Consumer Health Plan Satisfaction Survey

New Deloitte Center for Health Solutions Survey

Staff Reporters

Nine out of 10 Americans are not completely satisfied with their health plans, according to “The Deloitte Center for Health Solutions 2008 Survey of Health Care Consumers.”

The Survey:

According to the survey of what more than 3,000 Americans thought about a variety of healthcare issues; these findings were reported:

  • 73 percent are interested in accessing information about quality or price from their health plans,
  • 78 percent would rather customize their insurance by selecting the benefits and features they value, rather than choose their plans from a few pre-packaged options,
  • 78 percent are interested in online access to medical records and test results,
  • 76 percent want e-mail communication with doctors,
  • 72 percent support online office visit scheduling, and
  • 46 percent would like a software program or web site [cloud computing] to create a personal health record.  

Assessment

Tommy Thompson, senior advisor at Deloitte and former secretary of health and human services in the Bush Administration, said dissatisfaction with health plans should serve as a wake-up call for health insurers to offer more quality and transparency information; according to HealthLeaders Media, June 20, 2008

Conclusion

Is there a disparity-gap in this study between provider and patient opinions; or is it more accurate than not? Please comment?

Related Information Sources:

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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RAC Contractors to be Identified

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CMS Aims to Reduce Fraud

[By Staff Writers]

This month, the Centers for Medicare and Medicaid Services [CMS] will name the auditing firms that will review hospitals’ books for payment mistakes, while hospital officials say results in other states suggest the auditors will give priority to recovering overpayments.

The RAC Program

Under the so-called Recovery Asset Contractor [RAC] program, CMS pays auditors a fee based on the amount of improper payments discovered.

Hospital officials worry this “bounty hunter” approach – the second for CMS after medical practice audits – will create a bias in auditors to focus only on collecting government overpayments, reported the Pittsburgh Business Times on June 16, 2008.

Pilot Program Results

Some hospitals point to a pilot audit program in New York, Florida and California, which found $357.2 million in overpayments and just $14.3 million in underpayments. Medicare estimates its error rate at 3.9 percent in 2007, down from 9.8 percent in 2003, but still totaling $10.8 billion in improper payments

Assessment

Is this another instance of brute intimidation or just honest review?

Conclusion

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Economics of Variable Annuities

The “Ups and Downs” of Variable Investments

[By Staff Writers]

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The chief advantage of variable annuities is that investment income or gains are not currently taxable. However, when distributions are made, all gain is ordinary income, even if substantially all of the gains realized on the investment were capital gains.

Investments made directly by a Family Owned Business [FOB] member, for example, does not achieve tax deferral. But, assuming the dividends and other income are small (e.g., a growth portfolio), and all gains are capital gains taxed at the maximum rate, then direct investment may be a far superior method of investment.

Forbes summed it up, saying, “Don’t be a sucker!”

Despite Forbes’ warning, variable annuities are not necessarily an easy investment decision.

Sales Growth

Sales of variable annuities have continued to grow despite the reduction of capital gain rates in the recent years of the Bush Presidency, and the future is unknown. But, if the deferral is long enough, or if the portfolio throws-off ordinary income (e.g., a bond portfolio), then variable annuities may be desirable. However, doctors and medical professionals should exercise caution about variable annuities.

Fees and Expenses

Variable annuity fees vary widely from carrier to carrier but in many cases they are still high, putting such investments at a competitive disadvantage. If the fees are reasonable, and the medical professional client intends to invest in high yield bonds (also know as junk bonds), then a variable annuity can be attractive.

The same is true for traders who move in and out of funds and earn a large amount of short-term capital gains. In any event, all doctors should check the fees charged by the insurance company because they vary widely. Some funds that charge fees also have outperformed other funds.

Taxation

Investing in traditional equity can give rise to dividends of 1.5% (the average) that is subject to taxation. Variable annuities shelter the dividends, but at a cost often reaching 1.25%. This is not exactly an attractive investment trade-off.

Capital Gains

In addition, all capital gains derived from the portfolio are taxable as ordinary income when distributed; also not a good result.

Distributions upon Death

Assets held outright get a step-up in basis upon death. Variable annuity distributions are income-in-respect-of-a-decedent. Thus, there is no step-up in basis. This is harsh taxation, and the combined estate and income taxes can be 100% (e.g. the decedent’s estate may be is subject to a 5% surtax).

Thus, a 55-60% estate tax and a 35-40% ordinary income tax rate results in 100% taxation and confiscation. Counting the limitation on a deduction, the effective tax rate might be 42%, causing the combined taxes to exceed 100%. If the estate taxes can be deducted from the income taxes, the taxation of variable annuities is lessened.

Moreover, if a family business client has a charitable interest, using income-in-respect-of-a-decedent property to fund a gift to charity is a sound planning idea (the charity pays no income taxes and gifts to charities are not subject to estate taxes). Here, variable annuities may have one big advantage; they can prevent creditors from reaching assets. However, if this is a concern then the same results can be achieved by using an asset protection trust.

globe

Assessment

Tax deferral always appeals to medical and other clients, but in some cases, variable annuity tax deferral may not be a effective tax planning tool. In addition, postmortem planning can help to reduce the tax burden to children.

Variable annuities require clear analysis and discussion. Doctors, and their accountants and financial advisors should discuss this issue before investing in them. The reason, quite simply, is that most doctors do not like to pay current tax and they may leap at a variable annuity which can result in increased taxation. How ironic!

Conclusion

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Living Trust Myth-Busters

Reality Bites for Some Doctors

Staff Writers

Medical professionals are turning to living trusts in increasing numbers for their estate planning needs. But, two major trust myths need to be explored.

Myth 1:  Living trusts save taxes.

Reality: They do not. Income earned by a living trust is taxable to the physician or other grantor, and when he or she dies, the assets are includable in the estate for estate tax purposes. All traditional planning methods (i.e., marital deduction, estate tax exemption, charitable giving) are available to all estates—whether or not the assets are in a living trust.

Myth 2: Living trusts save probate expenses.

Reality: Living trusts do avoid probate, which makes them attractive to medical professionals, but the question is whether the costs of establishing and administering the trust outweigh probate costs. Living trusts are quite useful, however, when the grantor owns real estate in more than one state. The living trust avoids ancillary probate in other states, which can result in significant savings—especially if the investments are relatively modest because ancillary probate can cost more than the real estate is worth. Likewise, living trusts are helpful if a discretionary investment manager is used. Living trusts also result in faster estate proceeds transference.

Assessment

A living trust should be only a part of a physician’s estate plan. Currently, living trusts are commonly used in conjunction with wills www.MedicalBusinessAdvisors.com

Conclusion

What has been your experience with living trusts; pro or con? Comments are appreciated.

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

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MD Compensation and Benchmarking Tools

MGMA and ValueSource Release Software

Staff Reporters

Free online compensation and productivity benchmarking tools for physician practices are now available from ValueSource Software and the Medical Group Management Association [MGMA].

Dashboards in the Cloud

The two web-based [internet computing] dashboards enable physicians and group practices to enter a few easy-to-find variables about physician compensation, and production and costs, and then compare themselves to national norms. Practice managers select their specialty from a pull-down menu, enter information about compensation, collections, gross charges, ambulatory encounters, surgery/anesthesia cases, and work RVUs, etc.

Assessment

The internet based cloud dashboards compare that data to national norms and produce a series of six gauges that measure physician performance in specific areas.

Conclusion

Please opine if you have used these new tools in your practice, clinic or hospital setting; and tell us what you think. Your review and evaluation is appreciated and will assist Executive-Post readers.

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Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Medical Cultural Disparity

A Real or Perceived Contemporary Concept?

Staff Writers

Question

Joseph R. Betancourt, MD, MPH, director of The Disparities Solutions Center at Massachusetts General Hospital [www.massgeneral.org/disparitiessolutions] was asked during a recent interview with Physician’s News Digest how he defined the emerging concept of “medical cultural competency.”

Answer

He replied that he viewed it as basically an “expansion of patient-centered care,” which he said is characterized by the physician’s awareness of and agreement with “the need to be attentive to the health beliefs, values and perspectives of the patient.”

Conclusion

And so, is this the same or different from participatory or collaborative Healthcare 2.0.

Your opinions and comments are appreciated.

Related Information Sources:

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Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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CRNA Salaries Rise – Exceed Some MDs

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Merritt Hawkins & Associates Study  

[Staff Reporters56399869]

Some nurses land higher salaries than primary care doctors, according to staffing firm Merritt Hawkins & Associates.

The Survey 

In the past year, nurse anesthetists recruited through the staffing firm Merritt Hawkins & Associates, landed salaries that averaged $185,000; compared to the pay for family practice doctors hired through the firm, who averaged $172,000; and internists, who averaged $176,000; according to a Wall Street Journal report, on June 18, 2008.

Assessment

The Merritt Hawkins figures for the nurses are higher than some other sources, like the Medical Group Management Association. The MGMA also tracks health care salaries and puts nurse anesthetists’ median compensation at $140,000 per year. The discrepancy may be because fewer employers go through recruiters to hire the nurses, and those who do are willing to pay top dollar.

Related Information Sources

Medical Assistant Job Description: Learn about the salaries of those who assist with medical procedures: http://www.medicalassistantschools.org/what-does-a-medical-assistant-do/

Conclusion

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Faux Healthcare 2.0 Collaboration for Terminal Patients?

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American Society of Clinical Oncology Study

[By Staff Writers]

Only one-third of terminally ill cancer patients said their doctors had discussed end-of-life care, according to a recent federally funded study presented at the American Society of Clinical Oncology conference in Chicago.

Study Results

According to the study, patients who had these talks were no more likely to become depressed than those who did not. Moreover, they were less likely to spend their final days in hospitals tethered to machines, avoided costly futile care, and with loved ones more at peace after they died, reported the Associated Press on June 15, 2008.

Assessment

The study was the first to look at what happens to patients if they are, or are not, asked what kind of care they’d like to receive if they were dying, according to lead researcher Dr. Alexi Wright of the Dana-Farber Cancer Institute in Boston. The study involved 603 people in Massachusetts, New Hampshire, Connecticut and Texas. All had failed chemotherapy for advanced cancer and had life expectancies of less than a year.

And so, is the emerging new concept of collaborative or participatory medicine – known as Healthcare 2.0 – fact, fiction or just plain hype?

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Conclusion

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Doctors Unite!

On the “Open Letter from America’s Physicians”

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

As we have seen in this healthcare-charged election season, almost every form of political activism or debate has moved online. So, it is no surprise that a coalition of disgruntled physicians would electronically socialize and network together, as seen with www.sermo.com

About Sermo – Peer 2 Peer Doctor Network

First billed as a physician’s only online community, where 65,000 doctors around the nation exchanged the latest medical insights with each other to improve patient clinical outcomes, some portions of the Sermo community have morphed into a kind of political action committee [PAC] representing a particular flavor of zealot doctor activist.

Political Activism

And, not to miss out on a marketing opportunity, Sermo has allowed itself to be used as a vehicle for an open letter signed by physicians, decrying the state of domestic healthcare, that’s only going to get more public.

According to Mr. Matthew Arnold of Medical Marketing & Media, the letter is a physicians’ manifesto of sorts, composed by selected Sermo doctors demanding an end to intrusive insurers and overzealous regulators. To date it has garnered 5,200 signatures in the several weeks since it was posted on www.mmm-online.com

So, You Want a Revolution?

According to Arnold, “There’s a sense of revolution in this,” said Dr. Daniel Palestrant, founder and CEO of the physician social networking site, which boasts around 70,000 members. “It’s doctors coming together for the first time, voicing discontent with the representation they’ve had to date, and making it clear to the public that the quality of care is going to be suffering based on some of these outside forces.” http://www.mmm-online.com/Fed-up-Sermo-docs-draft-manifesto/article/112006

Doctors Unite

The “Open Letter from America’s Physicians,” hosted at www.doctorsunite.org blames “The insurance industry’s undue authority and oppressive control over healthcare processes,” “Excessive and misguided government regulation” and “The practice of defensive medicine in response to a harmful and costly legal environment” for America’s healthcare crisis, and vows: “We, the physicians of the United States, will no longer remain silent. We will not tolerate a healthcare system where those without medical expertise or genuine interest in our patients’ health have absolute control.”

Assessment

As almost every other form of political activism has moved online, don’t be surprised to see more websites, blogs, wikis or social e-communities like this. Of course, if the details get specific, it’s tricky to know whether the coalition of disgruntled doctors will stay together, and/or whether Sermo will emerge as representing a new breed of doctor “turned-political-pundit.”

Conclusion

And so, is political activism an appropriate initiative for the medical community; why or why not?

Might it be considered more self-serving; or more patient centric? Your thoughts and comments are appreciated.

Related Information Sources:

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Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

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Key-Man Life Insurance Proceeds Ruling

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IRS Tax Exempt Treatment Ruling

[By Robert Whirley, CPA]

A recent revenue ruling has been issued by the Internal Revenue Service addressing the tax exempt treatment of life insurance policy proceeds on “key-man” policies of Subchapter S-Corporations; medical and/or otherwise. 

Excerpts

Revenue Ruling 2008-42 concludes that premiums paid by the S-Corporation on an employer-owned life insurance contract, of which it is directly or indirectly a beneficiary, do not reduce the S-Corporation’s AAA. Further, the benefits received because of the death of the insured from an employer-owned life insurance contract that meets an exception under Code Sec. 101(j)(2) do not increase its AAA.

Assessment

This may sound like Greek to some doctors. The affect is that life insurance proceeds on key-man policies in an S-Corporation are essentially trapped in the corporation. Any distribution of that cash to surviving S-Corporation shareholders – or to the estate of the deceased shareholder – triggers a taxable event.   

It is therefore vital for any doctor with a life policy paid by your medical practice, or other S-corporation, to discuss the tax policy and estate planning particulars with your accountant.

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Conclusion

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The Cure for Claims Campaign [CCC]

Reducing Healthcare Administrative Burdens and Costs

Staff Writers

To help reduce the administrative burden of ensuring accurate insurance payments for physician services, the American Medical Association [AMA] recently launched the “Cure for Claims” Campaign [CCC] and unveiled the first AMA National Health Insurer Report Card on claims processing.

Goals

The goal of the AMA campaign is to hold health insurance companies accountable for making claims processing more cost-effective and transparent, as physicians divert substantial resources – as much as 14 percent of their total revenue – to ensure accurate insurance payments for their services.

The National Health Insurer Report Card [NHIRC]

The AMA’s new National Health Insurer Report Card provides physicians and the public with information on the timeliness, transparency and accuracy of claims processing by health insurance companies. Based on a random sample pulled from more than 5 million electronically billed services, the NHIRC examines the claims processing performance of Medicare and seven national commercial health insurers: Aetna, Anthem Blue Cross Blue Shield, CIGNA, Coventry Health Care, Health Net, Humana and United Healthcare.

Study Results

According to the June 16, 2008 AMA study: 

  • There is wide variation in how often health insurers pay nothing in response to a physician claim (from less than 3 percent to nearly 7 percent), and in how they explain the reason for the denial. There was no consistency in the application of codes used to explain the denials, making it expensive for physician practices to determine how to respond.
  • Health insurers reported to physicians the correct contracted payment rate only 62 to 87 percent of the time. When health insurers report an amount that does not adhere to the contracted rate, it adds additional, unnecessary costs to the physician practice to evaluate the inconsistency.
  • More than half of health insurers do not provide physicians with the transparency necessary for an efficient claims processing system.
  • There is wide variation among payers as to how often they apply computer generated edits to reduce payments (from a low of less than .5 percent to a high of over 9 percent). Payers also varied on how often they use proprietary rather than public edits to reduce payments (ranging from zero to as high as nearly 72 percent).

Assessment

The use of undisclosed proprietary insurance claims edits, only serve to inhibit the flow of transparent information to physicians, adding additional administrative costs to reconcile their health insurance claim issues.

Conclusion

Your thoughts and comments are appreciated. Will likely outcomes of the CCC and NHIRC be real, or illusionary?

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

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Perceptions of Electronic Health Records

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New Awareness Study

[By Staff Writers]

Kaiser Permanente, through independent market research company StrategyOne, conducted a nationwide survey between May 8-11, 2008 to gauge the awareness and perceptions of electronic health records.

Survey Findings:

  • 38 percent have used their insurance company’s online tools to learn more about their care, up from 29 percent in 2007.
  • 47 percent had a preference for doctors who use EHRs and 61 percent had a preference for insurance companies who employed EHRs.
  • 51 percent agreed that health IT should be a top priority for the next president to ensure that all Americans have access to their own personal medical records [PMRs] electronically.

Assessment

Americans continue to have concerns about privacy issues. Assurance is required, from all who store personal medical data, that patient information is secure.

Source: Kaiser Permanente, June 12, 2008.

Conclusion

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Meet an Executive-Post Sponsor

The Institute of Medical Business Advisors, Inc

July 7, 2008

PRESS RELEASE: iMBA, Inc

Atlanta, Georgia

The Executive-Post at www.HealthcareFinancials.com is now proudly sponsored, in-part, by the Institute of Medical Business Advisors Inc.

Since inception in 2000, iMBA Inc has become one of North America’s leading professional health consulting firms; and focused provider of textbooks, CDs, tools, templates, onsite and distance education for the health economics, administration and financial management policy space. Other consulting services include:

  • Medical Practice Valuations and Appraisals
  • Practice Management Solutions
  • Physician Focused Financial Planning
  • Health Economics and Financial Benchmarking
  • Health Information Technology
  • Wealth Policies and Investment Management
  • Fiduciary Second Opinion Evaluations
  • Litigation Support Services
  • Special Projects, etc.

As competition increases, and the cognitive demands of the global marketplace change, iMBA Inc is well positioned with offices in five states and Europe to meet the needs of medical colleagues, related advisory and corporate health clients today; and into the future.

For more information, please visit: www.MedicalBusinessAdvisors.com

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Getting IRS Answers

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Even When You Shouldn’t Ask

By Staff Writers

Our complex tax system has sparked moves toward a flat tax in 2008 and other efforts at simplification. But until such a change occurs—if it ever does—we are stuck with what we have. This means many doctors and all taxpayers will continue to be confused and uncertain about their tax situations, and they will have a lot of questions.

The IRS Source

According to many experts, the IRS, which should be the best source for doctor answers, does not come through nearly often enough. But, it does offer some options. Which one you choose depends on the complexity and nature of the problem. Some simple, straightforward questions may be readily answered by a phone call. But for questions that are more complicated, it might be better to do it in a letter—following IRS guidelines—and get a written answer. And, in some cases, you may be better off not asking the question in the first place.

Phoning the IRS

Getting through to the IRS can be difficult. Its lines are often busy, especially during tax season. According to a not-so-recent report by the General Accounting Office, only 20% of callers got through to the IRS on the first call during last year’s tax return season (50% eventually got through). The IRS itself says you should avoid calling during lunch hours or on Mondays. But more serious is the reliability of the information you get. And, as a rule, the IRS will not stand behind its oral advice.

Example:

—Emma and James Clarke called an IRS helpline and asked whether they would be taxed on funds they wanted to withdraw from an individual retirement account (IRA) to buy a home. The Clarkes believed that they were told the transactions would result in no tax. So they withdrew the funds. When the IRS taxed them on the withdrawals, the Clarkes went to the Tax Court. They argued that they should not be taxed because they had relied on the erroneous advice of an IRS representative.

The IRS said that the Clarkes had misunderstood. According to the IRS, its representative told them only that they would not face the 10% tax on early withdrawals since they were over age 59½.

The Tax Court had no way of knowing whether the Clarkes had misunderstood or had been given mistaken advice. But the court said it did not matter. The tax law calls for taxes on IRA withdrawals, and the IRS had to follow the law.

Note: The IRS is not legally bound by mistakes its agents may make.

Precautions

The risk of getting incorrect advice does not mean that you should never call the IRS. But you should do some things to protect yourself. In particular, after you get an answer to your question, ask the IRS representative if information on the subject appears in any IRS publication. Then order the publication from the IRS and check the answer you received.

For example, suppose you want to know whether you can claim your father as your dependent. Even if the IRS representative says you can, you would be smart to check the IRS’s Publication 17, Your Federal Income Tax, which sets forth all the requirements for claiming someone as a dependent. Even if the representative is knowledgeable, it’s easy in a conversation for one party to misunderstand the other.

The same basic principles apply if you visit a local IRS office and speak to an agent. You can then easily pick up the publications you need, too.

If you use your computer to surf the Internet, you now can get some forms and basic information from the IRS via the World Wide Web (www.irs.ustreas.gov). But you cannot yet ask questions and get tax help this way.

Writing for Help

You will get the most protection by writing to the IRS with your question, because it will have to send you the answer. Then, if you follow this written advice and it turns out to be wrong, penalties you would otherwise owe will be avoided.

Private letter rulings

—These are among the most common forms of IRS guidance. You would request a private letter ruling from the IRS National Office when you want to know the tax impact of some strategy or transaction you are considering. Such a ruling is like insurance. As long as you give full and accurate details of the proposed transaction, you can rely on the ruling. (You cannot rely on private letter rulings issued to other taxpayers, but you can study them for signs of how the IRS views particular transactions.)

A small medical business might seek a letter ruling to be sure, for instance, that fringe-benefit plans or corporate restructuring will be tax-free.

Example

—A company was engaged in two businesses, A and B. The company needed capital to finance B’s new technology product. It found a venture capitalist willing to invest in B, but not in A. So the company sought to spin off B to a new corporation. The IRS said that there would be no tax on the transaction.

If your transaction will achieve the desired results, the IRS may suggest ways you can fix it. If the IRS plans to issue a negative ruling, it may offer you a chance to withdraw your request.

Technical advice memos

—Similar to letter rulings, these also come from the IRS National Office but are most often requested when a technical question comes up during the course of an audit. IRS agents themselves regularly request them. But, as a taxpayer, you can request such advice yourself. Technical advice memos are usually retroactive, but you can request relief from retroactivity if it would hurt you.

Technical advice memos may be issued on some of the same matters as letter rulings. Typical memos deal with such issues as whether a medical office worker is an employee or an independent contractor, validity of pension plans, and use of accounting methods.

Example

—A repairman had worked in an auto body shop for several years. Originally, he was classified as an employee. Then the shop owner turned the business over to his son, who designated the worker as an independent contractor. But the worker’s job did not change. He worked eight to 10 hours a day at the shop, using some of his own tools—but also some of the shop’s tools and equipment. He was paid half of the total amount of the bill for the repairs he did. But receiving his pay did not hinge on whether the customer paid; he took no risk. The IRS ruled in a technical advice memo that the worker was an employee.

Example

—A company asked the IRS to rule on whether its pension plan was qualified for tax breaks. The IRS said yes. A year later, the IRS realized the plan violated the rules because it excluded some workers who put in more than 1,000 hours a year. In a technical advice memo, the IRS said that the company would have to amend the plan to comply with the tax law. But because the company had relied on the IRS ruling in good faith and had originally disclosed all of the facts, the change did not have to be made retroactively.

When Not to Ask

There is no reason not to call the IRS with a basic question so you can fill out your tax return correctly. You probably will not even have to give your name. But if you want a letter ruling, first weigh the pros and cons.

In some situations—for example, to change your accounting method—you must get an advance ruling. In other cases, an advance ruling may be desirable because you want to be sure of the tax consequences of a transaction. Moreover, as we said, the IRS may suggest ways to restructure the transaction to get the tax result you want.

However, sometimes it’s unwise to seek IRS advice. You may not have time for a ruling—they generally take two or three months. Or, if the transaction offers no chance for flexibility, you will be stuck if the IRS gives you a negative response. (You must attach the ruling—favorable or not—to your return.) The National Office will review all related issues and transactions when it examines your request. So you must also be sure such scrutiny will not create a problem for you.

Cost is another factor. Fees vary by type of ruling, but a typical one would be $500. Then you need professional assistance in preparing your request and responding to IRS questions.

Assessment

The IRS will not answer every question. It will not give you a “comfort ruling”—where the answer is clear or reasonably certain. And it will not rule in hypothetical situations.

Letter rulings are public information, but you don’t lose your privacy. The IRS will have you sign a deletion statement: You can tell it to block out items that would reveal your identity. Most all physicians and medical professionals should do this.

Conclusion

Your comments are appreciated. What has been your experience with IRS queries?

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“S” Corporation [Case Law] Tax Advantages

Family Owned Business [FOB]

Staff Writers

fp-book1

Some doctors understand the advantages that S corporations have over regularly taxed C corporations—and vice versa. But, an unfamiliar Tax Court decision, more than a decade ago, points up an advantage for S corporations that are sometimes overlooked.

Scenario

Suppose the owners of a family corporation are about to retire. Their children will buy their stock, giving them a note for the purchase price. The children will, of course, pay interest on the note.

Tax Difference

If the corporation is an S corporation, the younger generation will be able to write off their interest payments in full.

On the other hand, if it’s a C corporation, they may have few or no deductions.

Why the difference?

Because interest you pay to buy S corporation stock is considered “business” interest, and that’s fully deductible. On the other hand, interest paid to purchase C corporation stock is treated as “investment” interest. And the tax rules say that investment interest is deductible only to the extent of your investment income (dividends, interest income, etc.). If you don’t have any investment income, you get no deduction for your interest payments.

Naturally, that brings up another question: Why is the ownership of a C corporation considered an investment, while the ownership of an S corporation is treated as a business? For the answer to that, let’s look at the above mentioned Tax Court case.

Case Report

Three brothers, Milton, Leo, and Dale Russon, founded Russon Brothers Mortuary as a regular C corporation. The business did well, and the Russon brothers began training their four sons, Scott, Brent, Robert, and Gary, in the mortuary business.

Eventually, the four younger Russons were trained and actively involved in the business, and the older Russons were ready to hang up their hats. The younger Russons agreed to buy all the stock in Russon Brothers for $999,000. Each of the four younger Russons agreed to pay one-fourth of the purchase price, with 10% payable up front and the remainder to be paid in 180 equal monthly payments at 9% interest.

Agreement

The agreement gave the four younger Russons their right to exercise ownership rights, including “the right to all dividends from the stock,” subject to certain limitations. One of those limitations provided that the buyers could not “declare or pay any dividends or make any distributions” without written permission from the older Russons. After the sale, the four younger Russons continued to run the mortuary business, and their fathers retired.

On his tax returns following the sale, Scott Russon deducted the interest he paid on the purchase price for the Russon Brothers stock. However, the IRS denied the deduction on the grounds that the interest was subject to the investment-interest limitation.

Scott Russon countered that his interest should be treated as fully deductible business interest. After all, he bought the stock so that he and the other younger Russons could conduct the business full time and “earn a living.” Moreover, he contended that he couldn’t have purchased the stock as an investment since Russon Brothers had never paid a dividend in its entire history.

Tax Payer Loser

The Tax Court concluded that the Russon Brothers stock was “held for investment,” and the interest paid to acquire the stock was subject to the investment-interest limitation [Russon, 107 T.C. No. 15].

The court pointed out that property “held for investment” includes any property of the type which produces interest, dividend, or royalty income. And, in the court’s view, that means property that normally produces those types of income—regardless of whether it actually produces such income.

The tax law does not require corporate stock to pay a dividend before it becomes investment property. What’s more, the court pointed out that the definition of investment property is inclusive and applies uniformly to every taxpayer; it does not depend on a taxpayer’s mind-set when buying the property.

Finally, the court pointed out that the possibility of the Russon Brothers stock actually paying dividends was clearly contemplated by all the Russons when they drew up the sales agreement. The agreement gave the younger Russons the right to “all the dividends from the stock,” subject only to the written consent of the older Russons until the purchase price was fully paid.

S Corporation Advantage

If Russon Brothers had been an S corporation; it would have been a different story. The IRS has said that interest paid to buy an S corporation is treated as interest to purchase the corporation’s assets, not its stock [Notice 89-50]. Thus, the interest the Russons paid would have been treated as fully deductible business interest to the extent the assets were used in the corporation’s business [Notice 88-20]. And since virtually all of Russon Brothers’ assets were used in the active conduct of its mortuary business, Scott Russon would have been entitled to his deductions.

Assessment

There is one bright spot for astute doctors and other buyers of C corporations. You can switch. The IRS has ruled that once a C corporation is converted to an S corporation, interest paid thereafter will be treated as paid for the assets, not the stock. So your interest will become fully deductible business interest [Ltr. Rul. 9040066].

Conclusion

Of course, switching to an S corporation has other important tax consequences. So you will want to talk things over with your tax adviser before making a final decision. And so, your thoughts and comments are appreciated.

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Marital Dissolution, Buy-Sell Agreements and Practice Value

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Doctors, Divorce and Medical Practice Worth

[By Mark P. Gross; JD]

Determining how to value the business interest of each medical partner is a critical element of the buy-sell agreement.

Family law courts, however, have broad discretion about whether to accept or reject the validity and binding effects of the formula stated in these agreements. When assessing whether the formula is binding in the dissolution proceeding, the courts consider, in general: (1) the proximity of the date of the agreement to the date of the marital separation to ensure that the agreement was not entered into while contemplating a marital dissolution; (2) the existence of an independent motive outside of divorce for entering into the buy-sell agreement, (e.g., the desire to protect all shareholders against the affects of a business dissolution); and (3) whether the value determined by the formula used in the agreement is similar to the value produced by other methodologies.

Case Law

For example, in one case [Nichols v Nichols (1994) 27 Cal. App.4th 661, 671-672], these factors were enunciated. The attorney-husband became a partner shareholder and signed a stock purchase and sales agreement under which the price of the stock was determined by a formula based on the book value of all the firm’s assets, except its accounts receivable, goodwill and work in progress, etc. When the husband and wife began divorce proceedings, the husband’s expert valued the community interest of the husband’s stock according to the stock purchase agreement.

The wife’s expert valued the interest by the book value of the firm’s net assets including accounts receivable, goodwill, and work in progress. The dispute went to the family law court and the court ruled in favor of the husband. The appellate court upheld the decision.

The appellate court noted that the agreement was entered into eight years prior to separation and thus did not appear to anticipate the divorce. The firm had an independent motive for entering into the stock purchase agreement, (i.e., avoiding a major economic impact on the firm when a partner leaves). More importantly, the court found no evidence that the stock purchase agreement was designed to deprive the wife of any rights.

A Marital Settlement Agreement

In drafting the buy-sell agreement, the principals of any medical practice or business should view it as a marital settlement agreement.

In a separate divorce case [Slater v Slater (1979) 100 Cal. App. 3d 241, 245, 160], the asset being divided was the husband’s interest in his medical practice partnership.

During the parties’ marriage, the husband and wife both signed the partnership agreement which specifically provided that the partnership could buy back the husband’s interest upon his death, withdrawal, or expulsion. Under the agreement, the purchase price was to be the husband’s interest in the capital account plus the total of the accounts receivable [ARs] less than six months old.

The agreement further stated that “the partners agree that a portion of the purchase price as determined above includes the sale of their interest in the goodwill of the partnership, and in the event of their withdrawal or expulsion from the partnership, that they will not enter into the practice of medicine in that portion of Alameda County for a period of three years.”

Trial Court Proceedings

The trial court proceedings, in determining the value of the husband’s medical practice according to the partnership agreement, found it had a goodwill factor of zero.

The wife appealed claiming the trial court erred in setting a value of zero on the goodwill of the husband’s practice, pursuant to the withdrawal provision of the partnership agreement. The appellate court reversed the trial court’s decision with directions to value of the husband’s interest in the partnership. It rejected the husband’s contention that his wife was bound by the terms of the agreement—even though she had signed it. It found that the agreement was irrelevant because the asset being divided in the dissolution of marriage was not the husband’s contractual withdrawal rights; rather it was his interest in the partnership.

Therefore, the wife was not bound by the terms of the withdrawal provision, and the trial court was not precluded from valuing the goodwill of the husband’s practice. This is a troubling decision and probably an incorrect one.

Fair Market Valuation [FMV] Factors are Key

In order for a buyout plan to better withstand rigorous examination in the family law court, the buyout price should be related to fair market factors of the business and should not be intended to deprive the non-shareholder spouse of any community interest.

A formula should be used based on profitability instead of a fixed price (as in the actuarial business example), and an explanation for the formula should be developed. Having the spouse sign the agreement is probably a good idea.

Fiduciary Duty

Other issues in drafting a buy-sell agreement include breach of fiduciary duty.

California Family Code Section 721(b), for example, states that transactions between a husband and wife are subject to the general rules governing fiduciary relationships. Because the buyout provision is tantamount to an agreement disposing of a community asset, the rules governing fiduciary duties may apply and render the provision voidable or chargeable to the principal spouse for greater value. Therefore, a buy-sell agreement that too heavily favors the principal spouse may not be of any value in a dissolution proceeding.

Community Interest

Finally, when both parties in a divorce agree to the disposition of the community interest in the stock of a company upon dissolution of marriage, the rules governing disclosure apply, including disclosure of valuation. Neither spouse may dispose of community personal property for less than fair and reasonable value [FMV] without the written consent of the other, and each part has an obligation to fully disclose proper valuations of assets. In equitable distribution states, similar disclosure rules are applicable.

Assessment

Buy-sell agreements should be created early in the family-owned business. Once accomplished, unpleasant issues can be discussed before the emotional baggage weighs upon the parties’ sensibilities. It is much easier and more prudent to include the divorce scenario in the agreement up front instead of waiting until it becomes an issue (the agreement already deals with death, disability, and business dissolution). To ensure proper wording of the marital dissolution portion of the buy-sell agreement, a draft of the document should be reviewed by a family attorney prior to execution. With a solid plan in place in the event of divorce, the family business will be better able to weather the stormy events that can sometimes occur within a family.

What are your thoughts and opinions on this often contentious topic, from the spouse, doctor, legal and medical partner perspective? Your comments are appreciated.

About the Author: Mark P. Gross Esq. is a shareholder in the Encino, Calif., law firm of Alpert, Barr & Gross.

Conclusion

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Events-Planner: July 2008

JULY 2008

Staff Writers

“Keeping track of important health economics and financial industry meetings, conferences and summits”.  

July 10-11: Health Reform & the 2008 Elections: What’s Ahead for Health Care Access, Delivery and Financing? Washington Court Hotel, Capitol Hill; Washington, DC | Phone: 800-521-4323

July 14: Medicare Advantage Special Needs Plans | Institute for International Research, Washington, DC.

July 15-17: 3rd Annual Achieving Return on Investment for Wellness; Hamilton Crowne Plaza Hotel; Washington, DC | Phone: 800-647-7600

July 15-18: Association of Medical Directors of Information Systems Symposium, Ojai Valley Inn, Ojai, CA | Phone: 530-596-4477

July 16: Medicare Marketing Compliance | Financial Research Associates, Chicago, Illinois.

July 21-22: Optimizing Managed Care Contracting for Hospitals; Boston, MA | Phone: 800-647-7600

July 21-22 Executive Forum on Rx Benefit Management for Employers and Health Plans; Las Vegas

July 22-23: The 3rd Annual World Congress Leadership Summit on the Road to Interoperability; Boston Waterfront Hotel; Boston, MA | Phone: 800-767-9499 

July 23-25: 2nd Annual Public Health Care Congress; Mandarin Oriental Hotel; Washington, DC | Phone: 800-817-8601 

July 24-26: Health Forum Leadership Summit; Manchester Grand Hyatt; San Diego, CA | Phone: 312-893-6897

July 25: SCF Arizona Medical Provider Seminars 2008; Worker’s Compensation, Sheraton Tucson Hotel | 602-631-2513 lbrott@scfaz.com  

July 29-31: Medicare Today & Tomorrow; Washington, DC | Phone: 800-647-7600

July 30-31: The 2nd Annual Leadership Summit on Process Improvement and Business Excellence in Healthcare; Hilton Suites Chicago Magnificent Mile; | Phone: 781.939.2410 

Please send in your meetings and dates for listing in the next issue of our Events-Planner: MarcinkoAdvisors@msn.com

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Ending Governmental Barriers to e-Prescribing

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AMA’s – HOD Wants End to Governmental e-Prescribing Barriers
[By Staff Writers]

According to Modern Healthcare [June, 2008] the American Medical Association’s-House of Delegates [HODs] adopted a resolution calling for an end to government-imposed barriers to e-prescribing.

The Resolution

The resolution called for the removal of all federal Medicare and state Medicaid requirements mandating the use of paper prescription forms for certain drugs – that the AMA initiate discussions with the federal Drug Enforcement Administration to allow e-prescribing of schedule 2 drugs – and that Medicare or Medicaid payments not be contingent upon adoption of e-prescribing.

Assessment

The resolution also called on the AMA to work with federal and private entities to ensure universal acceptance by pharmacies of electronically transmitted prescriptions.

Pills

Assessment

Should we really bite the [Medicare] “hand that feeds us?”

Conclusion

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Worthless FOB Stocks

Getting the Tax Deduction

Staff Writers

All physicians and other investors should know when their stock becomes worthless.

Example Scenario:

Some time ago, an FOB physician investor [Family Owned Business] founded two FOBs: One was doing fine while the other floundered. Under the IRS Tax Code, the investor can receive a loss deduction on the second FOB if: 1) the stock is worthless, and 2) the loss is claimed in the year it became worthless.

Definition of “Worthless”

The problem often is determining when a stock is completely “worthless”—there is no deduction for partial worthlessness. A company does not have to file for bankruptcy or end operations for its stock to be worthless.

Generally, if an FOB’s liability greatly exceeds its assets, and there is no real hope of continuing the business at a profit, the stock is considered worthless under the Tax Code. Often, to prove a worthless loss deduction, the business owner sells his or her stock at a nominal price.

Loss is Limited

The amount of the loss has traditionally been limited to the business owner’s tax basis. Capital losses are used to offset capital gain, but $3,000 can be used as a deduction against ordinary income. The $3,000 can be carried forward indefinitely.

Section 1244

If the business’s stock qualified as Section 1244 stock, the loss is an ordinary and fully deductible loss (subject to dollar limitations). In these cases, the loss is deductible against ordinary income. Obviously, if a loss is deductible against ordinary income in the first year, the taxpayer will receive a significant tax savings.

Most FOBs issue Section 1244 stock if it is qualified as a “small business corporation.”  To qualify, the total capital invested at the time the stock is issued cannot exceed $1 million. In addition, the FOB must have less than 50% of its gross receipts from passive sources: rents, royalties, dividends, and investment income.

In other words, the majority of the receipts must come from operating an active trade or business. Finally, the maximum loss is $50,000 for an individual; $100,000 for a couple. When organizing an FOB, the stock should be classified as Section 1244 stock if it qualifies.

Assessment

Financial professionals and accountants must advise their clients about “worthless” FOB stocks to ensure the deduction is claimed. Medical professionals should also be aware of this concept.

Conclusion

Have you ever had a worthless stock? How did you deal with it and what were your experiences? What has changed relative to the above review, if anything? Is Section 1244 indexed? Please opine and comment.

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The Annual Gift Exclusion

Avoid Estate Taxes by Giving-it-Away

Staff Reporters

A doctor may transfer up to $12,000 a year as a tax-free gift to another person. This also applies to gifts of present interests, which includes gifts (if they satisfy the rules of Section 2503 (c) of the Code) to trusts. If the doctor or other donor is married and the spouse consents to join in the gift, the tax-free exclusion is $24,000.

Gifting Limits

The annual tax-free transfer may not seem significant, to some, but there is no limit to the number of donees eligible for such gifts each year. If the gift program is started early and continued every year, it can result in substantial savings.

Example—A physician or other couple with three married children and three grandchildren can utilize the annual exclusion to gift up to [9 X $24,000] = $216,000 tax-free. If they consistently do this for twenty years, the tax-free transfer amount is $4.32 million. Had they not made such life transfers, the federal estate tax on this amount could deprive the family of several million dollars.

In making joint gifts, a gift tax return, Form 709, must be filed to indicate the non-owner spouse’s consent. If each spouse gives his or her separate property and no gift exceeds the annual exclusion, no gift-tax return is required.

The current $12,000 exclusion amount is indexed in $1,000 increments periodically for inflation.

Direct Gifts for Medical or Educational Purposes

There is no dollar limit on the amount a person can give each year for the benefit of another person’s medical care or education. However, the gift must be made directly to the medical or education provider (such as a hospital or college).

“Education” includes not only higher education, but also primary and secondary schooling as well (for example, prep school). These direct gifts can be made in addition to the annual gift amount specified above. This is especially useful for educational gifts since most high net worth individuals have medical coverage.

Like the annual exclusion, there is no family relationship requirement for making the gift.

Gifts to Qualified State Tuition Plans

Many states, like New York, now offer qualified tuition plans that allow tax-advantaged savings for higher education. These plans are fashioned like an IRA. The earnings on the contributions are not taxed annually but become taxable and are subject to penalties when withdrawn for non-qualified education expenses.

In addition, special gift-tax rules offer additional tax-saving opportunities. From a gift-tax perspective, the contributions are treated as present-interest gifts and qualify for the annual gift-tax exclusion. There is a special election that contributors can make which allows the gift to be treated as having been made repeatedly over five years.

Gifts up to the Exemption Amount

Even if gifts exceed the tax-free transfer limits, there may still not be current gift-tax cost to donors. Each person can give away up to the estate tax exemption amount which increased from $2 million to $3.5 million between 2006 and 2009.Of course, to the extent that the exemption amount is used to shelter lifetime transfers, it is not available to the donor’s estate.

Assessment

However, using the full exemption amount during life yields an important advantage. The appreciation on the amount transferred is also removed from the donor’s estate.

Conclusion

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About Tax Record Retention

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Which Ones to Keep—How Long?

[By Staff Writers]fp-book2

By law, we are all required to keep records the IRS could use to determine our tax liability accurately. And doctors, more than most, know what it’s like to keep records. So you should retain whatever papers and documents support or clarify your calculations. If the IRS thinks you owe it money, you—both as an individual taxpayer and as a medical business owner—must prove it wrong. Your records are your only real protection if the IRS sets its sights on you for an audit.

Query: But what papers? And how long does the IRS have to determine your taxes for any given year? Do you have to keep everything forever? He following information may provide some clarity to this query.

Individual Tax Records

Accuracy means more to the IRS than the form of recordkeeping you use. Even more important is thoroughness. While certain papers are more significant than others, all of them together build your case for stated adjusted gross income, taxable income, deductions, exemptions, etc. For example:

Income:

Your medical, and other, employment-related records are top priority. The basic ones are W-2s from your hospital, clinic or medial practice, W-2P (for recipients of pensions, annuities, and IRA payouts), and 1099s for freelance income, speaking and pharmaceutical fees, and royalties, etc. You will also need 1099s that show interest and dividend income, as well as stock brokerage statements and any other documents that contain information pertaining to the amount you report as income.

Deductions

Generally, to back up your various deductions, the records you keep should include all related canceled checks and receipts. Here are some specific deductions and their requirements:

Medical expenses:

Keep all canceled checks and receipts. Keep records of any expense reimbursed or paid directly by medical insurance and medical insurance policies on which you deduct the premium cost. The person on whose behalf payments were made should be noted on every check, bill, and receipt.

Mortgage interest:

Keep bank (or mortgage company) statements, notes, and canceled checks.

Child-care credit:

Maintain a record of the name and address of the person or center providing the care, copies of canceled checks, and receipts to verify costs, and amounts paid for household services during the year. The latter will allow you to differentiate costs if the IRS tries to claim your child-care payments were really for a housekeeper. If you pay an individual to provide child care, keep a record of his or her taxpayer ID number, since you need that to get the credit.

Alimony:

You should maintain a copy of the divorce decree, separate maintenance agreement, or other document that specified the basis for the payments; name and address of the ex-spouse to whom you made payments; and canceled alimony checks. If you made payments indirectly through insurance policies, annuity contracts, or endowments, keep the documents showing the source of the payments.

Charitable contributions:

To prove charitable contributions, keep canceled checks and receipts showing the donee’s name, plus the date and amount of the contributions. If you don’t have a check, you need other reliable records showing the same information. If contributions are made by credit card, keep the receipt, the bill, and a statement from the charity with the required information. If you make a contribution of above certain periodically indexed thresholds, or more, to a particular charity, you must get a written acknowledgment from the charity (letter, postcard, etc.). A canceled check is not enough. Generally speaking, if you make separate deminimus contributions each year, the written acknowledgment rule may not apply.

A donation of property will complicate recordkeeping. You need the same items as above, plus a description of the property and the place you made the contribution. You should also keep documents showing the method you used to determine the fair market value of the property, with a signed copy of appraisal reports, if any. If you have an agreement with the charitable organization regarding the use of the donated property, hang on to a copy of that as well.

For property, you will also need documents showing how and why you acquired the property and your cost or other basis (except for publicly traded securities) if you held it for less than one year. For property valued over certain thresholds, you must get a qualifying appraisal and keep a copy of the report

IRS

Business Tax Records

As a medical business owner, your recordkeeping requirements are more substantial. There are so many more soft spots where the IRS can probe. The following areas are of particular importance:

Depreciation:

Keep any records needed to establish the reasonableness of a depreciation deduction, such as the original sales receipt showing what you paid for the property. Records must show the yearly depreciation claimed.

Withholding:

Keep all compensation records. For each employee, show name, address, job, and Social Security number, total amount and date of each wage payment, and any other type or form of payment; amount of wages subject to withholding; amount of tax collected; employee W-4 forms; and any agreement with employees regarding additional withholding.

Travel and entertainment:

The IRS does not accept estimates. You must keep itemized bills and receipts, Back them up with a diary showing cost, time, place of travel or entertainment, business purpose, and business relationship of guests.

Also, you must keep a log of your business use of items, such as a car, pager, computer, or server; or PDA, ipod or cell phone, etc., that you use partly for business and partly for personal purposes. For travel, your diary should show the date of departure and return, plus how many days of the total trip were spent on business. If you are an independent medical contractor, keep a diary of your daily work activities. This will reinforce the specific items and pull them together.

How Long to Retain Records?

By law, you have to keep tax records “as long as material” to the administration of the tax law. Since the statute of limitations runs for three years from the time you file your return or the due date of the return (whichever is later), and the IRS is free to audit your return during this time, you want to keep the records at least that long. After an assessment, the IRS has six years to begin collecting, so you are up to nine years. But you then have two years to claim a refund after payment, giving you a grand total of 11 years.

This may seem extreme, and not everyone keeps records that long. Many individuals keep records for six years—the amount of time the IRS has to audit if it suspects a gross error—an underreporting of 25% or more of the gross income shown on your return.

The 11-year time frame is the maximum time frame for assessment, collection, and refund claim. Business owners would be wise to use that period as a rule of thumb, even if individual taxpayers don’t.

Homeowners—

Keep any documents connected to home ownership that have a bearing on your taxes, if any, for the entire time you own your home. If you sell your home, keep the documents as long after the last tax filing as they have a bearing on your tax records. Remember the newer rules for homeowner tax exemption.

Withholding—

These records are subject to a special four-year retention rule. Most doctors and medical business owners keep them longer.

Fraud

In the case of fraud, there is no limit on the time the IRS has to charge you. But here, the burden of proof shifts to the IRS, and you get the presumption of innocence. So you need not feel you have to keep records forever to protect yourself against such an accusation. 

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Dining and IRS Induced Gastroenteritis

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Doctor’s Beware Taxation on Rebates

[By Staff Writers]

In the past decade or so, several companies has been marketing a culinary twist on airline frequent flyer programs—a kind of frequent-eater program.

Under the program, doctors who love to hold “business meetings”, and other diners use their regular credit cards to charge meals at participating restaurants, and the program sends them a rebate check for 20% of the bill.

Not All Gravy

While a 20% discount on restaurant meals sounds appealing to most everyone, you should be aware that it’s not all gravy. In some cases, the IRS is likely to take the position that those rebate checks represent taxable income to a medical executive who is using the program for business dining.

The IRS has not specifically addressed the issue of rebates on restaurant bills. But, in a private letter ruling back in 1993, it did give examples of when cash frequent flyer awards will be taxed [Ltr. Rul. 934007]. Here are some examples:

Example 1—

Your medical practice buys you tickets for a medical conference trip. The tickets entitle you to a cash payment under the airline’s frequent flyer program. If you do not turn the cash payment over to your company, the IRS says you have received a taxable fringe benefit.

Example 2—

You pay for air flights for which you take a business expense deduction. You subsequently receive a cash frequent flyer award. In this case, the IRS says you have taxable income to the extent that your prior deduction saved you taxes.

Back to the Table

Now, let’s get back to the discount dining program. By analogy to the IRS rulings, if you are reimbursed by your practice for the full amount charged on your credit card, the IRS will view the 20% rebate check as a taxable fringe benefit that must be reported on your tax return.

Or, suppose you are a self-employed doctor and take a deduction based on the full amount of the meals charged on the credit card. The cash rebate would be taxable to the extent the deduction produced tax savings. (Note: Since only 50% of the cost of business meals is deductible, only 50% of the rebate check will have produced tax savings.)

Practice Angle

How your medical practice decides to address the issue of dining discounts may be more a matter of tactics, than taxes.  In theory, allowing its employees to pocket their dining discounts could jeopardize the tax-free treatment of business meal reimbursements for all employees.

For example, in a 1995 ruling, the IRS said that a company’s travel reimbursement arrangement did not qualify for tax-free treatment because employees were permitted to retain frequent flyer awards for their own personal use [Ltr. Rul. 9547001].

However, the ruling aroused a storm of controversy, and higher-ups at the IRS quickly announced that they would reconsider the ruling in limbo. But, it is very likely that the company in question triggered its own tax troubles by making the right to retain frequent flyer miles an official part of its reimbursement plan, rather than an unofficial “perk” for employees.

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IRS

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Assessment

The IRS may be less likely to raise the tax issue if a medical practice plan has no policy on rebates and awards, or officially requires employees to account for them to the company. And so, is this an example of the “friendlier IRS” that a former tax-commissioner spoke about, or that was mentioned in a previous Medical Executive-Post? Did we miss anything else? Has anything changed recently? Please opine and comment?

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Post-Nuptial Agreements for Doctors

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Protecting Physician Business Assets

[By Dr. David E. Marcinko MBA]

Pre-nuptial agreements are becoming well known; but post-nuptial agreements are not so known.

Family Business Environment

Prenuptial agreements are increasingly common in family business environments. In some cases, the business owner or a shareholder’s agreement may require certain family members to enter into prenuptial agreements with their prospective spouses.

However, postnuptial agreements are becoming equally popular—and for the same reasons. They protect the family business if a family member divorces, becomes disabled, or dies.

State Laws Vary

Only a few states have laws governing the enforceability of postnuptial agreements.

For example, New York law makes no distinction between prenuptial and postnuptial agreements.

In other states, postnuptial agreements are valid only under specified conditions, which vary by state. In some cases, a postnuptial agreement is valid only if each spouse has a certain net worth. 

Another provision requires that each spouse be represented by counsel, while in some states couples must be married for two years before they can prepare a legally valid postnuptial agreement. Some states, such as North Carolina, require a court proceeding and a judge’s approval.

Where state law is silent, it is unclear whether postnuptial agreements will be enforced. New Jersey recently held that a postnuptial agreement was not valid because it was signed under duress. The spouse had said, “Either sign a postnuptial agreement, or there will be a divorce.”

Full Disclosure Needed

In the absence of duress, if there is full disclosure of financial assets and separate representation by counsel, postnuptial agreements should be valid.

For example, Donald Trump executed a postnuptial agreement with his first wife. She challenged it, but the court granted her the amount stipulated in the document ($25 million).

Assessment

Prenuptial agreements are a sensitive issue and can be difficult to propose; especially for physicians with other family business interests.

Postnuptial agreements can be equally problematic to discuss, but they too can offer some degree of protection for doctors with other family business interests.

Conclusion

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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Concierge Medical Practice Fee-Setting

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Pricing Decisions for Medical Providers

Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

dem21

Professional fee-setting and related pricing decisions for a concierge medical practice, like most businesses rather than most medical-entities, is complex and will significantly affect the doctor’s profits.

New Markets

When a concierge medical practice is first introduced into a local market, the physician-executive must make a choice between charging higher fees in order to recoup practice launch and development costs quickly; or charging lower fees and/or annual retainer subscriptions and extending his/her losses into the growth stage of the practice’s life-cycle. 

This is why consultants and franchisor’s suggest that it may be better to convert an existing practice in-situ, to a concierge model; than start the concierge practice from de-novo, scratch. Nevertheless, the choice should be a conscious one; rather than automatically made by default.

And, the decision will depend upon how target patients are expected to view the practice and its carefully selected medical services. 

Premium Pricing Strategy

If there is “premium-status or swagger” attached to concierge medical practice ownership, then a “price-skimming” approach might be used.  Price skimming, by definition, means setting initial professional fees high in order to achieve profits sooner; and then lowering them as the practice matures. Doctors who use this strategy will experience profits during the introductory stage of the concierge practice’s life cycle, and then reap organizational and operational economies of scale, down-line.

Early Adopter Strategy

If status is not an issue, the doctor may decide to charge lower fees in an attempt to achieve more rapid market local penetration and faster movement into the more profitable early-adopter stage.

A word of warning! If you set initial fees much lower than a price you can maintain and still make a profit, or have adequate working-capital set aside, it is imperative that you make the patient-subscriber aware of the fact that this initial low price is a special promotion that will be increased when over. Patients do not react very positively to unexpected large price increases and may believe the doctor is simply engaging in gouging activity.

Competition

If a doctor has competitors in the local marketplace, s/he can price services above, equal to, or below them.

Fees above one’s competitors implies that services are superior and deserve higher fees; while pricing below the competition level can imply the doctor is proving extra-value to patients in terms of cost-savings.

Pricing at the competitive level is the hardest strategy to follow for any concierge medical practice, but is the only appropriate one in an environment of pure competition. This is typically not yet the case for CM in most areas, to-date.

Assessment

Before settling on a specific fee schedule for your practice, make sure that you know the type of competitive environment that surrounds you and whether demand for your concierge medical services is elastic or inelastic.

Conclusion

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The Consumer-Patient Purchaser Disclosure Project

Advancing Healthcare Transparency and Advocacy

Staff ReportersVooDoo

The Consumer-Purchaser Disclosure Project http://healthcaredisclosure.org, and various collaborating organizations, recently announced that a “comprehensive national agreement” has been reached with “leading physician groups and health insurers on principles to guide how health plans measure doctors’ performance and report the information to consumers.”

Stakeholders-on-Board

Stakeholders signing on to support the initiative include AARP, AFL-CIO, the Leapfrog Group, the National Business Coalition on Health, the National Partnership for Women and Families, the Pacific Business Group on Health, the American College of Physicians, the American Academy of Family Physicians, the American Medical Association, the American College of Cardiology, the American College of Surgeons, America’s Health Insurance Plans, Aetna, Cigna, UnitedHealthcare and WellPoint; etc.

Goals and Objectives

According to website and PR announcements, the goal of the “Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs” is to create a national set of principles regarding measuring doctors’ performance and reporting such information to consumers. Health plans adopting the Patient Charter agree to a standard set of performance measurement principles and reporting. The also agree to have their consumer reporting assessed by an independent review organization.

Assessment

The CP-DP is not a new idea. There is a multitude of provider ranking and data comparison initiatives that are available to patients-consumers. Some significant other initiatives include: 

  • CMS provides comparative data tools for Hospitals, Nursing Homes, Home Health, and Dialysis at www.medicare.gov
  • The Leapfrog Group (www.leapfrog.org ) annually publishes their national list of “Top Hospitals” 
  • Thomson annually publishes the national list of 100 Top Hospitals based upon proprietary benchmarks and AHRQ patient safety measures, available at www.100tophospitals.com 
  • NCQA publishes listings of “NCQA-Recognized physicians” that “have met the highest standards of quality care in the areas of heart/stroke care, diabetes care, back pain and systematic processes.” at www.ncqa.org
  • WellPoint (www.wellpoint.com) now provides Zagat consumer rating tools for physicians for its health plan members in selected markets.

And, the new program hopes to bring increased credibility, security, transparency and fairness to the process, and to benefit all stake holders of the healthcare industrial complex.

Conclusion

Your thoughts and comments are appreciated; as a medical provider, financial advisor, healthcare executive, economist and ultimate patient? Is this VooDoo advocacy; or not?

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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The Herd Mentality of Wall Street [Advice or Avarice?]

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Understanding the Channel-of-Distribution Follies

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Former Investment Advisor and Reformed Certified Financial Planner™dem23

As a former surgeon, insurance agent, physician-executive who took an honest run at Wall Street’s PPMC infamy in the late 90s; a board certified financial advisor and stock-broker; and current writer, editor, publisher and speaker-consultant on health economic topics – I am not your typical citizen journalist or blogger. Although, I am the founding editor-in-chief of a successful peer-reviewed 1,200 page, quarterly print journal, our companion on-ground publication

For example, I’m not crusty; honest! I don’t often wear – but do have – a fedora, and only occasionally look like I just slouched out of Ben Hecht’s circa,1928 play, “The Font Page.”  I prefer stubble to a shave, and ooze skepticism. OK; call it cynicism, if you will. I do however, reckon myself a professional and independent journalist; as well as one heck-of-a-health economist, personal financial consultant and certified “doubting Thomas.”

Independent Means Un-Bossed and Un-Bowed

Yet, I don’t belong to the American Medical Association [AMA], the Financial Planning Association [FPA] or the American Management Association [AMA]. Actually, I’m not really a team player at all; although my wife does call me one who is “carefully selective”. She is aware of the few teams I’ve successfully played for in my career.

And, I am not afraid to write about the financial services industry; in print or online [see The Financial Services Industry Explained].

Link: https://healthcarefinancials.wordpress.com/2007/11/28/the-financial-services-industry

The Implosion

And so, it is with much repetitive irony that I watch supposedly independent and credible Wall Street firms stagger from one mistake to another, every few years, goading their retail financial advisors to promote – dare I say it – “push” – one flimsy financial product or strategy [CDOs and sub-prime home mortgages] that doesn’t work anymore for the sake of lucre.

And then, the same firm’s clean-house after imploding like they have recently done, by rounding up folks to blame, and firing them for having a herd-mentality.

Shame on them; their advisors [really non-fiduciary brokers and salesmen], naïve clients; and especially the clients that are medical colleagues. Shit-aki, mushrooms for brains; all!

This time however, it was the well known CEO heads that were lopped off. To use a financial medical-metaphor, these guys were “de-capitated”:

  • Merrill Lynch = Stan O’Neal
  • Citigroup = Charles Prince
  • UBS =   Peter Wuffli and Marcel Ospel
  • Wachovia = Ken Thompson
  • AIG = Maurice “Hank” Greenberg
  • Bear Stearns = James Cayne 

Of course, I wrote, called and tried to contact several of these “star CEOs” several years ago, to no avail. For a while, I was probably even on their secretarial email radar and telephone block lists.   

Mary’s Lamb to Slaughter

Now, one must wonder if/when the CEO slaughter of Kerry Killinger at WaMu will follow-much like Mary’s little lamb? So far, it hasn’t completely; but he has been stripped of his role as Chairman of the Board.

Remember, Executive Post readers, it was Kerry who oversaw the star-crossed folly into the sub-prime credit-lending fiasco that haunts us all. But, rest assured, I won’t try to contact him. He is very busy at the moment.

Reputations Lost?

So, will these Wall Street firms lose their pristine reputations as kings-of-the-universe? Nope, not a chance! Some pundits even say that in 2-3 years, the public will have forgotten the shenanigans of these guys and their investment banks and wire-houses [broker-dealers]. It’s called the science of “reputational-risk-management” and these firms coldly calculate it into their business plans.

Just Say No

I say, don’t let them. I say, never-forget. I say, ask for and demand a fiduciary financial advisor next time. It wont’ indemnify you from all financial mischief, of course, but it’ll be a good start. Use an independent registered financial advisor and dis-intermediate the broker-salesmen.

http://www.CertifiedMedicalPlanner.org

Or, don’t be surprised when, not if, something similar happens again.

Assessment

To see how staggering the recent write-downs and credit-loses some firms have written-off, per wholesale banking employee [non-retail brokerage or private client wealth management staff],

Just visit this website: www.HereIsTheCity.com

The site’s findings are amazing.

Full Disclosure

I was a “financial advisor” for SunAmerica/AIG more than a decade ago. I saw the industry “inside-out” with developing problems; back then.

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Selecting Tax-Return Preparers

What Doctors Need to Know about Preparers

Staff Writers

Most doctors and medical professionals are not thinking about tax season right now. But, according to Executive-Post supporter Rachel Pentin-Maki; RN, MHA “now may be the best time to rethink your relationship with your tax-preparer.”

All Tax Preparer’s not equal!

All tax return preparers are not the same. They possess varying levels of expertise and hold different credentials. If you are thinking about hiring a new tax preparer to do your 2008 return next year, you may want to begin your search soon so you have sufficient time to investigate and evaluate your options.

Specialty Needs

If you are aware of any significant tax issues when doing your return, find out if he or she has expertise in this area. For example, a recently divorced single father will want a tax return preparer that is knowledgeable about the tax ramifications of divorce and how it affects his return. Similarly, if you’ve recently sold a rental property at a loss, you’ll want a preparer who can advise you on reporting that loss.

Of course, medical specificity is paramount. An accountant who has many doctor-clients is a good start, but does he/she really know anything about activity based medical cost accounting?

Experience Counts

It’s usually wise to select a preparer who has been in the tax business for at least several years. However, should you opt to go with a less experienced preparer, be sure that individual has access to more experienced professionals who can address any complex tax issues that may arise during the preparation of your tax-return?

Types and Stripes

The complexity of your return, and not necessarily the amount of your income, should guide you in selecting a tax preparer, and resulting professional fees. Essentially, there are five types of preparers:

Certified Public Accountants (CPAs)—

These accountants have passed a rigorous examination which includes an entire section on tax issues. Many specialize in taxes and are experienced in handling complicated tax issues. In addition, if they are members of the American Institute of CPAs [AICPA], they must meet stringent continuing education requirements to maintain their memberships.

Commercial Agents—

These individuals work for large national organizations. They usually work only during tax season and have been trained by the organization. Most are form-driven. They are not, however, required to have a minimum level of education, nor have they passed an exam administered by a regulatory body.

Enrolled Agents—

These tax return preparers must pass a two-day examination given by the Internal Revenue Service or meet an lRS experience requirement. In addition, members of the National Association of Enrolled Agents or its state chapters must take at least 30 hours of class work in tax matters each year.

Public Accountants—

Many public accountants are tax advisers. These individuals have not taken the exams and are not obligated to meet the experience requirements of CPAs. In some states, public accountants must be licensed, but in others, anyone can claim the title.

Tax attorneys—

Like CPAs, tax attorneys must meet continuing education requirements and are subject to regulations by the states where they practice. Most tax attorneys don’t specialize in tax return preparation. Instead, they tend to be more involved in tax planning and tax litigation.

Fees

Some tax return preparers work for a fixed fee while others charge hourly rates. In either case, be sure to clarify in advance how much or on what basis the preparer will charge you to do your return. Keep in mind that it’s up to you to provide the preparer with the information necessary to do your return. Unorganized or missing files and receipts are likely to result in more work for the preparer and higher costs for you.

Assessment

Keep in mind, too, that only enrolled agents, CPAs, and tax attorneys are authorized to practice before the IRS. This means that they can represent you throughout the entire IRS audit process; commercial agents and public accountants may not.

Conclusion

What has been your experience with the above accounting types? Is medical specificity really required? Please comment, opine and send us your “tax preparer war-stories.”

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

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Ensuring the Welfare of a Disabled Child

Special Financial Planning Techniques Required

By Roger J. Warrum

If a doctor or medical professional has a mentally or physically disabled child, special estate provisions are needed to ensure the continued care and comfort of that child after the parents’ deaths.

Estate Planning

When designing an estate plan for a doctor with a disabled child, it must provide not only financial security, but personal security as well—without jeopardizing the medical practice as a business entity. The plan must allow the child to continue functioning and making some sort of contribution, according to his or her abilities and lifestyle.

Direct Bequests

In some cases, funds left directly to the child at death may be attached and used by the government. Consequently, direct bequests may not be the best option.

If a doctor wishes to leave the child shares in a family business as a means of support, for example, the best way is to establish a trust that will define how the stock can be converted to cash and how that cash will be spent for the benefit of the child.

To represent the child’s best interests, the doctor might appoint a pair of trustees: one with the financial expertise to invest the trust or assets well -and- another individual who will look out for the child’s welfare to act as the child’s guardian.

Spendthrift Trust

A “discretionary” spend thrift trust is used to provide the trustee discretion to decide when the money will be spent and on what spent.

If the trust is set up solely for the “maintenance” of a disabled child, a state organization caring for the child can attempt to attach the funds.

However, if the trust document specifies the money is to be used for the “benefit and enjoyment” of the child, the state usually is unable to attach the assets.

The share of the estate provided for the disabled child may differ from the share of other children. In many cases, a disabled child requires more funds to care for his or her needs than his or her siblings might require.

Important Issues

When designing an estate plan for the parent(s) of a disabled child, a number of issues must be decided:

• To whom does the doctor want to entrust the care of the child?

• What is the doctor’s wishes regarding the child’s development?

• How should the trust be funded; for example the trust could use a life insurance policy or be funded with other assets?

Assessment

The key elements in planning for a disabled child include:

1. Establishing a trust to be used for the benefit and enjoyment of the child, which cannot be attached by a state or institution should the child need to be institutionalized;

2. Helping to select a guardian, specifying more than one in order of priority;

3. Helping to prepare a letter to the guardian stating desires and wishes for the child; and,

4. Planning to fund the trust and determining the amount to be placed in the trust.

Conclusion

Your thoughts, opinions and experiences with this limited-focus topic are appreciated; please comment? What other issues are involved?

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Physician Buy-Sell Agreements

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A Details Checklist

[By Staff Reporters]biz-book3

All medical practice and other business agreements that dictate what happens to a physician’s property should be addressed in a document called a “buy-sell agreement.”  

Definition 

A buy-sell agreement stipulates what would happen to your medical practice should you die, become disabled, leave, or wish to retire. The agreement states that your partner or partners will buy your interest upon your death and stipulates that your estate will sell your interest. It is a binding agreement to both parties. 

Its’ structure with differing model types, has been addressed in the Executive-Post previously, by Lawrence E. Howes CFP™ and Joel B. Javer; CFP™. 

Link: https://healthcarefinancials.wordpress.com/2008/02/06/medical-practice-buy-sell-agreements

But now, the following check-list is submitted for consideration, as this very personal document is created after reviewing the following issues, and more: 

Checklist:

A buy-sell agreement should address at least the following events:

  • Death of doctor,
  • Disability of doctor,
  • Retirement of doctor,
  • Voluntary or involuntary termination of doctor,
  • Number of disability-months required for physician to give up ownership in the practice,
  • Age requirements to retire from the group (for example, to qualify for retirement, a physician must be at least 62 years old; otherwise the withdrawal is considered voluntary),
  • In the case of a voluntary withdrawal, agreement specifies how much notice is required,
  • In the case of a voluntary withdrawal, agreement specifies whether there will be penalties to the buy-out price if the owner forms a competing practice, joins a competing practice, or violates the employment contract,
  • In the case of an involuntary withdrawal, agreement specifies how much notice is required,
  • Agreement specifies the required vote to admit a new physician into the group,
  • Reasonableness of the buy-out price of an ownership interest has been reviewed,
  • If the buy-out price is to be based on an appraised value, the qualifications of the appraiser have been assessed,
  • Agreement specifies, based on the current practice environment, whether goodwill should be paid to a departing owner,
  • The manner in which the buy-out price will be paid has been established and reviewed,
  • The tax consequences of the buy-out provisions have been reviewed,
  • The buy-out amount has been calculated for each owner using the current formula in the agreement,
  • Each owner has reviewed the calculations,
  • All parties agree to the reasonableness of the buy-out amounts.

Assessment

What else should or could be included in the above checklist; please comment and opine?

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Crafting a Medical Practice Mission Statement

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Solidifying Guiding Principles

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chiefbiz-book]

The mission statement is an important and fundamental document that reminds doctor’s why they are in medical practice. This document reflects the physician-executive’s beliefs about life, practice, patients, employees, reimbursement and medical vendors. It serves as a guide for him or her to make choices about how to allocate time and medical practice resources.

Essential Elements

There are no firm rules about what a medical practice mission statement should contain or how long it should be.

For some doctors, a succinct statement is appropriate; for others, it may take two to four pages to capture the mission. However, the critical element in every mission statement is the physician-executive’s belief that he or she can uphold every principal in the statement.

Prepare and Revise

To help doctors prepare or revise a mission statement, they should create a list of things that make their patients, practice and employees unique, and then incorporate them into the statement.

Some doctors prepare multi-page mission statements that include up-to-date biographies, along with a list of personal commitments and a vision for the future.

Others write a paragraph or two on their beliefs, goals and practice philosophy, detailing how they plan to hold themselves accountable to their mission statement.

Mission Statement Elements

Here are some other important elements of any medical practice mission statement: 

  • It should include both a local vision with global beliefs, because this view helps keep things in perspective when patients get caught-up in their day-to-day business and personal lives; and healthcare needs.
  • A mission statement should include steps that support the doctor’s vision. These steps can be written in either a list format or incorporated in paragraph form. It is sometimes important to commit to specific facts, figures, or goals in your mission statement. Mission statements are designed to communicate principal beliefs and ideals, but a statement of specific goals and outcomes should be included as well, to suit the doctor’s purpose and patient’s needs.
  • It must be stable, yet flexible. Because a mission statement is about who the doctor is and what he or she believes, the core elements should remain relativity stable. However, as patients and doctors age, medical care philosophy and needs may change. Doctors should review their mission statements annually and revise them to accommodate any new principles, patient needs or beliefs.
  • A mission statement should inspire. Doctor’s mission statements should inspire and motivate potential patients. This is the most important criterion, so have sample patients look at the document and see if it inspires him or her and the family around the practice. They also should be able to return to their mission statements for guidance about how they want to manage their own healthcare.
  • A mission statement should also inspire the doctor to do their best professionally. A doctor’s mission statements will have no real value unless it inspires and motivates; internally and externally.
  • Finally, a mission statement should include a vision of what the doctor’s practice wants to become. A mission statement should state practice ideals, not current reality. This is a statement about who the doctor wants his patient to become too—and not necessarily what the patient’s health is today. For example: what characteristics does the patient need to improve [blood pressure, weight, cholesterol levels, skin appearance, cardiac output, oral hygiene, etc] for overall health and physical well-being?

Assessment

Remember, a mission statement serves as a guide only if the doctor commits to making it a part of his or her medical practice.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Hospitals Avoiding Non-Emergency Care

Reducing Emergency Department Workloads and Expenses

[By Staff Writers]

As most Medical Executive-Post readers know, hospitals are under more intense pressure than ever to avoid bad-debt expenses and reduce write-offs. For example, according to one study, total emergency room visits, classified as non-urgent conditions increased from 10 percent 1997 to 14 percent in 2006, according to research by the Center on Studying Health System Change [CSHSC].

Collection Strategies

One collection strategy is to pro-actively ask for payment up-front, or vigorously pursue claims after the bill has been incurred; using either in-house or outsourced collection agencies. Another novel idea is to auction-off patient ARs, as previously mentioned here:

Link: https://healthcarefinancials.wordpress.com/2008/06/09/hospitals-auction-debt/

It’s Called Triage

But, yet another “new-wave” method for Emergency Departments [EDs] is to determine [remember the concept of triage] that patient’s who don’t need costly care, don’t receive it. That’s why, in part, a growing number of hospitals are working to redirect non-urgent care patients away from costly ED care and over to outpatient clinics.

This concept is a derivative of the “onsite / remote step-down units” proposed by our managing-editor Hope Rachel Hetico; RN, MHA, CMP™ several years ago.

Clinical Care Strategies

To address such issues, hospitals are adopting these and other strategies targeting non-urgent patients coming to the ED.

For example, according to FierceHealthFinance, some have shifted nurse practitioners to screen patients, and to set appointments with outpatient caregivers, and primary care doctors for those who need it.

When patients with non-urgent issues return repeatedly, such nurses can help the ED create care plans that set the patient up with medical homes.

In some cases this can change ED patient inflow dramatically; one Miami ED for example, referred an average of 50 patients a day to clinics over 18 months, according to the report.

Assessment

Of course, we are long-time proponents of the nurse practitioner, and DNP, models.

Stemming the Primary Care Exodus with DNPs.

Link:https://healthcarefinancials.wordpress.com/2008/05/29/stemming-the-primary-care-exodus/

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

DICTIONARIES: http://www.springerpub.com/Search/marcinko
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HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
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INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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Majority-Minority Relationships in Practice Appraisals

Disparate Principles Affect Medical Practice Worth

Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Did you know that majority shareholder-doctors in a medical practice have a fiduciary obligation to minority shareholders-doctors?

Actions Scrutinized

Yes, it’s true. In fact a minority medical practice owner is entitled to scrutinize every action made by the majority owner. In particular, majority shareholders have fiduciary obligations to minority shareholders. The majority owner physician cannot favor his or her best interests over the best interests of either the business or the minority shareholders. Often, however, the majority’s actions are supported by the business judgment rule.

Business Judgment Rule

Under the business judgment rule, the majority’s good faith decisions regarding management or governance of the practice business-entity are presumed to be valid. However, acts of self-dealing and self-preference shift the burden of proof concerning the fairness of certain decisions back to the majority shareholders. Disagreements often arise when the majority decides to sell all of the practice’s business’s assets.

Sale of Assets

In a sale of assets, the only recourse of the minority shareholder physician may be to exercise dissenter’s rights concerning the fairness of the purchase price. The minority usually cannot block such a transaction. However, if the minority owns more than 10%, some states can make it difficult for the majority to squeeze out the minority.

In most cases, the minority will be unsuccessful in getting a higher price if they are squeezed out unless the majority is receiving special additional payments (non-competition agreements or medical consulting clauses).

If the minority cannot be squeezed out, they can block any sale (20% ownership may be sufficient to block a sale).

Minority owners may attempt to expand their rights to participate in the affairs of a practice in a manner disproportionate to the ownership rights.

Purchase of Additional Shares

If the majority shareholder buys additional shares when capital is needed, the minority will be diluted. In this case, the minority may challenge the purchase price or seek to have a bank loan expanded, for example.

Compensation

Salaries and bonuses are also subject to fiduciary obligations. Disagreement can arise if minority shareholders believe compensation for their services (as opposed to share ownership) is too low.

Assessment

Although some young doctors are not even aware of majority-minority shareholder disparities, other areas of dispute include new practice opportunities and retaining and compensating key employees. In addition, expansion through acquisition is often a disputed subject.

Conclusion

Your comments are appreciated as either a mature [majority shareholder], or emerging new [minority shareholder] physician. And, please be sure to tell us about your experiences, good or bad.

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

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The Uniform Prudent Investor’s Act

A Trust Primer for Physicians

By Charles L. Stanley; CFP™ ChFCfp-book1

Since inception, the Uniform Prudent Investor Act (UPIA) has changed the financial advisory landscape. Essentially, the act modified the legal criteria of “prudent investing” for trusts.

Now, all assets owned by a trust are considered “investments” for purposes of the Uniform Prudent Investor Act. Consequently, for example, if a trust owns a life insurance policy or an annuity, it is considered an investment for purposes of the UPIA. Anointed doctors, and other trustees and their advisors, are subject to the Act.

Background

The UPIA (California Probate Code Article 2.5) was adopted by the Uniform Conference of Commissioners on Uniform State Laws in 1994. When determining whether or not certain investing is “prudent,” the standard is applied to the whole portfolio rather than to individual investments.

Risk Analysis

The UPIA radically changes the analysis of risk. The UPIA considers risk as unavoidable. For example, fixed income instruments carry the risk of loss of purchasing power, even though the principal may not be reduced in terms of real numbers. Risk is often desirable so long as it is sufficiently compensated. The UPIA seeks to compel the trustees to analyze the trade-offs between risks and returns, taking into consideration the needs and objectives of the trust.

Restrictions Eliminated

The restrictions on what type of investments can be held in trust have been eliminated. The doctor trustee, or other, can invest in anything that plays an appropriate role in achieving the risk/return objectives of the trust and that meets the other requirements of prudent investment. The trustee’s duty to diversify trust assets is codified in the UPIA. It is now recognized that proper effective diversification may enhance returns and/or reduce risk at the same time.

Delegation of Duty Permitted

The UPIA rejected the traditional trust rule that generally prohibited “delegation of duty” by trustees, especially the duty of investment of trust assets. Delegation is now permitted, subject to safeguards. Agents are now made liable if they do not follow the new law.

What Must Trustees Do?

To comply with the UPIA, trustees must review trust assets (16049) and make and implement decisions to either keep or discard assets in order to bring the trust portfolio into compliance with the purposes, terms, distribution requirements, and other circumstances of the trust. For example: 

  • The trustee must diversify the assets of the trust unless it is prudent not to do so (16048). Accordingly, it would not be acceptable for the trust to hold all cash, or all municipal bonds.
  • The trustee must either comply with the Act in full or have the trust amended to restrict the requirements to diversify trust assets.
  • The trustee must delegate if he or she believes that he or she doesn’t the expertise to perform certain functions, this is particularly anticipated in the area of investment management.
  • The trustee is expected to document all of the above and to be available for review either by beneficiaries and/or courts should they become involved. This includes a written Investment Policy Statement [IPS], as previously discussed in the Executive-Post. The act doesn’t specifically require this, but how would one prove they had been acting as a prudent trustee without documentation?
  • The trustee must periodically review the circumstances, assets, and any professional delegates whom he or she has retained to assist him or her.
  • The portfolio must be periodically rebalanced to maintain the established risk/reward characteristics identified in the Investment Policy Statement [IPS]. This is also not specifically stated, but is implied in 16047(b) and is a part of proper portfolio management according to Modern Portfolio Theory [MPT].
  • The act requires the costs of management to be “reasonable.”
  • The trustee must deal impartially with beneficiaries when there are two or more beneficiaries and must invest impartially, taking into account the differing interests of the beneficiaries.

Assessment

In most states, trust language can draft the trustee out of any and all requirements of the Uniform Prudent Investor Act. Some attorneys are doing this. So medical professionals and others should check trust language carefully. This article is not a “final answer” in regard to compliance with the Uniform Prudent Investor Act. But, we seek your thoughts, ideas, experiences, opinions and comments on the UPIA; especially from medically focused financial advisors and estate attorneys. For example, are there other compliance issues to consider?

Conclusion

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Corporate Minutes and IRS Tax Savings

It Pays for Doctors to Keep Good Records

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]Dr. David E. Marcinko MBA

More than a few medical professionals have ownership in small corporations outside of their medical practice, or day-job as physician-healers. More are contemplating same, as the healthcare insurance crisis grows, and the social and economic swagger of physicians decrease.

Small Corporations

But, some of these doctor-involved small corporations generally are not too formal in their day-to-day operations. Formality could even interfere with effective functioning of the emerging matrix business environment. On the other hand, doctors are notoriously stubborn, egotistical and business directors, officers and shareholders are usually the same few people. They are in contact daily. They might easily agree on a capital expenditure during a chance meeting in the stairwell, hospital, clinic, medical office or golf course,

Annual Meetings

But, if the formal procedures of large corporations seem out of place in the closely held corporation, holding an annual meeting and recording all matters in corporate minutes is not as pointless as it may appear.

Accurate and complete corporation minutes can produce real tax savings. The IRS keeps a sharp watch on closely held corporations. Corporate minutes can provide an excellent—and sometimes the only—defense against possible unfavorable tax consequences.

How Minutes Count

Corporations often enjoy a favorable tax rate compared to their owner’s personal rates. They also benefit from deductions and credits an individual or unincorporated business cannot get. But, to get all the tax benefits due you, you should make business decisions in a way that shows sound business purpose and intent. Your corporate minutes are proof of your good intentions should you ever be audited by the IRS.

Corporate Minutes

Corporate minutes have a particular format, just as the problem orientated medical record [POMR] that we are all familiar with, has its own style. For example, corporate minutes, along with receipts, invoices, and correspondence, serve as evidence in several important areas: 

Executive Compensation

Your minutes should show that any salary increase for an executive or officer has been formally approved and ratified by the board of directors. The basis for the raise should be noted in detail. Minutes should include relevant factors which can justify a raise such as: expanded job duties and/or time, contributions to company growth, and the need to match competitors’ salaries.

The minutes should also describe the scope of the job and what the increase will be. Such information is designed to satisfy the IRS and the courts that the compensation is reasonable and the increase is legitimate. With this information, the IRS is less likely to suspect that you are using a raise to disguise a dividend. Both dividends and compensation are taxable to the recipient. But dividends, unlike compensation, cannot be deducted by the corporation.

Date Protection

Dates of the minutes that support the increase can be extra protection. The minutes can show that the decision was made and implemented well before year-end earnings could be accurately projected. Large raises or across-the-board increases granted close to year end, when earnings are high, lead the IRS to see dividends in disguise.

Loan Verifications

Corporate minutes also verify that loans made to executives are loans and not taxable compensation or dividends. They also confirm the nature of such corporate largesse as gifts to individuals (such as to the surviving spouse of a deceased senior executive). Since the IRS considers intention in business actions, your minutes can show that you have sound business motives from the start.

Keep in mind, however, that loans from the corporation to employee/ shareholders must meet other criteria. Nothing you have in writing, including the minutes, will win the day if your loans appear to be dividends. If you fail to repay them, pay interest on them, provide collateral, etc., there is a good chance the IRS will rule that the advances are dividends.

Excess Accumulated Earnings

Corporations can accumulate earnings of up to certain indexed limits. Anything above that may face an excess accumulated earnings tax. Under some circumstances you may keep earnings above the limit without penalty; this is common in scientific and health technology fields. Some of the acceptable reasons for excess accumulation are:

• plans to expand or diversify

• plans to buy new equipment or build up inventory

• projected investment in business-related properties

• to maintain working capital as a hedge against borrowing

• to make loans needed to maintain business

• to provide for actual-potential lawsuits, contested tax or profit loss

• to meet profit-sharing and pension plan obligations

Your plans can be immediate or long-range. They just have to be for a reasonable business purpose. Dates when plans were made and details as to their implementation, when included in corporate minutes, supply proof of that. If you include estimates, market analysis, receipts, and other related documentation of the purpose as part of the record, you will add weight to your case.

Step Transactions

Corporate minutes can also perform the same function for step-transactions. Step transactions consist of steps taken over time toward achieving one objective. Such plans, if recorded in your corporate minutes, can justify your holding on to excess earnings without tax penalty. Even if the plan is abandoned at any “step,” you can state the reasons in your minutes and effectively forestall a penalty.

Retirement and other Pension Plans

To obtain maximum tax savings for your business and your employees, any pension, profit-sharing, or stock-option plan has to satisfy IRS rules. If it does, your employees defer taxes on your contributions and their investment earnings until those funds are distributed to them. Your corporation gets a tax deduction for its contributions.

To get IRS approval, you must submit documentary evidence supporting your plan along with your application. Your corporate minutes supply some of that evidence. They should show the date the plan was adopted and ratified, contain figures demonstrating financial ability, and show that the plan was intended to be permanent. Once you have obtained IRS approval, your annual contributions should be detailed in succeeding corporate minutes to protect your corporate deductions.

Dividends

Your corporate minutes play a part in determining the taxable nature of dividends. Generally, a dividend paid out in the form of stock isn’t taxable to the shareholder until the stock is sold. Dividends paid in cash or property is taxable income in the year they are paid. But if shareholders can choose between taking a dividend in stock or in cash or property, the dividend is taxable to them no matter which method they elect.

To settle such tax questions (and get the best tax results for you), your corporate minutes should clearly reflect the form of dividend being offered to stockholders.

Mergers, Consolidations, etc

To earn tax-exempt status, the minutes must show that a merger or other action serves a bona fide business purpose. It’s OK if the merger will save you taxes, but there must be a business reason as well. For instance, the reorganization will enable you to cut costs, or the merger will bring needed technical skills to the business. The minutes should include a specific plan for the transaction and how it is to be carried out.

Corporate Meetings

One reason for a closely held corporation to hold a “formal” annual meeting is to create corporate minutes. Tax advantages can be further ensured by holding other meetings and recording minutes whenever any major business decision is made. Neither a board meeting nor the corporate minutes recording it need be elaborate or time-consuming. There is not a required format for minutes. Their value lies in what they say, not how they say it, although accuracy and clarity count.

One company officer must be the “secretary,” responsible for calling the meeting, notifying members, drawing up the agenda, and distributing it in advance. The secretary is also responsible for recording the date, time, and place of the meeting, the attendance, and all important matters settled (although someone else can physically take the notes). After the minutes have been prepared, the secretary distributes copies to all board members (and the company attorney). Getting their signatures on the minutes isn’t necessary but can be helpful.

Assessment

Don’t waste time trying to record every point that’s brought up at the meeting. Enter only final decisions. In a closely held corporation, most of the discussion has probably preceded the actual meeting. The meeting serves only to formalize those final decisions—and essential details—for the record.

Conclusion

What is missing from the above, if anything? Your experiences and comments are appreciated.

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

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IRS Offers-in-Compromise

Understanding the IRS Tax Reform Act

By Staff Writers

In 1998, the IRS received 105,255 offers-in-compromise, but accepted only 25,052 offers—a mere 24%; and the exact number for medical professionals is unknown.

The IRS Reform Act

However, the IRS Reform Act later revamped the provisions for offers-in-compromise and the IRS, reacting to the changes, announced that it would be more flexible in considering offers-in-compromise in the future. In addition, under new rules, taxpayers can have up to two years to pay the accepted compromise amount.

Re-trained Staff

The IRS now trains staff specifically to handle such offers. In accordance with the Act, rejected offers will be reviewed to determine whether the action was in the best interest of the taxpayer. The IRS has updated Form 656 to process the offers.

Submitting the Offer

When submitting an offer-in-compromise, the offer must specify the maximum amount a taxpayer can pay after taking into account basic living expenses. Essentially, this means the IRS will consider each taxpayer’s financial situation individually. But, college education for children is an expense most people pay, yet the IRS generally does not factor in educational expenses when determining a taxpayer’s living expenses. .

In the past, the IRS relied on a standard cost-of-living formula to determine what taxpayers could afford, not on each taxpayer’s own expenses.

The IRS automatically can accept offers if: 1) there is doubt about the liability for the tax, and 2) there is doubt that the taxpayer can ever pay the full amount of the tax. If a taxpayer is claiming there is doubt about the liability, the taxpayer will need the help of a tax professional to spell out the rationale for his or her position. If the offer is based on inability to pay, the financial information in the worksheets to the IRS, Form 656, should be completed.

Quick-Sale Value

Remember, as a medical professional or other, the IRS can consider the taxpayer’s future income, as well as his or her current assets when evaluating an offer. Individuals can exclude certain minimum assets of household effects, and trade and business tools. The value of the taxpayer’s assets is based upon a “quick-sale” valuation. Again the taxpayer may need to help to justify his financial position.

The key is determining the full value of the assets and the discounts for quick sales, in addition to the taxpayer’s living expenses. An amount higher than the IRS standard generally cannot be permitted. Again, this will be based on the taxpayer’s documentation.

Collection Procedures

The IRS’s ability to begin collection procedures while an offer-in-compromise is under consideration has been sharply limited by the Act. This is true even if after an offer is rejected, but the taxpayer appeals the decision.

Cash offers must be paid within 90 days of acceptance. For deferrals, payments must be made within two years after the offer is accepted. Alternately, the taxpayer can pay the offer over the statutory period for collecting the tax.

Innocent Spouse Rule

The IRS also has added innocent spouse relief to offers-in-compromise, so now the IRS will not collect from a taxpayer’s spouse if the taxpayer defaults on his or her compromise agreement.

Assessment

As noted previously the taxpayer has a right to appeal rejected offers. In addition, he or she can submit another offer. But, in the end, only time will tell if the IRS remains taxpayer friendly.

Conclusion

Your thoughts and experiences are appreciated; please comment and opine. Is this a real or perceived new IRS OiC ploy? IOW: The gentler side of Uncle Sam? 

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Product Details  Product Details

Marketing Intangible Concierge Medical Services

Understanding Intangible Products

[By Staff Writers]

biz-book3

Concierge medicine (also known as direct care) is a relationship between a patient and a PCP in which the patient pays an annual fee or retainer. This may or may not be in addition to other charges.

In exchange for the retainer, doctors provide enhanced care. Other terms in use include boutique medicine, retainer-based medicine, and innovative medical practice design.

The practice is also referred to as membership medicine, concierge health care, cash-only practice, direct care, direct primary care, and direct practice medicine. While all concierge medicine practices share similarities, they vary widely in their structure, payment requirements, and form of operation. In particular, they differ in the level of service provided and the fee charged.

Intangibles

Concierge practice and related medical services are intangible products; even though most marketing theories that apply to products apply equally to services. Yet, medical services do have some differences.

For example, medical services are: 

  • Intangible,
  • Highly perishable,
  • Variable quality,
  • Inseparable from medical provider, and,
  • Difficult to quality-assess.

Perishability

Of what value to an airline is an empty seat on an airplane, once the airplane leaves the runway?  This level of perishability creates unique problems for doctors that marketers of tangible products do not have. And, it is an appointment scheduling capacity issue, as well.

Quality Issues

Did your favorite hair stylist ever give you a bad haircut? Assessing the quality of a hair cut is something that is not difficult for most of us to do; however, it is not that easy for most patients to asses the quality of the medical care they receive. Is s/he a good physician only because we are still alive? 

Assessment

The average patient has a difficult time assessing quality for highly specialized medical services and must rely on surrogates to help determine quality levels. These proxies have been mentioned in the Medical Executive-Post, and elsewhere, as consumer quality and related transparency issues are growing.

Thus, patients consider their physician a good one if he has a nice bedside manor, and a friendly staff; when in reality these factors have no direct relationship to the physician’s level of expertise.

Conclusion

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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

Product DetailsProduct Details

Alimony versus Child Support

Tax Consequences for Physicians

[By Staff Writers]

Tax considerations are critical when preparing divorce agreements; and an understanding of the applicable sections of the Tax Code is essential for all medical professions in this situation.

In short, alimony is deductible for the payer while child support is not; so it is important for a separation agreement to stipulate that taxpayers report the payments in the same manner. If the person making the payment reports it as alimony, the recipient must include it in income.

The IRS Code Rules

However, when determining whether payments made to a former spouse are alimony or child support, the IRS looks not merely at the agreement, but at how the payments are used. The Code has specific rules for alimony. The payments must be: 

  • Made pursuant to a divorce decree or separation agreement,
  • Made by a payer who is not living in the same household as the recipient, and
  • Payments may not extend beyond the lifetime of either the payer or the recipient.

The last provision can be a trap under some divorce decrees. For example, a doctor makes monthly installments designated as alimony. However, lump-sum payments also designated as alimony are payable under the agreement. In some states, such payments must be made even if the former spouse dies. Alimony payments are not deductible when made to a former spouse after he or she has died.

Front Loaded Payments

In some divorce decrees, alimony payments are front-loaded. Large alimony payments are made in the early years, and then payments dwindle later on. The IRS sometimes challenges whether these arrangements actually are alimony. Property transferred during marriage that is incident to the divorce is not alimony. Such transfers have no tax consequences and should not be claimed as alimony.

Exceptions

While most physician-payers want support payments to be deductible, there are exceptions. In a recent case, the divorce decree ordered one spouse to pay alimony. However, the payer had very little taxable income. Most of his income was from tax-exempt bonds. After negotiations, it was agreed that the payer would not take the alimony deduction, and the recipient spouse would exclude the payment from income.

Child Support

Child support is not deductible for the payer, and the recipient may exclude it from income. However, the parent who has custody of the child or children receives the dependency exemption, but the parties can agree that the payer will receive the exemption(s), provided he or she contributes more than 50% to the costs of the child’s support.

For the non-custodial parent to claim the dependency exemption(s), IRS Form 8322 must be signed by the custodial parent and filed with the IRS. But, you may claim the exemption in alternating years, if you wish.

Assessment

In sum, when negotiating a divorce settlement, there are a number of tax traps to avoid. In some cases the payer may not want alimony payments to be deductible. In other cases payments designated as alimony may not qualify under the Code. The medical business advisor and attorney must determine what is best for his or her client.

Conclusion

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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

Product Details  Product Details

Hospitals Auctioning Patient Debt

Online Sale of Patient ARs

Staff Reporters

In another sign of the contracting economic times, FierceHealthFinance is reporting that some struggling hospitals are using the internet as a new channel to cut their write-offs, and bad debt ratios which lower stock prices, if publicly-held.

Exit the Debt Collectors – Enter the Auctioneers

Rather than simply hiring agencies to collect patient bills, some hospitals have begun to put ARs up for auction online. Bidders on the debt include the same agencies that serve the hospitals, some of which provide guaranteed payments to hospitals in exchange for access to the debt. The auctions are also attracting other companies that buy the debt outright.  

Intermediary Channels

Many of these auctions are run through intermediary channels like www.ARxChange.com, a TriCap Technology Group site; while others use www.medipent.com Medipent LLC. The companies vet collectors to see that they will use the right tactics before participating in auctions, and also, try to make sure they comply with the hospital standards for collections. Also, hospitals have the final say over who bids on their accounts.

Critics

Despite safeguards, some critics argue that auctions change the dynamics of hospital collections, unfavorably. Usually, collectors are paid a percentage of what they collect, sometimes more when they collect more. But, in many of these cases, winning bidders get to keep all of the money they collect. This gives them a greater incentive to be aggressive in their tactics, according to the Wall Street Journal.

Assessment

When will debt-auctioning filter down to the individual clinic and medical practice level? “It is only a matter of time”, according to industry expert Hope Rachel Hetico; RN, MHA, CMP™ of Atlanta, Georgia

Conclusion

Your thoughts, opinions and comments are appreciated?

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

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Ask a Financial Advisor

Certified Medical Planner

Second-to-Die Life Insurance

QUESTION: Why has second-to-die life insurance become so popular with medical professionals and others?

Conclusion

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BLOG: www.MedicalExecutivePost.com

Product DetailsProduct DetailsProduct Details

Product Details  Product Details

Survey on Convenient Care Medical Clinics

Possible Solution to the Healthcare Dilemma?

Staff Reporters

Another new survey suggests that convenient care medical clinics (CCMCs) could be a potential solution to health care issues, if fears can be alleviated; at least in the Keystone State.

The Survey

The survey by Widener University in Elder Pennsylvania, found that while baby-boomers aged 43 to 64 were most interested in using these clinics, many also expressed concerns regarding the quality of care likely to be delivered.

Aged played a significant role in a person’s likelihood of using a CCMC: among respondents aged 43 to 49, more than half (54 percent) were very likely or somewhat likely to use the clinics, while that number dropped to a mere 25 percent among those over 80 years of age.

Assessment

Access to health insurance influences an individual’s likelihood of using a CCMC: the percentage of respondents who were very likely or somewhat likely to use a CCMC was higher among individuals without health care insurance, than among those with insurance (65 percent versus 40 percent).

Women in the survey indicated they were very likely to worry about misdiagnosis (25 percent), yet they were more inclined to use these types of facilities than men (43 percent versus 37 percent).

Please visit related Executive-Posts for more information on this emerging topic.

Conclusion

Your thoughts and comments on the above survey are appreciated? Is the CCMC concept revolutionary, or merely evolutionary, and how do DNPs fit in the model?

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

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Legacy of Values

Book Review

By Laurence J Stybel; Ed.D.

Stybel, Peabody & Associates, Inc.

It could be argued that, in family businesses and medical practices, net worth is the sum of three things: cash and securities, material objectives and values.

Passing wealth through the generations without effectively passing along values condemns many families to the stereotypical cycle summarized in the phrase, “from poverty to poverty in three generations.”

The book: Legacy [The Giving of Life’s Greatest Treasures], by Barrie Sanford Greiff MD (HarperCollins, 1999), particularly focuses on defining values as part of the family legacy.

Greiff, a psychiatrist who works with corporations and executives, ties together lessons learned in both his professional and personal lives to create a guide for developing strong, values-based family relationships to preserve the family business’s health and the family’s wealth and well-being.

Amazon Link:

http://www.amazon.com/Legacy-Giving-Lifes-Greatest-Treasures/dp/0060392835/ref=sr_1_1?ie=UTF8&s=books&qid=1212869346&sr=1-1

Assessment

Feel free to comment on this book review, or the book itself. Or, write a book review on another tome that has affected you positively, or negatively, in some way. It does not have to be a newly released work. Just something that you believe Executive Post readers will find informative, enjoyable and/or helpful. 

Conclusion

Please avoid currently popular books and general self-help best sellers. We seek to expose lesser known authors to our growing niche audience and oeuvre’ of specialty reviews.  

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New Hospital Rating Service

Join Our Mailing List

Consumers Union

[By Staff Reporters]Hospital Access Management

The nonprofit Consumers Union is launching a new hospital ratings service, adding to the growing competition to provide online consumer information about health care, as reported in the Wall Street Journal.

A Consumer Reports Publication

The effort, by the publisher of Consumer Reports magazine, is a gamble that the credibility of the magazine’s name and its no-advertising stance can translate into the field of health care.

Of course, it is no secret that doctors and other medical providers have objected to some evaluations proposed previously, by insurers and others,

Content and Functionality

The online hospital service will include about 3,000 facilities, and consumers will be able to view a graph showing how intensely each hospital treats patients, on a scale from zero for the most conservative, to 100 for the most aggressive.

Intensity of care is based on time spent in the hospital and the number of doctor visits, while the index reflects the hospital’s handling of nine serious conditions, including cancer and heart failure when it treats patients in the last two years of life.

Assessment

The new Consumer Reports online offering will also include a dollar figure that reflects an average out-of-pocket cost for doctor visits during the last two years of life, for the nine listed conditions, though that doesn’t match up to the charge for any particular service.

Link: http://www.consumerreports.org/health/home.htm

Conclusion

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The Dartmouth Atlas Project

Documenting Medical Resource Variations

Staff Reporters

For more than 20 years, the Dartmouth Atlas Project [DAP] has documented glaring variations in how medical resources are distributed and used in the United States.

Purpose

According to its website, the project uses Medicare data to provide comprehensive information and analysis about national, regional and local markets, as well as individual hospitals and their affiliated physicians.

Information Uses

These reports, used by policymakers, the media, health care analysts and others, have radically changed the understanding of the efficiency and effectiveness of our health care system. This valuable data forms the foundation for many of the ongoing efforts to improve health and health systems across America.

Assessment

This website provides access to all DAR reports and publications, as well as interactive tools to allow visitors to view specific regions and perform their own comparisons and analyses. It is well worth a look by all healthcare stakeholders, and Executive-Post readers.

Link: http://www.dartmouthatlas.org

Conclusion

Your thoughts and comments are appreciated.

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Paying for Health Care and Insurance

New Survey Reveals 28% Report Financial Problems

Staff Reporters

A new survey by the Kaiser Family Foundation recently asked this question.

Q: As a result of recent changes in the economy, have you and your family experienced any of the following problems, or not? Was this a serious problem, or not?

A: Results are included in the summarized chart below.

 

 

Percent saying each was a “serious problem”

Problems paying for gas

44%

Problems getting a good-paying job or a raise in pay

29%

Problems paying for health care and health insurance

28%

Problems paying your rent or mortgage

19%

Problems paying for food

18%

Problems with credit card debt or other personal debt

18%

Losing money in the stock market

16%

Source: Kaiser Family Foundation Health Tracking Poll: Election 2008 (conducted April 3-13, 2008). www.kff.org.

Conclusion

Your thoughts, opinions and comments are appreciated?

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Meet an Executive-Post Sponsor

Certified Medical Planner™ program

The Executive-Post at www.HealthcareFinancials.com is now proudly sponsored, in-part, by the Certified Medical Planner program. This asynchronous online educational program is the leading provider of health economics and medical management information for financial advisors and medical business consultants. And, it is authorized to license and monitor the Certified Medical Planner™ certification mark of professional distinction.

With the addition of fiduciary requirements to the Certified Financial Planner’s® Board’s Standard of Professional Conduct, the adoption of the Pension Protection Act [PPA] and the vacating of the broker-dealer exemption, the need for health economics education in the physician advisory space is at an all-time high.

The online Certified Medical Plannerprogram imparts the healthcare specificity – physician focused financial planning knowledge – and the integrated medical practice management expertise that is needed to help devise solutions and raise the bar of advisory competence and accountability for all those serving medical professionals in the modern era. 

For more information, please visit: www.CertifiedMedicalPlanner.com

 

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Electronic Patients

Revolutionizing Healthcare

Staff Reporters

Included among our most popular Executive-Post topics are: medical practice valuations, Wal-Mart, DNPs, business and medical marketing plan, investments, asset returns, medical ethics, the financial services industry and various op-ed posts.

We believe however, there will soon be another very popular post, with comments on how e-patients will revolutionize healthcare!

Revolutionize Healthcare

According to Susannah Fox, by taking advantage of new online health tools, e-patients and health professionals now have the ability to create equal partnerships that enable individuals to be equipped, enabled, empowered and engaged in their health and health care decisions.

Tom Ferguson MD

At least, that that was the vision of Dr. Tom Ferguson. He coined the term e-patients and launched www.e-patients.net in 2006. At the time, Ferguson intended to upload his book-length overview of the online health revolution, “E-patients: How They Can Help Us Heal Health Care.”

Link: http://www.e-patients.net/e-Patients_White_Paper.pdf

Unfortunately however, he died a month later after losing a fifteen-year battle with multiple myeloma.

Health 2.0 Developments

Following Ferguson’s death, a group of his friends and colleagues completed the paper and adopted the blog to carry on his work, as well as their own perspectives on various Health 2.0 developments.

Assessment

We think the “E-patients” paper remains relevant in 2008, as his apostles hope to extend the findings into the future.

Wiki version: http://www.acor.org/e-patients

Conclusion

Your comments and opinions on the paper, and related matters, are appreciated.

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Nurses in e-Charge

Trends in Clinical Information Systems Technology 

Staff Reporters

Recently, iMBA Inc www.MedicalBusinessAdvisors.com and the Executive-Post participated in a Healthcare Informatics survey on nursing clinical information systems [CIS].

The top five CIS functions were:

  1. Electronic documentation
  2. PACS
  3. EMR/EHRs
  4. Automated alerts
  5. Cross-continuum patient records

Assessment

The following link has a summary of white-paper results from that survey
http://survey.opinionresearch.com/surveys/J35584NOV2007/First_Look.pdf

Conclusion

You thoughts and comments are appreciated.

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Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Source: “New WSJ.com/Harris Interactive Study Finds Satisfaction with Retail-Based Health Clinics Remains High.” Harris Interactive, May 21, 2008. http://www.harrisinteractive.com

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

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Patient Survey of Retail Health Clinics

One-Third Lack a Family Doctor

[Staff Reporters]Hospital Access Management

According to results of an online survey of 4,937 US adults conducted by Harris Interactive® between May 2 and 6, 2008 for the Wall Street Journal Online’s Health Industry Edition, 30% of patients who used retail-based health clinics do not have a primary care provider.

Other findings include: 

  • The use of retail-based health clinics has remained consistent over the past few years, with seven percent of US household in 2005, five percent in 2007 and again seven percent in 2008, and;
  • US adults believe retail-based healthcare clinics can provide low-cost basic services to people who cannot afford care (78%) and to anyone when doctors’ offices are closed (81%).  

Assessment

Although an increasing number of participants said they were satisfied with staff qualifications; a narrowing majority were still worried about the qualifications (65%), and the potential that serious medical problems might not be accurately diagnosed (65%).

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Product DetailsProduct DetailsProduct Details

Debt-Based Portfolio Decisions

An Establishment Checklist

By Staff Writers

Determining the percentage of debt-based assets for any medical investment portfolio – personal, institutional or endowment – is an often difficult decision.

Too much risk may lead to default loss, while too little risk may cause under-performance in the portfolio; neither optimizing the efficient frontier.

And so, the following checklist may help initiate the discussion, or at least take it to another level.

Physician-Executive Checklist for Establishing a Debt-Based Portfolio

 

Action

 

Responsible Party

 

Due Date

 

 

Determine the portfolio 

 

 

 

 

 

portion to be invested

 

 

 

 

 

in debt-based securities

 

 

 

 

 

 

 

Determine what investment

 

 

 

 

 

vehicles are to be used

 

 

 

 

 

(e.g., individual portfolio

 

 

 

 

 

manager, mutual funds)

 

 

 

 

 

 

 

Determine investment

 

 

 

 

 

characteristics needed and

 

 

 

 

 

what strategies are to be used

 

 

 

 

 

 

 

Select a portfolio manager or

 

 

 

 

 

choose some other method of

 

 

 

 

 

investing in bonds

 

 

 

 

 

 

 

Establish doctor’s accounts

 

 

 

 

 

 

 

Communicate desired services

 

 

 

 

 

 

 

Execute program to establish

 

 

 

 

 

portfolio

 

 

 

 

 

 

 

Review the accounts and

 

 

 

 

 

confirm executed plans

 

 

 

 

 

 

 

 

 

 

 

Conclusion

How do you determined the percentage and type of debt-based assets that are appropriate for your own personal portfolio; please comment and opine – what other parameters must be considered – are you too risk-tolerant or risk-adverse? Do you even use debt at all?

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

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Office Appointment “Reservation Fees”

Minimizing the Patient “No-Show” Problem

Staff Writers

In what is perhaps the next evolution of office-based medical practice – at least according to American Medical News reports – some physicians are now making their patient’s reserve office appointment slots with a cash deposit in case of “no-show.”

Much like their plastic surgery, new-wave anti-aging esthetics, cash-only, cosmetic-dental or concierge practice colleagues, these doctors are serving up their healthcare offerings much like a fine restaurant serves its cuisine.

Causation

According to anecdotal research, the average no-show rate for medical practices is about 5 to 10 percent, while the rate can be higher if the office has a larger percentage of new, Medicare. Medicaid, indigent or self-pay patients

Deposits

Physicians who charge de-minimis deposits – ranging from $10 to half an office visit cost – emphasize the primary goal is to cut down missed appointments and increase office efficiency; not generate revenue.  

“This is not like a Blockbuster™ store late-fee, or about making money through cancellation-fees”, according to Executive-Post managing-editor Hope Rachel Hetico, RN, MHA, CMP™ of Atlanta

Results

Of course, cancellation-fees are not new, but are retroactive and may bespeak a “certain perception of avarice” according to Hetico; and are a “pain to collect.” 

But, “appointment reservation-fees” are pro-active, and give the perception of “gravitas and physician-patient collaboration”. 

And, the practice may yield patients who are more faithful about showing up, or at least giving notice if they can’t; while fewer empty slots mean more cash-flow and practice revenue.

Conclusion

What are your thoughts and opinions on this emerging business management practice; legitimate business strategy or bad public relations move? Please comment.

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

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