BOARD CERTIFICATION EXAM STUDY GUIDES Lower Extremity Trauma
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Many financial planning websites mention fees, as required, but still remain opaque to potential clients because the advisor wants to control the discussion and understandably wishes to avoid the website shopper phenomenon.
But, physicians and all investors can still control the discussion, and still provide transparency, because posting up front pricing information doesn’t mean presenting information in a vacuum!
For example, a 1%/year fee doesn’t have to just be 1%; it can be 1%, compared to an industry average cost of X%, where the average cost of an actively managed mutual fund is Y%.
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Similarly, it doesn’t have to be a retainer fee of $1,000/year; it can be a retainer fee for less than the cost of a monthly cable bill! And, a financial plan doesn’t cost $1,500; it costs 8-12 hours of staff time to craft extensive, customized solutions; but saves the doctor-client so much more!
And, if services have a range of potential prices, they might be provided with some insight into the factors that impact the price. Modern young and internet savvy doctors expect this sort of information.
Analysts at Morgan Stanley downgraded Charles Schwab Corp (NYSE: SCHW) on Tuesday, citing concerns over cash sorting and regulatory changes. But, Schwab CEO Walt Bettinger recently said that the company’s banking unit had enough liquidity to cover if 100% of its bank deposits ran off without having to sell a single security — Morgan Stanley says otherwise. Schwab’s recent performance has not been up to Morgan Stanley’s expectations, with customers moving cash out of sweep accounts into money market funds at a rate twice that which the bank had been modeling.
The S&P 500® Index rose 23 points (0.57%) to 4050.84; the Dow Jones industrial average was up 141 points (0.43%) at 32859.03; the NASDAQ Composite was up 87 points (0.73%) at 12013.47.
The 10-year Treasury yield slipped 2 basis points to 3.555%.
CBOE’s Volatility Index was little changed at 19.14.
When I am approached by a prospective client, the question they always ask without fail is “Are you properly licensed?” This is actually the wrong question to ask. The right question should be, “Which license do you have?”
The Types of Licenses
Generally, there are two types of licenses for people who call themselves a “financial advisor.” People who passed the series #65 test and people who passed the series #7 test. The nature of these two licenses is as far apart as heaven and earth.
The Securities License
Series #7 is a securities license. People who have passed this test can legally be a stock-broker. They are actually prohibited by law to give financial advice, except incidental to the financial products they are selling.
A financial advisor with a series #7 license can receive third party payments like kickbacks, commissions etc in conjunction with the products they sell you. They are not required to put your interest first as they are not your fiduciary. Legally they abide by a much lenient “suitability standard.” That is, if they think the product is suitable for you, irrespective of the cost, they are legally off the hook.
All of Morgan Stanley, Merrill Lynch and other Wall Street firms’ financial advisors are required to pass the series 7# license.
The Advisor License
Series #65 is an advisor license. People who have passed this test are legally called registered investment advisors or RIA representative. An RIA representative’s compensation is in the form of fees paid directly by the client. He or She is prohibited to receive any third party payment unless disclosed to and approved by the client first.
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Assessment
When searching for a financial advisor, it’s crucial to find out what licensure he or she has. Do not use a stock-broker as your financial advisor – unless you’re in the habit of letting you friendly neighborhood used car salesman hand pick your vehicle purchases.
Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.
Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com
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Colleagues know that I enjoy personal coaching and public speaking and give as many talks each year as possible, at a variety of medical society and financial services conferences around the country and world. All in a Corona safe environment.
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These include lectures and visiting professorships at major academic centers, keynote lectures for hospitals, economic seminars and health systems, end-note lectures at city and statewide financial coalitions, and annual lectures for a variety of internal yearly meetings.
In economics, the Golden Rule savings rate is the rate of savings which maximizes steady state level or growth of consumption, as for example in the Solow growth model.
Although the concept can be found earlier in John von Neumann and Maurice Allais‘s works, the term is generally attributed to Edmund Phelps who wrote in 1961 that the golden rule “do unto others as you would have them do unto you” could be applied inter-generationally inside the model to arrive at some form of “optimum“, or put simply “do unto future generations as we hope previous generations did unto us.”
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The Solow growth model
In the Solow growth model, a steady state savings rate of 100% implies that all income is going to investment capital for future production, implying a steady state consumption level of zero. A savings rate of 0% implies that no new investment capital is being created, so that the capital stock depreciates without replacement. This makes a steady state unsustainable except at zero output, which again implies a consumption level of zero.
Somewhere in between is the “Golden Rule” level of savings, where the savings propensity is such that per-capita consumption is at its maximum possible constant value.
Assessment
Put another way, the golden-rule capital stock relates to the highest level of permanent consumption which can be sustained.
Conclusion
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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements.
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Inflation has hit record levels this year as demand for goods and services far outpaced supply, and many companies are still trying to bounce back from the shutdowns of early 2020. Health systems, which have razor-thin operating margins even in the best of times, aren’t an exception.
“In the past, we’ve always said that healthcare was kind of recession-proof because demand for healthcare keeps going, regardless of what’s happening in the economy,” said Tina Wheeler, leader of consulting firm Deloitte’s US healthcare practice.
But in the last year, inflation hovered around 8% for much of the year, while medical-care prices increased by only 4.8%, according to Wheeler. Since medical costs are negotiated between hospitals and payers years in advance, hospitals can’t just raise their prices now to keep up with the pace of inflation, said Gerard Brogan Jr., senior vice president and chief revenue officer at Northwell Health.
Inflation could cause an additional $370 billion more in healthcare spending than the expected baseline increase by 2027, according to McKinsey.
The national health expenditure could grow at a rate of 7.1% over the next five years, compared to the expected economic growth rate of 4.7%, according to McKinsey.
By the end of 2021, total hospital expenses per adjusted discharge were up 20.1% compared to 2019, according to the trade group American Hospital Association.
Rising interest rates also hurt hospitals since their main access to capital is through issuing tax-exempt bonds, Wheeler said. The rising cost of capital limits hospitals’ ability to fund projects, like opening a new oncology center to treat patients, for example. Keep reading here
CVS expects to finalize its $8 billion acquisition of Signify Health this week, the retail pharmacy giant said yesterday. CVS beat out both Amazon and UnitedHealth Group to buy Signify, a value-based provider network. The company announced the deal last September, and executives said they expect it to close “on or around March 29th.”
In a phone call following the deal announcement, Shawn Guertin, EVP and CFO at CVS, said the company anticipates that acquiring Signify will “generate attractive returns” for CVS. The acquisition strengthens CVS’s goal of becoming a value-based healthcare company and could give it a leg up over rival Walgreens. Both companies have doubled down on value-based care in the last couple of years, making several multi-billion dollar deals, such as Walgreens’s $5.2 billion VillageMD acquisition in 2021 and CVS’s $10.6 billion takeover of Oak Street Health.
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The U.S. Food and Drug Administration has approved NARCAN, an overdose-reversing nasal spray, for over-the-counter, non-prescription sale, the agency just announced. The FDA green light marks the first naloxone product approved for use without a prescription. Naloxone rapidly reverses the effects of an opioid overdose, including situations where fentanyl is involved. In the 12-month period ending in October 2022, the United States recorded 101,750 overdose deaths, primarily from opioids including fentanyl, according to the FDA.
“Today’s action paves the way for the life-saving medication to reverse an opioid overdose to be sold directly to consumers in places like drug stores, convenience stores, grocery stores and gas stations, as well as online,” the agency said in a news release.
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Here’s how the major indexes performedyesterday:
The S&P 500® Index rose roughly 57 points (1.42%) to 4027.83; the Dow Jones industrial average was up 323 points (1.0%) at 32717.73; the NASDAQ Composite was up 210 points (1.79%) at 11926.24.
The 10-year Treasury yield was little changed at 3.575%.
CBOEs Volatility Index was down 80 basis points (4.01%) at 19.17.
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When it comes to purchasing a medical practice, there are a variety of factors that one must consider in evaluating the worth of the practice. Assessing the value of a practice is fraught with potential landmines if one does not go into the process with a strong understanding of some key principles to medical practice valuation.
According to the Dictionary of Health Economics and Finance, practice valuation is the “formal process of determining the worth of healthcare or other medical business entity at a specific point in time and the act or process of determining fair market value.” Fair market value is defined as “ … the price at which a willing buyer will buy and a willing seller will sell an asset in an open free market with full disclosure.”
The Internal Revenue Service (IRS) Revenue Ruling 59-60 clearly states that fair market value “is essentially a future prophecy and must be based on facts available at the required date of appraisal.”
Unfortunately, one cannot directly observe the value of a medical practice as there are a number of underlying issues. Obviously, the buyer and seller are pursuing opposite objectives, and this reality is not necessarily conducive to facilitating clarity on those issues.
Accordingly, let us consider a few mistakes that are commonly made by physicians who are considering the purchase of a medical practice.
A Guide To The Myths And Realities Of Medical Practice Valuation
• Valuations are material representations providing a range of transferable worth. • Valuations are reproducible estimates based on economic assumptions. • Valuations are not “back of the envelope multiples” using specious benchmarks. • Valuations are defensible and should be “signed off” by the completing firm attesting to origination guidelines and in accordance with the Uniform Standards of Professional Appraisal Practice (USPAP) and IRS formats as needed. • Financial accounting value (book value) is not fair market value. • Professional valuators represent only one party. The buyer or seller-owner is the client. • Unbiased valuators do not provide financing or equity participation schemes.
Knowing The Distinctions Among Engagement Types
The Institute of Medical Business Advisors uses three levels that approximate engagement types for the industry. These levels are comprehensive valuation, limited valuation and ad-hoc valuation.
A comprehensive valuation is an extensive service designed to provide an unambiguous opinion of the value range. It is supported by all procedures that valuators deem relevant with mandatory onsite review. This gold standard is suitable for contentious situations like divorce, partnership dissolution, estate planning and gifting, etc. The written opinion of value is applicable for litigation support activities like depositions and trial. It is also useful for external reporting to bankers, investors, the public and IRS, etc.
A limited valuation lacks additional suggested USPAP procedures. It is considered to be an “agreed upon procedure,” which is used in circumstances in which the client is the only user. For example, one may use the limited valuation when updating a buy-sell agreement or when putting together a practice buy-in for a valued associate. This limited valuation would not be for external purposes. No onsite visit is needed. A formal opinion of value is not rendered.
An ad-hoc valuation is a low level engagement that provides a gross and non-specific approximation of value based on limited limited parameters or concerns by involved parties. Neither a written report nor an opinion of value is rendered. The ad-hoc valuation is often used periodically as an internal organic growth/decline gauge.
Are You Following Industry Standards And Rules?
Specifically, when it comes to USPAP transactions involving physician practices, the following points are implied by the industry and the IRS.
• Discounted cash flow analysis is the most relevant income approach and must be done on an “after-tax” basis. It generally produces a higher value but is costly, detail-oriented and time consuming. • Project practice collections based on reasonable assumptions for the practice and market, etc. • Physician compensation is based on market rates consistent with age, experience and productivity. • Majority (control) premiums and minority (lack of control) discounts are also to be considered. A majority premium is the amount paid to gain enough ownership to set policies, direct operations and make decisions for the practice. A minority discount for partial ownership does not allow this power. Thus, majority ownership is valuated higher than minority ownership purchase.
What About Personal Goodwill And Practice Goodwill?
Goodwill represents the difference between practice purchase price and the value of the net assets. Personal goodwill results from the charisma, skills and reputation of a specific doctor. These attributes accrue solely to the individual, are not transferable and cannot be sold. Personal goodwill has little or no economic value.
Transferable medical practice goodwill has value, may be transferred and is defined as the unidentified residual attributes that contribute to the propensity of patients and managed care contracts (and their revenue streams) to return in the future.
However, bear in mind that the Goodwill Registry, an older source used to determine the average percentage of revenue contributed to practice goodwill, has sparse to no podiatry input, may be dated for some specialties and leads to abnormally high values.
In addition to various multiple factors, one must also appreciate the impact of a changing environment and practice transfer in a local market, which can augment or blunt goodwill value. It is also important to determine whether patients or HMOs return because of true goodwill or are mandated to do so by contractual obligations.
Now to further confuse the issue, how each kind of goodwill is allocated in situations like divorce depends on state law. For example, some courts weigh in on the apportionment of both kinds of goodwill, other courts exclude both kinds of goodwill and other courts pursue a case-by-case approach.
Understanding ‘Excess Earnings Capitalization’ And Compensation Issues
Another way to determine goodwill value is through “excess earnings capitalization.” This economic method looks at the difference between salary and what you would have to pay a comparable doctor replacement.
As an example, when you subtract the numbers and divide the result by 20 percent, an important percentage referred to as the capitalization rate emerges. The final number gives a dollar value for practice goodwill. Courts seem to prefer this method in divorce situations because it tends to reflect a practice’s current value.
Regardless of the practice business model, physician compensation is inversely related to practice value. In other words, the more a doctor takes home in above average salary, the less the practice is generally worth and vice versa.
Emphasize Practice Specifics Over Benchmarks And Formulas
In the stable economic past, physicians may have used industry benchmarks as quick and inexpensive substitutes for professionally prepared valuations. However, this practice can be fraught with peril if challenged. The courts seem to frown on this simplistic and dated methodology. Moreover, generic benchmark formulas assume a financial statement reporting standard that just does not exist with contemporary professional valuations.
Therefore, almost every competitive issue that impacts value should be addressed with each practice engagement. This includes but is not limited to:
• contemporary dislocations by third parties, Medicare and commercial payers; • retail clinics and changes in supply/ demand and specialty trends; • the rise of ambulatory surgery centers, walk-in clinics and specialty hospitals; • outsourced care and medical tourism; • alterations in resource based-relative value units, ambulatory payment classifications (APCs), diagnosis-related groups (DRGs) and newer Medicare-severity diagnosis-related groups (MS-DRGs); and • the Medicare Modernization Act, HIPAA, OSHA, the EEOC and other regulations.
One must also consider the impact of current employee trends to high-deductible health care plans and private concierge medicine. Another consideration is employer shifts away from defined benefits plans to defined contribution plans.
Aggregating Or ‘Normalizing’ Financial Information: What You Should Know
In addition to possibly conducting employee interviews, one must gather appropriate financial information in order to properly value a practice. As a starting point, interested physician buyers should be able to see the following information for the most recent three-year period.
It is especially important to eliminate one-time, non-recurring practice expenses. These are adjusted for excessive or below normal expenses on the profit and loss statement. Such “normalization” can produce a big surprise for benchmark proponents and formula-driven advocates when a selling doctor runs personal expenditures through the practice that a buyer or court would not consider legitimate. Of course, one is less likely to encounter such shenanigans when the valuation is conducted according to professional USPAP and IRS style guidelines.
For example, we recall one doctor who painted his home and wrote it off as a valid business expense. Deleting other major expenses such as country club memberships make a practice look more profitable. This is good news if you are selling it. It is bad news if you are getting a divorce.
Conversely, you may have to defend legitimate business expenses that an appraiser may seek to normalize. For example, doctors may pay for a vehicle through their practice. If they use the vehicle to travel between multiple offices and hospitals, the expense may be legitimate.
Also realize that the appraiser may also add expenses that have not been incurred. For example, the appraiser may add an office manager’s salary if your spouse is in that role for free. This produces a lower appraised value and is common in small podiatry practices. Honorarium is another example that does not figure into value calculations.
Of course, normalization is a sophisticated and time intensive process. However, the expert earns his or her professional fee, and defends the resulting valuation range when challenged.
Keys To Selecting The Right Valuator Professional
The most important credentials to look for are fiduciary level experience, specificity and independence. Some doctors mistakenly turn to those who may have never appraised a practice before. Just because an appraiser has initials behind his or her name, it does not mean he or she understands the peculiarities of medical specialties. Agents, brokers, solicitors and other intermediaries are not fiduciaries.
Physicians looking to assess a practice for possible sale/purchase should only select an independent health economist, who will be your advocate under Securities Exchange Commission (SEC), IRS or other relevant managerial accounting guidelines.
Moreover, be very wary if the valuation is not done in an independent manner or, worse, performed for both parties simultaneously.
Essential Insights On Professional Fees And What You Can Expect
Of course, it is almost impossible to answer concerns regarding fees without specific information. The cost of a valuation can range from $0 to $50,000 for an onsite team of experts for behemoth practices and ambulatory surgery centers. Keep in mind that in most cases you want to ensure the value determination will stand up to IRS scrutiny so the $0 rule of thumb approach is not an option.
However, most reputable firms use a blended fee schedule of fixed and hourly rates (plus expenses). Internists should expect to spend approximately $5,000 to $10,000 for an average sized practice and a limited appraisal that is completely suitable for most internal activities.
External appraisals or poorly aggregated financial information, onsite reviews and litigation support services incur additional costs. However, most doctors find the money well spent. Expect to pay a retainer and sign a formal professional engagement letter.
Finally, once the practice price is agreed upon, sales contract terms and agreements present a plethora of financing challenges for both parties to consider. For example, one must negotiate bank loans (if they are even available), payment rates and length, personal promissory guarantees, down payment offsets, earn-out arrangements and Uniform Commercial Codes.
Final Notes
Do not be surprised if a sales broker does not consider the aforementioned issues as the modern health era emerges. Most agent-appraisers are predominantly concerned with earning commissions by working both transaction parties and may not represent your best interests. Also be aware that they are usually not obliged to disclose conflicts of interest and do not provide testimony as a court approved expert witness.
However, it is a fait accompli that medical practice worth is presently deteriorating. As the population ages and third-party reimbursements plummet, doctors are commoditized and traditional retail medicine is replaced by more efficient wholesale business models like workplace health clinics. The subprime mortgage default fiasco, credit freeze, potential tax reform law expiration, the ACA, VBC, capitation payments and the political specter of a nationalized healthcare system only add fuel to the macroeconomic fires of uncertainty. Do not forget the corona pandemic.
As a result, a good medical practice is no longer good business necessarily and retiring doctors can no longer automatically expect to extract premium sales prices. Moreover, uninformed young physicians should not be goaded to overpay.
Markets: The NASDAQ stumbled for the second straight day as rising bond yields banged up the tech sector, which is ultrasensitive to higher interest rates.
Alibaba: Shares in the Chinese e-commerce giant popped after it announced the most extreme restructuring in its history: It’s going to split up into six business units (“mini Alibabas”) that could each go IPO separately.
Et Cetera and More
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AMC stock popped 13% after a report from The Intersect claimed Amazon was considering buying the theater chain.
Lucid, the EV startup, is laying off ~18% of its workforce, or around 1,300 employees.
Disney has cut its metaverse division as part of 7,000 layoffs, according to the WSJ.
McKinsey, the consulting firm that usually recommends layoffs at other companies, is cutting about 1,400 roles from its own roster.
Substack is allowing writers on its platform to buy shares in the company for as little as $100. Substack has already raised $82 million in venture capital.
This National Physicians Week, from March 25–31, we can show doctors we appreciate them as much as they deserve with creative gifts, simple notes, and appreciation posts online.
Doctors deal with years of school, grueling shifts, and emotionally difficult decisions, and still manage to care for us with focus and kindness. Physicians drastically improve the duration and quality of life for everyone, and throughout history have done their best to use cutting-edge science to care for others.
Physician appreciation is also symbolized by a red carnation, so be sure to bring one to your favorite doc this week!
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Here Are the Top Ten Ways To Celebrate National Physicians Week in 2023:
Send a doctor red carnation and/or gift of your choice to show appreciation.
Host a Zoom or virtual celebration.
Doctors can take the day off (If the schedule permits)
Record and post a video to show gratitude for your doctor and physicians nationwide.
Encourage others and spread the word about National Physicians Week on and offline.
Write or share an article about National Physicians Week.
Offer product or service discounts to doctors.
Host an office party to celebrate staff physicians.
Plan a happy hour or networking event for physicians and the community.
A rare alignment of five planets will be visible in the night sky this week, but this Tuesday [tonight] evening will be your best bet. Just head outside right after sunset, look west, and you’ll see Mercury, Venus, Mars, Jupiter, and Uranus appear to line up in an arc shape below the crescent moon. Anyone on Earth should be able to see it, even if you’re living in a city with light pollution.
The word syzygy is often used to describe interesting configurations of astronomical objects in general. For example, one such case occurred on March 21, 1894, around 23:00 GMT, when Mercury transited the Sun as would have been seen from Venus, and Mercury and Venus both simultaneously transited the Sun as seen from Saturn. It is also used to describe situations when all the planets are on the same side of the Sun although they are not necessarily in a straight line, such as on March 10, 1982.
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Here’s how the mixed markets fared yesterday on Monday:
The S&P 500® Index was up 6.54 points (0.16%) at 3977.53; the Dow Jones industrial average was up 194.55 points (0.6%) at 32432.08; the NASDAQ Composite was down 55.12 points (0.47%) at 11768.84.
The 10-year Treasury yield was up around 17 basis points at 3.542%.
CBOEs Volatility Index was down 1.05 points (4.8%) at 20.71.
Outside of the financial sector, energy also had a good day Monday, as the apparent return to calm in the world of banks helped ease concerns about the economy. Oil prices recovered, with West Texas Intermediate rising more than 5% to roughly $73.
There is no way to eliminate all the risks associated with starting a medical practice, or launching any innovative concept in the health 2.0 ecosystem. However, entrepreneurial focused doctors can improve their chance of success with good planning and preparation. So, prior to starting your practice, merging, franchising or purchasing an existing one, ask yourself the following sobering questions. Hopefully, such reflection will enhance success, or at least prevent an unmitigated catastrophe. (www.sba.gov)
The Questions to Consider
1. Is medical practice ownership and physician entrepreneurship right for you?
It will be up to you, and your consultants; not someone else telling you to develop projects, organize your time or follow through on details. Your must be self motivated.
2. Do you like people and get along with different personality types?
Practice owners need to develop working relationships with a variety of people including patients, customers, vendors, staff, other physicians, and professionals like lawyers, accountants, consultants and bankers. Can you deal with a demanding patient, an unreliable vendor or cranky staff person in the best interest of your practice?
3. Can you make decisions and leave with ambiguity?
Practice owners are required to make independent decisions constantly; often quickly, under pressure and without all the facts. Ambiguity is a constant.
4. Do you have the physical and emotional stamina?
Practice ownership can be challenging, fun and exciting. But it’s also a lot of work. As a physician-owner, can you face twelve hour work days? As a doctor, can you offer advice, service, care and moral support 24/7?
5. How long can you live on your current savings?
Most small medical practice startups induce a declining bank balance in the early going. So, it’s wise to look at your expenses and determine how long you can live on your savings, and what personal costs you can temporarily eliminate. Emotionally, it’s easier to tighten expenses when you’re contemplating a new practice, than it is to cut back after you’ve started. Financial consultants and accountants that perform consolidated financial statement preparation and analysis are vital in this regard. A two to five year margin of safety is not unusual and may be needed
6. How deeply in debt can you go?
Medical practice business debt can be good. It can fund expansion, improve profit ratios and cash flow. For physician entrepreneurs, business debt is often personal debt. Many start a practice by deferring payments for their own labor. Although lenders may make loans to a practice, the physician-owner will often be required to personally guarantee the loan. So, although the debt is on the business’s books, is ultimately the doctors’ debt should the practice fail.
7. What about health insurance?
If your current residency, fellowship or job offers health insurance, and is subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA), you might be able to keep your coverage by paying the premiums, plus another 2% for administrative costs. You may keep your coverage under COBRA for up to 18 months and is a useful stopgap. For example, pay the premiums for six months or until another health insurance plan is obtained. Others suggestions are working spouse coverage with family benefits, or an HMO; or Medical or Health Savings Account (HSA/MSA).
8. Can you line up credit in advance?
Some new practice owners may set up a home equity line of credit that will let them borrow money at 1-2 percentage points over the prime rate or less. Lenders are more willing to make loans to someone who has a steady paycheck than to a new practice entrepreneur. If you have an excellent credit rating, you can probably get a home equity or other secured loan, but with more paperwork than in the recent past. Once you’re a self-employed practice owner, you’ll probably have to provide your most recent tax returns before getting approval. But, today, the biggest obstacle to a practice loan is a home mortgage. Domestic credit has been very tight since 2007, even for physicians.
9. What if you can’t manage the practice?
Disability insurance, unlike health insurance, usually cannot be transferred to an individual policy when you leave your job to start a new venture. So, get your own disability policy while you are still employed. Once you have the policy established and are paying the premiums, you should be able to keep the policy when you go out on your own. Remember, benefits received on a policy paid by you are free of federal income tax. Benefits on a policy paid for by a previous employer were taxable.
10. How well do you plan and organize?
Research indicates that many medical practice failures could have been avoided through better planning. Good organization of financials, inventory, schedules, information technology, medical services and human resources can help avoid many pitfalls.
11. Is your determination and drive strong enough to maintain your motivation?
Running a practice can wear you down. Some doctor-owners feel burned out by having to carry all the responsibility on their shoulders. Strong motivation can make the practice succeed and will help you survive slowdowns as well as periods of burnout.
12. How will the practice affect your family?
The first few years of practice startup can be hard on family life. The strain of an unsupportive spouse may be hard to balance against the demands of starting a medical business. There also may be financial difficulties until the business becomes profitable, which could take years. You may have to adjust to a lower standard of living or put family assets at risk.
13. How do you feel about the Patient Protection and Affordable Care Act of 2010?
Most provisions of the PPACA take effect over the next four to eight years, including expanding Medicaid eligibility, subsidizing insurance premiums, providing incentives for businesses to provide health care benefits, prohibiting denial of coverage/claims based on pre-existing conditions, establishing health insurance exchanges, and support for medical research. The expense of these provisions are offset by a variety of taxes, fees, and cost-saving measures, such as new Medicare taxes for high-income brackets, cuts to the Medicare Advantage program in favor of traditional Medicare, and fees on medical devices and pharmaceutical companies. There is also a tax penalty for citizens who do not obtain health insurance. Decreased physician reimbursement is a component, as well.
Are you a medical innovator or healthcare entrepreneur? I am available for queries – thanks again for your interest.
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Conclusion
Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.
Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com
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In Part 1, we discussed how to establish fair market value (FMV) for a medical practice in the article, “Establish Your Practice’s Fair Market Value.” This time, we’ll review important terms and conditions for the sale transaction.
Unfortunately, as a general rule, medical practice worth is presently deteriorating. A good medical practice is no longer a good business necessarily, and selling doctors can no longer automatically expect to extract a premium sale price. Nevertheless, appraising your medical practice on a periodic basis can play a key role in obtaining maximum value for it.
Competent practice valuation specialists typically charge a retainer to cover out-of-pocket expenses. Fees should not be based on a percentage of practice value, and may take 30-45 days to complete. Flat fees should be the norm because a sliding scale or percentage fee may be biased toward over-valuation in a declining marketplace. Fees range from $7,500-$50,000 for the small to large medical practice or clinic.
Expect to pay a retainer and sign a formal, professional engagement letter. Seek an unbiased and independent viewpoint. Buyer and sellers should each have their own independent appraisal done, using similar statistics, accounting measures, and economic assumptions.
At the Institute of Medical Business Advisors, Inc www.MedicalBusinessAdvisors.com we use three engagement levels that vary in intensity, purpose, and cost:
1. A comprehensive valuation provides an unambiguous value range. It is supported by most all procedures that valuators deem relevant, with mandatory onsite review. This gold standard is suitable for contentious situations. A written “opinion of value” is applicable for litigation support activities like depositions and trial. It is also useful for external reporting to bankers, investors, the public, Internal Revenue Service (IRS), etc.
2. A limited valuation lacks additional suggested Uniform Standards of Professional Appraisal Practice (USPAP) procedures. It is considered to be an “agreed upon engagement,” when the client is the only user. For example, it may be used when updating a buy/sell agreement, or when putting together a practice buy-in for a valued associate. This limited valuation would not be for external purposes, so no onsite visit is necessary and a formal opinion of value is not rendered.
3. An ad-hoc valuation is a low level engagement that provides a gross non-specific approximation of value based on limited parameters or concerns involved parties. Neither a written report nor an opinion of value is rendered. It is often used periodically as an internal organic growth/decline gauge.
Structure Sales Transactions
When the practice price has been determined and agreed on, the actual sales deal can be structured in a couple of ways:
(1) Stock Purchase v. Asset Purchase
In an asset transaction, the buyer will receive a tax amortization benefit associated with the intangible value of the business. This tax amortization represents a non-cash expense benefiting the buyer. In this case, the present value of those future tax benefits is added to the business enterprise value.
(2) Corporate Transactions
Typical private deals in the past involved some multiple (ratio) of earning before income taxes (EBIT)—usually a combination of cash, restricted stock, notes receivable, and possibly assumption of liabilities. For some physician hospital organizations, and public deals, the receipt of common stock can increase the practice price by as much as 40-50 percent (to accept the corresponding business risk, in lieu of cash).
Complete the Deal
The deal structure will vary depending on whether the likely buyer is a private practitioner, health system or a corporate partner. Some key issues to consider in the “art of the deal” include:
Working capital (in or out?): Including working capital in the transaction will increase the sale price.
Stock vs. asset transaction: Structuring the deal as an asset purchase will increase practice value due to the tax amortization benefits received by the buyer for intangible assets of the practice.
Common stock premium: The total sale price can be significantly higher than a cash equivalent price for accepting the risk and relative illiquidity of common stock as part of the payment.
Physician compensation: If your goal is to maximize practice value, take home a lower salary to increase practice sale price. The reverse is also true.
Understand Private Deal Structure
Assuming a practice sale is a private transaction, deal negotiations are based on the following pricing methodologies:
Seller financing: Many transactions involve an earn-out arrangement where the buyer puts money down and pays the balance under a formula based on future revenues, or gives the seller a promissory note under similar terms. Seller financing decreases a buyer’s risks (the longer the terms, the lower the risk). Longer terms demand premiums, while shorter terms demand discounts. Premiums that buyers pay for a typical seller-financed practice are usually more than what you would expect from a simple time value of money calculation, as a result of buyer risk reduction from paying over time, rather than up front with a bank loan or all cash. Remember to obtain a life insurance policy on the buyer.
Down payment: The greater the down payment for acquisition of a medical practice, the greater the risk is to the buyer. Consequently, sellers who will take less money up front can command a higher than average price for their practice, while sellers who want more down usually receive less in the end.
Taxation: Tax consequences can have a major impact on the price of a medical practice. For instance, a seller who obtains the majority of the sales price as capital gains can often afford to sell for a much lower price and still pocket as much or more than if the sales price were paid as ordinary income. Value attributed to the seller’s patient list, medical records, name brand, good will, and files qualifies for capital gains treatment. Value paid for the selling doctor’s continuing assistance after the sale and value attributed to a non-compete agreement are taxed at ordinary income. A buyer willing to allocate more for items with capital gains treatment, or a seller willing to take more in ordinary income, can frequently negotiate a better price. This is the essence of economically prudent practice transition planning.
Sidestep Common Buyer Blunders
Here are 10 blunders to avoid, as a buyer:
1. Believing the selling doctor’s attestations. Always verify data through an independent appraisal.
2. Wanting to change the culture of the practice. Be careful: Patients may not adjust quickly to change.
3. Using all available cash without keeping a reserve for potential contingencies.
4. Creating a conflict with the seller by recognizing a weakness and continually focusing on it for a bargain price.
5. Failing to realize that managed care plan contracts can be lost quickly or may not be always transferable.
6. Suffering from analysis paralysis. Money cannot be made by continually checking out a medical practice, only by actually running one.
7. Not appreciating the uniqueness of each practice, and using inaccurate “rules of thumb” from the golden age of medicine.
8. Not realizing that practice worth and goodwill value have plummeted lately and continue to decline in most parts of the country.
9. Not understanding that practice brokers may play both sides of the buy/sell equation for profit. Brokers usually are not obligated to disclose conflicts of interest, are not fiduciaries, and do not provide testimony as a court-approved expert witness.
10. Not hiring an appraisal professional who will testify in court, if need be, using the IRS-approved USPAP methods of valuation. Always assume that the appraisal will be contested (many times, it is).
After pricing and contracting due diligence has been performed, the next step in the medical practice sale process—as Donald Trump might say—is just good, old-fashioned negotiation.
Cimasi, R.J., A.P. Sharamitaro, T.A. Zigrang, L.A.Haynes. Valuation of Hospitals in a Changing Reimbursement and Regulatory Environment. Edited by David E. Marcinko. Healthcare Organizations: Financial Management Strategies. Specialty Technical Publishers, 2008.
Marcinko, D.E. “Getting it Right: How much is a plastic surgery practice really worth?” Plastic Surgery Practice, August 2006.
Marcinko, D.E., H.R. Hetico. The Business of Medical Practice (3rd ed). Springer Publishing,New York,N.Y., 2011.
Marcinko, D.E. and H.R. Hetico. Risk Management and Insurance Planning for Physicians and Advisors. Jones and Bartlett Publishers, Sudbury, Mass., 2007.
Marcinko, D.E. and H.R. Hetico. Financial Planning for Physicians and Advisors. Jones and Bartlett Publishers, Sudbury, Mass., 2007.
Marcinko, D.E. and H.R. Hetico. Dictionary of Health Insurance and Managed Care. Springer Publishers, New York, N.Y., 2007.
Marcinko, D.E. and H.R. Hetico. Dictionary of Health Economics and Finance. Springer Publishers,New York,N.Y., 2007.
Ark’s Back-to-Back Sale: Ark Invest’s Ark Innovation ETF (NYSE: ARKK) and Ark Next Generation Internet ETF (NYSE: ARKW) sold 119,151 and 11,547 shares of Tesla, respectively, on Friday, daily trade information from the company showed. Friday’s disposals totaled 130,698 shares, valued at $24.98 million. On Thursday, Ark’s ARKK and ARKW cumulatively sold 139,000 shares valued at $26.8 million. Wood’s firm divested $51.78 million worth of Tesla stock this week.
Ark has been a buyer of Tesla shares since the stock’s decline late last year. The last sale by the firm ahead of this past week’s liquidation was in early September. 2022. On the other hand, Elon Musk is reportedly handing out stock awards to Twitter employees at a valuation of ~$20 billion. He bought the company for $44 billion last year.
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SVB was finally sold. Well, at least a large portion of it. First Citizens BancShares, a Raleigh-based regional bank, is scooping up SVB’s deposits, loans, and 17 branches that will reopen today under new ownership. About $90 billion of SVB’s assets will remain with the FDIC, which took control of SVB following its epic collapse over two weeks ago. The sale is meant to “instill confidence in the banking system,” the CEO of First Citizens said, and it seems to be working for now: Regional lenders like First Republic Bank are surging premarket.
The concept of socially responsible investing is far from new; the first SRI fund appeared in 1952. Since then, these funds have used social and ethical screens to exclude companies selling products like tobacco, alcohol, or firearms.
You may not have heard of the next generation of SRI funds, called ESG funds, which means environmental, social and governance funds. Social responsibility is just one-third of the expanded focus of these funds, which also look to include companies that are sensitive to the environment and have more holistic corporate governance.
Updates
In recent years, ESG investing has exploded. According to a July 11, 2018, article in Forbes, The Remarkable Rise of ESG, by Georg Kell, over $20 trillion is invested in ESG funds. This accounts for 25% of all the professionally managed assets in the world. There are currently 275 ESG mutual funds and ETF’s from which to choose.
Yet one facet of investing in ESG funds is widely misunderstood. While ESG investing may help you feel better about yourself, it does not actually impact or hamper the companies you choose not to own.
This may come as a surprise to many ESG investors, who commonly believe that by not owning the shares of an offensive company they are restricting the flow of capital to that company, thereby imperiling its existence. For the most part, that isn’t the case.
The offenders
Listed among the worst offending companies by several ESG organizations are Philip Morris, WalMart, Tyson Foods, Pepsi Corporation, Coca-Cola, and Chevron. No dedicated ESG investors would have these companies in their portfolios. None of these companies would care or be hurt in the least if you didn’t own any of their shares.
Why?
The only time a company benefits from a sale of stock is when the company initially goes public (called an initial public offering, or IPO) or issues additional new shares to raise capital. These are actually fairly rare events.
Most stocks are bought and sold in the “secondary” market through exchanges like the New York Stock Exchange. These platforms facilitate transactions between individuals or institutions wanting to buy or sell shares in a company. The money moves between the buyer and the seller; none of the money goes to the company.
Another way companies receive funding to support their ventures is to borrow money from investors. This is called issuing a bond and is similar to an IPO, only the investor receives a promise from the company to pay them back at some future date and receives interest on the loan in the meantime.
Just like stocks, bonds are only issued by a company once. From then on, buying and selling bonds is done on the open market, and none of the money paid or received goes to the company.
So if you want to punish a company, don’t buy stocks or bonds it issues directly. Otherwise, excluding its shares from your portfolio has no effect on the company’s profits or cash flow.
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Assessment
But if no one bought a company’s shares on the secondary market, wouldn’t that have an impact? Yes, it most certainly would. If the demand for the shares of a company dried up, the company’s stock price would plummet.
The problem is the demand for the shares of these companies isn’t going away as long as they remain profitable. If 25% of investors purchase ESG funds, that leaves 75% of the market willing to buy these companies. This includes the 20% of stocks owned by passive index funds, which own the entire market.
CONCLUSION
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Florida is pulling $2 billion from BlackRock in the largest divestment ever made as part of the growing vendetta against Environmental, Social, and Governance (ESG) investing practices. Florida Governor Ron DeSantis and other Republican leaders claim that by taking ESG standards into account when making investment decisions, the firm isn’t prioritizing the bottom line. But, for a few years, things were good. In 2020 and 2021, ESG funds outperformed the market by ~4.3%.
DEFINITION: According to Wikipedia, ESG (environmental, social, and corporate governance) data reflect the externalities (costs to others) an organization is generating with respect to the environment, to society and to corporate governance. ESG data can be used by investors to assess the material risk the organization is taking and by the organization itself as metrics for strategic and managerial purposes. Investors may also use ESG data beyond assessing material risks to the organization in their evaluation of enterprise value, specifically by designing models based on assumptions that the identification, assessment and management of sustainability-related risks and opportunities in respect to all organizational stakeholders leads to higher long-term risk-adjusted return. Organizational stakeholders include but not limited to customers, suppliers, employees, leadership, and the environment.
Since 2020, there has been accelerating interest in overlaying ESG data with the Sustainable Development Goals (SDGs), developed based on work by United Nations beginning in the 1980s.
The term ESG was popularly used first in a 2004 report titled “Who Cares Wins”, which was a joint initiative of financial institutions at the invitation of UN. In less than 20 years, the ESG movement has grown from a corporate social responsibility initiative launched by the United Nations into a global phenomenon representing more than US$30 trillion in assets under management. In the year 2019 alone, capital totaling US$17.67 billion flowed into ESG-linked products, an almost 525 percent increase from 2015, according to Morningstar, Inc.. Critics claim ESG linked-products have not had and are unlikely to have the intended impact of raising the cost of capital for polluting firms, and have accused the movement of greenwashing.
DeSantis ran his most recent campaign on fighting the “woke ideology” he believes is infiltrating the state. As part of the fight, Florida passed a resolution in August that said ESG standards should be ignored when investing state funds.
And he’s not the only one:
Other Republican-controlled states, including Missouri and Louisiana, have moved almost $1.3 billion away from BlackRock for similar reasons.
Texas flagged BlackRock as a financial firm that boycotts the state’s energy industry (something BlackRock has denied).
Meanwhile, Democrats aren’t happy either…they criticize BlackRock and ESG investing in general for not going far enough (and for using lax standards that let oil giants onto lists of ESG investments).
Bottom line: According to the Morning Brew, BlackRock and Florida are now cursed to yell “How could you prioritize politics over returns?” back and forth for eternity, and the debate over ESG investing is far from over. Republicans are poised to take over the House—after a campaign season that BlackRock poured record cash into—so we’re likely to see more drama play out at the federal level soon.
A recent poll of 2,510 American adults by Ipsos found:
• 87% of Americans feel politicians have lost touch with what the public needs from their health care. • 86% of Americans agree that Congress should focus on cracking down on abusive health insurance practices that make it harder for people to get the care they need. • 71% of Americans would rather see Congress focus more on reducing the overall costs of health care coverage such as premiums, deductibles, and co-pays.
* Profits are down, and they’re set to plummet even further. (Wired $) * A hedge fund that invested heavily in FTX is shutting down. (FT $) * Tim Berners-Lee thinks crypto is comparable to gambling. (CNBC)
Over the past decade, the Federal Reserve has manipulated asset prices by interfering with free markets by deciding what both short-term and long-term interest rates should be. This resulted in an increase in risk-taking behavior among investors.
Risk became a four-letter word uttered only by curmudgeons; the only thing investors feared was being left out. The more risk you took, the more money you made – until you lost it all.
Jack Dorsey’s wealth tumbled after Hindenburg Research targeted his payments company Block, per Bloomberg. The short seller alleged Block misled investors “with inflated metrics” Block’s share price tumbled as much as 22% on Thursday on Hindenburg’s report.
Short seller Hindenburg Research has hit another billionaire’s fortune with a report. Jack Dorsey, the co-founder of payments company Block and Twitter, saw his net worth tumble by $526 million, or 11%, to $4.4 billion after the US-based research firm led by Nathan Anderson accused Block of misleading investors in a March 23 report, according to Bloomberg. Dorsey isn’t on the list of the world’s 500 richest persons on the Bloomberg Billionaires Index currently. He was previously featured at number 456 with a net worth of $5.41 billion on March 22nd, per Insider’s scan of the Index on Wednesday.
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Investors sparked a furious selloff in Deutsche Bank AG and thrust one of Europe’s most important lenders into the center of concerns about the health of the global financial system. Shares of Germany’s largest lender tumbled as much as 15%, their third consecutive day of losses, though they later regained some ground and were recently down 10%. The cost to insure against its default using credit-default swaps soared to their highest levels since 2020.
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Chairman Jerome Powell was ambiguous this week about future Federal Reserve moves, suggesting “some additional policy firming may be needed.”
Treasury yields dropped near seven-month lows, a seeming indication of escalating recession worries after the Fed raised its benchmark lending rate nine times to a range of 4.75% to 5% over the past year. The release next week of updated data on consumer confidence, inflation, and economic growth will likely be in focus.
The swings in stock prices this week “were consistent with the unclear outlook for monetary policy, the banking system, and the broader economy,” says Kevin Gordon, senior investment strategist at Charles Schwab. “More time needs to pass before we know the true impact of the expected tightening in credit conditions.”
The S&P 500® Index was up 22.27 (0.6%) at 3970.99; the Dow Jones industrial average was up 132.28 (0.4%) at 32,237.53; the NASDAQ Composite was up 36.56 (0.3%) at 11,823.96.
The 10-year Treasury yield was little changed at about 3.374%.
CBOE’s Volatility Index was down 0.87 at 21.74.
The real estate sector led the gainers Friday, followed by consumer staples and health care. Financials and consumer discretionary stocks edged lower, and technology stocks were little changed, though the tech-focused NASDAQ Composite still notched its second straight weekly gain. Gold and crude oil futures both declined, while the U.S. dollar strengthened.
Eye doctors can track changes in your vision, as well as detect abnormalities in the retinas and lenses of the eyeball. If your eyes are reddened and itchy and the issue is not resolved with over-the-counter eye drops, make sure you see a doctor to eliminate the possibility of an eye infection.
VISION RULE: Here’s your reminder to practice the 20-20-20 rule: Every 20 minutes, take a 20-second break from your screen and look at something 20 feet away.
Wall Street’s $30 billion infusion into First RepublicBank didn’t manage to calm investors’ jitters about how banks are holding up. The regional bank’s stock tanked againFriday, dragging most of the market down with it. Moody’s Investors Service downgraded its credit rating on First Republic Bank to junk, citing a “deterioration in the bank’s financial profile.” First Republic’s debt rating was cut to B2 from Baa1, Moody’s said. Fitch Ratings and S&P Global Ratings downgraded First Republic Bank’s debt earlier this week.
The downgrade reflects “the deterioration in the bank’s financial profile and the significant challenges First Republic Bank faces over the medium term in light of its increased reliance on short-term and higher cost wholesale funding due to deposit outflows,” Moody’s analysts said in a release.
And, SVB’s parent company filed for Chapter 11 bankruptcy yesterday, buying it time to pay off creditors and making it easier to sell off its assets (but the bank itself, currently in the hands of the FDIC, isn’t part of the filing). Meanwhile, President Biden called on Congress to make it easier to punish bank executives if their mismanagement causes a bank to collapse, including allowing regulators to claw back their pay.
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But Big Tech stocks got a boost from investors looking to park their cash in non-bank companies, pushing Microsoft to its best weeks in almost eight years.
Mass firings at tech companies continue as Accenture (NYSE:ACN) just announced plans to lay off around 19,000 people, or 2.5% of its current workforce, in the next 18 months. Over half of the departures will consist of people in non-billable corporate functions, the professional services firm said.
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Despite strong gains early this week, antifungal drug developers lost steam even after Cidara Therapeutics (NASDAQ:CDTX) won FDA approval for its candidemia treatment Rezzayo. Shares of Cidara (CDTX) and its rival in antifungal space Scynexis (NASDAQ:SCYX) jumped amid concerns of a fast-spreading fungal infection caused by yeast species Candida auris in the U.S. New approval of Rezzayo for fungal disease candidemia and invasive candidiasis has failed to reignite the interest, with Cidara (CDTX) and Scynexis (SCYX) trading at least 20% lower. Meanwhile, Cidara (CDTX) has not replicated its regulatory success on the financial front, reporting lower-than-expected financials for Q4 2022 on Thursday.
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The following is a round-up of today’s market activity:
The S&P 500® Index was up 11.75 (0.3%) at 3948.72; the Dow Jones industrial average was up 75.14 (0.2%) at 32,105.25; the NASDAQ Composite was up 117.44 (1.0%) at 11,787.40.
The 10-year Treasury yield was down about 11 basis points at 3.391%.
CBOE’s Volatility Index was up 0.35 at 22.61.
The energy sector led declines Thursday as crude oil futures fell back under $70 a barrel, with financials and consumer staples also losing ground. Technology and communications stocks managed to hold onto gains.
Finally, gold futures surged over 2% to a one-year high near $2,000 an ounce.
Unethical and illegal trading by specialists or market makers. A specialist may buy a stock for themselves from Dr. John Q. Public even though a better price is available from another seller. The specialist can view bid and ask prices and then manually mis-match them, or see ahead to a less favorable price. It happens in this editor’s experience, by observing how long it takes for a stop order to execute after the stop price was reached. This practice is a form of shimming. ***
Trading Imbalance
A situation where a large block of stock is put up for sale, but not enough buyers are available for purchase, and a market maker is unable to buy the imbalance. Lightly traded and tightly held stocks are considered temporarily illiquid during such imbalances. On occasion, a trading halt is put into place until enough buyers are available to purchase the deficit. On rare occasion, a handful of buyers can buy the stock at a huge discount if the stock was not halted during the imbalance. On the New York Stock Exchange, large stocks usually have a “delayed open” for such imbalances, as a trading specialist will fill the order by lining up buyers for the block, and then open trading for the stock for the day. ***
Triple Witching Hour
The final hour of trading on a Friday when stock index futures, stock index options, and stock options all expire. This happens on the third Friday in March, June, September, and December. See Quadruple Witching Hour. ***
One nonprofit, United Network for Organ Sharing, has had a monopoly on running the system for nearly four decades, but the government’s proposal includes potentially bringing more organizations in, as well as upping funding and modernizing the computer systems involved.
DEFINITION: Junk bonds are bonds that carry a higher risk of default than most bonds issued by corporations and governments. A bond is a debt or promise to pay investors interest payments along with the return of invested principal in exchange for buying the bond. Junk bonds represent bonds issued by companies that are financially struggling and have a high risk of defaulting or not paying their interest payments or repaying the principal to investors. Junk bonds are also called high-yield bonds since the higher yield is needed to help offset any risk of default.
AT1 DEFINITION: Additional Tier 1 bonds are also known as “contingent convertibles,” or “CoCos”. They were created in the wake of the 2008 financial crisis as a way for failing banks to absorb losses, making a taxpayer-funded bailout less likely. They are a risky bet — if a lender gets into trouble, this class of bonds can be quickly converted into equity, or written down completely. Because they are higher-risk, AT1s offer a higher yield than most other bonds issued by borrowers with similar credit ratings, making them very risky. If AT1s are converted into equity, this supports a bank’s balance sheet and helps it to stay afloat. They also pave the way for a “bail-in”, or a way for banks to transfer risks to investors and away from taxpayers if they get into trouble.
UBS’s emergency takeover of Credit Suisse may have been necessary to avert a financial crisis, but at least one group is Yosemite Sam-level angry over how the deal shook out. Investors holding $17 billion worth of Credit Suisse’s additional tier-one bonds were shocked to discover that their $17 billion was now worth a grand total of…$0. The value of those bonds had been completely wiped out in the deal.
Additional tier-one bonds, or AT1 bonds for short, were established after the 2008 financial crisis to reduce the likelihood that taxpayers would have to bail out a failed bank. AT1s are considered riskier assets, but with that risk comes higher potential returns.
So, if these bondholders knew they were taking on risk, why are they so upset?
According to MorningBrew, mainly because, in this unusual deal, they got wiped out while shareholders didn’t. That’s not how the order of operations usually works:
When a write-down happens, shareholders traditionally suffer losses before bondholders get hit.
This deal flipped the food chain, and livid AT1 bondholders are now huddling up with lawyers about potential legal action.
Cathie Wood just revealed that her flagship fund ARK Invest lost over $2 billion last year. Her struggles sum up how rising interest rates are affecting markets, according to the CEO of JPMorgan Asset Management. “When the Federal Reserve hits the brakes, something goes through the windshield,” George Gatch said.
Cathie Wood’s Ark Invest also sold $13.5 million worth of Coinbase stock. The famed money manager now holds a 7% stake in the crypto exchange worth $837 million. Shares of Coinbase are up nearly 30% in the past five trading sessions as crypto prices rallied.
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Moderna – which received about $10 billion in taxpayer money to produce its COVID-19 vaccine and has since earned billions more in profits selling it – was sued in early 2022 by Genevant Sciences and Arbutus Biopharma Corp., which accused Moderna of using technology they have patented in its vaccine. The two companies have asked a federal court in Delaware to award them damages for the infringement.
Alex Coffey, senior trading strategist at TD Ameritrade, said recent turmoil in the banking industry has effectively tightened credit conditions, possibly making further rate increases by the Fed unnecessary. Still, the Fed had to send a message that it’s not making an abrupt shift in its efforts to bring inflation down. The Fed has been in “cruise control” raising rates, “staying in the fast lane,” Alex says. “Now, it has turned off cruise and maybe changed lanes, but isn’t doing a quick move toward the off ramp. Today’s increase was not a ‘dovish’ hike, but also not the hawkish stance that was feared.”
“We’re near the end of the tightening cycle,” he adds. “But they have to do this slowly.”
The Fed commentary appeared to briefly soothe the market, causing the S&P 500® Index to rise as much as 1% soon after the central bank’s announcement, but the benchmark changed direction in the last hour of trading. The reversal may have in part been in response to the ambiguity of Powell’s words, as well as continuing concern about a potential recession.
And so, the following is a round-up of today’s domestic market activity:
The S&P 500 Index was down 65.90 (1.7%) at 3936.97; the Dow Jones industrial average was down 530.49 (1.6%%) at 32,030.11; the NASDAQ Composite was down 190.15 (1.6%) at 11,669.96.
The 10-year Treasury yield was down about 17 basis points at 3.44%.
American businesses are extending their cost-cutting initiatives to include offshore employee medical benefits, and facilities like the Bumrungrad Hospital in Bangkok, Thailand (cosmetic surgery), the Apollo Hospital in New Delhi, India (cardiac and orthopedic surgery) are premier examples for surgical care. Both are internationally recognized institutions that resemble five-star hotels equipped with the latest medical technology.
Foreign countries where I studied medicine and surgery, and practiced briefly, such as Finland, England, Canada and Germany are also catering to the English-speaking crowd, while dentistry is especially popular in Mexico and Costa Rica. Although this is still considered “medical tourism,” Mercer Health and Benefits was retained a decade ago by three Fortune 500 companies interested in contracting with offshore hospitals and The Joint Commission [TJC] has accredited 88 foreign hospitals through a joint international commission.
To be sure, when India can discount costs up to 80%, the effects on domestic hospital reimbursement and physician compensation may be assumed to increase downward compensation pressures.
Dateline: WASHINGTON—The Federal Reserve raised its key short-term interest rate by a quarter percentage point today, pushing ahead with its aggressive campaign to tame inflation despite financial turmoil following Silicon Valley Bank’s collapse.
FOMC officials forecast another quarter point in rate increases this year to a peak range of 5% to 5.25%, in line with its December estimate and lower than the level markets anticipated before SVB’s meltdown.
In a statement after a two-day meeting, the Fed acknowledged recent strains in the nation’s banks and said they will soften the economy but added the financial system is stable.
D.C. CHERRY BLOSSOM FESTIVAL: The festivities began yesterday, a few days earlier than intended. DC is coming off of a historically warm winter, and the blossoms will be their fluffiest selves (aka “peak bloom”) March 22–25.
The following is a round-up of yesterday’s market activity:
The S&P 500 Index was up 51.3 (1.3%) at 4002.87, its highest close since March 6th; the Dow Jones industrial average was up 316.02 (1.0%) at 32,560.60; the NASDAQ Composite was up 184.57 (1.6%) at 11,869.11, the highest close since February 15th.
Treasury yield was up about 12 basis points at 3.594%.
According to HealthcareBrew, thousands of doctors are expected to reach retirement age in the next three years, and their replacements won’t be physicians. Instead, physician assistants (PAs) and nurse practitioners (NPs) will increasingly provide primary care services, according to a report from consulting firm Mercer.
By 2026, 21% of family medicine, pediatric, and obstetrics and gynecology physicians—or about 32,000 doctors—will be 65 or older, and Mercer anticipates about 23,000 physicians will leave the profession permanently. At the same time, demand for primary care physicians is expected to grow 4%, the report found.
PAs and NPs—also called advanced practice providers (APPs) or physician extenders—are highly trained medical professionals. To become a PA, you have to have both a bachelor’s and a master’s, some clinical work experience, pass the Physician Assistant National Certifying Exam, and then apply to get licensed in your state (you know, easy peasy). It takes seven to nine years to go through that process, compared to 11+ years to become an MD.
To become an NP, you must have both a bachelor’s and a master’s in nursing, become a registered nurse, and pass a national NP board certification exam. It takes between six to eight years to become an NP.
Compared to physicians, PAs and NPs are “considerably younger professions with less than half the retirement risk,” the Mercer report stated. Roughly 40,000 PAs and NPs join the workforce annually.
“We’re certainly going to see increasing demand for APPs,” David Mitchell, a partner in Mercer’s career consulting business and a specialist in the healthcare industry, told Healthcare Brew.
While most state licensing boards require a physician to oversee APPs, both PAs and NPs have the authority to do many services primary care physicians do, like seeing and diagnosing patients, ordering lab tests, and writing prescriptions, said Mitchell.
Executives at GSK Plc (NYSE: GSK), Moderna Inc (NASDAQ: MRNA), and CSL Seqirus, owned by CSL (OTC: CSLLY), said they are developing or about to test sample human vaccines against bird flu as a precautionary measure against a future pandemic. Others, like Sanofi SA (NASDAQ: SNY), “stand ready” to begin production if needed, with existing H5N1 vaccine strains in stock. The U.N. said it had signed legally binding agreements with 14 manufacturers for 10% of their pandemic flu vaccine in a mix of donated doses and doses to be bought at affordable prices.
Shares in troubled First Republic Bank crashed more than 46% on Monday, after reports the San Francisco-based bank may need to raise more funds despite a $30bn (£24bn) rescue last week.
***
U.S. stocks ended the day higher, as the financials sector bounced back amid the recent choppiness in the markets. Meanwhile, uncertainty remained regarding whether the turmoil will impact the Fed’s monetary policy decision on Wednesday. Banking stocks continued to be in focus, as UBS Group agreed to acquire Credit Suisse for a little over $3.0 billion, while the Fed and five other major central banks took action to increase the availability of liquidity for the financial system.
Treasury yields were higher, and the U.S. dollar was lower, while crude oil and gold prices gained ground.
Asia finished broadly lower, and markets in Europe rose sharply, as investors around the world contend with the latest updates surrounding global banks.
OK – I was a Certified Financial Planner® before my academic team launched the Certified Medical Planner™ online and on-ground chartered education and board certification designation program a few years ago. I am now CFP reformed and in remission.
Enter the Certified Medical Planner™ CharteredDesignation
Today, we are of course, gratified that Certified Medical Planner™ mark notoriety is growing organically in the healthcare, as well as financial services, industry.
Even uber-blogger Mike Kitces MSFS, MTAX, CFP, CLU, ChFC, RHU, REBC, CASL has taken note of us in his musings on the Nerd’s Eye View website. And, the reality is that there are a growing number of CFP educational programs at the post-CFP niche market level.
But, none for healthcare industrial complex: for doctors … by doctors!
Popularity of our Text Books
However, it is our modern, innovative and proprietary Certified Medical Planner™ textbooks and dictionaries that have exploded in the academic marketplace.
In fact, they are now redacted in thousands of medical, graduate, law and B-schools and libraries, as well as colleges and universities throughout the nation. This includes the Library of Congress, National Institute of Health and the Library of Congress.
What Gives?
We have been told that this textbook popularity and publishing success is because of their balanced and peer-reviewed nature; something not very widespread in the financial services industry that is prone to gross and overstated advertising, salesmanship and marketing hyperbole. And, for this we are very gratified.
But, is there another reason our books are so popular?
A bit of networking and research suggests that interested folks may be eschewing the actual course work in favor of just the high quality textbooks! UGH!
So, what do you think? Matriculation with the professional mark versus self study without the designation mark. Please opine.
Conclusion
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Malpractice Allegations Alter Practice Patterns of Emergency Department Doctors
QUERY: When physicians are accused of malpractice, how does this experience affect their practice of medicine?
Researchers Caitlin Carroll, David M. Cutler and Anupam Jena use administrative data on all emergency medicine physicians in Florida to answer this question in How Do Physicians Respond to Malpractice Allegations? Evidence from Florida Emergency Departments (NBER Working Paper 28330).
Crypto currency was touted as antidote to central banking.
But with its own flaws, is the system itself to blame for this crypto market crash?
***
Cryptocurrencies were supposed to offer a new, virtual alternative to the current, mundane, “corrupt” system, in which a few dozen bureaucrats in conference rooms around the world – central bankers – manipulate the most important commodity of all – interest rates – the price of money.
The collapse of FTX (a cryptocurrency exchange that was valued at $30 billion just a few months ago) and the subsequent bankruptcies revealed what may have started as a kernel of sincere libertarian ideas to stand up to endless money printing and debt creation in our financial system, has been hijacked by what appears to be an immutable flaw of the human condition: our greed and desire to get rich fast.
In 2023, the official first day of spring is today Monday, March 20th. This date marks the “spring equinox” in the Northern Hemisphere. So, what is the spring equinox and is it always on the 20th? Read on to learn more—plus, enjoy ideas on how to celebrate the season!
UBS agreed to buy its embattled rivalCredit Suisse for 3 billion Swiss francs ($3.25 billion) yesterday, with Swiss regulators playing a key part in the deal as governments looked to stem a contagion threatening the global banking system.
“With the takeover of Credit Suisse by UBS, a solution has been found to secure financial stability and protect the Swiss economy in this exceptional situation,” read a statement from the Swiss National Bank, which noted the central bank worked with the Swiss government and the Swiss Financial Market Supervisory Authority to bring about the combinationof the country’s two largest banks.
Bitcoin prices climbed to as high as $27,293 last week, wrapping up the cryptocurrency’s best week since January 2021. And it has Silicon Valley Bank and friends to thank for it. Crypto diehards claim bitcoin’s gains are the result of people losing faith in traditional banking after SVB and Signature imploded (though it’s worth noting that Signature was a big player in the crypto world).
However, after the second-and third-biggest bank failures in history, economists started second-guessing whether the Fed would stick to the plan to hike interest rates again or change course to protect the rest of the very fragile banking industry. That could mean the crypto market, which slid into the dreaded Crypto Winter in the first half of last year because of macroeconomic factors like the Fed’s rate hikes, might finally be approaching spring.
So, according to MorningBrew, the Fed’s interest rate decision next week will likely serve as crypto’s redeux. And despite the banking industry hoping Jerome Powell pauses the interest rate hikes, February’s inflation numbers showed that the Fed may need to stick to its original plan to keep inflation in check.
Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.
Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com
OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:
Blue Cross Blue Shield has deployed several trackers on its website, according to the web extension Ghostery, a tool that can tell you what kind of technology web pages are using.
Ghostery returned a list of trackers from Twitter, Google, and LinkedIn.
Though we don’t know specifically what kind of data is being transferred, these pixels are usually installed to help marketing departments. Tracking pixels, for the uninitiated, are hidden or embedded graphics that can give a more complete picture of a customer’s journey: what they’ve clicked on, if they’ve searched for something specific, if they’ve put something in a shopping cart, or whether an advertisement drove them to, say, Blue Cross Blue Shield’s homepage. For example, if an insurer wants to show that its ads are working, it can use a pixel to determine that it was their ad that got someone to finally sign up for health insurance, not Susan in HR.
Trackers are ubiquitous, but experts and consumers have raised serious questions about the data that’s shared between companies. For example, investigative reporting outlet The Markup found that hospitals shared sensitive information with Facebook through the Meta pixel. And just this month, Indianapolis-based Community Health Network reported that pixels may have affected 1.5 million of its patients.
For more, read Marketing Brew’s interview with sociologist Mary F.E. Ebeling, who wrote a book about the collection of sensitive health data.
It is not uncommon for practicing physicians to have more than a dozen separate insurance policies to protect their medical practice and personal assets. Yet, most doctors understand very little about their policies.BOOK REVIR
Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™explains to physicians and insurance professionals the background, theory, and practicalities of medical risk management, asset protection methods, and insurance planning.
The book presents information in a manner that is convenient and highly useful for busy medical practitioners. It discusses the medical records revolution and addresses concerns regarding cloud computing, data security, and technological threats.
The book covers modern health law and policy, including fraud and abuse, workplace-violence, Medicare compliance, HIPAA regulations, AR protection strategies with internal controls, P4P and value based care, insurance and reputation management, and how the ARA legislation is impacting physician practices. It also includes case models and examples that provide you with a real-world understanding of how to recognize and reduce personal and medical practice risks.
With time at a premium for all, and so much information packed into one well-organized resource, this book is a must-read for every physician and financial advisor that serves the health care sector. The book will help physicians make better decisions about the risks they face and will help financial advisors improve the value they provide to their clients who are doctors.
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