How Stock-Brokers Execute Trades

What Every Physician-Investor Should Know

And … Why Trade Execution Isn’t Instantaneous!

By Dr. Gary L. Bode MSA CPA CMP [Hon]; PC

http://www.CertifiedMedicalPlanner.org

Dr. Gary Bode; CPA, MSA, CMP

Many physician investors who trade through online brokerage accounts assume they have a direct connection to the securities markets.

But, they don’t. When you press “enter,” your order is sent over the Internet to your broker – who in turn decides which market to send it to for execution. A similar process occurs when you call your broker to place a trade.

While trade execution is usually seamless and quick, it does take time. And prices can change quickly, especially in fast-moving markets. Because price quotes are only for a specific number of shares, MD investors may not always receive the price they saw on their screen or the price their broker quoted over the phone. By the time your order reaches the market, the price of the stock could be slightly – or very – different.

Note: No SEC regulations require a trade to be executed within a set period of time. But if firms advertise their speed of execution, they must not exaggerate or fail to tell investors about the possibility of significant delays.

Tip: To avoid buying or selling a stock at a price higher or lower than you wanted, place a limit order rather than a market order. A limit order is an order to buy or sell a security at a specific price. A buy limit order can only be executed at the limit price or lower, and a sell limit order can only be executed at the limit price or higher. When you place a market order, you can’t control the price at which your order will be filled.

Example: You want to buy the stock of a “hot” IPO that was initially offered at $9, but don’t want to end up paying more than $20 for the stock. Place a limit order to buy the stock at any price up to $20. By entering a limit order rather than a market order, you will not be caught buying the stock at $90 and then suffering immediate losses as the stock drops later in the day or the weeks ahead.

Caution: Your limit order may never be executed because the market price may quickly surpass your limit before your order can be filled. But by using a limit order you also protect yourself from buying the stock at too high a price. 

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ABOUT

Dr. Gary L. Bode was Chief Executive Officer of Comprehensive Practice Accounting, Inc., a firm specializing in providing tax solutions to medical professionals. Originally, he was a board certified podiatrist and managing partner of a multi-office medical practice for a decade before earning his Master of Science degree in Accounting from the University of North Carolina. He then served as Chief Financial Officer [CFO] for a private mental healthcare facility. Today, Dr. Bode is a nationally known Certified Public Accountant, financial author, educator, and speaker. Areas of expertise include producing customized managerial accounting reports, practice appraisals and valuations, restructurings, and innovative financial accounting as well as proactive tax positioning and tax return preparation for healthcare facilities. He has been quoted in Newsweek.

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CROWD-FUNDING: Income Tax Implications

By Staff Reporters

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Crowdfunding is a popular way to raise money online. People often use crowdfunding to fund raise for a business, for charity, or for gifts. It’s important to know that money raised through crowdfunding may be taxable.

Do you have to pay taxes on the money you receive from GoFundMe, etc?

Generally, you will not owe taxes on donated funds you receive from a crowdfunding platform. The IRS considers the money received from GoFundMe to be a gift instead of income, so it is typically not taxable. A gift is any transfer of cash or property you make to an individual without receiving full consideration in return, according to the IRS. People who donate money to GoFundMe to help pay for medical expenses are typically doing it out of generosity and do not expect anything in return. 

Some money raised through crowdfunding may NOT be considered a gift.

Under federal tax law, gross income includes all income from any source, unless it’s excluded from gross income by law. In most cases, gifts aren’t included in the gross income of the person receiving the gift. Here’s what people involved in crowdfunding should know:

  • If a crowdfunding organizer is raising money on behalf of others, the money may not be included in the organizer’s gross income, as long as the organizer gives the money to the person for whom they organized the crowdfunding campaign.
  • If people donate to a crowdfunding campaign out of generosity and without expecting anything in return, the donations are gifts. Therefore, they will not be included in the gross income of the person for whom the campaign was organized.
  • However, not all contributions to crowdfunding campaigns are gifts and may be taxable.
  • When employers give to crowdfunding campaigns for an employee, those contributions are generally included in the employee’s gross income.

Taxpayers may want to consult a trusted tax pro for information and advice regarding how to treat amounts received from crowdfunding campaigns.

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PHYSICIANS: Seeking Vital [Non-Clinical] Second Opinions?

By Dr. David Edward Marcinko MBA CMP™

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When You May Need a Business, Management or Financial Planning Second Opinion?

The Marcinko & Associates second opinion service is a physician-to-advisor telephone or e-mail portal that connects independent financial and business management professionals and consultants, with doctors or healthcare executives desiring affordable and unbiased financial or business advice on an as-needed, or per-use basis.

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Medical professionals and healthcare executives can now receive direct access to us in the areas of Practice Enhancement, Investing, Financial Planning, Asset Allocation, Portfolio Management, Insurance, Mortgage and Lending, Practice Management, Information Technology, Human Resources and Employee Benefits. To assist our doctor / healthcare executive members, we can be contracted with per-hour or per-project fees, and contacted by client phone, email or secure instant messaging.

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This Marcinko & Associates service is designed to fill a growing need for medically focused financial or managerial advice that traditional consultants have not been able to serve.

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STOCK ORDERS: Positions All Doctors Should Know

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BY DR. DAVID E. MARCINKO MBA MEd CMP®

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Miscellaneous STOCK Orders and MARKET Positions

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Beside market, limit and stop orders, there are some other miscellaneous orders for the physician or guided investor, to know:

A stop limit order is a stop order that, once triggered or activated, becomes a limit order. Realize that it is possible for a stop limit to be triggered and not executed, as the limit price specified by the doctor may not be available.

In addition, there are all or none and fill or kill orders, and even though both require the entire order to be filled, there are distinct differences. An all or none (AON) is an order in which the broker is directed to fill the entire order or none of it.

A fill or kill (FOK) is an order either to buy or to sell a security in which the broker is directed to attempt to fill the entire’ amount of the order immediately and in full, or that it be canceled.

The difference between an all or none and a fill or kill order is that with an all or none order, immediate execution is not required, while immediate execution is a critical component of the fill or kill. Because of the immediacy requirement,

FOK orders are never found on the specialist’s book. Another difference is that AON orders are only permitted for bonds, not stocks, while FOK orders may be used for either.

Also, there exists an immediate or cancel order (IOC), which is an order to buy or sell a security in which the broker is directed to attempt to fill immediately as much of the order as possible and cancel any part remaining. This type of order differs from a fill-or-kill order which requires the entire order to be filled. An IOC order will permit a partial fill. Because of the immediacy requirement, IOC and FOK orders are never found on the specialist’s book.

 Long and Short Positions

A long buy position means that shares are for sale from a market makers inventory or owned by the medical investor outright. Market makers take long positions when customers and other firms wish to sell, and they take short positions when customers and other firms want to buy in quantities larger than the market maker’s inventory. By always being ready, willing, and able to handle orders in this way, market makers assure the investing public of a ready market in the securities in which they are interested. When a security can be bought and sold at firm prices very quickly and easily the security is said to have a high degree of liquidity, also known as marketability. 

A short position investor seeks to make a profit by participating in the decline in the market price of a security.

Now; let’s see how these terms, long and short, apply to transactions by medical investors [rather than market makers] in the securities markets.

When a doctor buys any security – he is said to be taking a long position in that security. This means the investor is an owner of the security. Why does a doctor take a long position in a security? Well, receiving dividend income to make a profit from an increase in the market price is one reason. Once the security has risen sufficiently in price to satisfy the investor’s profit needs, the investor will liquidate his long position, or sell his stock. This would officially be known as a long sale of stock, though few people in the securities business use the label “long sale”. This is the manner in which the above investor had made a profit is the traditional method used; buy low, sell high.

Let’s look at an actual investment in General Motors to investigate this principle further. A medical investor has taken a long position in 100 shares of General Motors stock at a price of $70 per share. This means that the manner in which he can do that is by placing a market order which will be executed at the best “available market price at the time, or by the placing of a buy limit order with a limit price of $70 per share. The investor firmly believes, on the basis of reports that he has read about the automobile industry and General Motors specifically, that at $70 a share, General Motors is a real bargain. He believes that based on its current level of performance, it should be selling for a price of between $80 and $85 per share. But, the doctor investor has a dilemma. He feels certain that the price is going to rise but he cannot watch his computer, or call his broker, every hour of every day. The reason he can’t watch is because patients have to be seen in the office. The only people who watch a computer screen all day are those in the offices of brokerage firms (stock broker registered representatives), and doctor day traders, among others. 

In the above example, with a sell limit order, if the doctor investor was willing to settle for a profit of $12 per share, what order would he place at this time? If you said, “sell at $82 good ’til canceled”, you are correct. Why GTC rather than a day order? Because our doctor investor knows that General Motors is probably not going to rise from $70 to $82 in one day. If he had placed an order to sell at $82 without the GTC qualification, his order would have been canceled at the end of this trading day. He would have had to re-enter the order each morning until he got an execution at 82. Marking the order GTC (or open) relieves him of any need to replace the order every morning. Several weeks later, when General Motors has reached $82 per share in the market, his order to sell at 82 is executed. The medical investor has bought at 70 and sold at 82 and realized a $12 per share profit for his efforts.

Let’s suppose that the medical investor, who has just established a $12 per share profit, has evaluated the performance of General Motors common stock by looking at the market performance over a period of many years. Let’s further assume that the investor has found by evaluating the market price statistics of General Motors that the pattern of movement of General Motors is cyclical. By cyclical, we mean that it moves up and down according to a regular pattern of behavior.

Let’s say the investor has observed that in the past, General Motors had repeated a pattern of moving from prices in the $60 per share range as a low, to a high of approximately $90 per share. Further, our investor has observed that this pattern of performance takes approximately 10 to l2 months to do a full cycle; that is, it moves from about 60 to about 90 and back to about 60 within a period of roughly l2 months. If this pattern repeats itself continually, the investor would be well advised to buy the stock at prices in the low to mid 60’s hold onto it until it moves well into the 80’s, and then sell his long position at a profit. However, what this means is that our investor is going to be invested in General Motors only 6 months of each year. That is, he will invest when the price is low and, usually within half a year, it will reach its high before turning around and going back to its low again. How can the doctor-investor make a profit not only on the rise in price of General Motors in the first 6 months of the cycle, but on the fall in price of General Motors in the second half of the cycle? One technique that is available is the use of the short sale.

The Short Sale

If a doctor investor feels that GM is at its peak of $ 90 per share, he may borrow 100 shares from his brokerage firm and sell the 100 shares of borrowed GM at $ 90. This is selling stock that is not owned and is known as a short sale. The transaction ends when the doctor returns the borrowed securities at a lower price and pockets the difference as a profit. In this case, the doctor investor has sold high, and bought low. 

Odd Lots

Most of the thousands of buy and sell orders executed on a typical day on the NYSE are in 100 share or multi-100 share lots. These are called round lots. Some of the inactive stocks traded at post 30, the non-horseshoe shaped post in the northwest corner of the exchange, are traded in 70 share round lots due to their inactivity. So, while a round lot is normally 700 shares, there are cases where it could be 10 shares. Any trade for less than a round lot is known as an odd lot. The execution of odd lot orders is somewhat different than round lots and needs explanation.

When a stock broker receives an odd lot order from one of his doctor customers, the order is processed in the same manner as any other order. However, when it gets to the floor, the commission broker knows that this is an order that will not be part of the regular auction market. He takes the order to the specialist in that stock and leaves the order with the specialist. One of the clerks assisting the specialist records the order and waits for the next auction to occur in that particular stock. As soon as a round lot trade occurs in that particular stock as a result of an auction at the post, which may occur seconds later, minutes later, or maybe not until the next day, the clerk makes a record of the trade price.

Every odd lot order that has been received since the last round lot trade, whether an order to buy or sell, is then executed at the just noted round lot price, the price at which the next round lot traded after receipt of the customer’s odd lot order, plus or minus the specialist’s “cut “.  Just like everything else he does, the specialist doesn’t work for nothing. Generally, he will add 1/8 of a point to the price per share of every odd lot buy order and reduce the proceeds of each odd lot sale order by 1/8 per share. This is the compensation he earns for the effort of breaking round lots into odd lots. Remember, odd lots are never auctioned but, there can be no odd lot trade unless a round lot trades after receipt of the odd lot order. 

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Establishing Your Medical Practice’s Fair Market Value

Medical Practice Valuation

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By Dr. David Edward Marcinko, MBA, MEd, CMP

www.CertifiedMedicalPlanner.org

In recent years, the physician practice market has experienced a noticeable increase in practice merging and acquisitions. Medical practices are being acquired by health systems as a result of Accountable Care Organization (ACO) delivery models; etc.

For physicians, the decision to buy, sell, or merge a medical practice is more complicated than ever, and determining a medical practice’s worth is crucial to this process.

Value Isn’t an Absolute Number

A medical practice’s tangible and intangible assets can be grouped into two broad categories:

  • Physical assets: Examples are real estate, medical records, leaseholds, medical equipment and furnishings, and accounts receivable (A/R).
  • Non-physical assets: These include goodwill, restrictive covenants, buy/sell agreements, managed care contracts, and an assembled workforce.

Estimates of value differ markedly, depending on the purpose of the appraisal, the acumen of the appraiser, etc. To help determine the value, some important questions to consider are:

  • What is the value of the practice for purchase or sale?
  • What is the value of a practice for merger?
  • What is the value of practice assets for joint venture with a corporate partner?
  • What is the value to establish buy-in or buy-out arrangements for partners?
  • What is the value of practice assets for purchase or sale, apart from ongoing operations?

To answer these questions, physicians (buyers and sellers) must understand how practices are valuated—beginning with the following informal, and then more formal, definitions:

Informal Terms of Valuation

  • The “asking price” is often arbitrary and difficult to substantiate, and typically is reduced 25-50 percent after negotiations.
  • The “creative price” is derived by way of creative financing. For example, the practice may provide the down payment.
  • The “emotional price” may involve either a motivated buyer or seller, who pays an under- or overinflated price for the practice.
  • The “friendly price” is reserved for associates, partners, or other colleagues.
  • The “realistic price” is one that both buyer and seller believe is fair.

Formal Terms of Valuation

  • Most appraisers use “fair market value” (FMV) as the standard to derive a reasonable value for a practice. FMV means an arm’s length transaction between an unpressured, informed buyer and an unpressured, informed seller.
  • The “business enterprise value” of a practice equals a combination of all assets (tangible and intangible), and the working capital, of a continuing business.
  • The value of “owner’s equity” equals the combined values of all practice assets (tangible and intangible), less all practice liabilities (booked and contingent).
  • The “working capital value” equals the excess of current assets (cash, A/R, supplies, inventory, prepaid expenses, etc.) over current liabilities (accounts payable, accrued liabilities, etc.).

Realizing that there is no absolute sales price is the essence of FMV. When determining valuation, look for a price range with a reasonable floor and ceiling.

Understand The Lingo

If you are a practice buyer or seller, make sure you understand terms and appraisal definitions.

That’s a lesson George Farmer, a primary care physician in Florida, learned the hard way. He asked his accountant to appraise his business. When he was ready to sell, his attorney (who also happens to be his brother-in-law) drew up the sales contract. Farmer was pleased that the practice sold quickly for its full asking price.

What he didn’t know (but would discover) is that accounting or “book” value—the figure his accountant gave him—is far different than the FMV that he could have received.

Was the CPA wrong? Not really. Was the doctor incorrect? No. But each was operating under a different set of terms and definitions, without knowledge of each other’s perspectives.

How to Begin Valuation

The following steps should occur before the practice appraisal process begins:

  • Retain an appraiser (for each side) who understands the changing health care industry.
  • Aggregate historic practice business information and consolidated financial statements, operating statistics, payer mix, CPT® utilization, acuity rates, etc.
  • Eliminate one-time, non-recurring expenses, adjusted or normalized for excessive or below normal expenses.
  • Understand key assumptions used in financial projections.

To determine value, appraisers should follow the American Society of Appraisers’ Principles of Appraisal Practice and Code of Ethics. The IRS issued guidelines in 1995 further suggesting that appraisers use the general methods of the Uniform Standards of Professional Appraisal Practices (USPAP), which recognize three approaches to medical practice valuation.

1. Income Methods

There are two methods to value a practice by income:

(a) Capitalization Method: The excess earnings or capitalization method estimates value by dividing normalized historical or current income by an appropriate rate of return for the buyer. This method does not require assumptions.

(b) Discounted Method: Discounted Cash Flow (DCF): Analysis requires assumptions to estimate practice value by discounting future net cash flows to their present worth based on market rates of return required by an investor. Understanding the key assumptions produces a meaningful estimate of practice value. These assumptions may include:

  • projections of future practice revenue, productivity, reimbursement trends, and shifts in payer mix
  • projections of practice cost structures and projected physician compensation
  • after-tax practice cash flows
  • reinvestments to replace equipment or other assets
  • residual practice value at the end of the forecast period
  • discount rate based on the practice specific weighted average cost of capital
  • practice efficiencies, operations, and competitive market conditions

The DCF analysis consistently produces higher values than other methods of estimating practice value because there may be supportable reasons to forecast improvements in future practice performance.

2. Marketplace Multiples

Market transaction multiples are ratios developed by correlating actual practice sale prices to key practice performance measurements. Common multiples include comparisons of sale price to revenue, sale price to earnings before interest and taxes (EBIT), sale price to earnings before interest, taxes, and depreciation allowance (EBITDA), gross revenue, net revenue, and the sale price to number of physicians.

Market transaction multiples are typically limited to serving as a benchmark for testing the reasonableness of the other approaches. They are becoming less common and less useful.

3. Cost Approach

The cost approach calls for identification and separate valuation of all the practice assets, including goodwill, depreciated over 15 years.

The cost approach is more labor intensive than using the enterprise analysis to estimate practice value; especially for a new practice, which typically includes the expenses to acquire space, office furnishings, equipment, marketing, advertising, staff development, and losses incurred during the startup period. This estimate of “replacement cost or cost avoidance” value represents an upper limit (or ceiling) of value, and generally is not considered useful in estimating the value of an established medical practice.

Net Income Statement Adjustments

When analyzing a set of financial statements to determine practice value, adjustments (normalizations) generally are needed to produce a clearer picture of likely future income and distributable cash flow. It also allows more of an “apples to apples” line item comparison. This normalization process usually consists of making three main adjustments to a medical practice’s net income (profit and loss) statement.

1. Non-Recurring Items: Estimates of future distributable cash flow should exclude non-recurring items. Proceeds from the settlement of litigation, one-time gains/losses from the selling of assets or equipment, and large write-offs that are not expected to reoccur, each represent potential nonrecurring items. The impact of nonrecurring events should be removed from the practice’s financial statements to produce a clearer picture of likely future income and cash flow.

2. Perquisites: The buyer of a medical practice may plan to spend more or less than the current doctor-owner for physician executive compensation, travel and entertainment expenses, and other perquisites of current management. When determining future distributable cash flow, income adjustments to the current level of expenditures should be made for these items.

3. Non-cash Expenses: Depreciation expense, amortization expense, and bad debt expense are all non-cash items which impact reported profitability. When determining distributable cash flow, you must analyze the link between non-cash expenses and expected cash expenditures.

The annual depreciation expense is a proxy for likely capital expenditures over time. When capital expenditures and depreciation are not similar over time, an adjustment to expected cash flow is necessary.

Some practices reduce income through the use of bad debt expense rather than direct write-offs. Bad debt expense is a non-cash expense that represents an estimate of the dollar volume of write-offs that are likely to occur during a year. If bad debt expense is understated, practice profitability will be overstated.

Balance Sheet Adjustments

Adjustments also can be made to a practice’s balance sheet to remove non-operating assets and liabilities, and to restate asset and liability value at market rates (rather than cost rates).

Assets and liabilities that are unrelated to the core practice being valued should be added to or subtracted from the value, depending on whether they are acquired by the buyer. Examples include the asset value less outstanding debt of a vacant parcel of land, and marketable securities that are not needed to operate the practice. Other non-operating assets, such as the cash surrender value of officer life insurance, generally are liquidated by the seller and are not part of the business transaction.

Assessment

With a basic understanding of practice valuation and the steps involved, buyers and sellers will be better prepared for next steps.

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:

Additional Reading:

Cimasi, Robert James: Valuation of Hospital in a Changing Reimbursement and Regulatory Environment. Marcinko, DE (Editor): Healthcare Organizations (Financial Management Strategies). Institute of Medical Business Advisors Inc., Atlanta, Ga., 2011

Marcinko, DE: “Getting it Right,” How Much is a Plastic Surgery Practice Really worth? Plastic Surgery Products, August 2006.

Marcinko, DE and Hetico, HR: The Business of Medical Practice (third edition). Springer Publishing,New York, N.Y., 2011.

Marcinko, DE and Hetico; HR: Risk Management and Insurance Planning for Physicians and Advisors, Jones and Bartlett Publishers, Sudbury,Mass., 2007.

Marcinko, DE and Hetico; HR: Financial Planning for Physicians and Advisors, Jones and Bartlett Publishers, Sudbury, Mass., 2007.

Marcinko, DE and Hetico, HR: Dictionary of Health Insurance and Managed Care, Springer Publishing, New York, N.Y., 2007.

Marcinko, DE and Hetico, HR: Dictionary of Health Economics and Finance, Springer Publishing, New York, N.Y., 2007.

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ECONOMIC INDICATORS: “Lipstick Index” and “Cosmetic” Others?

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DEFINITION: According to Wikipedia, the lipstick index is a term coined by Leonard Lauder, chairman of the board of Estee Lauder, used to describe increased sales of cosmetics during the early 2000s recession. Lauder made the claim that lipstick sales could be an economic indicator, in that purchases of cosmetics – lipstick in particular – tend to be inversely correlated to economic health. The speculation was that women substitute lipstick for more expensive purchases like dresses and shoes in times of economic distress.

Lauder identified the Lipstick index as sales across the Estee Lauder family of brands. Subsequent recessions, including the late-2000s recession, provided controverting evidence to Lauder’s claims, as sales have actually fallen with reduced economic activity. Conversely, lipstick sales have experienced growth during periods of increased economic activity. As a result, the lipstick index has been discredited as an economic indicator. The increased sales of cosmetics in 2001 has since been attributed to increased interest in celebrity-designed cosmetics brands.

In the 2010s, many media outlets reported that with the rise of nail art as fad in the English-speaking countries and as far afield as Japan and the Philippines, nail-polish had replaced lipstick as the main affordable indulgence for women in place of bags and shoes during recession, leading to talk of a Nail Polish index. Similar sentiment was noted during the coronavirus pandemic, when the mandated use of face masks to prevent the spread of the disease resulted in an increase of eye makeup purchases, suggesting a Mascara index.

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Now, decades after former Estée Lauder chairman Leonard Lauder first recognized the infamous “lipstick index”—the idea that cosmetics sales hold steady and sometimes spike during economic downturns—the same company posted a relatively downbeat earnings report.

Currently, the economy’s not great, but not abysmal, which makes for two possible interpretations of Estée Lauder’s latest report: Either the economy’s better than it seems, or the lipstick index was always a bit off.

The cosmetics giant reported declining sales figures, while weakening its full-year forecast. “For full-year fiscal 2023, we delivered organic sales growth and prestige beauty share gains in many developed and emerging markets, but Asia travel retail pressured results, particularly in skin care, and we continued to experience softness in North America,” the report said.

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Waffle House Index: https://medicalexecutivepost.com/2022/10/08/what-is-the-waffle-house-index/

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What is Medical Practice FINANCIAL RATIO ANALYSIS?

BY DR. DAVID E. MARCINKO MBA MEd CMP®

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Financial ratio analysis typically involves the calculation of ratios that are financial and operational measures representative of the financial status of a clinic or medical practice 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.

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

  • 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.
  • 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.
  • 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.
  • Profitability. Indicates the overall net effect of managerial efficiency of the enterprise. To determine the profitability of the enterprise for bench marking 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.

The selection of financial ratios for analysis and comparison to the organization’s performance requires careful attention to the homogeneity of data. Bench marking of intra-organizational data (i.e., internal bench marking) 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.

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PHYSICIAN ACQUISITION: The Art of Acquiring Your Medical Practice

Part Two: Medical Practice Valuation

By Dr. David Edward Marcinko, MBA, MED, CMP

www.CertifiedMedicalPlanner.org

In Part 1, we discussed how to establish fair market value (FMV) for a medical practice in the article, “Establish Your Practice’s Fair Market Value.” This time, we’ll review important terms and conditions for the sale acquisition and transaction.

LINK: https://medicalexecutivepost.com/2023/02/02/establish-your-practices-fair-market-value/

Valuation Types

Unfortunately, as a general rule, medical practice worth is presently deteriorating. A good medical practice is no longer a good business necessarily, and selling doctors can no longer automatically expect to extract a premium sale price. Nevertheless, appraising your medical practice on a periodic basis can play a key role in obtaining maximum value for it.

Competent practice valuation specialists typically charge a retainer to cover out-of-pocket expenses. Fees should not be based on a percentage of practice value, and may take 30-45 days to complete. Flat fees should be the norm because a sliding scale or percentage fee may be biased toward over-valuation in a declining marketplace. Fees range from $7,500-$50,000 for the small to large medical practice or clinic.

Expect to pay a retainer and sign a formal, professional engagement letter. Seek an unbiased and independent viewpoint. Buyer and sellers should each have their own independent appraisal done, using similar statistics, accounting measures, and economic assumptions.

At the Institute of Medical Business Advisors, Inc www.MedicalBusinessAdvisors.com we use three engagement levels that vary in intensity, purpose, and cost:

1. A comprehensive valuation provides an unambiguous value range. It is supported by most all procedures that valuators deem relevant, with mandatory onsite review. This gold standard is suitable for contentious situations. A written “opinion of value” is applicable for litigation support activities like depositions and trial. It is also useful for external reporting to bankers, investors, the public, Internal Revenue Service (IRS), etc.

2. A limited valuation lacks additional suggested Uniform Standards of Professional Appraisal Practice (USPAP) procedures. It is considered to be an “agreed upon engagement,” when the client is the only user. For example, it may be used when updating a buy/sell agreement, or when putting together a practice buy-in for a valued associate. This limited valuation would not be for external purposes, so no onsite visit is necessary and a formal opinion of value is not rendered.

3. An ad-hoc valuation is a low level engagement that provides a gross non-specific approximation of value based on limited parameters or concerns involved parties. Neither a written report nor an opinion of value is rendered. It is often used periodically as an internal organic growth/decline gauge.

Structure Sales Transactions and Acquisitions

When the practice price has been determined and agreed on, the actual sales deal can be structured in a couple of ways:

(1) Stock Purchase v. Asset Purchase

In an asset transaction, the buyer will receive a tax amortization benefit associated with the intangible value of the business. This tax amortization represents a non-cash expense benefiting the buyer. In this case, the present value of those future tax benefits is added to the business enterprise value.

(2) Corporate Transactions

Typical private deals in the past involved some multiple (ratio) of earning before income taxes (EBIT)—usually a combination of cash, restricted stock, notes receivable, and possibly assumption of liabilities. For some physician hospital organizations, and public deals, the receipt of common stock can increase the practice price by as much as 40-50 percent (to accept the corresponding business risk, in lieu of cash).

Complete the Deal

The deal structure will vary depending on whether the likely buyer is a private practitioner, health system or a corporate partner. Some key issues to consider in the “art of the deal” include:

  • Working capital (in or out?): Including working capital in the transaction will increase the sale price.
  • Stock vs. asset transaction: Structuring the deal as an asset purchase will increase practice value due to the tax amortization benefits received by the buyer for intangible assets of the practice.
  • Common stock premium: The total sale price can be significantly higher than a cash equivalent price for accepting the risk and relative illiquidity of common stock as part of the payment.
  • Physician compensation: If your goal is to maximize practice value, take home a lower salary to increase practice sale price. The reverse is also true.

Understand Private Deal Structure

Assuming a practice sale is a private transaction, deal negotiations are based on the following pricing methodologies:

Seller financing: Many transactions involve an earn-out arrangement where the buyer puts money down and pays the balance under a formula based on future revenues, or gives the seller a promissory note under similar terms. Seller financing decreases a buyer’s risks (the longer the terms, the lower the risk). Longer terms demand premiums, while shorter terms demand discounts. Premiums that buyers pay for a typical seller-financed practice are usually more than what you would expect from a simple time value of money calculation, as a result of buyer risk reduction from paying over time, rather than up front with a bank loan or all cash. Remember to obtain a life insurance policy on the buyer.

Down payment: The greater the down payment for acquisition of a medical practice, the greater the risk is to the buyer. Consequently, sellers who will take less money up front can command a higher than average price for their practice, while sellers who want more down usually receive less in the end.

Taxation: Tax consequences can have a major impact on the price of a medical practice. For instance, a seller who obtains the majority of the sales price as capital gains can often afford to sell for a much lower price and still pocket as much or more than if the sales price were paid as ordinary income. Value attributed to the seller’s patient list, medical records, name brand, good will, and files qualifies for capital gains treatment. Value paid for the selling doctor’s continuing assistance after the sale and value attributed to a non-compete agreement are taxed at ordinary income. A buyer willing to allocate more for items with capital gains treatment, or a seller willing to take more in ordinary income, can frequently negotiate a better price. This is the essence of economically prudent practice transition planning.

Sidestep Common Buyer Blunders

Here are 10 blunders to avoid, as a buyer:

1. Believing the selling doctor’s attestations. Always verify data through an independent appraisal.

2. Wanting to change the culture of the practice. Be careful: Patients may not adjust quickly to change.

3. Using all available cash without keeping a reserve for potential contingencies.

4. Creating a conflict with the seller by recognizing a weakness and continually focusing on it for a bargain price.

5. Failing to realize that managed care plan contracts can be lost quickly or may not be always transferable.

6. Suffering from analysis paralysis. Money cannot be made by continually checking out a medical practice, only by actually running one.

7. Not appreciating the uniqueness of each practice, and using inaccurate “rules of thumb” from the golden age of medicine.

8. Not realizing that practice worth and goodwill value have plummeted lately and continue to decline in most parts of the country.

9. Not understanding that practice brokers may play both sides of the buy/sell equation for profit. Brokers usually are not obligated to disclose conflicts of interest, are not fiduciaries, and do not provide testimony as a court-approved expert witness.

10. Not hiring an appraisal professional who will testify in court, if need be, using the IRS-approved USPAP methods of valuation. Always assume that the appraisal will be contested (many times, it is).

After pricing and contracting due diligence has been performed, the next step in the medical practice sale process—as Donald Trump might say—is just good, old-fashioned negotiation.

Electronic Downloads

Part I: Part I

Part II: Part II

Additional Reading:

Cimasi, R.J., A.P. Sharamitaro, T.A. Zigrang, L.A.Haynes. Valuation of Hospitals in a Changing Reimbursement and Regulatory Environment. Edited by David E. Marcinko. Healthcare Organizations: Financial Management Strategies. Specialty Technical Publishers, 2008.

Marcinko, D.E. “Getting it Right: How much is a plastic surgery practice really worth?” Plastic Surgery Practice, August 2006.

Marcinko, D.E., H.R. Hetico. The Business of Medical Practice (3rd ed). Springer Publishing,New York,N.Y., 2011.

Marcinko, D.E. and H.R. Hetico. Risk Management and Insurance Planning for Physicians and Advisors. Jones and Bartlett Publishers, Sudbury, Mass., 2007.

Marcinko, D.E. and H.R. Hetico. Financial Planning for Physicians and Advisors. Jones and Bartlett Publishers, Sudbury, Mass., 2007.

Marcinko, D.E. and H.R. Hetico. Dictionary of Health Insurance and Managed Care. Springer Publishers, New York, N.Y., 2007.

Marcinko, D.E. and H.R. Hetico. Dictionary of Health Economics and Finance. Springer Publishers,New York,N.Y., 2007.

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PREFERRED versus COMMON Stock?

Is there a Difference?

What is the Difference?

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By Dr. David Edward Marcinko MBA MEd CMP®

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A common stock is the least senior of securities issued by a company. 

A preferred stock, in contrast, is slightly more senior to common stock, since dividends owed to the preferred stockholders should be paid before distributions are made to common stockholders. 

However, distributions to preferred stockholders are limited to the level outlined in the preferred stock agreement (i.e., the stated dividend payments).  Like a fixed income security, preferred stocks have a specific periodic payment that is either a fixed dollar amount or an amount adjusted based upon short-term market interest rates. 

However, unlike fixed income securities, preferred stocks typically do not have a specific maturity date and preferred stock dividend payments are made from the corporation’s after tax income rather than its pre-tax income.  Likewise, dividends paid to preferred stockholders are considered income distributions to the company’s equity owners rather than creditors, so the issuing corporation does not have the same requirement to make dividend distributions to preferred stockholders. 

So, preferred stock is generally referred to as a “hybrid” security, since it has elements similar to both fixed income securities (i.e., a stated periodic payments) and equity securities (i.e., shareholders are considered owners of the issuing company rather than creditors). 

Convertible preferred stocks (and convertible corporate bonds) are also considered hybrid securities since they have both equity and fixed income characteristics.   A convertible security whether a preferred stock or a corporate bond, generally includes a provision that allow the security to be exchanged for a given number of common stock shares in the issuing corporation. The holder of a convertible security essentially owns both the preferred stock (or the corporate bond) and an option to exchange the preferred stock (or corporate bond) for shares of common stock in the company. 

ASSESSMENT: Thus, at times the convertible security may behave more like the issuing company’s common stock than it does the issuing company’s preferred stock (or corporate bonds), depending upon how close the common stock’s market price is to the designated conversion price of the convertible security.

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

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REAL ESTATE Investing for Physicians

SOME GUIDELINES FOR COLLEAGUES

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By Dr. David Edward Marcinko MBA CMP®

SPONSOR: http://www.CertifiedMedicalPlanner.org

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According to Rick Kahler MS CFP® ChFC CCIM [www.KahlerFinancial.com] real estate is one of the largest asset classes in the world. The family home is the largest asset many middle-class Americans own. And, real estate makes up a significant portion of the net worth of many wealth accumulators. Directly owning real estate is not an investment for the faint of heart, the armchair investor, or the uneducated. Most wealth accumulators would do well to leave direct ownership of real estate to the pros and invest in real estate investment trusts (REITs) instead [personal communication].

Still, as we have seen, the lure of investing in a tangible asset like real estate is enticing for high risk tolerant physician-investors who need a sense of control and interaction with their investments. If you are among them, here are a few guidelines that may keep you on a profitable path.

1. Don’t attempt to purchase investment real estate without the help of a commercial real estate specialist who is a fiduciary bound to look out for your best interest. Engage a Certified Commercial Investment Member (CCIM) with years of training and experience in analyzing and acquiring investment real estate. To find a CCIM near you, go to http://www.ccim.com.

2. You will sign a disclosure agreement that will tell you who the Realtor represents. Be sure the Realtor you engage represents you and not the seller, both parties, or neither party.

3. Never trust the income and expense data provided by the seller’s Realtor. While a seller represented by a CCIM will have a greater chance of supplying you with accurate data, most will significantly understate expenses and overstate the capitalization rate. Selling Realtors often understate the average annual cost of repairs and maintenance. I estimate this annual expense at 10%.

4. Another often understated expense is management. Many owners manage their own properties, so the selling broker doesn’t include an estimate for management expenses. They should. Real estate doesn’t manage itself, ever. You will either need to hire professional management or do your own management (always a scary proposition). Even if you do it yourself, you have an opportunity cost of your time, so you must include a management fee in the expenses. Most small residential apartments and single-family homes will pay 10% of their rents to a manager.

5. You must verify all the costs presented to you by the seller’s Realtor. Demand copies of at least the last three and preferably five years of tax returns. Research items like utility bills, property taxes, legal fees, insurance costs and repairs, maintenance costs, replacement reserves, tax preparation and all management fees. As a rule of thumb, expenses will average 40% of rental income on average-aged properties where the tenants pay all utilities except water. Newer properties may have expenses as low as 35%, while older properties can be as high as 50%.

6. By subtracting the vacancy rate and stabilized expenses from the rent, you will find the net operating income. This is the income you will put in your pocket—assuming the property is paid for. By dividing the net operating income by the purchase price, you will find the return you will receive on your investment, called the capitalization or “cap” rate. In Rapid City SD, for example, the cap rate tends to be 4% for single-family homes, 5% to 8% for duplexes to eight-plexes, and 8% to 12% for larger residential and commercial properties.

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

ASSESSMENT: Yes, physician-investors and all of us can build wealth with real estate. You just need to educate yourself, work hard, start conservatively, think long-term, and be prepared for lean years. This is not a quick or easy path to riches. Your comments are appreciated. Thank You.

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Keep your Investing Options Open – Doctor

OR – Hedge your Bets

By Dr. David Edward Marcinko MBA MEd CMP™

http://www.CertifiedMedicalPlanner.org

[Publisher-in-Chief]

As a physician executive or investor, if you don’t ordinarily deal in options or other financial derivatives, you may need to brush up on puts and calls, straddles, strangles (or combinations), forwards, futures, swaps, spreads, and non-equity options such as stock index options. Options and other financial derivatives can be used by astute physicians, financial advisors and investment managers not only as a tool to better manage the investment risks potentially affecting portfolio returns, but to craft truly value-added investment strategies customized to meet investors’ needs. The three main types of risk of equity securities (individual company, industry, and market) can be mitigated with options.

Individual Company Risk

Individual company risk can be addressed with equity options in that company’s stock. Industry risk can be reduced through the use of narrow-based index options, while market risk can be mitigated with broad-based index options. Sophisticated hedging and risk management strategies can be designed using both equity and stock index options.

Exotic Stock Options?

Some doctors feel that options have been generally thought of as too risky or exotic or requiring too much capital, resulting in a general lack of comfort. A decade ago, these opinions have no doubt been shaped by the collapse of Bearings and the resulting bitter litigation by Proctor & Gamble and Gibson Greetings against Bankers Trust. Last decade, it was Enron, Tyco, WorldCom, Lehman Brothers, AIG, BA, Fannie, Freddie and all those involved in the “flash-crash” of 2008-09; etc.

Assessment

Generally, premiums paid in buying puts or calls are nondeductible capital expenditures and may produce a capital gain or loss depending upon whether the option is sold prior to exercise, the call expires unexercised, or, if the option is exercised, it is added to the basis of the stock (call) or deducted from it (put). Premiums received for writing puts or calls are not included in income upon receipt but are deferred until the option expires, is exercised, or a closing transaction is entered into. Non-equity options (index options) are marked to market at year end (same as for futures) with 60% considered long-term capital gain and 40% considered short-term.

Note: “An Introduction to Options and Other Financial Derivative Strategies,” by Thomas J. Boczar, Trust & Estates, February 1997, pp. 43–68, INTERTEC/K-III Publishing.

The primary objectives in using derivatives are:

1. Risk management and hedging (reducing or eliminating downside risk, monetizing a position, deferring and possibly avoiding capital gains taxes)

2. Leveraging investment capital

3. Enhancing after-tax returns

4. Creating customized risk/return profiles

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Why [Some] Doctors Won’t Ever Work for Uncle Sam

Understanding the Medical Career Path

[circa 2024]

cropped-dem 

By Dr. David E. Marcinko MBA, MEd, CMP

By Eugene Schmuckler PhD, MBA, CTS

www.MedicalBusinessAdvisors.com

MEDICARE FOR ALL?

Who seeks or writes about, physician careers under a M-4-Uber scenario?

When you think about careers, how many adults are truly aware of their own interests, values, strengths and weaknesses during their teen years? As with much of human behavior, career choices actually go through a series of stages.

Psychologists have for years identified stages of human development.  Kohlberg discussed stages of moral development. In the 1970’s, Daniel Levinson published The Season’s of a Man’s Life, a project he undertook when he began to look inward and tried to understand his behaviors, values and attitudes to work. Discussions with his university colleagues indicated that what he was experiencing was not unique to him.

Traditional Career Routes

For many years the prevailing thought was that the correct way to function in the labor market was to gain employment with a company progressing through the years until such time as you were eligible to receive the “gold watch”, the symbol of retirement. If you entered a professional discipline such as medicine or law, you did that for the rest of your life.

Alternate Career Paths

Today there are still individuals who follow these traditional patterns but there are other career paths that may be taken.

The most traditional career route follows a linear path, one that most of you have rejected. This entails gaining employment in a large, bureaucratic organization with a tall pyramidal structure [command-control]. It involves a series of upward (hopefully) moves in the organization until the career limit is reached. As the individual progresses upward in the organization he or she may work in different functional departments such as marketing, finance, and production. Organizations having these paths seek employees who tend to be highly oriented toward success defined in organizational terms and exhibit “leadership” skills. In general, these people demonstrate a strong commitment to the workplace. A person with this type of orientation (Organizationalist) exhibits the following tendencies:

  1. A strong identification with the organization; seeking organization rewards and advancement that are important measures of success and organizational status.
  2. High morale and job satisfaction.
  3. A low tolerance for ambiguity about work goals and assignments.
  4. Identification with superiors, showing deference toward them, conforming and complying out of a desire to advance; maintains the chain of command and compliance, and views respect for authority as the way to succeed.
  5. Emphasis on organizational goals of efficiency and effectiveness, avoiding controversy and showing concern for threats to organizational success.

As many readers of the Medical Executive-Post are aware, you have followed the expert medical career path, building a career on the basis of personal competence, or the development of a profession (legal or accounting professionals). As you are so painfully aware, you invest heavily, personally and financially in acquiring a particular skill and then you spend the major portion of your life following that skill. Unlike the pyramidal structure of the linear path, career paths are found in organizations that tend to be relatively flat, have departments in which there is a functional emphasis, emphasize quality and reliability, and have reward systems containing a strong recognition component.

md

Medical Professionals are Different

Medical professionals are folks who are job-centered – not organization centered – viewing the demands of the organization as a nuisance that they seek to avoid [THINK: Gregory House MD].

However, that avoidance is impossible since the healthcare professional must have an organization in which to work. This is even more prevalent in today’s era of managed health care and e-Health 2.0, than ever before. At work, professionals experience more role conflict and are more alienated. Medical professionals exhibit these four tendencies:

  1. An experience of occupational socialization that instills high standards of performance in the chosen field; highly ideological about work values.
  2. Sees organizational authority as non-rational when there is pressure to act in ways that are not professionally acceptable.
  3. Tends to feel that their skills are not fully utilized in organizations; self-esteem may be threatened when they do not have the opportunity to do those things for which they have been trained;
  4. Seeks recognition from other professionals outside the organization, and refuses to play the organizational status game except as it reflects their worth relative to others in the organization. Professionals are very concerned with personal achievement and doing well in their chosen field. Organizational rewards serve to reflect the professional’s importance relative to others in the system. This recognition may be extremely fulfilling, especially when he or she is accorded higher status and pay than others. In the absence of organizational rewards the professional may use material objects (large homes, expensive cars) as a way of reflecting status and accomplishment.

Performance not Authority

Medical professionals are of the opinion that successful performance, not compliance with authority, is more reinforcing. With this mindset it is not surprising why many medical practitioners balk at working in the managed health care, state-run or governmental lead healthcare environment. Many professionally oriented people come from the middle class and have become successful through a higher level of education or by other efforts to acquire competence.

The Spiral Career Path

Those on the spiral career path make periodic moves from one occupation to another. Individuals who follow this career path tend to have high personal growth motives and are relatively creative. Usually these changes come after you have developed competence in the occupation you are working in and you think it is time to change what you do. The ideal spiral career path is to move from one occupation to an area related to it. This enables you to use some of the basic knowledge that you developed in your past work and to transfer it to your new occupation. The difference between this path and the linear path discussed above is that in this case the mobility pattern is lateral, not upward.

The Transitory Career Path

People who take the transitory career path cannot seem to, and perhaps do not want to settle down. The pattern is one of consistent inconsistency in their work. These are individuals who may find a great deal of satisfaction working as healthcare consultants. The work style is marked by an ability to do many things reasonably well. They value independence and variety, and they work best in relatively loose and unstructured organizations that tolerate the type of freedom they demand in their work.

Sam (1)

The Indifferents          

We have so far discussed the four types of career paths and two career orientations. A final form of career orientation is that of the indifferents, those who simply work for a paycheck. Will this be the result of Obama care? These are individuals who do their work well, but they are not highly committed to their job or the organization. Some characteristics of indifferents are:

  1. More oriented toward leisure, not the work ethic (is it Friday yet?); separates work from more meaningful aspects of life, and seeks higher-order need satisfaction outside the work organization.
  2. Tends to be alienated from work and not committed to the organization.
  3. Rejects status symbols in organizations.
  4. Withdraws psychologically from work and organizations when possible.

Assessment

Indifferents are not necessarily born that way; some are actually a product of their work experiences. People who once had an organizational orientation and were highly loyal may no longer follow orders without question.

For example, you may have had a medical officer manager who very early in his or her career was extremely committed to you and your medical practice, hospital or healthcare organization. He or she may seek rewards and want to advance. However, in later career life, after having been passed over several times for promotion, the person seeks rewards elsewhere. Thus, it is possible that through office practices, your healthcare organization may turn highly committed organizationalists (or medical professionals) into relative indifferents; HMO patsies or grunts for Uncle Sam.

Conclusion

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Note: Dr. Gene Schmuckler is director of behavioral economics. He is an expert on physician career re-engineering, and a retired Professor of Organizational Behavior who taught Dr. Marcinko [our Publisher-in-Chief] in business school, a decade ago.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko and Dr. Schmuckler are available for seminar or speaking engagements .Contact: MarcinkoAdvisors@msn.com

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Brousseau, K.R., Driver, M.J., Eneroth, K. and Larson, R.: Career Pandemonium: Realigning organizations and individuals. Academy of Management Executive 10 (4), 52-66. 1996

Presthus, R. The Organizational Society. New York, NY: St. Martin’s Press.

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Documentation for a Medical Practice FMV Appraisal

Office Operations and Processes also Important

By Dr. David Edward Marcinko; MBA, MEd, CMP™

[Editor-in-Chief]

To successfully complete a medical practice financial analysis and fair-market valuation [FMV] engagement, the following is a description of the documents that are typically required.

According to Robert James Cimasi MHA, AVA, CMP™ of Health Capital Consultants LLC, most of this information is analogous to that required for the valuation of other types of healthcare service sector entities.

A. Important Documents

  • Historical Financial Statements

Important for identifying key variables and trends for analysis. The consultant should obtain year-end financial statements for a sufficient, relevant period to allow reliable analysis, e.g., the most recent three-five years. If, however, significant changes such as technological upgrades, product shifts, or environmental changes have occurred or the five-year period is not long enough, or too short, to assess the entity’s performance during changes in its business cycle or economic conditions, a longer or shorter period may be needed.

  • Tax Returns

Obtain tax returns to understand the entity’s tax position and to obtain additional accurate financial data. The returns provide a summary of tax policies and elections that affect tax expense and net income.

  • Forecasts and Proformas

Prospective financial information (e.g., forecasts, proformas, and budgets) should be requested to provide an indication of the entity’s opinion of its earnings potential as well as its historical ability to meet projections. This data may be especially useful if the consultant must produce a proforma or valuation of future earnings or cash flows.

  • Legal Documents

The consultant should review all significant legal documents to obtain an understanding of the ownership interests and relationships and to determine if contractual arrangements affect the entity’s operations and overall value. Some of the documents to be reviewed include:

Articles of Incorporation, stockholder, or partnership agreements. These agreements indicate ownership interests and the owners’ rights and obligations. Also, any stock option agreements should be considered. This will help the consultant determine or verify the type of interests involved.

Stock books. Review of these can help the consultant ascertain the relative size of various ownership interests and identify transactions in the entity’s stock.

Existing buy-sell agreements. These may provide an indication of the value of the entity or an ownership interest in it. Such agreements, however, are often structured based on factors other than the entity’s fair market value.

Purchase and sale agreements involving prior transactions of the entity’s stock. These provide indications of the entity’s value and any offers or letters of intent to sell or purchase stock should be carefully reviewed under IRS Revenue Ruling 59-60, which includes “Sales of the stock and the size of the block of stock to be valued” in a list of factors that, “although not all-inclusive are fundamental and require careful analysis in each case.” IRS Ruling 59-60 further requires:

   Sales of stock of a closely held corporation should be carefully investigated to determine whether they represent transactions at arm’s length. Forced or distress sales do not ordinarily reflect fair market value nor do isolated sales in small amounts necessarily control as the measure of value. This is especially true in the valuation of a controlling interest in a corporation. Since, in the case of closely-held stocks, no prevailing market prices are available, there is no basis for making an adjustment for blockage. It follows, therefore, that such stocks should be valued upon a consideration of all the evidence affecting the fair market value. The size of the block of stock itself is a relevant factor to be considered. Although it is true that a minority interest in an unlisted corporation’s stock is more difficult to sell than a similar block of listed stock, it is equally true that control of a corporation, either actual or in effect, representing as it does an added element of value, may justify a higher value for a specific block of stock.

Managed care and other service contracts. Types and numbers of managed care contracts should be reviewed, including whether they are with healthcare maintenance organizations (HMOs), preferred provider organizations (PPOs), or point-of-service (POS) contracts; whether they are on a discounted fee-for-service basis and if so, the size of the discount; whether they include a withhold percentage to only be paid based on quality criteria; or whether they are a flat fee per enrollee (“capitated”). Special terms such as the non-transferability of the contract to a new owner must be noted, e.g., managed care contracts often require that the provider be included on a panel of credentialed providers in order to contract to provide services.

Key doctor and managers’ employment contracts. Such agreements can reveal excess compensation above fair market value or “golden parachute” provisions in the event the business is sold.

Loan and lease agreements. These agreements may contain restrictive covenants, special demand clauses, or working capital requirements that affect the value of the entity. The length and terms of lease agreements is also important.

Documents relating to current, pending, or threatened litigation. These may indicate major contingent liabilities that may affect an entity’s value.

Patent/trademark documents. These documents may indicate the existence of valuable intangible assets. The absence of these documents could indicate the absence of a value consideration claimed by the client.

appraisers

  • Office operations and Staff

Consultants should also gain an understanding of the entity’s operations and key personnel. This can be accomplished by touring the facilities, interviewing key managers, and obtaining additional operational data. Obtaining enough information to thoroughly understand the entity, its operations, and its environment is the objective. The consultant becomes aware of operational data or contracts that may affect value by reviewing the following types of documents:

Corporate documents, including stockholder and director lists, compensation schedules for officers and directors, schedule of key man life insurance policies and organizational charts.

Operational documents, including practice business plans, brochures, price lists, catalogs and other product information, sales forecasts, data on customers and suppliers, and capital budgets.

Reports of other professionals, including appraisals on specific assets and reports by other consultants.

Other internal information, including documents or details relating to potential public offerings for debt or equity, venture capital prospectus or similar information, and tracking of incurred but not reported (IBNR) expenses.

  • Loan Agreements

The medical practice may have loaned or borrowed funds from affiliates. Such loan arrangements may require adjustments to be made to the economic value of the subject entity.

Uncollectible loans receivable should have been written off.

Collectible loans receivable may still be considered non-operating assets and evaluated separately.

Loans payable to related parties may be structured as demand notes, but there may be little chance that such loans will be repaid. Such loans may be considered either long-term debt or a form of owners’ equity.

B. Site Visit / Interview Information

The following types of information specific to the medical practice should be gathered by the financial executive or healthcare consultant. This information may be obtained through an interview, questionnaire, or preferably a site visit.

Valuation

  • Background Information

Include such information as the number of years the entity has operated at its current location and in the community, as well as the office hours.

  • Building Description

Include the location (urban/suburban), proximity to hospitals and other medical facilities, and its size, construction, electrical and computer wiring, age, access to parking, and so on.

  • Office Description

Approximate acquisition details and price, as well as ownership or lease details should be included.  The square footage and number of rooms, and a description of different office areas should be outlined, including, where applicable: medical equipment, including all diagnostic imaging and major medical equipment; pharmacy, laboratory, examination rooms, waiting rooms, and other areas.

  • Management Information Systems

Document types of hardware and software and the cost, age, and suitability of all components, including their management functions, reporting capabilities, and integration between programs.

  • History of the Practice Entity

Give the date founded and by whom, the number of full-time equivalent (FTE) physicians in practice by year, the physicians who have joined and left the entity, the dates they practiced at the entity, and their relationship and practice arrangement with the entity.

  • Office Staff Description

Include the number and types of non-physician positions as well as the tenure and salary of all current employees.

  • Competitive Analysis

Include details of hospital programs impacting practice, growth or decline in the volume of business and the reasons, association with other physicians, competitive strengths and threats, the number and volume of procedures performed, any change in the number and volume, and the corresponding fees.

  • Patient Base Information

Encompass income distribution and percentages from different payors, the number of new patients and total patients seen per week, the age mix of patients, the number of hours spent in patient care per week, and the number of surgeries performed.

  • Managed Care Environment

Detail the terms and conditions of all managed care contracts including discounts and withholds, the impact on referral patterns and revenues, willingness to participate in risk sharing contracts and capitation, and the entity’s managed care reporting capabilities.

  • Hospital Privileges and Facilities

List all hospital privileges held by physician members of the medical practice and the requirements for acquiring privileges at the different local hospitals.

  • Credit Policy and Collections

Include practice policies for billing and payment, use of collection agencies, acceptance of assignments, other sources of revenues, and an aged breakdown of accounts receivable.

  • Financial Management

Include cash management procedures and protections, credit lines and interest, controls to improve payment of accounts payable, late payment frequency, formal or informal financial planning methods, and budgeting processes.

  • Operational Assessment Include governance structure for the entity, detailing responsibilities and procedures for performance, conflicts, recruitment, outcomes measures, case management, reimbursement, income, continuing medical education (CME), credentialing, and utilization review.

Assessment

Allow for discussion of overall relationships with physicians in the community, practice concerns, and needs.

Source: “Research and Financial Benchmarking in the Healthcare Industry”

By Robert James Cimasi; MHA, ASA, CBA. AVA, CM&AA, CMP™
By Todd A. Zigrang; MHA, MBA, CHE
By Anne P. Sharamitaro; Esq

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. What did we forget and what is your experience? Why did you need a medical practice valuation?

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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FINANCE: Financial Planning for Physicians and Advisorsation?

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The Long and Short of Portfolio Construction

Long-Short Portfolio Construction vs. Long-Only

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

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Long-Short is an active portfolio construction discipline that balances long positions in high expected return securities and short positions in low expected return securities of approximately equal value and market sensitivity. This type of portfolio is “neutralized” or immunized against changes in value of the underlying market and, therefore, has zero systematic (beta) risk. If the selected securities perform as expected, the long-short positions will provide a positive return, whether the market rises or falls.

Misconceptions

While long-short portfolios are often perceived and portrayed as much costlier and much riskier than long-only, it is inherently neither. Much of the incremental cost and risk is either largely dependent on the amount of leverage employed or controllable via optimization. Those costs and risks that are not controllable—financial intermediation costs of borrowing shares to short, the trading costs incurred to meet long-short balancing, margin requirements, uptick rules, and the risks of unlimited losses on short positions—do not invalidate the viability of long-short strategies.

Long-Short Advantages

Compared with long-only portfolios, long-short portfolios offer enhanced flexibility not only in the control of risk and pursuit of return, but also in asset allocation. Basic market-neutral portfolios achieve a return consisting of three components: (1) interest on funds held as a liquidity buffer, (2) interest on the short sale proceeds maintained with the broker, and (3) the return spread between the aggregate long and aggregate short positions in the portfolios.

Disadvantages

Share borrow-ability and uptick rules make short-selling more difficult and costly than going long. Also, it may be legally or contractually restricted for some investors, such as mutual funds. Inefficiencies may be concentrated in overpriced stocks and, accordingly, short sales of the most overpriced stocks may offer higher positive returns than long purchases of underpriced stocks.

Assessment

Long-only portfolios are confined to altering the weighting of securities within an index in order to realize an excess return. Long-short portfolios are not constrained by index weights and, because they can short securities, they can “underweight” a security by as much as investment insights and risk considerations dictate. Long-short portfolios can be enhanced by “equitizing” them using stock index futures.

Note: “The Long and Short on Long-Short” by Bruce I. Jacobs and Kenneth N. Levy, The Journal of Investing, Spring 1997, pp. 73–86, Institutional Investor, Inc.

Conclusion

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What is a Stock Market Index IMPLIED OPEN?

FINANCIAL TERMS AND DEFINITIONS FOR PHYSICIANS AND ALL INVESTORS

By Dr. David E. Marcinko MBA MEd CMP®

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The stock markets have been near all time highs, lately. Physician colleagues and clients are so excited that they are even checking the overnight status of favorite stocks and/or the domestic/overseas markets.

Some colleagues are even becoming a bit OCD by checking the implied open of various markets the night before. But, what exactly is the Implied Open? How is it calculated?

DEFINITION: The Implied Open attempts to predict the prices at which various stock indexes will open, at 9:30am New York time. It is frequently shown on various cable television channels prior to the start of the next business day.

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EXAMPLE: Considering the DJIA as an example, the basis of calculating implied open is the price of a “DJX index option futures contract”. This is not the price of the DJIA itself but rather the current ticker price of an option issued by the Chicago Board Options Exchange.

CBOE: The Chicago Board Options Exchange, located at 400 South LaSalle Street in Chicago, is the largest U.S. options exchange with annual trading volume that hovered around 1.27 billion contracts at the end of 2014. CBOE offers options on over 2,200 companies, 22 stock indices, and 140 exchange-traded funds.

CALCULATION: https://www.quora.com/How-do-you-calculate-the-implied-open-from-futures

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NOTE: We would like to remind you that new amendments adopted by the U.S. Securities Exchange Commission (SEC) have gone into effect as of September 28, 2021. These amendments restrict the ability of market makers to publish OTC quotations for those companies that have not made required current financial and company information available to regulators and investors.

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Musings on “Sector” Mutual Funds

A Historical Review

By Dr. David Edward Marcinko MBA, MEd, CMP™

www.CertifiedMedicalPlanner.org

[Publisher-in-Chief]

Although less than 5-10% of the total number of mutual funds are considered true sector funds, year after year, 40-50% or more of the top-performing funds have been sector funds. However, for some physician investors sold on a buy-and-hold strategy, sector funds may not be their cup of tea. But, sector funds do offer an opportunity to outperform the market indices, possibly even substantially, according to Marshall Schield in “Developing a Sector Funds Strategy” (Personal Financial Planning, November/December 1996, pp. 39–42, Warren, Gorham & Lamont, [800] 950-1205).

A Volatile Strategy

Typically sector funds are more volatile than the majority of growth funds. This volatility springs from: (1) the fact that the majority of stocks in a particular sector fund move together, thereby magnifying the fund’s movement; (2) the focus of the sector fund manager only on stocks in that sector, enabling him or her to target high potential stocks; and (3) the rotation of “in” and “out” sectors at particular times.

So – What’s a Doctor Investor to Do?

An investor in sector funds needs a strategy that will target sectors on the upswing and signal when to move out of declining funds. When selecting sector funds, Schield recommends building a list of funds that are manageable, full of choices in all types of markets, diversified (three to four funds for an aggressive portfolio or 10–12 for a less aggressive approach) and liquid.

The Balancing Act

Also, develop a healthy balance—not a “hit-or-miss” approach. Schield suggested using the “relative strength” approach for sector selection by computing the percent change in the price of funds over a certain number of days and then ranking them for short-term, intermediate, and long-term periods. With respect to determining the proper timing for buying or selling, the author suggests the use of an individual fund timing system, such as comparing the current NAV of the sector against a moving average for 50 or 75 days or combining both short- and long-term moving averages.

Simplicity Rules

In creating buy-and-sell signals:

  • Keep it simple and manageable.
  • Do not look for perfection.
  • Practice patience.
  • Cut losses and let profits run.
  • Stick with your relative strength.
  • Buy/sell signals consistently.

Assessment

Most of all; be prepared to spend and invest the time necessary to be successful. But, have you or your sector funds been successful in the last decade, or so? If so, which sectors? Please opine?’

Conclusion

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

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KEY PRINCIPLES: Assessing Medical Practice Financial Value via U.S.P.A.P. Rules

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When it comes to purchasing a medical practice, there are a variety of factors that one must consider in evaluating the worth of the practice. Assessing the value of a practice is fraught with potential landmines if one does not go into the process with a strong understanding of some key principles to medical practice valuation.

   According to the Dictionary of Health Economics and Finance, practice valuation is the “formal process of determining the worth of healthcare or other medical business entity at a specific point in time and the act or process of determining fair market value.” Fair market value is defined as “ … the price at which a willing buyer will buy and a willing seller will sell an asset in an open free market with full disclosure.”

   The Internal Revenue Service (IRS) Revenue Ruling 59-60 clearly states that fair market value “is essentially a future prophecy and must be based on facts available at the required date of appraisal.”

   Unfortunately, one cannot directly observe the value of a medical practice as there are a number of underlying issues. Obviously, the buyer and seller are pursuing opposite objectives, and this reality is not necessarily conducive to facilitating clarity on those issues.

   Accordingly, let us consider a few mistakes that are commonly made by physicians who are considering the purchase of a medical practice.

A Guide To The Myths And Realities Of Medical Practice Valuation

   • Valuations are material representations providing a range of transferable worth.
   • Valuations are reproducible estimates based on economic assumptions.
   • Valuations are not “back of the envelope multiples” using specious benchmarks.
   • Valuations are defensible and should be “signed off” by the completing firm attesting to origination guidelines and in accordance with the Uniform Standards of Professional Appraisal Practice (USPAP) and IRS formats as needed.
   • Financial accounting value (book value) is not fair market value.
   • Professional valuators represent only one party. The buyer or seller-owner is the client.
   • Unbiased valuators do not provide financing or equity participation schemes.

Knowing The Distinctions Among Engagement Types

   The Institute of Medical Business Advisors uses three levels that approximate engagement types for the industry. These levels are comprehensive valuation, limited valuation and ad-hoc valuation.

   A comprehensive valuation is an extensive service designed to provide an unambiguous opinion of the value range. It is supported by all procedures that valuators deem relevant with mandatory onsite review. This gold standard is suitable for contentious situations like divorce, partnership dissolution, estate planning and gifting, etc. The written opinion of value is applicable for litigation support activities like depositions and trial. It is also useful for external reporting to bankers, investors, the public and IRS, etc.

   A limited valuation lacks additional suggested USPAP procedures. It is considered to be an “agreed upon procedure,” which is used in circumstances in which the client is the only user. For example, one may use the limited valuation when updating a buy-sell agreement or when putting together a practice buy-in for a valued associate. This limited valuation would not be for external purposes. No onsite visit is needed. A formal opinion of value is not rendered.

   An ad-hoc valuation is a low level engagement that provides a gross and non-specific approximation of value based on limited limited parameters or concerns by involved parties. Neither a written report nor an opinion of value is rendered. The ad-hoc valuation is often used periodically as an internal organic growth/decline gauge.

Are You Following Industry Standards And Rules?

   Specifically, when it comes to USPAP transactions involving physician practices, the following points are implied by the industry and the IRS.

   • Discounted cash flow analysis is the most relevant income approach and must be done on an “after-tax” basis. It generally produces a higher value but is costly, detail-oriented and time consuming.
   • Project practice collections based on reasonable assumptions for the practice and market, etc.
   • Physician compensation is based on market rates consistent with age, experience and productivity.
   • Majority (control) premiums and minority (lack of control) discounts are also to be considered. A majority premium is the amount paid to gain enough ownership to set policies, direct operations and make decisions for the practice. A minority discount for partial ownership does not allow this power. Thus, majority ownership is valuated higher than minority ownership purchase.

What About Personal Goodwill And Practice Goodwill?

   Goodwill represents the difference between practice purchase price and the value of the net assets. Personal goodwill results from the charisma, skills and reputation of a specific doctor. These attributes accrue solely to the individual, are not transferable and cannot be sold. Personal goodwill has little or no economic value.

   Transferable medical practice goodwill has value, may be transferred and is defined as the unidentified residual attributes that contribute to the propensity of patients and managed care contracts (and their revenue streams) to return in the future.

   However, bear in mind that the Goodwill Registry, an older source used to determine the average percentage of revenue contributed to practice goodwill, has sparse to no podiatry input, may be dated for some specialties and leads to abnormally high values.

   In addition to various multiple factors, one must also appreciate the impact of a changing environment and practice transfer in a local market, which can augment or blunt goodwill value. It is also important to determine whether patients or HMOs return because of true goodwill or are mandated to do so by contractual obligations.

   Now to further confuse the issue, how each kind of goodwill is allocated in situations like divorce depends on state law. For example, some courts weigh in on the apportionment of both kinds of goodwill, other courts exclude both kinds of goodwill and other courts pursue a case-by-case approach.

Understanding ‘Excess Earnings Capitalization’ And Compensation Issues

   Another way to determine goodwill value is through “excess earnings capitalization.” This economic method looks at the difference between salary and what you would have to pay a comparable doctor replacement.

   As an example, when you subtract the numbers and divide the result by 20 percent, an important percentage referred to as the capitalization rate emerges. The final number gives a dollar value for practice goodwill. Courts seem to prefer this method in divorce situations because it tends to reflect a practice’s current value.

   Regardless of the practice business model, physician compensation is inversely related to practice value. In other words, the more a doctor takes home in above average salary, the less the practice is generally worth and vice versa.

Emphasize Practice Specifics Over Benchmarks And Formulas

   In the stable economic past, physicians may have used industry benchmarks as quick and inexpensive substitutes for professionally prepared valuations. However, this practice can be fraught with peril if challenged. The courts seem to frown on this simplistic and dated methodology. Moreover, generic benchmark formulas assume a financial statement reporting standard that just does not exist with contemporary professional valuations.

   Therefore, almost every competitive issue that impacts value should be addressed with each practice engagement. This includes but is not limited to:

   • contemporary dislocations by third parties, Medicare and commercial payers;
   • retail clinics and changes in supply/ demand and specialty trends;
   • the rise of ambulatory surgery centers, walk-in clinics and specialty hospitals;
   • outsourced care and medical tourism;
   • alterations in resource based-relative value units, ambulatory payment classifications (APCs), diagnosis-related groups (DRGs) and newer Medicare-severity diagnosis-related groups (MS-DRGs); and
• the Medicare Modernization Act, HIPAA, OSHA, the EEOC and other regulations.

   One must also consider the impact of current employee trends to high-deductible health care plans and private concierge medicine. Another consideration is employer shifts away from defined benefits plans to defined contribution plans.

Aggregating Or ‘Normalizing’ Financial Information: What You Should Know

   In addition to possibly conducting employee interviews, one must gather appropriate financial information in order to properly value a practice. As a starting point, interested physician buyers should be able to see the following information for the most recent three-year period.

   • Practice (corporate) tax returns
   • Equipment/automobile leasing and/or tax depreciation schedules
   • Accounts receivable aging schedule
   • Consolidated financial statements (P&L, cash flow, balance sheet and retained earnings)
   • Prior buy-sell and/or non-compete agreements

   It is especially important to eliminate one-time, non-recurring practice expenses. These are adjusted for excessive or below normal expenses on the profit and loss statement. Such “normalization” can produce a big surprise for benchmark proponents and formula-driven advocates when a selling doctor runs personal expenditures through the practice that a buyer or court would not consider legitimate. Of course, one is less likely to encounter such shenanigans when the valuation is conducted according to professional USPAP and IRS style guidelines.

   For example, we recall one doctor who painted his home and wrote it off as a valid business expense. Deleting other major expenses such as country club memberships make a practice look more profitable. This is good news if you are selling it. It is bad news if you are getting a divorce.

   Conversely, you may have to defend legitimate business expenses that an appraiser may seek to normalize. For example, doctors may pay for a vehicle through their practice. If they use the vehicle to travel between multiple offices and hospitals, the expense may be legitimate.

   Also realize that the appraiser may also add expenses that have not been incurred. For example, the appraiser may add an office manager’s salary if your spouse is in that role for free. This produces a lower appraised value and is common in small podiatry practices. Honorarium is another example that does not figure into value calculations.

   Of course, normalization is a sophisticated and time intensive process. However, the expert earns his or her professional fee, and defends the resulting valuation range when challenged.

Keys To Selecting The Right Valuator Professional

   The most important credentials to look for are fiduciary level experience, specificity and independence. Some doctors mistakenly turn to those who may have never appraised a practice before. Just because an appraiser has initials behind his or her name, it does not mean he or she understands the peculiarities of medical specialties. Agents, brokers, solicitors and other intermediaries are not fiduciaries.

   Physicians looking to assess a practice for possible sale/purchase should only select an independent health economist, who will be your advocate under Securities Exchange Commission (SEC), IRS or other relevant managerial accounting guidelines.

   Moreover, be very wary if the valuation is not done in an independent manner or, worse, performed for both parties simultaneously.

Essential Insights On Professional Fees And What You Can Expect

   Of course, it is almost impossible to answer concerns regarding fees without specific information. The cost of a valuation can range from $0 to $50,000 for an onsite team of experts for behemoth practices and ambulatory surgery centers. Keep in mind that in most cases you want to ensure the value determination will stand up to IRS scrutiny so the $0 rule of thumb approach is not an option.

   However, most reputable firms use a blended fee schedule of fixed and hourly rates (plus expenses). Internists should expect to spend approximately $5,000 to $10,000 for an average sized practice and a limited appraisal that is completely suitable for most internal activities.

   External appraisals or poorly aggregated financial information, onsite reviews and litigation support services incur additional costs. However, most doctors find the money well spent. Expect to pay a retainer and sign a formal professional engagement letter.

   Finally, once the practice price is agreed upon, sales contract terms and agreements present a plethora of financing challenges for both parties to consider. For example, one must negotiate bank loans (if they are even available), payment rates and length, personal promissory guarantees, down payment offsets, earn-out arrangements and Uniform Commercial Codes.

Final Notes

   Do not be surprised if a sales broker does not consider the aforementioned issues as the modern health era emerges. Most agent-appraisers are predominantly concerned with earning commissions by working both transaction parties and may not represent your best interests. Also be aware that they are usually not obliged to disclose conflicts of interest and do not provide testimony as a court approved expert witness.

   However, it is a fait accompli that medical practice worth is presently deteriorating. As the population ages and third-party reimbursements plummet, doctors are commoditized and traditional retail medicine is replaced by more efficient wholesale business models like workplace health clinics. The subprime mortgage default fiasco, credit freeze, potential tax reform law expiration, the ACA, VBC, capitation payments and the political specter of a nationalized healthcare system only add fuel to the macroeconomic fires of uncertainty. Do not forget the corona pandemic.

   As a result, a good medical practice is no longer good business necessarily and retiring doctors can no longer automatically expect to extract premium sales prices. Moreover, uninformed young physicians should not be goaded to overpay.

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The Author

Dr. Marcinko is a nationally known speaker and the founding partner of the iMBA Inc and http://www.MedicalExecutivePost.com He is also the Academic Provost for http://www.CertifiedMedicalPlanner.org

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FINANCIAL EDUCATION PODCAST: CMPs™ are In … Are CPAs Out?

CERTIFIED MEDICAL PLANNER

By Staff Reporters

SPONSOR: http://www.CertifiedMedicalPlanner.og

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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).

MORE: https://www.wsj.com/lifestyle/careers/accounting-salary-cpa-shortage-dec2caa2?utm_campaign=mb&utm_medium=newsletter&utm_source=morning_brew

PODCAST: https://www.ted.com/talks/dan_bricklin_meet_the_inventor_of_the_electronic_spreadsheet

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MDs RETIRING: 23,000 Physicians Will Retire by 2026

By Staff Reporters

SPONSOR: http://www.CertifiedMedicalPlanner.org

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Thousands of doctors are expected to reach retirement age in the next three years, and their replacements won’t be physicians.

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

Instead, physician assistants (PAs) and nurse practitioners (NPs) will increasingly provide primary care services, according to a report from consulting firm Mercer.

MORE: https://www.healthcare-brew.com/stories/2023/03/16/non-mds-will-provide-primary-care?cid=31157347.24865&mid=349b552221c994e2540a304649746d7c&utm_campaign=hcb&utm_medium=newsletter&utm_source=morning_brew

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RELATED: https://www.kevinmd.com/2023/04/rural-americas-health-care-crisis-unmasking-the-physician-shortage-epidemic.html

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ACOs: Regulatory Environment Scrutiny

By Health Capital Consultants, LLC

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Because of the federal government’s preference for, and reliance on the success of, accountable care organizations (ACOs), some ACOs assume their legal status shields the organization from legal scrutiny on all issues.

However, since the 2010 advent of ACOs, the law has adapted uniquely to these organizations. This fourth installment of a five-part series on the valuation of ACOs will discuss this unique regulatory environment in which ACOs operate. (Read more…) 

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ACOs: A Brief History of Accountable Care Organizations

ACOs to the Rescue – Not Yet!

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By Dr. David E. Marcinko MBA CMP®

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According to the Health Dictionary Series of administrative terms; valuation expert and colleague Robert James Cimasi MHA, ASA, AVA CMP of www.HealthCapital.com; an ACO is a healthcare organization in which a set of providers, usually large physician groups and hospitals, are held accountable for the cost and quality of care delivered to a specific local population. ACOs aim to affect provider’s patient expenditures and outcomes by integrating clinical and administrative departments to coordinate care and share financial risk [personal communication]

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Enter the PP-ACA

Since their four-page introduction in the PP-ACA of 2010, ACOs have been implemented in both the Federal and commercial healthcare markets, with 32 Pioneer ACOs selected (on December 19, 2011), 116 Federal applications accepted (on April 10, 2012 and July 9, 2012), and at least 160 or more Commercial ACOs in existence today.

Federal Contracts

More recently, Donna Marbury writing in Medical Economics, revealed that Federal ACO contracts are established between an ACO and CMS, and are regulated under the CMS Medicare Shared Savings Program (MSSP) Final Rule, published November 2, 2011.  ACOs participating in the MSSP are accountable for the health outcomes, represented by 33 quality metrics, and Medicare beneficiary expenditures of a prospectively assigned population of Medicare beneficiaries. If a Federal ACO achieves Medicare beneficiary expenditures below a CMS established benchmark (and meets quality targets), they are eligible to receive a portion of the achieved Medicare beneficiary expenditure savings, in the form of a shared savings payment.

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Commercial Contracts

Commercial ACO contracts are not limited by any specific legislation, only by the contract between the ACO and a commercial payer. In addition to shared savings models which may not be in effect for another 3-5 years, Commercial ACOs may incentivize lower costs and improved patient outcomes through reimbursement models that share risk between the payer and the providers, i.e., pay for performance compensation arrangements and/or partial to full capitation.

Although commercial ACOs experience a greater degree of flexibility in their structure and reimbursement, the principals for success for both Federal ACOs and Commercial ACOs are similar. And, nearly any healthcare enterprise can integrate and become an ACO, larger enterprises, may be best suited for ACO status.

Medicare Contracts

Assessment

Larger organizations are more able to accommodate the significant capital requirements of ACO development, implementation, and operation (e.g., healthcare information technology), and sustain the sufficient number of beneficiaries to have a significant impact on quality and cost metrics.

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Conclusion

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Certified Medical Planner®

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FINANCIAL PLANNING

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INVESTMENT ANALYSIS

PORTFOLIO MANAGEMENT

MERGERS AND ACQUISITIONS

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How to Monitor Hedge Funds

Four Ways to Monitor after Purchase

By Dr. David Edward Marcinko MBA, MEd, CMP™

SPONSOR: www.CertifiedMedicalPlanner.org

[Publisher-in-Chief]

Hedge funds (broadly defined as private investment vehicles that trade a variety of long and short equities, derivatives, futures contracts, and options in a variety of capital markets) have grown in size and importance in client portfolios because of superior performance, until late [2008-09 and 2022], and readily available investor capital.

Risk Factors

Physicians and clients often ask us to assess certain risk factors and a variety of investment entity structural characteristics associated with hedge funds. Accordingly, we must often be involved in discussing clients’ specific risk/return desires and expectations as they consider such investments.

Four Key Post-Investment Issues:

  1. A change in core investment strategies or risk postures from those which are documented in the investment policy statement—Among these are the specific markets to be traded, the degree of financial leverage to be employed or allowable, the underlying instruments or contracts to be used, and the investment strategies to be pursued under various conditions. Hence, there is no substitute for careful and regular assessment by the planner of changes in how and what an investment manager is trading and communication of such to the client.
  2. Use of financial leverage can dramatically increase returns just as poor performance can be accentuated—The key issue for the planner is whether a given investment manager’s use of leverage changes over the life of the hedge-fund investment, thereby possibly affecting the client’s initial desired risk/return profile.
  3. The composition of the performance return, particularly with respect to the long-term capital gain component.
  4. Asset growth—Regularly monitor and evaluate whether it is detrimental to performance and capable of causing an erosion of performance over a long-term horizon.

Assessment

http://www.MarcinkoAssociates.com

Often, after a hedge-fund investment has been made, if performance over time is good (or even adequate), both the doctor client and the financial advisors or planner may assume that there has been no material changes in investment strategy or structural characteristics that warrant attention or concern. Such changes often occur subtly over time and, if performance erodes, and the client may feel that the planner did not adequately monitor the investment. Hence the necessity for the above warning post

Note: “Post investment Issues Regarding Hedge Funds,” by Richard L. Fisher, Personal Financial Planning, November/December 1996, pp. 14–19, Warren, Gorham & Lamont, 1-800-950-1205.)

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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OUR TAKE: Private Equity and Venture Capital

By Lon Jefferies MBA CMP™ CFP®

By Dr. David Edward Marcinko MBA CMP®

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Private equity and venture capital investments typically involve ownership of shares in a company and represent title to a portion of the company’s future earnings. However, private equity is an equity interest in a company or venture whose stock is not yet traded on a stock exchange.

Venture capital is typically a special case of private equity in which the investment is in a company or venture that has little financial history or is embarking on a high risk/high potential reward business strategy.

Like real estate, private equity and venture capital investments generally share a general lack of liquidity and a lack of comparability across different individual investments. The lack of liquidity comes from the fact that private equity and venture capital investments are typically not tradable on a stock exchange until the company has an IPO.

The lack of comparability is due to the fact that most private equity and venture capital investments are the result of direct negotiation between the investor/venture capitalist and the existing owners of the company  /venture.

With widely divergent terms and provisions across different investments, it is difficult to make general claims regarding the characteristics of private equity and venture capital investments.

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PODCAST: How Financial Advisors Acquire Physician Clients

It’s About Deep Niche Knowledge [An AV Presentation]

By Vicki Rackner MD

Enter the CMPs vicki

AUDIO-VIDEO PRESENTATION

PODCAST; https://www.youtube.com/watch?v=W0SGlL0UzXE#t=22

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About the Author

Vicki Rackner MD, author, speaker, ME-P thought-leader and President of Targeting Doctors, helps financial advisors accelerate their practice growth by acquiring more physician clients. She calls on her experience as a practicing surgeon, clinical faculty at the University of Washington School of Medicine and nationally-noted expert in physician engagement to offer a bridge between the world of medicine and the world of business.

Conclusion

BEWARE FINANCIAL ADVISORS: ChatGPT and A.I. is Coming for Your Job?

Finance Jobs (Financial Analysts, Personal Financial Advisors and Consultants, etc.)

By Staff Reporters

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SPONSOR: http://www.CertifiedMedicalPlanner.org

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

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Like market research analysts, financial analysts, personal financial advisors, and other jobs in personal finance that require manipulating significant amounts of numerical data can be affected by Artificial Intelligence, Mark Muro, a researcher at The Brookings Institute, said recently.

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

“AI can identify trends in the market, highlight what investments in a portfolio are doing better and worse, communicate all that, and then use various other forms of data by, say, a financial company to forecast a better investment mix.” 

These analysts make a lot of money, he said, but parts of their jobs are auto-matable.

READ HERE: https://tinyurl.com/4zk5ert7

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SPDRs vs. Index Mutual Funds

Understanding Vehicular Pros and Cons

By Dr. David Edward Marcinko MBA MEd CMP™

[Publisher-in-Chief]

It is possible to buy or sell during a trading day with SPDRs, just as one would with a common stock, and, accordingly, the trading price may be set anytime during the day. This could prove valuable in a sudden market downturn. Also, they may be traded using the same types of orders used for stocks (market, limit, at the close, and at the opening) and sold short, even on a downtick.

However, dividend reinvestment is provided by only a few brokers. Since SPDRs represent passive equity portfolios, they tend to be fully invested in the stock market, which removes a significant drag on performance; their expense ratios are significantly below that of stock mutual funds in general, and below many index mutual funds; and they have virtually no turnover and accordingly, minimal capital gains.

Index Mutual Funds

Index funds, on the other hand, may only be purchased or redeemed at the net asset value (NAV) at the end of the trading day. Short sales are not possible; however, dividend reinvestment is available.

The Disadvantages

On the down side, SPDRs are sold like common stocks and, therefore, incur brokerage commissions, but this can be minimized by using discount brokers. SPDRs have been so successful that both the American and New York Stock Exchanges launched internationally indexed products modeled after SPDRs in the spring of 1996. They are termed World Equity Benchmark Shares (WEBS) and Country Baskets.

Note: “Index Stocks: An Introduction to SPDRs—S&P 500 Depository Receipts,” Robert T. Kleiman, in his article, AAII Journal, January 1997, pp. 23–26, American Association of Individual Investors [312] 280-0170).

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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On Purchasing Individual BONDS!

A Seldom Discussed Investing Topics for Doctors and All Investors Until Now?

By Dr. David Edward Marcinko MBA MEd CMP®

http://www.MarcinkoAssociates.com

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SPONSOR: http://www.CertifiedMedicalPlanner.org

Now – Trading individual bonds is not like trading stocks. Stocks can be bought at uniform prices and are traded through exchanges. Most bonds trade over the counter, and individual brokers price them.  But, price transparency has gotten better in the last decade. 

For example, in 1999, the bond markets gained clearness from the House of Representatives’ Bond Price Competition Improvement Act of 1999. Responding to this pioneering law, the site http://www.investinginbonds.com was established. This site provides current prices on bonds that have traded more than four times the previous day. With the advent of Investinginbonds.com and real-time reporting of many trades, investors are much better off today.  Many well regarded brokers including Schwab, Ameritrade, and Fidelity Investments now have dedicated websites devoted to bond trading and pricing. 

Fidelity Investments chose to disclose its fee structure for all bonds, making it clear what it will cost you per trade. Fidelity charges $1 per bond trade. Some on-line brokers charge a flat fee as well, ranging from $10.95 at Zions Direct to $45 at TD Ameritrade. Depending on the number of bonds trading, one may be more complimentary than another. The trading fee disclosures, however, do not divulge the spreads between the buy and sell price embedded in the transaction that some dealer is making in the channel. Keep in mind that only by comparison shopping can assist you in finding the best transaction price, after all fees are taken into account. Other sites may not charge any fee, but rather embed the profit in the spread.

Despite the difficulty in pricing and transparency, investing in individual bonds offers several rewards over purchasing bond mutual funds.

First, bond mutual funds never mature.

Second, you know exactly what you will be receiving in interest each year.  You will also know the exact maturity date. 

Furthermore, your individual investment is protected against interest rate risk, at least over the full term to maturity.  Both individual bonds and bond funds share interest-rate risk (the risk of locking up an investment at a given rate, only to see rates rise). This pushes bond prices down.  At least with an individual bond, you can re-invest it at the higher, market rate once the bond matures.

But, the lack of a fixed maturity date on a bond mutual fund causes an open ended problem; there is no promise of the original investment back.  Short of default, an individual bond will return all principal and pay all interest assuming you hold it to maturity.  Bond funds are not likely to default as most funds maintain positions in hundreds of individual bonds.  The force of interest rate risk to individual bond or bond mutual fund prices depends on the maturity of a bond investment: the longer the maturity of a bond or bond fund (average), the more the price will drop due to rising rates. This is known as duration.

Duration is a statistical term that measures the price sensitivity to yield, is the primary measurement of a bond or bond fund’s sensitivity to interest rate changes.  Duration indicates approximately how much the price of a bond or bond fund will adjust in the reverse direction given a rise in interest rates. For instance, an individual bond with an average duration of five years will fall in value approximately 5% if rates rise by 1% and the opposite is accurate as well.

Although stated in years, duration is not simply a gauge of time. Instead, duration signals how much the price of your bond investment is likely to oscillate when there is an up or down movement in interest rates. The higher the duration number, the more susceptible your bond investment will be to changes in interest rates.  If you have money in a bond or bond fund that holds primarily long-term bonds, expect the value of that fund to decline, perhaps significantly, when interest rates rise. The higher a bond’s duration, the greater its sensitivity to interest rates alterations. This means fluctuations in price, whether positive or negative, will be more prominent.

For example, a bond fund with 10-year duration will diminish in value by 10 percent if interest rates increase by one percent. On the other hand, the bond fund will rise in value by 10 percent if interest rates descend by one percent. The important concept to remember is once you recognize a bond’s or bond fund’s duration, you can forecast how it will react to a change in interest rates.

UPDATE:

The yield on the 10-year Treasury note serves as a benchmark for interest rates across the US economy. Since bond prices and yields move in opposite directions, falling yields signal higher demand for Treasuries.

Why it matters: At the most basic level, the 10-year yield is a key indicator of investors’ confidence in future US economic growth. As the Delta variant spreads and threatens to slow the economic recovery, the fall in yields means investors are souring on a mega growth spurt and snapping up safer assets rather than riskier stocks.

What does this mean for inflation? Because investors sell bonds when they think inflation is coming, the runup in bond prices means the worst of Wall Street’s inflation concerns may be over. “It feels like we have moved from thinking inflation will be transitory, to fearing growth will be transitory,” Art Hogan, chief marketing strategist at National Securities, said.

ASSESSMENT: Your thoughts are appreciated.

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

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PHYSICIANS BEWARE: Financial “Advice”

BEWARE THE “DOCTOR EFFECT”

Bread for the advisor – Crumbs for the client

By Dr. David Edward Marcinko MBA CMP

SPONSOR: http://www.MarcinkoAssociates.com

Several years ago a group of highly trusted and deeply experienced financial services professionals and estate planners noted that far too many of their physician clients, using traditional stock brokers, management consultants and financial advisors, seemed to be less successful than those who went it alone. These Do-it-Yourselfers [DIYs] had setbacks and made mistakes, for sure. But, the ME Inc. doctors seemed to learn from their mistakes and did not incur the high management and service fees demanded from general or retail one-size-fits-all “advisors.

”In fact, an informal inverse relationship was noted, and dubbed the “Doctor Effect.” In others words, the more consultants an individual doctor retained; the less well they did in all disciplines of the financial planning and medical practice management, continuum.

Of course, the reason for this discrepancy eluded many of them as Wall Street brokerages and wire-houses flooded the media with messages, infomercials, print, radio, TV, texts, tweets, and internet ads to the contrary. Rather than self-learn the basics, the prevailing sentiment seemed to purse the holy grail of finding the “perfect financial advisor.” This realization was a confirmation of the industry culture which seemed to be: Bread for the advisor – Crumbs for the client!

And so, at D.E. Marcinko & Associates, our informed cadre’ of technology focused and highly educated doctors, nurses, financial advisors, attorneys, accountants, psychologists and educational visionaries decided there must be a better way for their healthcare colleagues to receive financial planning advice and related management services within a culture of fiduciary responsibility.

CMP: http://www.CertifiedMedicalPlanner.org

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BEWARE: Junk Health Insurance and Medical Billing Fees

By Staff Reporters

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President Joe Biden is cracking down on what the White House calls “junk” health insurance plans – namely, less-robust and short-term coverage that the Trump administration expanded as a cheaper alternative to Obamacare AHA plans.

Biden announced a draft regulation which, once finalized, would limit temporary plans to four months instead of the current three-year maximum. It would also require more disclosure on coverage limits.

“This rule would help make these plans fairer and help ensure that consumers know what they’re getting when they sign up for insurance,” said White House domestic policy advisor Neera Tanden. “When they don’t know what they’re getting and get these gigantic bills, they can feel like it’s a scam.”

CITE: https://medicalexecutivepost.com/2022/03/04/podcast-the-no-surprises-medical-billing-act/

The president also announced new guidance on medical billing stemming from 2020’s No Surprises Act. The guidance would limit the ability of insurers that contract with hospitals to claim provided care was not in network and have customers pay more money. Health plans also would need to disclose facility fees that are increasingly charged to patients and can surface as an unexpected cost in a medical bill.

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

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MEDICAL ETHICS: Managing Risk is a Component of Real Health Caring

Demanding High Moral Standards of Self … and Economic HEALTHCARE Organizations

Dr. David Edward Marcinko MBA MEd CMP®

SPONSOR: http://www.CertifiedMedicalPlanner.org

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It has been argued that physicians have abdicated the “moral high ground” in health care by their interest in seeking protection for their high incomes, their highly publicized self-referral arrangements, and their historical opposition toward reform efforts that jeopardized their clinical autonomy. 

Experts Speak

In his book Medicine at the Crossroads, colleague and Emory University professor Melvin Konnor, MD noted that “throughout its history, organized medicine has represented, first and foremost, the pecuniary interests of doctors.” He lays significant blame for the present problems in health care at the doorstep of both insurers and doctors, stating that “the system’s ills are pervasive and all its participants are responsible.” 

In order to reclaim their once esteemed moral position, physicians must actively reaffirm their commitment to the highest standards of the medical profession and call on other participants in the health care delivery system also to elevate their values and standards to the highest level.

Evolution

In the evolutionary shifts in models for care, physicians have been asked to embrace business values of efficiency and cost effectiveness, sometimes at the expense of their professional judgment and personal values.  While some of these changes have been inevitable as our society sought to rein in out-of-control costs, it is not unreasonable for physicians to call on payers, regulators and other parties to the health care delivery system to raise their ethical bar. 

Harvard University physician-ethicist Linda Emmanuel noted that “health professionals are now accountable to business values (such as efficiency and cost effectiveness), so business persons should be accountable to professional values including kindness and compassion.” 

Within the framework of ethical principles, John La Puma, M.D., wrote in Managed Care Ethics, that “business’s ethical obligations are integrity and honesty.  Medicine’s are those plus altruism, beneficence, non-maleficence, respect, and fairness.”

Incumbent in these activities is the expectation that the forces that control our health care delivery system, the payers, the regulators, and the providers will reach out to the larger community, working to eliminate the inequities that have left so many Americans with limited access to even basic health care. 

Charles Dougherty clarified this obligation in Back to Reform, when he noted that “behind the daunting social reality stands a simple moral value that motivates the entire enterprise”. 

ASSESSMENT

Health care is indeed grounded in caring. And, managing risk is a component of caring. It arises from a sympathetic response to the suffering of others.

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Whither the CERTIFIED MEDICAL PLANNER™ Marks?

Wither the CERTIFIED MEDICAL PLANNER™ Professional Certification?

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DEAR INVESTMENT ADVISORS, CPAs, FINANCIAL PLANNERS, FINANCIAL ADVISORS & INSURANCE AGENTS

We believe that:

If you do not have a market niche; you are not deeply informed
If you are not deeply informed; you can’t different yourself
If you can’t differentiate yourself; you can’t differentiate price
If you can’t differentiate price; you have no market power
If you have no market power; you have no unique knowledge
If you have no unique knowledge; you have fewer profits

If you have fewer profits; you are not likely a CMP™

CMP

PROGRAM CURRICULUM: Enter the CMPs

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Dean Gene Schmuckler PhD MBA MEd CTS
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POPULATION HEALTH: Management?

By Dr. David Edward Marcinko MBA CMP

SPONSOR: http://www.MarcinkoAssociates.com

What is population health management?

The Care Continuum Alliance, an alliance of stakeholders across the continuum of care, is working precisely toward the goal of improving the health of populations. They espouse a detailed set of principles and a model of “population health management.” It can be summed up, in the broadest sense, as the care provider community, in partnership with patients and their families, conducting proactive and collective monitoring of the patient’s healthcare quality, adherence, access, and outcomes with the goal of improving the health of an entire patient population.

As such, population health management stresses wellness and prevention through lifestyle and disease management and complex case management to remove the gap between zero care and costly chronic or emergency care. It emphasizes the full spectrum of needs from prevention and wellness to keeping healthy people and at-risk people healthy, to better manage the care of those with chronic conditions, and to still be ready to provide emergent or acute care services. In most cases, it also includes the involved providers taking on accountability for the financial risk and quality of care provided.

We have been working with administrative and physician leaders across the country to grapple with what it will mean to actually foster valuable population health management in the different communities they serve. It is clear that this is a whole new paradigm and that the years of experience and training that have brought them to where they are today may not have sufficiently prepared them for what is to come. It requires a well-coordinated and complete continuum of care, with new metrics and advanced analytics. As one might expect,while clusters of resistance to the idea remain, most have flung themselves into learning mode and are beginning to “act their way into new thinking.”

However, we also see a big risk in powering ahead without revisiting the role of a key stakeholder group—patients and their families, whose experience and perspective are often left behind, but whose actions will have a profound effect on the future success of population health management efforts.

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

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Its earnings season once again and CVS Health beat Wall Street estimates with $2.3 billion in profit during Q3. Humana raised its Medicare Advantage enrollment projections again.

And, population management telehealth giant Amwell inked a major federal contract but has seen its losses balloon in 2023.

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What Physician Investors STILL NEED TO KNOW about “Monte Carlo” Simulation?

Probability Forecasting and Investing

By Dr. David Edward Marcinko MBA MEd CMP™

[Editor-in-Chief] www.CertifiedMedicalPlanner.org

dr-david-marcinko1Recently, I had a physician-client ask me about Monte Carlo simulation. You know the routine: what it is and how it works, etc.

From Monaco

Named after Monte Carlo, Monaco, which is famous for its games of chance, MCS is a technique that randomly changes a variable over numerous iterations in order to simulate an outcome and develop a probability forecast of successfully achieving an outcome.

In endowment management, MCS is used to demonstrate the probability of “success” as defined by achieving the endowment’s asset growth and payout goals.  In other words, MCS can provide the endowment manager with a comfort level that a given payout policy and asset allocation success will not deplete the real value of the endowment.

Quantitative Tools Problematic

The problem with many quantitative tools is the divorce of judgment from their use. Although useful, MCS has limitations that should not supplant the endowment manager’s, FA or physician-investor’s, experience.

MCS generates an efficient frontier by relying upon several inputs: expected return, expected volatility, and correlation coefficients. These variables are commonly input using historical measures as proxies for estimated future performance. This poses a variety of problems.

  • First, the MCS will generally assume that returns are normally distributed and that this distribution is stationary.  As such, asset classes with high historical returns are assumed to have high future returns.
  • Second, MCS is not generally time sensitive. In other words, the MCS optimizer may ignore current environmental conditions that would cause a secular shift in a given asset class returns.
  • Third, MCS may use a mean variance optimizer [MVO] that may be subject to selection bias for certain asset classes. For example, private equity firms that fail will no longer report results and will be eliminated from the index used to provide the optimizer’s historical data.

Healthcare Investment Risks

A Tabular Data Example

This table compares the returns, standard deviations for large and small cap stocks for the 20-year periods ended in 1979 and 2010.

Twenty Year Risk & Return Small Cap vs. Large Cap (Ibbotson Data)

[IA Micro-Cap Value 14.66 17.44 24.69 0.44]

1979

2010

Risk

Return

Correlation

Risk

Return

Correlation

Small   Cap Stocks 30.8% 17.4% 78.0% 18.1% 26.85% 59.0%
Large   Cap Stocks 16.5% 8.1% 13.1% 15.06%

[Reproduced from “Asset Allocation Math, Methods and Mistakes.” Wealthcare Capital Management White Paper, David B. Loeper, CIMA, CIMC (June 2, 2001)]

The Problems

Professor David Nawrocki identified a number of problems with typical MCS in that their mean variance optimizers assume “normal distributions and correlation coefficients of zero, neither of which are typical in the world of financial markets.”

Dr. Nawrocki subsequently described a number of other issues with MCS including nonstationary distributions and nonlinear correlations.

Finally, Dr. Nawrocki quoted financial advisor, Harold Evensky MS CFP™ who eloquently notes that “[t]he problem is the confusion of risk with uncertainty.” Risk assumes knowledge of the distribution of future outcomes (i.e., the input to the Monte Carlo simulation). Uncertainty or ambiguity describes a world (our world) in which the shape and location of the distribution is open to question.

Assessment

Contrary to academic orthodoxy, the distribution of U.S. stock market returns is “far from normal.”[1] Other critics have noted that many MCS simulators do not run enough iterations to provide a meaningful probability analysis.

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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[1]   Nawrocki, D., Ph.D. “The Problems with Monte Carlo Simulation.” FPA Journal (November 2001).

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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™

Some Modern Issues Impacting Hospital Revenue Cycles

By Carol S. Miller RN CPM MHA

Sponsor: http://www.CertifiedMedicalPlanner.org

By Dr. David Edward Marcinko MBA MEd CMP™

Carol S. Miller “Collectively the healthcare industry spends over $350 Billion to submit and process claims while still working with cumbersome workflows, inefficient processes, and a changing landscape marked by increasing out-of-pocket cost for patients as well as increasing operating costs.”

The Norm Continues Downhill

For many years hospitals and healthcare organizations have struggled to maintain and improve their operating margins.  They continue to face a widening gap between their operating costs and the revenues required to cover not only current costs, but also to finance strategic growth initiatives and investments.

Faced with increased operational costs and associated declines in rates of reimbursement, many healthcare hospital executives and leaders are concerned that they will not achieve margin targets.  To stabilize the internal financial issue, some hospital have focused on lowering expenses in order to save costs – an area they control and an area that will show an immediate impact; however, that is not the best solution.

Beware Cost Reductions

Hospital executives are concerned with the effect that these reductions may have on patient quality and service.  Finding ways to maximize workflow to lower operating costs is vital.  Every dollar not collected negatively impacts short- and long term capital projects, lowers patient satisfaction scores and possibly affects quality of patient care.

Status Today

Hospitals, healthcare organizations and all medical providers are under great pressure to collect revenue in order to remain solvent. And so, here are some of the issues impacting the modern hospital revenue cycle as Obama-Care, or the PP-ACA of 2010, as launched last decade?

Issues Impacting the Revenue Cycle

Several of the major leading issues facing the revenue cycle are:

  • Impact of Consumer-driven Health – This process has emerged as a new approach to the traditional managed care system, shifting payment flows and introducing new “non-traditional” parties into the claims processing workflow.  As market adoption enters the mainstream, consumer-driven health stands to alter the healthcare landscape more dramatically than anything we have seen since the advent of managed care.  This process places more financial responsibility on the consumer to encourage value-drive healthcare spending decisions.
  • Competing high-priority projects –Hospitals are feeling pressured to maximize collections primarily because they know changes are coming down the pike due to healthcare reform and they know they will need to juggle these major initiatives along with the day-to-day revenue cycle operations.
  • Lack of skilled resources in several areas – Hospital have struggled to find the right personnel with sufficient knowledge of project management, clinical documentation improvement, coding and other revenue cycle functions, resulting in inefficient operations.
  • Narrowing margins – Declines in reimbursement are forcing hospitals to look at their organization to determine if they can increase efficiencies and automate to save money.  Hospitals are faced with the potential of increased cost to upgrade and adapt clinical software while not meeting budget projections.  There are a number of factors contributing to the financial pressure including inefficient administrative processes such as redundant data collection, manual processes, and repetitive rework of claims submissions.  Also included are organizations using outdated processes and legacy technologies.
  • Significant market changes – Regardless of what happens with the Patient Protection and Affordable Care Act, hospitals will have to deal with fluctuating amounts of insured and uninsured patients and variable payments.
  • Limited access to capital – With the trend towards more complex and expensive systems, industry may not have the internal resources and funding to build and manage these systems that keep pace with the trends.
  • Need to optimize revenue – There are five core areas hospitals have to examine carefully and they are:
    • ICD-10 – This is an entirely new coding and health information technology issue but is also a revenue issues
    • System integration – Hospitals need to look at integrating software and hardware systems that can combine patient account billing, collections and electronic health records.
    • Clinical documentation – Meaningful use will require detailed documentation in order for payment to be made and this is another revenue issue.
    • Billing and claims management – Reducing denials and reject claims, training staff, improving point-of-service collections and decreasing delays in patient billing can improve the revenue cycle productivity,
    • Contract analysis – Hospitals need to focus more on negotiating rates with insurers in order to increase revenue.

Hospital

Conclusion

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3 FINANCIAL SLANG “T” Terms

DEFINITIONS Physician-Investors Need to Know

By. Dr. David E. Marcinko MBA MEd CMP®

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SPONSOR: http://www.CertifiedMedicalPlanner.org

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Trading AheadUnethical and illegal trading by specialists or market makers.
A specialist may buy a stock for themselves from Dr. John Q. Public even though a better price is available from another seller. The specialist can view bid and ask prices and then manually mis-match them, or see ahead to a less favorable price. It happens in this editor’s experience, by observing how long it takes for a stop order to execute after the stop price was reached.
This practice is a form of shimming.
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Trading ImbalanceA situation where a large block of stock is put up for sale, but not enough buyers are available for purchase, and a market maker is unable to buy the imbalance. Lightly traded and tightly held stocks are considered temporarily illiquid during such imbalances.
On occasion, a trading halt is put into place until enough buyers are available to purchase the deficit. On rare occasion, a handful of buyers can buy the stock at a huge discount if the stock was not halted during the imbalance.
On the New York Stock Exchange, large stocks usually have a “delayed open” for such imbalances, as a trading specialist will fill the order by lining up buyers for the block, and then open trading for the stock for the day.
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Triple Witching HourThe final hour of trading on a Friday when stock index futures, stock index options, and stock options all expire. This happens on the third Friday in March, June, September, and December. See Quadruple Witching Hour.
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What is “Shelf Registration” for Securities?

What is “Shelf Registration” for Securities?

Dr. David E. Marcinko MBA CMP

http://www.MARCINKOASSOCIATES.com

SPONSOR: http://www.CertifiedMedicalPlanner.org

A relatively new method of registration under the Act of ’33 is known as shelf registration.

Under this rule, an issuer may register any amount of securities that, at the time the registration statement becomes effective, is reasonably expected to be offered and sold within two years of the initial effective date of the registration.

Once registered, the securities may be sold continuously or periodically within 2 years without any waiting period for a registration to clear issuers generally like shelf registration because of the flexibility it gives them to take advantage of changing market conditions.

LINK: https://www.crcpress.com/Comprehensive-Financial-Planning-Strategies-for-Doctors-and-Advisors-Best/Marcinko-Hetico/p/book/9781482240283

In addition, the legal, accounting, and printing costs involved in issuance are reduced, since a single registration statement suffices for multiple offerings within the 2 year period. In effect, what the issuer does is register securities that will meet its financing needs for the next 2 years.

It issues what it needs at the current time, and puts the balance on the “shelf” to be taken off the shelf as needed.

Conclusion:

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The Private Placement (Regulation D) Securities Exemption

What it is – How it works?

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By Dr. David Edward Marcinko MBA MEd CMP

http://www.CertifiedMedicalPlanner.org

Since the Securities Act of 1933 requires disclosure of all public offerings (other than the exemptions just described), it should make sense that any securities offering not offered to the public would also be exempt. The Act provides a registration exemption for private placements, know as Regulation D.

Since one of the stated purposes of the Act of 1933 is to prevent fraud on the sale of new public issues, an issue which has only a limited possibility of injuring the public may be granted an exemption from registration. The SEC just doesn’t have the time to look at everything so they exempt offerings which do not constitute a “public offering”. Strict adherence to the provisions of the law, however, is expected and is scrutinized by the SEC. This exemption provision of the Act of ’33 lies within Regulation D.

Regulation D describes the type and number of investors who may purchase the issue, the dollar limitations on the issue, the manner of sale, and the limited disclosure requirements. Bear in mind at all times that from the issuer’s viewpoint, the principal justification for doing a private, rather than public offering, is to save time and money, not to evade the law.

NOTE: Remember, it is just as illegal to use fraud to sell a Regulation D issue as it is in a public issue. However, if done correctly, a Regulation D can save time and money, and six separate rules (501-506).

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The Rules

Rule 501: Accredited investors are defined as: corporations and partnerships with net worth of $5,000,000 not formed for the purpose of making the investment; corporate or partnership “insiders”; individuals and medical professionals with a net worth (individual or joint) in excess of $1,000,000; individuals with income in excess of $200,000 (or joint income of $300,000) in each of the last two years, with a reasonable expectation of having income in excess of $200,000 (joint income of $300,000) in the year of purchase; and any entity 100% owned by accredited investors. 

Rule 502: The violations of aggregation and integration are defined:

Aggregation: Sales of securities in violation of the dollar limitations imposed under Rules 504 and 505 (506 has no dollar limitations).

Integration: Sales of securities to a large number of non-accredited investors, in violation of the “purchaser limitations” set forth in Rules 505 and 506 (504 has no “purchaser limitations”). 

Rule 503: Sets forth notification requirements. An issuer will be considered in violation of Regulation D, and therefore subject to Federal penalties, if a Form D is not filed within 15 days after the Regulation D offering commences. 

Rule 504: Enables a non-reporting company to raise up to $1,000,000 in a 12-month period without undergoing the time land expense of an SEC registration. Any number of accredited and non-accredited investors may purchase a 504 issue. 

Rule 505: Enables corporations to raise up to $5,000,000 in a 12-month period without a registration. The “purchaser limitation” rule does apply here. It states that the number of non-accredited investors cannot exceed 35. Obviously, we would have few problems if only medical investors in private placements were accredited investors, but that is not always the case. Since we are limited to a maximum of 35 non-accredited investors, how we count the purchasers becomes an important consideration. The SEC states that if a husband and wife each purchase securities in a private placement for their own accounts, they count as one non- accredited investor, not two. It would also be true that if these securities were purchased in UGMA accounts for their dependent children, we would still be counting only one non- accredited investor. In the case of a partnership, it depends upon the purpose of the partnership. If the partnership was formed solely to make this investment, then each of the partners counts as an individual accredited or non-accredited investor based upon their own personal status, but if the partnership served some other purpose, such as a law firm, then it would only count as one purchaser.

Rule 506: Differs from 505 in two significant ways. The dollar limit is waived and the issuer must take steps to assure itself that, if sales are to be made to non-accredited investors, those investors meet tests of investment “sophistication”.

Generally speaking, this means that either the individual non-accredited investor has investment savvy and experience with this kind of offering, or he is represented by someone who has the requisite sophistication. This representative, normally a financial professional, such as an investment advisor, accountant, or attorney, is referred to in the securities business as a Purchaser Representative.

Regulation D further states that no public advertising or solicitation of any kind is permitted. A tombstone ad may be used to advertise the completion of a private placement, not to announce the availability of the issue. As a practical matter, however, whether required by the SEC or not, a Private Offering Memorandum for a limited partnership, for example, is normally prepared and furnished so that all investors receive disclosure upon which to base an investment judgment.

If any of the provisions of the Securities Act of 1933 are violated by an issuer, underwriter, or investor, this is known as “statutory underwriting” of underwriting securities in violation of statute. One who violates the ’33 Act is known as a statutory underwriter. One all too common example of this occurs when a purchaser of a Regulation D offering offers his unregistered securities for re-sale in violation of SEC Rule 144, an explanation of which is given below.

In simple English, SEC Rule 144 was created so that certain re-sales of already-existing securities could be made without having to file a complete registration statement with the SEC. The time and money involved in having to file such a registration is usually so prohibitive as to make it uneconomical for the individual seller. What kinds of re-sales are covered by Rule 144 and are important to the medical investor? Let’s first define a few terms. 

Restricted Securities: Are unregistered Securities purchased by an investor in a private placement. It is also called Letter Securities or Legend Securities referring to the fact that purchasers must sign an “Investment Letter” attesting to their understanding of the restrictions upon re-sale and to the “Legend” placed upon the certificates indicating restriction upon resale. 

Control Person: A corporate director, officer, greater than 10% voting Stockholder, or the spouse of any of the preceding, are loosely referred to as Insiders or Affiliates due to their unique status within the issuer. 

Control Stock: Stock held by a control person. What makes it control stock is who owns it, not so much how they acquired it. 

Non-Affiliate: An investor who is not a control person and has no other affiliation with the issuer other than as an owner of securities.

Rule 144 says that restricted securities cannot be offered for re-sale by any owner without first filing a registration statement with the SEC:

  1. unless the securities have been held in a fully paid-for status for at least two years;
  2. unless a notice of Sale is filed with the SEC at the time of sale and demonstrating compliance with Rule 144
  3. unless small certain quantity apply: 

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Assessment

  • Rule 500 – Use of Regulation D
  • Rule 501 – Definitions and terms used in Regulation D
  • Rule 502 – General conditions to be met
  • Rule 503 – Filing of notice of sales
  • Rule 504 – Exemption for offerings not exceeding $5,000,000
  • Rule 505 – No longer availible effective May 22, 2017
  • Rule 506 – Exemption for unlimited offering
  • Rule 507 – Disqualifying provision relating to exemptions 504, 505 and 506
  • Rule 508– Insignificant deviations from a term, condition or requirement of Regulation D

Conclusion

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Walking Doctors Through a Stock Exchange Trade

Understanding the Traditional Process

By Dr. David Edward Marcinko MBA MEd CMP

SPONSOR: http://www.CertifiedMedicalPlanner.org

To see how the transactions are actually handled on the floor of an exchange, let us assume that an order to buy 100 shares of General Electric has been given by a doctor customer to the registered representative (stock broker), of a member firm in Atlanta. The order is a market order (an order to buy at the lowest possible price at the time the order reaches the floor of the exchange). This order is telephoned by direct wire, or computer, to the New York office of the member firm, which in turn telephones its order to its clerk on the floor of the exchange.

Each member firm has at least one member of the exchange representing them making trades on the floor. Each one of these members is assigned a number for identification. When the floor clerk receives the order to purchase the General Electric, he causes his member’s call number to appear on 3 large boards situated so that one is always in view. These boards are constantly watched brokers so that they will know when wanted at the phone, since there’s too much noise on the floor to use a paging system. Seeing his number on the board, the broker hurries to his telephone station or cell phone and receives the order to buy 100 shares of G.E. “at the market”. Acting as a commission broker, he immediately goes to the post where G.E. is traded and asks “how’s G.E”, of the specialist?

Order and Position Types

At this point, it is important to understand the different types of orders and positions that can be used to buy and sell securities from the specialist.

Market Order:

A market order is an order to be executed at the best possible price at the time the order reaches the floor. Market orders are the most common of all orders. The greatest advantage of the market order is speed. The doctor specifies no price in this type of order, he merely orders his broker to sell or buy at the best possible price, regardless of what it may be. The best possible price on a buy is the lowest possible price. The best possible price on a sell is the highest possible price. In other words, if a medical professional customer is buying, he logically wants to pay as little as possible, but he is not going to quibble over price. He wants the stock now, whatever it takes to get it. If he’s a seller, the doctor client wants to receive as much as possible, but will not quibble, he wants out, and will take what he can get, right now. No other type of order can be executed so rapidly. Some market orders are executed in less than one minute from the time the broker phones in the order. Because the investor has specified no price, a market order will always be executed. The doctor is literally saying, “I will pay whatever it takes, or accept whatever is offered”.

Limit Order:

The chief characteristic of a limit order is that the doctor decides in advance on a price at which he decides to trade. He believes that his price is one that will be reached in the market in reasonable time. He is willing to wait to do business until he has obtained his price even at the risk his order may not be executed either in the near future or at all. In the execution of a limit order, the broker is to execute it at the limit price or better. Better, means that a limit order to buy is executed at the customer’s price limit or lower, in a limit order to sell, at price limit or higher. If the broker can obtain a more favorable price for his doctor customer than the one specified, he is required to do so.

Order Length:

Now, even though the doctor has given his price limit, we need to know the length of effectiveness of the order. Is the order good for today only? If so, it is a day order, it automatically expires at the end of the day.  Alternatively, the doctor may enter an open or, “good until canceled” order. This type of order is used when the doctor believes that the fluctuations in the market price of the stock in which he’s interested will be large enough in the future that they will cause the market price to either fall to, or rise to, his desired price, i.e. his limit price. He is reasonably sure of his judgment and is in no hurry to have/his order executed. He knows what he wants to pay or receive and is willing to wait for an indefinite period.

Years ago, such orders were carried for long periods of time without being reconfirmed. This was very unsatisfactory for all parties concerned.  A doctor would frequently forget his order existed and, if the price ever reached his limit and the order was executed, the resulting trade might not be one he wished to make. To avoid the problem, open (GTC) orders must be reconfirmed by the doctor customer each six months. Does that mean six months after the order is entered? … No! The exchange has appointed the last business day of April and the last business day of October as the two dates per year when all open orders must be reconfirmed.

Example: Dr. Smith wants to buy 100 shares of XYZ. The price has been fluctuating between 50 and 55. He places a limit order to buy at 51, although the current market price is 54. Limit orders to buy (buy limit orders) are always placed below the current market. To do otherwise makes no sense. It is possible that, within a reasonable time, the price will drop to 51 and his broker can purchase the stock for him at that price. If the broker can purchase the stock at less that 51, that would certainly be fine with the doctor customer since he wants to pay no more than 51. A sell limit order works in reverse and is always placed above the current market price.

Example: Dr. Smith wants to sell 100 shares of XYZ stock. The order is 54. A sell limit order is place at 56. Sell limit orders are always placed above the market price. As soon as the pride rises to 56, if it ever does, the broker will execute it at 56 or higher. In no case will it be executed at less than 56.

The advantage of the limit order is that the doctor has a chance to buy at less or to sell at more than the current market price prevailing when he placed the order. He assumes that the market price will become more favorable in the future than it is at the time the order is placed. The word” chance ” is important. There is also the “chance” that the order will not be executed at all. The doctor just mentioned, who wanted to buy at 51, may never get his order filled since the price may not fall that low.  If he wanted to sell at 56, the order may also not ever be executed since it might not rise that high during the time period the order is in effect.

Stop Orders:

A very important type of order is the stop order, frequently called a stop-loss order. There are two distinct types of stop orders. One is the stop order to sell, called a sell stop, and the other is a stop order to buy, called a buy stop. Either type might be thought of as a suspended market order; it goes into effect only if the stock reaches or passes through a certain price.

The fact that the market price reaches or goes through the specified stop price does not mean the broker will obtain execution at the exact stop price. It merely means that the order becomes a market order and will be executed at the best possible price thereafter. The price specified on a stop order bears a relationship to the current market price exactly opposite to that on a limit order. Whereas a sell limit is placed at a price above the current market, a sell stop is placed at a price below the current market. Similarly, while a buy limit is placed at a price below the current market, a buy stop is placed at a price above the current market. Why would a doctor investor use a stop order?

There are two established uses for stop orders. One of them might be called protective; the other might be called preventive.

Protective: This order protects a doctors’ existing profit on a stock currently owned.

For example, a doctor purchases a stock at 60. It rises to 70. He has made a paper profit of $10 per share. He realizes that the market may reverse itself. He therefore gives his broker a stop order to sell at 67. If the reversal does occur and the price drops to 67 or less, the order immediately becomes a market order. The stock is disposed of at the best possible price. This may be exactly 67, or it may be slightly above or below that figure. Why? …Because what happened at 67 was that his order became a market order; the price he actually received was dependent upon the next activity in the market. Let us suppose that the sale was made at 66 1/2. The doctor customer made a gross profit of 6 1/2 points per share on his original purchase. Without the stop order, the stock may have dropped considerably below that before the customer could have placed a market order and his profit might have been less or, in fact, he might have even sold at a loss.

Preventive:

A doctor purchases 100 shares of a stock at 30. He obviously anticipates that the price of the stock will rise in the near future (why else would he buy?). However, he realizes that his judgment may be faulty. He therefore, at the time of purchase, places a sell stop order at a price somewhat below his purchase price, for example, at 28. As yet, he has made neither profit nor loss; he’s merely acting to prevent a loss that might follow if he made the wrong bet and the stock does fall in price. If the stock does drop, the doctor knows that once it gets as low as 28, a market order will be turned in for him and, therefore, he will lose only 2 points or thereabout. It might have been much more had he not used the sell stop.

Miscellaneous Orders and Positions

Beside market, limit and stop orders, there are some other miscellaneous orders to know.

A stop limit order is a stop order that, once triggered or activated, becomes a limit order. Realize that it is possible for a stop limit to be triggered and not executed, as the limit price specified by the doctor may not be available.

In addition, there are all or none and fill or kill orders, and even though both require the entire order to be filled, there are distinct differences. An all or none (AON) is an order in which the broker is directed to fill the entire order or none of it. A fill or kill (FOK) is an order either to buy or to sell a security in which the broker is directed to attempt to fill the entire”‘ amount of the order immediately and in full, or that it be canceled.

The difference between an all or none and a fill or kill order is that with an all or none order, immediate execution is not required, while immediate execution is a critical component of the fill or kill. Be cause of the immediacy requirement, FOK orders are never found on the specialist’s book. Another difference is that AON orders are only permitted for bonds, not stocks, while FOK orders may be used for either.

Also, there exists an immediate or cancel order (IOC), which is an order to buy or sell a security in which the broker is directed to attempt to fill immediately as much of the order as possible and cancel any part remaining. This type of order differs from a fill or kill order which requires the entire order to be filled. An IOC order will permit a partial fill. Because of the immediacy requirement, IOC and FOK orders are never found on the specialist’s book.

Long and Short Positions

A long buy position means that shares are for sale from a market makers inventory, or owned by the medical investor, outright. Market makers take long positions when customers and other firms wish to sell, and they take short positions when customers and other firms want to buy in quantities larger than the market maker’s inventory. By always being ready, willing, and able to handle orders in this way, market makers assure the investing public of a ready market in the securities in which they are interested. When a security can be bought and sold at firm prices very quickly and easily, the security is said to have a high degree of liquidity, also known as marketability.

A short position investor seeks to make a profit by participating in the decline in the market price of a security.

Now, let’s see how these terms, long and short, apply to transactions by medical investors, rather than market makers, in the securities markets.

When a doctor buys any security, he is said to be taking a long position in that security. This means the investor is an owner of the security. Why does a doctor take a long position in a security? Besides – receiving dividend income, to make a profit from an increase in the market price. Once the security has risen sufficiently in price to satisfy the investor’s profit needs, the investor will liquidate his long position, or sell his stock. This would officially be known as a long sale of stock, though few people in the securities business use the label “long sale”. This is the manner in which the above investor had made a profit is the traditional method used; buy low, sell high.

Let’s look at an actual investment in General Motors to investigate this principle further. A medical investor has taken a long position in 100 shares of General Motors stock at a price of $70 per share. This means that the manner in which he can do that is by placing a market order which will be executed at the best “available market price at the time, or by the / placing of a buy limit order with a limit price of $70 per share. The investor firmly believes, on the basis of reports that he has read about the automobile industry and General Motors specifically, that at $70 a share, General Motors is a real bargain. He believes that based on its current level of performance, it should be selling for a price of between $80 and $85 per share. But, the doctor investor has a dilemma. He feels certain that the price is going to rise but he cannot watch his computer, or call his broker, every hour of every day. The reason he can’t watch is because patients have to be seen in the office. The only people who watch a computer screen all day are those in the offices of brokerage firms (stock broker registered representatives), and doctor day traders, among others.

In the above example, with a sell limit order, if the doctor investor was willing to settle for a profit of $12 per share, what order would he place at this time? If you said, “sell at $82 good ’til canceled”, you are correct. Why GTC rather than a day order? Because our doctor investor knows that General Motors is probably not going to rise from $70 to $82 in one day. If he had placed an order to sell at $82 without the GTC qualification, his order would have been canceled at the end of this trading day. He would have had to re-enter the order each morning until he got an execution at 82. Marking the order GTC (or open) relieves him of any need to replace the order every morning. Several weeks later, when General Motors has reached $82 per share in the market, his order to sell at 82 is executed. The medical investor has bought at 70 and sold at 82 and realized a $12 per share profit for his efforts.

Let’s suppose that the medical investor, who has just established a $12 per share profit, has evaluated the performance of General Motors common stock by looking at the market performance over a period of many years. Let’s further assume that the investor has found by evaluating the market price statistics of General Motors is that the pattern of movement of General Motors is cyclical. By cyclical, we mean that it moves up and down according to a regular pattern of behavior. Let’s say the investor has observed that in the past, General Motors had repeated a pattern of moving from prices in the $60 per share range as a low, to a high of approximately $90 per share. Further, our investor has observed that this pattern of performance takes approximately 10 to l2 months to do a full cycle; that is, it moves from about 60 to about 90 and back to about 60 within a period of roughly l2 months. If this pattern repeats itself continually, the investor would be well advised to buy the stock at prices in the low to mid 60’s hold onto it until it moves well into the 80’s, and then sell his long position at a profit. However, what this means is that our investor is going to be invested in General Motors only 6 months of each year. That is, he will invest when the price is low and, usually within half a year, it will reach its high before turning around and going back to its low again. How can the doctor investor make a profit not only on the rise in price of General Motors in the first 6 months of the cycle, but on the fall in price of General Motors in the second half of the cycle? One technique that is available is the use of the short sale.

The Short Sale

If a doctor investor feels that GM is at its peak of $ 90 per share, he may borrow 100 shares from his brokerage firm and sell the 100 shares of borrowed GM at $ 90. This is selling stock that is not owned and is known as a short sale. The transaction ends when the doctor returns the borrowed securities at a lower price and pockets the difference as a profit. In this case, the doctor investor has sold high, and bought low.

Odd Lots

Most of the thousands of buy and sell orders executed on a typical day on the NYSE are in 100 share or multi-100 share lots. These are called round lots. Some of the inactive stocks traded at post 30, the non-horseshoe shaped post in the northwest corner of the exchange, are traded in 70 share round lots due to their inactivity. So, while a round lot is normally 700 shares, there are cases where it could be 10 shares. Any trade for less than a round lot is known as an odd lot. The execution of odd lot orders is somewhat different than round lots and needs explanation.

When a stock broker receives an odd lot order from one of his doctor customers, the order is processed in the same manner as any other order. However, when it gets to the floor, the commission broker knows that this is an order that will not be part of the regular auction market. He takes the order to the specialist in that stock and leaves the order with the specialist. One of the clerks assisting the specialist records the order and waits for the next auction to occur in that particular stock. As soon as a round lot trade occurs in that particular stock as a result of an auction at the post, which may occur seconds later, minutes later, or maybe not until the next day, the clerk makes a record of the trade price.

Every odd lot order that has been received since the last round lot trade, whether an order to buy or sell, is then executed at the just noted round lot price, the price at which the next round lot traded after receipt of the customer’s odd lot order, plus or minus the specialist’s “cut “.  Just like everything else he does, the specialist doesn’t work for nothing. Generally, he will add 1/8 of a point to the price per share of every odd lot buy order and reduce the proceeds of each odd lot sale order by 1/8 per share. This is the compensation he earns for the effort of breaking round lots into odd lots. Remember, odd lots are never auctioned but, there can be no odd lot trade unless a round lot trades after receipt of the odd lot order.

Conclusion

And so, 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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Hurdle Rates V. Highwater Marks V. Claw Back Provisions

More on Hedge Funds and Fees

dem-2By Dr. David Edward Marcinko MBA MEd CMP®

SPONSOR: http://www.CertifiedMedicalPlanner.org

Many physicians and other investors — even those that meet net worth guidelines — are surprised to learn that there exists a $500 – 999 billion, or more, alternative investment industry that is not generally marketed to the public. Such alternative investments have also been known as hedge funds or private investment funds.

Unlike mutual funds, these alternative investments can be structured in a wide variety of ways. Because of the very same regulations discussed above, these funds cannot be advertised, but they are far from illegal or illicit.

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History

In fact, physicians were among the most significant early investors in one of the last century’s most successful hedge funds. Mr. Warren Buffett, Chairman of Berkshire Hathaway, Inc. and a legendary investor got his start in 1957 running the Buffett Partnership, an alternative investment fund not open to the general public. Mr. Buffett’s first public appearance as a money manager was before a group of physicians in Omaha, Nebraska. Eleven decided to put some money with him. A few of these original investors followed him into Berkshire Hathaway, now among the most highly valued companies in the world.

The alternative investment, or hedge, funds of today are similar to the original Buffett Partnership in many ways. So, we will discuss several unique terms which potential investors should be aware.

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Hurdle Rate

Hedge funds may feature a hurdle rate as part of the calculation of the fund manager’s performance incentive compensation. Also known as a “benchmark,” the hurdle rate is the amount, expressed in percentage points, an investor’s capital account must appreciate before the account becomes subject to a performance incentive fee. Potential medical investors should view the hurdle rate as a form of protection in context with other features of the fee arrangement.

The hurdle rate, which benchmarks a single year’s performance, may be considered mutually exclusive of any other year, or the hurdle rate may compound each year. The former case is more common. In the latter case, a portfolio manager failing to attain a hurdle rate in the first year will find the effective hurdle rate considerably higher during the second year.

Once a fund manager attains the hurdle rate for an investor, the medical investor’s capital account may be charged a performance incentive fee only on the performance above and beyond the hurdle rate. Alternatively, the account may be charged a performance fee for the entire level of performance, including the performance required to attain the hurdle rate. Other variations on the use of the hurdle rate exist, and are limited only by the contract signed between the fund manager and the investor. The hurdle rate is not generally a negotiating point, however.

Example:

A fund charges a performance fee with a 6 percent hurdle rate, calculated in mutually exclusive manner. Dr. Lanouettea, a radiologist investor places $100,000 with the fund. The first year’s performance is 5 percent. The investor therefore owes no performance fee during the first year because the portfolio manager did not attain the hurdle rate. During year two, the portfolio manager guides the fund to a 7 percent return. Because the hurdle rate is mutually exclusive of any other year, the portfolio manager has attained the 6 percent hurdle rate and is entitled to a performance fee.

Highwater Mark

Some funds feature a highwater mark provision, also known as a ”loss-carryforward” provision. As with the hurdle rate, potential investors should consider the highwater mark a form of protection. A high water mark is an amount equal to the greatest value of an investor’s capital account, adjusted for contributions and withdrawals. The high water mark ensures that the hedge fund manager charges a performance incentive fee only on the amount of appreciation over and above the highwater mark set at the time the performance fee was last charged. The current trend is for newer funds to feature this highwater mark, while older, larger funds may not feature it.

Example:

A fund charges a 20 percent performance fee with a highwater mark but no hurdle rate. Dr. Butalak, a dentist investor contributes $100,000 to the fund. During the first year, the hedge fund manager grows that capital account to $110,000 and charges a 20 percent performance fee, or $2,000. The ending capital account balance and highwater mark is therefore $108,000. During year two, the account falls back to $100,000, but the highwater mark remains $108,000. During year three, in order for the manager to charge a performance fee, the manager must grow the capital account to a level above $108,000.

Clawback Provision

Rarely, a fund may provide investors with a clawback provision. This term, borrowed from the venture capital fund world, such provisions result in a refund to the investor of all or part of a previously charged performance fee if a certain level of performance is not attained in subsequent years. Such refunds in the face of poor or inadequate performance may not be legal in some states or under certain authorities.

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:

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

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VENTURE CAPITAL: In the Digital Health Care Space

Dr. David Edward Marcinko MBA CMP

SPONSOR: http://www.MarcinkoAssociates.com

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At Marcinko & Associates, we appreciate that Venture Capital funding for entrepreneurs in the digital health space cooled a bit in 2020-22 following a red-hot 2018-20. And, overall, digital health companies raised $15.3 billion last year, down from the $29.1 billion raised in 2021—but still above the $14.1 billion raised in 2020, according to Rock Health a seed fund that supports digital health startups.

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

Nevertheless, other analysts predict VC investors and Investment Bankers will still put a good amount of money into digital health in 2024 thru 2027, especially in alternative care, drug development, health information technology, artificial intelligence, EMRs and software that reduces physician workload.

An essential first part of attracting VC interest and IB money is the crafting and presentation of your formal business plan [“elevator pitch”]; as well as the needed technical and managerial experience. This too is crucial for success and exactly where we can assist.

Of course, companies focused on scaling and growing will have different needs across the business lifecycle.

And so, no matter where you are in your journey—from seeking early funding to making final preparations for your IPO—we have equity and insightful administration solutions for you and can assist at any stage of your growth spectrum.

MORE: https://marcinkoassociates.com/fmv-appraisals/

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How May We Serve You?

E-mail: MarcinkoAdvisors@msn.com

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PHYSICIAN’S BEWARE: Psychological “INVESTING MIND TRAPS”

By Dr. David Edward Marcinko MBA MEd CMP

SPONSOR: http://www.MarcinkoAssociates.com

As, as human beings, our brains are booby-trapped with psychological barriers that stand between making smart financial decisions and making dumb ones. The good news is that once you realize your own mental weaknesses, it’s not impossible to overcome them. 

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

In fact, psychiatrist and medical colleague Wes Boyd MD PhD MA related the following mind-traps and investing impediments that have yet to be appreciated by the financial planning community writ-large:

  • Anchoring happens when we place too much emphasis on the first piece of information we receive regarding a given subject. For instance, when shopping for a wedding ring a salesman might tell us to spend three months’ salary. After hearing this, we may feel like we are doing something wrong if we stray from this advice, even though the guideline provided may cause us to spend more or less than we can afford. Ditto for buy / sell stock recommendations without our own due diligence.
  • Myopia makes it hard for us to imagine what our lives might be like in the future. For example, because we are young, healthy, and in our prime medical practice earning years now, it may be hard for us to picture what life will be like when our health depletes and we know longer have the earnings necessary to support our standard of living. This short sighted thinking makes it hard to save adequately when we are young, when saving does the most good.
  • Gambler’s fallacy occurs when we subconsciously believe we can use past events to predict the future. It is common for the hottest sector during one calendar year to attract the most doctor investors the following year. Of course, just because an investment did well last year doesn’t mean it will continue to do well this year. In fact, it is more likely to lag the market.
  • Avoidance is simply procrastination. Even though you may only have the opportunity to adjust your health care plan through your employer once per year, researching alternative health plans is too much work and too boring for us to get around to it. Consequently, we stick with a plan that may not be best for us.
  • Loss aversion affected many investors during the stock market crash of 2008. During the crash, many doctors decided they couldn’t afford to lose more and sold their investments. Of course, this caused the investors to sell at market troughs and miss the quick, dramatic recovery.
  • Overconfident investing happens when we believe we can out-smart other investors via market timing or through quick, frequent trading. Data convincingly shows that people who trade most often under-perform the market by a significant margin over time.
  • Mental accounting takes place when we assign different values to money depending on where we get it from. For instance, even though we may have an aggressive saving goal for the year, it is likely easier for us to save money that we worked for than money that was given to us as a gift.
  • Herd mentality makes it very hard for humans to not take action when everyone around us does. For example, we may hear stories of people making significant profits buying, fixing up, and flipping homes and have the desire to get in on the action, even though we have no experience in real estate.

CMP: http://www.CertifiedMedicalPlanner.org

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PSYCHOLOGICAL “TRAPS” of Investing

MIND TRAPS PHYSICIAN INVESTORS MUST REDUCE AND AVOID AT ALL COSTS

See the source image

By Dr. David E. Marcinko MBA MEd CMP®

SPONSOR: http://MarcinkoAssociates.com

CMP logo

SPONSOR: http://www.CertifiedMedicalPlanner.org

As human beings, our brains are booby-trapped with psychological barriers that stand between making smart financial decisions and making dumb ones. The good news is that once you realize your own mental weaknesses, it’s not impossible to overcome them.

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

In fact, Mandi Woodruff, a financial reporter whose work has appeared in Yahoo! Finance, Daily Finance, The Wall Street Journal, The Fiscal Times and the Financial Times among others; related the following mind-traps in a September 2013 essay for the finance vertical Business Insider; as these impediments are now entering the lay-public zeitgeist.

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8 Psychological Traps All Stock Investors Should Avoid - YouTube

 Anchoring happens when we place too much emphasis on the first piece of information we receive regarding a given subject. For instance, when shopping for a wedding ring a salesman might tell us to spend three months’ salary. After hearing this, we may feel like we are doing something wrong if we stray from this advice, even though the guideline provided may cause us to spend more than we can afford.

 Myopia makes it hard for us to imagine what our lives might be like in the future. For example, because we are young, healthy, and in our prime earning years now, it may be hard for us to picture what life will be like when our health depletes and we know longer have the earnings necessary to support our standard of living. This short-sightedness makes it hard to save adequately when we are young, when saving does the most good.

 Gambler’s fallacy occurs when we subconsciously believe we can use past events to predict the future. It is common for the hottest sector during one calendar year to attract the most investors the following year. Of course, just because an investment did well last year doesn’t mean it will continue to do well this year. In fact, it is more likely to lag the market.

 Avoidance is simply procrastination. Even though you may only have the opportunity to adjust your health care plan through your employer once per year, researching alternative health plans is too much work and too boring for us to get around to it. Consequently, we stick with a plan that may not be best for us.

 Loss aversion affected many investors during the stock market crash of 2008. During the crash, many people decided they couldn’t afford to lose more and sold their investments. Of course, this caused the investors to sell at market troughs and miss the quick, dramatic recovery.

 Overconfident investing happens when we believe we can out-smart other investors via market timing or through quick, frequent trading. Data convincingly shows that people who trade most often underperform the market by a significant margin over time.

 Mental accounting takes place when we assign different values to money depending on where we get it from. For instance, even though we may have an aggressive saving goal for the year, it is likely easier for us to save money that we worked for than money that was given to us as a gift.

MORE: https://medicalexecutivepost.com/2021/09/04/more-on-money-psychology/

RELATED: https://medicalexecutivepost.com/2014/12/15/on-internet-investing-psychology/

 Herd mentality makes it very hard for humans to not take action when everyone around us does. For example, we may hear stories of people making significant profits buying, fixing up, and flipping homes and have the desire to get in on the action, even though we have no experience in real estate.

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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™ book cover

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“ACTIVE” INVESTMENT STRATEGIES: For Physicians

And … why doctors are different?

By Dr. David Edward Marcinko MBA MEd CMP

SPONSOR: http://www.MarcinkoAssociates.com

By Dr. David Edward Marcinko MBA CMP

There are two distinct forms of financial analysis investment strategies often used by medical colleague investors who desire to pursue an active investment strategy.

Technical Analysis: Technical analysts, sometimes referred to as chartists, use historical price data and transaction volume data to identify mis-priced securities. A key belief shared by technical analysts is that stock prices follow recurring patterns and that once these historical patterns are identified, they can be used to identify future security prices. The heart of technical analysis is identifying significant shifts in the macro/micro economic supply and demand factors for a particular securities investment.

Skeptics of technical analysis generally subscribe to the notion that the markets efficiently and accurately price securities. In fact, the weak form of the Efficient Market Hypothesis [EMH] is based on the view that investors cannot consistently earn superior returns using historical data and technical analysis alone.

Fundamental Analysis: In contrast to technical analysis – which relies on historical market returns / transactions data – fundamental analysis focuses on the underlying company’s assets, earnings, risks, dividends and intrinsic security factors to identify mis-priced securities.

Furthermore, investors using fundamental analysis can use either a top-down or bottom-up approach:

  • The top-down investor starts with global economics, including both international and national economic indicators. These may include GDP growth rates, inflation, interest rates, exchange rates, productivity and energy prices. They subsequently narrow their search to regional / industry analysis of total sales, price levels, the effects of competing products, foreign competition and entry or exit from the industry. Often they refine their search to the best business in the area being studied.
  • The bottom-up investor starts with specific businesses, regardless of their industry / region, and proceeds in reverse of the top-down approach. Bottom-up investing is an approach that focuses on analyzing individual stocks and de-emphasizes the significance of macroeconomic and market cycles. In other words, bottom-up investing typically involves focusing on a specific company’s fundamentals, such as revenue or earnings, versus the industry or the overall economy. The bottom-up investing approach assumes individual companies can perform well even in an industry that is under performing, at least on a relative basis.

And so, a medical professional utilizing fundamental analysis is attempting to find securities that are trading at market prices below their intrinsic value. Skeptics suggest this is difficult or almost impossible to achieve.

Thus, while technical analysis focuses on market price history, a security’s intrinsic fundamental analysis is determined independent of the security’s market value. Of course, a combination of both fundamental and technical analysis can also be considered.

DOCTORS ARE DIFFERENT: https://marcinkoassociates.com/doctors-unique/

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CAN: Doctor-Patient Intimacy be Electronic?

e Communication Tales from the Treatment Room

dem-2

By Dr. David Edward Marcinko MBA MEd CMP®

www.CertifiedMedicalPlanner.org

Today’s electronic media makes physician-patient communication possible; yet there is another kind of intimacy. ICTs—information and communication technologies—enable 24/7 monitoring of basic information such as blood pressure, glucose levels, pulse, and respiration, etc.

Example:

In one study, an ICT not only made it easier for patients to stay in touch with their doctors, the outcomes were also significantly better.[i] Today, Hippocrates is no longer trailing patients around the house to keep track of their snacks and moods. But Hippocrates has gone digital in the form of a wearable device that records subtle changes in biological markers and communicates them instantaneously to a health provider.

While this is obviously a great advance, we suggest you pause for a moment before plugging in.

Why?

ICTs and social media tools can make a difference to one of the most important dimensions—physiological outcomes. But you can have the latest interactive technology at your disposal and still fail to be connected.

Example:

A story that a friend told me shows how.

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One morning, her elderly father was touching up the paint on his sailboat. Nearby, another boat-owner, who happened to be an emergency medical technician, noticed her father was struggling to breathe and that his lips had turned purple. A trip to the local community hospital led to a barrage of high-tech tests and procedures, a diagnosis of emphysema, later complications with cerebral hematomas, and hospitalizations and re-hospitalizations that brought him into contact with a neurologist, a neurosurgeon, a cardiologist, and a pulmonologist.

Throughout her father’s medical ordeal, the team of specialists stayed in touch with each other and the primary care physician via various electronic media. But one person remained out of the loop—her father. One day, six months into the experience, the primary care physician phoned our friend’s mother to check on his patient. Her father recalls thinking, “Why was he calling her?”

The physician was communicating, but he was emotionally disconnected.

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The Moral

The moral of the story: communication needs to be patient-centered in both electronic and psychological terms. That means understanding how someone likes to communicate and making sure the medium fits the message. Electronic media are just part of the equation. The other is the doctor-patient relationship. Once a relationship is established, it may be fine to use e-mail to send information about dosage.

But, delivering a new diagnosis may require the extra effort of scheduling a phone call or a face-to-face visit. Today, since you have so many Health 2.0 choices, it takes some effort to select the right way to communicate in a particular situation.

Use the Right Relationship Strategy

A colleague recently shared another story about an encounter with a specialist.

Example:

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After an examination for a minor ailment, he was told that there might be a medicated lotion that could ameliorate his condition. The doctor thought for a moment, then swiveled around to the computer on his desk. As our colleague watched the screen, his physician typed a few words into a search engine. Up popped a list and he wrote out a script. “Try this,” his doctor concluded. “I think it will help.”

It did, almost overnight.

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The Moral

Even though his physical problem had disappeared completely, our colleague felt there was something missing in the interaction. “It bothered me that my doctor turned to the Web for help at that moment. He found a cure, but I felt he wasn’t paying attention to me.”

The physician is supposed to be an authority who has a special relationship to the patient. “Anybody can Google,” our colleague complained. Was he being unreasonable? Maybe.

But; this story tells us something important about technology—it cuts both ways.

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aahnofx

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Assessment

Everyone has their own preferences when it comes to how they want to interact with each other and with technology. If these preferences are explicit and aligned, the chances for a productive partnership are high. The preferences, however, are many and complex. You can easily get lost in the tangled thicket of interpersonal styles and virtual mediums.

In the Web 2.0 environment, it helps to narrow down the endless choices to just a few options.

MORE: Is Text Messaging being Overlooked as an Engagement Tool in Healthcare?

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:

[i] Hanson, William M. The Edge of Medicine: The Technology That Will Change Our Lives. New York, NY: Palgrave Macmillan, 2008.

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REVIEW: Style-Based Stock Portfolio Performance Evaluations

Stock or Manager Relevance Comparisons and Philosophy

By Dr. David Edward Marcinko MBA, MEd, CMP™

SPONSOR: http://www.CertifiedMedicalPlanner.org

[Publisher-in-Chief]

One relatively recent performance evaluation approach that was developed to help improve the relevance of comparisons is the separation of stock universes and managers by style. This classification method attempts to distinguish between stocks or manager philosophies based upon general financial characteristics of the investments.

The Managers

In very general terms, a manager is often a growth manager if the investment approach that the manager uses focuses on stocks showing growth and momentum in its earnings and price.

A value manager is generally considered to be a manager that attempts to identify under-valued securities based upon fundamental analysis of the company.  A stock may be considered either “growth” or “value” based on a given set of valuation measures such as price-to-earnings, price-to-book value, and dividend yield.

The Style

The goal of style-based performance comparisons is to take some of the biases of the market environment out of the comparison, since a portfolio’s returns will ideally be evaluated versus a universe of alternatives that represent similar investment characteristics facing the same basic market environment.  Thus, if the environment is one in which investors in stocks with strong past earnings and price momentum have generally performed better than those using fundamental analysis to find under-valued stocks, comparing the growth/momentum portfolio to a growth index or universe should help eliminate the bias.

Style-based universes can help the medical professional better understand the basic environment captured over a given performance time period.

However, there are significant limitations with the various approaches to constructing style-based stock and manager universes that should be understood if they are to be used in direct performance comparisons.  Taking style-based stock universes separately from style-based manager universe, one of the most significant issues regarding the categorization of stocks by “growth” and “value” styles is the lack of agreement in the specification of what a growth stock is versus a value stock.  With some universes divided by price-to-book value, others by price-to-earnings and/or dividend yields and some by combinations of similar variables, stocks are often classified very differently by two different stock universes.  Further, stocks move across a broad spectrum as their price and fundamentals change, resulting in stocks constantly moving between growth and value categories for any given universe.  If there is ambiguity in the rating of a given stock, then the difficulty is only compounded when we attempt to boil what may be complex investment processes of an investment manager or mutual fund portfolio manager to a simple classification of growth or value.  A beaten down cyclical stock that no self-respecting growth/momentum manager would purchase may be classified as “growth” because it has a high price-to-earnings ratio (i.e., from low earnings) or a high price-to-book value (i.e., from asset write-offs).  Value managers are not the only ones to own low valuation stocks that have improving earnings.

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The second problem with style categorization is that managers are often misclassified or they purposefully “game” the categorization of their own process in order to appear more competitive.  As an example, if a manager that typically looks for relatively strong earnings/price momentum is lagging in a period when “growth” managers are outperforming, the rank of the manager can be improved simply by claiming a “value” approach.  Morningstar’s “style box” classification of mutual funds by size and style of the current portfolio highlight this problem for any given fund by showing how their portfolio has changed its classification annually.

Current Events

The stock market has been booming lately. Up almost 100% since March 2009, after being down almost 50%. And so, perhaps this is a good time to re-evaluate the performance of your investment portfolio[s].

Assessment

However, this leads to an interesting question for the medical professional or his/her advisor: If a manager is still using the same basic investment philosophy and disciplines, but their “style” category has changed according to the ratings service, should you fire them?  If the answer is “yes”, then the burden of monitoring and the cost of manager turnover are an inevitable part of narrow style based performance comparisons.

But, if the answer is “no,” then it is easy to see the difficulty of fitting every management approach into a simple style box.  The more reasonable alternative is to use style-based stock and manager universes as a tool for understanding the environment, rather than an absolute performance benchmark.

Conclusion

And so, 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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About Tombstone Securities Advertising and the “New Issue” Propsectus

SPONSOR: http://www.CertifiedMedicalPlanner.org

A Primer for Physician Investors and Medical Professionals

By: Dr. David Edward Marcinko; MBA, MEd, CMP™

[Editor-in-Chief]

[PART 2 OF 8]

BU Dr. Marcinko

NOTE: This is an eight part ME-P series based on a weekend lecture I gave more than a decade ago to an interested group of graduate, business and medical school students. The material is a bit dated and some facts and specifics may have changed since then. But, the overall thought-leadership information of the essay remains interesting and informative. We trust you will enjoy it.

Introduction

Despite the SEC restrictions, noted in Part I of this series, some idea of potential demand for a new security issue can be gauged and have a bearing on  pricing decisions.

For example, as CEO of a medical instrument company, or interested investor, would you rather see a great deal of interest in a potential new issue or not very much interest?  There is however, one kind of advertisement that the underwriter can publish during the cooling off period. It’s known as a tombstone ad.  The ad makes it clear that it is only an announcement and does not constitute an offer to sell or  solicit the issue, and that such an offering can only be made by  prospectus.  SEC Rule 134 of the 1933 Act  itself, refers to a tombstone ad as “communication not deemed a prospectus”  because it makes reference to the prospectus in the ad. Tombstones have received their name because of the sparse nature of details found in them.

However, the most popular use of the tombstone ad is to announce the effectiveness of a new issue, after it has been successfully issued. This promotes the success of  both he underwriter, as well as the company.

Since distributing securities involves potential liability to the investment bank, it will do everything possible to protect itself.  So, near the end of the cooling off period, a meeting is held between the underwriter and the corporation. It is known as a due diligence meeting. At this meeting they both discuss amendments that are going to be necessary to make the registration statement complete and accurate. The corporate officers, and the underwriters sign, the final registration statement. They have civil liability for damages that result from omissions of material facts or

Mis-statements of fact. They also have criminal liability if the distribution is done by use of fraudulent, manipulative, or deceptive means. Due diligence takes on a whole new meaning when  incarceration from a half-hearted effort underwriting efforts can occur. The investment bank strives to ensure that there have been no material changes to the issuer or the terms of the issue since the registration statement was filed.

Again, as a physician, how would you feel if you were an investment banker raising capital for a new pharmaceutical company that had developed a drug product that was highly marketable. But, on the day after the issue was effective, there was a major news story indicating that the company was being sued for patent infringement? What effect do you think that would have on the market price of this new issue? It would probably plunge. How could this situation have been prevented? The due diligence meeting is more than a cocktail party or a gathering in a smoke filled room. Otherwise, the company would require specially trained people, to do a patent search lessening the likelihood of this scenario. At the due diligence meeting, work is done on the preparation of the final prospectus, but the investment bank does not set the public offering price or the effective date at this meeting. The SEC will eventually set the effective date for the registration and it is on that date that the final offering price will be determined.

Once the SEC sets the effective date, sales may be executed and money can be accepted by the investment bank. It is at this time that the final prospectus, similar to the red herring but without the red ink and with the missing numbers, is issued. A prospectus is an abbreviated form of the registration statement, distributed to purchasers, on and after the effective date of  the registration. It is not the same as the registration statement. A typical registration statement consists of papers that stand more than a foot high; rarely does a prospectus go beyond 40 or 50 pages. All purchasers will receive a final prospectus and then it becomes permissible for the underwriter to provide sales literature.

In addition to the requirement that a prospectus must be delivered to a purchaser of new issues no later than with confirmation of the trade, there are two other requirements that healthcare executives investors should know.

90-day: When an issuer has an initial public offering (IPO), there is generally a lack of publicly available material relating to the operations of that issuer.  Because of this, the SEC requires that all members of the underwriting group make available a prospectus on an IPO for a period of 90 days after the effective date.

4O-day: Once an issuer has gone public, there are a number of routine filings that must be made with the SEC so there is publicly available information regarding the financial condition of that issuer. Since additional information is now available, the SEC requires that, on all issues other than IPOs, any member of the underwriting group must make available a prospectus for a period of 40 days after the effective date.

In the event that the investment bankers misgauged the marketplace, and the issue moves quite slowly, it is possible that information contained in the prospectus would be rendered obsolete by the SEC. Specifically, the SEC requires that any prospectus used more than 9 months after the effective date, may not have any financial information more than 16 months old. It can however, be amended or stickered, with updated information, as needed.

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

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Syndication Among Underwriters

Because the investment banking firm may be underwriting (distributing) a rather large dollar amount of securities, to spread its risk exposure, it may form a group made up of other investment bankers or underwriters, known as a syndicate. The syndicate is headed by a syndicate manager, or lead underwriter, and it is his job to decide whether to participate in the offering. If so, the managing underwriter will sign a non-binding agreement called a letter of intent. .

If all has gone well and the market place is sufficiently interested in the security, and the SEC has been satisfied with respect to the registration statement, it is time for all parties to the offering to formalize their relationships with a contract including the basic understandings reflected in the letter of intent. Three principal underwriting contracts are involved in the usual public offering, each serving a distinct purpose. These are the: Agreement among Underwriters, Underwriting Agreement, and the Dealer Agreement.

In the Agreement Among Underwriters (AAU), the underwriters committing to a portion of the issue, enter into an agreement establishing the nature and terms of their relationship with each other. It designates the syndicate manager to act on their behalf, particularly to enter into an Underwriting Agreement with the issuer, and to conduct the offering on behalf of each  of them. The AAU will designate the managing underwriter’s compensation (management fee) for managing the offering.

The authority to manage the offering includes the authority to: agree with the issuer as to the public offering price; decide when to commence the offering; modify the offering price and selling commission; control all advertising; and, control the timing and effectiveness of the registration statement by quickly responding to deficiency letters. Each underwriter agrees to purchase a portion of the underwritten securities, which is known as each under-writer’s allotment (allocation).  It is normally signed severally, but not jointly, meaning each underwriter is obligated to sell his allocation but bears no financial obligation for any unsold allotment of another underwriter. This is referred to as a divided account or a Western account. Much less frequently, an undivided or Eastern account, will be used. Each underwriter is responsible for unsold allotments of others, based upon a  proportionate share of the offering.

The above comments referred to firm commitment underwriting. Another type of underwriting commitment  however, is known as best efforts underwriting. Under the terms of  best efforts underwriting, the underwriters make no commitment to buy or sell the issue, they simply do the best they can, acting as an agent for the issuer, and having no liability to the issuer if none of the securities are sold. There is no syndicate formed with a best efforts underwriting. The investment bankers form a selling group, with each member doing his best to sell his allotment. Two variations of a best efforts underwriting are: the all-or-none, and the mini-max (part-or-none) underwriting. Under the provisions of an all-or-none offering, unless all of the shares can be distributed within a specified period of time, the offering will terminate and no subscriptions or orders will be accepted or filled. Under mini-max, unless a set minimum amount is sold, the offering will be terminated.

SEC Rule 15c2-4 requires the underwriter to set up an escrow account for any money received before the closing date, in the event that it is necessary to return the money to prospective purchasers. If the “minimum”, or the “all” contingencies are met, the monies in escrow go to the issuer with the underwriters retaining their appropriate compensation. In order to make sure that investors are properly protected, the escrow account must be maintained at a bank for the benefit of the investors until every appropriate event or contingency has occurred. Then, the funds are properly returned to the investors. If the money is to be placed into an interest bearing account, it must have a maturity date no later than the closing date of the offering, or the account must be redeemable at face with no prepayment penalty as regards principal.

Underwriter Compensation Hierarchy

As we have seen, in a firm commitment the underwriter buys the entire issue from the issuer and then attempts to resell it to the public. The price at which the syndicate offers the securities to the public is known as the public offering price. It is the price printed on the front page of the prospectus.

However, the managing underwriter pays the issuer a lower price than this for the securities. The difference between that lower price and the public offering price is known as the spread or underwriting discount. Everyone involved in the sale of a new issue is compensated by receiving part of the spread. The amount of the spread is the subject of negotiations between the issuer and the managing underwriter, but usually is within a range established by similar transactions between comparable issuers and underwriters. The spread is also subject to NASD [now FINRA] review and approval before sales may commence. The spread is broken down by the underwriters so that a portion of it is paid to the managing underwriter for finding and packaging the issue and managing the offering (usually called the manager’s fee); and a portion is retained by each underwriter (called the underwriting or syndicate allowance) to compensate the syndicate members for their expenses, use of money, and assuming the risk of the underwriting. The remaining portion is allocated to the selling group and is called selling concession. It is often useful to remember the compensation hierarchy pecking order in the following way:

  • Spread (syndicate manager).
  • Underwriters allowance (syndicate members)
  • Selling concession (selling group members)
  • Re-allowance (any other firm)

While the above deal with corporate equity, the only other significant item with respect to corporate debt is the Trust Indenture Act of 1939. This Federal law applies to public issues of debt securities in excess of $5,000,000. The thrust of this act is to require an indenture with an independent trustee (usually a bank or trust company) who will report to the holders of the debt securities on a regular basis.

Successful marketing of a new issue is a marriage between somewhat alien factors: compliance and numerous Federal, state, and self-regulatory rules and statutes; along with finely honed and profit-motivated sales techniques. It’s not too hard to see that there could be a real, or apparent, conflict of interest here. Most successful investment bankers have built their excellent reputations upon their ability to properly balance these two objectives consistently, year after year.

PART ONE:

Understanding investment banking rules, securities markets, brokerage accounts, margin and debt

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HEDGE FUNDS: A Brief Review for Physicians

By Christopher J. Cummings CFA CFP™

By Dr. David Edward Marcinko MBA MEd CMP™

SPONSOR: http://www.CertifiedMedicalPlanner.org

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A hedge fund in the United States is generally a limited partnership providing a limited number of qualified investors with access to general partner investment decisions with little restriction in the type of investments or use of leverage. While the flexibility available to a hedge fund from a regulatory standpoint implies a high degree of potential risk, there is a wide range of investment philosophies, strategies, security types and objectives captured under the broad title of hedge fund.

Thus, generalizations regarding the characteristics of hedge funds are even less appropriate than with mutual funds, and evaluation of the investment characteristics and merits of a hedge fund strategy must be on a case-by-case basis. Likewise, the cost structure of a hedge fund often includes a base management fee to the general partner plus a performance-based fee or percentage of the profits, and must be evaluated on a case-by-case basis.

Several different investment vehicles operate under the oversight of varying regulatory bodies which provide access to an investment-managers’ discretionary decisions. While each approach generally represents ownership of an underlying pool of securities, there is usually a great deal of flexibility for the manager to deviate from a specific asset class or investment approach. Also, the fee structure of each vehicle can vary greatly and be quite large once distribution fees and sales charges are taken into account.

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Thus, it is important for a medical professional to remember the following:

1. Evaluate the features and costs of an investment vehicle carefully;

2. Consider the cash flows and valuations of the securities that the manager or management approach will focus on as if the investments were being made directly, and above all;

3. Read the prospectus or agreement carefully before making any investment.

4. Visit: http://www.MarcinkoAssociates.com

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The M1 and M2 Money Supply

By Staff Reporters

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DEFINITION: In macro-economics, the money supply (or money stock) refers to the total volume of currency held by the public at a particular point in time. There are several ways to define “money”, but standard measures usually include currency in circulation (i.e. physical cash) and demand deposits (depositors’ easily accessed assets on the books of financial institutions . The Central Bank [FOMC] of a country may use a definition of what constitutes legal tender for its purposes.

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Though there are a few variations of money supply, most economists tend to focus on M1 and M2. The former takes into account cash and coins in circulation, as well as demand deposits in checking accounts and traveler’s checks. In other words, money that’s either in your hand or can be accessed very easily.

Meanwhile, M2 accounts for everything in M1 and adds savings accounts, money market funds, and certificates of deposit (CDs) below $100,000. It’s money you have access to, but it takes a little extra effort to put this capital to work. It’s M2 money supply that’s raising eyebrows on Wall Street and making history.

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What’s of interest is what’s happened to M2 money supply over the trailing year. Following a peak of $21.7 trillion in July 2022, M2 has fallen to a fresh reading of $20.81 trillion, as of May 2023. Although the May reading was higher than April and broke a nine-month downtrend, we’ve still witnessed a 4.1% aggregate drop in M2 from its all-time high. 

Considering that M2 enjoyed a historic expansion during the pandemic, it’s certainly possible that a 4.1% decline can be shrugged off as nothing more than money supply reverting back to the mean. But history suggests otherwise.

Though history rarely repeats itself on Wall Street, it often rhymes. We haven’t seen a meaningful year-over-year decline in M2 money supply since the Great Depression in 1933.

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And so, based on what we’re seeing from M2 money supply, commercial bank lending, and domestic banks tightening their lending standards for C&I loans, the ingredients for a U.S. recession are most definitely there. Stock losses have, historically, been most pronounced in the months that follow the official declaration of a recession by the eight-economist panel of the National Bureau of Economic Research.

However, Wall Street’s performance is largely dependent on your investment time frame. If you’re patient, these and other potentially worrisome money metrics represent nothing more than temporary white noise.

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