The CSO Life Insurance Table

Do You Know About the “New-Old” 2001-2009 CSO Life Insurance Table?

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chiefinsurance-book  

As physicians and medical professionals, we know that all life insurance and annuity product pricing is based on mortality – the expectation of when, not if, death will occur.  

But, did you know that at its December 2002 meeting, the National Association of Insurance Commissioners (NAIC, http://www.naic.org) approved a new mortality table for individual life insurance products sold in the United States.  

The 2001 Commissioners Standard Ordinary (CSO) Table is the new valuation mortality table – insurers will use it to determine mortality risk when they calculate their own company reserves.  So, all physicians should be aware that this may lead to structural changes to term policies including a reduction in term rates and higher issues ages for level term products.   

The good news is that several large insurers have already lowered term rates 20-30%. 

The trouble is that the “new CSO table” is not required to be used by all insurance companies until 2009! 

Your comments are appreciated? 

More on: “New Risks for Physicians to Manage”

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Annuity Taxation Basics

The Annuity Taxation Primer for Physicians

By: Gary A. Cook, MSFS, CFP®, CLU, ChFC, RHU, LUTCF, CMP™ (Hon); with Kathy D. Belteau, CFP®, CLU, ChFC, FLMI, and Philip E. Taylor, CLU, ChFC, FLMI insurance-book

Introduction  

The tax treatment of annuities is dependent on whether it is a qualified or non-qualified annuity.  Although both permit the tax-deferred growth of the investment and both have penalties for early distributions, they are governed under different sections of the IRC. 

Qualified Annuity Taxation

Qualified annuities are treated no different than any other tax-qualified retirement investment.  Growth of the investment, whether fixed interest or variable-based, escapes current taxation under one of the 400-series IRC sections. 

Additionally, if the funds are withdrawn prior to age 59½, there is a 10 percent penalty.  As the money is withdrawn, every dollar is taxed as ordinary income.  

Finally, fund distributions must begin no later than April 1 of the calendar year following the year when the owner turns age 70½.

Non-Qualified Annuity Taxation 

The taxation of non-qualified annuities is generally contained within IRC § 72.  Again, the annuity is provided tax-deferred growth and the 10 percent penalty for early withdrawal.  The manner that distributions are taken, however, will determine the nature of their taxation.

Withdrawals

Withdrawals from non-qualified annuities are taxed in one of two ways depending upon when the annuity was issued.  Annuities issued prior to 8/14/82 had FIFO accounting (first in, first out). Since principal was first in, it came out first, tax-free.  With annuities issued on 8/14/82 and thereafter, taxation changed to LIFO (last in, first out). Simply put, withdrawals are now taxable since interest is withdrawn first.  

However, if annuitization is chosen, the insurance company using governmental tables develops an exclusion ratio.  This permits a portion of each received payment to be considered a return of principle and thus only a portion of each payment is taxable.  This exclusion ratio remains in effect until the insurance company has returned all of the original principle to the owner.  After that, every payment received will be considered 100 percent earnings and totally subject to ordinary income taxation. 

The 10% Excise Penalty Tax      

Just like an IRA, there is a 10% excise tax penalty on premature withdrawals for deferred annuities.  The government extends tax advantages to the annuity for retirement purposes. The government also extends tax disadvantages to taxpayers who do not use the annuity for retirement. All interest withdrawn prior to the owner being age 59½ will be subject to a 10% excise tax penalty.  

Exceptions to this penalty tax are disability of taxpayer, distribution from a pre 8/14/82 annuity, death of the owner, payout from an immediate annuity or substantially equal payments over the taxpayer’s life expectancy.

Wealth Transfer Issues

Regardless of whether the medical professional or healthcare practitioner has a qualified or non-qualified annuity, extreme care must be given when specifying beneficiaries.  Although these investments have great potential for appreciating sizable amounts of wealth during a lifetime, they are, unfortunately, very poor vehicles for the transfer of this wealth to successor generations after death.

Upon the death of an annuity owner, an annuity can be subject to both federal estate and federal income taxes.  This double taxation often results in a 40 to 70 percent loss of annuity value before the heirs can receive it.   The retired medical professional should seek wealth transfer advice if he/she holds a large portion of their wealth in annuities or other qualified plans such as IRAs. One good strategy to consider may be the Stretch IRA. 

Conclusion

As always, your thoughts and comments on this Executive-Post are appreciated.

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A Brief Overview of Annuities for Physicians

[By Gary A. Cook, MSFS, CFP®, CLU, ChFC, RHU, LUTCF, CMP™ (Hon)]

[By Kathy D. Belteau, CFP®, CLU, ChFC, FLMI]

[By Philip E. Taylor, CLU, ChFC, FLMI]fp-book1

 Introduction

Annuities were reportedly first used by Babylonian landowners to set aside income from a specific piece of farmland to reward soldiers or loyal assistants for the rest of their lives.

Today’s annuities substitute cash for farmland; however the concept is the same. In 1770, the first annuities were sold in the United States and were issued by church corporations for the benefit of ministers and their families. Annuities have grown on a tax-deferred basis since enactment of the Federal Income Tax Code in 1913.  They began to gain widespread acceptance in the early 1980s when interest rates credited exceeded 10%.  During the last two decades, annuities have been the fastest growing sector of premiums for life insurance companies.

Nevertheless, are they actually “needed” by contemporary physicians – – or merely “sold” to them? 

An annuity is a legal contract between an insurance company and the owner of the contract. The insurance company makes specific guarantees in consideration of money being deposited with the company.

Annuities are generally classified as fixed or variable – deferred or immediate.  As their names indicate, deferred annuities are designed as saving funds to accumulate for future use.They are growth-oriented products where the tax on the interest earned is deferred until the money is withdrawn.  An immediate annuity is used for systematically withdrawing money without concern for the money lasting until the end.  The insurance company assumes this risk.

Deferred Annuities

The deferred annuity contract, like a permanent life insurance policy, has been found by some to be a convenient method of accumulating wealth.  Funds can be placed in deferred annuities in a lump sum, called Single Premium Deferred Annuities, or periodically over time, called Flexible Premium Deferred Annuities.  Either way, the funds placed in a deferred annuity grow without current taxation (tax-deferred).  .

Fixed Deferred Annuity

Fixed deferred annuities provide a guaranteed minimum return of return (usually around 3 percent per year) and typically credit a higher, competitive rate based on the current economic conditions.

Fixed annuities are usually considered conservative investments as the principal (premium) is guaranteed not to vary in value. Insurance companies are required by state insurance laws to maintain a reserve fund equal to the total value of fixed annuities.  Fixed annuities are also protected by State Guaranty Fund Laws. 

Example: 

Dr. Park, a retired physician, desires a safe financial vehicle for $100,000 of her excess savings.  She doesn’t need the earnings of this investment for current income and also wants to reduce her income tax liability.  She decides to purchase a fixed deferred annuity with her $100,000.  The annuity guarantees a 3 percent annual return and the current rate is 6 percent. 

After the first year, $6,000 of interest is credited to the annuity and Dr. Park has no current income taxes as a result.  If the 6 percent interest rate does not change, after 3 years, the annuity will have $119,102 of value.

Variable Deferred Annuity

Recently, variable deferred annuities have become very popular.  Like fixed annuities, variable deferred annuities offer tax-deferred growth, but this is where the similarities end.  Variable annuities are not guaranteed.  The appreciation or depreciation in value is totally dependent on market conditions.

Variable deferred annuities assets are maintained in separate accounts (similar to mutual funds) that provide different investment opportunities.  Most of the separate accounts have stock market exposure, and therefore, variable annuities do not offer a guaranteed rate of return.

But, the upside potential is typically much greater than that of a fixed annuity. The value of a variable deferred annuity will fluctuate with the values of the investments within the chosen separate accounts.  Although similar to mutual funds, there are some key differences.  These include:

·  A variable annuity provides tax deferral whereas a regular mutual fund does not

·  If a variable annuity loses money because of poor separate account performance, and the owner dies, most annuities guarantee at least a return of principal to the heirs.  This guarantee of principal only applies if the annuity owner dies.  If the annuity value decreases below the amount paid in, and the annuity is surrendered while the owner is alive, the actual cash value is all that is available.

·  When money is eventually withdrawn from a deferred annuity, it is taxable at ordinary income tax rates.  With taxable mutual funds, they can be liquidated and taxed at lower, capital gains rates.

·  There is also a 10 percent penalty if the annuity owner is under 59½ when money is withdrawn.  There is no such charge for withdrawals from a mutual fund.

· The fees charged inside of a variable annuity (called mortality and expense charges) are typically more than the fees charged by a regular mutual fund. 

Assessment

Variable deferred annuities are sensible for physicians who want stock market exposure while minimizing taxes.  Most financial advisors and Certified Medical Planners™ [CMP™] recommend regular mutual funds when the investment time horizon is under 10 years.  But if the time horizon is more than 10 years, variable annuities may occasionally become more attractive because of the additional earnings from tax-deferral. 

Both types of deferred annuities are subject to surrender charges.  Surrender charges are applied if the annuity owner surrenders the policy during the surrender period, which typically run for 5 to 10 years from the purchase date.  The charge usually decreases each year until it reaches zero.  The purpose of the charge is to discourage early surrender of the annuity. 

Equity Index Annuity 

The equity index annuity combines the basic elements of both the variable and the fixed annuity. The credited interest earnings are generally linked to a percent of increase in an index, such as the Standard & Poor’s 500 Composite Stock Price Index (S&P 500). This percentage is called the Participation Rate and may be guaranteed for a specified period of up to 10 years or adjusted annually. Thus, the physician annuity owner is able to participate in a portion of market gains while limiting the risk of loss. 

Typically, the indexed annuity has a fixed principal, with the insurance company and contract owner sharing the investment risk.  If the S&P 500 Index goes up, so do interest earnings.  If it declines, the insurance company guarantees the principal.   

So, the physician contract owner accepts the risk of an unknown interest yield based on the growth or decline of the S&P 500.  Medical professionals and healthcare practitioners should pay particular attention to surrender penalties, asset management fees and any monthly caps on appreciation. 

Immediate Annuities

Immediate annuities provide a guaranteed income stream.  An immediate annuity can be purchased with a single deposit of funds, possibly from savings or a pension distribution, or it can be the end result of the deferred annuity, commonly referred to as annuitization.  Just like deferred annuities, immediate annuities can also be fixed or variable.  

Immediate annuities can be set up to provide periodic payments to the policy owner annually, semiannually, quarterly or monthly.  The annuity payments can be paid over life or for a finite number of years.  They can also be paid over the life of a single individual or over two lives. 

Insurance Agent Commissions

Immediate Fixed Annuity

Immediate fixed annuities typically pay a specified amount of money for as long as the annuitant lives.They may also be arranged to only pay for a specified period of time, i.e., 20 years.  They often contain a guaranteed payout period, such that, if the annuitant lives less than the guaranteed number of years, the heirs will receive the remainder of the guaranteed payments. 

A note of caution here, as the selection of an immediate annuity is an irrevocable decision! 

Example: 

Dr. Jones is 70 years old and retired.  He is only of average wealth, but is concerned that if he lives too long, he could deplete his savings.  He decides to use $100,000 and purchase a lifetime immediate annuity with 20 years certain.  The insurance company promises to pay him $7,000 per year as long as he lives. If Dr. Jones dies four years after purchase, he would only have received $28,000 out of a $100,000 investment.  However, his heirs will receive $7,000 for the next 16 years.  If Dr. Jones survives to the age of 98, he would have received $196,000 (or 28 years of $7,000).

Immediate Variable Annuity

Immediate variable annuities provide income payments to the annuitant that fluctuates with the returns of the separate accounts chosen.  The theory is that since the stock market has historically risen over time, the annuity payments will rise over time and keep pace with inflation.   If this is indeed what happens, it is a good purchase, but it cannot be guaranteed. 

Some companies will, at a minimum, provide a guarantee of a low minimum monthly payment no matter how poorly the separate accounts perform.

Split annuities

A popular method of adding income and yet still accumulating savings is through the use of two separate annuity policies.  Part of the funds is placed in an immediate annuity to provide monthly income.  The balance is placed in a deferred annuity grows to the total value of the premium paid for both annuities.  

The income that is received from the Immediate Annuity includes a portion of the initial premium, as well as the taxable interest earned.   Only the portion of income that is interest is taxable. The ratio between the annuity principal and interest being paid out is called an Exclusion Ratio. 

Example:

Dr. Jeanne Jones has put $100,000 into a 5-year non-tax deferred vehicle at 5%. The earnings to supplement Jeanne’s retirement is $25,000.  With a combined federal and state tax of 33%, the net after tax income would be $16,750. Jeanne takes the same $100,000 using the split annuity concept she would receive $24,444 over the 5 years.  Based on an exclusion ration of 89%, her total taxable amount is $2,797.  This would yield $923 in taxes at the same 33% tax rate.  Jeanne would have $23,521 of spendable income with the split annuity compared to the $16,750.

Qualified Annuities

The term qualified refers to those annuities which permit tax-deductible contributions under one of the Internal Revenue Code (IRC) sections, i.e., § 408 Individual Retirement Accounts (IRA), § 403(b) Tax Sheltered Annuities, § 401(k) Voluntary Profit Savings Plans.  Qualified annuities can also result from a rollover from such a plan.  

Assessment

Currently, there is much lively debate in the industry as to whether an annuity, which is tax-deferred by nature, should be used as a funding vehicle within a tax-qualified plan, i.e., a tax-shelter within a tax-shelter.  Since the investment options within the annuity are also generally available to the plan participant without the additional management expenses of the annuity policy, it is felt this could be a breach of fiduciary responsibility. And, most insurance agents are not fiduciaries. 

Both the National Association of Securities Dealers (NASD) and the Securities and Exchange Commission (SEC) have gone on record as criticizing these sales.  

However, there are numerous examples of deferred annuities that have outperformed similar investment-category mutual funds, even after taking the annuity expenses into account. 

Conclusion

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Pro Bono Medical Care

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The Demise of Pro Bono Medical Care?

[By Staff Writers]

biz-book3A survey some years back suggested that more than 40% of the country’s doctors are doing less pro-bono work due to managed care, and the resulting decrease in personal income.  

To combat this unintended economic phenomenon today, the organization Volunteers in Healthcare – now with the American Academy of Family Physicians – offers a free information patient record system to track the medical care given to the uninsured.

The system allows you to track and store information on patients, visits, providers, clinics, referrals and more.  It is guide-driven with sample reports that can be reconstituted to provide summary statistics on patients and providers. 

Conclusion

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Competitive Practice Strategies for Physicians

How Physicians Must Develop a Strategic Competitive Practice Philosophy!

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It is currently believed that a general medical, or even broad specialty, practice will have limited appeal to patients and buyers of healthcare services in the future. 

In its place, a doctor must philosophically decide if she or he is to become a (1) discount, (2) service or (3) value-added provider, and then aggressively pursue this business cultural and competitive strategy. 

Here is the lowdown on three strategic competitive philosophical types: 

The Service Provider:  

A provider committed to a service philosophy must be willing to do whatever it takes to satisfy the patient. 

For example, this may mean providing weekend, weeknight, or holiday office hours, instead of a routine 9-5 schedule. House calls, hospital visits, prison calls and nursing home rounds would be included in this operational model.  

In 2001, the number of physician house calls billed to Medicare in the aggregate was about 1.5 million annually, according to the American Association of Home Care Physicians. Since then it has doubled, and the national organization is getting more requests from doctors about house calls. Current membership stands at about 1,500 doctors.  The Medicare premium for home visits is about 1.5 times what it pays for office visits. 

In a real life example, Dr. Keri Miller DO, now an assistant professor of family and community medicine at the University of Georgia, School of Osteopathic Medicine, first began making house calls shortly after beginning practice, in 2003.  

In another example, high-tech companies, located in Silicon Valley and Southern California are even importing medical specialists, and mobile treatment facilities, onto their corporate campuses to care for workers. Children, elderly patients or those with mental, physical or chemically induced challenges are all fertile niches of a core service philosophy.  

Up to about 30% of all medical providers today; and slowly growing  

Think: Nordstrums, Cartier and Sak’s, etc. 

The Discount Provider:  

A discount medical provider is one who has made a conscious effort to practice low cost, but high volume medicine.   

For example, discount providers must depend on economics of scale to purchase bulk supplies, since this model is ideal for multi-doctor practices. 

Otherwise, several practitioners must establish a network, or synergy to create a virtual organization to do so.  In this manner, malpractice insurance, major equipment and other recurring purchases can be negotiated for the best price.  Para-professional, and non-professional, medical care extenders and substitutes must also be used in place of more costly medical providers.

Another major commitment must be made to computerized office automation devices, HIT, EMRs, CPOE systems, etc.  By necessity, such as offices are small, neatly but sparsely furnished, with functional and utilitarian assets.  Most all managed care contracts just be aggressively sought since patient flow and volume is the key to success in this competitive philosophical type. 

About 60% of all providers today; but the denouement has begun.  

Think: WalMart, K-Mart, Office-Deport, or Home Depot, etc. 

The Value-Added Medical Provider: 

A value-added medical provider is committed to practicing at the highest and riskiest levels of medical and surgical care and has the credentials and personality to do so.   

Value differentiation is based on such factors as: board-certification extended training, hospital privileges, subspecialty identification or other unique attributes such as fluency in a second language or acceptance into an ethnocentric locale. This brand identification must be inculcated in all you do, as you continually answer the question: What can I offer that no one else can?   

Approaching about 5-10% of all providers today; but much less for pure concierge or boutique medical practices.

Think: Nieman-Marcus, etc.  

Conclusion: 

Remember, it is better for a physician to consciously decide which competitive strategy to purse; than merely fall into one model, by unthinking default.

Practice Pro-Forma Accounting Statements

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What are Medical Practice Pro-Forma Financial Statements?

[By Staff Writers]

biz-book1Since a start-up medical practice has no historical financial information, simplified Pro Forma’s are estimated statements that are typically projected for 3 years.  They demonstrate the best care, worst case and most likely financial scenarios of a new practice, clinic, healthcare entity, etc. Computerized spreadsheets are ideal for this task.  Other relevant financial information may be included, as needed. 

 Net Income (Profit and Loss) Statement 

By allocating a practice’s profit or loss into operating groups, banks or investors can isolate profitable revenue centers and isolate unprofitable costs drivers. In certain managed care contracts, an analysis to identify unit or per dollar revenues, gross profits and/or gross margins, is vital.  Other non-cash expenses (i.e., depreciation, amortization and deferred taxes) are then deducted from revenues to determine overall net income. All is included in the income statement.  

Cash Flow Statement 

The Statement of Cash Flow (SCF) projects estimated cash flows by month, quarter and year, along with the anticipated timing of cash receipts and disbursements.  The office’s bills and obligations are paid out of cash flow, not net income.  It is very important for accrual based accounting practices; especially in terms of Medicare, Medicaid, MCOs, PPOs and HMOs producing insurance payment time delays and other aged accounting methodologies.  Cash flow reflects the internal generation of fund available to supply operating capital.  

 Balance Sheet 

The Balance Sheet (BS) forecasts the financial condition, assets and liabilities, of an office at a singular point in time.  It projects the ability to meet financial obligation and the capacity to absorb financial setbacks without becoming insolvent. 

Statement of Retained Earnings 

This is a fourth new financial statement, but it is not usually a pro-forma statement since little cash is generated from a new medical practice

Conclusion

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Domestic and Healthcare Economic Indicators

What are Domestic and Medical Economic Indicators?

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There are 12 leading, 6 lagging and 4 co-incidental indicators for the United States economy. And, there are 3 macro-economic medical indicators for physicians and the healthcare industrial complex. Their purpose is to help evaluate which period of the business cycle is in play. 

 

Leading Economic Indicators:  

1. Average workweek for manufacturing production workers

2. Layoff rate in manufacturing

3. New orders for consumer goods

4. Vendor performance and slow/on-time deliveries

5. New business formation

6. New building permits for private housing *

7. Contracts and orders for plants and equipment

8. Net changes in inventories

9. Change in sensitive prices

10. Change in total liquid assets

11. Stock prices

12. Money supply 

  

Co-incidental Economic Indicators: 

1. Employees on non-agricultural payrolls

2. Personal income

3. Industrial production

4. Manufacturing and trade sales 

 

Lagging Economic Indicators:

1. Average duration of unemployment

2. Manufacturing and trade inventories

3. Labor costs per unit of output

4.  Average bank prime interest rates

5. Commercial and industrial loans outstanding

6. Ration of consumer installment dent to personal income [* Often considered the leading, leading economic indicator]. 

Specific Medical Economic Indicators for Physicians 

  1. Medical Labor Production is a measure of medical professional output per hour, or per each unit (patient) of labor. Managed care has decreased labor production cost in medicine.
  2. Unit Medical Labor Costs represent the cost of physician labor (treatment), per unit (CPT code) of output.
  3. Capacity of Medical Utilization is a percentage of the maximum rate at which a medical office, clinical hospital or surgical center can operate under normal conditions. At the rate nears 100 percent, efficiency declines due to mechanical breakdowns, burnout of doctors and employees, and less experienced medical care extenders and para-professionals, etc.

Like domestic economic indicators, these evaluate the macro-economic healthcare business cycle which may be entering the depressed state. And so, what do you think; doctor colleagues and laymen, alike?

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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What is the Business Cycle?

The Business [Economic] Cycle Explained

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The business cycle is also known as the economic cycle and reflects the expansion or contraction in economic activity. Understanding the business cycle and the indicators used to determine its phases may influence investment or economic business decisions and financial or medical planning expectations. 

Although often depicted as the regular rising and falling of an episodic curve, the business cycle is very irregular in terms of amplitude and duration. Moreover, many elements move together during the cycle and individual elements seldom carry enough momentum to cause the cycle to move.  

However, elements may have a domino effect on one another, and this is ultimately drives the cycle, too.  We can also have a large positive cycle, coincident with a smaller but still negative cycle, as may be seen in the current healthcare climate of today. 

  1. First Phase: Trough to Recovery (service and production driven)

Scenario: A depressed GNP leads to declining industrial production and capacity utilization. Decreased workloads result in improved labor productivity and reduced labor (unit) costs until actual producer (wholesale) prices decline. 

  1. Second Phase: Recovery to Expansion (patient and consumer driven)

Scenario: CPI declines (due to reduced wholesale prices) and consumer real income rises, improving consumer sentiment and actual demand for consumer goods. 

  1. Third Phase: Expansion to Peak (service and production driven)

Scenario: GNP raises leading to increased industrial production and capacity utilization. But, labor productivity declines and unit labor costs and producer (wholesale) prices rise. 

  1. Fourth Phase: Peak to Contraction (patient and consumer driven)

Scenario: CPI rises making consumer real income and sentiment erode until consumer demand, and ultimately purchases, shrink dramatically.  Recessions may occur and economists have an alphabet used to describe them.  

For example, with a “V” graph shape, the drop and recovery is quick. For a “U” shaped graph, the economy moves up more sluggishly from the bottom. A “W” is what you would expect: repeated recoveries and declines. An “L” shaper recession describes a prolonged dry economic spell or even depression.

Some pundants believe we may be entering the generalized “U” economic phase, along with the “L” medical economic business cycle. 

What do you think?