SPECIAL PURPOSE VEHICLE: Defined

By dcpalter

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What is an SPV and When Do You Need One?

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A special purpose vehicle (SPV), or a special purpose entity (SPE), is a legal entity that a parent company creates to hold separate assets from the parent’s balance sheet.


Its purpose is to isolate the parent company from any potential credit or financial risk that may arise from the SPV and is often used to pursue riskier projects, securitize debt, or transfer assets.
Since an SPV is separate from the parent company, it isn’t affected by the parent’s performance, and the parent isn’t typically affected by the performance of the SPV. If the parent goes bankrupt and is no longer in existence, the SPV can carry on.

This makes an SPV bankruptcy remote. This also means that the parent company is unaffected by the loss if the SPV fails.

MORE: https://www.wallstreetoasis.com/resources/skills/strategy/special-purpose-vehicle-spv

Related: https://medicalexecutivepost.com/2024/07/26/spac-v-direct-listing-v-ipo/

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PHYSICIAN RETIREES: Home Ownership V. Home Renting

THEFIVE-FIVE” FINANCIAL RULE

By Staff Reporters

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Many of the pros of home ownership will appeal to medical retirees for whom their home is their castle and who appreciate being settled both financially and geographically:

  • 1. Building equity in your home: Each mortgage payment you make brings you closer to owning your house free and clear with no payments. If you can buy a new home or condo outright by selling your current home, you can still build equity in your new home over time.
  • 2. Predictability: If you have a fixed-rate mortgage, your mortgage payments will remain consistent for years and you don’t have to worry about a landlord ever making you move.
  • 3. Tax benefits: You can deduct mortgage interest and property taxes up to certain limits.
  • 4. Customization: You don’t need a landlord’s permission to alter and improve your home.
  • 5. Home appreciation: Homes generally increase in value, so you can increase your net worth by owning a property.

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Renting also has five significant upsides, particularly for physician retirees who want greater freedom to travel and to make bigger moves — potentially across the country or even abroad:

  • 1. Extreme flexibility: You can leave your property after giving notice and go wherever you want much more easily than with an illiquid home you’d have to sell first.
  • 2. Lower upfront costs: You only have to pay first and last month’s rent and a security deposit to move into a rental, not make a large home down payment.
  • 3. No maintenance concerns: If something breaks, your landlord is responsible for the cost of fixing it and the actual repairs. You don’t have to build up an emergency fund for maintenance.
  • 4. Predictable expenses: For the duration of your lease, your monthly housing costs including utilities will remain consistent, even if the cost of energy goes up, for example.
  • 5. Lack of worry: If you’re in a rental apartment, you won’t have to concern yourself with shoveling snow, mowing grass or other matters of upkeep.

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DAILY UPDATE: Dow & S&P 500 Post Best Week Since 2023

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US stocks turned higher on Friday to cap a chaotic week on Wall Street, as investors weighed the latest tariff-related developments in the trade war between the US and China.

The S&P 500 (^GSPC) rose 1.8% after seesawing earlier in the session. The tech-heavy NASDAQ Composite (^IXIC) climbed 2.1%. The Dow Jones Industrial Average (^DJI) advanced 1.5%, about 600 points.

Trump’s fast-moving tariff policy has whiplashed stocks this week with historic gains during Wednesday’s session but sharp losses on Thursday.

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In the end, the S&P 500 and Dow had their best weeks since 2023, while the NASDAQ’s 7% weekly gain was its best since 2022.

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Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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MICROSOFT: 50 Years

By Staff Reporters and Morning Brew

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Microsoft is celebrating its 50th birthday this week looking like a formerly washed up A-lister who’s suddenly rebounded and getting Oscar noms again.

Ever since Bill Gates and Paul Allen huddled in a garage in 1975 to start a company that’d define the experience of sitting in front of a boxy white PC monitor, Microsoft has had an uneven run. But after years of getting roasted for Internet Explorer, it now seems to be back on top—even briefly beating Apple as the world’s most valuable public company last year.

The tech giant can not only boast bonanza earnings, it also feels like a purveyor of the next big thing again, leading in the AI race through its partnership with OpenAI.

Windows washed

In the 1990s, it felt like Microsoft’s computer geeks were the overlords of tech. Windows powered most PCs, Internet Explorer became the go-to browser, and proficiency in Office tools became standard resume skills. But in the following decade, the company slept on internet tech and smartphones, ceding ground to Apple, Alphabet, and Meta.

It responded by going into midlife crisis mode, aka blowing cash on a series of questionable acquisitions to stay hip. That…didn’t help. By the 2010s, only grandparents could be reached @hotmail.com, Windows phones were a rarity, and no one used Bing as a verb.

When Gates stepped away from running the company in 2000, its new CEO Steve Ballmer grew its revenue threefold by the end of his tenure in 2013. He spearheaded Microsoft’s foray into gaming with the Xbox console and started its blockbuster cloud computing product Azure. But Microsoft’s profit growth slowed dramatically thanks to a massive cash bleed from its shopping spree.

  • It dropped $6.3 billion on the owner of ad tech platforms aQuantive to compete with Google’s ad business in 2007, only to write it off as a dud five years later.
  • The company burned at least $8 billion trying to make Windows phones a bigger force by buying Nokia’s cellphone division in 2014.
  • Microsoft paid $8.5 billion for Skype in 2011, which must’ve made it extra painful to announce that it was sunsetting the video calling service this winter.

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Cash-slinging comeback kid

When it blew out forty candles in 2015, the tech giant was looking past its prime. The stock was trading at around $35 a share, well below its $58 peak in 1999. Its net profit for the year was $12 billion. But investors who held on until now were rewarded with shares going for $374 on its birthday this week after the company reported a net profit of $88 billion in the last financial year.

Much of the revenue now comes from its Azure cloud computing business, which has been boosted by the booming AI industry ravenous for server power.

  • When Microsoft’s current CEO Satya Nadella stepped into the role in 2014, he doubled down on Azure to make Microsoft into a B2B behemoth selling computing power to tech companies.
  • It is now the world’s second largest cloud provider after Amazon Web Services, with a 21% market share, according to Synergy Research Group.

Microsoft also bought some businesses that didn’t fail, including LinkedIn—the thought leadership hub with a user base that has soared to 1 billion since the 2016 acquisition. It also owns GitHub, the leading code-sharing platform for software developers. And in its biggest purchase yet, it snagged gaming IP giant Activision Blizzard that owns Call of Duty and World of Warcraft for a whopping $68 billion in 2022, hoping to make itself a dominant caterer to the Xbox joystick-wielding crowd.

It’s an AI company now

The not-quite-acquisition that really got Microsoft its groundbreaker’s glitz back was pouring $13 billion into OpenAI.

Having gotten in on the ground floor of the AI boom, Microsoft is harnessing OpenAI’s models to power its CoPilot AI agent, which it embedded into its Office tools and Teams app. This pits it against other tech giants betting that AI agents automating tasks will be the biggest in-cubicle revolution since Excel.

Cite: Morning Brew April 5, 2025

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ROTH: Conversion Considerations for Physicians

Why would a doctor consider a Roth IRA conversion?

By Staff Reporters

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A Roth conversion involves transferring funds from a traditional retirement account—such as a 401(k), 403(b), or individual retirement account (IRA) funded with pre-tax dollars—into a Roth IRA.

The biggest benefit lies in the tax treatment of the converted funds. Once the funds are in the Roth IRA, future growth of those assets is tax-free. Withdrawals in retirement are also tax-free, assuming they meet certain criteria. As with any strategy, there are important considerations to keep in mind.

When you convert funds to a Roth IRA, the amount converted is taxable income in that tax year. For example, if you convert $100,000 from a traditional IRA to a Roth IRA, that $100,000 will be added to your taxable income in the conversion year.

Converting large amounts can result in a significant tax bill and may push you into a higher tax bracket. Even so, using retirement funds to pay taxes may make sense for those looking to convert large IRAs to reduce their future required minimum distributions (RMDs).

The timing of your Roth conversion matters too. Generally, it’s a good idea to convert when your income is lower—for example, after you’ve retired and before you begin drawing Social Security. You may also choose to convert over the course of several years to spread out the tax impacts. But if you can get comfortable with these considerations, a Roth conversion can provide you with benefits beyond tax-free growth and withdrawals.

Some of these benefits are:

  • Tax diversification. Having both traditional and Roth accounts allows you to manage your tax liability in retirement. For example, if your income in a given year is higher than expected, you can withdraw from the Roth IRA without increasing your taxable income.
  • No RMDs. Traditional IRAs and 401(k)s require you to begin taking RMDs at age 73. Roth IRAs have no RMD requirement during your lifetime. With a Roth account, you have more control over your retirement withdrawals and can leave the funds to grow for your heirs.
  • Benefits for heirs. Roth IRAs can be passed on to beneficiaries, who can inherit the account income tax-free. This means your heirs can enjoy the tax-free growth and withdrawals if the Roth IRA has been held for five years or more—a significant advantage, especially if your beneficiaries are in a higher tax bracket.

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DAILY UPDATE: Stocks Crushed Again!

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US stocks got crushed on Thursday, pulling back from the previous day’s historic rally amid concerns that President Trump’s broad trade offensive has become a direct confrontation with China.

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The S&P 500 (GSPC) dropped almost 3.5%, while the tech-heavy NASDAQ Composite (IXIC) tumbled 4.3%. The Dow Jones Industrial Average (^DJI) fell about 1,000 points, or 2.5%. The 10-year Treasury yield (^TNX), in high focus amid bond market whiplash, ended the day flat around 4.39%.

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The major averages sank to session lows after the White House confirmed updated tariff figures released on Thursday brings the total increased levies on Chinese goods to 145%, not 125% as previously stated.

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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FINANCIAL MODELING TERMS: All Physicians Should Review and Know

By Staff Reporters

SPONSOR: http://www.CertifiedMedicalPlanner.org

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Financial Modeling is one of the most highly valued, but thinly understood, skills in financial analysis. The objective of financial modeling is to combine accounting, finance, and business metrics to create a forecast of a company’s future results.

According to Jeff Schmidt, a financial model is simply a spreadsheet, usually built in Microsoft Excel, that forecasts a business’s financial performance into the future. The forecast is typically based on the company’s historical performance and assumptions about the future and requires preparing an income statement, balance sheet, cash flow statement, and supporting schedules (known as a three-statement model, one of many types of approaches to financial statement modeling). From there, more advanced types of models can be built such as discounted cash flow analysis (DCF model), leveraged buyout (LBO), mergers and acquisitions (M&A), and sensitivity analysis

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DEFINED TERMS

Discounted Cash Flow (DCF): A valuation method used to estimate the value of an investment based on its expected future cash flows, adjusted for the time value of money. It’s like deciding whether a treasure chest is worth diving for now, based on the gold coins you’ll be able to cash in later.

Sensitivity Analysis: This involves changing one variable at a time to see how it affects an outcome. Imagine tweaking your coffee-to-water ratio each morning to achieve the perfect brew strength.

Budget – A budget is the amount of money a department, function, or business can spend in a given period of time. Usually, but not always, finance does this annually for the upcoming year.

Rolling ForecastA rolling forecast maintains a consistent view over a period of time (often 12 months). When one period closes, finance adds one more period to the forecast.

Topside – A topside adjustment is an overlay to a forecast. This is typically completed by the corporate or headquarter team. As individual teams submit a forecast, the consolidated result might not make sense or align with expectations. When this occurs, the high-level teams use a topside adjustment to streamline or adjust the consolidated view.

Monte Carlo Simulation: Picture yourself at the casino, but instead of gambling your savings away, you’re using this technique to predict different outcomes of your business decisions based on random variables. It’s like playing financial roulette with the odds in your favor.

What-If Analysis: Ever daydream about what would happen if you took that leap of faith with your business? This tool allows you to explore various scenarios without risking a dime. It’s like trying on outfits in a virtual dressing room before making a purchase.

Leveraged Buyout (LBO) Model: This is a bit like orchestrating a heist, but legally. It’s about acquiring a company using borrowed money, with plans to pay off the debts with the company’s own cash flows. High stakes, high rewards.

Mergers and Acquisitions (M&A) Model: Picture two puzzle pieces coming together. This model evaluates how combining companies can create a new, more valuable entity. It’s the corporate version of a matchmaker.

Three Statement Model: The holy trinity of financial modeling, linking the income statement, balance sheet, and cash flow statement. It’s like weaving a tapestry where each thread is crucial to the overall picture.

Capital Asset Pricing Model (CAPM): A formula that calculates the expected return on an investment, considering its risk compared to the market. It’s like choosing the best roller coaster in the park, balancing thrill and safety.

Cash Flow Forecasting: This is your financial weather forecast, predicting the cash flow climate of your business. It helps you plan for sunny days and save for the rainy ones.

Cost of Capital: The price of financing your business, whether through debt or equity. It’s like the interest rate on your growth engine, pushing you to maximize every dollar invested.

Debt Schedule: A timeline of your business’s debts, showing when and how much you owe. It’s your roadmap to becoming debt-free, one milestone at a time.

Equity Valuation: Determining the value of a company’s shares. It’s like assessing the worth of a rare gemstone, ensuring investors pay a fair price for a piece of the treasure.

Financial Leverage: Using debt to amplify returns on investment. It’s like using a lever to lift a heavy object, increasing force but also risk.

Forecast Model: A crystal ball for your finances, projecting future performance based on past and present data. It’s your guide through the financial wilderness, helping you navigate with confidence.

Operating Model: A detailed blueprint of how a business generates value, mapping out operational activities and their financial impact. It’s like laying out the inner workings of a clock, ensuring every gear turns smoothly.

Revenue Growth Model: This tracks potential increases in sales over time, charting a course for expansion. It’s like plotting your ascent up a mountain, anticipating the effort required to reach the summit.

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TREASURY NOTES: Panic Attack Mode?

By Staff Reporters

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Treasury notes are typically considered one of the world’s safest safe-haven assets—the US has always repaid bondholders on their investment, plus yield (interest). That’s why you can usually count on the bond market to rally when the stock market craters. And, vice-versa. But not this time:

  • The benchmark 10-year bond yield, which moves inversely to bond prices, had its steepest spike this week since the 2008 financial crisis. The 10-year yield is more closely watched than the 30-year yield (which also spiked) in part because it influences home and auto loan rates.
  • A Treasury auction of 3-year bonds on Tuesday was met with the softest demand since December 2023. That helped drive the bond sell-off on fears of a pullback among international investors, who hold $8.5 trillion in US Treasuries (Japan and China lead the pack).

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DAILY UPDATE: Medicare Rates and Indian Health Service as Stocks Markets Experience Explosive Surge!

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Stat: 5.06%. That’s how much Medicare payment rates will increase for 2026, doubling what was previously proposed. (the Wall Street Journal)

Quote: “The move displays the utmost disrespect for public service. It is clearly designed to force talented scientists and health experts to leave government. It is also an insult to those healthcare professionals in the Indian Health Service who dedicate their lives to providing healthcare services on tribal lands.”—Richard Besser, CEO of the nonprofit Robert Wood Johnson Foundation, on offers to reassign HHS workers on administrative leave to the Indian Health Service (NPR)

Read: Some psychologists are offering free or low-cost therapy for federal healthcare workers. (Stat)

CITE: https://tinyurl.com/2h47urt5

US stocks rocketed higher on Wednesday as President Trump announced a 90-day pause on tariffs for most countries, yet at the same time upped increasingly ballooning levies on China.

The benchmark S&P 500 (^GSPC) roared up over 9.5%, posting its best day since 2008. The tech-heavy NASDAQ Composite (^IXIC) rallied a whopping 12% for its second-best day on record and its biggest gain since 2001. The Dow Jones Industrial Average (^DJI) was up over 7.8%, or roughly 3,000 points.

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REPUTATIONAL BANKRUPTCY: Of the American Dollar

By Vitaliy Katsenelson CFA

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The Reputational Bankruptcy of the American Dollar
I am in an unenviable position. The policy coming out of the White House has a significant impact on economics, more than ever before in my career. If I say anything positive about that policy, I’ll be put in the MAGA camp. If I criticize it, I’ll be accused of suffering from Trump derangement syndrome. I am hired by you to make the best investment decisions possible. Rather than see me as engaged in political commentary, I’d ask that you view my remarks as purely analytical.

Let me give you this analogy. I live in Denver. Let’s imagine I am a huge Broncos fan, and the Broncos are playing the Chicago Bears. If I am betting a significant amount of money on this game, I should put my affinity for the Broncos and hatred of the Chicago Bears aside and analyze data and facts. The Broncos are either going to win or lose; my wanting them to win has zero impact on the outcome. The same applies to my analysis here. My motto in life is Seneca’s saying, “Time discovers truth.” I just try to discover it before time does.

When it comes to politics, I also have a significant advantage. I was not born in this country. From a young age, I was brainwashed about communism, not about team Republican versus team Democrat. The failure of the Soviet Union de-brainwashed me fast concerning the virtues of communism and converted me into a believer in free markets.

As a result, I never bought into either party’s ideology, and thus in the last four presidential elections I voted for a Republican, an independent, a Democrat, and wrote in my youngest daughter, Mia Sarah (not in that order). In my articles I have criticized the policies of both Biden (student loan forgiveness, unions) and Trump (Bitcoin reserve).

I remind myself that in times like these you have to be a nuanced thinker. Some of Trump’s policies are terrific, others … not so much (I am being diplomatic here).

Scott Fitzgerald once said “The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time, and still retain the ability to function.” In 2025 we are taking this “first-rate intelligence” test daily.

What will happen to the US dollar? The US dollar will likely continue to get weaker, which is inflationary for the US. Let me start with some easily identifiable reasons:

We have too much debt. We ran 6-7% budget deficits while our economy was growing and unemployment was at record lows. Now we have $36 trillion in debt. Our interest expenses exceed our defense spending, and these costs will continue to climb. If/when we go into recession, we may see something we have not seen in a long time – higher interest rates. Our budget deficits will balloon to between 9–12%, and the debt market, realizing that inflation (i.e., money printing) is inevitable, will say, “Pay up!”

New competition from Bitcoin. President Trump’s approval of Bitcoin as a potential reserve currency is one of the most self-serving and anti-American things I’ve seen any president do. The US dollar is the world’s reserve currency. We still have little competition for that title. China could be a contender, but it is not a democracy and has capital controls. This policy has no upside for America, only downside.

A stronger Europe. Ironically, we may inadvertently create a stronger Europe by threatening to abandon NATO. I don’t want to insult European clients (or my European friends), but the following analogy describes the US-Europe relationship on some level: Europe gradually evolved into a trust fund kid (when it came to security) and the US turned into its sugar daddy. The trust fund kid was incredibly dependent on the sugar daddy. It criticized its parent for being a barbarian and money-driven, but it relied heavily on that parent to protect it from bullies.

President Trump cut off Europe’s allowance by threatening that the US might not protect Europe from Russia. This has forced Europe to spend more money on defense. Outside of Germany (which has little debt), few European economies can afford that. This may force Europe (or at least some European countries) to become more pragmatic – to cut social programs and bureaucracy. If this leads to a stronger Europe both economically and militarily, the euro will be competing with the US dollar. This is a big if.

Our new foreign policy.

When people describe President Trump’s foreign policy as “transactional,” they’re highlighting a fundamental shift in how America engages with the world – one with profound implications for our global standing, national interests, and the US dollar. The shift affects both types of capital – financial and reputational.

Reputational capital isn’t at risk in ‘one-shot’ transactions like house selling. Imagine you’re selling your primary residence and moving elsewhere. Do you disclose every flaw, or let the buyer figure things out? Your incentive is to maximize short-term profits. You’ll likely never meet this buyer again, and therefore there are incentives not to care what they’ll think of you afterward. You’ll be transactional, seeking the highest price possible for your biggest asset. This exemplifies a ‘one-shot’ system where future interactions aren’t expected.

Contrast this with a relationship- and trust-based system. Now imagine you are a homebuilder in a small town. Your suppliers only extend credit if you have a reputation for paying on time. Your employees do quality work only if you treat them fairly. Your buyers tell friends about their experience with you. The incentives naturally create a relational approach. In this trust-based system, incentives skew toward maximizing long-term profits, where reputational capital becomes the glue creating continuity.

Reputational capital radiates predictability – you know how someone will behave based on their history – but operating with low or negative reputational capital is difficult and expensive. People won’t enter long-term contracts with you or will demand external guarantees. Many potential partners will simply refuse to deal with you.

Building reputational capital works like adding pennies to a jar – each good deed incrementally adds to your standing. Yet reputational capital can collapse instantly by removing the jar’s bottom. A single breach of trust doesn’t just remove one penny; it can wipe out your entire balance and plunge you into reputational bankruptcy. The math is brutally asymmetric: good deeds might add a point or two, while bad deeds subtract by factors of 50 or 100.

This doesn’t mean transactions shouldn’t be profitable. If you’re accumulating reputational capital while consistently losing money, you’re probably in the wrong business. Each deal should be evaluated considering both long-term financial and reputational capital.

Individual transactions can sacrifice some profit but cannot afford to lose reputational capital. A “one-shot” transactional approach used in a trust-system environment may provide greater short-term profitability, but if this success comes at the expense of reputational capital, the long-term consequences for America’s global position could be devastating.

This brings us to our current foreign policy.

Relationships between nations are a trust-based system. I’d argue it’s a super-relational system because it’s multigenerational, lasting beyond the life of any one human. Reputational capital is paramount here.

Part of the US’s strength has been the soft power – the reputational capital – it exerted. We had a lot of friends, which helped us to be more effective in dealing with our foes. We keep telling ourselves that America is an “exceptional” nation. This exceptionalism didn’t just come from our financial and military might – it accumulated based on our reputational capital.

Though we don’t always succeed, we are a people who try to do the right thing. Our exceptionalism has been earned through our actions. We are the country that helped rebuild Europe and gave it six decades to repay lend-lease. We toppled communism.

I don’t know the nuances of the Ukraine mineral deal, but initially it had the optics of extortion. Though I think the renegotiated and signed version appears to be fair to both sides, forcing repayment while Ukraine is dodging Russian missiles made the US look transactional.

Actions by President Trump over the last month have undermined our reputation. We are quickly becoming a “one-shot” transactional player in a trust-based environment. Imposing tariffs on Canada on a whim to try to get it to become the 51st state erodes American reputational capital. So does not ruling out America invading Greenland. This puts us on the same moral plane as Russia invading Ukraine.

The conversation about tariffs has many nuances. For instance, I don’t know anyone who opposes reciprocal tariffs – they seem fair and don’t consume any reputational capital. But tariffs that are used as weapons in a trade war in order to annex another country erode reputational capital. Threatening to leave NATO and not protect countries that don’t spend enough on their defense diminishes reputational capital. Maybe the only way to get European countries to spend on defense was to threaten not to defend them – you can agree or disagree with the rationale behind each of Trump’s decisions, but what can’t be argued is that they undermined our reputational capital.

As we lose soft power, our influence will diminish, and thus so will perceptions of our power. The world will start looking at us not from the perspective of the continuity of generations but of presidential cycles. The word of the American president will have an expiration date of the next presidential or mid-term election.

There are two negotiation styles – Warren Buffett’s and Donald Trump’s. Both have their advantages and disadvantages. Buffett will give you one offer and one offer only. Once the deal is agreed to, even just verbally, that is the deal. Critics would say that there is downside to that predictability, as foes know how you are going to respond. Donald Trump’s style is to be unpredictable, which has its own advantages when you deal with foes – it keeps opponents guessing. But it destroys trust with your allies.

In a world of fiat currencies, all currency is a financial and reputational promise. President Trump, with the help of DOGE (and maybe even tariffs) may increase our financial strength. I hope he does, but it will likely come at a very high cost to our reputational capital, and therefore US global influence and the US dollar will continue its decline.

How are we positioned for this?

About half of our portfolio is foreign companies whose sales are not in dollars. They will benefit from a weaker dollar. We also have exposure to oil, which is priced in the US dollar and usually appreciates when the dollar weakens.

A weaker dollar means our imports will become more expensive, which is inflationary. We own many companies with pricing power and also companies that have claims on someone else’s revenues. Take Uber for example: they get about 20% of each ride. If the cost of the ride goes up, so does their dollar take.

Why does President Trump keep pushing crypto?

In July 2019, Trump said the following: “I am not a fan of Bitcoin and other cryptocurrencies, which are not money, and whose value is highly volatile and based on thin air.” Five years later he promised to establish the US Crypto Reserve, and in 2025 he did.

What changed? There is no logical reason for an American president to endorse crypto. None. Here is the honest answer: Crypto bros made mega-contributions to his campaign.

To top it off, three days before he took office he issued $TRUMP – a shitcoin. Believe it or not, “shitcoin” is a technical term in the crypto community (any coin other than Bitcoin is called a shitcoin by Bitcoin “maximalists”, folks who believe Bitcoin is the one and only digital currency). The future sitting president literally issued – I don’t want to call it a currency, so I guess shitcoin is the right name – that will at some point decline to zero in value. In other words, he’ll fleece his loyal followers who purchase $TRUMP of billions of dollars.

I previously referenced both reputational capital and soft power. These types of acts by a sitting president subtract from both.

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STOCK MARKET: Panic Buying Apple A18 Processor iPhones

By Staff Reporters

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Just after midnight, President Trump’s “reciprocal” tariffs went into effect against 86 countries. Analysts have estimated that the new US average effective tariff rate is north of 20%, the highest in more than 100 years. Ahead of the tariff deadline, markets swung violently, mostly way down: According to Bloomberg’s Cameron Crise, yesterday was the fourth straight trading day when the S&P 500’s trading range was 5% or more. That’s only happened in 1987, 2008, and 2020.

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The Apple A18 and Apple A18 Pro are a pair of 64-bit ARM-based system on a chip (SoC) designed by Apple Inc., part of the Apple silicon series. They are used in the iPhone 16 and iPhone 16 Pro lineups and the iPhone 16e, and built on a second generation 3 nm process by TSMC.

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Yesterday, for several hours on Tuesday, it looked like stocks were going to regain some of the ground lost during the market’s very bad week. But after the Trump administration made it clear that its increased tariffs on China would go into effect, all three indexes plunged. Apple, which makes most of its iPhones in China, was hit harder than many of its Big Tech peers.

So shoppers are thinking it’s better to have an Apple A18 processor and not need it, than to need it and not have it. Apple customers are scrambling to buy new iPhones out of fear that the company could raise prices to offset President Trump’s tariffs.

Employees at locations throughout the US said they’re being bombarded with questions about potential price hikes and have witnessed customers panic-buying phones. Though Apple declined to comment to Bloomberg, its retail stores reportedly saw higher sales over the last weekend than in previous years.

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DAILY UPDATE: Medical Un-Affordability as Stock Market Rebound Collapses

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Stat: 11%. That’s the share of US residents who said they couldn’t afford medical care or medication over a three-month period, according to a new Gallup survey. (the New York Times)

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An epic stock-market bounce turned into a historic fizzle, extending the bruising selloff sparked by President Donald Trump’s sweeping tariff measures to a fourth straight session.

SPX-1.57% saw an intra-day gain of 4.05% evaporate to end with a loss of 1.6%, marking its biggest blown percentage gain since Oct. 14th, 2008, during the darkest days of the 2007-09 financial crisis. And it’s the first time the S&P 500 was up more than 4% at its intra-day high but finished with a loss of more than 1%, based on data going back to 1978, according to Dow Jones Market Data.

DJIA-0.84% rallied 1,461 points, or 3.85%, at its intra-day peak, but ended the day down more than 400 points, its biggest erased percentage gain since April 2020.The tech-heavy NASDAQ Composite.

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Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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ACO REACH: A New Model

ACCOUNTABLE CARE ORGANIZATIONS

Realizing Equity, Access, and Community Health

By Staff Reporters

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Model Overview

The ACO REACH Model provides novel tools and resources for health care providers to work together in an ACO to improve the quality of care for people with Traditional Medicare. REACH ACOs are comprised of different types of providers, including primary and specialty care physicians.

The ACO REACH Model makes important changes to the previous Global and Professional Direct Contracting (GPDC) Model which include:  

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  1. Promote Provider Leadership and Governance. The ACO REACH Model includes policies to ensure doctors and other health care providers continue to play a primary role in accountable care. At least 75% control of each ACO’s governing body generally must be held by participating providers or their designated representatives, compared to 25% during the first two Performance Years of the GPDC Model. In addition, the ACO REACH Model goes beyond prior ACO initiatives by requiring at least two beneficiary advocates on the governing board (at least one Medicare beneficiary and at least one consumer advocate), both of whom must hold voting rights. 
     
  2. Protect Beneficiaries and the Model with More Participant Vetting, Monitoring and Greater Transparency. CMS will ask for additional information on applicants’ ownership, leadership, and governing board to gain better visibility into ownership interests and affiliations to ensure participants’ interests align with CMS’s vision. We will employ increased up-front screening of applicants, robust monitoring of participants, and greater transparency into the model’s progress during implementation, even before final evaluation results, and will share more information on the participants and their work to improve care. Last, CMS will also explore stronger protections against inappropriate coding and risk score growth. 

MORE: https://www.cms.gov/priorities/innovation/innovation-models/aco-reach

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DAILY UPDATE: VA EHR Snafu and Stock Market Volatility

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e Department of Veterans Affairs announced plans last week to accelerate the rollout of its embattled electronic health records system. Lawmakers, meanwhile, continue to call for oversight despite concerns over the future of the modernization program. The VA added nine new medical facilities in Ohio, Kentucky, Indiana, and Alaska to the deployment schedule, along with four sites in Michigan that will launch in 2026 after the program expansion has largely been on hold since April 2023, when the agency acknowledged glitches in the system had contributed to at least four veterans’ deaths and “catastrophic harm” to others.

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After a roller coaster day, the Dow closed lower by 349 points, or 0.91%. The broader S&P 500 fell 0.23%. The NASDAQ Composite was 0.1% higher after fluctuating between gains and losses. Wall Street’s fear gauge, the CBOE Volatility Index, or VIX, on Monday closed at the highest level since the Covid pandemic as investors fretted over the market’s next move. The VIX surpassed an intraday level of 50 points midday Monday, a rare level associated with extreme volatility.

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Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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IPOs: Delayed

By Staff Reporters

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Initial Public Offering Defined

IPO stands for initial public offering. It is when a company takes a portion of their shares and makes them available for the general public to buy on the open market. It is a way for the company to raise money by selling those shares to the general public. You can usually access shares from an IPO by working directly with an investment bank.

Paused IPOs

Private companies StubHub and Klarna each paused their imminent plans to go public.

Klarna, which was set to IPO on this Monday, was expected to jump-start the frozen IPO market this year with an expected ~$15 billion valuation.

StubHub, meanwhile, reportedly wants to wait for the market to calm down before resuming its plans to go public.

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BLACK MONDAY REDEUX: Interesting Day or Financial Crisis?

BILL ACKMAN versus JIM KRAMER

By Staff Reporters

SPONSOR: http://www.CertifiedMedicalPlanner.org

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Interesting Day?

Markets: Last week’s market bloodbath will go down in the history books. The S&P 500’s 10% plunge on Thursday and Friday, after President Trump announced massive tariffs, ranks among the steepest two-day decline in the last 70 years, on par with Black Monday in 1987, the post-Lehman Brothers rout in 2008, and the Covid plunge in March 2020. More than $6 trillion was wiped out from stocks over two days, and the NASDAQ entered a bear market, down 20% from a previous high.

Trading restarted at 9:30 am ET for what Bill Ackman predicts will be “one of the more interesting days in our country’s economic history.”

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Monday Crash?

On the other hand, CNBC host and market commentator Jim Cramer just warned that America is in store for another “Black Monday” market crash similar to the record 1987 collapse if President Trump doesn’t curtail his tariff plan.

Cramer — who noted that the 1987 crash saw the Dow Jones Industrial Average fall by 22.6% in a single day — said the bloodbath could be repeated after the brutal two-day sell-off following the announcement of Trump’s sweeping tariffs against nearly 90 countries.

If the president doesn’t try to reach out and reward these countries and companies that play by the rules, then the 1987 scenario … the one where we went down three days and then down 22% on Monday, has the most cogency,” Cramer said on his show Saturday, referencing the worst single-day fall in the history of the Dow.

QUESTION: Who is correct; Ackman or Cramer?

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Registered Investment Advisor VERSUS Hedge Fund Manager

SPONSOR: http://www.CertifiedMedicalPlanner.org

By Staff Reporters

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A hedge fund is a limited partnership of private investors whose money is pooled and managed by professional fund managers. These managers use a wide range of strategies, including leverage (borrowed money) and the trading of nontraditional assets, to earn above-average investment returns. A hedge fund investment is often considered a risky, alternative investment choice and usually requires a high minimum investment or net worth. Hedge funds typically target wealthy investors.

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The Hedge Fund manager I am considering is a Registered Investment Adviser [RIA]

QUESTION: What is a Registered Investment Advisor?

If the fund manager is an entity, then any individual you deal with will be a registered investment adviser representative. If the fund manager is an individual, then that individual is a registered investment adviser. In either case, the designation implies several steps have been taken.

In order to become a registered investment adviser, an individual must register for and pass the Series 65 Uniform Investment Adviser Law Exam, a three-hour, 130-question computer-based exam administered by the North American Securities Administrators Association. Topics covered include economics and analysis, investment vehicles, investment recommendations and strategies, and ethics and legal guidelines. A passing score is 70 percent or higher.

Once an individual has passed the Series 65, he or she must then apply via Form ADV to become a registered investment adviser. This application is made to either a state authority or to the SEC, depending on the adviser’s assets under management. If assets under management exceed $30 million, then the adviser must register with the SEC.

Form ADV consists of two parts. Part I provides general information to the regulatory authority. Part II is designed to be distributed to potential clients, and includes disclosure of a decent amount of information about the adviser. If the manager is a registered investment adviser, then you should expect to receive as part of the offering documentation either a current copy of Part II of the adviser’s Form ADV or a brochure that contains all the current information in Part II of Form ADV.

In addition to filing Form ADV and paying a small fee, the registered investment adviser becomes subject to extra administrative/regulatory burden as well as capital adequacy requirements that state the Adviser must maintain certain net worth levels.

By and large, because of the extra administrative burden as well as restrictions on certain activities, hedge fund managers attempt to avoid registering as investment advisers. Whether such managers can or cannot avoid such registration is largely dependent upon the state in which the manager operates. In California, for instance, hedge fund managers must register as investment advisers. In New York, such registration is not necessary. Not surprisingly, hedge fund managers located in California are rare, while they are quite plentiful in New York. 

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MEDICAL DEVICES: Special Considerations

By Staff Reporters

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INFORMATION TECHNOLOGY CONSIDERATIONS FOR MEDICAL DEVICES

In 2013, the Food and Drug Administration (FDA) issued its first cybersecurity safety communication, followed in 2014 by final guidance. It struck a reasonable balance between new regulations (almost none) and guidance (in the form of non-binding recommendations).

In 2015, the Federal Trade Commission (FTC) released a staff report entitled Internet of Things: Privacy & Security in a Connected World, in which it recommend that Internet of Things (IoT) style devices, which of course include medical and clinical devices, need to maintain a good security posture. It’s worth noting that the FDA, FTC, and other government regulators are centering on a few key guidelines. The following recommendations come directly from the FTC report.

Companies should build security into their devices at the outset, rather than as an afterthought. As part of the security by design process, companies should consider:

  • Conducting a privacy or security risk assessment
  • Minimizing the data they collect and retain
  • Testing their security measures before launching their products
  • Companies should train all employees about good security, and ensure that security issues are addressed at the appropriate level of responsibility within the organization
  • Companies should retain service providers that are capable of maintaining reasonable security and provide reasonable oversight for these service providers.
  • When companies identify significant risks within their systems, they should implement a defense-in-depth approach, in which they consider implementing security measures at several levels.
  • Companies should consider implementing reasonable access control measures to limit the ability of an unauthorized person to access a consumer’s device, data, or even the consumer’s network.
  • Companies should continue to monitor products throughout the life cycle and, to the extent feasible, patch known vulnerabilities

According to colleague Shahid N. Shah MS, the FTC report and FDA guidelines are remarkably consistent. When thinking of cybersecurity and data privacy, engineers tend to think about authentication, authorization, and encryption. Those are the relatively easy topics. For safety-critical devices, however, things are much more difficult and need to encompass a larger surface of questions, including but not limited to:

  • Asset Inventory: Is the device discoverable, and can it associate itself with standard IT inventory systems so that revision management, software updates, and monitoring can be automated?
  • Cyber Insurance: Does the device have enough security documentation to allow it to be insured by standard cyber insurance riders?
  • Patching: How is the firmware, operating system (OS), or application going to be patched by IT staff within hospitals (or the home for remote devices)?
  • Internal Threats: Has the device been designed to circumvent insider (hospital staff, network participants, etc.) threats?
  • External Threats: Has the device been designed to lock down the device from external threats?
  • Embedded OS Security: Is the device sufficiently hardened at the operating system level, such that no extraneous software components, which increase the attack surface, are present?
  • Firmware and Hardware Security: Are the firmware and hardware components sourced from reputable suppliers and free of state-sponsored spying?
  • Application Security: Is the Microsoft Security Development Lifecycle (SDL) or similar software security assurance process integrated into the engineering process?
  • Network Security: Have all network protocols not in use by the device been turned off so that they are not broadcasting?
  • Data Privacy: What data segmentation, logging, and auditing is being done to ensure appropriate data privacy?
  • HIPAA Compliance: Have proper steps been followed to ensure Health Insurance Portability and Accountability Act (HIPAA) compliance?
  • FISMA Compliance: If you’re selling to the federal government, have proper steps, such as use of Federal Information Processing Standard (FIPS) certified encryption, been followed to ensure Federal Information Security Management Act (FISMA) compliance?
  • Data Loss Prevention (DLP): Is there monitoring in place to ensure data leakage outside of the device doesn’t occur?
  • Vulnerabilities: Have common vulnerabilities such as the Open Web Application Security Project (OWASP) Top 10 been reviewed?
  • Data Sharing: Are proper data sharing agreements in place to allow sharing of data across devices and networks?
  • Password Management: Are passwords hardcoded into the device or made configurable?
  • Configuration Protection: Are configuration files properly check-summed and protected against malicious changes?

ASSESSMENT

It is vital to perform a security assessment on a healthcare practice to understand the environment, identify risks and perform risk mitigation. A one-time security assessment with risk mitigation is not sufficient in 2025. This is a continuous process that needs to be performed religiously to maintain a secure and compliant practice.

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EMOTIONAL INTELLIGENCE: How EQ Can Make You a Better Investor

By Vitaliy Katsenelson CFA

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How Emotional Intelligence Can Make You a Better Investor. You can also listen to a professional narration of this article on iTunes & online.
Your knee hurts, so you pay a visit to your favorite orthopedist. He smiles, maybe even gives you a hug, and then tells you: “I feel your pain. Really, I do. But I don’t treat left knees, only right ones. I find I am so much better with the right ones. Last time I worked on a left knee, I didn’t do so well.”

Though many professionals — doctors as well as lawyers, architects and engineers — get to choose their specializations, they rarely get to choose the problems they solve. Problems choose them. Investors enjoy the unique luxury of choosing problems that let them maximize the use of not just their IQ but also their EQ — emotional intelligence.

Let’s start with IQ. Our intellectual capacity to analyze problems will vary with the problem in front of us. Just as we breezed through some subjects in college and struggled with others, our ability to understand the current and future dynamics of various companies and industries will fluctuate as well. This is why we buy stocks that fall within our sphere of competence. We tend to stick with ones where our IQ is the highest.

Though we usually think about our capacity to analyze problems as being dependable and stable over time, it isn’t. It might be if we were characters from Star Trek, with complete control over our emotions, like Mr. Spock, or who lacked emotions, like Lieutenant Commander Data. This is where our EQ comes in.

I am not a licensed psychologist, but I have huge experience treating a very difficult patient: me. And what I have found is that emotions have two troublesome effects on me. First, they distort probabilities; so even if my intellectual capacity to analyze a problem is not impacted, my brain may be solving a distorted problem. Second, my IQ is not constant, and my ability to process information effectively declines under stress. I either lose the big picture or overlook important details. This dilemma is not unique to me; I’m sure it affects all of us to various degrees.

The higher my EQ with regard to a particular company, the more likely that my IQ will not degrade when things go wrong (or even when they go right). There is a good reason why doctors don’t treat their own children: Their ability to be rational (properly weighing probabilities) may be severely compromised by their emotions.

A friend of mine who is a terrific investor, and who will remain nameless though his name is George, once told me that he never invests in grocery store stocks because he can’t be rational when he holds them. If we spent some Freudian time with him, we’d probably discover that he had a traumatic childhood event at the grocery store (he may have been caught shoplifting a candy bar when he was eight), or he may have had a bad experience with a grocery stock early in his career. The reason for his problem is irrelevant; what is important is that he has realized that his high IQ will be impaired by his low EQ if he owns grocery stocks.

There is no cure for emotions, but we can dramatically minimize the impact they have on us as investors by adjusting our investment process. First and foremost, investors have the incredible advantage of picking domains where they can remain rational.

To be a successful investor, you don’t need Albert Einstein’s IQ (though sometimes I wish I had Spock’s EQ). Warren Buffett undoubtedly has a very high IQ, but even the Oracle of Omaha chooses carefully his battles; for instance, he doesn’t invest in technology stocks.

Investors have the luxury of investing only in stocks for which both their IQ and EQ are maximized, because there are tens of thousands of stocks out there to choose from, and they need just a few dozen.

Meanwhile, I hope when I go see the doctor, he will tell me, “I don’t do left knees,” because the best result will come from a doctor who while treating me will utilize both IQ and EQ.

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BLOGGING: All Doctors Please Beware!

WARNING – WARNING

By Dr. DavidEdwardMarcinko; MBA MEd

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According to www.NPR.org, there are more than120,000 health care forums on the Internet with opinions ranging from pharmaceuticals, to sexual dysfunction, to acne. The same goes for commercial doctor blogs that promote lotions, balms and potions, diets and vitamins, minerals, herbs, drinks and elixirs, or various other ingest-ants, digest-ants or pharmaceuticals, etc.

And, to other doctors, the blogging craze is a new novelty where there are no rules, protocols, standards or precise figures on how many “medical-doctor” or related physician-blogs are “out there.” Unfortunately, too many recount gory ER scenes, or pictorially illustrate horrific medical conditions, or serious and traumatic injuries. Of course, others simply are medical practice websites, or those that entice patients into more lucrative plastic surgery or concierge medical practices. Some are from self-serving/credible plaintiff-seeking attorneys wishing to assist patients.

Not all physician blogs are geared toward practice information, marketing or medical sensationalism. In fact, just the opposite seems to be the case in extremely candid blogs, like “Ranting Docs”, “White Coat Rants,” “Grunt Docs”, “Cancer Doc,” “The Happy Hospitalist,” “Mom MD”, “Cross-Over Health”, “Angry Docs” and “M.D.O.D.,” which bills itself as “Random Thoughts from a Few Cantankerous American Physicians.”

According to some of these, they are more like personal journals, or public diaries, where doctors vent about reimbursement rates, difficult cases, medical mistakes, declining medical prestige and control, and/or what a “bummer” it is to have so many patients die; not pay, or who are indigent, noncompliant. We call these the “disgruntled doctor sites.” Some even talk about their own patients, coding issues, or various doctor-patient shenanigans.

But, according to psychiatrist and blogger Dr. Deborah Peel and others, the problem with blogging about patients is the danger that one will be able to identify themselves – the doctor – or that others who know them will be able to identify them.”  Her affiliation, Patient Privacy Rights, rightly worries that patients might track back to the individual, and adversely affect their employment, health insurance or other aspects of life.

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And, according to Dr. Jay S. Grife; MA Esq., it is certainly true that if a doctor violates a patient’s privacy there could be legal consequences. Under HIPAA, physicians could face fines or even jail time. In some states, patients can file a civil lawsuit if they believe a doctor has violated their privacy. Still, internet privacy issues are an evolving gray-area that if not wrong, may still be morally and ethically questionable [personal communication].

Our colleague Robert Wachter MD, author of the blog called “Wachter’s World,” says it’s important for doctors to be able to share cases, as long as they change the facts substantially. On the other hand, the author of “Wachter’s World” and a leading expert on patient safety alternately suggests “You might say we as doctors should never be talking about experiences with our patients online or in books or in articles.” But, he says that “patients shouldn’t take all the information on blogs at face value. Taken for what they are — unedited opinions, and in some cases entertainment — blogs can give readers some useful insight into the good, the bad and the ugly of the medical profession”. Link: http://www.the-hospitalist.org/blogs

Well, fair enough! But, doctors unhappy with their current medical career choice, or its modern evolution, should probably consider counseling or even career change guidance, re-education and re-engineering. It is very inappropriate to vent career frustrations in a public venue. It’s far better for the blog to be private and/or by invitation only; if at all [Personal communication].

We believe that a hybrid mash-up of both views can be wholly appropriate, or grossly inappropriate in some cases. Of course the devil is in the details; linguistics and semantics aside. Nevertheless; what is not addressed in electronic physician “mea-culpas” are the professional liability risks and concerns that are evolving in this quasi-professional, quasi-lay, communication forum.

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Example: We have seen medical mistakes, and liability admissions of all sorts, freely and glibly presented. In fact,

“Some physicians find that the act of liability blogging as a professional confession that is useful in moving past their malpractice mistakes. And, it is also a useful way to begin a commitment to a better professional life of caring in the future. It helps eliminate the toxic residue and angst of professional liability and guilt. Moreover, as they are unburdened of past acts of omission or commission, doctors should remember to also forgive those who have wronged them. This helps greatly with the process and brings additional peace.”

However, although some may say that this electronic confession is good for the soul, it may not be good for your professional liability carrier, or you, when plaintiff’s attorneys release a legion of IT focused interns, or automated bots, searching online for your self-admissions and scouring for your self-incriminations. Of course, a direct connection to a specific patient may still not be made and no HIPAA violation is involved. But, a vivid imagination is not need needed to envision this type of blind medical malpractice discovery deposition query even now.

QUESTION: “Doctor Smith, I noted all the medical errors admitted on your blog. What other mistakes did you make in the care and treatment of my client?”

And so, the question of plausible deniability, or culpability, is easily raised.  If you must journalize your thoughts for sanity or stress release; do it in print. And, don’t tell anyone about it so the diary won’t be subpoenaed. Then tear it up and throw it away. Remember, with risk management, “It is all about credibility.” Don’t trash yours! These thoughts may be especially important if you covet a medical career as a researcher, editor, educator, medical expert or something other than a working-class or employed physician.

EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit a RFP for speaking engagements: CONTACT: MarcinkoAdvisors@outlook.com 

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HEDGE FUND: Wrap Fees?

Staff Reporters

SPONSOR: http://www.CertifiedMedicalPlanner.org

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A hedge fund is a limited partnership of private investors whose money is pooled and managed by professional fund managers. These managers use a wide range of strategies, including leverage (borrowed money) and the trading of nontraditional assets, to earn above-average investment returns. A hedge fund investment is often considered a risky, alternative investment choice and usually requires a high minimum investment or net worth. Hedge funds typically target wealthy investors.

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My stock broker is telling me about a “wrap-fee” program involving a hedge fund manager.

QUESTION: What is a Wrap Fee?

A wrap fee program is a service that provides investment advice and portfolio management to clients for one all-inclusive fee. The fee pays for the services provided to the client, including but not limited to securities transactions, portfolio management, research, brokerage, and administrative services. Wrap fee programs also provide an understanding of a client’s financial goals and objectives; research and selection of assets; implementation of investment decisions; account statements, and access to real-time financial data.

The Investment Advisers Act of 1940 regulates investment advisors when they offer these wrap fee programs and requires them to provide comprehensive disclosure documents before investing. This act helps ensure clients have access to all important information that affects their investment decisions.

QUESTION: Why do I need my stock broker? Can I just go directly to the hedge fund manager?

Yes, you can, but you may find a different fee arrangement when you reach the hedge fund manager, and you may be participating in an unethical transaction. When hedge fund managers set up separate accounts for wrap-fee clients, they agree to take a set fee in exchange for managing this money. They also enter into agreements with one or more brokers to help market this aspect of their money management business. A portion of the wrap fee you pay goes to the broker, and a portion goes to the manager. Incentive compensation is not generally used.

When approached directly, hedge fund managers will typically offer only the hedge fund, complete with incentive compensation and pooled investment features. However, if the hedge fund manager is willing to set up a separate account, it is possible that the investor will find the set fee much less than what he or she would have paid in a wrap fee account through a broker.

Finally, the very large caveat to all this is that the ethics of a hedge fund manager who steals clients from brokers with whom he has a marketing relationship ought to be called into question. And when it comes to hedge funds, the ethics of the manager are of paramount importance.

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DAILY UPDATE: Microsoft Tempers A.I. as Hershey Buys LesserEvil and Stock Markets Crater!

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Microsoft is reportedly pulling back on data center projects around the world as it reexamines its AI plans. Hershey reportedly bought the popcorn brand LesserEvil for $750 million.

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US stocks cratered on Friday with the Dow Jones Industrial Average (^DJI) plunging more than 2,200 points after China stoked trade-war fears and Fed Chair Jerome Powell warned of higher inflation and slower growth stemming from tariffs.

The Dow pulled back 5.5% to enter into correction territory. Meanwhile, the S&P 500 (^GSPC) sank nearly 6%, as the broad-based benchmark capped its worst week since 2020. The tech-heavy NASDAQ Composite (^IXIC) dropped 5.8% to close in bear market territory.

CITE: https://tinyurl.com/tj8smmes

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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FINANCIAL RATIOS: Profitability for Doctors

By CFI Team and Staff Reporters

SPONSOR: http://www.MarcinkoAssociates.com

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Profitability Ratios

Profitability ratios measure a company’s ability to generate income relative to revenue, balance sheet assets, operating costs, and equity. Common profitability financial ratios include the following:

The gross margin ratio compares the gross profit of a company to its net sales to show how much profit a company makes after paying its cost of goods sold:

Gross margin ratio = Gross profit / Net sales

The operating margin ratio, sometimes known as the return on sales ratio, compares the operating income of a company to its net sales to determine operating efficiency:

Operating margin ratio = Operating income / Net sales

The return on assets ratio measures how efficiently a company is using its assets to generate profit:

Return on assets ratio = Net income / Total assets

The return on equity ratio measures how efficiently a company is using its equity to generate profit:

Return on equity ratio = Net income / Shareholder’s equity

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STOCK MARKETS PLUNGE: A Friday Redeux

BREAKING US STOCK MARKET NEWS

By ME-P Staff Reporters

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Stocks in the U.S. opened sharply lower on Friday, extending a slide from the previous trading session triggered by President Trump’s announcement of sweeping new tariffs on U.S. imports earlier this week. 

The S&P 500 fell 144 points, or 2.5%, to 5,252 as of 9:34 a.m. EST. The Dow Jones Industrial Average tumbled 1,006 points, or 2.5%, and the NASDAQ Composite slid 3.1%.

The indexes’ free-fall Thursday was their biggest one-day drop since 2020, with more than $2 trillion in investor wealth erased from the S&P 500. The S&P 500 and Dow each sank more than 4% yesterday, while the tech-heavy NASDAQ plunged nearly 6%. 

NOTE: Drops of this magnitude aren’t unheard of on Wall Street, but they’re rare. Over the last 25 years, the S&P 500 has fallen 4% in a single day 38 times, according to Adam Turnquist, chief technical strategist for brokerage firm LPL Financial.

UPDATE: [1:06pm EST]

DJIA 38,962.49 -1,583.44 (-3.91%)

NASDAQ 15,779.20 -771.41 (-4.66%)

S&P 500 5,148.70 -247.82 (-4.59%)

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MONEY SCRIPTS: Fundamental Subconscious Beliefs and Economic Behavioral Patterns Defined

SALES PSYCHOLOGY FOR INVESTMENT ADVISORS, FINANCIAL ADVISORS, INSURANCE AGENTS, WEALTH MANAGERS AND FINANCIAL PLANNERS

By Dr. David Edward Marcinko; MBA MEd CMP®

http://www.MarcinkoAssociates.com

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SPONSOR: http://www.CertifiedMedicalPlanner.org

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Stocks were decimated yesterday in the first full trading day following President Trump’s tariff announcement. It was the biggest single-day decline since the start of the Covid-19 pandemic in March 2020. Every Magnificent Seven stock was battered—Apple worst of all. And so perhaps it is a good time to discuss the concept of “Money Scripts”.

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Money Scripts are unconscious beliefs about money that are typically only partially true, are developed in childhood, and drive adult financial behaviors. Money scripts may be the result of “financial flashpoints,” which are salient early experiences around money that have a lasting impact in adulthood. Money scripts are often passed down through the generations and social groups often share similar money scripts. And so, we argue that Money scripts are at the root of all illogical, ill-advised, self-destructive, or self-limiting financial behaviors.

In research at Kansas State University [KSU], researchers identified four distinct Money script patterns, which are associated with financial health and predict financial behaviors. These include: (a) money avoidance, (b) money worship, (c) money status, and (d) money vigilance [personal communication Brad Klontz, PsyD, CFP®, Kenneth Shubin-Stein, MD, MPH, MS, CFA and Sonya Britt, PhD, CFP®].

And so, we all like to think our financial decisions are fully rational, but the truth is that our subconscious beliefs have a dramatic impact on our money and financial decisions. These money scripts are important to know and understand. A summary is below:

            Money Avoidance

Money avoidance scripts are illustrated by beliefs such as “Rich people are greedy,” “It is not okay to have more than you need,” and “I do not deserve a lot of money when others have less than me.” Money avoiders believe that money is bad or that they do not deserve money. They believe that wealthy people are corrupt and there is virtue in living with less money. They may sabotage their financial success or give money away even though they cannot afford to do so. Money avoidance scripts may be associated with lower income and lower net worth and predict financial behaviors including ignoring bank statements, overspending, financial dependence on others, financial enabling of others, and having trouble sticking to a budget.

            Money Worship 

Money worship is typified by beliefs such as “More money will make you happier,” “You can never have enough money,” and “Money would solve all my problems.” Money worshipers are convinced that money is the key to happiness. At the same time, they believe that one can never have enough. Money worships have lower income, lower net worth, and higher credit card debt. They are more likely to be hoarders, spend compulsively, and put work ahead of family.

            Money Status

Money status scripts include “I will not buy something unless it is new,” “Your self-worth equals you net worth,” and “If something isn’t considered the ‘best’ it is not worth buying.” Money status seekers see net worth and self-worth as being synonymous. They pretend to have more money than they do and tend to overspend as a result. They often grew up in poorer families and believe that the universe should take care of their financial needs if they live a virtuous life. Money status scripts are associated with compulsive gambling, overspending, being financially dependent on others, and lying to one’s spouse about spending.

            Money Vigilance

Money vigilant beliefs include “It is important to save for a rainy day,” “You should always look for the best deal, even if it takes more time,” and “I would be a nervous wreck if I did not have an emergency fund.” The money vigilants are alert, watchful and concerned about their financial welfare. They are more likely to save and less likely to buy on credit. As a result, they tend to have higher income and higher net worth. They also have a tendency to be anxious about money and are secretive about their financial status outside of their household. While money vigilance is associated with frugality and saving, excessive anxiety can keep someone from enjoying the benefits that money can provide.

Identification

When money scripts are identified, it is helpful to examine where they came from. A simple behavioral finance technique involves reflecting on the following questions:

  • What three lessons did you learn about money from your mother?
  • What three lessons did you learn about money from your father?
  • What is your first memory around money?
  • What is your most painful money memory?
  • What is your most joyful money memory?
  • What money scripts emerged for you from this experience?
  • How have they helped you?
  • How have they hurt you?
  • What money scripts do you need to change?

Conclusion

Ideally, from a balanced middle ground, we can see past the limitations of money scripts, our self and others who are polarized. Those who believe “Money is meant to be spent” or “Money is meant to be saved” have a world view that results in extreme positions. Labeling them as “correct” or “wrong” is not a useful way to try to shift anyone’s polarized money script beliefs.

EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit a RFP for speaking engagements: CONTACT: MarcinkoAdvisors@outlook.com 

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DAILY UPDATE: DJIA Plummets 1,700 Points While NASDAQ & S&P 500 Plunge for Biggest Drop Since 2025

MEDICAL EXECUTIVE-POST TODAY’S NEWSLETTER BRIEFING

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Roughly $2.5 trillion was erased from the S&P 500 Index on Thursday amid worries that President Donald Trump’s sweeping new round of tariffs could plunge the economy into a recession. The damage was heaviest in companies whose supply chains are most dependent on overseas manufacturing. Apple Inc., which makes the majority of its US-sold devices in China, fell 9.3%. Lululemon Athletica Inc. and Nike Inc., among companies with manufacturing ties to Vietnam, were both down more than 9%. Target Corp. and Dollar Tree Inc., retailers whose stores are filled with products sourced outside of the US, dropped more than 10%.

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The tech-heavy NASDAQ Composite (^IXIC) led the sell-off, plummeting 6%. The S&P 500 (^GSPC) sank nearly 5%, while the Dow Jones Industrial Average (^DJI) tumbled 4%. The Dow’s 1,700-point drop was the fifth-worst in its history.

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Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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MEMORY: Eidetic V. Photographic

By Staff Reporters

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Eidetic memory refers to the ability to vividly recall images from memory after only a few instances of exposure, with high accuracy for a short time after exposure, without using a memory aid.

Photographic memory, though often used interchangeably with eidetic memory, implies the ability to recall extensive details, like entire pages of text, with high precision. Genuine photographic memory’s existence is debated and hasn’t been conclusively proven.

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TRADITIONAL INVESTMENT PORTFOLIO DIVERSIFICATION MODEL: Routed by Larry Fink CEO of BlackRock?

BREAKING NEWS – MARKET VOLATILITY

By Staff Reporters

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US stocks nosedived on Thursday, with the Dow tumbling more than 1,200 points as President Trump’s surprisingly steep “Liberation Day” tariffs sent shock waves through markets worldwide. The tech-heavy NASDAQ Composite (IXIC) led the sell-off, plummeting over 4%. The S&P 500 (GSPC) dove 3.7%, while the Dow Jones Industrial Average (^DJI) tumbled roughly 3%. [ongoing story].

So, does the traditional 60 stock / 40 bond strategy still work or do we need another portfolio model?

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The 60/40 strategy evolved out of American economist Harry Markowitz’s groundbreaking 1950s work on modern portfolio theory, which holds that investors should diversify their holdings with a mix of high-risk, high-return assets and low-risk, low-return assets based on their individual circumstances.

While a portfolio with a mix of 40% bonds and 60% equities may bring lower returns than all-stock holdings, the diversification generally brings lower variance in the returns—meaning more reliability—as long as there isn’t a strong correlation between stock and bond returns (ideally the correlation is negative, with bond returns rising while stock returns fall).

CORRELATION: https://medicalexecutivepost.com/2024/10/27/correlation-diversification-in-finance-and-investments/

For 60/40 to work, bonds must be less volatile than stocks and economic growth and inflation have to move up and down in tandem. Typically, the same economic growth that powers rallies in equities also pushes up inflation—and bond returns down. Conversely, in a recession stocks drop and inflation is low, pushing up bond prices.

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  • But, the traditional 60/40 portfolio may “no longer fully represent true diversification,” BlackRock CEO Larry Fink writes in a new letter to investors.
  • Instead, the “future standard portfolio” may move toward 50/30/20 with stocks, bonds and private assets like real estate, infrastructure and private credit, Fink writes.
  • Here’s what experts say individual investors may want to consider before dabbling in private investments.

It may be time to rethink the traditional 60/40 investment portfolio, according to BlackRock CEO Larry Fink. In a new letter to investors, Fink writes the traditional allocation comprised of 60% stocks and 40% bonds that dates back to the 1950s “may no longer fully represent true diversification.

DI-WORSIFICATION: https://medicalexecutivepost.com/2024/04/09/what-is-financial-portfolio-di-worsification-2/

EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit a RFP for speaking engagements: MarcinkoAdvisors@outlook.com 

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MEDICAL OFFICE: Patient Satisfaction Management

The “Soft Science” of Patient Relationship Management

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By Dr. David Edward Marcinko; MBA MEd CMP

SPONSOR: http://www.CertifiedMedicalPlanner.org

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INTRODUCTION

Patient satisfaction occurs when patient perceptions exceed their expectations. They get an intangible “something extra” from their visit, above what they paid for. When patient expectations match their perceptions, mutual obligations are fulfilled, making both practitioner and patient “break-even”.

The clinical result, within a relevant range, is only part of the patient’s perceptions. Numerous sub-conscious impressions comprise the remainder. We’ve all had patients love us despite a less than optimal result. We’ve all had patients angrily leave the practice over some non-clinical matter like a trivial billing dispute. A patient’s perception of any health care service is colored by a vast array of prior experiences that set up current expectations. The patient is pleased to the extent that his current perceptions exceed his/her pre existing expectations. This encompasses far more than the clinical result (within a relevant range), and includes such non-treatment issues as the demeanor of the staff, condition of the physical premises, psychological comfort during the visit, etc.

Remember, all patients talk about you anyway. In the past, a happy patient told four others about what a nice doctor you are. Today, patients post website comments or blogs immediately after their visits. They are more likely to complete treatment and follow instructions, thus obtaining a better medical outcome, and, generating additional fees for the practice. They pay quicker, cause less bad-debt and help create a pleasant environment for us to work in.

An unhappy patient vehemently tells nine others, onground or online, what a nasty greedy rip-off artist you are. Sad, but true! They are not as likely to complete treatment, thus incurring a less than optimal result, and generate fewer fees. They pay slower, if at all, create a stressed environment and detrimentally affect the attitude of other patients in the office.

Try to eliminate problems that might cause negative perceptions (i.e., a filthy restroom) and implement controls that help assure positive perceptions. Patient satisfaction is a soft managerial science. It is a numbers game. Most patients don’t pre-define what would be “acceptable” from this encounter, but have vaguely defined ranges of prior expectations anyway, gleaned from a lifetime of health care related experience. Any variance between these this “acceptable” range of expectations and each trivial encounter invokes some degree positive or negative feeling in the patient.

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The total perception of the office experience is an aggregate of multiple trivial, often subliminal, observations. Patient satisfaction is an intangible and amorphous process complicated by:

Inter patient variables: Significant differences between patients in their “expectations”.
Intra patient variables: A single patient can perceive the same thing or situation differently at different times, depending on uncontrollable variables like mood, or, context of occurrence which may (sometimes and/or partially) be controllable by the practice.
Luck of the draw” in physical variables: Does Sally or Mary escort the patient to the exam room? Was it the blue or green exam room? Did the last patient to use the rest room, five minutes ago, leave a disgusting mess?
Heterogeneous staff variables: Even with appropriate training, people are not machines and have their own quirks.

ASSESSMENT

By proactively anticipating the entire visit, from the patient’s perspective, the practitioner can structure and arrange things such that most patients have, mostly positive perceptions, most of the time. This can be done despite all the potential hetero-genicity of the above factors. Patient satisfaction can be improved in any office, and can be done by anyone.

CONCLUSION

Because patient satisfaction is a multi-faceted amorphous subject, there are multiple correct approaches to the subject and no “cook book” recipe on how to proceed. Try and get the big picture. Identify the worst areas and fix them. Identify the best areas and reinforce them. Proceed slowly. It can be done one facet at a time. Adapt things to your own managerial style and personality. Be completely open to suggestion and change.

Finally, be aware that patient relationship and satisfaction implementation strategies frequently overlap.

EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit a RFP for speaking engagements: MarcinkoAdvisors@outlook.com 

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DAILY UPDATE: Newsmax Surges but HHS, FDA, CDC & Zelle Go Down as Jittery Stock Markets Rise

MEDICAL EXECUTIVE-POST TODAY’S NEWSLETTER BRIEFING

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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants

Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily

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Stocks looked like a very concerning EKG recently, fluctuating throughout as investors weighed today’s tariff announcement. The Newsmax meme stock kept on surging, stacking a 180% gain on top of Monday’s 735% spike to skyrocket over 900% since the conservative media outlet went public earlier this week.

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U.S. stocks whipped through another dizzying day Wednesday in the final hours before President Donald Trump’s unveiling of the tariffs promised as part of his “Liberation Day,” which could drastically remake the global economy. The S&P 500 rose 0.7%, but only after careening between an earlier loss of 1.1% and a later gain of 1.1%. It’s had a pattern this week of opening with sharp drops only to finish the day higher.

The Dow Jones Industrial Average added 235 points, or 0.6%, and the NASDAQ composite climbed 0.9%. Both also veered from sharply lower in the morning to sharply higher in the afternoon before doubling back.

CITE: https://tinyurl.com/tj8smmes

Mass layoffs at health agencies begin. The purge of thousands of Health and Human Services (HHS) employees announced last week by Secretary Robert F. Kennedy Jr. started yesterday, with senior leaders at the FDA, CDC, and other departments saying they had been pushed out. Among those removed were the FDA’s chief tobacco regulator, its top veterinarian, and medical officers in charge of new drug approvals.

f you like to use Zelle to send money to others, you need to find a new solution. On April 1st, the digital payment app shut down.

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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PHYSICIAN PAYMENT INCREASE: Excluded by Continuing Resolution

By Health Capital Consultants, LLC

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Continuing Resolution Excludes Physician Payment Increase Again

On March 15th, 2025, President Donald Trump signed a continuing resolution (CR) that avoided a government shutdown and funds the federal government for the rest of the fiscal year, i.e., through September 30th, 2025.

Perhaps more notable than what was included in the spending bill was what was once again excluded. While the COVID-era tele-health waivers were temporarily extended, Medicare physician payment rates were not addressed, meaning physicians will continue experiencing a 2.93% pay cut for 2025.

This Health Capital Topics article discusses the healthcare provisions included in and excluded from the CR, and the impacts on healthcare providers. (Read more…)

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OBTAIN: An Unbiased Second Financial Planning Opinion

By Ann Miller RN MHA CPHQ CMP

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Finally … Fiduciary second investing and financial planning opinions right here!

Telephonic or electronic advice for medical professionals that is:

  • Objective, affordable, medically focused and financially personalized
  • Rendered by a pre-screened financial consultant for doctors and medical professionals
  • Offered on a pay-as-you-go basis, by phone or secure e-mail transmission

The iMBA Discussion Forum™ is a physician-to-financial advisor telephone or e-mail portal that connects independent financial professionals to doctors, nurses or healthcare executives desiring affordable and unbiased financial planning advice.

Medical professionals and healthcare executives can now receive direct access to pre-screened iMBA professionals in the areas of Investing, Financial Planning, Asset Allocation, Portfolio Management, Insurance, Mortgage and Lending, Human Resources, Retirement Planning and Employee Benefits. To assist our medical professional and healthcare executive members, we can be contracted with per-minute or per-project fees, and contacted by client phone, email or secure instant messaging.

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HEDGE FUNDS: In Individual Retirement Accounts?

By Staff Reporters

SPONSOR: http://www.CertifiedMedicalPlanner.org

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QUESTION: What is a Hedge Fund?

A hedge fund is a limited partnership of private investors whose money is pooled and managed by professional fund managers. These managers use a wide range of strategies, including leverage (borrowed money) and the trading of nontraditional assets, to earn above-average investment returns. A hedge fund investment is often considered a risky, alternative investment choice and usually requires a high minimum investment or net worth. Hedge funds typically target wealthy investors.

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QUESTION: Can I invest my Individual Retirement Account [IRA] in a Hedge Fund?

This is up to the manager, but there is no legal restriction on a hedge fund accepting individual retirement account (IRA) assets. IRA accounts are not well suited for funds that make extensive use of leverage, however. In such cases, the fund is likely to generate significant amounts of unrelated business taxable income (UBTI) – profits of the fund attributable to the use of leverage. The holder of an IRA account must pay taxes on UBTI, even if the UBTI was generated in an IRA account.

But, today’s hedge funds may or may not use leverage. Many hedge funds are not hedged at all, but rather are just specialized versions of regular long stock portfolios. If such funds do not use much leverage, IRA investors will not encounter much difficulty with UBTI and should not hesitate in considering these funds.

In considering whether to accept IRA money, hedge fund managers must consider several factors. If the only type of retirement money accepted by the hedge funds is IRA money, then the manager has no limit on how much retirement money the fund can accept. If, however, there are other types of retirement money invested in the fund, such as pension funds, IRA money will be counted towards a total of 25 percent of fund assets that can be invested in retirement accounts before the fund becomes subject to the Employment Retirement Income Security Act of 1974 (ERISA). Funds subject to ERISA regulations face a heavy administrative burden and more restrictions than most fund managers like.

Finally, IRA distributions from a hedge fund are subject to the standard 20 percent withholding unless the funds are directly rolled over to other qualified plans.

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DAILY UPDATE: Superior HealthPlan, Larry Fink and the Mixed Stock Markets

MEDICAL EXECUTIVE-POST TODAY’S NEWSLETTER BRIEFING

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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants

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The CEO of a Texas health insurance company was fired after admitting before a DOGE panel of state lawmakers that he hired private investigators to spy on customers and obtain sensitive details about their lives. Mark Sanders was dismissed from his duties as chief executive of Austin-based Superior HealthPlan after he testified before the Texas House Delivery of Government Efficiency Committee in a hearing on Medicaid procurement last week.

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US stocks closed mixed on Tuesday as investors cautiously counted down to President Trump’s highly anticipated “Liberation Day” rollout of sweeping new reciprocal tariffs. The S&P 500 (^GSPC) rose about 0.4%, extending the gains the benchmark index secured on Monday, while the Dow Jones Industrial Average (^DJI) fell just below the flatline. The tech-heavy NASDAQ Composite (^IXIC) rebounded to close up around 0.9%.

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BlackRock CEO Larry Fink said private markets should be open to all investors, not just the wealthy few in his annual letter to investors (here.)

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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ACCOUNTABLE CARE ORGANIZATION: A Financially Toxic Contract Example for Physicians

SPONSOR: http://www.MarcinkoAssociates.com

By. Dr. David Edward Marcinko; MBA MEd CMP®

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SPONSOR: http://www.CertifiedMedicalPlanner.org

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WARNING – DISASTROUS ACO EXAMPLE – WARNING

GIVEN CASH FLOW MODEL

Suppose that in a new Accountable Care Organization [ACO] contract, a certain medical practice was awarded a new global payment or capitation styled contract that increased revenues by $100,000 for the next fiscal year. The practice had a gross margin of 35% that was not expected to change because of the new business. However, $10,000 was added to medical overhead expenses for another assistant and all Account’s Receivable (AR) are paid at the end of the year, upon completion of the contract.

Cost of Medical Services Provided (COMSP):

The Costs of Medical Services Provided (COMSP) for the ACO business contract represents the amount of money needed to service the patients provided by the contract.  Since gross margin is 35% of revenues, the COMSP is 65% or $65,000.  Adding the extra overhead results in $75,000 of new spending money (cash flow) needed to treat the patients. Therefore, divide the $75,000 total by the number of days the contract extends (one year) and realize the new contract requires about $ 205.50 per day of free cash flows.

Assumptions

Financial cash flow forecasting from operating activities allows a reasonable projection of future cash needs and enables the doctor to err on the side of fiscal prudence. It is an inexact science, by definition, and entails the following assumptions:

  • All income tax, salaries and Accounts Payable (AP) are paid at once.
  • Durable medical equipment inventory and pre-paid advertising remain constant.
  • Gains/losses on sale of equipment and depreciation expenses remain stable.
  • Gross margins remain constant.
  • The office is efficient so major new marginal costs will not be incurred.

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Physician Reactions:

Since many physicians are still not entirely comfortable with global reimbursement, fixed payments, capitation or ACO reimbursement contracts; practices may be loath to turn away short-term business in the ACA era.  Physician-executives must then determine other methods to generate the additional cash, which include the following general suggestions:

1. Extend Account’s Payable

Discuss your cash flow difficulties with vendors and emphasize their short-term nature. A doctor and her practice still has considerable cache’ value, especially in local communities, and many vendors are willing to work them to retain their business

2. Reduce Accounts Receivable

According to most cost surveys, about 30% of multi-specialty group’s accounts receivable (ARs) are unpaid at 120 days. In addition, multi-specialty groups are able to collect on only about 69% of charges. The rest was written off as bad debt expenses or as a result of discounted payments from Medicare and other managed care companies. In a study by Wisconsin based Zimmerman and Associates, the percentages of ARs unpaid at more than 90 days is now at an all time high of more than 40%. Therefore, multi-specialty groups should aim to keep the percentage of ARs unpaid for more than 120 days, down to less than 20% of the total practice. The safest place to be for a single specialty physician is probably in the 30-35% range as anything over that is just not affordable.

The slowest paid specialties (ARs greater than 120 days) are: multi-specialty group practices; family practices; cardiology groups; anesthesiology groups; and gastroenterologists, respectively. So work hard to get your money, faster. Factoring, or selling the ARs to a third party for an immediate discounted amount is not usually recommended.

3. Borrow with Short-Term Bridge Loans

Obtain a line of credit from your local bank, credit union or other private sources, if possible in an economically constrained environment. Beware the time value of money, personal loan guarantees, and onerous usury rates. Also, beware that lenders can reduce or eliminate credit lines to a medical practice, often at the most inopportune time.

4. Cut Expenses

While this is often possible, it has to be done without demoralizing the practice’s staff.

5.  Reduce Supply Inventories

If prudently possible; remember things like minimal shipping fees, loss of revenue if you run short, etc.

6. Taxes

Do not stop paying withholding taxes in favor of cash flow because it is illegal.

Hyper-Growth Model:

Now, let us again suppose that the practice has attracted nine more similar medical contracts. If we multiple the above example tenfold, the serious nature of potential cash flow problem becomes apparent. In other words, the practice has increased revenues to one million dollars, with the same 35% margin, 65% COMSP and $100,000 increase in operating overhead expenses. 

Using identical mathematical calculations, we determine that $750,000 / 365days equals $2,055.00 per day of needed new free cash flows!  Hence, indiscriminate growth without careful contract evaluation and cash flow analysis is a prescription for potential financial disaster.

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SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit a RFP for speaking engagements: CONTACT: MarcinkoAdvisors@outlook.com 

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DAILY UPDATE: DJIA Rebounds to End Volatile Month

MEDICAL EXECUTIVE-POST TODAY’S NEWSLETTER BRIEFING

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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants

Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily

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US stocks rebounded Monday to cap a volatile month and quarter as trade-war worries mount in the run-up to President Trump’s tariff bonanza later in the week.

The tech-heavy NASDAQ Composite (^IXIC) closed down about 0.1%, while the S&P 500 (^GSPC) recuperated losses of as much as 1.7% to close up nearly 0.6%. The Dow Jones Industrial Average (^DJI) erased early morning losses to gain 1%, or about 400 points.

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Markets wrapped up March on a woeful note after a rough month and quarter beset by Trump’s fast-evolving tariff policy. Last week was the fifth in six weeks that the NASDQ Composite and S&P 500 ended the week in the red. The benchmark index is down over 4.5% to start the year while the NASDAQ has lost over 10%, finishing with their worst quarters since 2022.

Some of the biggest-name megacaps have led the decline. NVIDIA (NVDA) fell Monday as it has neared a 20% loss so far this year, while TESLA (TSLA) has lost more than 35%.

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Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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MEDICARE: Four Payment Models Ended Early

By Health Capital Consultants, LLC

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Four Medicare Payment Models Ended Early

In the latest iteration of Trump Administration healthcare cuts, the Centers for Medicare & Medicaid Services (CMS) announced on March 12th, 2025 that four Center for Medicare and Medicaid Innovation (CMMI) payment models would be sunset at the end of 2025, earlier than originally scheduled.

Cutting these models, which decision was based on “a comprehensive and data-driven review of [CMS’s] model portfolio,” are anticipated to save nearly $750 million (although the source of these savings was not detailed).

This Health Capital Topics article discusses the models being ended and the impact on healthcare stakeholders. (Read more…)

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MEDICAL PRACTICE SALES: Contracting for Succession Planning

[Reviewing Terms, Conditions and Selling Agreements]

By Dr. Charles F. Fenton III JD

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Dealing with many issues concerning the actual contract that affect the purchase or sale of a medical practice can be daunting. For example, this chapter will not deal with issue of determining whether or not a physician should retire. Nor will it determine the proper Fair Market Value [FMV] of the practice. However, physicians may be assisted in both instances by a medically focused financial advisor, or valuation specialist. [AVA, CPA-CVA, Certified Medical Planner™; etc] working in conjunction with an experience  health care contract attorney to act as an advocate and determine certain contingencies that might occur, and protect him/her from them.

THE PARTIES

The first determination is whether the party at interest is an individual, group of individuals, or an entity (such as a partnership, limited liability partnership, limited partnership, limited liability company, or corporation – whether an S corporation, C corporation or a professional corporation). In many instances, even if the party at interest is an individual is an entity, the individual or individuals behind the entity should be made parties to the agreement.

From the buyer’s perspective, the purchase of a medical practice is a highly person-oriented business. The practice value depends much upon the personality of the current treating physicians. If the current treating physicians are also the owners of the entity, then binding those individuals (especially as applies to the restrictive covenant) is of primary importance.

If the current treating physicians are not owners of the entity, but rather employees, then a determination of whether they will continue in their same positions or whether the buyer will be taking over the treatment of patients becomes the prime focus. If the current treating physicians will be continuing in their same positions, then their current employment contract must be reviewed to determine whether the rights of the seller will accrue to the buyer.

If the rights of the seller will not accrue to the buyer, then the Purchase and Sale Agreement must have a provision that makes the continued employment of those current-treating physicians a condition to consummation of the sale. In such instances, the new employment agreement might be an exhibit to the main agreement and executed contemporaneously with the main agreement.

If the current treating physicians will not be continuing in their same position and if the purchaser will be assuming treatment of the patients, then the main agreement must provide for the dissolution of the employment agreement and provision must be made for restricting the ability of those physicians from competing with the buyer. If the employment contract with the seller contains a restrictive covenant, then the buyer must ensure that such covenants will accrue to the buyers benefit. Otherwise, the buyer should insist that those physicians sign restrictive covenants. In such an instance, a portion of the purchase price may need to be allocated towards the consideration for those restrictive covenants and paid directly to those physicians.

DATE OF AGREEMENT AND CLOSING DATE

In general, it usually does not matter when the agreement is dated. It should usually be dated once all the terms are agreed to and the parties desire to bind each other and to be bound. In certain instance, the parties may have reached an agreement, but certain issues (such as the obtaining of a state license to practice medicine) may be outstanding. In such a case, then an option can be given by either the seller or the buyer to bind the other to sell or buy the practice upon exercise of the option. Giving an option can also push the agreement date into the future. The option will usually be given with token consideration (e.g., one hundred dollars) and will have a fixed expiration date (e.g., thirty to ninety days).

The determination of the closing date is more important than the date that the agreement is dated. Just like in the purchase of a house where certain issues (such as obtaining a mortgage and home inspection) must occur before closing, in the purchase of a practice, there may be certain issues which require time to undertake before the actual transfer can be consummated. For example, the buyer may still need to obtain financing or the landlord may need to approve the assignment of the lease.

RECITALS

The recitals – or “whereas” clauses – traditionally enunciate the reasons the parties are entering into the agreement. In the sale of the practice the recitals may simply state that the buyer wishes to buy the practice and the seller wishes to sell the practice. Yet, there is a modern growing tendency among contract attorneys to eliminate the “whereas” clauses as some attorneys feel that such language is antiquated. In such instances, the agreement will simply have a paragraph or two delineation of the “Purpose” of the agreement.

ARTICLES, SECTIONS, AND PARAGRAPHS

The agreement will often be divided and numbered in some logical fashion, either into articles, sections, paragraphs, or a combination of these. The reason for doing so is twofold. First, it allows ready reference to the numbered paragraph, and secondly it allows the agreement to be divided and grouped in logical associations.

BINDING THE PARTIES

The first paragraph of the first article will often bind the seller to sell and the buyer to buy the practice under the terms of the agreement. The rest of the agreement simply spells out those terms.

WHAT IS PURCHASED?

The agreement must disclose the items which are being transferred and the items which are not considered part of the agreement. This section should be crystal clear, so that anybody reading the contract (and hence a court which may be called upon to enforce the contract) and not privy to the preliminary negotiations will know what is part of the agreement and what is not part of the agreement.

[1] Sale of Stock vs. Sale of Assets

In most cases, well-informed financial advisors [FAs] will recommend that the buyer solely purchase the assets of the practice and not the stock of the practice. By purchasing selected assets, the buyer is ensured that he will not become responsible for the known or unknown liabilities of the corporation. In prior days, avoiding purchasing the stock of the corporation was a wise recommendation.

However, with the advent of managed care, the purchase of the stock of the corporation can provide the new practitioner with certain competitive advantages. It may take a new practitioner three to nine months to get onto enough managed care panels to make the practice profitable. Purchase of the stock of the corporation ensures the new practitioner of acquiring the Federal Tax Identification Number [TIN], Personal Identification Number [PIN], Drug Enforcement Agency [DEA], Centers for Medicare and Medicaid [CMS], Global Location Number [GLN] , National Provider Identifier [NPI], HIE-Form 834 transmission number, Durable Medical Equipment Number [DME]  etc, of the corporate entity. Since most managed care corporations identify providers by the Federal TIN, purchase of the stock of the corporation should allow the new practitioner to be enrolled on managed care panels in a shorter period of time.

[2] Items Purchased

Items purchased often lists the tangible and intangible property of the seller which will be transferred to the buyer. Such items often include:

  1. A detailed inventory of the tangible assets to be purchased;
  2. A detailed listing of the inventory of the practice;
  3. The names and addresses of all of the patients of record treated by the seller;
  4. The patient medical records maintained by seller;
  5. The computer records maintained by seller;
  6. All licenses, permits, accreditation and franchises issued by any federal, state, municipal, or quasi-government authority relating to the use, maintenance or operation of the practice, running to or in favor of seller, but only to the extent that they are accepted by buyer;
  7. All of sellers’ right, title, and interest in and to all real estate and equipment leases, if any, services agreements, employment and professional service contracts relating to the practice but only to the extent that the foregoing are accepted by buyer;
  8. Assignment of lease should be attached and be incorporated to the agreement;
  9. All existing telephone numbers used in connection with the operation of the practice and all yellow page advertising of the practice; and
  10. The goodwill of the practice, which includes seller’s assistance and cooperation in transfer of all sellers’ rights and interests in the practice to buyer and any other intangible assets of the practice not listed in any other category.

Certain items purchased, such as [paper or electronic] medical records, governmental licenses, fax, email, website and telephone numbers have special considerations as discussed below.

[3] Medical Records

The seller should protect its future need to use the transferred patient medical records. In the current managed care environment, providers are subject to strict scrutiny. Even after leaving practice the provider may find himself subject to a government or third party audit or subject to a medical malpractice lawsuit. Therefore, the provider should ensure that the contract allows for him to take future possession of the specific medical record(s) of the practice in order to mount an appropriate defense.

[4] Governmental Licenses

Certain government licenses and permits may be nontransferable. These would include items such as the federal and state employer identification numbers, as these are unique to seller as a corporate entity. Likewise, other items unique to seller include Medicare identification numbers, Medicaid identification numbers, NPIs and UPINs. The buyer would have to purchase the stock of the corporation order to acquire such items, which is another advantage of a stock transaction versus an asset transaction. Likewise, some local business licenses may or may not be transferable.

[5] Telephone and Fax Numbers, Website URLs and Twitter [X] Accounts, etc

Transference of the telephone numbers often requires that a special local telephone company form authorizing transfer of the telephone numbers to the buyer. Often the new owner of the telephone number will also become liable for any current yellow page advertisement monthly fees. It is the same with an URL or website or e-mail address or office Twitter X account, etc.

[6] Items Not Purchased

Items not purchased or “excluded items” often list the personal items of the parties or of the employees of the parties. Such items would often include:

  1. All cash on hand or on deposit;
  2. All accounts receivable generated prior to the closing date;
  3. All prepaid expenses, utility deposits, tax rebates, insurance claims, credits due from suppliers and other allowances after Closing Date;
  4. The personal effects, including but not limited to photographs, diplomas, uniforms, books, mementos, memorabilia, personally owned art and any personal property owned by them;
  5. Life insurance, disability insurance, and disability buy-out insurance on seller;
  6. Motor vehicles used in connection with the practice;
  7. Any or all tangible-intangible assets used in conjunction with another practice of seller; and
  8. All other assets owned by seller other than those specifically described as items purchased.

The exact items transferred will often depend upon the prior negotiations of the parties. For example, the parties may have agreed that the accounts receivable will be transferred with the practice. In such an instance, the accounts receivable will be listed as an item to be purchased.

PURCHASE PRICE AND TERMS

The price of the transaction (or the value of the practice) is often the one item that is aggressively negotiated between the parties. That is because both the buyer and the seller are overly concerned with “how much?” As this chapter demonstrates, there are a lot more details that go into the negotiation and final contract than just the price. The buyer or seller would be doing themselves a disservice to consider the other factors simply “lawyer details.” Many additional terms of the agreement should be considered by one side or the other as “walk-way” conditions. The party that fully adheres to their additional terms is likely to find the other party capitulating to them. This is because the other party will most likely be fixated on the price.

The purchase price should be delineated in the agreement. Furthermore, the method of payment of the purchase price should be delineated. Although the usual method of payment would be cash, there are other methods available as well.

Cash payment can be made by an official bank cashier’s check, by a certified check, by deposit of funds into an escrow account, or by other method agreed upon by the parties.

Non-cash type transactions include loan agreements and exchanges. Exchanges can provide certain tax benefits if the exchange is a “like kind” exchange. A like kind exchange would occur when parties swap practices. For example, a group practice might have several offices. As part of the breakup of the group, the parties might exchange their stock of one office for all of the stock of another office. Like kind exchanges have strict guidelines that must be adhered to or the tax advantages will disappear. The reader is cautioned to get current legal and financial advice prior to the time of exchange.

It is in the seller’s best interest to get all cash at the time of closing. Then the seller can walk away and not worry about the success or failure of his predecessor. The seller will not have to worry about collecting periodic payments. The seller will not have to worry about placing the buyer in default or about eventually having to repossess the practice and begin to practice medicine at that office again. If a seller repossesses a practice, the buyer may have driven the patients away or lost the managed care contracts (why else would the buyer not be able to honor the loan agreement?). So the repossessed practice will have a significantly lower market value – if it is even marketable at that time.

On the opposite end of the spectrum, it is in the buyer’s best interest to get long and lean loan terms. First, by getting loan terms, the buyer will often have to come up with much less initial capital. Second, because of the discussion in the preceding paragraph, the seller has a vested interest in ensuring that the buyer succeeds once the practice changes hands.

If the transaction involves a seller-financed loan, then the agreement should specify the terms. Additionally, a separate loan agreement and security agreement should be attached as exhibits to the agreement. Finally, in order to perfect the security agreement, the lien should be recorded at the local courthouse in accordance to local rules and customs.

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ALLOCATION OF PURCHASE PRICE

The final purchase price will actually be the amalgamation of various assets of the practice. Those assets include the tangible and intangible assets. The tangible assets include the hard assets (such as computers, treatment tables, chairs and furniture, DME and x-ray machines, etc) and the soft assets (such as Q-tips, paper and cotton balls). The intangible assets will include going concern value, goodwill, and the value of any restrictive covenant.

The parties should delineate the allocation of the purchase price amongst those various categories to reach a mutual best fit with the potential tax obligations. The buyer is the one who should strive to make the allocation fit his needs as best as possible.

Generally, the sale of the assets will be ordinary income to the seller and taxed at the seller’s usual rate. The buyer will be able to depreciate the purchased items. However, the characterization of those assets and the allocated portion of the purchase price will determine how much can be depreciated and over what time period the items can be depreciated.

As a general rule, soft assets can be depreciated fully in the year of purchase. Generally, hard assets can be depreciated over a three to seven year time period, depending upon the class of the asset. Also, under Section §179, a certain dollar amount can be “expensed” or deducted in the year of purchase. The sooner and the faster that the assets can be deducted the less current taxes that the buyer will be required to pay. However, intangible assets generally must be deducted over a 15-year period. This prolongs the tax benefits of any payments characterized as such.

Nonetheless, purchase of the assets results in better tax consequences that purchase of the stock of the practice. When stock is purchased, there is no depreciation allowance allocated in the current or subsequent years. Instead, the cost of the stock becomes the “basis” of the buyer in the practice. Any gain or loss from that basis will only have tax benefits or tax consequences in the year that the stock is sold or becomes worthless.

Because of the tax consequences of the characterization of the allocations of the purchase price, it is important that the agreement delineate the portion of the practice price which is allocated to each category.  Each party should further agree never to claim a different allocation in any future tax filings. Generally, the soft and hard assets will be valued at their current actual cash value. In no event should the purchase price allocated to the soft and hard assets exceed the actual initial cost that the seller paid for the item. The only exception to the foregoing would be if the sale involved the transfer of an appreciable asset.

LEASE ASSIGNMENT

The agreement should provide that upon closing that the seller will assign the lease to the buyer. The buyer then acquires possession of the premises and assumes responsibility for the lease payments.

Sellers often do not understand that even though they do not practice at the leased premises and even though the buyer is making the lease payments, that the seller still remains liable to the landlord under the original lease. Usually this does not present a problem for the seller. But if the buyer abandons the premises or stops making the lease payments, then the landlord will look to the seller for the lease payments through the expiration of the lease.

If the seller has signed a restrictive covenant, then the seller may find himself in the unenviable position of making lease payments for the premises and prohibited from practicing at the premises. The seller should protect himself from this possibility. Therefore, the seller should ensure that the original agreement contains a provision that if the seller becomes liable under the lease that the seller can enter onto the premises, take possession of the practice and the practice assets and can practice medicine at the location until the seller’s liabilities are extinguished.

INDEMNIFICATION AND EXCLUSION/INCLUSION OF LIABILITIES

During the sale of a medical practice, each party will have certain liabilities that the other party should not assume and should not be required to assume. A mutual indemnification clause will act to ensure that each party remains liable for its own liabilities.

In a medical practice, the most common liability is a claim of medical malpractice against the provider. The seller has an interest in insuring that he is not liable for any claim brought by a patient that resulted after he leaves the practice and the buyer has an interest in insuring that she is not liable for any claim brought by a patient that resulted before she acquired the practice.

There are other areas of liability in the sale of a medical practice that may not be readily apparent. These include premise liability (e.g., slip and fall claims), employment claims (e.g., unemployment liability, sexual harassment, discrimination, and wrongful termination claims), tax claims (e.g., unpaid employment taxes and income or sales tax liabilities), and third party payer claims (e.g., Medicare recoupment claims). Consult your insurance agent to determine whether you can obtain insurance coverage to limit your liability under these clauses.

Medical practitioners should understand the full risk of signing an indemnification or hold harmless clause. If a claim is brought against the other party, then the party giving indemnification can be forced to pay any judgment or settlement incurred by that other party. The party giving indemnification can even be required to pay the other party’s attorney bills. This is an important point that the reader should consider carefully: Even if the other party successfully defends a claim, the indemnifying party can be held liable for the other party’s attorney’s fees. Since attorney fees can mount up rapidly, the indemnifying party can find itself responsible for thousands or even tens or thousands of dollars of attorneys’ fees.

If at all possible, one should never sign an indemnification agreement, whether in the sale of a medical practice, a managed care contract, or even a home security monitoring contract. Sometimes, one has no choice but to assume the risk and sign the contract. If at all possible, one should strive to sign such clauses in a corporate capacity and not in an individual capacity. If that is not possible, then seek insurance to minimize the risk. Indemnification clauses and the potential unlimited risk that they pose is one reason why the professional should undertake a carefully planned asset protection program.

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OTHER FACTORS AND CLAUSES 

[A] Integration

As a general rule, once parties have seen fit to put their agreement in writing, then no prior oral agreement regarding the same subject is binding. A paragraph stating that the written agreement contains the entire understanding of the parties simply reflects this rule of contract construction. Such a paragraph also places the parties on notice that any oral representation of the other party that has not been placed in the contract will be worthless.

[B] Construction

At times a court may hold any ambiguities in a contract against the party that prepared the agreement or that had the agreement prepared for them. If the party on the other side of the contract is an individual that was not represented by counsel and especially if that party has had very little business experience (such as a physician or medical provider recently in practice), courts are much more likely to hold ambiguities against the drafter of the agreement.

A paragraph regarding the construction of the agreement and stating that the agreement was formed from negotiation (as opposed to a “take-it-or-leave-it” proposition) can identify for any court constructing the contract that the court should not hold any ambiguities against the drafter. After all, even with negotiated contracts, one party or the other draws up the agreement.

[C] Choice of Law

In the United States today, it is common for parties in different states to have business dealings with each other. Likewise, in the sale of a medical practice, the buyer may begin negotiations in one state and then move to the practice state after consummation of the sale. In a similar vein, following the sale the buyer may move to another state.

In most cases, the various state laws should be similar on the contractual issues involved in the sale of a medical practice. However, a statement in the contract identifying the state whose laws will govern the contract will eliminate one possible source of dispute involving a side issue to the contract. In the vast majority of contracts, the laws of the state where the practice is physically located should be chosen by the parties to govern the contract

[D] Choice of Venue

Just like providing for choice of law, a side issue to the contract can be eliminated by choosing ahead of time the venue to resolve any conflicts that may arise. The venue is simply the place where the conflict will be decided. In most cases, the parties should choose the trial court of the county in which the practice is located.

[E] Survival of Obligations

An agreement to purchase a medical practice contains two aspects. First is the transference of the practice assets in exchange for the purchase price. Second are the various other terms, such as preservation of the medical records. By providing that these obligations survive the closing, each party is assured that the other party will not claim that the actual closing of the agreement extinguished the rights of the parties under the agreement.

 [F] No Waiver Clause

A provision providing that a party does not waive its rights unless such a waiver is committed to writing allows a party to be a “nice guy” without risking its future rights. In some instances, if a party does not insist upon full compliance by the other party, then the first party may be considered to have waived its rights and may have no recourse against the other party.

There may be instances when the forbearance to exercise a right under the contract will benefit both parties. For example, if the buyer cannot pay the seller an installment on time, the seller may agree to extend the time for payment of that installment. The no waiver clause allows the seller to refuse to extend the time for payment of a future installment. Without the clause the buyer might be able to argue that the seller had waived its future rights to timely payments.

[G] Notices

There may be various reasons under the contract why one party may need to give a notice to the other party. Most often such notice will be that a party is claiming that the other is in breach of some provision of the agreement.

By specifying the address and method of delivery of any notice, the sending party can be assured that a court will rule that the receiver had actual or constructive notice.

Such a provision should also provide that one type of notice would be a change of address. Such a change of address notification would then supersede the address delineated in the agreement.

In most cases, the agreement should provide that the counsel to the party would receive a copy of any notice. This accomplishes two goals. First, there is a greater likelihood that the receiving party would receive actual notice. If the receiving party had moved and had failed to provide notice of the change of address, then the party’s counsel would have received the notice. Secondly, the party’s counsel would have received the notice in a timely manner and could take any immediate action that may be necessary.

[H] Severability Clause

A severability clause helps to ensure that if one provision is held by a court to be illegal or unenforceable, then the offending clause will be stricken from the agreement and the parties will be held to the agreement without the clause.

Without a severability clause, if a court finds that one provision of the agreement illegal or unenforceable, then the court has the power to strike down the entire agreement. Although even with a severability clause a court could strike down the entire agreement, the severability clause tells the court that the intent of the parties was that only the offending clause be stricken and essentially asks the court to honor the parties’ intent.

[I] Further Assurances Clause

After execution of the agreement, the parties may discover that certain other documents are necessary to complete the transaction. Unless such documents materially change the meaning and purpose of the agreement, a further assurance clause requires the party of parties to execute and deliver the document.

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CLOSING – SETTLEMENT

The closing or settlement date should be chosen for a mutually time and place. Generally the date will be between 30 and 90 days from the execution of the agreement. This will allow the buyer and the seller adequate time to complete any conditions precedent to closing. At closing, the buyer will tender to the seller the agreed upon funds and will execute any loan and security agreements required under the purchase and sale agreement. If the restrictive covenant also contains a buyer’s covenant, then the buyer will execute that document. The seller will deliver to the buyer a bill of sale for the assets of the practice, will execute the restrictive covenant, will deliver the keys to the practice, and will surrender the assets and the premises to the buyer. Both the buyer and the seller will execute the lease assignment.

Many of the provisions of the agreement will survive the closing. This includes any agreement to prorate expenses not allocated in at the closing, the restrictive covenant agreement, the indemnifications, and any seller’s right maintained in the medical records.

TRANSITION

Both the seller and the buyer have certain interests to protect after the closing which would require the seller to stay with the practice for a period of time following the closing. The seller may have ongoing treatment plans with certain patients (such as post-operative follow-up treatment). The agreement should specify that the seller be allowed to continue at the practice location for the purpose of finishing such treatment plans. Although the buyer may be fully capable of completing such treatment plans, both the buyer and seller should be cognizant that the patient may claim abandonment. Allowing the seller to complete treatment plans in progress will mitigate against any perceived or actual claims of abandonment.

The buyer will want to require the seller to stay with the practice for a certain period of time, usually between three to six months. During that time, the seller will act to introduce the buyer to the current patients and the buyer will begin treatment of any new patients to the practice. In this way, the transition will appear smooth and natural to the current patients.

Of course, during the transition period, the seller will have the right to be paid by the buyer. To avoid misunderstanding, the method of payment should be reduced to writing. Usually the rate of compensation will be the profit margin percentage of the practice allocated to all income collected from the seller’s efforts during the time period in question. An astute negotiator might be able to require the seller to function during the transition period as an implicit condition for the payment of the practice price.

RESTRICTIVE COVENANTS

As part of the purchase price the buyer is paying for intangible assets of the practice. A medical practice is a highly individual based business. The practice depends in large part upon the reputation of the selling physician. For that reason, the buyer must ensure that the seller cannot use that highly individualized asset to compete against the practice for which she has just paid a high sum. The restrictive covenant protects this interest of the buyer.

A restrictive covenant actually contains several covenants to protect the buyer’s interests. These include not only the obvious covenant not to compete, but also a covenant regarding financial interests, a covenant regarding solicitations, and a covenant regarding proprietary information.

The first covenant is the covenant not to compete. In this covenant, the seller agrees not to compete with the practice in the geographic area during the time term of the agreement. This covenant prohibits the seller from actually practicing or from practicing indirectly. For example, the seller could not set up a clinic within the geographic area during the time period and employ a nurse practitioner to treat patients under his medical license.

The next covenant would be the covenant regarding financial interests. In this covenant, the seller is prohibited from investing in a competing business (i.e., medical practice), within the geographic area during the time period. This provision prevents the seller from investing in such a medical practice, even if he does not directly treat patients at that location.

The third covenant would be the covenant regarding solicitation. In this covenant the seller agrees not only to refrain from contacting patients of the practice during the time period, but also to refrain from contacting employees of the practice. If the seller maintains another office location which will not be sold, then the seller should ensure that the agreement provides that the seller is allowed to treat patients which find themselves to that practice location. Otherwise, the seller may be liable for patient abandonment and may also violate managed care contracts.

A final covenant would be a covenant regarding proprietary information. Simply by the fact of operating the practice, the seller has obtained certain proprietary information about the practice. This includes patient lists, accounting information, managed care contracts, and forms and handbooks. The seller should be prohibited from using such knowledge to the detriment of the practice.

 [A] Time and Distance

The time and distance covered by the restrictive covenants must be reasonable. If either the time or distance is unreasonable, then a court might strike down the entire restrictive covenant.

A reasonable time is usually between two to five years. A two-year time period should be the minimum that the buyer should insist upon. The purpose of the time period is to allow sufficient time for the practice patients to consider the buyer as their “doctor” and to lose confidence in the selling doctor. For that reason, any time period over five years is likely to be considered an unreasonable restraint.

On the other hand, a reasonable distance depends upon many individual factors. A reasonable distance in an urban area like New York City would most likely be completely unreasonable in rural areas, such as rural Iowa. In most metropolitan areas, a five to ten mile radius from the practice location is likely to be considered reasonable. In rural areas, an entire county or even several contiguous counties may be considered reasonable. The main determination of the reasonableness of the distance factor is the total area from which the practice draws its patients.

Most practice management software programs allow for delineation of the practice patient base determined by zip code. That will provide the parties a starting point from which to negotiate the distance factor of the restrictive covenant.

[B] Buyer’s Covenants

The restrictive covenant should also contain buyer’s covenants, although it may seem counterintuitive that the buyer, having paid the seller tens of thousands of dollars for the practice, should be required to sign buyer’s covenants. However, a buyer’s covenant is an important part of the restrictive covenant. Under the purchase agreement, the seller might retain the right to repossess the practice, the practice assets, and the premises. This is most likely to happen when the seller finances the purchase price and the buyer defaults on the payments. It can also happen when the seller assigns the lease to the buyer and the buyer either abandons the premises or otherwise causes a default under the lease. The seller then remains liable as principle under the lease.

For those reasons, the restrictive covenant should provide that if the seller is required to enter onto the premises and take possession of the practice, then the Seller is relieved of his obligations under the restrictive covenants and the buyer now becomes bound by those same obligations. Such buyer’s covenants will prevent the buyer from abandoning the practice and then setting up a nearby competing practice.

CORPORATE RESOLUTION

Most medical practices being sold are corporate entities. If the transaction is a sale for stock, then the transaction is between private parties – the buyer paying cash and the seller transferring the stock.

However, in those cases where the buyer is purchasing the assets of the corporate practice, then the corporation must take certain prerequisite steps. Generally, a corporation, through its officers and directors, is prohibited from selling significant assets without permission of the shareholders.

For that reason, a shareholder meeting must be held and the shareholders at that meeting must approve a resolution allowing the officers and directors to sell significant assets of the corporation.

ASSESSMENT

The contract regarding the sale of a medical practice is the final agreement of the parties. Such a contract should only be executed after sufficient investigation into the practice and upon consultation with proficient professionals, including attorneys, accountants, FAs and practice management consultants. Understanding the basic terms and conditions of a contract regarding the sale of a medical practice is the first step in successfully negotiating the best agreement possible. Before one can negotiate for a certain provision, one must first be aware of the possibility of such a provision and its possible ramifications.

So, what else can FAs and consultants do to help plan properly for the sale of a medical practice, physician succession planning, and this major life liquidity event? Some experience FAs suggest constructing a “dry run template analysis” so the doctor can envision what life will be like after the sale, and what their corresponding financial needs might be. When the practice is sold, life is very different because many expenses that the practice paid become expenses the doctor now must pay.  And so, the use of an astute financial advisor, practice valuation specialist, and healthcare contract attorney is highly advised.

CONCLUSION

As we have seen, the purchase price of a medical practice, although am important part of any sale, should only be considered one element of the negotiations. There are many clauses and provisions of a contract regarding the sale of the medical practice, which if not negotiated favorably should be considered factors to initiate the party to walk away from the sale.

EDUCATION: Books

References and Readings:

  • Boundy, Charles: Business Contracts Handbook Gower Pub, NY 2010
  • Fenton, CF: Contracts Regarding the Sales of a Medical Practice. Financial Planning for Physicians and Healthcare Professionals; Aspen Publishers, New York, NY, 2003.
  • Hekman, K: Buying, Selling & Merging a Medical Practice. Keneth Hekman, New York 2008.
  • Katz, D: Psychic Income, Financial Advisor, page 36, 2014.
  • Walker, Lewis: The Ultimate Transition. Financial Advisor, page 33, 2014.
  • Schatzki, M: Negotiation Speak: Winning Words and Phrases for Sales, Purchasing, Contract and Other Business Negotiations – All the Dialogue and Skills You Need to Come Out Ahead, Dynamic Negotiations, Chicago, IL 2009.
  • UCC, Commercial Contracts and Business Law Blog:  LexisNexis 2010.
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THE END

MERGER ARBITRAGE: Risk Arbitrage Defined

By Dr. David Edward Marcinko; MBA MEd CMP

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Sponsor: http://www.CertifiedMedicalPlanner.org

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Merger Arbitrage (a.k.a. Risk Arbitrage)

Merger risk arbitrage, while a subset of a larger strategy called event-driven arbitrage, represents a sufficient portion of the market-neutral universe to warrant separate discussion.

Merger arbitrage earned a bad reputation in the 1980s when Ivan Boesky and others like him came to regard insider trading as a valid investment strategy. That notwithstanding, merger arbitrage is a respected strategy and when executed properly, can be highly profitable. It bets on the outcomes of mergers, takeovers and other corporate events involving two stocks which may become one.

Example:

A classic example is acquisition of SDL Inc. (SDLI) by JDS Uniphase Corp (JDSU). On July 10, 2010 JDSU announced its intent to acquire SDLI by offering to exchange 3.8 shares of its own shares for one share of SDLI. At that time, the JDSU shares traded at $101 and SDLI at $320.5. It was apparent that there was almost 20 percent profit to be realized if the deal went through (3.8 JDSU shares at $101 are worth $383 while SDLI was worth just $320.5).

This apparent mispricing reflected the market’s expectation about the deal’s outcome. Since the deal was subject to the approval of the U.S. Justice Department and shareholders, there was some doubt about its successful completion.

Risk arbitrageurs who did their homework and properly estimated the probability of success bought shares of SDLI and simultaneously sold short shares of JDSU on a 3.8 to 1 ratio, thus locking in the future profit. Convergence took place about eight months later, in February 2011, when the deal was finally approved and the two stocks began trading at exact parity, eliminating the mis-pricing and allowing arbitrageurs to realize a profit.

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Hedge Fund Research defines the strategy as follows:

Merger Arbitrage,also known as risk arbitrage, involves investing in securities of companies that are the subject of some form of extraordinary corporate transaction, including acquisition or merger proposals, exchange offers, cash tender offers and leveraged buy-outs. These transactions will generally involve the exchange of securities for cash, other securities or a combination of cash and other securities. Typically, a manager purchases the stock of a company being acquired or merging with another company, and sells short the stock of the acquiring company. A manager engaged in merger arbitrage transactions will derive profit (or loss) by realizing the price differential between the price of the securities purchased and the value ultimately realized when the deal is consummated. The success of this strategy usually is dependent upon the proposed merger, tender offer or exchange offer being consummated.

When a tender or exchange offer or a proposal for a merger is publicly announced, the offer price or the value of the securities of the acquiring company to be received is typically greater than the current market price of the securities of the target company. Normally, the stock of an acquisition target appreciates while the acquiring company’s stock decreases in value. If a manager determines that it is probable that the transaction will be consummated, it may purchase shares of the target company and in most instances, sell short the stock of the acquiring company. Managers may employ the use of equity options as a low-risk alternative to the outright purchase or sale of common stock. Many managers will hedge against market risk by purchasing S&P put options or put option spreads.

Cite: https://www.hfr.com See § 23.03[E].



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COGNITIVE BIAS: Negativity V. Pessimism

By Staff Reporters

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Negativity bias is not totally separate from pessimism bias, but it is subtly and importantly distinct. In fact, it works according to similar mechanics as the sunk cost fallacy in that it reflects our profound aversion to losing. We like to win, but we hate to lose even more.

And so, according to cognitive scientist Mackenzie Marcinko PhD, when we make a decision, we generally think in terms of outcomes—either positive or negative. The bias comes into play when we irrationally weigh the potential for a negative outcome as more important than that of a positive outcome.

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Pessimism bias on the other hand, is a cognitive bias that causes people to overestimate the likelihood of negative things and underestimate the likelihood of positive things, especially when it comes to assuming that future events will have a bad outcome.

For example, the pessimism bias could cause someone to believe that they’re going to fail an exam, even though they’re well-prepared and are likely to get a good grade.

According to colleague Dan Ariely PhD, The pessimism bias can distort people’s thinking, including your own, in a way that leads to irrational decision-making, as well as to various issues with your mental health and emotional well being.

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Providing Physician Centric [Not Advisor Centric] Holistic Financial Planning Advice

BY DR. DAVID EDWARD MARCINKO MBA MEd CMP

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SPONSOR: http://www.MarcinkoAssociates.com

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Selecting a Healthcare Focused Financial Advisory Team

Most retail financial services products are designed to enhance the well-being of the Financial Advisor and vendor at the expense of clients.

The clients get only the leftovers.

Of course, no one tells them that secret.

They have to figure it out for themselves.

As the old line goes, “Where are the customers’ boats?”

Rowland, M: Planning Periscope [Where Advisors are the Clients]. Financial Advisors Magazine; page 36, April 2014.

EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit a RFP for speaking engagements: MarcinkoAdvisors@outlook.com 

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LEGAL: Expert Witness Defined

By Staff Reporters

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What exactly is an Expert Witness?

At D.E. Marcinko & Associates an “expert witness” possesses specialized knowledge in a particular field and is qualified to provide deposition or testimony in court and under oath. This testimony can be based on their personal experience, education, training and/or research. The role of an expert witness is to provide objective and unbiased opinions, analysis, and insights to help a lawyer, judge and/or jury understand technical or complex issues related to the case.

EDUCATION: Books

An expert witness can be called by either the prosecution or the defense in a legal case. The expert witness may be required to provide a written report or affidavit detailing their opinions, analyses and conclusions, and they may be asked to testify in court to provide oral testimony and answer questions from the judge and lawyers.

MORE: https://marcinkoassociates.com/expert-witness/

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Paradox V. Oxymoron

DEFINITIONS

By Staff Reporters

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Paradoxes are broader concepts that may include statements, situations, or phenomena, revealing a truth through contradiction (e.g., “less is more”).

Oxymorons are combinations of two contradictory words to create a new meaning (e.g., “deafening silence”).

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Most people tend to confuse a paradox with an oxymoron, and it’s not hard to see why. Most oxymoron examples appear to be compressed version of a paradox, in which it is used to add a dramatic effect and to emphasize contrasting thoughts. Although they may seem greatly similar in form, there are slight differences that set them apart.

A paradox consists of a statement with opposing definitions, while an oxymoron combines two contradictory terms to form a new meaning. But because an oxymoron can play out with just two words, it is often used to describe a given object or idea imaginatively.

As for a paradox, the statement itself makes you question whether something is true or false. It appears to contradict the truth, but if given a closer look, the truth is there but is merely implied.

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HOSPITAL: Finances Hold Steady in 2025

By Health Capital Consultants, LLC

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Hospital Finances Held Steady in First Month of 2025

In the first month of 2025, hospital revenue and expenses both increased, balancing each other out and resulting in continued steady financial performance for hospitals, according to Kaufman Hall’s January 2025 National Hospital Flash Report.

Revenues grew more quickly in the inpatient setting, as more patients were treated in the hospital and emergency department than in outpatient settings. While expense increases were largely driven by drug costs, the rate of that growth has significantly slowed.

This Health Capital Topics article reviews the report and the current state of hospital operations. (Read more…) 

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CELEBRATE: National Physicians Week 2025

EDITOR-IN-CHIEF

By Dr. David Edward Marcinko; FACFAS MBA MEd

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NATIONAL PHYSICIANS WEEK

National Physicians Week sets out March 25-31 to honor the healers dedicated to the art of medicine. In 2017, National Physicians Week highlighted the shortage of physicians in the United States against a growing landscape of minorities joining the ranks.

#NationalPhysiciansWeek

“In hindsight, I am proud of what we have accomplished in a short period of time, including raising the recognition of our group and spotlighting the years of sacrifice by those in our profession to serve our patients. We are poised to initiate actionable efforts to engage and educate our physician community.”

Cite: Dr. Kimberly Funches Jackson, President

Today in 2025, let’s explore the invaluable contributions of physicians, celebrate their hard work during National Physicians Week, and highlight the essential role that locum doctors play in enhancing healthcare delivery.

A Week to Honor All Physicians

National Physicians Week is a celebration of the remarkable work that doctors do every single day. From diagnosing complex conditions to providing life-saving treatments, physicians dedicate themselves to improving the health and well-being of their patients. It’s a week for healthcare professionals, patients, and communities to come together and show appreciation for the doctors who make a difference in our lives.

Physicians work long hours, face immense pressure, and make critical decisions daily. Their contributions go beyond the walls of the hospital, as many are also involved in research, teaching, and community outreach.

So, this week, it’s important to acknowledge not only their professional expertise but also the compassion and resilience they exhibit in their work.

EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit a RFP for speaking engagements: CONTACT: MarcinkoAdvisors@outlook.com 

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DAILY UPDATE: NIH, FDA, CMS and HHS Nominees as Stock Markets Collapse

MEDICAL EXECUTIVE-POST TODAY’S NEWSLETTER BRIEFING

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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants

Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily

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Dr. Jay Bhattacharya is officially the new NIH director. The Senate voted to confirm the Stanford University professor’s appointment on March 26 in a 53–47 vote. Marty Makary MD was also confirmed as FDA commissioner in the same hearing in a 56–44 vote. The appointments come as additional “healthcare disruptors,” alongside Robert F. Kennedy Jr.’s confirmation as HHS secretary and Mehmet Oz’s nomination as head of the Centers for Medicare and Medicaid Services. The nominees have faced backlash from the medical community following their controversial stances on topics like vaccinations and alternative medical practices.

CITE: https://tinyurl.com/2h47urt5

US stocks tanked on Friday as Wall Street grappled with President Trump’s escalating trade war and weighed signs of reinvigorated inflation pressures as consumer sentiment plummets.

The Dow Jones Industrial Average (^DJI) dropped more than 700 points or nearly 1.7%, while the benchmark S&P 500 (^GSPC) fell almost 2%. The NASDAQ Composite (^IXIC) dropped 2.7% as tech stocks led the declines.

CITE: https://tinyurl.com/tj8smmes

As noted above, the major averages fell on Friday after the release of a hotter-than-expected Personal Consumption Expenditures index reading, which includes the Federal Reserve’s preferred inflation gauge of “core” PCE. The reading showed prices increased more than expected last month, rising 0.4% month over month and 2.8% year over year, continuing a stubborn plateau on the path to the Fed’s 2% target.

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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THEORY: Linguistics and Cognitive Sciences

By Staff Reporters

Sponsor: http://www.MarcinkoAssociates.com

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Avram Noam Chomsky is an American professor known for his traditional work in linguistics and political activism. Sometimes called “the father of modern linguistics”, Chomsky is also one of the founders of the field of cognitive science. He is a laureate professor of linguistics at the University of Arizona and an professor emeritus at MIT.

And so, modern linguists today approach their work with scientific rigor and perspective [STEM], although they use methods that were once thought to be solely an academic discipline of the humanities.

Contrary to this humanitarian belief, according to Professor Mackenzie Hope Marcinko PhD of the University of Delaware, linguistics is now multidisciplinary. It overlaps each of the human sciences including psychology, neurology, anthropology, and sociology. Linguists conduct formal studies of sound structure, grammar and meaning, but also investigate the history of language families, and research language acquisition.

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DENTAL Care “Deserts”

By Staff Reporters

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Dental care in America divides people into two camps: those who can afford regular preventive care and cleanings, and those who can’t.

These so-called dental deserts contribute to a deep disparity in overall health. People who live in these places are more likely to get tooth decay and develop severe health problems. They also spend more money on care, and more time seeking health assistance in an emergency.

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Stat: 25 million. That’s how many US residents live in areas without enough dentists, according to a recent Harvard University study.

A growing movement against fluoride is adding to the risk of tooth decay in these “dental deserts.” (NPR)

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PHYSICIAN NET WORTH: Versus Average Family

By Dr. David Edward Marcinko MBA MEd CMP®

SPONSOR: http://www.MarcinkoAssociates.com

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Average Net Worth of an American Family

Both median and average family net worth surged between 2019 and 2022, according to the U.S. Federal Reserve. Average net worth increased by 23% to $1,063,700, the Fed reported in October 2023, the most recent year it published the data. Median net worth, on the other hand, rose 37% over that same period to $192,900.

You might wonder why the average and median net worth figures are so different. That’s because when you take the average of something, you add together every value in a data set and then divide that figure by the number of individual values.

When calculating a median, you simply look at the middle figure within a data set. That said, an average figure can be significantly higher or lower than a median figure if there are extreme outliers – meaning a group of people with significantly more net worth than the rest of the group can bring the average higher.

Average Net Worth by Age

The average net worth of someone younger than 35 years old is $183,500, as of 2022. From there, average net worth steadily rises within each age bracket. Between 35 to 44, the average net worth is $549,600, while between 45 and 54, that number increases to $975,800. Average net worth surges above the $1 million mark between 55 to 64, reaching $1,566,900.

Average net worth again rises for those ages 65 to 74, to $1,794,600, before falling to $1,624,100 for the 75 and older group. The median net worth within every single age bracket, however, is much lower than the average net worth.

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Physicians [MD/DO] Net Worth by Specialty

A 2023 Medscape report shows the top 10 specialties with the most survey respondents saying they are worth more than $5 million.

  1. Plastic Surgery (31% of all survey respondents)
  2. Orthopedics (28%)
  3. Gastroenterology (25%)
  4. Urology (23%)
  5. Cardiology (22%)
  6. Ophthalmology (18%)
  7. Radiology (17%)
  8. Oncology (17%)
  9. Pathology (14%)
  10. Ob/Gyn (14%)

EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit a RFP for speaking engagements: CONTACT: MarcinkoAdvisors@outlook.com 

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DAILY UPDATE: HHS Cuts Jobs as US Stocks Slip

MEDICAL EXECUTIVE-POST TODAY’S NEWSLETTER BRIEFING

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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants

Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily

A Partner of the Institute of Medical Business Advisors , Inc.

http://www.MedicalBusinessAdvisors.com

SPONSORED BY: Marcinko & Associates, Inc.

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Daily Update Provided By Staff Reporters Since 2007.
How May We Serve You?
© Copyright Institute of Medical Business Advisors, Inc. All rights reserved. 2025

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Health and Human Services Secretary Robert F. Kennedy Jr. is expected to announce 10,000 employees will be cut, the Wall Street Journal reported today—the latest round of layoffs in the Trump administration’s push to slash the size of the federal workforce.

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US stocks slid lower on Thursday after President Trump pushed ahead with hefty new tariffs on auto imports, stoking concerns about a potential full-on trade war and global economic harm. The S&P 500 (^GSPC) and the Dow Jones Industrial Average (^DJI) fell just over 0.3% on the heels of a losing day for the major gauges. The tech-heavy NASDAQ Composite (^IXIC) led the losses, falling more than 0.5%.

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Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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