More importantly isn’t the time of doctors worth something a little more valuable? I don’t know maybe like taking care of patients? Unfortunately, there’s not much we can do about these mandatory regulations. Maybe the best thing we can do is get a group of us disruptors together, form our own accredited conference, and work to solve the broken healthcare system. I’ll suggest Tuscany, but I’m open to suggestions. #cme #physicianburnout #physicians #healthcare #medicaleducation #physicianwellness

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While 61% of human #health determinants’ impacts are #controllable with support systems, they only get $1,822B spending vs medical care’s 11% impacts w $3,237B spending in the US in 2017. When we connect those structural stats of #spending vs health impact with current and prevalence burdens & costs of diseases globally, we might see mismatched #focus, #investments, and spendings that reflected in heavy #burdens & #costs on many humans and their families around the world. 🌏 What’re the immediate actions would you, your Org’s leaders, and teams would take to improve your 61% health impacts that are controllable with literacy, support systems, etc? Giang Pham bePrana Wellness Infographic by bePrana Wellness Stats by World Health Organization & goinvo.

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What are the different ways you pay for healthcare? 1. Insurance premiums through private insurers. 2. Taxes that fund government programs like Medicare and Medicaid. 3. Cash payments you're on the hook for via copays and deductibles. What's going to happen when healthcare costs go up 8-9% next year and our population keeps getting sicker and sicker? And we keep "investing" in more sickcare? 1. Your taxes will go up (or at least government funding will get shifted to cover these costs reducing investments in other areas) 2. Private insurance premiums will go up astronomically again 3. You're copay or deductible will increase shifting more risk to you This should come as no surprise to anyone... Start fixing the problem or budgeting for higher costs I guess you could just keep sticking your head in the sand as well like so many do :) #healthcare #business #hr #benefits #ceo #insurance

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It's interesting how battle lines have been drawn so firmly on GLP1's - Ozempic, WeGovy, etc... - particularly around the recent data suggesting that the US Obesity Rate fell for the first time in a long time due, likely in no small part, to GLP1's. There is a lot of "Is this amazing," or is this "a huge problem" going on in the fitness/wellness/general world. Perhaps we don't wants to hear or say this, but we need to look at this with more nuance because IT DEPENDS! In a world that is heavily dominated by soundbites, memes, and shallow-depth thought going viral, I find myself increasingly in conversations where the reality is far more complex than one sentence, and I don't think it's optimal to have a stance so firm that it fails to take into account the myriad of volatility associated with health. For ex, 1. Do we know the long-term effects of GLP1's for weight loss clients? Absolutely not because they haven't been out long enough. We can speculate, but let's make sure to say it's speculation 2. Do the pharma companies have our best interests at heart? In any large organization there are clearly champions of the customer as well as champions for the companies' bottom lines. 3. Do GLP1's cause potential issues with loss of muscle mass? This appears to be true in the studies that have been run. However, if somebody can lose a lot of weight where they otherwise couldn't have before, is it a net positive? IT DEPENDS! 4. Is a 1.6% decrease in obesity rate a new trend? By definition, it is not because it is only one data point in a multi-year/decade history, particularly when 10 years ago we were in the mid/high 30%'s. Can we speculate about if it's a good/bad thing? We sure can 5. Will all humans respond to GLP1's the same way? Absolutely not - physically, mentally, emotionally (and also financially) matters in how people react to medications like this. 6. Will the "wolves" come into this market because it's exploding, creating a negative outcomes? Who knows, but we are seeing seriously large numbers of new players enter the space Like all complex and challenging situations (health / obesity / meds), let's make sure we ask great questions to smart/credible people to CONTINUE opening our eyes more and more good and bad. It's a fact that we already have an emotional opinion (that darn human behavior thing haha) but in a topic this big, we owe it to ourselves to dig more deeply https://lnkd.in/dS4sy-J8 https://lnkd.in/dNKg-NJv

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Spitball Sunday - Let's redistribute the $300B of acute care revenue ALREADY BEING REDISTRIBUTED, but let's not have it go to pharma AND let's make it an actual investment in health and not a temporary fix. Introducing the "Food" GLP-1. And if you insist, it can be a companion to current GLP-1's. Details after the tidbits below. If you are in healthcare today, I caution you not to scroll on by thinking this doesn't apply to you. I read hims & hers Q3 earnings and let me assure you, healthcare is about to blindsided. Here are some tibdits: 🤩 You're seeing mass market adoption of the personalization options across all of these categories...which is really bringing a level of clinical excellence, adherence, stickiness, retention, and customer demand 👀 And what that's doing is something really special...very rarely accessible to the mass market...hyper personalization approach to understand the underlying factors driving your weight gain 😵‍💫 70% of patients on the Hims & Hers platform that are getting...personalized treatment are adhering to the treatment (vs 40% in the traditional brick-and-mortar system) 💲 We ended the third quarter with over 400,000 subscribers on the platform from ZIP codes where the average household income is below $50,000, with nearly 40,000 of those subscribers in weight loss NOW THE SPITBALL CONCEPT - 12 month food based step-down program (MUST BE quality of food over quantity) 🍫 L-Nutra, Inc fast mimicking program Prolon Fast (Joseph Antoun) 🥘 Some highly personalized/democratized high quality MTM think LifeChef Mark Redlus (but only if we can get nutritionally dense food #regenerativeagriculture into the supply chain - I know Carter Williams and Katie Stebbins and my entire food posse can help here) #regenerativeagriculture 👩‍🍳 Integrated nutritional support / meal planning / food delivery EatLove PRO Monique Nadeau Kelly's Choice LLC Kelly Springer MS, RD, CDN 🥦 Regenerative fresh produce FreshRx Oklahoma Erin W. Martin 📱 MAYBE some low-cost personalized behavioral nudging think MediKarma Kris Narayan MYNDSET Michael Mircea Bidu Lirio Marten den Haring 💰 After the 12 months cash pay option for maintenance version of above THIS is how you help people. THIS is how you reverse disease. Take this one step further & add the clinical team, you have a health plan. If hims & hers isn't already thinking about their own health plan I'd be surprised and either way Craig Primack MD, FACP, FAAP. MFOMA, Dipl. ABOM we should talk. Spoiler - this isn't really a spitball - this is inevitable. Something like this is the only way out. N of 1 healthcare is happening, if it sounds foreign, it shouldn't. BP2 Health (and tons of others) can't unsee this vision. Robert Sundelius, FACHE Gary W. Druckenmiller, Jr. Josh Erndt-Marino Prasanthi Tondapu Tyler Hemmingson Martin Tull Peter Cranstone Clancy Harrison Geoffrey Rutledge Neil M. Meltzer, MPH, MHA Padmaja Patel,Sean Sullivan and on and on.. Please tag yourself.

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You hear the whispers all day long....you need to go digital for your practice to survive... Good news, you still can. If I had to develop a strategy without knowing your business at all here are the 4 tactics you can do TODAY. 1. Implement Telehealth Services Telemedicine Platform: Choose a HIPAA-compliant telemedicine platform that integrates with your existing EHR. Offer virtual consultations, follow-ups, and remote monitoring to meet the growing demand for telehealth. Patient Education: Educate your patients on how to use telehealth services. Use email campaigns, social media, and your website to provide instructions and promote the convenience of virtual care. 2. Leverage EHR and Practice Management Software EHR Optimization: Ensure your EHR system is fully optimized for efficient documentation, billing, and reporting. Customize templates to streamline patient visits and reduce administrative workload. Automation: Implement automation for routine tasks like appointment reminders, billing, and patient follow-ups to enhance efficiency and reduce manual errors. 3. Enhance Patient Engagement with Digital Tools Patient Portal: Offer a secure patient portal where patients can access their medical records, test results, and communicate with the practice. Encourage patients to use the portal for appointment scheduling and prescription refills. Mobile App Integration: Consider offering a mobile app that syncs with your EHR system, providing patients with easy access to their health information and enabling real-time communication with the practice. 4. Use Data Analytics for Practice Growth Patient Data Analysis: Utilize data analytics to track patient demographics, health trends, and treatment outcomes. This can help identify areas for improvement in patient care and operational efficiency. Performance Metrics: Regularly review key performance indicators (KPIs) such as patient satisfaction, appointment no-show rates, and revenue cycle metrics. Use this data to make informed decisions and refine your practice’s strategy. Give yourself more time to be the physician and stop getting stuck doing paperwork & charts all day long.

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The birth of the MedSLP Collective was an unexpected journey that began during my time running a mobile FEES business in New York. Despite support from medical professionals, we faced a challenge: SLPs weren’t making many FEES referrals. This revealed a crucial insight - many SLPs weren’t fully aware of the benefits for their patients. Our field needed more education. To address this, I started a blog and newsletter for the SLPs I worked with. What began as a modest effort unexpectedly sparked a movement, as the content spread rapidly, revealing a deep hunger for specialized knowledge among SLPs. As the blog gained traction, I found myself at a crossroads. The demands of a growing online presence competed with the mobile FEES business. Inspired by podcasts I listened to during long drives, I decided to transform the blog into The Swallow Your Pride Podcast, which debuted at #11 on the iTunes Science and Medicine chart. The podcast’s success clarified my mission: provide accessible, high-quality education to SLPs everywhere. This led to a membership platform offering bite-sized education, designed to fit into the busy lives of practicing SLPs. When I floated this idea, the response was astounding - 300 people signed up overnight. This journey has been transformative. It’s a testament to the power of listening to our colleagues, adapting to their needs, and continuously innovating how we share knowledge. The Collective and our membership platform are the fruits of this journey. They represent not just my vision, but our profession’s collective desire to grow, learn, and provide the best possible care for our patients. As we continue to evolve and expand our educational offerings, I’m reminded daily of the passion and dedication that defines our field. To everyone who has been part of this journey - thank you. Your enthusiasm, curiosity, and commitment to excellence continue to inspire and shape the future of our profession. The Collective was born from a simple desire to educate, but it has grown into a movement that empowers SLPs to provide better care and achieve their full potential. #medslp #medslpcollective #slpeducation

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5% of people, 51% of healthcare spend It's not that average spending is $13,500 per person It's that: 1% spend $160,000 per person 5% spend $71,000 per person 50% spend $385 per person Want to attack healthcare costs? Stop the bottom 50% from entering the top 6% How? Consider this: 90% of our health expenditure is on chronic conditions 90% of Type 2 diabetes is preventable 80% of heart disease is preventable 40% of dementia is preventable 40% of cancer is preventable Also consider that total spending per person in the bottom 50% was only $385 We aren't spending enough on keeping people healthy That's the ticket to bending the cost curve P.S. If you liked this breakdown, you'll love The Healthcare Breakdown, where I breakdown topics in healthcare for aspiring healthcare operators, founders, and professionals Check it out here: https://buff.ly/47NeASx See you out there!

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Healthcare founders - you have to get specific about your ideal customer profile. Your target market isn't "health systems" Northwell Health is incredibly different than a small regional system doing $500 million in annual revenue on Cerner. Your target market isn't mental health. A private practice on Healthie is wildly different from a community mental health center on Qualifacts. 1. Size of organization 2. Existing tech stack 3. Specialty and subspecialty And so much more can impact how good of a fit you are. You don't have time to waste resources changing deals with little chance to close. I strongly recommend asking these for these three items on your website lead form. It gives you the foundation to creating a lead scoring system from. Article in the comments.

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For those #healthcare leaders who are scratching their heads on how to approach the new #CMS #CMMI #TEAM mandate, this blog will get you started on the right foot! https://lnkd.in/ebZGxXjR

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Doctor visits seem to be getting shorter and shorter. This makes sense if you think about it from a business standpoint. Each year health insurance companies put a double squeeze on practices: 1. Lower reimbursements to physicians 2. Increase the overhead required to collect payments in the form of extra paperwork, prior authorizations etc. More person-hours needed, usually means extra staff is required. In order to keep the boat from sinking, physicians have had to turn to very high volume models. "See more patients doctor". Obviously there are only so many hours in the day, so what we get are overloaded schedules. These high volume schedules will obviously mean shorter appointment times. Medicine is also something that is necessary time dependent. So the shorter your visit, the worse job your doctor will probably do when they see you. Worse communication, skipped problems, no time to go the extra mile. The end result is worse care for the patient, and significant physician frustration. This leads to burnout because the docs know they aren't doing a good of job as they would like. Solution? Docs need to stop taking only insurance and patients need to stop using theirs for basic visits if they actually want to see a doc in a timely manner and spend time with them. #healthcare #medicine #healthinsurance

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[Sneak peek into this week's edition of "Rx Writer's Digest"] Al in Healthcare is becoming more efficient and sophisticated at facilitating doctors and other healthcare professionals. The potential for Al in healthcare is huge. Keeping that in mind, here is the highlight of the new edition going to be published tomorrow. ➡ Top 8 applications of AI in Healthcare ➡ Limitations of Al in Healthcare If you have not subscribed to the newsletter yet, click the link in the comments section. The cherry on top!! It's free for a limited time 🐣 ------------------------------------------------------------------------------------ I am Roma Ehsan, a pharmacist/ medical writer. I write for healthcare businesses and experts targeting their audience to signal their messages. #medicalwriting #healthcarewriting #clinicalwriting #moderntrendsinhealthcare #linkedinwriting #healthcareprofessionals

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Yeah, Walmart, we get it. Healthcare is hard. Inexplicably sometimes. It's why the Haven venture, despite being a brainchild of some of our best business minds, couldn't get off the ground to circumvent some of the industry's biggest challenges (or even just one of them ... Big Health Insurance). Here's my favorite part of Walmart's announcement that they're closing up shop on their primary care venture(s): "The decision to close is due the "challenging reimbursement environment" and rising operating costs, which have resulted in a lack of profitability." Lack. Of. Profitability. Next time you hear about rising healthcare costs, think twice about what part of the industry they're talking about. Doctors? Primary care clinics? Hospitals? To be clear the kind of annual profits the average public hospital (and most corporate and non-profit hospitals as well) sees is what Walmart would view as a rounding error -- in a quarter. But take that statement apart a bit more, and think about Wal-Mart's choice of wording: "challenging reimbursement environment". How do you negotiate to get the best possible premium rates for your employee health insurance plan but still complain about the business operations that effectively shut down your operation? You don't. You throw in the towel and go back to competing with e-commerce. https://lnkd.in/g_DMSCWE

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