BOARD CERTIFICATION EXAM STUDY GUIDES Lower Extremity Trauma
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Stocks surged and stayed higher all yesterday day on news of Donald Trump’s presidential victory. The Dow rocketed over 1,350 points as soon as markets opened, and all three indexes ended the day at record highs.
Treasuryyields have paralleled Trump’s chances of taking the White House for the last few weeks, and his election sent them soaring to over 4.46% at one point today.
Oil and gold both fell as the dollar rose after Trump’s win. The greenback popped on the promise of Trump’s protectionist tariff policies and the lower likelihood of the Fed cutting interest rates as fast as previously expected.
Bitcoin surged as traders celebrated the beginning of the new, friendlier regulatory environment that Trump promised during his campaign.
Classic: Investment purchases and private expenditures of healthcare firms, the value of related construction, and the change in inventory during the year.
Modern: Gross Revenue Per Day is the average amount charged by a hospital for one day of inpatient care (gross inpatient revenue divided by patient-census days).
Gross Revenue Per Discharge: The average amount charged by a hospital to treat an inpatient from admission to discharge (gross inpatient revenue divided by discharges).
Gross Revenue Per Visit: The average amount charged by a hospital for an outpatient visit (gross outpatient revenue divided by outpatient visits).
HFRI: Fund of Funds invests with multiple managers through funds or managed accounts. The strategy designs a diversified portfolio of managers with the objective of significantly lowering the risk (volatility) of investing with an individual manager.
The Fund of Funds manager may allocate funds to numerous managers within a single strategy, or with numerous managers in multiple strategies. The investor has the advantage of diversification among managers and styles with significantly less capital than investing with separate managers.
Posted on November 3, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Health Capital Consultants, LLC
Two recent court actions may serve as harbingers for the future of healthcare fraud and abuse laws. In September 2024, a federal judge in the Southern District of West Virginia ordered parties in a qui tamFalse Claims Act and Stark Law case to brief the court on the implications of Loper Bright Enterprises v. Raimondo on the interpretation of the Stark Law to the case at hand.
That same month, a federal judge in the Middle District of Florida dismissed a qui tam lawsuit on a novel theory that the False Claims Act’s whistleblower provisions are unconstitutional.
This Health Capital Topics article discusses these cases and the potential impact on federal fraud and abuse laws. (Read more…)
In-network refers to a health care provider that has a contract with your health plan to provide health care services to its plan members at a pre-negotiated rate. Because of this relationship, you pay a lower cost-sharing when you receive services from an in-network doctor.
What does out-of-network mean?
Out-of-network refers to a health care provider who does not have a contract with your health insurance plan. If you use an out-of-network provider, health care services could cost more since the provider doesn’t have a pre-negotiated rate with your health plan. Or, depending on your health plan, the health care services may not be covered at all.
Classic: Any medical provider, supplier or facility that is in-network is one that has contracted with your health insurer to provide services;as above.
Modern: Depending on your plan, if you visit an out-of-network provider, it may not be covered or might be only partially covered. When making appointments with various doctors and service providers, you may notice some are listed as “in-network” while others are “out-of-network.”
THINK: Medicare Advantage {Part C] Plans
Example: You can expect a higher deductible and out-of-pocket limit at out-of-network providers. Your coinsurance and co-payment may also be higher for out-of-network providers.
Classic Definition: Employers write checks that cover most health insurance premiums for employees and their dependents. But as the late Princeton health economist Uwe Reinhardt PhD once explained, employer-sponsored insurance is like a pickpocket taking money out of your wallet at a bar and buying you a drink. You appreciate the cocktail until you realize you paid for it yourself.
Modern Circumstance: With health coverage, employers write the check to the insurer, but employees bear the cost of the premium — the entire premium, not just the portion listed as their contribution on their pay stub. The premium money that goes to the insurance company is cash that employers would otherwise deposit in employees’ accounts like the rest of their salary.
Paradox Example: The fallacy paradox is in thinking an employer’s contribution comes out of profits. In fact, higher health insurance premiums mean lower wages for workers. Since 1999, health insurance premiums have increased 147 percent and employer profits have increased 148 percent. But in that time, average wages have hardly moved, increasing just 7 percent. Clearly workers’ wages, not corporate profits, have been paying for higher health insurance premiums. Health care costs are one — though not the only — reason wages have stagnated over the last few decades. With health insurance costs rising faster than growth in the economy, more labor costs go to benefits like health insurance and less to take-home pay. Yet the paradox that employees don’t pay for their own health insurance is widespread:
The first reason is that individuals cannot be sure what causes their wages to change or remain stagnant for decades.
The second reason is that employers want Americans to believe that they pay for their workers’ health insurance.
The third reason is that there are those who profit from the employment-based system: drug companies, device manufacturers, specialty physicians and high-income individuals.
And so, they all want you to believe companies are being magnanimous in giving you insurance, but they are not!
What Is CREDIT? Credit is a contractual agreement in which a borrower receives a sum of money or something else of value and commits to repaying the lender later, typically with interest. Credit is also the creditworthiness or credit history of an individual or a company. Good credit tells lenders you have a history of reliably repaying what you owe on loans. Establishing good credit is essential to getting a loan.
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Credit Analysis is a form of financial analysis used primarily to determine the financial strength of the issuer of a security, and the ability of that issuer to provide timely payment of interest and principal to investors in the issuer’s debt securities. Credit analysis is typically an important component of security analysis and selection in credit-sensitive bond sectors such as the corporate bond market and the municipal bond market.
Credit Default Swap Index (CDX) is a credit derivative, based on a basket of CDS, which can be used to hedge credit risk or speculate on changes in credit quality.
Credit Default Swaps (CDS) are credit derivative contracts between two counter parties that can be used to hedge credit risk or speculate on changes in the credit quality of a corporation or government entity.
Credit Quality reflects the financial strength of the issuer of a security, and the ability of that issuer to provide timely payment of interest and principal to investors in the issuer’s securities. Common measurements of credit quality include the credit ratings provided by credit rating agencies such as Standard & Poor’s and Moody’s. Credit quality and credit quality perceptions are a key component of the daily market pricing of fixed-income securities, along with maturity, inflation expectations and interest rate levels.
Credit Rating Agency (CRA) is a company that assigns credit ratings for issuers of certain types of debt obligations as well as the debt instruments themselves. In the United States, the Securities and Exchange Commission (SEC) permits investment banks and broker-dealers to use credit ratings from “Nationally Recognized Statistical Rating Organizations” (NRSRO) for similar purposes. As of January 2012, nine organizations were designated as NRSROs, including the “Big Three” which are Standard and Poor’s, Moody’s Investor Services and Fitch Ratings.
A Credit Rating Downgrade by a credit rating agency (such as Standard & Poor’s, Moody’s or Fitch), of reducing its credit rating for a debt issuer and/or security. This is based on the agency’s evaluation, indicating, to the agency, a decline in the issuer’s financial stability, increasing the possibility of default (defined below). A downgrade should not to be confused with a default; a debt security can be downgraded without defaulting. (And, conversely, a debt issuer can suddenly default without being downgraded first–credit ratings and credit rating agencies are not infallible.)
Credit Ratings are measurements of credit quality provided by credit rating agencies). Those provided by Standard & Poor’s typically are the most widely quoted and distributed, and range from AAA (highest quality; perceived as least likely to default) down to D (in default). Securities and issuers rated AAA to BBB are considered/perceived to be “investment-grade”; those below BBB are considered/perceived to be non-investment-grade or more speculative.
Credit Risk is the risk that the inability or perceived inability of the issuers of debt securities to make interest and principal payments will cause the value of those securities to decrease. Changes in the credit ratings of debt securities could have a similar effect.
Credit Risk Transfer Securities (CRTS) are the unsecured obligations of the GSEs (Government Sponsored Enterprises). Although cash flows are linked to prepays and defaults of the reference mortgage loans, the securities are unsecured loans, backed by general credit rather than by specified assets.
Investors waited for the Magnificent 7 stock reports to begin rolling last evening. The NASDAQ rose to a new high on optimism while the Dow Jones fell, and the S&P 500 split the difference.
Alphabet announced earnings after the bell yesterday, Microsoft and MetaPlatforms reveal their latest quarters today, Amazon and Apple on Thursday afternoon.
The 10-year Treasury yield hit a 4-month high this afternoon before paring back a bit as traders struggle to find a signal in all the market noise.
Oil rebounded a bit from yesterday’s terrible day, though it still ended the trading session lower.
Posted on October 28, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Staff Reporters
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Peak earnings season: Five of the Magnificent SevenStocks will be among the 181 companies reporting their earnings this week. Alphabet is in the Mag Seven lead-off spot on Tuesday, Microsoft and Meta step to the plate on Wednesday, and Apple and Amazon rounding out the lineup and this baseball metaphor on Thursday. These companies account for almost 25% of the S&P 500, which is up 40% over the past year and not far off its record closing number from earlier this month. But, the approaching election, it could be a volatile week in the stock markets.
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Markets: Stocks are currently driving the narrative on Wall Street. Last week, bonds sold off in a big way (driving yields to their highest level since July) in a sign investors are dialing back expectations of more aggressive rate cuts from the Federal Reserve.
Stocks nevertheless handled the bond volatility with aplomb, and with help from Tesla’s 22% one-day rise, the NASDAQ is sitting within 2% of its record high.
It’s good to have money stashed in the stock market when the market is doing well. The number of people with at least $1 million in their 401(k) and IRA accounts jumped 12% in the second quarter 2024, according to a report from Fidelity Investments, largely tracking the market’s gain during that period. It’s the third straight quarter of growth in $1+ million accounts and close to a record high.
But start saving now, because building a hard-boiled nest egg through retirement accounts takes time: The average age of a 401(k) millionaire is 59, Fidelity said.
Posted on October 25, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By: Christian Hernandez MBA – Apple Health Care Services
Richard Melnyck MBA MS
Mark Friedman PhD Department of Accounting
Howard Gitlow PhD Department of Management Science University Miami
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BACKGROUND
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Homecare has long been one the most cost-effective methods of treating patients. Yet today, homecare providers face significant challenges: reimbursement cuts, mandatory accreditation, and influencing policy changes. So, how can homecare managers efficiently sustain a cutting edge, consistent and quality focused practice amidst this changing landscape?
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It is time the homecare industry tap into the high-tech tools and proven management theories that together make up “Six sigma” management. This article will provide a solid point of reference for managers interested in adopting “Six Sigma” management. In today’s stiff economic climate, organizations are once again turning to “Six Sigma”strategies as a means to reduce their bottom lines.
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However, its cost cutting aspect is technically more of a by product than the core of its theory. “Six Sigma” management is practiced in many organizations across all sectors of the global economy. Companies such as drug giant Merck, Cadbury, and Dunkin’ Brands are increasingly turning to Six Sigma to lift their bottom lines.
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The term “Lean Management” is an old buzz word that still excites managers. Lean Management stems from the term Lean Manufacturing, which was a derivative of Total Quality Management (TQM) —considered one of the earlier versions of “Six Sigma”.
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Over the years, “Six Sigma” has evolved from a ground-breaking management system to one of the most proven methods for instituting change, reducing errors and eliminating inefficiencies. These management utilities run through the entire spectrum of organizational applications, from confronting the serious issues mentioned above to routine business functions.
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The resurgence of Japan’s economy in the 70’s and 80’s is largely attributed to TQM. “In the auto industry, manufacturers such as Toyota and Honda became major players. In the consumer goods market, companies such as Toshiba and Sony led the way. These foreign competitors were producing lower-priced products with considerably higher quality.”
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A young clinician representative advising to consider the cost versus value of medicine. Health care concept for economic cost-effectiveness analysis, driving down medical costs, improved access.
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Value Based CareClassic Definition: Value-based care is a type of payment model that pays doctors and hospitals for treating patients in the right place, at the right time and with just the right amount of care. You can look at it as a financial incentive to motivate healthcare providers to meet specific performance measures related to the quality and efficiency of the process. The same way, it penalizes weaker experiences, such as medical errors. The concept is often counter-intuitive.
Modern Circumstance: As healthcare costs continue to rise, value-based care has been growing in popularity compared to the traditional fee-for-service method.
Think: HMOs, PPOs, capitation payments and Medicare Advantage [Part C].
Paradox Examples:
Payment: A physician paid through fee-for-service compensation might like to see a packed medical office waiting room. More patients and services equate to higher pay. But, the same doctor paid through a VBC contract might wish to see an emptier waiting room as s/he will get the exact same daily pay for seeing fewer patients and working much less.
Prospectivity: Traditional Fee-for-Service medicine treats sick patients. VBC medicine seeks to keep patients healthy and out of the doctor’s office.
Posted on October 23, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
MEDICAL EXECUTIVE-POST–TODAY’SNEWSLETTERBRIEFING
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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants
“Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily“
A Partner of the Institute of Medical Business Advisors , Inc.
The IRS has announced the annual inflation adjustments for the year 2025, including tax rate schedules, tax tables and cost-of-living adjustments. These are the official numbers for the tax year 2025—that tax year begins January 1, 2025. These are not the numbers that you’ll use to prepare your 2024 tax returns in 2025 (you’ll find those official 2024 tax numbers here). These are the numbers that you’ll use to prepare your 2025 tax returns in 2026.
Trump Media & Technology Group rose 9.87% to its highest level since July as the “Trump trade” wagering on the former president to regain the White House picks up steam.
Quest Diagnostics isn’t just a sad, windowless building where you get your blood drawn—it’s also been a pretty profitable investment. Shares rose 6.88% on strong earnings and revenue growth.
STOCKS DOWN
Stop us if you’ve heard this one before: Target is cutting the price of 2,000 products ahead of the holiday season. Shares sank 1.13% as shareholders digest what appears to be a desperate move to boost sales.
Verizon Communications dropped 5.03% after missing on both revenue and earnings estimates. But the real problem was slowing customer growth and phone sales.
Defense contractors were in the earnings spotlight today, and none of them did well. GE Aerospace tumbled 9.07% despite beating analyst forecasts and Lockheed Martin fell 6.12% after sales missed estimates.
Genuine Parts, better known as NAPA Auto Parts, plummeted 20.96% after earnings missed estimates and the company announced lower fiscal year forecasts.
The SPX fell 2.78 points (–0.05%) to 5,851.20; the Dow Jones Industrial Average® ($DJI) lost 6.71 points (–0.02%) to 42,924.89; and the $COMP gained 33.12 points (0.18%) to 18,573.13.
The 10-year Treasury note yield (TNX) added two basis points to 4.2%.
The CBOE Volatility Index® (VIX) fell to 18.15, down from above 20 a week ago.
Although some might view a budget as unnecessarily restrictive, sticking to a spending plan can be a useful tool in enhancing the wealth of a medical practice. So, I will emphasize keys to smart budgeting and how to track spending and savings in these tough economic times.
There is an aphorism that suggests, “Money cannot buy happiness.” Well, this may be true enough but there is also a corollary that states, “Having a little sure reduces the unhappiness.”
Unfortunately, today there is more than a little financial unhappiness in all medical specialties. The challenges range from the commoditization of medicine, aging demographics, Medicare reimbursement cutbacks and increased competition to floundering equity markets, the home mortgage crisis, the squeeze on credit and declines in the value of a practice. Few doctors seem immune to this “perfect storm” of economic woes.
Far too many physicians are hurting and it is not limited to above-average earning professionals. However, one can strive to reduce the pain by following some basic budgeting principles. By adhering to these principles, physicians can eliminate the “too many days at the end of the month” syndrome and instead develop a foundation for building real wealth and security, even in difficult economic climates like we face today.
There are three major budget types. A flexible budget is an expenditure cap that adjusts for changes in the volume of expense items. A fixed budget does not. Advancing to the next level of rigor, a zero-based budget starts with essential expenses and adds items until the money is gone. Regardless of type, budgets can be extremely effective if one uses them at home or the office in order to spot money troubles before they develop.
For the purpose of wealth building, doctors may think of this budget as a quantitative expression of an action plan. It is an integral part of the overall cost-control process for the individual, his or her family unit or one’s medical practice.
Preparing a net income statement (lifestyle cash flow budget) is often difficult because many doctors perceive it as punitive. Most doctors do not live a disciplined spending lifestyle and they view a budget as a compromise to it. However, a cash flow budget is designed to provide comfort when there is surplus income that can be diverted for other future needs. For example, if you treat retirement savings as just another periodic bill, you are more likely to save for it.
You may construct a personal cash budget by recording each cash receipt and cash disbursement on a spreadsheet. Only the date, amount and a brief description of the transaction are necessary. The cash budget is a simple tool that even doctors who lack accounting acumen can use. Since it is possible to track the cash-in and cash-out in the same format used for a standard check register, most doctors find that the process takes very little time. Such a budget will provide a helpful look at how well you are staying within available resources for a given period.
We then continue with an analysis of your operating checkbook and a review of various source documents such as one’s tax return, credit card statements, pay stubs and insurance policies. A typical statement will show all cash transactions that occur within one year. It is helpful to establish a monthly equivalent to all items of income and expense. For the purposes of getting started, note items of income and expense by the frequency you are accustomed to receiving or spending them.
What You Should Know About The ‘Action Plan’ Cash Budget
For a medical office, the first operations budget item might be salary for the doctor and staff. Operating assets and other big ticket items come next. Some of our doctors/clients review their office P&L statements monthly, line by line, in an effort to reduce expenses. Then they add back those discretionary business expenses they have some control over.
Now, do you still run out of money before the end of the month? If so, you had better cut back on entertainment, eating dinner out or that fancy, new but unproven piece of medical equipment. This sounds draconian until you remind yourself that your choice is either: live frugally later or live a simpler lifestyle now and invest the difference.
As a young doctor, it may be a difficult trade-off. By mid-life, however, you are staring retirement in the face. That is why the action plan depends on your actions concerning monetary scarcity, a plan that one can implement and measure using simple benchmarks or budgeting ratios. By using these statistics, perhaps on an annual basis, the doctor can spot problems, correct them and continue planning actively toward stated goals like building long-term wealth.
Useful Calculations To Assess Your Budgeting Success
In the past, generic budgeting ratios would emphasize not spending more than 15 to 20 percent of your net salary on food or 8 percent on medical care. Now these estimates have given way to more rigorous numbers. Personal budget ratios, much like medical practice financial ratios, represent comparable benchmarks for parameters such as debt, income growth and net worth. Although these ratios are still broad, the following represent some useful personal budgeting ratios for physicians.
• Basic liquidity ratio = liquid assets / average monthly expenses. Cash-on-hand should approach 12 to 24 months or more in the case of a doctor employed by a financially insecure HMO or fragile medical group practice. Yes, chances are you have heard of the standard notion of setting enough cash aside to cover three months in a rainy day scenario. However, we have decried this older laymen standard for many years in our textbooks, white papers and speaking engagements as being wholly insufficient for the competitively unstable environment of modern healthcare.
• Debt to assets ratio = total debt / total assets. This percentage is high initially but should decrease with age as the doctor approaches a debt-free existence
• Debt to gross income ratio = annual debt repayments / annual gross income. This represents the adequacy of current income for existing debt repayments. Doctors should try to keep this below 20 to 25 percent.
• Debt service ratio = annual debt repayment / annual take-home pay. Physicians should aim to keep this ratio below 25 to 30 percent or face difficulty paying down debt.
• Investment assets to net worth ratio = investment assets / net worth. This budget ratio should increase over time as retirement approaches.
• Savings to income ratio = savings / annual income. This ratio should also increase over time as one retires major obligations like medical school debt, a practice loan or a home mortgage.
• Real growth ratio = (income this year – income last year) / (income last year – inflation rate). This budget ratio should grow faster than the core rate of inflation.
• Growth of net worth ratio = (net worth this year – net worth last year) / net worth last year – inflation rate). Again, this budgeting ratio should stay ahead of inflation.
In other words, these ratios will help answer the question: “How am I doing?”
Pearls For Sticking To A Budget
Far from the burden that most doctors consider it to be, budgeting in one form or another is probably one of the greatest tools for building wealth. However, it is also one of the greatest weaknesses among physicians who tend to live a certain lifestyle.
In fact, we have found that less than one in 10 medical professionals have a personal budget. Fear, or a lack of knowledge, is a major cause of procrastination. Fortunately, the following guidelines assist in reversing this microeconomic disaster.
1. Set reasonable goals and estimate annual income. Do not keep large amounts of cash at home or office. Deposit it in an FDIC insured money-market account for safety. Do not deposit it in a money market mutual fund with net asset value (NAV) that may “break the buck” and fall below the one-dollar level. Track actual bills and expenses.
2. Do not pay bills early, do not have more taxes withheld from your salary than needed and develop spending estimates to pay fixed expenses first. Fixed expenses are usually contractual and usually include housing, utilities, food, Social Security, medical, debt repayments, homeowner’s or renter’s insurance, auto, life and disability insurance, etc. Reduce fixed expenses when possible. Ultimately, all expenses get paid and become variable in the long run.
3. Make it a priority to reduce variable expenses. Variable expenses are not contractual and may include clothing, education, recreational, travel, vacation, gas, cable TV, entertainment, gifts, furnishings, savings, investments, etc. Trim variable expenses by 5 to 20 percent.
4. Use “carve-outs or “set-asides” for big ticket items and differentiate true wants from frivolous needs.
5. Calculate both income and expenses as a percentage of your total budget. Determine if there is a better way to allocate resources. Review the budget on a monthly basis to notice any variance. Determine if the variance was avoidable, unavoidable or a result of inaccurate assumptions. Take corrective action as needed.
6. Know the difference between saving and investing. Savers tend to be risk adverse while investors understand risk and take steps to mitigate it. Watch mutual fund commissions and investment advisory fees, which cut into return-rates. Keep investments simple and diversified (stocks, bonds, cash, index, no-load mutual and exchange traded funds, etc.).
Sooner or later, despite the best of budgeting intentions, something will go awry. A doctor will be terminated or may be the victim of a reduction-in-force (RIF) because of cost containment initiatives.4 A medical practice partnership may dissolve or a local hospital or surgery center may close, hurting your practice and livelihood. Someone may file a malpractice lawsuit against you, a working spouse may be laid off or you may get divorced. Regardless of the cause, budgeting crisis management encompasses two different perspectives: awareness and execution.
First, if you become aware that you may lose your job, the following proactive steps will be helpful to your budget and overall financial condition.
• Decrease retirement contributions to the required minimum for company/practice match. • Place retirement contribution differences in an after-tax emergency fund. • Eliminate unnecessary payroll deductions and deposit the difference to cash. • Replace group term life insurance with personal term or universal life insurance. • Take your old group term life insurance policy with you if possible. • Establish a home equity line of credit to verify employment. • Borrow against your pension plan only as a last resort.
If you have lost your job or your salary has been depressed, negotiate your departure and get an attorney if you believe you lost your position through breach of contract or discrimination. Then execute the following steps to recalculate your budget and boost your wealth rebuilding activities.
• Prioritize fixed monthly bills in the following order: rent or mortgage; car payments; utility bills; minimum credit card payments; and restructured long-term debt.
• Consider liquidating assets to pay off debts in this order: emergency fund, checking accounts, investment accounts or assets held in your children’s names.
• Review insurance coverage and increase deductibles on homeowner’s and automobile insurance for needed cash.
• Then sell appreciated stocks or mutual funds; personal valuables such as furnishings, jewelry and real estate; and finally, assets not in pension or annuities if necessary.
• Keep or rollover any lump sum pension or savings plan distribution directly to a similar savings plan at your new employer, if possible, when you get rehired.
• Apply for unemployment insurance.
• Review your medical insurance and COBRA coverage after a “qualifying event” such as job loss, firing or even after quitting. It is a bit expensive due to a 2 percent administrative fee surcharge but this may be well worth it for those with preexisting conditions or who are otherwise difficult to insure. One may continue COBRA for up to 18 months.
• Consider a high deductible Health Savings Account (HSA), which allows tax-deferred dollars like a medical IRA, for a variety of costs not normally covered under traditional heath insurance plans. Self-employed doctors deduct both the cost of the premiums and the amount contributed to the HSA. Unused funds roll over until the age of 59½, when one can use the money as a supplemental retirement benefit.
• Eliminate unnecessary variable, charitable and/or discretionary expenses, and become very frugal.
Final Notes
The behavioral psychologist, Gene Schmuckler, PhD, MBA, sometimes asks exasperated doctors to recall the story of the old man who spent a day watching his physician son treating HMO patients in the office. The doctor had been working at his usual feverish pace all morning. Although he was working hard, he bitterly complained to his dad that he was not making as much money as he used to make. Finally, the old man interrupted him and said, “Son, why don’t you just treat the sick patients?” The doctor-son looked at his father with an annoyed expression and responded, “Dad, can’t you see, I do not have time to treat just the sick ones.”
Always remember to add a bit of emotional sanity into your budgeting and economic endeavors.
Regardless of one’s age or lifestyle, the insightful doctor realizes that it is never too late to take control of a lost financial destiny through prudent wealth building activities. Personal and practice budgeting is always a good way to start the journey.
NOTE: Dr. Marcinko is a former Certified Financial Planner and current Certified Medical Planner™. He has been a medical management advisor for more than a decade. He is the CEO of http://www.MarcinkoAssociates.com
The authors acknowledge the assistance of Mackenzie H. Marcinko PhD in the preparation of this article.
The science of the modern medical practice valuation can be traced to the Estate of Edgar A. Berg v. Commissioner (T. C. Memo 1991-279). In this case, the Court criticized CPAs as not being qualified to perform business valuations, failing to provide analysis of an appropriate discount rates, and making only general references to justify their “Opinion of Value.”
In rejecting accountants, the Court accepted IRS economists because of background, education and training, as well as discount rate calculations and reproducible evidence applied to the assets being examined. This marked the beginning of the Tax Court leaning toward the side with the most comprehensive appraisal. Previously, it had a tendency to “split the difference.” Now, some feel the Berg case launched the valuation profession; especially for contemporaneous health economists.
But, it was not until after 1995 that the IRS issued guidelines for the valuation of physician practices. As a result, the Uniform Standards of Professional Appraisal Practice [USPAP] requires that a blended constellation of three recognized valuation approaches (income, market, and cost approaches) be considered when estimating fair market value.
Operative Valuation Definitions
When pursuing any discussion of medical practice worth, two key elements must be understood: (1) the valuation process, and (2) fair market value. According to the Dictionary of Health Economics and Finance
Practice valuation is the “the formal process of determining the worth of a healthcare or other medical business entity, at a specific point in time, and the act or process of determining fair market value.”
Fair market value [FMV] is “a legal term generally meaning the price at which a willing buyer will buy, and a willing seller will sell an asset in an open free market with full disclosure.” IRS Revenue Ruling 59-60 clearly states that FMV “is essentially a future prophesy and must be based on facts available at the required date of appraisal”
Unfortunately, the value of a medical practice cannot be directly observed by activity in thinly traded private markets. Perhaps this is why we continually observe the following valuation blunders? They are committed by both sellers and buyers who are pursuing opposite objectives; sale price maximization versus price minimization?
Top 10 Blunders:
Not Understanding What a Medical Practice Valuation Is and Is Not
Valuations are not source document fraud audits.
Valuations are material representations providing a range of transferable worth.
Valuations are reproducible estimates based on economic assumptions.
Valuations are not “back-of-the envelope multiples” using specious benchmarks.
Valuations are defensible and “signed-off” attesting to USPAP/IRS formats.
Financial accounting value [book-value] is not fair market value.
Professional valuators represent only one party at arm’s length; not both sides.
Engagement solicitor and/or valuation payer is the client.
Unbiased valuators do not provide financing or equity-participation schemes. Although not standardized, the Institute of Medical Business Advisors, Inc uses the following three levels that approximate engagement types for the industry.
2. A Limited Valuation lacks additional suggested USPAP procedures. It is considered an “agreed-upon-procedure”, used in circumstances where the client is the only user [i.e., updating a buy-sell agreement, or practice buy-in for a valued associate] and not for external purposes. No onsite visit is needed. A formal Opinion of Value is not rendered.
3. Not Observing Industry Standards, Rules and Regulations
Specifically, in USPAP transactions involving physician practices, the IRS implied:
Ad-Hoc Valuation is low level engagement that provides a gross and non-specific approximation of value based on limited meters by involved parties. Neither a written report, nor an Opinion of Value is rendered. It is often used periodically as an internal organic growth / decline gauge.
A Comprehensive Valuation is an extensive service designed to provide an unambiguous Opinion of Value range. It is supported by all procedures that valuators deem relevant with mandatory onsite review. This “gold-standard” is suitable for contentious situations like divorce, partnership dissolution, estate planning and gifting, etc. The written Opinion of Value is applicable for litigation support activities like depositions and trial. It is also useful for external reporting to bankers, investors, the public and IRS, etc.
4. Not Understanding Engagement Types and Levels
Discounted cash flow (DCF) analysis is the most relevant income approach and must be done on an “after-tax” basis.
Practice collections must be projected based on reasonable assumptions for the practice and market; etc.
Physician compensation must be based on market rates consistent with age, experience and productivity.
Majority premiums and minority discounts are to be considered.Goodwill represents the difference between practice purchase price and the value of the net assets. Personal goodwill results from the charisma, skills and reputation of a specific doctor. Its attributes accrue solely to the individual, are not transferable and can’t be sold. It has little or no economic value as it “goes to the grave” with the doctor. Transferable medical practice goodwill has value, may be transferred, and is defined as the unidentified residual attributes that contribute to the propensity of patients and managed care contracts (and their revenue streams) to return in the future (Schilbach v. Commissioner, T.C. Memo 1991-556). And so, one must also appreciate the: (i) impact of a changing environment; (ii) practice transfer in a local market which can augment or blunt goodwill value; and the (iii) determination of whether patients or HMOs return because of true goodwill, or are mandated by contractual obligations; among many other multi-variable determinants.
Even the Goodwill Registry however, a classic source used to determine the average percentage of revenue contributed to practice goodwill, may be dated for some specialties leading to abnormally high values.
5. Not Understanding the Value of Practice Goodwill: Unlimited life span.
6. Not Understanding the Value of Personal Goodwill: Limited life span.
Now, to further confuse the issue, how each kind of goodwill is allocated in situations like divorce depends on state law. For example, some courts include both kinds of goodwill to be apportioned – some exclude both – and others pursue a case-by-case approach.
7. Not Understanding “Excess Earnings Capitalization”
Another way to determine goodwill value is through “excess earnings capitalization.” This economic method looks at the difference between salary, and what you’d have to pay a comparable doctor replacement.
As an example, when you subtract the numbers, and divide the result by 20%, an important percentage referred to as the Capitalization Rate emerges. The final number gives a dollar value for practice goodwill. Courts seem to prefer this method in divorces because it tends to reflect a practice’s current value.
8. Not Understanding the Present Compensation versus Future Value Paradox
Regardless of practice business model, physician compensation is inversely related to practice value. In other words, the more a doctor takes home in above-average salary, the less the practice is generally worth, and vice versa; ceteris paribus
9. Substituting Benchmarks and Formulas for Practice Specificity
In the stable economic past, industry benchmarks might have been used as quick and inexpensive substitutes for professionally prepared valuations. Muck like preparing one’s own income tax return today – while legal – it is a fraught with peril if challenged. The Courts seem to frown on this simplistic and dated methodology.
Moreover, generic benchmark formulas assume a financial statement reporting standard that just does not exist in public accounting.
Therefore, most every competitive issue that impacts value should be addressed with each practice engagement. This includes, but is not limited to contemporary dislocations by third parties, Medicare and commercial payers; retail clinics and changes in supply/demand and specialty trends; rise of ambulatory surgery centers and specialty hospitals; outsourced care and medical tourism, alterations in resource based-relative value units, APCs, DRGs and newer MS-DRGs; the Medicare Modernization Act, HIPAA, OSHA, EEOC, Sarbanes-Oxley and US Patriot Acts, PP-CA, and ACOs; among other regulations.
Current employee trends to high-deductible health care plans [HD-HCPs] and private concierge medicine must also be considered, as well as demographic and employer shifts to defined contribution plans – from defined benefits plans – to name just a few more complicating issues.
10. Not Aggregating or “Normalizing” Financial Information
Employees may be interviewed and financial information must be gathered before a medical practice can be properly valued. The following data, for the most recent three year period, serves as a starting point:
Sample medical record chart review is increasingly being demanded.
It is especially important to eliminate one-time, non-recurring practice expenses. These are adjusted for excessive or below normal expenses on the profit and loss statement. Such “normalization” can produce a big surprise for benchmark proponents and formula-driven advocates when a selling doctor runs personal expenditures through the practice that a buyer [or Court] wouldn’t consider legitimate. Of course, such shenanigans are less noted using professional USPAP/IRS guidelines. Conversely, you may have to defend legitimate business expenses that an appraiser may seek to normalize. For example, doctors may pay for a vehicle through their practice, but if used to travel between multiple offices and hospitals, the expense may be legitimate. Of course, normalization is a sophisticated and time-intensive process. But, it is where the expert earns his/her professional fee, and defends the resulting valuation range when challenged.The most important credential to look for is fiduciary experience, specificity and independence. Some doctors mistakenly turn to those who may have never appraised a practice before. And, just because an appraiser has initials behind his name, doesn’t mean he understands the peculiarities of medical specialties, especially podiatry. We believe that only an independent health economist, who will be your advocate under Securities Exchange Commission [SEC] fiduciary [not lower “suitability”] guidelines, should be selected. Of course, it is almost impossible to answer concerns regarding fees without specific information. The cost of a valuation can range from $0 (benchmarks-rule of thumb) to $50,000 for an onsite team of experts for behemoth practices and ambulatory surgery centers. Keep in mind that in most cases you want to ensure the value determination will stand up to IRS scrutiny, so the $0 rule-of-thumb is not an optionExternal appraisals, or poorly aggregated financial information, onsite reviews and litigation support services incur additional costs; yet most doctors find the money well spent. Expect to pay a retainer and sign a formal professional engagement letter.
Assessment
Don’t be surprised if a sales-broker does not consider the above issues as the modern health era emerges. Most agent-appraisers are predominantly concerned with earning commissions by working both transaction parties, and may not represent your best interests. And, they are usually not obliged to disclose conflicts-of-interest and don’t provide legal testimony.
As a result, a good medical practice is no longer necessarily a good business; and retiring doctors can no longer automatically expect to extract premium sales prices. Moreover, uninformed young physicians should not be goaded to over-pay. Regardless of your dismay – or delight – in the changing healthcare milieu, always be foreword thinking and remember the admonition, Trust-but Verify, for any business transaction.
But, it is a fait accompli that medical practice worth is presently deteriorating. As the population ages and third-party reimbursements plummet, doctors are commoditized and traditional retail medicine is replaced by more efficient wholesale business models like workplace health clinics. The recent sub-prime mortgage de-fault fiasco, potential tax-reform law expiration and the political specter of a nationalized healthcare system, only adds fuel to the macro-economic fires of uncertainly.
Finally, once practice price is mutually agreed upon, sales contract terms and agreements present a plethora of financing challenges for both involved parties to consider [bank loan payment rates and length, personal promissory guarantees, down-payment offsets, earn-out arrangements, Uniform Commercial Codes-1 asset guarantees, etc] in their due-diligence efforts.
However, most reputable firms use a blended fee-schedule of fixed and hourly rates (plus expenses). So, doctors should expect to spend approximately $5,000-15,000 for an average sized – limited appraisal – that is completely suitable for most internal activities.
Moreover, look-out if the valuation not done at an-arm’s-length and independent manner; or worse still, if it is performed for both parties simultaneously.
Selecting the Wrong Valuator and Not Understanding Professional Fees
Realize too, that the appraiser may also add expenses that have not been incurred; like an office manager’s salary if your spouse is in that role for free. This produces a lower appraised value and is common in small medical practices. Honoraria are another example that does not figure into value calculations.
For example, we recall one doctor who painted his personal residence and wrote it-off as a valid business expense. Deleting other major expenses such as country club memberships, make a practice look more profitable—good news if you’re selling it, bad news if you’re getting a divorce.
Conclusion
Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.
Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com
Posted on October 12, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Staff Reporters
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Back-End Ratio or Back Ratio
DEFINITION: The sum of your monthly mortgage payment and all other monthly debts (credit cards, car payments, student loans, etc.) divided by your monthly pre-tax income.
Traditionally, lenders wouldn’t give people loans that increased this ratio past 36%, but they often do now.
Posted on October 10, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
MEDICAL EXECUTIVE-POST–TODAY’SNEWSLETTERBRIEFING
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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants
“Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily“
A Partner of the Institute of Medical Business Advisors , Inc.
Kamala Harris announced a plan to broaden Medicare to cover home healthcare for the first time in an effort to help the “sandwich generation” of Americans who are taking care of both their children and their parents.
WeightWatchers said it will offer cheaper copycat versions of Novo Nordisk’s weight loss drug, Wegovy.
Reddit gained 0.31% thanks to Jefferies analysts, who debuted their coverage of the social media stock with a “buy” rating, praising the company’s AI potential.
Biogen climbed 1.90% after the FDA gave its treatment for kidney transplant patients a special Breakthrough Therapy Designation.
Cruise stocks sailed higher today, in spite of the oncoming hurricane in the Gulf of Mexico. Norwegian Cruise Line, Carnival, and Royal Caribbean popped 10.91%, 7.05%, and 5.26%, respectively, on upgrades from Citi analysts.
Astera Labs jumped 15.60% after it debuted a new family of data center switches built specifically for AI.
Helen of Troy soared 17.88% thanks to a stronger-than-expected earnings report from the struggling consumer goods manufacturer.
Arcadium Lithium continued to rocket higher today after mining behemoth Rio Tinto announced it’s buying the lithium miner for $5.85 per share. Arcadium shares rose 30.90%.
Stocks down
Boeing just can’t catch a break: Talks with striking machinists broke down and the airplane manufacturer withdrew its recent contract offer. Shares sank 3.41% on the news.
US-traded shares of German life sciences company Bayer dropped 6.96% after a US court decided it will hear arguments that products from Bayer brand Monsanto allegedly harmed people.
Trump Media & Technology Group finally settled down after a wild rally following a wild rally in Pennsylvania featuring Elon Musk, falling 5.64% today.
The S&P 500® index (SPX) rose 40.91 points (0.71%) to 5,792.04, a new record-high close; the Dow Jones Industrial Average® ($DJI) added 431.63 points (1.03%) to 42,512.00, also a new closing high; and the NASDAQ Composite® ($COMP) increased 108.70 points (0.60%) to 18,291.62.
The 10-year Treasury note yield (TNX) climbed three basis points to 4.06%, the highest since late July.
In 2023, about 36% of Hispanic or Latino candidates waiting for a transplant received one, compared to 58% of non-Hispanic white candidates, according to the US Department of Health and Human Services Office of Minority Health.
Stat: $1.8 trillion. That eye-watering number is the federal budget deficit as of September 30th, according to the Congressional Budget Office. Higher interest rates, and increases in Social Security and Medicare, are driving the budget gap. (the Wall Street Journal)
Posted on October 9, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
ByNeal Baum MD
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There’s a saying by John Wanamaker who pontificated, “Half the money I spend on advertising is wasted; the trouble is, I don’t know which half”.
Today you have opportunities to determine which parts of your marketing efforts are effective and what is wasted. However, you have to measure your marketing results.
This article will discuss marketing metrics and how to use them to get the best bang for your marketing buck.
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The cost per acquisition (CPA)
Not all initial phone callers to a medical practice will convert to paying patients. The 50 patients who made appointments can be plugged into the equation, i.e., campaign costs divided by patients who became paying patients or $2,000 divided by 50 equals $40, representing the patient acquisition cost (PAC).
Now, if each patient who entered the practice spends $800 over the patient’s lifetime, that’s an increase in income of $40,000, not shabby for $2,000 in marketing expenses.
Source: Neil Baum, MD, Physicians Practice [8/26/22]
According to the Dupont Decomposition Equation – which involves the conglomeration of net operating income, revenues, expenses and average operating assets – ROI and economic profit is increased in three prioritized ways:
Cost and expense reductions.
Revenue increases [Rev]
Reduced average operating assets [AOO]
Note: ROI = NOI / Rev X Rev / AOO
Cost and expense reductions
Although many hospitals have reduced expenses, postponed projects and put clinical or information technology projects on hold because of the current healthcare conundrum, this may be unwise and quality may suffer. And, mental health care programs are almost always the first cost center to be reduced in tough times.
Upgrades today, especially with concurrent marketing and advertising promotions, may well be considered a strategic competitive advantage, and at bargain basement prices for those with cash or credit. This cost reduction is easy because it gives the biggest buck-bang in the ROI equation, and is the first line of ROI augmentation by savvy administrators and CEOs. It is also intuitive and wholly “wrung-out” in the marketplace, to date.
Revenue increases
On the other hand, revenues can usually be only incrementally increased by improving services like emergency care, urgent care, wellness, out-patient and/or surgical departments. This is the more difficult part of the equation and yields a positive, but lesser return in the ROI equation.
The following medical practice procedures will markedly increase upfront office collections:
Train staff to handle exceptions. What is your policy if the patient payment is significant? Will you allow 25% payments—one today and three over the next three months? Communicate your policy to all staff. What will you do if a patient shows up without an insurance card? There will be other exceptions. Train employees to call the appropriate practice-management contact when an exception does not fit in the categories you provide and make sure those managers are responsive.
Understand that not everyone will shine in collections. The value of this new front-desk function should be reflected in job descriptions and wages. Track staff performance and hold employees accountable for collection goals. The most successful practices collect in the 90% range.
Provide professional signage that states your basic policy. “Payments are due at time of service.” Avoid typewritten, lengthy explanations taped to walls or desks that look like clutter.
Reduced average operating assets
Finally, any delay in updating facilities – while easy and may reduce operating assets – there is little ROI advantage and profit potential. Of course, facility asset upgrades mean borrowing funds through tax-exempt bonds – the main source of debt for most hospitals – and is currently difficult or impossible in this climate. Loans from banks, private investors, angels, venture capitalists or other financial institutions are similarly difficult to obtain. Thus, this part of the equation may often be neglected; as is the case now.
The modern medical practice is both similar, and unlike, other businesses today. This disparity often adds to confusion for the private practitioner. And so, the experts at iMBA Inc, list the top 25 most urgent questions in practice financial management, asked by clients to date.
Assessment
Since inception in 2000, the Institute of Medical Business Advisors Inc., has become one of North America’s leading professional health consulting and valuation firms; and focused provider of textbooks, CDs, tools, templates, onsite and distance education for the health economics, administration and financial management policy space. As competition and litigation support activities increase 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 clients and corporate customers today; and into the future.
And so, your thoughts and comments on this Medical Executive-Post are appreciated. Tell us what you think. Send in your own questions. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.
Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com
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Posted on October 5, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
MEDICAL EXECUTIVE-POST–TODAY’SNEWSLETTERBRIEFING
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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants
“Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily“
A Partner of the Institute of Medical Business Advisors , Inc.
PayPal completed its first transaction using its proprietary stablecoin to pay an invoice to Ernst & Young. It’s a milestone for the payments company’s advance into cryptocurrency.
The free IRS tax filing software, which was piloted in 12 states for the 2024 tax season, will be available in 24 states for 2025.
Your loss is our gain: Shares of airline stocks popped on the news of Spirit’s problems. Delta Air Lines ascended 3.84%, United Airlines climbed 6.47%, and Frontier Group Holdings soared 16.43%.
Albemarle popped 8.25% on the rumor that mining behemoth Rio Tinto may try to make an acquisition of the lithium miner. Other potential takeover targets rose as well, including Arcadium (up 10%) and SQM (up 3%).
Abercrombie & Fitch rose 9.10% thanks to an upgrade from JP Morgan analysts, who are bullish about the fashion retailer’s recent momentum.
Ubisoft Entertainment skyrocketed 29.87% on the news that the video game maker’s parent company and founders are considering a buyout.
Homebuilder stocks sank on today’s strong jobs report, which propelled treasury yields higher, which means that mortgage rates aren’t getting any lower. D.R. Horton dropped 2.91%, Lennar fell 2.52%, and Toll Brothers lost 2.57%.
Transportation stocks fell thanks to an agreement between port owners and longshoremen to put the recent strike on pause. Moller-Maersk lost 5.37%, while Zim IntegratedShipping Services stumbled 12.55%.
The S&P 500® index (SPX) climbed 51.13 points (0.9%) to 5,751.07 up 0.22% for the week;the Dow Jones Industrial Average® ($DJI) added 341.16 points (0.81%) to 42,352.75, up 0.09% for the week; and the NASDAQ Composite® ($COMP) rose 219.37 points (1.22%) to 18,137.85, up 0.1% for the week.
The 10-year Treasury note yield (TNX) soared 13 basis points to 3.98%, finishing the week up 23 basis points. The 2-year yield rose 37 basis points this week.
The CBOE Volatility Index® (VIX)fell to 18.58 but remains elevated from last month’s lows, likely on geopolitical concerns.
Only 2% of the homes hit by Hurricane Helene in Georgia, North Carolina, and South Carolina had a policy protecting them against catastrophic flooding, according to an analysis by Politico and E&E News.
The US Hiring Pace picked up strongly in September and the unemployment rate ticked down to 4.1%, signs the U.S. economy had continued momentum in a month the Federal Reserve delivered its first interest-rate cut in four years. U.S. employers added 254,000 jobs last month, the Labor Department said Friday.
Posted on October 3, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
What it is – How it works By staff reporters
DEFINITION:
In economics, the Laffer curve is a representation of the relationship between rates of taxation and the resulting levels of government revenue.
The Laffer curve claims to illustrate the concept of taxable income elasticity—i.e., taxable income will change in response to changes in the rate of taxation.
The Laffer Curve is a theory developed by supply-side economist Arthur Laffer to show the relationship between tax rates and the amount of tax revenue collected by governments.
The curve is used to illustrate Laffer’s main premise that the more an activity such as production is taxed, the less of it is generated. Likewise, the less an activity is taxed, the more of it is generated.
Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.
Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. https://medicalexecutivepost.com/dr-david-marcinkos-bookings/
Posted on October 2, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
MEDICAL EXECUTIVE-POST–TODAY’SNEWSLETTERBRIEFING
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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants
“Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily“
A Partner of the Institute of Medical Business Advisors , Inc.
The FTC said it would allow Chevron’s $53 billion purchase of Hess, but it barred Hess CEO John B. Hess from sitting on Chevron’s board over his communications with OPEC.
Soon, students may not need an extra year of college to attain CPA licensure. The AICPA and NASBA have proposed a “competency-based experience pathway” to licensure—with no post-bachelor’s coursework required.
Energy was the top-performing sector in the S&P 500 today thanks to rising fears of fighting between Iran and Israel. APA Corp. rose 4.91%, Halliburton climbed 3.10%, and Occidental Petroleum gained 3.33%.
Defensestocks rose for much the same reason, with Lockheed Martin up 3.66%, NorthropGrumman trading 3.04% higher, and L3Harris Technologies up 3.03%
Hess Corp. and Chevron rose after the FTC declared that, as long as John Hess isn’t allowed to sit on the board, the two companies might be allowed to merge. Shares of Hess gained 2.34%, while Chevron climbed 1.68%.
New Fortress Energy popped 6.49% on the news that it has priced a public offering of 46 million shares at $8.46 per share. That will go a long way to helping the struggling energy stock rake in some much-needed cash.
ArcosDorados, the world’s biggest McDonald’s franchisee, jumped 14.56% after it renewed its agreement with McDonald’s, locking down a flat royalty rate for the next decade.
What’s down
Signet Jewelers fell 7.91% on the news that CEO Virginia Drosos, who has led the company to strong success over the past seven years, will retire.
HP sank 3.09% after Citi analysts downgraded the company based on lower PC and printer demand in the years ahead.
Disney received a rare analyst downgrade today from Raymond James analysts, who think that theme park attendance will continue to slow in the next 12 to 18 months. Shares dropped 2.14%.
Amentum Holdings plummeted 20.16% only a day after the engineering services company debuted on the S&P 500.
Here’s where the major stock market benchmarks ended:
The S&P 500® index (SPX)fell 53.73 points (–0.93%) to 5,708.75; the Dow Jones Industrial Average® ($DJI) declined 173.18 points (–0.41%) to 42,156.97; the NASDAQ Composite® ($COMP) lost 278.81 points (–1.53%) to 17,910.36.
The 10-year Treasury note yield (TNX) fell six basis points to 3.74%.
The CBOE Volatility Index® (VIX) jumped to 19.28, the highest in nearly a month.
The American economy is seemingly fairing so well that UBS has signaled a potential return to the glory days. The European finance giant believes Uncle Sam is inching closer to a ‘Roaring 20s’ scenario, placing the likelihood of an incoming booming economic cycle at 50%. The phrase goes back to the same decade a century ago, when massive economic growth prompted a construction boom and rising prosperity for families.
Disposablecredit cards are the newest innovation to help reduce fraud and assumed identity scams on e-commerce based websites. As with traditional credit cards, these cards are numbered, but used only once. Then, electronically they are erased so that there is nothing left in the merchant’s database for hackers to steal.
But, in 2014, Congress began looking at new ways to keep personal credit card information safe after several high-profile security breaches at some of America’s top retailers.
WHY? Current credit cards use easy to hack magnetic strip technology from the 1960s. Many consumers want more secure “pin & chip” cards which have been in use in Europe for years. Even though micro-chip technology costs billions to implement, merchants are moving in that direction as they issue new cards to consumers. Most modern polls show nearly half of all people surveyed are extremely concerned about the safety of their personal credit card information.
Burner Cards: Similar to a burner phone or “throwaway” social media account, burner credit cards are temporary, virtual credit cards that are not your “main” credit card. The bank or burner card app will give you a temporary number that links back to your main credit card which you can use for online purchases.
An ANonymousCreditCard provides an extreme degree of privacy and prevents the tracking of your expenses by a spouse, people with bad intentions or government monitoring agencies. It is important to realize that there are plenty of legitimate reasons for wanting to buy something discreetly through an AnonymousCreditCard.
Credit Card Mistakes to Avoid
No number has as far-reaching an impact on your money as your credit scores.
Here are some obstacles, physicians and all of us, should dodge on the road to financial security:
If you are denied a credit card, you have the right to obtain a credit report free from the agency which denied you. Your request must be made in writing and within thirty-sixty days. Consumer credit is governed by the Fair Credit Reporting Act (FCRA). The regulations are issued by and enforced by the Federal Trade Commission. Certain states offer consumers additional rights. Credit reporting agencies are referred to as a “consumer reporting agency”.
The enterprise value [EV] tends to be thought of as a theoretical takeover price if a company were to be bought. It is calculated as market capitalization plus debt, minority interest and preferred shares, minus total cash and cash equivalents.
Enterprise value = common equity at market value (this line item is also known as “market cap”) + debt at market value (here debt refers to interest-bearing liabilities, both long-term and short-term) + minority interest at market value, if any + preferred equity at market value + unfunded pension liabilities and other debt-deemed provisions – value of associate companies – cash and cash equivalents.
Echoing Elon Musk and my colleague medical Michael Burry MD has warned about American consumers’ debt woes.
Echoing the likes of Tesla’s Elon Musk and “The Big Short” investor Michael Burry, a veteran economist has warned that American households have racked up historic amounts of debt — and the economy will pay the price.
“Consumers are just waking up to the fact that they’re financing their spending by running up their credit cards, and that the interest on those credit cards is over the top, out of control, and off the hook right now,” Carl Weinbergtold CNBC. Record credit-card debt threatens to spark a consumer-spending slowdown soon, Carl Weinberg said.
“That’s going to lead to a retrenchment in consumer spending as we get into the new year” the chief economist at High Frequency Economics said. Weinberg expects the US economy to cool but not slide into recession, and he sees inflation fading.
PS: Mike Burry contributed to our 800 page textbook on investing for physicians.
Posted on September 24, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
BITCOIN MINER HALVING
By Staff Reporters
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DEFINITION: After the network mines 210,000 blocks—roughly every four years—the block chain reward given to Bitcoin miners for processing transactions is cut in half. This event is called halving because it cuts the rate at which new bitcoins are released into circulation in half. This rewards system will continue until about 2140, when the proposed limit of 21 million coins is reached. At that point, miners will be rewarded with fees for processing transactions, which network users will pay. These fees ensure miners are still incentivized to participate and keep the network going.
And, so, the total value of the world’s most popular cryptocurrency surpassed $1 trillion yesterday for the first time since 2021. The overall crypto market, meanwhile, broke $2 trillion in market cap, fueled by investor confidence. If crypto were a publicly traded company, it would be the fourth-largest in the world behind Microsoft, Apple, and Saudi Aramco.
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HALVING – The quadrennial event, expected to take place today or tomorrow, was built into bitcoin’s original code to cut the amount of new coins going into circulation in half every four years. The purpose is to thwart inflation and increase the currency’s value. Bitcoin’s mysterious creator, Satoshi Nakamoto, designed the crypto so that only 21 million bitcoins would ever exist. It will take about a century to hit that number, but as it approaches the cutoff, the crypto hose slowly constricts. No one’s sure what happens next
Historically, halvings have coincided with big jumps in price—the coin’s first halving in 2012 saw the price jump from $12.35 to $127 within five months, according to Time. But critics argue that the narrative around halving is much stronger than the actual event. Even bitcoin experts aren’t sure what will happen with the volatile asset. It already hit a record high of over $73,750 in March, thanks to the spot bitcoin ETF approval. And, lest we forget, the whole FTX thing happened since the last halving.
Posted on September 22, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Staff Reporters
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*** Individuals Working in Care Management Rose by 63.8% Nearly 100 entities responded to the Sixth Annual Survey of Healthcare Consumer Engagement Practices. According to the survey:
• 65.8% of respondents reported that member experience was within the scope of their role in 2021: • 40.5% of respondents indicated their role included some responsibility for on-boarding and retention • Individuals working in care management rose by 63.8% • Individuals working in digital transformation rose by 50.4% • Individuals working in population health grew by 47.1% Source:Engagys, December 16, 2021 CITE: https://www.r2library.com/Resource/Title/082610254
ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients. The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.
When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, the ACO will share in the savings it achieves for the Medicare program.
Now, suppose that in a new Accountable Care Organization [ACO] contract, a certain medical practice was awarded a new global payment or capitation styled contract that increased revenues by $100,000 for the next fiscal year. The practice had a gross margin of 35% that was not expected to change because of the new business. However, $10,000 was added to medical overhead expenses for another assistant and all Account’s Receivable (AR) are paid at the end of the year, upon completion of the contract.
Cost of Medical Services Provided (COMSP):
The Costs of Medical Services Provided (COMSP) for the ACO business contract represents the amount of money needed to service the patients provided by the contract. Since gross margin is 35% of revenues, the COMSP is 65% or $65,000. Adding the extra overhead results in $75,000 of new spending money (cash flow) needed to treat the patients. Therefore, divide the $75,000 total by the number of days the contract extends (one year) and realize the new contract requires about $ 205.50 per day of free cash flows.
Assumptions
Financial cash flow forecasting from operating activities allows a reasonable projection of future cash needs and enables the doctor to err on the side of fiscal prudence. It is an inexact science, by definition, and entails the following assumptions:
All income tax, salaries and Accounts Payable (AP) are paid at once.
Durable medical equipment inventory and pre-paid advertising remain constant.
Gains/losses on sale of equipment and depreciation expenses remain stable.
Gross margins remain constant.
The office is efficient so major new marginal costs will not be incurred.
Physician Reactions:
Since many physicians are still not entirely comfortable with global reimbursement, fixed payments, capitation or ACO reimbursement contracts; practices may be loath to turn away short-term business in the ACA era. Physician-executives must then determine other methods to generate the additional cash, which include the following general suggestions:
1. Extend Account’s Payable
Discuss your cash flow difficulties with vendors and emphasize their short-term nature. A doctor and her practice still has considerable cache’ value, especially in local communities, and many vendors are willing to work them to retain their business
2. Reduce Accounts Receivable
According to most cost surveys, about 30% of multi-specialty group’s accounts receivable (ARs) are unpaid at 120 days. In addition, multi-specialty groups are able to collect on only about 69% of charges. The rest was written off as bad debt expenses or as a result of discounted payments from Medicare and other managed care companies. In a study by Wisconsin based Zimmerman and Associates, the percentages of ARs unpaid at more than 90 days is now at an all time high of more than 40%. Therefore, multi-specialty groups should aim to keep the percentage of ARs unpaid for more than 120 days, down to less than 20% of the total practice. The safest place to be for a single specialty physician is probably in the 30-35% range as anything over that is just not affordable.
The slowest paid specialties (ARs greater than 120 days) are: multi-specialty group practices; family practices; cardiology groups; anesthesiology groups; and gastroenterologists, respectively. So work hard to get your money, faster. Factoring, or selling the ARs to a third party for an immediate discounted amount is not usually recommended.
3. Borrow with Short-Term Bridge Loans
Obtain a line of credit from your local bank, credit union or other private sources, if possible in an economically constrained environment. Beware the time value of money, personal loan guarantees, and onerous usury rates. Also, beware that lenders can reduce or eliminate credit lines to a medical practice, often at the most inopportune time.
4. Cut Expenses
While this is often possible, it has to be done without demoralizing the practice’s staff.
5. Reduce Supply Inventories
If prudently possible; remember things like minimal shipping fees, loss of revenue if you run short, etc.
6. Taxes
Do not stop paying withholding taxes in favor of cash flow because it is illegal.
Hyper-Growth Model:
Now, let us again suppose that the practice has attracted nine more similar medical contracts. If we multiple the above example tenfold, the serious nature of potential cash flow problem becomes apparent. In other words, the practice has increased revenues to one million dollars, with the same 35% margin, 65% COMSP and $100,000 increase in operating overhead expenses. Using identical mathematical calculations, we determine that $750,000 / 365days equals $2,055.00 per day of needed new free cash flows! Hence, indiscriminate growth without careful contract evaluation and cash flow analysis is a prescription for potential financial disaster.
Posted on September 22, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Staff Reporters
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Technavio has announced its latest market research report titled Kitchen Sinks Market by End-user and Geography – Forecast and Analysis 2022-2026
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Kitchen Sink stock market disclosures are a communication technique commonly used by political parties, public companies and businesses, although it’s not so well known by the public. The idea is to release all of your bad news at the same time rather than creating a drip-drip effect over an extended period of time.
Steven Barnett, professor of communications at the University of Westminster, says it’s used by organizations when they have some really shocking news they know they are not going to get away with burying. “You’re saying: ‘Let’s just sweep up every piece of bad news we’ve got, put it all in one place, take all of the flak and deal with it at the same time'”. “When you’re announcing the worst figures in your corporate history, you know it’s never going to be a page two story.”
It’s the opposite of the “dead cat” strategy where you distract people from something that is garnering a lot of attention. The idea being that, by placing a dead cat on the table, you make people look in a different direction.
“If you know that you have pretty appalling news, it makes absolute sense to get it all out at the same time because the speed and intensity of the news cycle demands that the agenda moves on so you know you’ll be out of the spotlight within 48 hours.”
Once the value of all personal assets and liabilities is known, net worth can be determined with the following formula: Net worth = assets minus liabilities. Obviously, higher is better.
In The Millionaire Next Door, Thomas H. Stanley, PhD, and William H. Danko give the following benchmark for net worth accumulation. Although conservative for physicians of a past generation, it may be more applicable in the future because of current managed care environment. Here is the guide: Multiple your age by your annual pre-tax income from all sources; except inheritances, and then divide by ten.
Example:
As an HMO pediatrician, Dr. Curtis earned $ 90,000 last year. So, if she is 35, her net worth should be at least $ 315,000.
How do you get to that point? In a word, consume less and save more. Stanley and Danko found that the typical millionaire set aside 15 percent of earned income annually and has enough invested to survive 10 years, at current income levels if he stopped working.
Question: If Dr. Curtis lost her job tomorrow, how long could she pay herself the same salary? Could you?
Posted on September 20, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
Cons from the Austrian School of Economics
By Staff Reporters
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According to Coinmena, fractional reserve banking is a system in which banks are only required to have a fraction of bank deposits from their customers backed by actual cash on hand or available for withdrawal. This is done to expand the economy by enabling banks to free idle capital for commercial lending while keeping a sufficient amount for customer withdrawals.
The creation of the fractional reserve?
The fractional reserve system was first established by the Swedish Riksbank in 1668 after establishing the first central bank in the world. The idea came about after banks realized that there is a minimal chance that all the customers would come to claim their money from the bank at once; therefore, instead of hoarding the money in a vault, it could be used to grow and expand the economy through commercial loans. Fractional reserve banking became more popular around the world after the U.S. enacted The Federal Reserve Act of 1913, which created the Federal Reserve Bank, now known as the U.S. Central bank.
When a customer deposits money into their bank account, the money is no longer directly theirs. The bank holds custody of the customer deposits, and they provide the customer with a deposit account that they can withdraw their money from upon demand.
The bank now has full control of the money as the custodian. The bank can opt to reserve a small percentage of the deposited amount (fractional reserve) and loan the rest or use it for another commercial purpose. The reserve amount usually ranges between 3% to 10%. Although, during harsh economic times, the central banks can lower this reserve requirement to 0%. The Covid-19 pandemic forced central banks around the world to lower the reserve requirement to help stimulate the economy.
Example
Customer A deposits 100,000 AED in Bank 1. Bank 1 loans Customer B 90,000 AED
Customer B deposits 90,000 AED in Bank 2. Bank 2 loans Customer C 81,000 AED
Customer C deposits 81,000 AED in Bank 3. Bank 3 loans Customer D 72,900 AED
Customer D deposits 72,900 AED in Bank 4. Bank 4 loans Customer E 65,610 AED
Customer E deposits 65,610 AED in Bank 5. Bank 5 loans Customer F 59,049 AED
As you can see, the original amount of 100,000 AED has been expanded to represent deposited money for five accounts, and the total existing money supply is 468,559 AED, including the final loan. This is a basic representation of the money multiplier effect.
The system works on the basic principles of debt. The money deposited into the bank by a customer is considered a debt (liability) on the bank to the customer and an asset for the customer. The banks then loan out this money with an interest rate to make a profit for themselves and have the principal amount to pay back their original debt to the depositor (customer).
Pros & Cons of fractional reserve
Banks have the most benefit from a fractional reserve system as this is the way they make their profits. Additionally, customers can also earn interest through their savings or deposit account paid from the interest profits made by the bank. Governments also support this system because it encourages spending and provides economic stability and growth.
Economists from the Austrian School of Economics argue that this system is unsustainable and risky given that most countries rely on a credit-based system and not hard money. Additionally, a fractional reserve system runs the risk of a bank run. Essentially, if people lose faith in a bank to be able to pay back all the depositor’s money, it would trigger a “run on the banks” or “bank run.” It is not typical behavior for customers to go claim their money from the bank all at once, but it has happened in the past, with the most notorious example being the 1929 Great Depression in the U.S. In this case, the banks would only be able to pay out only 3% of depositors, equal to the fractional reserve requirement.
Posted on September 18, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Staff Reporters
BREAKING NEWS
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Jerome Powell and the Federal Reserve Bank just said that it is cutting its benchmark interest rate by 0.50 percentage points, marking the first reduction in four years and moving to ease borrowing costs as inflation-weary consumers are grappling with high rates on everything from mortgages to credit cards.
It is the first drop in the federal funds rate — or what banks charge each other for short-term loans — since the U.S. central bank lowered rates to nearly zero in March 2020 amid an economic standstill caused by the pandemic.
But as prices surged during the health crisis, the FOMC repeatedly hiked rates into a target range of 5.25% to 5.5%, the highest in 23 years, in an effort to curb inflation.
Posted on September 18, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
At 2 pm EST Today
By Staff Reporters
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ABOUT THE FEDERAL OPEN MARKET COMMITTEE
The term “monetary policy” refers to the actions undertaken by a central bank, such as the Federal Reserve, to influence the availability and cost of money and credit to help promote national economic goals. The Federal Reserve Act of 1913 gave the Federal Reserve responsibility for setting monetary policy.
The Federal Reserve controls the three tools of monetary policy–open market operations, the discount rate, and reserve requirements. The Board of Governors of the Federal Reserve System is responsible for the discount rate and reserve requirements, and the Federal Open Market Committee is responsible for open market operations. Using the three tools, the Federal Reserve influences the demand for, and supply of, balances that depository institutions hold at Federal Reserve Banks and in this way alters the federal funds rate. The federal funds rate is the interest rate at which depository institutions lend balances at the Federal Reserve to other depository institutions overnight.
Changes in the federal funds rate trigger a chain of events that affect other short-term interest rates, foreign exchange rates, long-term interest rates, the amount of money and credit, and, ultimately, a range of economic variables, including employment, output, and prices of goods and services.
And so, the macroeconomic FOMC is kicking off at 2pm ET today, when the Fed will announce the first interest rate cut in over four years. But, financial watchers are split between two predictions: a standard 0.25% cut or a more aggressive one of 0.5% (investors are betting on the latter, while many analysts think the former).
Regardless of its size, today’s rate cut and subsequent ones are expected to make borrowing cheaper for consumers and businesses, with ripple effects throughout the economy.
Posted on September 17, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Staff Reporters
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Stocks were mixed yesterday as Wall Street waits for the Fed to cut interest rates tomorrow. The Dow Jones Industrial Average closed at a record high and the S&P 500 inched up. But the tech-heavy NASDAQ slipped, partly because Apple fell after analysts pointed out that demand for the iPhone 16 hasn’t equaled the kind of frenzy new models commanded in the past.
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Boeing seeks to hoard its cash. While dealing with a strike by 30,000 unionized factory workers that has shut down production of its 737 planes and could cost the company $500 million a week, Boeing has instituted a hiring freeze and other money-saving measures.
Posted on September 17, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
MEDICAL EXECUTIVE-POST–TODAY’SNEWSLETTERBRIEFING
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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants
“Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily“
A Partner of the Institute of Medical Business Advisors , Inc.
It’s going to be a gloomy October for some 1,800 PwC employees. The Big Four firm has announced it’ll be laying off around 2.5% of its US unit’s workforce next month, the Wall Street Journal reported. About half of the job cuts will take place offshore. The cuts will occur mainly in PwC’s US advisory, products, and technology operations functions.
Alcoa climbed 6.09% on the news that it will sell its stake in a joint venture with Saudi Arabia Mining Co. to the tune of $1.1 billion in stock and cash.
Bausch + Lomb Corp popped 14.66% on a report from the Financial Times that the eyewear company is considering selling itself to get out from under a massive debt load.
Nuvalent soared 28.27% on impressive results from Phase 1 trials of its new cancer treatments.
What’s down
Apple fell 2.78% just a few days before its big iPhone 16 launch on Friday thanks to reports that demand for the new phone may be lower than anticipated.
Walgreens Boots Alliance sank 2.06% after it agreed to pay $106.8 million for charging the US government for prescriptions it never filled.
Yelp tumbled 3.03% thanks to Bank of America analysts initiating their coverage of the reviews website with a bearish “underperform” rating.
Trump Media & Technology Group gave up some of its recent gains, falling 3.84% only a few days after soaring on the news that former President Donald Trump won’t sell his shares of the company.
The S&P 500® index (SPX) added 7.07 points (0.13%) to 5,633.09; the Dow Jones Industrial Average® ($DJI) rose 228.30 points (0.55%) to 41,622.08; the NASDAQ Composite® ($COMP) dropped 91.84 points (–0.52%) to 17,592.13.
The 10-year Treasury note yield (TNX) fell about three basis points to 3.62%, a new 15-month closing low.
The BOE Volatility Index® (VIX) inched up to 16.99.
Stat: 2%. That’s how much the birth rate declined from 2022 to 2023. (CDC)
Quote: “Every year they choose not to act, they will be complicit.”—Christine McComas, a mother from Maryland whose daughter died after she was cyberbullied, on members of the House attempting to pass a bill to regulate social media for children (Politico)
Read: UK Prime Minister Keir Starmer said the National Health Service must “reform or die,” and laid out a 10-year plan to fix it. (Reuters)
Walt Ehmer, the president and CEO of Waffle House and a member of the board of trustees for the Atlanta Police Foundation, has died at age 58, the foundation announced last Sunday; 2024. Ehmer joined Waffle House in 1992 and quickly rose to senior leadership, becoming president of the company in 2002, and later adding the titles of CEO and chairman, according to information from Georgia Tech University, his alma mater.
“His leadership, dedication and warmth touched the lives of many, both within the Waffle House family and beyond. He leaves behind a remarkable legacy,” Mayor Andre Dickens said in a news release.
415 Restaurants Closed in Georgia and Elsewhere in 2022
The Waffle House Index [WHI] is an informal metric named after the Waffle House restaurant chain, headquartered in Georgia, and used by the Federal Emergency Management Agency (FEMA) to determine the effect of a storm and the likely scale of assistance required for disaster recovery.
IOW: “If you get there and the Waffle House is closed? Well, that’s really bad”, according to Craig Fugate – Former Head of the Federal Emergency Management Agency [FEMA].
Posted on September 12, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Staff Reporters
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At the most general level, economists may define wealth as “the total of anything of value” that captures both the subjective nature of the idea and the idea that it is not a fixed or static concept. Various definitions and concepts of wealth have been asserted by various people in different contexts. Defining wealth can be a normative process with various ethical implications, since often wealth maximization is seen as a goal or is thought to be a normative principle of its own. A community, region or country that possesses an abundance of such possessions or resources to the benefit of the common good is known as wealthy.
What does wealth mean to you?
In a recent survey by Edelman Financial Engines, 57% of respondents said they’d feel wealthy if they had $1 million in the bank. But for many people, that’s not enough.
Among those with $500,000 and $3 million in assets, 53% said it would take over $3 million in the bank for them to feel wealthy, and 33% said it would take over $5 million. Given that these are amounts some people will never even come close to amassing in their lifetimes, it may be hard to wrap your head around these answers.
Posted on September 11, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Health Capital Consultants, LLC
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It’s the most wonderful time of the year – Survey Season! Beginning in late May each year, numerous industry normative benchmark physician production and compensation surveys begin publishing the most recent year’s reports. These healthcare and specialty specific surveys annually report specific types of physician compensation and productivity metrics across the country for various specialties and are widely used by hospitals, physician practices, and healthcare compensation and valuation experts, are often used for the determination of Fair Market Value (FMV) physician compensation for regulatory compliance purposes.
Additionally, the government has referenced and utilized industry normative benchmark compensation surveys (including those listed below) in reviewing and litigating physician compensation arrangements, indicating their reliance on this data as well. (Read more…)
Posted on September 6, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Health Capital Consultants, LLC
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On July 26, 2024, the U.S. Department of Justice (DOJ) filed a complaint in intervention against Murphy Medical Center, doing business as Erlanger Western Carolina Hospital, and Chattanooga-Hamilton County Hospital Authority, doing business as the Erlanger Health System and Erlanger Medical Center. The government’s complaint, filed in the U.S. District Court for the Western District of North Carolina, alleges that Erlanger violated the Stark Law, and subsequently submitted false claims to the Medicare program in violation of the False Claims Act (FCA).
Posted on September 5, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Staff Reporters
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An increasingly common leasing scam is the money factor lie
The “money factor” in leasing is the financing cost of a monthly lease payment and is similar to an interest rate – and it’s important to know the difference. The money factor is a small decimal and should be shown as such, whereas the interest rate is a percentage. A deceitful sales person will count on you not knowing the difference.
For example, a interest rate of 2.5% is not the same as a factor of .0025 and when the latter is used to calculate your lease payment, he or she ends up overcharging you. As a result, you have to pay much more over the lease term without realizing it.
To calculate the money factor, use this formula: Money Factor = Lease Charge / (Capitalized Cost * Residual Value) * Lease Term. It’s important to note that the customer’s credit score determines the money factor. The higher your credit score is, the lower the money factor on the lease will be.
One way to calculate the money factor is by converting it to an APR. To do this, you multiply the money factor by 2,400. If a car dealer provides you with an interest rate, divide it by 2,400 to find the money factor.
In another example, if you are quoted a money factor of .003 on a loan, that would be (2,400x.003) 7.2%. If the car dealer quotes you an interest rate of 4.2%, you can divide it by 2,400 to find the money factor of .00175.
The money factor may be shown in an easier-to-read format, like 1.75 instead of .00175. This can often confuse customers because it appears to be a low interest rate. But don’t be fooled by a money factor presented as a factor of 1,000. Always be sure to ask if the number you are given is the APR or the money factor. If it’s the money factor, convert it to APR so that you can clearly see the interest rate.
Posted on September 1, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Staff Reporters
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It seems many of America’s millionaires are saving for retirement. Thanks largely to a stock market, the number of 401(k) millionaires hit a new record last quarter—rising 2.5% to 497,000, as per Fidelity. It was the third quarter in a row of growth for retirement savings, Quartzreports, and the average amount in retirement accounts hit $127,100.
But even those who have made it to the $1 million mark haven’t quite hit the figure most Americans think they need to retire comfortably. That’d be $1.46 million, according to the latest survey by Northwestern Mutual.
The decision to sell, buy or merge a medical practice, while often financially driven, and is inherently an emotional one for these impact investors who went into the profession largely because of a deep seated zeal to help others.
Still, beyond impact investing musings, there are other economic reasons for a practice valuation that include changes in ownership, determining insurance coverage for a practice buy-sell agreement or upon a physician-owner’s death, organic growth meter, establishing stock options, or bringing in a new partner; etc.
Practice appraisals are also used for legal reasons such as divorce, bankruptcy, breach of contract and minority shareholder complaints. In 2002, the Financial Accounting Standards Board (FASB) issued rules that required certain intangible assets to be valued, such as goodwill. This may be important for practices seeking start-up, service segmentation extensions, or operational funding. Some other reasons for a medical practice appraisal, and the considerations that go along with them, are discussed here.
Medical practice valuation may be required for estate planning purposes. For a decedent physician with a gross estate of more than current in-place tax limits, his or her assets must be reported at fair market value on an estate tax return. If lifetime gifts of a medial practice business interest are made, it is generally wise to obtain an appraisal and attach it to the gift tax return.
Note that when a “closely-held” level of value (in contrast to “freely traded,” “marketable,” or “publicly traded” level) is sought, the valuation consultant may need to make adjustments to the results. There are inherent risks relative to the liquidity of investments in closely held, non-public companies (e.g., medical group practice) that are not relevant to the investment in companies whose shares are publicly traded (freely-traded). Investors in closely-held companies do not have the ability to dispose of an invested interest quickly if the situation is called for, and this relative lack of liquidity of ownership in a closely held company is accompanied by risks and costs associated with the selling of an interest said company (i.e., locating a buyer, negotiation of terms, advisor/broker fees, risk of exposure to the market, etc.). Conversely, investors in the stock market are most often able to sell their interest in a publicly traded company within hours and receive cash proceeds in a few days. Accordingly, a discount may be applicable to the value of a closely held company due to the inherent illiquidity of the investment. Such a discount is commonly referred to as a “discount for lack of marketability.”
Discount for lack of marketability is typically discussed in three categories: (1) transactions involving restricted stock of publicly traded companies; (2) private transactions of companies prior to their initial public offering (IPO); and, (3) an analysis and comparison of the price to earnings (P/E) ratios of acquisitions of public and private companies respectively published in the “Mergerstat Review Study.”\
With a non-controlling interest, in which the holder cannot solely authorize and cannot solely prevent corporate actions (in contrast to a controlling interest), a “discount for lack of control,” (DLOC), may be appropriate. In contrast, a control premium may be applicable to a controlling interest. A control premium is an increase to the pro rata share of the value of the business that reflects the impact on value inherent in the management and financial power that can be exercised by the holders of a control interest of the business (usually the majority holders). Conversely, a discount for lack of control or minority discount is the reduction from the pro rata share of the value of the business as a whole that reflects the impact on value of the absence or diminution of control that can be exercised by the holders of a subject interest.
Several empirical studies have been done to attempt to quantify DLOC from its antithesis, control premiums. The studies include the Mergerstat Review, an annual series study of the premium paid by investors for controlling interest in publicly traded stock, and the Control Premium Study, a quarterly series study that compiles control premiums of publicly traded stocks by attempting to eliminate the possible distortion caused by speculation of a deal.
Buy-Sell Agreements
The ideal situation is for physician partners to put in place a buy-sell agreement when practice relationships are amicable. This establishes the terms for departure before they are required, and is akin to a prenuptial agreement in the marriage contract. Disagreements most often occur when a doctor leaves the group, often acrimoniously. Business operations of the practice decline, employee and partner morale suffers, feuding factions develop spilling over into the office, and the practice begins to implode creating a downward valuation spiral. And so, valuations should be done every 2-3 years, or as the economic circumstances of the practice change. Independence and credibility are provided, and emotional overtones are purged from the transaction.
Physician Partnership Disputes
Medical practice appraisals are often used in partnership disputes, such as breach-of-contract or departure issues. Obvious revenue declinations are not difficult to quantify. But, revenues may not immediately fall since certain Current Procedural Terminology [CPT®] code reimbursements may actually increase. Upon verification however, lost business may be camouflaged as the number of procedures performed, or number of patients decrease after partner departure.
Physicians getting divorced should get a practice appraisal, and either side may hire the appraiser, although occasionally the court will order an expert to provide a neutral valuation. Such valuations should be done in light of both court discovery rules and IRS requirements for closely held businesses. Generally, this requires the consideration of eight elements:
• Practice specialty and operating history
• Economic and healthcare industry condition
• Estimates of practice risks and future returns
• Book value and financial condition of the practice
• Practice future earning capacity
• Physician bonuses, dividends and distributions
• Intangible assets
• Comparable practice sales
Sometimes, the non-physician spouse may even desire a lifestyle analysis to evaluate the potential for under reported income, by a forensic accountant, or appraiser. A family law judge is often the final arbiter of different valuations, and because of varying state laws there may be 50 different nuances of what the practice is really worth.
Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, urls and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.
Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements.
Crowdfunding is a popular way to raise money online. People often use crowdfunding to fund raise for a business, for charity, or for gifts. It’s important to know that money raised through crowdfunding may be taxable.
Do you have to pay taxes on the money you receive from GoFundMe, etc?
Generally, you will not owe taxes on donated funds you receive from a crowdfunding platform. The IRS considers the money received from GoFundMe to be a gift instead of income, so it is typically not taxable. A gift is any transfer of cash or property you make to an individual without receiving full consideration in return, according to the IRS. People who donate money to GoFundMe to help pay for medical expenses are typically doing it out of generosity and do not expect anything in return.
Some money raised through crowdfunding may NOT be considered a gift.
Under federal tax law, gross income includes all income from any source, unless it’s excluded from gross income by law. In most cases, gifts aren’t included in the gross income of the person receiving the gift. Here’s what people involved in crowdfunding should know:
If a crowdfunding organizer is raising money on behalf of others, the money may not be included in the organizer’s gross income, as long as the organizer gives the money to the person for whom they organized the crowdfunding campaign.
If people donate to a crowdfunding campaign out of generosity and without expecting anything in return, the donations are gifts. Therefore, they will not be included in the gross income of the person for whom the campaign was organized.
However, not all contributions to crowdfunding campaigns are gifts and may be taxable.
When employers give to crowdfunding campaigns for an employee, those contributions are generally included in the employee’s gross income.
Taxpayers may want to consult a trusted tax pro for information and advice regarding how to treat amounts received from crowdfunding campaigns.
Posted on August 30, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Staff Reporters
Remember NFTs? This is an excellent history of OpenSea, the largest NFT marketplace, and all the chaos within its walls.
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You have to report your crypto and NFT transactions to the IRS
While not technically new, for 2024. the IRS is making a more concerted effort to track cryptocurrency sales and trades. Whenever you sell or trade your crypto or purchase an item with crypto, you trigger a taxable event. Currently, crypto is taxed like property, making it subject to short- or long-term capital gains taxes. This also means you can report any crypto losses to help offset any gains. Since 2022 saw a drastic drop and rise in the value of cryptocurrencies like bitcoin and ethereum, if you sold or traded your crypto at a loss, you may be able to reduce your tax bill by reporting your capital loss. The same goes for NFTs.
And though the IRS will flag any unreported crypto gains, if you don’t report a loss that can lower your tax burden, the IRS won’t adjust your return on your behalf. “If you leave it off, it stays off. “Tax deductible losses from your virtual currency activity do have real consequences on your tax return, and can save you real dollars.
So we always tell people, if you’ve got something that you don’t fully understand, you certainly should seek out guidance from a trained experienced tax professional.”
Posted on August 30, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Staff Reporters
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DEFINITION: Consumer confidence index (CCI) is a standardized confidence indicator providing an indication of future developments of households’ consumption and saving.
The index is based upon answers regarding household’s expected financial situation, their sentiment about the general economic situation, unemployment and capability of savings. An indicator above 100 signals a boost in the consumers’ confidence towards the future economic situation, as a consequence of which they are less prone to save, and more inclined to spend money on major purchases in the next 12 months. Values below 100 indicate a pessimistic attitude towards future developments in the economy, possibly resulting in a tendency to save more and consume less.
The decline in inflation and the expectation of an imminent interest rate cut have Americans feeling better about the economy than they have in a while, according to the latest update of the Conference Board’s consumer confidence index [CCI].
On the other hand, consumers are worried about the softening labor market. While the unemployment rate remains below historical standards at 4.3%, it has increased for four straight months—likely enough to convince J. Powell and the Federal Reserve to cut rates in September.
Posted on August 27, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
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Nvidia will drop its Q2 numbers on Wednesday. Investors will also look for an update from CEO Jensen Huang about reported delays in production of the company’s highly anticipated new Blackwell chips.
Andersen, the US unit of Andersen Global, is considering an IPO in 2025, the Wall Street Journal reported. Andersen Global, an association of consulting firms, was formed in the wake of the 2002 collapse of Big Five accounting firm Arthur Andersen. The parent company has more than 17,000 employees worldwide and earned around $1.9 billion in revenue last year.
Kroger gained 1.6% as the antitrust trial began over its plan to merge with rival Albertsons in a $25 billion deal.
XPeng ADRs (American Depositary Receipts) spiked 7.90% on news that the Chinese EV maker’s CEO bought more than 2 million of the company’s shares. Those ADRs are still down nearly 50% this year. Here’s what an ADR is, by the way.
What’s down
Nvidia (-2.25%), Super Micro Computer (-8.27%), and Broadcom (-4.05%) stunk up the joint today. Investors are biting their nails ahead of Nvidia’s earnings report on Wednesday.
Uber dropped 2.30% on a day it was hit with a record $324 million fine by the Dutch data protection regulator for violating EU personal data rules.
Intel plopped 2% after CNBC reported on Friday that the chipmaker has hired advisors to help defend the castle against activist investors.
The SPX dropped 17.77 points (–0.32%) to 5,616.84; the Dow Jones Industrial Average® ($DJI) rose 65.44 points (0.16%) to 41,240.52; the NASDAQ Composite®($COMP) fell 152.02 points (–0.85%) to 17.725.77.
The 10-year Treasury note yield (TNX) inched up about one basis point to nearly 3.82%.
The CBOE Volatility Index® (VIX) edged up to 16.09 but remains below its historic average.
Americans can receive free Covid-19 tests through the mail beginning next month.
Posted on August 25, 2024 by Dr. David Edward Marcinko MBA MEd CMP™
By Health Capital Consultants, LLC
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Demand for a variety of healthcare services – including those provided by hospitals – is likely to increase significantly in the near future, primarily as a result of the changing demographics of the U.S. population, most notably the growth in the number of Americans over the age of 65. Indeed, a Health Affairs study found that population aging alone will create approximately 0.74% annual growth in the demand for inpatient hospital services. While hospital consolidation is leading to operational efficiency for hospitals in providing services to an increasing number of patients, the federal government’s intensifying focus on anti-competitive behaviors in healthcare may hinder traditional consolidation efforts going forward.
This second installment in a five-part series on the valuation of hospitals reviews the competitive environment in which hospitals operate. (Read more...)
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