Providing value to providers by simplifying the process of identifying and monitoring mental health conditions.
An estimated 26% of Americans ages 18 and older — about 1 in 4 adults — suffers from a diagnosable mental disorder in a given year. Many people suffer from more than one mental disorder at a given time. In particular, depressive illnesses tend to co-occur with substance abuse and anxiety disorders. With the increasing demand for faster and efficient patient care, the lack of proper assessment often results in misdiagnosis.
The initial step in any treatment plan is getting the right diagnosis—but it’s not always as accurate as one would hope. This need in the market in mental health had brought us to build an online health assessment tool to enrich patient visits by providing clinicians with precise patient information prior to meeting; eliminating misdiagnosing.
Clinicom is composed of compassionate healthcare professionals, mental health innovation leaders and pioneering technology developers.
Nelson M. Handal, MD attended Medical School at the Ruprecht Karl University in Heidelberg, Germany, and graduated from Universidad Mayor de San Andres in La Paz-Bolivia, his hometown. He completed his internship and residency training in General Psychiatry at the State University of New York Health Science Center at Syracuse in Syracuse, New York. Following residency, he completed his Fellowship in Child and Adolescent Psychiatry at the University of Miami School of Medicine in Miami, Florida. At the present time he is a Clinical Faculty at the Alabama College of Osteopathic Medicine in Dothan, Alabama.
His vision to create CliniCom® was born after many years of work focused on perfecting a mental health clinical model that uses technology while implementing sensible, practical, and modern clinical practices. Developing CliniCom® for over 10 years has been for him the most challenging and expensive endeavor, but it led to an article in Forbes in 2018 after CliniCom® was used by thousands of patients around the US. Clinicom was also awarded at the Psychiatry Innovation Lab at the American Psychiatric Association. Dr. Handal was invited to testify before the United States House Committee on Veterans’ Affairs regarding innovative technologies and treatments for veterans; he spoke about CliniCom®.
For the past 20 years, Dr. Nelson M. Handal has been the Founder, Chairman, and Medical Director for Dothan Behavioral Medicine Clinic a large and modern mental health clinic. Four physicians, two nurse practitioners and thirteen therapists serve about 180 patients a day, half of whom live more than an hour away.
He is also the Founder and Medical Director of Harmonex Neuroscience Research where he participated in clinical research as a primary investigator in over 80 clinical trials for the past 14 years. He was Chief Medical Officer with NLS Pharmaceutics from Switzerland in a critical award-winning research study.
Dr. Handal has dedicated much of his career to developing and implementing technologies that elevate the quality of patient care. In the late 1980s, Dr. Handal was president of one of the first international telemedicine referral services in the world. This system was featured in Business Week.
Awards include the Heroes in the Fight Award given by Mental Health America. Excellence in Public Mental Health Award given by the National Alliance on Mental Illness (NAMI). In addition, Dr. Handal has been recognized as one of America’s Top Psychiatrists given by the Consumers’ Research Council of America. Dr. Handal has also received the Patient’s Choice Award and the Mental Health Professional of the Year Award for Alabama. He was presented with the Clinical Scholar Award conferred by the University of Miami School of Medicine. His private practice, Dothan Behavioral Medicine Clinic, has received the Best of Dothan Award in the Physicians' category by the U.S. Local Business Association (USLBA). Dr. Handal is a Distinguished Fellow of the American Psychiatric Association and Diplomate of the American Board of Psychiatry and Neurology.
Mr. Handal is a driven Senior Executive, Innovator, and Clinical Research Professional. Mr. Handal has completed a myriad FDA phase I, II, & III studies in pharmaceuticals, and devices (Class II & III) over nearly two decades. According to Globaldata.com this puts Mr. Handal in the 99.92% of all 360,382 Clinical Researchers Globally. Mr. Handal brings expert level experience in Directing Clinical Research, Site Management, Contract Negotiations, Regulatory Compliance, GCP Training, and Project Management. He has Expertise in managing multiple therapeutic areas simultaneously in multiple settings including Neuroscience, Psychiatry, Sleep Medicine, Neurology, and Ophthalmology.
As a Director of Program Management for a Global CRO, Ignacio typically managed multiple, multi-million dollar protocols at one time across indications and continents. Ignacio is experienced in managing multiple complex teams globally. He is a results-oriented leader dedicated to delivering consistently high-quality, timely results with focus on meeting key stakeholder goals and expectations. Expertise in building, cultivating, and managing, productive relationships with Pharmaceutical companies, CROs, and other Clinical Trial Vendors.
Mr. Handal has led the creation and development of two nationally recognized clinical research centers, Harmonex Neuroscience Research and Trinity Research at Eye Center South. Harmonex Neuroscience is the clinical research institute that gave birth to Clinicom at its inception. Mr. Handal Led that organization as the Director of Clinical Research and started this center de novo. Mr. Handal also teamed up with world renowned Ophthalmologist Dr. Sebastian Heersink of MIT and Wills Eye institute fame to create a world class research institute Trinity Research at the 3rd largest surgical center in the country, Eye Center South. Ignacio is an Entrepreneur and job creator. In 2008 Ignacio founded Downtown Investment Group. D.I.G. preserved and redeveloped a large portion of the historic district in his hometown of Dothan, Alabama. Preserving 50,000sqft of structures in the Historic District. With over 64+ jobs created in the city's core and millions in revenue generated via his venues “The District” and “Saint Andrews Market” a former Ford Assembly Plant turned local Market place. Ignacio has served as a Historic preservation commissioner for the City of Dothan Alabama from 2010-2012. Ignacio is a Microbiologist by training and was the President of the College of Science and Mathematics at Auburn University, where he founded his first business at age 18 with 13 employees, AUscene Magazine, notably interviewing leading figures like Maya Angelou and Lee Corso, for his monthly publication of over 10,000 magazines from 1999-2003.
In addition to providing advice to Clinicom through service on the Board of Directors; James Riddle is the Vice President for Research Services & Strategic Consulting for Advarra where he employs his extensive experience managing large operations and technology teams in the human subject protection, research administration, and regulatory fields to grow Advarra worldwide. Mr. Riddle is also a faculty member, mentor, and regular speaker for Public Responsibility in Medicine and Research (PRIM&R); a member of the CTTI Steering Committee; and leader of the SASI technology domain accreditation team.
Prior to joining Advarra, Mr. Riddle served as a leader of the human subject protection and animal care and use program at the Fred Hutchinson Cancer Research Center, one of the nation’s largest independent cancer research centers. In addition, he has served on the board of the Northwest Association for Biomedical Research (NWABR), was an AAHRPP site visitor, and was the Vice President of Operations and Director of Technology at another large central IRB. His expertise includes reengineering operational processes, systems evaluations, development and implementation of technology solutions, integration of technology solutions with operations, and management of large IRB and IACUC systems.
Mr. Riddle has a bachelor’s degree in accounting with an emphasis in computer science from Western Washington University, College of Business and Economics.
David is the Chief Financial Officer of Clinicom Healthcare, Inc. the World’s first comprehensive digital mental health assessment tool. As CFO David is responsible for managing all financial aspects of the company including funding, financial reporting, financial planning, accounting, strategic relationships and all aspects of financial negotiations.
Prior to this David was Chief Risk Officer (CRO) for State Street Global Advisors, the third largest asset manager in the World and a subsidiary of State Street Bank (GSIFI). David oversaw all investment, trading, credit, operational, liquidity, regulatory and fiduciary risk. David chaired or was a member of the Management Risk and Capital Committee, Risk Committee, Global Investment Committee, IT Steering Committee and Global Product Committee. <
David was previously Chief Risk Officer for State Street Bank’s largest subsidiary, State Street Global Services, overseeing custody, accounting, fund administration and alternative asset servicing for $28 Trillion in assets. David served on the Boards of State Street Bank and Trust Company, NA and State Street Bank of California, NA, was Chairman of the Charitable Asset Management Committee and served on the Valuation Committee for one of Boston’s largest asset managers.
Before joining State Street David was the Head of Risk Management for Pioneer Investments where he oversaw all investment, trading, IT and Operational Risk for $70 billion in AUM. David was on numerous committees including serving as the Chair of the Trade Management Committee.
David also has experience as the Head of Counterparty Risk for Harvard Management Company where he was responsible for counterparty and credit risk for all equity, private equity, fixed income and commodity derivative investment strategies within Harvard’s endowment and its associated arbitrage portfolios. David also served as a Commercial Banker for Bank of America covering the real estate, health care and service industries.
David graduated from The Citadel Military College of SC with a BS in Business Administration and received his MBA from Baylor University’s Hankamer School of Business. David currently serves as an advisor or board member of The Citadel’s Baker School of Business and La Vida.
Dr. McCleod is a Board Certified Child and Adolescent Psychiatrist who has been in practice since 2003. She is the Chief Medical officer for Clinicom Healthcare Inc. She is a investigator in many clinical research studies. Dr. McCleod is the current Medical Director of Southeast Alabama Youth Services' Diversion Center and the Boys and Girls Attention Group Homes. She is owner and founder of J.C. McCleod, MD Psychiatric, PLLC. She serves as a clinical faculty member for the Alabama College of Osteopathic Medicine supervising medical students. She also supervises nursing, counseling, and social work students in the field of psychiatry as a clinical preceptor. She has recently retired from Laurel Oaks Behavioral Health Center, an acute and residential in-patient psychiatric care for children and adolescents, where she was the Medical Director from 2009-2020. She is the former medical director of Bradford Health Clinic, an intensive out-patient center for treatment of adults and adolescents with substance dependence in Dothan, Alabama from 2006-2018.
She is a native of Chicago, Illinois and completed her Bachelor of Science Degree at Howard University in Washington, DC. She received her Medical Degree from the University of Illinois, College of Medicine. She completed her residency in General Psychiatry, and fellowship in Child and Adolescent Psychiatry both at Emory University in Atlanta, Georgia. Dr. McCleod is Board Certified in General Psychiatry as well as Child and Adolescent Psychiatry. She is licensed to practice medicine in the states of Alabama and Georgia.
Dr. McCleod is a Fellow of the American Psychiatric Association, and a member in good standing of the American Academy of Child and Adolescent Psychiatrists, the American Medical Association and the National Medical Association. She is a life member of the Global Directory of Who's Who in American Professionals. She received the Mental Health Professional of the Year Award given by the National Alliance for the Mentally Ill (NAMI), Wiregrass in 2009. She was on the board of directors for NAMI Alabama from 2017-2019.
She served as the 12th and again as the 14th chapter President of Alpha Kappa Alpha Sorority, Incorporated, Kappa Pi Omega Chapter, and was voted as the chapter's 2010 “Soror of the Year”. She actively volunteers in many community service projects. She's a member of Greater Beulah Baptist Church. She is married to Don McCleod, CPA, and they have two children, Don Robert and Michelle.
Dynamic executive leadership is Jim Breidenstein's trademark. The breadth of his experience spans business and commercial operations, strategic planning/execution, sales, marketing, product launch and team building within the digital therapeutics, mHealth, MedTech, medical device and healthcare sectors in startup, mid-cap and Fortune 500 environments.
Consistently recruited to “work his commercial magic”, Jim's career is defined by his relentless pursuit of winning.
Whether challenged to steer a disruptive startup, launch a revolutionary technology, scale a company, carve a foothold in a new market or turnaround an underperforming organization, he repeatedly answers the call with profitable outcomes. Jim currently serves as Chief Business Officer for CLINICOM HEALTHCARE INC. where he oversees the commercialization, and market creation for CLINICOM’S groundbreaking mental health technology.
As a true market creator and a leader that's never satisfied with the status quo, Jim took his executive leadership skills to the new and uncharted frontier of digital therapeutics as VP of Global Commercial Development at Pear Therapeutics. There he designed the industry's 1st commercialization strategy for prescription digital therapeutics for the addiction/insomnia market. In doing so, he set himself apart by establishing a precedent for the next generation of companies with opportunities for enhanced time-to-market, ramp-to-revenue and cost containment.
Recruited to CCO by a NASDAQ-traded MedTech company, CHF-Solutions, Jim spearheaded the turnaround of commercial operations to lift revenue 24%+ while simultaneously partnering with the CEO on initiatives to raise $23M in business-critical funding. Taking on broader executive responsibilities at Surgical Theater, as President/COO of this 3D virtual reality imaging startup, Jim navigated the company through a strategic shift to elevate sales 2.5x to $10M.
One of Jim's most notable achievements is as Senior VP at Cardiovascular Systems (CSI). As a key member of the C-suite, he played a leadership role in the successful turnaround of this late-stage medical device startup to drive revenue from $54M to $200M+, company valuation from $110M to $1.4B and stock price from $7 to $41 per share.
In the VP of Sales & Customer Operations position at Neuronetics, Jim once again delivered powerful results. At this disruptive startup, he established and defined strategic corporate direction for the commercial, sales, marketing and customer service groups, fueling growth from zero to $30M and subsequent $94M IPO.
An extraordinary period of Jim's career was with Kyphon, an innovator of minimally invasive surgical instruments. Hired in on the ground floor, he earned progressive promotions to ultimately secure a corporate role as Director of Sales managing hundreds of employees. Jim achieved his personal quotas for 28 consecutive quarters as an instrumental player in the company's 7-year growth from zero to $470M and subsequent acquisition by Medtronic for $4.2B.
Early on Jim gained valuable Fortune 500 experience with Baxter Healthcare, Tyco Healthcare and ADP. He has a BA in Business Studies from the State University College at Buffalo and is a graduate of an Executive Educational Program in Marketing Healthcare Products at The Kellogg School of Management at Northwestern.
Marcus contributed to the development of the first Internet graphic browser in 1993 and again in 2004 with the propagation of Podcasting. His marketing experience includes work with brands like Nokia, Guitar Center, Farmers Insurance, GoDaddy, AmeriGas and Foot Locker.
Passionate, Dynamic, Driven, Leader are just a few of the words to describe D.J. Nix. A professional with
a strong desire to see everyone reach their potential, D.J. has been responsible for motivating and
educating young people and adults for over 26 years. With a Bachelor of Science Degree in History/
Communications from the University of Montevallo, a Master of Education and Leadership Certificate
from Alabama State University and an Education Specialist and Leadership Degree from the University of
West Alabama, D.J. knows what it takes for a student to succeed in school as he has done it himself.
However, he is not only concerned about helping high performing students excel, but is also dedicated to helping marginalized students set goals and realize their personal best. D.J. is currently the President and CEO of Remedial Education and Mental Health Counseling of Alabama. In his role, he focuses on helping discover the whys of student disengagement and how to overcome mental and physical obstacles to achievement. He is a retired principal who also worked directly in a professional capacity with mental health initiatives in central Alabama. Although he has direct experience as an educator in both the secondary and collegiate levels, he often uses his expertise to diagnose issues and develop the best course of action for success in individuals and organizations. His engaging personality serves him well as he uses his knowledge of a variety of topics for relationship and consensus building.
Not only does he have the soft skills often recognized in quality leadership, but he also has the hard skills needed for setting and keeping budgets along with fundraising, obtaining grants, operational management and human resource development. One of the key things to know about D.J. is that he cares about making a difference in people’s lives. He has a profound vision of investing in children and wants to foster the whole child. He believes in a total approach to growth, and that little things matter. His attention to detail, along with his coaching type of encouragement, can help even the average achiever strive to become better. D.J. is a man of action that gets the right things done while positively affecting the lives he touches through his work.
Harry Serves as the Director of Corporate Development for Clinicom.
He helps develop relationships with Customers, Corporations & Family Offices. Harry brings years of finance and sales experience to the Clinicom Team.
Mr. Eagens is a driven financial markets executive that has been exposed to the incredible growth that is shaping the Global HealthCare Industry specifically via Telemedicine. More importantly, over the last several years having had the privilege of experiencing firsthand the drive, the passion & the commitment by our medical community to help others while creating tremendously successful business models. It started over 5 years ago when he was invited to prepare & present various potential financial liquidity events on behalf of a US based Biopharma drug developer. Having the unique fortune of learning from & working directly with one of the world’s leading experts for the human digestive system with the primary focus being fighting cystic fibrosis. This individual has personally saved many lives & has extended many lives by decades. Learning more & more became very exciting as the motivation grew from there. During this time frame the work flows of the Medical & the Medical Insurance Industries came to the forefront as the various sources of US Dollar & UK Sterling based funding alternatives were continuously evaluated.
Mr. Eagens recently has worked directly with the CEO & Founder of an Industry leading DNA analysis firm that has its own CLIA-certified lab. All facets of domestic & global Marketing & Sales expansion was analyzed, reviewed and documented. Multiple strategic partner relationships were developed & put in place for this initiative. Now within weeks of working with Clinicom it became clear that his professional experience to date has prepared him for the opportunities that lie ahead for the Team at Clinicom. Specifically, helping to prepare a fourteen-year-old SaaS business model as a “mature startup” now moving directly into the revenue producing mode. Combined with building the Clinicom brand awareness throughout the Medical & the HealthCare Industries. Clinicom provides efficiency tools that put the patients success first.
Harry Eagens professional business experience summary inclusive of title & responsibilities.
The NASDAQ Stock Market – Managing Director of NASDAQ Transaction Services
SPEAR, LEEDS AND KELLOGG, INC – VP SLK Capital Markets, Institutional Equity Sales Trading
FIDELITY INVESTMENTS – VP & National Sales Director, Fidelity Brokerage Technologies Group
REUTERS INFORMATION SERVICES, INC – Global Accounts Sales Manager
SHEARSON LEHMAN HUTTON, INC – VP, Futures Trading Division
PAINE WEBBER, INC – Director of the Precious Metals & the Futures Trading Desk
DEAK-PERERA, INC – Chief Precious Metals Trader & Spot FX Trader
Michael Gronau is Director of Finance with Clinicom Healthcare, Inc.
He is presently helping to drive the financial planning and fundraising strategy of the company by building out the financial projections, analyzing performance and suggesting appropriate funding strategies for Clinicom.
Presently, Michael also serves as an elected official on the town council in his home town. On council Michael serves as Council President, Chairman of the Finance Committee, Water Commissioner and is responsible for the town’s technology infrastructure.
Prior to joining Clinicom Michael spent the last 15 years in the private investment banking world working with small boutique firms to help entrepreneurs prepare for private equity investments. Michael’s primary focus and skills were on problem solving, operations and financial modeling.
Michael began his career building a multimillion-dollar enterprise called, On-Site, a service company, that included multiple business arms and a national reach. Michael successfully grew and sold his business at a young age. One of the keys to the success of “On-Site” was the ability to build trust with customers and hosts which translated into lucrative agreements with a litany of Fortune 500 companies like Merck, Johnson & Johnson, Bristol Myers Squibb, ADP, and Merrill Lynch. Michael distinguished his company by providing excellent renowned support and service.
Katie is a market creator and was on the original Commercial leadership team at the World First FDA approved Digital Therapeutic from Pear. Katie brings nearly 20 years of valuable industry experience to Clinicom, including commercialization and market creation.
Katie has been a VP level sales and marketing executive for industry leaders like Pear Therapeutics, CHF Solutions, Zoll, and Novartis.
Bill St John is Senior Advisor to Clinicom for Capital Strategies, Life Sciences and Management.
Bill has 25 years of experience in the biotechnology and pharmaceutical business. This experience includes founding four successful biotech firms and serving as incoming CEO for several pharmaceutical firms.
Bill has served as Managing Director of the University Funds, an early-stage venture capital firm and advisor to private equity firms. He is an expert in due diligence, technology transfer, and regular lectures on the subject.
Bill is currently a consultant to select early-stage companies and early-stage venture funds…
Mr. St. John holds a BS degree from Seattle University and an MS in Molecular Biology from The Ohio State University…
Devin is a Fortune seasoned leader experienced in start-up and growth-stage company development. He is passionate about bringing innovative technology and service businesses to market, focused on bridging care gaps and transforming care engagement throughout the continuum.
Devin has an in-depth first-hand knowledge of the State Agency/Payer/Provider/Patient healthcare ecosystem specializing in network development, value-based care, data analytics, cost containment, market strategy, and key stakeholder relationship building.
Devin led go-to-market strategy, analysis, revenue forecasting, operations optimization, and investor presentations. During his time at Baxter Pharmaceutical, Grifols Biopharmaceutical, Fresenius Medical Care, and United Health Group, he secured $4B in annual new business, delivered transformative interventions improving patient utilization metrics by 35%(average), and $400M in cost-containment. Devin has managed significant P&Ls (from start-up to $100M and had collaborative oversight of $10B) while leading teams to build a national community-based provider network of 4000+ individual organizations. He has successfully managed and mentored teams large (400+) and small across multiple functions and highly matrixed organization and marketplace structures.
Stuart Adams is the Director UK – Europe – Middle East for Clinicom Healthcare Inc. Stuart is a first-round investor in Clinicom and in addition to providing strategic and tactical guidance to the Clinicom Executive Team in the US, Stuart is himself quietly researching and laying foundations for future expansion into EMEA (Europe, Middle East and Africa) so as not to distract from the focus on domestic US activities as Clinicom continues to expand throughout USA.
Based in Edinburgh, Scotland, Stuart is an angel investor and advisor to several entrepreneurial start-up businesses and founders across Health-Tech, Fin-Tech and Capital Markets. Stuart serves as a non-executive director at AKJ Jensen Investment Management and Investment Tribe Limited and advisory board member at SquareBook Limited.
With a background in Financial Markets; over the past 20+ years, Stuart has worked with many founders and their businesses providing strategic advice and insight as they scale. With specific experience in helping businesses land and launch, often advising companies coming to EMEA from the US, he has amassed an extensive network of contacts throughout EMEA and beyond. Stuart has also helped business re-structure, raise finance, and is tightly connected to the investment community and trusted by myriad family offices in EMEA.
Mrs. Baldwin is the Director of Clinical Research for Clinicom Healthcare, Inc. Mrs. Baldwin graduated Summa Cum Laude from Troy University with a Master's degree in Counseling Psychology. She completed a Bachelor of Science in Psychology from Troy State University.
Mrs. Baldwin worked directly with children and adolescents at Harmonex Neuroscience Research and Laurel Oaks Behavioral Health Center.
Mrs. Baldwin began her research career at Harmonex as a research assistant, later becoming a clinical research associate responsible for coordinating a myriad of trials for nearly two decades. Since 2008 she has served as the Director of Clinical Research for Clinicom Healthcare Inc and Harmonex, and oversees the initiation, regulatory documentation, contractual negotiations, and management of all clinical studies.
Mrs. Turner helps to run day to day operations at Clinicom Healthcare, Inc. Angela has been with the company for nearly a decade. She works directly with the public to educate the community about Clinicom, research and our clinical trials through community outreach, health conferences, and volunteering at local non-profit organizations.
She has also been an integral part of developing business relationship with some of the earliest Clinicom Healthcare clients. Her exemplary support and people skills have been a true asset for the company. She believes the road to success and happiness is to live by the 3P's: Practice, Patience and Persistence.
First online comprehensive Psychiatric assessment through Clinicom.com.2004
Assessment can screen for up to 50 conditions. Clinicom used as pre-screener for clinical research. Primary clinical testing was conducted at 12 initial clinical beta testing sites.2008
Additional Beta test sites added. Algorithm Builder developed to provide faster, more efficient assessments.2011-2014
All Clinicom algorithms updated from DSM4 to DSM5.2013
Added additional conditions. Upgraded Encryption, HIPAA 2015-16, New R&D Beta Sites added.2015
Alerts, Graphs, Custom Assessments, Additional R&D Beta sites added.2016
Added follow up feature. Clinicom translated to Spanish, Mandarin, Portuguese and Italian.
Clinicom added to Apple Store. Clinicom research study with COPE.2017
Clinicom accepted into Epic EMR app orchard. Clinicom validation study published in the May 2018 Journal of Psychiatric Research.2018
After 225,000 suggested diagnosis completed, Clinicom advanced from R&D version 7 to a commercially viable release version.2019
Clinicom V8 adds features such as Life sciences product line, Patient Triage module, Custom assessment templates, more options.
New members added to Executive team, Financial strategy team, Commercial Team and Technology team, Regulatory and Compliance work.
FDA CFR21 part 11. Full Software development life cycle documentation and testing complete.2020
Clinicom is available to help as many people as possible. Schedule a demo today and see how Clinicom can work for you and your patients! Let us show you how Clinicom's Insurance reimbursement can help grow your practice.2021
20.6% of U.S. adults experienced mental illness in 2019 (51.5 million people). This represents 1 in 5 adults.
16.5% of U.S. youth aged 6-17 experienced a mental health disorder in 2016 (7.7 million people)
People with depression have a 40% higher risk of developing cardiovascular and metabolic diseases than the general population. People with serious mental illness are nearly twice as likely to develop these conditions.
18.4% of U.S. adults with mental illness also experienced a substance use disorder in 2019 (9.5 million individuals)
High school students with significant symptoms of depression are more than twice as likely to drop out compared to their peers.
Across the U.S. economy, serious mental illness causes $193.2 billion in lost earnings each year