CERTIFIED MEDICAL PLANNER™: How Niche Financial Advisors Thrive!

Think Different – Be Different  – Thrive

[By Ann Miller RN MHA]

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http://www.CertifiedMedicalPlanner.org

Dear Physician Focused Financial Advisors

Did you know that desperate doctors of all ages are turning to knowledgeable financial advisors and medical management consultants for help? Symbiotically too, generalist advisors are finding that the mutual need for knowledge and extreme niche synergy is obvious.

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But, there was no established curriculum or educational program; no corpus of knowledge or codifying terms-of-art; no academic gravitas or fiduciary accountability; and certainly no identifying professional designation that demonstrated integrated subject matter expertise for the increasingly unique healthcare focused financial advisory niche … Until Now! 

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Enter the CMPs

“The informed voice of a new generation of fiduciary advisors for healthcare”

Think Different

 [Think Different – Be Different – Thrive]

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So, if you are looking to supplement your knowledge, income and designations; and find other qualified professionals you may want to consider the CMP® program.

Enter the Certified Medical Planner™ charter professional designation. And, CMPs™ are FIDUCIARIES, 24/7.

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

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

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RE-BROADCAST: An Interview with Fiduciary Bennett Aikin AIF®

On Financial Fiduciary Accountability

[By Dr. David E. Marcinko MBA MEd CMP™]

[By Ann Miller; RN, MHA]

Currently, there is a growing dilemma in the financial sales and services industry. It goes something like this:

  • What is a financial fiduciary?
  • Who is a financial fiduciary?
  • How can I tell if my financial advisor is a fiduciary?

Now, in as much as this controversy affects laymen and physician-investors alike, we went right to the source for up-to-date information regarding this often contentious topic, for an email interview and Q-A session, with Ben Aikin.ben-aikin

About Bennett Aikin AIF® and fi360.com

Bennett [Ben] Aikin is the Communications Coordinator for fi360.com. He oversees all communications for fi360. His responsibilities include messaging, brand management, copyrights and trademarks, and publications. Mr. Aikin received his BA in English from Virginia Tech in 2003 and is currently an MS candidate in Journalism from Ohio University.

Q. Medical Executive Post 

You have been very helpful and gracious to us. So, let’s get right to it, Ben. In the view of many; attorneys, doctors, CPAs and the clergy are fiduciaries; most all others who retain this title seem poseurs; sans documentation otherwise.

A. Mr. Aikin

You are correct. Attorneys, doctors and clergy are the prototype fiduciaries. They have a clear duty to put the best interests of their clients, patients, congregation, etc., above their own. [The duty of a CPA isn’t as clear to me, although I believe you are correct]. Furthermore, this is one of the first topics we address in our AIF training programs, and what we call the difference between a profession and an industry.  The three professions you name have three common characteristics that elevate them from an industry to a profession:

  1. Recognized body of knowledge
  2. Society depends upon practitioners to provide trustworthy advice
  3. Code of conduct that places the clients’ best interests first

Q. Medical Executive Post 

It seems that Certified Financial Planner®, Chartered Financial Analysts, Registered Investment Advisors and their representatives, Registered Representative [stock-brokers] and AIF® holders, etc, are not really financial fiduciaries, either by legal statute or organizational charter. Are we correct, or not? Of course, we are not talking ethics or morality here. That’s for the theologians to discuss.

A. Mr. Aikin

One of the reasons for the “alphabet soup”, as you put it in one of your white papers [books, dictionaries and posts] on financial designations, is that while there is a large body of knowledge, there is no one recognized body of knowledge that one must acquire to enter the financial services industry.  The different designations serve to provide a distinguisher for how much and what parts of that body of knowledge you do possess.  However, being a fiduciary is exclusively a matter of function. 

In other words, regardless of what designations are held, there are five things that will make one a fiduciary in a given relationship:

  1. You are “named” in plan or trust documents; the appointment can be by “name” or by “title,” such as CFO or Head of Human Resources
  2. You are serving as a trustee; often times this applies to directed trustees as well
  3. Your function or role equates to a professional providing comprehensive and continuous investment advice
  4. You have discretion to buy or sell investable assets
  5. You are a corporate officer or director who has authority to appoint other fiduciaries

So, if you are a fiduciary according to one of these definitions, you can be held accountable for a breach in fiduciary duty, regardless of any expertise you do, or do not have. This underscores the critical nature of understanding the fiduciary standard and delegating certain duties to qualified “professionals” who can fulfill the parts of the process that a non-qualified fiduciary cannot.

Q. Medical Executive Post 

How about some of the specific designations mentioned on our site, and elsewhere. I believe that you may be familiar with the well-known financial planner, Ed Morrow, who often opines that there are more than 98 of these “designations”? In fact, he is the founder of the Registered Financial Consultants [RFC] designation. And, he wrote a Foreword for one of our e-books; back-in-the-day. His son, an attorney, also wrote as a tax expert for us, as well. So, what gives?

A. Mr. Aikin

As for the specific designations you list above, and elsewhere, they each signify something different that may, or may not, lend itself to being a fiduciary: For example:

• CFP®: The act of financial planning does very much imply fiduciary responsibility.  And, the recently updated CFP® rules of conduct does now include a fiduciary mandate:

• 1.4 A certificant shall at all times place the interest of the client ahead of his or her own. When the certificant provides financial planning or material elements of the financial planning process, the certificant owes to the client the duty of care of a fiduciary as defined by CFP Board. [from http://www.cfp.net/Downloads/2008Standards.pdf]

•  CFA: Very dependent on what work the individual is doing.  Their code of ethics does have a provision to place the interests of clients above their own and their Standards of Practice handbook makes clear that when they are working in a fiduciary capacity that they understand and abide by the legally mandated fiduciary standard.

• FA [Financial Advisor]: This is a generic term that you may find being used by a non-fiduciary, such as a broker, or a fiduciary, such as an RIA.

• RIA: Are fiduciaries.  Registered Investment Advisors are registered with the SEC and have obligations under the Investment Advisers Act of 1940 to provide services that meet a fiduciary standard of care.

• RR: Registered Reps, or stock-brokers, are not fiduciaries if they are doing what they are supposed to be doing.  If they give investment advice that crosses the line into “comprehensive and continuous investment advice” (see above), their function would make them a fiduciary and they would be subject to meeting a fiduciary standard in that advice (even though they may not be properly registered to give advice as an RIA).

• AIF designees: Have received training on a process that meets, and in some places exceeds, the fiduciary standard of care.  We do not require an AIF® to always function as a fiduciary. For example, we allow registered reps to gain and use the AIF® designation. In many cases, AIF designees are acting as fiduciaries, and the designation is an indicator that they have the full understanding of what that really means in terms of the level of service they provide.  We do expect our designees to clearly disclose whether they accept fiduciary responsibility for their services or not and advocate such disclosure for all financial service representatives.

Q. Medical Executive Post 

Your website, http://www.fi360.com, seems to suggest, for example, that banks/bankers are fiduciaries. We have found this not to be the case, of course, as they work for the best interests of the bank and stockholders. What definitional understanding are we missing?

A. Mr. Aikin

Banks cannot generally be considered fiduciaries.  Again, it is a matter of function. A bank may be a named trustee, in which case a fiduciary standard would generally apply.  Banks that sell products are doing so according to their governing regulations and are “prudent experts” under ERISA, but not necessarily held to a fiduciary standard in any broader sense.

Q. Medical Executive Post 

And so, how do we rectify the [seemingly intentional] industry obfuscation on this topic. We mean, our readers, subscribers, book and dictionary purchasers, clients and colleagues are all confused on this topic. The recent financial meltdown only stresses the importance of understanding same.

For example, everyone in the industry seems to say they are the “f” word. But, our outreach efforts to contact traditional “financial services” industry pundits, CFP® practitioners and other certification organizations are continually met with resounding silence; or worse yet; they offer an abundance of parsed words and obfuscation but no confirming paperwork, or deep subject-matter knowledge as you have kindly done. We get the impression that some FAs honesty do-not have a clue; while others are intentionally vague.

A. Mr. Aikin

All of the evidence you cite is correct.  But that does not mean it is impossible to find an investment advisor who will manage to a fiduciary standard of care and acknowledge the same. The best way to rectify confusion as it pertains to choosing appropriate investment professionals is to get fiduciary status acknowledged in writing and go over with them all of the necessary steps in a fiduciary process to ensure they are being fulfilled. There also are great resources out there for understanding the fiduciary process and for choosing professionals, such as the Department of Labor, the SEC, FINRA, the AICPA’s Personal Financial Planning division, the Financial Planning Association, and, of course, Fiduciary360.

We realize the confusion this must cause to those coming from the health care arena, where MD/DO clearly defines the individual in question; as do other degrees [optometrist, clinical psychologist, podiatrist, etc] and medical designations [fellow, board certification, etc.]. But, unfortunately, it is the state of the financial services industry as it stands now.

Q. Medical Executive Post 

It is as confusing for the medical community, as it is for the lay community. And, after some research, we believe retail financial services industry participants are also confused. So, what is the bottom line?

A. Mr. Aikin

The bottom line is that lay, physician and all clients have a right to expect and demand a fiduciary standard of care in the managing of investments. And, there are qualified professionals out there who are providing those services.  Again, the best way to ensure you are getting it is to have fiduciary status acknowledged in writing, and go over the necessary steps in a fiduciary process with them to ensure it is being fulfilled.

Q. Medical Executive Post 

The “parole-evidence” rule, of contract law, applies, right? In dealing with medical liability situations, the medics and malpractice attorneys have a rule: “if it wasn’t written down, it didn’t happen.”  

A. Mr. Aikin

An engagement contract accepting fiduciary status should trump a subsequent attempt to claim the fiduciary standard didn’t apply. But, to reiterate an earlier point, if someone acts in one of the five functional fiduciary roles, they are a fiduciary whether they choose to acknowledge it or not.  I have attached a sample acknowledgement of fiduciary status letter with copies of our handbook, which details the fiduciary process we instruct in our programs, and our SAFE, which is basically a checklist that a fiduciary should be able to answer “Yes” to every question to ensure the entire fiduciary process is being covered.

Q. Medical Executive Post 

It is curious that you mention checklists. We have a post arguing that very theme for doctors and hospitals as they pursue their medial error reduction, and quality improvement, endeavors. And, we applaud your integrity, and wish only for clarification on this simple fiduciary query?

A. Mr. Aikin

Simple definition: A fiduciary is someone who is managing the assets of another person and stands in a special relationship of trust, confidence, and/or legal responsibility.

Q. Medical Executive Post 

Who is a financial fiduciary and what, if any, financial designation indicates same?

A. Mr. Aikin

Functional definition: See above for the five items that make you a fiduciary.

Financial designations that unequivocally indicate fiduciary duty: Short answer is none, only function can determine who is a fiduciary. 

Q. Medical Executive Post 

Please repeat that?

A. Mr. Aikin

Financial designations that indicate fiduciary duty: none. It is the function that determines who is a fiduciary.  Now, having said that, the CFP® certification comes close by demanding their certificants who are engaged in financial planning do so to a fiduciary standard. Similarly, other designations may certify the holder’s ability to perform a role that would be held to a fiduciary standard of care.  The point is that you are owed a fiduciary standard of care when you engage a professional to fill that role or they functionally become one.  And, if you engage a professional to fill a non-fiduciary role, they will not be held to a fiduciary standard simply because they have a particular designation.  One of the purposes the designations serve is to inform you what roles the designation holder is capable of fulfilling.

It is also worth keeping in mind that just being a fiduciary doesn’t equate to a full knowledge of the fiduciary standard. The AIF® designation indicates having been fully trained on the standard.

Q. Medical Executive Post 

Yes, your website mentions something about fiduciaries that are not aware of same! How can this be? Since our business model mimics a medical model, isn’t that like saying “the doctor doesn’t know he is doctor?” Very specious, with all due respect!

A. Mr. Aikin

I think it is first important to note that this statement is referring not just to investment professionals.  Part of the audience fi360 serves is investment stewards, the non-professionals who, due to facts and circumstances, still owe a fiduciary duty to another.  Examples of this include investment committee members, trustees to a foundation, small business owners who start 401k plans, etc.  This is a group of non-sophisticated investors who may not be aware of the full array of responsibilities they have. 

However, even on the professional side I believe the statement isn’t as absurd as it sounds.  This is basically a protection from both ignorant and unscrupulous professionals.  Imagine a registered representative who, either through ignorance or design, begins offering comprehensive and continuous investment advice.  Though they may deny or be unaware of the fact, they have opened themselves up to fiduciary liability. 

Q. Medical Executive Post 

Please clarify the use of arbitration clauses in brokerage account contracts for us. Do these disclaim fiduciary responsibility? If so, does the client even know same?

A. Mr. Aikin

By definition, an engagement with a broker is a non-fiduciary relationship.  So, unless other services beyond the scope of a typical brokerage account contract are specified, fiduciary responsibility is inherently not applicable.  Unfortunately, I do imagine there are clients who don’t understand this. Furthermore, AIF® designees are not prohibited from signing such an agreement and there are some important points to understand the reasoning.

First, by definition, if you are entering into such an agreement, you are entering into a non-fiduciary relationship. So, any fiduciary requirement wouldn’t apply in this scenario.

Second, if this same question were applied into a scenario of a fiduciary relationship, such as with an RIA, this would be a method of dispute resolution, not a practice method. So, in the event of dispute, the advisor and investor would be free to agree to the method of resolution of their choosing. In this scenario, however, typically the method would not be discussed until the dispute itself arose.

Finally, it is important to know that AIF/AIFA designees are not required to be a fiduciary. It is symbolic of the individuals training, knowledge and ongoing development in fiduciary processes, but does not mean they will always be acting as a fiduciary.

Q. Medical Executive Post 

Don’t the vast majority of arbitration hearings find in favor of the FA; as the arbitrators are insiders, often paid by the very same industry itself?

A. Mr. Aikin

Actual percentages are reported here: http://www.finra.org/ArbitrationMediation/AboutFINRADR/Statistics/index.htm However, brokerage arbitration agreements are a dispute resolution method for disputes that arise within the context of the securities brokerage industry and are not the only means of resolving differences for all types of financial advisors.  Investment advisers, for example, are subject to respond to disputes in a variety of forums including state and federal courts.  Clients should look at their brokerage or advisory agreement to see what they have agreed to. If you wanted to go into further depth on this question, we would recommend contacting Brian Hamburger, who is a lawyer with experience in this area and an AIFA designee. Bio page: http://www.hamburgerlaw.com/attorneys/BSH.htm.

Q. Medical Executive Post 

What about our related Certified Medical Planner® designation, and online educational program for financial advisors and medical management consultants? Is it a good idea – reasonable – for the sponsor to demand fiduciary accountability of these charter-holders? Cleary, this would not only be a strategic competitive advantage, but advance the CMP™ mission to put medical colleagues first and champion their cause www.CertifiedMedicalPlanner.org above all else. 

A. Mr. Aikin

I think it is a good idea for any plan sponsor to demand fiduciary status be acknowledged from anyone engaged to provide comprehensive and continuous investment advice.  I also think it is a good idea to be proactive in verifying that the fiduciary process is being followed.

Q. Medical Executive Post 

Is there anything else that we should know about this topic?

A. Mr. Aikin

Yes, a further note about fi360’s standards. I wrote generically about the fiduciary standard, because there is one that is defined by multiple sources of regulation, legislation and case law.  The process defined in our handbooks, we call a Fiduciary Standard of Excellence, because it covers that minimum standard and also best practice standards that go above and beyond.  All of our Practices, which comprise that standard, are legally substantiated in our Legal Memoranda handbook, which was written by Fred Reish’s law firm, who is considered a leading ERISA attorney.

Additional resources:

Q. Medical Executive Post 

Thank you so much for your knowledge and willingness to frankly share it with the Medical-Executive-Post.

Assessment

All are invited to continue the conversation with Mr. Aikin, asynchronously online, or thru this contact information:

fi360.com
438 Division Street
Sewickley, PA 15143
412-741-8140 Phone
866-390-5080 Toll-free phone
412-741-8142 Fax

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

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

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CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
BLOG: www.MedicalExecutivePost.com

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

SUBMITTED ESSAYS: Economics, Management and Finance from Advisors to Physicians

By Staff Reporters

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Finance, economics and management essays of most current interest to all physicians and healthcare professionals

READ ESSAYS: https://marcinkoassociates.com/articles-essays/

Check back periodically for practical updates. Our catalogue library of major books, texts, case models and dictionaries is suggested for additional financial, economic, business and medical practice management information and education.

COMMENTS APPRECIATED

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PHYSICIANS BEWARE: Traditional Financial Planning “Rules of Thumb”

DOCTORS AND MEDICAL PROFESSIONALS BEWARE?

We ARE Different!

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By Dr. David E. Marcinko MBA CMP®

SPONSOR: http://www.CertifiedMedicalPlanner.org

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  • While financial planning rules of thumbs are useful to people as general guidelines, they may be too oversimplified in many situations, leading to underestimating or overestimating an individual’s needs. This may be especially true for physicians and many medical professionals. Rules of thumb do not account for specific circumstances or factors occurring at a particular time, or that could change over time, which should be considered for making sound financial decisions.
  • Great Health Industry Resignation: https://medicalexecutivepost.com/2021/12/12/healthcare-industry-hit-with-the-great-resignation-retirement/

For example, in a tight job market, an emergency fund amounting to six months of household expenses does not consider the possibility of extended unemployment. I’ve always suggested 2-3 years for doctors. Venture capitalist lay-offs of physicians during the pandemic confirm this often criticized benchmark opinion of mine.

As another example, buying life insurance based on a multiple of income does not account for the specific needs of the surviving family, which include a mortgage, the need for college funding and an extended survivor income for a non-working spouse. Again a huge home mortgage, or several children or dependents, may be the financial bane of physician colleagues and life insurance.

CITE: https://www.r2library.com/Resource/Title/082610254

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EXAMPLES: Old/New Rules

  • A home purchase should cost less than an amount equal to two and a half years of your annual income. I think physicians in practice for 3-5 years might go up to 3.5X annual income; ceteras paribus.
  • Save at least 10-15% of your take-home income for retirement. Seek to save 20% or more.
  • Have at least five times your gross salary in life insurance death benefit. Consider 10X this amount in term insurance if young, and/or with several children or other special circumstances.
  • Pay off your highest-interest credit cards first. Agreed.
  • The stock market has a long-term average return of 10%. Agreed, but appreciated risk adjusted rates of return..
  • You should have an emergency fund equal to six months’ worth of household expenses. Doctors should seek 2-3 years.
  • Your age represents the percentage of bonds you should have in your portfolio. Risk tolerance and assets may be more vital.
  • Your age subtracted from 100 represents the percentage of stocks you should have in your portfolio. Risk tolerance and assets may still be more vital.
  • A balanced portfolio is 60% stocks, 40% bonds. With historic low interest rates, cash may be a more flexible alternative than bonds; also avoid most bond mutual funds as they usually never mature.

There are also rules of thumb for determining how much net worth you will need to retire comfortably at a normal retirement age. Here is the calculation that Investopedia uses to determine your net worth:

Compensation in the Physician Specialties: Mostly Stable - NEJM  CareerCenter Resources

RULES 72, 78 and 115: https://medicalexecutivepost.com/2022/01/30/the-rules-of-72-78-and-115/

INVITATION: https://medicalexecutivepost.com/2021/05/08/invite-dr-marcinko-to-your-next-big-event/

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ADVICE: Investment or Medical Practice Management Second Fiduciary Opinions

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MARCINKO & ASSOCIATES, Inc.

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Dr. David Edward Marcinko MBA MEd CMP®

Certified Medical Planner®

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FINANCIAL PLANNING

CAREER DEVELOPMENT

MEDICAL PRACTICE BUY IN / OUT

INVESTMENT ANALYSIS

PORTFOLIO MANAGEMENT

MERGERS AND ACQUISITIONS

PRACTICE APPRAISALS AND VALUATIONS

RETIREMENT PLANNING

FEE-ONLY

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CONTACT: Ann Miller RN MHA

EMAIL: MarcinkoAdvisors@msn.com

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REIMBURSEMENT: Valuation of Accountable Care Organizations

By Health Capital Consultants, LLC

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Valuation of Accountable Care Organizations: Reimbursement

The U.S. healthcare payment and delivery system is increasingly moving to a value- and quality-based system. Accountable care organizations (ACOs) are at the forefront of delivering high-quality and cost-effective care to millions of Medicare beneficiaries and privately insured patients, incentivized by substantial shared savings for those who increase quality while containing costs.

CITE: https://www.r2library.com/Resource

This third installment of a five-part series on the valuation of ACOs will discuss the reimbursement environment in which ACOs participate.(Read more…) 

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PODCAST: “Real ACOs Haven’t Been Tried Yet!”

What is an Accountable Care Organization?

DEFINITION: ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their 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.

Citation: https://www.r2library.com/Resource/Title/0826102549

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QUESTION: What happens when you’re a healthcare policy wonk and the pilot study for your pet program has failed miserably? 

ANSWER: You declare “Success!” in the editorial pages of the New England Journal of Medicine and demand that the program become nationwide and mandatory. I kid you not.  This is exactly what happens.

Thankfully, Anish Koka is vigilant and explains the blatant obfuscations and manipulations that the central planners engage in to have their way.

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And so, In this video, Anish and colleague Michel Accad, MD, will reveal the machinations, take the culprits to task, and discuss pertinent questions regarding health care organization: 

  • Does “capitation” reduce costs? 
  • Do employed physicians necessarily utilize fewer resources? 
  • What happens when a HMO and a traditional fee-for-service health system operate side-by-side in a community?
BMC and Accountable Care - Boston Medical Center

Enjoy!

PODCAST: http://alertandoriented.com/real-acos-havent-been-tried-yet/

Your thoughts are appreciated.

THANK YOU

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CASH FLOW ANALYSIS: Real Life ACO Accounting Example

ACCOUNTABLE CARE ORGANIZATION EXAMPLE

Touring with Marcinko | The Leading Business Education ...

BY DR. DAVID EDWARD MARCINKO MBA MEd CMP®

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What is an ACO?

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.

Citation: https://www.r2library.com/Resource/Title/0826102549

Case Model

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.

ASSESSMENT: Your comments are appreciated.

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PODIATRY PREP: Pass All Your Board Certification Examinations in 2024

Celebrating 30 Years of Your Success!

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Engineers at MIT want to optimize your jog. Some of the brightest minds in math and science have created a predictive model that can tell you what kind of shoe you would run best in. The model assesses a person’s height, weight, and leg length to simulate their gait in sneakers of different materials and mid-soles. It then projects the optimal shoe based on which one produces the most efficient running form (i.e., which uses as little energy as possible per stride).

And so, as 3D printing and related tech continue to drive sneaker innovation, the researchers say their model will be beneficial to designers who want to create new kinds of highly functional kicks (Adidas funded some of the research).

Why? Marketing and product sales, of course. But, some experts suggest improved shoes might increase your running away speed by 8-10% while reducing injuries.

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Pass ALL the Certification Boards!

By: http://www.PodiatryPrep.org

The Foot and Ankle Research Consortium, Inc. (FARC) is the leading publisher of Podiatric educational software. Since 1992, we have been producing the most effective and innovative method of preparing for ALL the Podiatry Board Examinations.

CURIOUS STUDY: Hallux Valgus Met I

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This includes: The American Board of Podiatric Surgery, The American Board Of Podiatric Orthopedics and Primary Podiatric Medicine, the American Podiatric Medical Specialties Board, ABLES and the PMLexis. (Now includes the latest information for all Board Re-Certifications).

CONTENTS: https://podiatryprep.org/compatibility-test/

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D.E. MARCINKO & ASSOCIATES: Financial Planning and Business Management Education for Physicians

By Dr. David Edward Marcinko MBA MEd CMP

CONSULTING ADVICE – NOT MANAGEMENT

“AT YOUR SERVICE”

E-mail: MarcinkoAdvisors@msn.com

SPONSOR: http://www.MarcinkoAssociates.com

Marcinko & Associates is financial guide. We help answer your questions in an empowering way. We educate and guide medical colleagues to understand their financial picture and to make better financial decisions. We strive to simplify everything, clear up confusion, and address specific needs and goals.

Simply put, we’re a financial services company on a mission to empower financial freedom for all healthcare professionals; only. We work with doctors, nurses, medical providers, individuals and all sizes of organizations to offer investment, wealth management and retirement solutions so everyone can have a clear and simple understanding of where their finances and career is today and where it is headed tomorrow.

Whatever your financial situation, we do not shame, criticize, or sell. We enrich, educate and empower. We work only with medical colleagues at every stage of their financial journey [students, interns, residents, practitioners, mid-career and mature physicians], through big life personal changes to annual employment reviews, in order to help them understand, invest, and protect their money and lifestyle.

CITE: https://www.r2library.com/Resource

For example, the following are current issues of review need for each Fall and Winter:

  • Financial planning reviews: 401-k, insurance, budget plans, investing, debt and savings, etc
  • Assess, develop, and align financial retirement and estate planning goals
  • Risk Management: Malpractice, home, life, medical, auto and personal indemnity
  • Life Insurance Need Reviews: whole, universal and term  
  • Business, operations, HR, employment negotiations and medical practice management
  • Annuity Need Reviews: Indexed and Fixed [Pros and Cons].

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At Marcinko & Associates we discuss specific needs and answer specific questions. We educate and make personalized recommendations that you are free to use, incorporate or disregard. Referrals to trusted specialists and strategic alliance partners then occur if – and as – needed [pro re nata].

SPONSOR: http://www.CertifiedMedicalPlanner.org

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Physician Electronic-Mail Bills

MY CHART”

By AMANDA SEITZ

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E-Mailing your Physician may Cost You like Your Attorneys!

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WASHINGTON (AP) — The next time you message your doctor to ask about a pesky cough or an itchy rash, you may want to check your bank account first — you could get a bill for the question.

Hospital systems around the country are rolling out fees for some messages that patients send to physicians, who they say are spending an increasing amount of time poring over online queries, some so complex that they require the level of medical expertise normally dispensed during an office visit. Patient advocates, however, worry these new fees may deter people from reaching out to their doctor and that they add another layer of complexity to the U.S. health care system’s already opaque billing process.

“This is a barrier that denies access and will result in hesitancy or fear to communicate and potentially harm patients with lower quality of care and outcomes at a much higher cost,” said Cynthia Fisher, the founder of Patient Rights Advocate, a Massachusetts-based nonprofit that pushes for hospital price transparency.

CITE: https://www.r2library.com/Resource/Title/082610254

The explosion of telehealth over the last three years — driven by the COVID-19 outbreak and relaxed federal regulations for online care — prompted many doctors to adopt more robust telecommunication with their patients. Consultations that once happened in an office were converted to computer or smart phone visits. And health care systems invited patients to use new online portals to message their doctors with a question at any time, American Medical Association president Jack Resneck Jr. told The Associated Press.

“When people figured out this is cool and could improve care, you saw hospitals and practice groups saying to patients, welcome to your portal … you can ping your physician with questions if you want,” Resneck said. “We found ourselves as physicians getting dozens and dozens of these a day and not having time built in to do that work.”

The charges vary for each patient and hospital system, with messages costing as little as $3 for Medicare patients to as much $160 for the uninsured. In some cases, the final bill depends on how much time the doctor spends responding.

READ HERE: https://my.clevelandclinic.org/online-services/mychart/messaging#msdynttrid=bAU8cKe-602S6wFIwSYop1KQswRcT2b2F5mRJ-92OEc

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MEDICAL COACHING: Physician Burnout and Career Change

SPONSORED BY: http://www.MarcinkoAssociates.com

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Most doctors report feeling overworked and are considering a change in career, according to a new poll.

Doximity, a virtual network for physicians, found that 81% doctors surveyed last fall said they felt overworked—a slight decline from 86% who reported burnout in 2022 but still up from 73% in 2021. Meanwhile, about three in five doctors said they were considering early retirement (30%), looking for another employer (15%), or leaving the profession altogether (14%), the poll found.

The findings, released last year, come amid reports of rising rates of physician burnout and dissatisfaction since after the Covid-19 pandemic.

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MICRO-CERTIFICATIONS: Financial Advisors Seeking Physician-Client Niche Success?

Micro-Credentials on the Rise

KNOWLEDGE RICHES IN SPECIALTY NICHES

DR. DAVID EDWARD MARCINKO MBA MEd CMP

SPONSOR: http://www.CertifiedMedicalPlanner.org

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Do you ever wish you could acquire specific information for your career activities without having to complete a university Master’s Degree or finish our entire Certified Medical Planner™ professional designation program? Well, Micro-Certifications from the Institute of Medical Business Advisors, Inc., might be the answer. Read on to learn how our three Micro-Certifications offer new opportunities for professional growth in the medical practice, business management, health economics and financial planning, investing and advisory space for physicians, nurses and healthcare professionals.

Micro-Certification Basics

Stock-Brokers, Financial Advisors, Investment Advisors, Accountants, Consultants, Financial Analyists and Financial Planners need to enhance their knowledge skills to better serve the changing and challenging healthcare professional ecosystem. But, it can be difficult to learn and demonstrate mastery of these new skills to employers, clients, physicians or medical prospects. This makes professional advancement difficult. That’s where Micro-Certification and Micro-Credentialing enters the online educational space. It is the process of earning a Micro-Certification, which is like a mini-degree or mini-credential, in a very specific topical area.

Micro-Certification Requirements

Once you’ve completed all of the requirements for our Micro-Certification, you will be awarded proof that you’ve earned it. This might take the form of a paper or digital certificate, which may be a hard document or electronic image, transcript, file, or other official evidence that you’ve completed the necessary work.

Uses of Micro-Certifications

Micro-Certifications may be used to demonstrate to physicians prospective medical clients that you’ve mastered a certain knowledge set. Because of this, Micro-Certifications are useful for those financial service professionals seeking medical clients, employment or career advancement opportunities.

Examples of iMBA, Inc., Micro-Certifications

Here are the three most popular Micro-Certification course from the Institute of Medical Business Advisors, Inc:

  • 1. Health Insurance and Managed Care: To keep up with the ever-changing field of health care physician advice, you must learn new medical practice business models in order to attract and assist physicians and nurse clients. By bringing together the most up-to-date business and medical prctice models [Medicare, Medicaid, PP-ACA, POSs, EPOs, HMOs, PPOs, IPA’s, PPMCs, Accountable Care Organizations, Concierge Medicine, Value Based Care, Physician Pay-for-Performance Initiatives, Hospitalists, Retail and Whole-Sale Medicine, Health Savings Accounts and Medical Unions, etc], this iMBA Inc., Mini-Certification offers a wealth of essential information that will help you understand the ever-changing practices in the next generation of health insurance and managed medical care.
  • 2. Health Economics and Finance: Medical economics, finance, managerial and cost accounting is an integral component of the health care industrial complex. It is broad-based and covers many other industries: insurance, mathematics and statistics, public and population health, provider recruitment and retention, health policy, forecasting, aging and long-term care, and Venture Capital are all commingled arenas. It is essential knowledge that all financial services professionals seeking to serve in the healthcare advisory niche space should possess.
  • 3. Health Information Technology and Security: There is a myth that all physician focused financial advisors understand Health Information Technology [HIT]. In truth, it is often economically misused or financially misunderstood. Moreover, an emerging national HIT architecture often puts the financial advisor or financial planner in a position of maximum uncertainty and minimum productivity regarding issues like: Electronic Medical Records [EMRs] or Electronic Health Records [EHRs], mobile health, tele-health or tele-medicine, Artificial Intelligence [AI], benefits managers and human resource professionals.

Other Topics include: economics, finance, investing, marketing, advertising, sales, start-ups, business plan creation, financial planning and entrepreneurship, etc.

How to Start Learning and Earning Recognition for Your Knowledge

Now that you’re familiar with Micro-Credentialing, you might consider earning a Micro-Certification with us. We offer 3 official Micro-Certificates by completing a one month online course, with a live instructor consisting of twelve asynchronous lessons/online classes [3/wk X 4/weeks = 12 classes]. The earned official completion certificate can be used to demonstrate mastery of a specific skill set and shared with current or future employers, current clients or medical niche financial advisory prospects.

Mini-Certification Tuition, Books and Related Fees

The tuition for each Mini-Certification live online course is $1,250 with the purchase of one required dictionary handbook. Other additional guides, white-papers, videos, files and e-content are all supplied without charge. Alternative courses may be developed in the future subject to demand and may change without notice.

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Contact: For more information, or to speak with an academic representative, please contact Ann Miller RN MHA CMP™ at Email: MarcinkoAdvisors@msn.com [24/7].

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VENTURE CAPITAL: Women’s Health Start-Ups

By Staff Reporters

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Women’s health startups are still closing multi million-dollar funding deals despite a challenging venture capital (VC) landscape in which VC dollars are on track to fall by 73% this year compared to last.

CITE: https://www.r2library.com/Resource

For example, in the last year, virtual maternity care program Pomelo Care raised $33 million in seed and Series A rounds led by Andreessen Horowitz; Caraway Health, a digital mental, physical, and reproductive health services platform, raised almost $17 million in a Series A round led by Maveron and GV (formerly Google Ventures); and Intrinsic, which acquires brands that make women’s health products, announced a $15 million equity fund raise (which is when a company raises money by selling its shares).

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PODCAST: RIP James Simons [Renaissance Technologies]

HEDGE FUND

By Staff Reporters

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“I did a lot of math. I made a lot of money, and I gave almost all of it away. That’s the story of my life.”

There are longer versions of the life story of Jim Simons, the legendary mathematician, quantitative investing pioneer, and philanthropist who just died at age 86, but his summary is pretty good.

In 1978, Simons started what would become his wildly successful hedge fund, Renaissance Technologies, where he used his mathematical savvy to deliver a performance that outpaced Warren Buffett and George Soros. Its signature fund averaged 66% annual returns.

With his wife, Marilyn Simons, he also started the Simons Foundation, which gave billions to causes they cared about—including, most recently, the Dublin–New York portals.

PODCAST: https://www.youtube.com/watch?v=QNznD9hMEh0

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PODCAST: “In-Elastic Demand” in Healthcare Economics

Economic Implications of Pain, Suffering and Imminent Death

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See the source image

By Eric Bricker MD

Examples of Inelastic Demand in Healthcare Are:
1) Emergencies
2) Patented Medications for Diseases That Have No Other Alternative Drugs
3) Doctor Specialties Where the Patient Has No Choice in the Services Such As Radiologists, Anesthesiologists and Pathologists [RAP]

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PODCAST: History Applied to Health Economics

Divining the Future?

By Eric Bricker MD

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CITE: https://www.r2library.com/Resource/Title/0826102549

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BUDGETING: For Physicians

Personal Physician Budgeting Thoughts

http://www.MARCINKOASSOCIATES.com

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BY DR. DAVID E. MARCINKO MBA CMP®

SPONSOR: http://www.CertifiedMedicalPlanner.org

Product Details

CITE: https://www.r2library.com/Resource/Title/082610254

Although some doctors might view a budget as unnecessarily restrictive, sticking to a spending plan can be a useful tool in enhancing the wealth of a practice. And so, I will emphasize keys to smart budgeting and how to track spending and savings in these tough economic times; like today with the stock market busts, venture capitalists invading health care, corona virus the pandemic, aging baby boomer physicians and the great resignation; etc.

   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 money can sure reduces the unhappiness.”

   Unfortunately, today there is still more than a little financial unhappiness in all medical specialties. The challenges range from the commoditization of medicine, aging demographics, Medicare reimbursement cutbacks, ACA, and increased competition to floundering equity markets, the squeeze on credit and declines in the value of a practice. Few doctors seem immune to this “perfect storm” of economic woes. And then Covid-19, corona, and covid.

   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.1

How To Prepare A Personal Cash Flow Budget

   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 medial office, the first operations budget item might be salary for the doctor and staff. Operating assets and other big ticket items come next. Some 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 podiatrist can spot problems, correct them and continue planning actively toward stated goals like building long-term wealth.2

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 the specter of rising 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.3

   In fact, I 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. The new limit is $250,000. 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.).4

How To Budget In The Midst Of A [Corona] Crisis

   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 of the corona pandemic. 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.”5

   Always remember to add a bit of emotional sanity into your budgeting and economic endeavors.6

   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.7

The Author:

Dr. Marcinko is a former university endowed chairman and professor, former certified financial planner and has been a medical management advisor for more than two decades. He is the CEO of www.MedicalBusinessAdvisors.com, a health economics and business finance consulting firm.

DEM avatar

References:

1. Marcinko DE (Ed). The Business of Medical Practice (Advanced Profit Maximizing Techniques for Savvy Doctors). Springer Publishers, New York, NY, 2000 and 2004 2. Marcinko DE (Ed). Financial Planning for Physicians and Advisors, Jones and Bartlett Publishers, Sudbury, MA, 2005 3. Marcinko DE (Ed). Risk Management and Insurance Panning for Physicians and Advisors, Jones and Bartlett Publishers, Sudbury, MA, 2006. 4. Marcinko DE, Hetico HR. The Dictionary of Health Insurance and Managed Care. Springer Publishing, New York, 2007. 5. Marcinko DE, Hetico HR. The Dictionary of Health Economics and Finance. Springer Publishing, New York, 2008. 6. Marcinko DE, Hetico HR. Healthcare Organizations (Financial Management Strategies). Standard Technical Publishers, Blaine, WA, 2009. Additional Reference 7. Schmuckler E. Bridging Financial Planning and Human and Human Psychology. In, Marcinko DE (Ed): Financial Planning for Physicians and Healthcare Professionals. Aspen Publications, New York, NY, 2001, 2002 and 2003.

PODCAST: Accounting Deception in Health Care

Examples of Exploitation and Deception?

BY ERIC BRICKER MD

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OPEN LETTER: MARCINKO Associates, Inc.

MISSION STATEMENT

Open Letter from the CEO

Dr. David Edward Marcinko MBA CMP™

http://www.MarcinkoAssociates.com

ALL MEDICAL AND HEALTHCARE COLLEAGUES

Did you know that at MARCINKO & Associates, all medical colleagues throughout the United States may contact us when they are considering the sale, purchase, strategic operating improvement, merger, acquisition and/or other financial business or related personal financial planning transaction?

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Our difference is “hard” knowledge and insider financial guidance that helps medical colleagues, nurses, private practitioners, clinics, ambulatory surgery, radiology and outpatient wound care centers realize their ultimate economic goals. This typically includes managerial and cost accounting, financial ratio analysis, fair market valuation business appraisals, business plan creation and personal financial planning.

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Our “expert witness” business litigation support service and divorce mediation, arbitration, asset division, settlement and second opinion offerings are always available, as well.

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And, our “soft” skill professional career guidance and mentoring center includes executive coaching, consulting and mentoring advisory programs for stressed, conflicted or burned-out physicians and medical practitioners.

Most importantly, our professional fees are reasonable and always transparent.

MARCINKO & Associates also serves universities, medical, business, graduate and nursing schools; physicians, dentists, podiatrists, optometrists and legal societies. This includes accountants, financial service providers, wealth and hedge fund managers, emerging entities, hospitals, CEOs and their BODs, the press, media and related organizations.

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Now, please review our website to learn more.

And, always retain us when needed.

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FINANCIAL AND HEALTH ECONOMICS BENCH MARKING

Understanding the operational and financial status of your organization or practice

[By Dr. David Edward Marcinko MBA MEd CMP™]

SPONSOR: http://www.MarcinkoAssociates.com

Dr. DEMFinancial benchmarking can assist healthcare managers and professional financial advisors in understanding the operational and financial status of their organization or practice.

The general process of financial benchmarking analysis may include three elements: (1) Historical subject benchmarking; (2) Benchmarking to industry norms; and, (3) Financial ratio analysis.

History

Historical subject benchmarking compares a healthcare organization’s most recent performance with its reported performance in the past in order to: examine performance over time; identify changes in performance within the organization (e.g., extraordinary and non-recurring events); and, to predict future performance.

As a form of internal benchmarking, historical subject benchmarking avoids issues such as: differences in data collection and use of measurement tools; and, benchmarking metrics that often cause problems in comparing two different organizations.

However, it is necessary to common size data in order to account for company differences over time that may skew results.

Benchmarking

Benchmarking to industry norms, analogous to Fong and colleagues’ concept of industry benchmarking,   involves comparing internal company-specific data to survey data from other organizations within the same industry. This method of benchmarking provides the basis for comparing the subject entity to similar entities, with the purpose of identifying its relative strengths, weaknesses, and related measures of risk.

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Financial Ratio Analysis

The process of benchmarking against industry averages or norms will typically involve the following steps:

  1. Identification and selection of appropriate surveys to use as a benchmark, i.e., to compare with data from the organization of interest. This involves answering the question, “In which survey would this organization most likely be included?”;
  2. If appropriate, re-categorization and adjustment of the organization’s revenue and expense accounts to optimize data compatibility with the selected survey’s structure and definitions (e.g., common sizing); and,
  3. Calculation and articulation of observed differences of organization from the industry averages and norms, expressed either in terms of variance in ratio, dollar unit amounts, or percentages of variation.

Trends

Financial ratio analysis typically involves the calculation of ratios that are financial and operational measures representative of the financial status of an enterprise.  These ratios are evaluated in terms of their relative comparison to generally established industry norms, which may be expressed as positive or negative trends for that industry sector. The ratios selected may function as several different measures of operating performance or financial condition of the subject entity.

The Selected Ratios

Common types of financial indicators that are measured by ratio analysis include:

  1. Liquidity. Liquidity ratios measure the ability of an organization to meet cash obligations as they become due, i.e., to support operational goals. Ratios above the industry mean generally indicate that the organization is in an advantageous position to better support immediate goals. The current ratio, which quantifies the relationship between assets and liabilities, is an indicator of an organization’s ability to meet short-term obligations. Managers use this measure to determine how quickly assets are converted into cash.
  2. Activity. Activity ratios, also called efficiency ratios, indicate how efficiently the organization utilizes its resources or assets, including cash, accounts receivable, salaries, inventory, property, plant, and equipment. Lower ratios may indicate an inefficient use of those assets.
  3. Leverage. Leverage ratios, measured as the ratio of long-term debt to net fixed assets, are used to illustrate the proportion of funds, or capital, provided by shareholders (owners) and creditors to aid analysts in assessing the appropriateness of an organization’s current level of debt. When this ratio falls equal to or below the industry norm, the organization is typically not considered to be at significant risk.
  4. Profitability. Indicates the overall net effect of managerial efficiency of the enterprise. To determine the profitability of the enterprise for benchmarking purposes, the analyst should first review and make adjustments to the owner(s) compensation, if appropriate. Adjustments for the market value of the “replacement cost” of the professional services provided by the owner are particularly important in the valuation of professional medical practices for the purpose of arriving at an ”economic level” of profit.

Data Homogeneity

The selection of financial ratios for analysis and comparison to the organization’s performance requires careful attention to the homogeneity of data. Benchmarking of intra-organizational data (i.e., internal benchmarking) typically proves to be less variable across several different measurement periods.

However, the use of data from external facilities for comparison may introduce variation in measurement methodology and procedure. In the latter case, use of a standard chart of accounts for the organization or recasting the organization’s data to a standard format can effectively facilitate an appropriate comparison of the organization’s operating performance and financial status data to survey results.

***Financial Planning MDs 2015

BOOK: Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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Operational Performance Benchmarking

Operational benchmarking is used to target non-central work or business processes for improvement.  It is conceptually similar to both process and performance benchmarking, but is generally classified by the application of the results, as opposed to what is being compared.  Operational benchmarking studies tend to be smaller in scope than other types of benchmarking, but, like many other types of benchmarking, are limited by the degree to which the definitions and performance measures used by comparing entities differ.  Common sizing is a technique used to reduce the variations in measures caused by differences (e.g., definition issues) between the organizations or processes being compared.

Common Sizing

Common sizing is a technique used to alter financial operating data prior to certain types of benchmarking analysis and may be useful for any type of benchmarking that requires the comparison of entities that differ on some level (e.g., scope of respective benchmarking measurements, definitions, business processes).  This is done by expressing the data for differing entities in relative (i.e., comparable) terms.

Example:

For example, common sizing is often used to compare financial statements of the same company over different periods of time (e.g., historical subject benchmarking), or of several companies of differing sizes (e.g., benchmarking to industry norms). The latter type may be used for benchmarking an organization to another in its industry, to industry averages, or to the best performing agency in its industry.  Some examples of common size measures utilized in healthcare include:

  1. Percent of revenue or per unit produced, e.g., relative value unit (RVU);
  2. Per provider, e.g., physician;
  3. Per capacity measurement, e.g., per square foot; or,
  4. Other standard units of comparison.

Assessment

As with any data, differences in how data is collected, stored, and analyzed over time or between different organizations may complicate the use of it at a later time.  Accordingly, appropriate adjustments must be made to account for such differences and provide an accurate and reliable dataset for benchmarking.

Conclusion

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PODCAST: Doctor Hospital Co-Owned Ambulatory Surgery Centers (ASC)

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FDA: Regulation of Laboratory Tests

By Staff Reporters

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The Food and Drug Administration wants to make sure that if someone is analyzing your blood and urine, it’s worth your time, so the agency just finalized regulations to govern the $10 billion lab test industry. Tests designed by laboratories have long gone without government scrutiny, but the FDA said the time has come to ensure these tests are accurate—though the new standards will be phased in over several years.

There are currently about 80,000 medical tests available from ~1,200 labs, per the FDA, and those will mostly be grandfathered in. Still, the industry has pushed back, saying the regulations will inhibit innovation, and could sue to block the rules from taking effect.

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PODCAST: CMPs™ are In … Are CPAs Out?

CERTIFIED MEDICAL PLANNER

By Staff Reporters

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Statistics: 7.4%. That’s the percentage drop in students who graduated with a degree in accounting in the 2021–2022 school year than the year before. Low starting salaries, heavy workloads, and uncertainty around AI are driving the exodus of students from choosing accounting degrees. (the Wall Street Journal).

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PODCAST: “All OR Nothing” Hospital Contracts

By Eric Bricker MD

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FTC: Finalizes Ban on Non-Compete Agreements

By Health Capital Consultants LLC

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On April 23rd, 2024, the Federal Trade Commission (FTC) issued a final rule that would ban employers from imposing non-competes on their employees. The FTC asserts that this exploitative practice keeps wages low, and suppresses new ideas. Notably, while the final rule will affect all industries, not just healthcare, this proposal comes at a time when healthcare employers across the U.S. are struggling with staffing shortages.

Existing noncompetes for the majority of workers will no longer be enforceable after the rule goes into effect (i.e., 120 days after publication in the Federal Register); however, the FTC ban appears likely to face a legal challenge, and it could be years before it can take effect.

Under the final rule, noncompetes for senior executives can remain in force under the new ruling, but employers may not enter in or attempt to enforce any new noncompetes, even if that includes a senior executive. The Commission also recognizes that they have no jurisdiction over not-for-profit entities, however they reserve the right to evaluate any entity’s non-profit status. The FTC specifically stated that “some portion of the 58% of hospitals that claim tax-exempt status as nonprofits and the 19% of hospitals that are identified as State or local government hospitals in the data cited by AHA likely fall under the Commission’s jurisdiction and the final rule’s purview.”

While most healthcare employees and workers, including physicians, believe that the ruling is long overdue and that noncompetes “impede patient access to care, limit physicians’ ability to choose their employer, contribute to burnout and stifle competition,” the American Hospital Association (AHA), stated that the “FTC’s final rule banning non-compete agreements for all employees across all sectors of the economy is bad law, bad policy, and a clear sign of an agency run amok.

Look for next month’s (May 2024) Health Capital Topics article that will discuss, in more detail, the final rule, reactions from healthcare industry stakeholders, and potential implications for healthcare valuations (both business and compensation valuations).

MORE: (Read the FTC’s Press Release Here)

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PODCAST: Medicare Advantage [Part C] Fraud?

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DOJ: Antitrust Reportedly Investigating UnitedHealth Group

By Health Capital Consultants, LLC

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On February 27, 2024, the Wall Street Journal (WSJ) reported that the Department of Justice (DOJ) has launched an antitrust investigation into UnitedHealth Group (UHG), the owner of the biggest health insurer in the U.S. and the leading manager of drug benefits and one of the largest networks of physician groups. This investigation comes as the Biden administration’s antitrust enforcers have ramped up investigations into some of the biggest U.S. companies, including Amazon, Apple, and Google.

CITE: https://www.r2library.com/Resource

This Health Capital Topics article reviews the reported government investigation. (Read more…)

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PODCAST: Cash Flow, Revenue & Entrepreneurial Leadership in Healthcare Business

THE ENTREPRENEURIAL M.D.

In this episode we are joined by Dr. Brent Jackson, Chief Medical Officer for Mercy General in Sacramento, CA to discuss the physician life-cycle, burnout, and transitioning into leadership within healthcare.

Play EpisodeDownload (40.4 MB)

Summary: Dr Brent Jackson discusses the flow of revenue throughout the medical industry.

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HUMANA: Exits Medicare Part C Plan Markets

By Staff Reporters

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Humana Plans to Leave Some Medicare Advantage Markets in 2025

Humana expects to exit Medicare Advantage (MA) markets in 2025, company executives told investors. The company reported its first quarter earnings April 24th. Humana posted $741 million in net income in the first quarter of 2024, beating investor expectations, but pulled its 2025 earnings guidance. 

On an April 24th 2024 call with investors, Humana executives said it will look to pull back benefits and exit some markets, as CMS continues phasing in risk adjustment changes. CMS published its final MA rate notice for 2025 earlier this month. The agency slightly cut benchmark payments and continued phasing in coding changes. Humana previously said the agency’s rates were lower than its expectations.

Other payers have signaled they will likely cut benefits to accommodate the rate notice. 

Source: Rylee Wilson, Becker’s Payer Issues [4/25/24]

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BANKS: Eight Types; plus 1

DOCTORS NEED TO KNOW

SPONSOR: https://marcinkoassociates.com/

By Dr. David Edward Marcinko MBA CMP

A general understanding of these bank types is suggested for any medical professional prior to launching a self-directed [ME, Inc] medical practice, clinic, guided investment strategy, personal financial plan or wealth building portfolio effort; etc.

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HOSPITALS: “Weighted Average Cost of Capital”

By Dr. David Edward Marcinko MBA CMP

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The Cost of Hospital Capital Is “WACC”

It is critical for physician executives to understand and to measure the total cost of hospital capital. Lack of understanding and appreciation of the total cost of capital is widespread, particularly among not-for-profit hospital and physician executives. The capital structure includes long-term debt and equity; total capital is the sum of these two, and, each of these components has cost associated with it.

For the long-term debt portion, this cost is explicit—it is the interest rate plus associated costs of placement and servicing. For the equity portion, the cost is not explicit and is widely misunderstood. In many cases, hospital capital structures include significant amounts of equity that has accumulated over many years of favorable operations.

Far too many executives wrongly attribute zero cost to the equity portion of their capital structure. Although it is correct that generally accepted accounting principles continue to assign a zero cost to equity, there is opportunity cost associated with equity that needs to be considered. This cost is the opportunity available to utilize that capital in alternative ways.

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In general, the cost attributed to equity is the return expected by the equity markets on hospital equity. This can be observed by evaluating the equity prices of hospital companies whose equity is traded on public stock exchanges. Usually, the equity prices will imply cost of equity in the range of 10%–14%. Almost always, the cost of equity implied by hospital equity prices traded on public stock exchanges will substantially exceed the cost of long-term debt. Thus, while many hospital executives will view the cost of equity to be substantially less than the cost of debt (i.e., to be zero) in nearly all cases, the appropriate cost of equity will be substantially greater than the cost of debt.

Hospitals need to measure their weighted average cost of capital (WACC). WACC is the cost of long-term debt multiplied by the ratio of long-term debt to total capital plus the cost of equity multiplied by the ratio of equity to total capital (where total capital is the sum of long-term debt and equity).

WACC is then used as the basis for capital charges associated with all capital investments. Capital investments should be expected to generate positive returns after applying this capital charge based on the WACC. Capital investments that do not generate returns exceeding the WACC consume enterprise value; those that generate returns exceeding WACC increase enterprise value. Therefore, physician and hospital executives need to be rewarded for increasing enterprise value.

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FTC: Non-Competition Contract Clause Agreements?

By Staff Reporters

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FTC Votes 3-2  to Ban Non-Compete Agreements, but Legal Challenges Expected

The Federal Trade Commission (FTC) just voted 3-2 to issue a final rule striking new non-compete agreements for all workers and phasing out existing non-competes for all but senior executives across “most employers.” The ban does not apply to non-profits including many of the country’s healthcare provider organizations due to the limitations of the FTC’s jurisdiction, one of several points of contention that has been raised by hospital industry groups that have opposed the ban.

The final rule will take effect 120 days after its publication in the Federal Register. To be in compliance, impacted employers will need to stop enforcing existing non-competes with workers other than senior executives, inform those who are no longer bound by existing non-competes and stop initiating new non-competes for all workers going forward, FTC staff said during an open meeting on the final rule held last week.

Source: Dave Muoio, Fierce Healthcare [4/23/24]

Moreover, the stay-or-pay contract practice requires nurses to put in a certain amount of time “or be required to pay money to their employer for an alleged debt, which could be tied to so-called training, a sign-on bonus, or other costs their employer claims are related to their employment,” according to National Nurses United (NNU), a union that represents about a quarter of a million registered nurses (RNs).

“The new FTC rule is a step in the right direction for nurses and those aspiring to take on this critical role in our communities,” NNU President Nancy Hagans said in a statement.

MORE: https://tinyurl.com/bdethdwh

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Three BOTS of Artificial Intelligence

A.I. and Computers

By Staff Reporters

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  • Google revealed its answer to ChatGPT: an “experimental conversational AI service” called Bard that’s currently in testing mode.
  • Microsoft (which invested in ChatGPT) announced its own surprise event scheduled for later today in order to “share some progress on a few exciting projects.”
  • Chinese tech giant Baidu confirmed it’s on track to introduce its AI chatbot, known as “Ernie Bot” in English, in March.

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LAUGH -or- CRY?

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IAN BEAN MD

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PODCAST: Artificial Intelligence in Healthcare

By Eric Bricker MD

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PODCAST: Artificial Intelligence in Medicine

MACHINE LEARNING AND NATURAL LANGUAGE PROCESSING

By Eric Bricker MD

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US INCOME GAP: A New Reality Check for Doctors NOT Going Broke!

Sobering News for all Medical Professionals

To Be Thankful

By Ann Miller RN MHA CMP

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Poverty in America

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Assessment

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

Our Other Print Books and Related Information Sources:

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e-BOOKS: For Doctors, Financial Advisors, CPAs, Insurance Agents, Medical Consultants and Health Law Attorneys

By Ann Miller RN MHA CMP

INTRODUCING OUR NEXT GENERATION e-BOOK LIBRARY FROM iMBA, Inc.

An e-book is an electronic or digital book that can be read on a computer or a handheld device.

Our new e-books consists of text, images, and are fixed to a specific spot on the page.

And, our e-books are a data files similar in content and structure to a word-processing document that comes in a PDF format. To use our e-books, you need to purchase and download it to a device that has a .pdf file reader app, such as ADOBE® or similar on a smartphone, tablet or computer. A PDF, also known as a portable document format, is the format most people are familiar with and used in our e-books. PDFs are known for their ease of use and ability to hold custom layouts. They are the most commonly used e-Book formats, especially by professionals and adult-learners.

You can then access the e-book and read it, or highlight pages and even take side notes.

e-Books Save Money

With no manufacturing, printing, binding or shipping costs, e-Books are cheaper than traditional hard or paper back books.The price of each specialized and highly niche focused e-Book [50-100 pages] is only $25, whereas similar paperback printed books of this type generally cost $145, or more!

Payable thru PayPal [3% courtesy surcharge applies].

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PODCAST: CVS Corporate History

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RETIREMENT: Can Doctors Afford It?

By Staff Reporters

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You’ve got a sense of your ideal retirement age. And you’ve probably made certain plans based on that timeline. But what if you’re forced to retire sooner than you expect? Aging baby-boomers, corporate medicine, the medical practice great resignation and/or the pandemic, etc?

RESIGNATION: https://medicalexecutivepost.com/2021/12/12/healthcare-industry-hit-with-the-great-resignation-retirement/

Early retirement is nothing new, but it’s clear how much the COVID-19 pandemic has affected an aging workforce. Whether due to downsizing, objections to vaccine mandates, concerns about exposure risks, other health issues, or the desire for more leisure time, the retired general population grew by 3.5 million over the past two years—compared to an annual average of 1 million between 2008 and 2019—according to the Pew Research Center.1 At the same time, a survey conducted by the National Institute on Retirement Security revealed that more than half of Americans are concerned that the COVID-19 pandemic has impacted their ability to achieve a secure retirement.2

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There’s no need to panic, but those numbers make one thing clear, says Rob Williams, managing director of financial planning, retirement income, and wealth management for the Schwab Center for Financial Research. Flexible and personalized financial planning that addresses how you’d cope if you had to retire early can help you make the best use of all your resources. 

So – Here are six steps to follow. We’ll use as an example a person who’s seeing if they could retire five years early, but the steps remain the same regardless of your individual time frame.

Step 1: Think strategically about pension and Social Security benefits

For most retirees, Social Security and (to a lesser degree) pensions are the two primary sources of regular income in retirement. You usually can collect these payments early—at age 62 for Social Security and sometimes as early as age 55 with a pension. However, taking benefits early will mean that you get smaller monthly benefits for the rest of your life. That can matter to your bottom line, even if you expect Social Security to be merely the icing on your retirement cake.

On the Social Security website, you can find a projection of what your benefits would be if you were pushed to claim them several years early. But if you’re part of a two-income couple, you may want to make an appointment at a Social Security office or with a financial professional to weigh the potential options.

For example, when you die, your spouse is eligible to receive your monthly benefit if it’s higher than his or her own. But if you claim your benefits early, thus receiving a reduced amount, you’re likewise limiting your spouse’s potential survivor benefit.

If you have a pension, your employer’s pension administrator can help estimate your monthly pension payments at various ages. Once you have these estimates, you’ll have a good idea of how much monthly income you can count on at any given point in time.

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Step 2: Pressure-test your 401(k)

In addition to weighing different strategies to maximize your Social Security and/or pension, evaluate how much income you could potentially derive from your personal retirement savings—and there’s a silver lining here if you’re forced to retire early. 

Rule of 55

Let’s say you leave your job at any time during or after the calendar year you turn 55 (or age 50 if you’re a public safety employee with a government defined-benefit plan). Under a little-known separation-of-service provision, often referred to as the “rule of 55,” you may be able take distributions (though some plans may allow only one lump-sum withdrawal) from your 401(k), 403(b), or other qualified retirement plan free of the usual 10% early-withdrawal penalties. However, be aware that you’ll still owe ordinary income taxes on the amount distributed. 

This exception applies only to the plan (including any consolidated accounts) that you were contributing to when you separated from service. It does not extend to IRAs. 

4% rule

There’s also a simple rule of thumb suggesting that if you spend 4% or less of your savings in your first year of retirement and then adjust for inflation each year following, your savings are likely to last for at least 30 years—given that you make no other changes to your withdrawals, such as a lump sum withdrawal for a one-time expense or a slight reduction in withdrawals during a down market. 

To see how much monthly income you could count on if you retired as expected in five years, multiply your current savings by 4% and divide by 12. For example, $1 million x .04 = $40,000. Divide that by 12 to get $3,333 per month in year one of retirement. (Again, you could increase that amount with inflation each year thereafter.) Then do the same calculation based on your current savings to see how much you’d have to live on if you retired today. Keep in mind that your money will have to last five years longer in this instance.

Knowing the monthly amount your current savings can generate will give you a clearer sense of whether you’ll have a shortfall—and how large or small it might be. Use our retirement savings calculator to test different saving amounts and time frames.

Step 3: Don’t forget about health insurance, doctor!

Nobody wants to spend down a big chunk of their retirement savings on unanticipated healthcare costs in the years between early retirement and Medicare eligibility at age 65. If you lose your employer-sponsored health insurance, you’ll want to find some coverage until you can apply for Medicare. 

Your options may include continuing employer-sponsored coverage through COBRA, insurance enrollment through the Health Insurance Marketplace at HealthCare.gov, or joining your spouse’s health insurance plan. You may also find discounted coverage through organizations you belong to—for example, the AARP. 

Step 4: Create a post-retirement budget

To make sure your retirement savings will cover your expenses, add up the monthly income you could get from pensions, Social Security, and your savings. Then, compare the total to your anticipated monthly expenses (including income taxes) if you were to retire five years early and are eligible, and choose to file, for Social Security and pension benefits earlier. 

Take into account various life events and expenditures you may encounter. You may not pay off your mortgage by the date you’d planned. Your spouse might still be working (which can add income but also prolong certain expenses). Or your children might not be out of college yet. 

You’re probably fine if you anticipate that your monthly expenses will be lower than your income. But if you think your expenses would be higher than your early-retirement income, some suggest that you take one or more of these measures:

  • Retire later; practice longer.
  • Save more now to fill some of the potential gap.
  • Trim your budget so there’s less of a gap down the road.
  • Consider options for medical consulting or part-time work—and begin to explore some of those opportunities now.

To the last point, finding a physician job later in life can be challenging, but certain employment agencies specialize in this area. If you can find work you like that covers a portion of your expenses, you’ll have the option of delaying Social Security and your company pension to get higher payments later—and you can avoid dipping into your retirement savings prematurely. 

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

ORDER: https://www.routledge.com/Risk-Management-Liability-Insurance-and-Asset-Protection-Strategies-for/Marcinko-Hetico/p/book/9781498725989

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Step 5: Protect your portfolio

When you retire early, you have to walk a fine line with your portfolio’s asset allocation—investing aggressively enough that your money has the potential to grow over a long retirement, but also conservatively enough to minimize the chance of big losses, particularly at the outset.

“Risk management is especially important during the first few years of retirement or if you retire early,” Rob notes, because it can be difficult to bounce back from a loss when you’re drawing down income from your portfolio and reducing the overall number of shares you own.  

To strike a balance between growth and security, start by making sure you have enough money stashed in relatively liquid, relatively stable investments—such as money market accounts, CDs, or high-quality short-term bonds—to cover at least a year or two of living expenses. Divide the rest of your portfolio among stocks, bonds, and other fixed-income investments. And don’t hesitate to seek professional help to arrive at the right mix. 

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Many people are unaccustomed to thinking about their expenses because they simply spend what they make when working, Rob says. But one of the most valuable decisions you can make about your life in retirement is to reevaluate where your money is going now.

This serves two aims. First, it’s a reality check on the spending plan you’ve envisioned for retirement, which may be idealized (e.g., “I’ll do all the home maintenance and repairs!”). Second, it enables you to adjust your spending habits ahead of schedule—whichever schedule you end up following. This gives you more control and potentially more income. 

Step 6: Reevaluate your current spending

For example, if you’re not averse to downsizing, moving to a less expensive home could reduce your monthly mortgage, property tax, and insurance payments while freeing up equity that could also be invested to provide additional monthly income.

“When you are saving for retirement, time is on your side”. You lose that advantage when you’re forced to retire early, but having a backup plan that anticipates the possibility of an early retirement can make the unknowns you face a lot less daunting.

CITE: https://www.r2library.com/Resource/Title/082610254

References:

1Richard Fry, “Amid the Pandemic, A Rising Share Of Older U.S. Adults Are Now Retired”, Pew Research Center, 11/04/2021, https://www.pewresearch.org/fact-tank/2021/11/04/amid-the-pandemic-a-rising-share-of-older-u-s-adults-are-now-retired/.

2Tyler Bond, Don Doonan and Kelly Kenneally, “Retirement Insecurity 2021: Americans’ Views of Retirement”, Nirsonline.Org, 02/2021, https://www.nirsonline.org/wp-content/uploads/2021/02/FINAL-Retirement-Insecurity-2021-.pdf.

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PERSONAL COACHING: Dr. Marcinko at Your Service!

By Ann Miller RN MHA CMP

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http://www.DAVIDEDWARDMARCINKO.com

Dr. David Edward Marcinko works with doctors, nurses, technicians and healthcare professionals who struggle with professional disillusionment, burnout, financial distress and an unbalanced life–all of which can happen at any stage of a medical career. Through our coaching sessions, medical and healthcare professionals can achieve a more meaningful, purposeful, and flourishing life.

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CONTACT: Ann Miller RN MHA CMP

MarcinkoAdvisors@msn.com

MORE: https://medicalexecutivepost.com/coach/

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CERTIFIED MEDICAL PLANNER™ Niche Financial Advisor Professional Designation

Think Different – Be Different  – Thrive

[By Ann Miller RN MHA]

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http://www.CertifiedMedicalPlanner.org

Dear Physician Focused Financial Advisors

Did you know that desperate doctors of all ages are turning to knowledgeable financial advisors and medical management consultants for help? Symbiotically too, generalist advisors are finding that the mutual need for knowledge and extreme niche synergy is obvious.

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planning

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But, there was no established curriculum or educational program; no corpus of knowledge or codifying terms-of-art; no academic gravitas or fiduciary accountability; and certainly no identifying professional designation that demonstrated integrated subject matter expertise for the increasingly unique healthcare focused financial advisory niche … Until Now! 

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Enter the CMPs

“The informed voice of a new generation of fiduciary advisors for healthcare”

Think Different

 [Think Different – Be Different – Thrive]

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So, if you are looking to supplement your knowledge, income and designations; and find other qualified professionals you may want to consider the CMP® program.

Enter the Certified Medical Planner™ charter professional designation. And, CMPs™ are FIDUCIARIES, 24/7.

Channel Surfing the ME-P

Have you visited our other topic channels? Established to facilitate idea exchange and link our community together, the value of these topics is dependent upon your input. Please take a minute to visit. And, to prevent that annoying spam, we ask that you register. It is fast, free and secure.

Conclusion

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

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Become a CMP

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

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

 Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners(TM)* 8

FINANCIAL ADVISORS: Finally Website Posting Their Fees?

Nevertheless – Physicians and All Investors Must be AWARE & INFORMED!

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Dr. David E. Marcinko MBA MEd CMP®

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Many financial planning websites mention fees, as required, but still remain opaque to potential clients because the advisor wants to control the discussion and understandably wishes to avoid the website shopper phenomenon.

But, physicians and all investors can still control the discussion, and still provide transparency, because posting up front pricing information doesn’t mean presenting information in a vacuum!

For example, a 1%/year fee doesn’t have to just be 1%; it can be 1%, compared to an industry average cost of X%, where the average cost of an actively managed mutual fund is Y%.

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See the source image

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Similarly, it doesn’t have to be a retainer fee of $1,000/year; it can be a retainer fee for less than the cost of a monthly cable bill! And, a financial plan doesn’t cost $1,500; it costs 8-12 hours of staff time to craft extensive, customized solutions; but saves the doctor-client so much more!

And, if services have a range of potential prices, they might be provided with some insight into the factors that impact the price. Modern young and internet savvy doctors expect this sort of information.

ASSESSMENT: Your thoughts are appreciated.

LINK: https://medicalexecutivepost.com/2015/04/06/understanding-the-failure-to-recognize-mutual-fund-fees/

MORE: https://medicalexecutivepost.com/2015/02/12/a-review-of-investing-expenses/

LINK: https://medicalexecutivepost.com/2018/04/26/the-six-types-of-investment-fees/

Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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INVITE DR. MARCINKO: https://medicalexecutivepost.com/dr-david-marcinkos-bookings/

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ONC: Push-Back Against Health IT Blocking Dis-Incentives

By Staff Reporters

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Certified Health Information Technology Reported by Clinicians for ...

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DEFINITION: The Office of the National Coordinator for Health Information Technology (ONC) is a staff division of the Office of the Secretary, within the U.S. Department of Health and Human Services. ONC leads national health IT efforts, charged as the principal federal entity to coordinate nationwide efforts to implement and use the most advanced health information technology [HIT] and the electronic exchange of health information.

CITE: https://www.r2library.com/Resource

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And so, hospitals and medical groups are now pushing back on ONC’s proposed information blocking disincentives, arguing that the financial penalties are “excessive,” “unfair” and will discourage participation in value-based care programs [VBC].

VBC: https://medicalexecutivepost.com/2023/08/14/value-based-care-guidelines-and-best-practices/

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What is a “Market-Neutral” Fund?

Market Neutral Funds Demystified

[A Special Report]

By Dimitri Sogoloff MD MBA & Dr. David E. Marcinko MBA MEd CMP

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Introduction

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It’s hard to believe that just 30 years ago, physician investors had only two primary asset classes from which to choose: U.S. equities and U.S. bonds.

Today, the marketplace offers a daunting array of investment choices. Rapid market globalization, technology advancements and investor sophistication have spawned a host of new asset classes, from the mundane to the mysterious.

Even neophyte medical investors can now buy and sell international equities, emerging market debt, mortgage securities, commodities, derivatives, indexes and currencies, offering infinitely more opportunities to make, or lose, money.

Amidst this ongoing proliferation, a unique asset class has emerged, one that is complex, non-traditional and not easily understood like stocks or bonds. It does, however, offer one invaluable advantage; its returns are virtually uncorrelated with any other asset class. When this asset class is introduced into a traditional investment portfolio, a wonderful thing occurs; the risk-return profile of the overall portfolio improves dramatically.

This asset class is known as a Market-Neutral strategy. The reason few medical professionals have heard of market neutral strategies is that most of them are offered by private investment partnerships otherwise known as hedge funds.

To the uninitiated, “hedge fund” means risky, volatile or speculative. With a market-neutral strategy however, just the opposite is true. Funds utilizing market-neutral strategies typically emphasize the disciplined use of investment and risk control processes. As a result, they have consistently generated returns that display both low volatility and a low correlation with traditional equity or fixed income markets. 

Definition of Market-Neutral

All market-neutral funds share a common objective: to achieve positive returns regardless of market direction. Of course, they are not without risk; these funds can and do lose money. But a key to their performance is that it is independent of the behavior of the markets at large, and this feature can add tremendous value to the rest of a portfolio.

A typical market-neutral strategy focuses on the spread relationship between related securities, which is what makes them virtually independent of underlying debt or equity markets. When two related securities are mispriced in relation to one another, the disparity will eventually disappear as the result of some external event. This event is called convergence and may take the form of a bond maturity, completion of a merger, option exercise, or simply a market recognizing the inefficiency and eliminating it through supply and demand.

Here’s how it might work

When two companies announce a merger, there is an intended future convergence, when the shares of both companies will converge and become one. At the time of the announcement, there is typically a trading spread between two shares. A shrewd trader, seeing the probability of the successful merger, will simultaneously buy the relatively cheaper share and sell short the relatively more expensive share, thus locking in the future gain.

Another example of convergence would be the relationship between a convertible bond and its underlying stock. At the time of convergence, such as bond maturity, the two securities will be at parity. However, the market forces of supply and demand make the bond underpriced relative to the underlying stock. This mispricing will disappear upon convergence, so simultaneously buying the convertible bond and selling short an equivalent amount of underlying stock, locks in the relative spread between the two.  

Yet another example would be two bonds of the same company – one junior and one senior. For various reasons, the senior bond may become cheaper relative to the junior bond and thus display a temporary inefficiency that would disappear once arbitrageurs bought the cheaper bond and sold the more expensive bond.

While these examples involve different types of securities, scenarios and market factors, they are all examples of a market-neutral strategy. Locking a spread between two related securities and waiting for the convergence to take place is a great way to make money without ever taking a view on the direction of the market.

How large are these spreads, you may ask? Typically, they are tiny. The markets are not quite fully efficient, but they are efficient enough to not allow large price discrepancies to occur.

In order to make a meaningful profit, a market-neutral fund manager needs sophisticated technology to help identify opportunities, the agility to rapidly seize those opportunities, and have adequate financing resources to conduct hundreds of transactions annually.  

Brief Description of Strategies

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The universe of market-neutral strategies is vast, spanning virtually every asset class, country and market sector. The spectrum varies in risk from highly volatile to ultra conservative. Some market-neutral strategies are more volatile than risky low-cap equity strategies, while others offer better stability than U.S Treasuries.

One unifying factor across this vast ocean of seemingly disparate strategies is that they all attempt to take advantage of a relative mispricing between various securities, and all offer a high degree of “market neutrality,” that is, a low correlation with underlying markets.

[A] Convertible Arbitrage

Convertible arbitrage is the oldest market-neutral strategy. Designed to capitalize on the relative mispricing between a convertible security (e.g. convertible bond or preferred stock) and the underlying equity, convertible arbitrage was employed as early as the 1950s.

Since then, convertible arbitrage has evolved into a sophisticated, model-intensive strategy, designed to capture the difference between the income earned by a convertible security (which is held long) and the dividend of the underlying stock (which is sold short). The resulting net positive income of the hedged position is independent of any market fluctuations. The trick is to assemble a portfolio wherein the long and short positions, responding to equity fluctuations, interest rate shifts, credit spreads and other market events offset each other.  

A convertible arbitrage strategy involves taking long positions in convertible securities and hedging those positions by selling short the underlying common stock. A manager will, in an effort to capitalize on relative pricing inefficiencies, purchase long positions in convertible securities, generally convertible bonds, convertible preferred stock or warrants, and hedge a portion of the equity risk by selling short the underlying common stock. Timing may be linked to a specific event relative to the underlying company, or a belief that a relative mispricing exists between the corresponding securities.

Convertible securities and warrants are priced as a function of the price of the underlying stock, expected future volatility of returns, risk free interest rates, call provisions, supply and demand for specific issues and, in the case of convertible bonds, the issue-specific corporate/Treasury yield spread.

Thus, there is ample room for relative misvaluations. Because a large part of this strategy’s gain is generated by cash flow, it is a relatively low-risk strategy. 

[B] Fixed-Income Arbitrage

Fixed-income arbitrage managers seek to exploit pricing inefficiencies across global markets.

Examples of these anomalies would be arbitrage between similar bonds of the same company, pricing inefficiencies of asset-backed securities and yield curve arbitrage (price differentials between government bonds of different maturities). Because the prices of fixed-income instruments are based on interest rates, expected cash flows, credit spreads, and related factors, fixed-income arbitrageurs use sophisticated quantitative models to identify pricing discrepancies.

Similarly to convertible arbitrageurs, fixed-income arbitrageurs rely on investors less sophisticated than themselves to misprice a complex security.

[C] Equity Market-Neutral Arbitrage

This strategy attempts to offset equity risk by holding long and short equity positions. Ideally, these positions are related to each other, as in holding a basket of S&P500 stocks and selling S&P500 futures against the basket. If the manager, presumably through stock-picking skill, is able to assemble a basket cheaper than the index, a market-neutral gain will be realized.

A related strategy is identifying a closed-end mutual fund trading at a significant discount to its net asset value. Purchasing shares of the fund gains access to a portfolio of securities valued significantly higher. In order to capture this mispricing, one needs only to sell short every holding in the fund’s portfolio and then force (by means of a proxy fight, perhaps) conversion of the fund from a closed-end to an open-end (creating convergence).

Sounds easy, right?

In considering equity market-neutral, you must be careful to differentiate between true market-neutral strategies (where long and short positions are related) and the recently popular long/short equity strategies.

In a long/short strategy, the manager is essentially a stock-picker, hopefully purchasing stocks expected to go up, and selling short stocks expected to depreciate. While the dollar value of long and short positions may be equivalent, there is often little relationship between the two, and the risk of both bets going the wrong way is always present.

[D] Merger Arbitrage (a.k.a. Risk Arbitrage)

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

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

A textbook example was the acquisition of SDL Inc (SDLI), by JDS Uniphase Corp (JDSU). On July 10, 2000 JDSU announced its intent to acquire SDLI by offering to exchange 3.8 shares of its own shares for one share of SDLI.

At that time, the JDSU shares traded at $101 and SDLI at $320.5. It was apparent that there was almost 20 percent profit to be realized if the deal went through (3.8 JDSU shares at $101 are worth $383 while SDLI was worth just $320.5). This apparent mispricing reflected the market’s expectation about the deal’s outcome. Since the deal was subject to the approval of the U.S. Justice Department and shareholders, there was some doubt about its successful completion. Risk arbitrageurs who did their homework and properly estimated the probability of success bought shares of SDLI and simultaneously sold short shares of JDSU on a 3.8 to 1 ratio, thus locking in the future profit.

Convergence took place about eight months later, in February 2001, when the deal was finally approved and the two stocks began trading at exact parity, eliminating the mispricing and allowing arbitrageurs to realize a profit. 

Merger Arbitrage, also known as risk arbitrage, involves investing in securities of companies that are the subject of some form of extraordinary corporate transaction, including acquisition or merger proposals, exchange offers, cash tender offers and leveraged buy-outs. These transactions will generally involve the exchange of securities for cash, other securities or a combination of cash and other securities.

Typically, a manager purchases the stock of a company being acquired or merging with another company, and sells short the stock of the acquiring company. A manager engaged in merger arbitrage transactions will derive profit (or loss) by realizing the price differential between the price of the securities purchased and the value ultimately realized when the deal is consummated. The success of this strategy usually is dependent upon the proposed merger, tender offer or exchange offer being consummated.  

When a tender or exchange offer or a proposal for a merger is publicly announced, the offer price or the value of the securities of the acquiring company to be received is typically greater than the current market price of the securities of the target company.

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

[E] Event-Driven Arbitrage

Funds often use event-driven arbitrage to augment their primary market-neutral strategy. Generally, any convergence which is produced by a future corporate event would fall into this category.

Accordingly, Event-Driven investment strategies or “corporate life cycle investing” involves investments in opportunities created by significant transactional events, such as spin-offs, mergers and acquisitions, liquidations, reorganizations, bankruptcies, recapitalizations and share buybacks and other extraordinary corporate transactions.

Event-Driven strategies involve attempting to predict the outcome of a particular transaction as well as the optimal time at which to commit capital to it. The uncertainty about the outcome of these events creates investment opportunities for managers who can correctly anticipate their outcomes.

As such, Event-Driven trading embraces merger arbitrage, distressed securities and special situations investing. Event-Driven managers do not generally rely on market direction for results; however, major market declines, which would cause transactions to be repriced or break, may have a negative impact on the strategy. 

Event-driven strategies are research-intensive, requiring a manager to do extensive fundamental research to assess the probability of a certain corporate event, and in some cases, to take an active role in determining the event’s outcome. 

Risk and Reward Characteristics

To help understand market-neutral performance and risk, let’s take a look at the distribution of returns of individual strategies and compare it to that of traditional asset classes.

 Table 1:  Average Return / Volatility of Market Neutral Strategies And Selected Traditional Asset Classes 

 

Strategy Average Return Annualized Volatility
Convertible Arbitrage 11.95% 3.57%
Fixed Income Arbitrage 8.33% 4.90%
Equity Market-Neutral 11.62% 4.95%
Merger Arbitrage 13.29% 3.51%
Relative Value Arbitrage 15.69% 4.31%
   Traditional Asset Classes:    
S&P 500 12.62% 13.72%
MSCI World 8.57% 13.05%
High Grade U.S. Corp. Bonds 7.26% 3.73%
World Government Bonds 5.91% 5.96%

The most important observation about this chart is that the Market Neutral funds exhibits considerably lower risk than most traditional asset classes.

While market-neutral strategies vary greatly and involve all types of securities, the risk-adjusted returns are amazingly stable across all strategies. The annualized volatility – a standard measure of performance risk – varies between 3.5 and 5 percent, comparable to a conservative fixed-income strategy.     

Another interesting statistics is the correlation between Market Neutral strategies and traditional asset classes and traditional asset classes

Table 2: Correlation between Market Neutral Strategies and Traditional Asset Classes

 

Asset Class/Strategy S&P500 MSCI World GovBonds CorpBonds

The correlation of all market neutral strategies to traditional assets is quite low, or negative in some cases. This suggests that these strategies would indeed play a useful role in the ultimate goal of efficient portfolio diversification.

To test the “market neutrality” of these strategies, we asked, “How well, on average, did these strategies perform during bad, as well as good, market months?”

It turns out, in good times and bad, these strategies displayed consistent solid performance. From 12/31/91, in months when S&P 500 was down, the average down month was 3.03 percent. Market Neutral strategies performed as follows:

  

Strategy Average Monthly Return
Convertible Arbitrage + 0.65%
Fixed Income Arbitrage + 0.50%
Equity Market-Neutral + 1.19%
Merger Arbitrage + 0.88%
Relative Value Arbitrage + 0.81%

In months when S&P 500 was up, the average up month was +3.24 percent.  Market Neutral strategies performed as follows:

  

Strategy Average Monthly Return
Convertible Arbitrage +1.17%
Fixed Income Arbitrage +1.20%
Equity Market-Neutral +1.37%
Merger Arbitrage +0.60%
Relative Value Arbitrage +1.25%

Clearly, a compelling picture emerges. While these strategies, on average, underperform during good times, they show a positive average return during both good and bad markets.

Inclusion of Market-Neutral in a Long-term Investment Portfolio

A critical concern for any medical investor considering a foray into a new asset class is how it will alter the long-term risk/reward profile of the overall portfolio. To better understand this, we constructed several hypothetical portfolios consisting of traditional asset classes:

·  US Treasuries (Salomon Treasury Index 10yrs+)

·  High Grade Corporate Bonds  (Salomon Investment Grade Index)

·  Speculative Grade Corporate Bonds  (High Yield Index)

·  US Blue chip equities  (Dow Jones Industrial Average)

·  US mid-cap equities  (S&P 400 Midcap Index)

·  US small-cap equities (S&P 600 Smallcap Index)

Portfolios varied in the level of risk from 100 percent U.S Treasuries (least risky) to 100 percent small-cap equities (most risky), and are ranked from 1 to 10, 1 representing the least risky portfolio.Each portfolio was analyzed on a Risk/Return basis using monthly return data since December 1991. The results are shown in Chart 1.Predictably, the least risky portfolio produced the smallest return, while the riskiest produced the highest return. This is perfectly understandable – you would expect to be compensated for taking a higher level of risk.

Chart 1: Risk/Return characteristics of traditional portfolios vs. Market Neutral strategies 

Clearly, the risk-return picture offered by Market Neutral strategies is much more compelling (lower risk, higher return) than that offered by portfolios of traditional assets. What happens if we introduce these market-neutral strategies into traditional portfolios? Let’s take 20 percent of the traditional investments in our portfolio and reinvest them in market-neutral strategies.

The change is dramatic: the new portfolios (denoted 1a through 10a) offer significantly less risk for the same return. The riskiest portfolio, for instance (number 10) offered 20 percent less risk for a similar return of a new portfolio containing market-neutral strategies (number 10a).   
 
Chart 2:  Result of inclusion of 20% of Market Neutral strategies in traditional portfolios 

This is quite a difference.  Everything else being equal, anyone would choose the new, “improved” portfolios over the traditional ones.

How to invest

The mutual fund world does not offer a great choice of market neutral strategies. 

Currently, there are only a handful of good mutual funds that label themselves market-neutral (AXA Rosenberg Market Netural fund and Calamos Market Neutral fund are two examples).

Mutual fund offerings are slim due to excessive regulations imposed by the SEC with respect to short selling and leverage, and consequently these funds lack flexibility in constructing truly hedged portfolios. The dearth of market-neutral offerings among mutual funds is offset by a vast array of choices in the hedge fund universe. Approximately 400 market-neutral funds, managing $60 billion, represent roughly 25% of all hedge funds.

Therefore, further focus will relate to the hedge fund universe, rather than the limited number of market-neutral mutual funds.

Direct investing in a market-neutral hedge fund is restricted to qualifying individuals who must meet high net worth and/or income requirements, and institutional investors, such as corporations, qualifying pension plans, endowments, foundations, banks, insurance companies, etc.

This does not mean that retail investors cannot get access to hedge fund exposure. Various private banking institutions offer funds of funds with exposure to hedge funds. Maaket-neutral funds are nontraditional investments. They are part of a larger subset of strategies known as alternative investments, and there is nothing traditional in the way doctors invest in them.

Hedge funds are private partnerships, which gives them maximum flexibility in constructing and managing portfolios, but also requires medical investors to do a little extra work.

[A] Lockup Periods

One of the main differences between mutual funds and hedge funds is liquidity. Market-neutral strategies have less liquidity than traditional portfolios. Quarterly redemption policies with 45- or 60-days notice are common. Many funds allow redemptions only once a year and some also have lock-up periods. In addition, few of these funds pay dividends or make distributions. These investments should be regarded strictly as long-term strategies.

[B] Managerial Risks

Success of a market-neutral strategy depends much less on the market direction than on the manager’s skill in identifying arbitrage opportunities and capitalizing on them.

Thus, there is significantly more risk with the manager than with the market. It’s vital for investors to understand a manager’s style and to monitor any deviations from it due to growth, personnel changes, bad decisions, or other factors.

[C] Fees

If you are accustomed to mutual fund fees, brace yourself; market-neutral investing does not come cheap.

Typical management fees range from 1 to 2 percent per year, plus a performance fee averaging 20 percent of net profits. Most managers have a “high watermark” provision; they cannot collect the performance fees until investors recoup any previous losses. Look for this provision in the funds’ prospectus and avoid any fund that lacks it. Even with higher fees, market-neutral investing is superior to most traditional mutual fund investing on a risk-adjusted return basis.

[D] Transparency

Mutual funds report their positions to the public regularly. This is not the case with market-neutral hedge funds. Full transparency could jeopardize accumulation of a specific position. It also generates front running: buying or selling securities before the fund is able to do so. While you should not expect to see individual portfolio positions, many hedge fund managers do provide a certain level of transparency by indicating their geographical or sector exposures, level of leverage and extent of hedging.

It does take a bit of education to understand these numbers, but the effort is definitely worthwhile. 

[E] Taxation

The issue of hedge fund taxation is quite complex and is often dependent on the fund and the personal situation of the investor. Advice from a competent accountant, specialized financial advisor, tax attorney with relevant experience is worthwhile. The bottom line is that investing in market-neutral funds is not a tax-planning exercise and it will not minimize your taxes.

On the other hand, it should not generate any more or fewer taxes than if you invested in more traditional funds.

From the medical investor’s perspective, the principal advantages of market-neutral investing are attractive risk-adjusted returns and enhanced diversification.

Ten years of data indicate that market-neutral portfolios have produced risk-adjusted returns superior to traditional investments. In addition, the correlation between the returns of market-neutral funds and traditional asset classes has been historically negligible.

Adding exposure of market-neutral return strategies to the asset mix within a consistent, long-term investment program offers a medical investor the opportunity to improve overall returns, as well as achieving some protection against negative market movements.

Now, after all of the above, has your impression of hedge funds in general or MN funds in particular, changed?

APPENDIX:  

Asset class weighting in traditional portfolios:
Portfolio US Treasuries US High Grade Corp Bonds US Low Grade Corp Bonds Large Cap Stocks Mid Cap Stocks Small Cap Stocks
1 50% 50%        
2   50% 50%      
3 10% 30% 50% 40%    
4   50%   50%    
5   10% 10% 50% 30%  
6     10% 50% 20% 20%
7     10% 30% 20% 40%
8       20% 20% 60%
9         20% 80%
10           100%

 

Conclusion

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Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners(TM)

Interest Rates and the Money Commodity

Medial Office Equipment Interest Rate Costs

David Edward Marcinko

Dr. David E. Marcinko; MBA, MEd, CMP™

[Publisher in Chief]

Physicians, administrators and healthcare entrepreneurs are aware of the compounding effect of interest. However, since interest is deductible as a medical office business expense, many seem to forget about it despite the fact that it must be continually paid until the asset is either purchased or otherwise disposed. 

So, what are the various types of interest rates important to the medical practitioner and commodity – money?

[1] Simple Interest

Simple interest is merely the pro rata interest on a loan or deposit and represents the most basic interest rate type.

For example, for every $100 Dr. Bill borrows at 12 percent annual interest, he pays twelve dollars per year. The interest is calculated by multiplying the principal or original amount, by the interest rate in decimal form (100 x .12). 

[2] Add-On Interest

Add on interest immediately attaches the annual interest amount, to the principal amount, at the beginning of the payment period. Payments are then made according to the number of years required.

The following formula is useful: 

Add-on-Interest minus Payment  = Total Interest on Balance/Number of Payments

For example, if Dr. William Needy borrows $10,000 at 8 percent add-on interest, he will repay $10,000 plus $ 800 ($10,000 x 8%) or $10,800, divided by twelve months, for a total of $900 per month, since $ 900/month x 12 months equals $10,800.  

[3] Discounted Interest

When using the discounted interest method, the interest amount is deducted from the principal right up front. Notice that this is the opposite of add-on-interest that is applied up front.

For example, if Dr. Bill borrows the same $ 10,000 at a discounted interest rate of 8 percent, he will only receive a $9,200 loan, since $10,000 – $800 is $9,200.

Obviously, the discount method is the most expense way to borrow money.  

[4] Annual Percentage Rate

 Most financial institutions advertise an annual percentage rates (APR) for loans, deposits and investments.  The APR is the periodic interest rate multiplied by the number of periods a year. If the APR is 12 percent, and interest is compounded monthly, you receive (or pay) 1 percent of your balance each month, and the balance shifts with each compounding. 

For example, if Dr. Bill deposits $ 100 dollars at 12 percent APR compounded monthly, he receives $ 1 interest the first month (1% of $100), $1.10 the second month (1% of $101), and so forth. If compounding is daily, the interest accumulates at the rate of 1/365 of the APR each day.  

Unless interest is compounded annually, the APR will be lower than the effective annual interest rate, discussed below. 

[5] Effective Interest Rate

It is important to differentiate between the effective interest rate and the APR, which is often the most prominent figure in advertisements for medical business equipment, consumer goods and financial services (loans, annuities, IRAs, CDs, investment analysis, college funding or retirement planning).  Although the APR is the periodic interest rate multiplied by the number of periods per year, the effective annual interest rate is the periodic rate, compounded. 

In our case, if the APR is 12 percent, compounded monthly, the monthly interest rate is 1 percent and the effective annual rate is the monthly rate compounded for 12 periods.

Therefore, if your calculation is for a single year, you can treat the effective rate as simple interest. If you deposit (or borrow) $1,000 at 12 percent APR, the effective rate is 12.68 percent, and interest for the first year is about $126.80 (12.68% of $1,000).

For longer periods, you can use the effective interest rate as the periodic interest rate, compounded annually. 

[a] “Rule of 72” (Double your Money)

The number of periods required to double a lump sum of money can be quickly estimated by using what is known as the “Rule of 72”. To get the number of periods, usually years, just divide 72 by the periodic interest rate, expressed as a whole number (not a decimal).

For example, if the annual interest rate is 10 percent, it will take about 7.2 years (72/10) to double any lump cache of money. Conversely, you can also calculate the interest rate required to double your money in a given period by dividing 72 by the term.

Thus, to double your money in ten years, you need to earn about 7.2 percent annual interest (72/10) = 7.2%).  

[b] “Rule of 78”

According to this method, interest is front end loaded like a home mortgage, or office condominium, to discourage prepayment of a loan and consequently preserve the lender’s profit. In other words, it is a method of calculating installment loan interest rebates. 

The number 78 comes from an approved method of accelerated tax depreciation, known as the “Sum of the Years Digits” (SOYD) method (i.e., 12 + 11 + 10 + 9 . . . = 78). This fact is important because, throughout the period of a loan, even though the payments are all the same, the portions that are interest and principal are very different.

Using this method for a one year loan shows that, in the first payment, 15.38 percent of the interest due is paid off, and by the sixth month, 73.08 percent of the interest is paid off.  This means, that if a physician makes a one year equipment loan with a total interest charge of $ 100 and pays the loan off in full with the sixth payments, he or she will not get an interest rebate of $ 50, but only $ 26.92, since $ 73.08 of the interest has already been prepaid. 

Most ethical lenders use simple interest rates for loan rebates, and the Rule of 78 is unfair according to many authorities.  

[c] “Rule of 116”

A derivative of the Rule of 72 is the Rule of 116.  This determines the number of years it takes for a principal amount to be tripled and is calculated by dividing the annual interest rate into 116.

The Rules of 72 and 78 are very handy for figuring the amount of interest payments made or growth of funds invested. They can also be used in reverse to calculate at what rate of interest money must be invested to double or triple in a certain number of years.     

[6] Medical Equipment Payback Cost Analysis

The payback period, expressed in years, is the length of time that it takes for the medical equipment investment to recoup its initial cost out of the cash receipts it generates. The basic premise is that the quicker the cost of an investment can be recovered, the better the investment is. It is most often used when considering equipment whose useful life is short and unpredictable.

When the same cash flow occurs every year, the formula is as follows: 

Investment Required / Net Annual Cash Inflow = Payback Period 

Thus, in today’s tightening medical reimbursement atmosphere, practice cost control and expense reduction is the easiest method to increase medical office profitability.  Keeping the cost of the commodity money in the form of interest rate charges, as low as possible, will assist in this endeavor 

Assessment

And so, how have these rules affected your medical office borrowing costs; if at all? Does these principles apply to the medical student loan crisis, today? 

***

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

The Medicare Cost-Control Efficiency Paradox

Essay on the Eight-Hundred Pound Gorilla in the Medical Treatment Room

By Dr. David E. Marcinko MBA MEd CMP

[Editor-in-Chief]

According to economist Austin Frakt PhD, and others, there is a school of thought that says Congress is incapable of controlling costs in the Medicare and Medicaid System [CMS].

And, then there is the reality known by all practicing medical professionals regardless of specialty orientation or degree designation. That is to say, CMS really can control healthcare costs and with great ferocity and efficiency, and to non-public sectors as well …. PARADOXICAL?

On Getting What You Wish For

Blogger Ezra Klein opines that one of the dirty little secrets of the health-care system is that Medicare has done a much better job controlling costs than private health insurers.

http://voices.washingtonpost.com/ezra-klein/2010/11/what_happens_when_medicare_con.html

A Forehead-Palm Moment

Of course, we doctors know that the real problem is that Medicare seemingly [think Seinfeld’s character George Costanza] controls costs all too well; but not really. It is just that CMS pays doctors too little and thus it appears costs are controlled. What really is happening is that physician fees are being reduced carte’ blanche.

Nevertheless, and regardless of semantics, CMS will never control costs much more efficiently than private insurance companies or doctors will simply abandon Medicare for related payment models like direct reimbursement or concierge medicine. This is happening right now. Physicians, osteopaths and podiatrists etc, are opting out of Medicare in increasingly large numbers. In a world where there’s only Medicare and Medicare to control costs, doctors can either take the pay cut or stop seeing patients, and stop being doctors. “Taking what they are given – because they’re working for a livin.”

So sorry that this seems like a forehead-palm moment for Ezra, but not for healthcare practitioners or the ME-P!

Too Much Demand Elsewhere

And, as we see from other countries, many young bright folks want to be doctors, even if being a doctor doesn’t make one particularly wealthy [high demand and high eventual supply produces lower provider costs in the long term?]. Think medical tourism.

Not so much the case anymore in this country [lower demand and lower eventual supply produces higher reimbursement costs to the doctor survivors in the very long term?].

Our Domestic World

But, we are not elsewhere. In fact, in our present domestic healthcare ecosystem, when Medicare decides to control costs, many doctors can simply stop accepting Medicare patients, and the politicians will lose their jobs. One political party then declares that Medicare is rationing and will hurt senior citizens. The other party capitulates and pays MDs more [SGR]. Then, the federal budget looks bad as it does now. The circle is complete when one party asserts that Medicare actually can’t contain costs but the private insurance companies will.  It all fails, in an unending circular Boolean-like loop of illogic.

Listen Up!

So, listen up AARP, politicians, CMS and seniors as I admonish you to be careful what you wish for [medical cost controls]. It might just come true. As Ezra rightly says; rinse, repeat – rinse, repeat – ad nausea. You simply can’t have it both ways.  You either choose to spend less and offend certain cohorts, or spend more and offend different factions.  Either way, you’re going to piss someone off. A good healthcare reimbursement system would try to make that decision rationally [a-politically]. But, at least it would make an economics driven decision; wouldn’t it?

Assessment

Is CMS really the eight hundred pound cost-controlled gorilla in the increasingly large Medicare treatment room? Why or why not? Now, relative to the ACA of 2010, please read: The Case for Public Plan Choice in National Health Reform [Key to Cost Control and Quality Coverage], by Jacob S. Hacker, PhD. Link: Jacob Hacker Public Plan Choice

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Do we have a Medicare cost control efficiency paradox? Or, are the economists just reveling in the publication banal? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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

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The PROSPERITY Paradox

Paradox of Prosperity

“A paradox of prosperity is revealed and shown to be stable in the cycles of economic advancement between generations. I would put the matter this way: If one accepts, for example, that Mr. Brokaw’s ‘Greatest Generation’ were characterized by prudence, diligence, and patriotism in deed rather than word, that very generation produced its opposite in the generation that followed it. That is to say, I have found it repeated across the ages and across cultures, that the more diligent a previous generation, as a natural propensity, the more licentious the generation that follows. Invariably therefore, the generation that exhibits the more cogent properties of character for the best sort of citizenship fails to produce a generation of the same or similar characteristics.”

***

***

“Paradox of Prosperity” was applied as a term of analysis in the recent New York Times, Wall Street Journal bestseller Rescue America: Our best America is only one generation away (published October 2011), which Professor Morris co-authored with Chris Salamone. There the inter-generational breakdown is given a fuller exposition. Morris, who has been a careful reader of Thorstein Veblen, particularly Veblen’s masterpiece The Theory of the Leisure Class, says his own advancement of this inter-generational thesis was influenced by Veblen. “I think”, says Morris, “Veblen gave some insight as to what is produced in the generation which follows one such as Tom Brokaw described. The Greatest Generations – if by that we mean a generation characterized by prudence and sacrifice – nearly always produces a generation which can be characterized as a leisure class. They consume without manufacturing. They project feelings over principles. In general terms, they lack a spirit of sacrifice because they abhor the notion of “Objective Values” and so lack the will to re-create or advance the social ethos created by their parent’s generation.” In cultural terms, the generation that followed the “Greatest Generation” were the baby boomers (essentially, the children of the Greatest Generation between 1945–1965). The “Boomers” fit the classic definition of a “leisure class”, which Veblen described as being characterized by Conspicuous Consumption.  To quote their description of their leisure class “they move values toward behavior, rather than behavior toward values”.

LINK: https://www.amazon.com/Dictionary-Health-Economics-Finance-Marcinko/dp/0826102549/ref=sr_1_6?ie=UTF8&s=books&qid=1254413315&sr=1-6

THANK YOU

PODCAST: Doctors, Money and Conflicts of Interest

Medical Ethics – Ever on Guard

***
By Aaron Carroll MD, MS
 ***
I’m a doctor. My father is a doctor. My colleagues are doctors, the people I train are doctors, lots and lots of my friends are doctors.
 ***
But, that doesn’t meant that doctors sometimes aren’t blind to certain issues like their own financial conflicts of interest. Sometimes we have to poke doctors with a stick. That’s how we show our love.
 ***
Conflicts of interest are the topic of this Healthcare Triage video.

PLAY VIDEO LINK

ECON

Assessment

This video episode is adapted from Aaron’s NYT piece on the topic. References can be found in the links there: http://www.nytimes.com/2014/09/09/ups…

John Green — Executive Producer
Stan Muller — Director, Producer
Aaron Carroll — Writer
Mark Olsen — Graphics

http://www.twitter.com/aaronecarroll
http://www.twitter.com/crashcoursestan
http://www.twitter.com/realjohngreen
http://www.twitter.com/olsenvideo

About the Author

Dr. Carroll has published some of the seminal work on various types of health care reform, and continues to be a sought after speaker on cost, quality and access-and the Affordable Care Act and its implications for our future. Considered one of the leading pediatric informaticists in the U.S. he has received millions of dollars in grants to explore the use of information technology in health care. Dr. Carroll was the Primary Investigator on a grant from the Agency for Healthcare Research and Quality to study the true impact of malpractice claims on the practice of medicine.

Conclusion

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

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

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