BOARD CERTIFICATION EXAM STUDY GUIDES Lower Extremity Trauma
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One of Milton Friedman’s most popular works, A Theory of the Consumption Function, challenged traditional Keynesian viewpoints about the household. This work was originally published in 1957 by Princeton University Press, and it reanalyzed the relationship displayed “between aggregate consumption or aggregate savings and aggregate income.”
Now, according to Wikipedia, Friedman’s counterpart Keynes believed people would modify their household consumption expenditures to relate to their existing income levels. Friedman’s research introduced the term “permanent income” to the world, which was the average of a household’s expected income over several years, and he also developed the permanent income hypothesis. Friedman thought income consisted of several components, namely transitory and permanent. He established the formula y = y p + y t {\displaystyle y=y_{p}+y_{t}} in order to calculate income, with p representing the permanent component, and t representing the transitory component.
Milton Friedman’s research changed how economists interpreted the consumption function, and his work pushed the idea that current income was not the only factor affecting people’s adjustment household consumption expenditures. Instead, expected income levels also affected how households would change their consumption expenditures. Friedman’s contributions strongly influenced research on consumer behavior, and he further defined how to predict consumption smoothing, which contradicts Keynes’ marginal propensity to consume. Although this work presented many controversial points of view which differed from existing viewpoints established by Keynes, A Theory of the Consumption Function helped Friedman gain respect in the field of economics. His work on the Permanent Income Hypothesis is among the many contributions which were listed as reasons for his Sveriges-Riskbank Prize in Economic Sciences. His work was later expanded on by Christopher D. Carroll, especially in regards to the absence of liquidity constraints.
Telemedicine: Fraud and Abuse During the COVID Pandemic
By Susan Walberg
The COVID-19 pandemic has brought with it huge challenges for people all over the world; not only the obvious health-related concerns but also shutdowns, unemployment, financial difficulties, and a variety of lifestyle changes as a result.
When the COVID pandemic struck, CMS quickly recognized that access to care would be an issue, with healthcare resources strained and many providers or suppliers shutting down their offices or drastically limiting availability. Patients who needed routine care or follow-up visits were at risk for not receiving services during a time when healthcare providers were scrambling to enhance infection control measures and implement other new safety standards to protect patients and healthcare workers.
The Centers for Medicare and Medicaid Services (CMS) has responded by easing restrictions and regulatory burdens in order to allow patients to receive the healthcare services they need without undue access challenges. One key area that has changed is the restrictions related to telehealth services, which were previously only paid by Medicare under certain circumstances, such as patients living in remote areas.
Among the changes and waivers CMS has offered, telemedicine reimbursement is among the more significant. Telemedicine services, which includes office visits and ‘check ins’ are now allowed and reimbursed by Medicare. In addition to reimbursement changes, CMS has also relaxed the HIPAA privacy and information security enforcement standards, paving the way for providers to adopt a new model of providing services electronically.
According to Wikipedia, in economics, inflation refers to a general progressive increase in prices of goods and services in an economy.[1] When the general price level rises, each unit of currency buys fewer goods and services; consequently, inflation corresponds to a reduction in the purchasing power of money.[2][3] The opposite of inflation is deflation, a sustained decrease in the general price level of goods and services. The common measure of inflation is the inflation rate, the annualised percentage change in a general price index.[4]
Healthcare Not a Part of the US Inflation Surge: Who Knew?
However, according to Jeff Goldsmith, overall health spending has only risen by 4.4% since January of 2020, and the percentage of GDP devoted to health has fallen by more than half a percent, from 18.1% pre-pandemic to 17.5% in October. This is despite four surges of COVID hospitalizations, overflowing ICUs and ERs, labor shortages, and other COVID-related stresses. Health system staffing levels are still nearly a half-million lower than they were pre-pandemic. Had the federal government not stepped in through the CARES Act, FEMA funding, and temporary suspensions of Medicare rate cuts, the nations’ hospitals would have been seriously damaged by COVID-related financial stresses, which are far from being over.
Data Platform: Their health provider members care for tens of millions of people and operate thousands of care facilities, providing more than 15% of all care in the United States. Clinical data from this care is de-identified daily and brought together in the Truveta platform to advance patient care and accelerate development of new therapies.
Just like real estate, butter has been around for thousands of years. Sometime in the 1800’s someone decided that there was a need for something that looked like butter, tasted similar to butter, but wasn’t butter. Along came margarine. Real estate investment trusts (REITs) are the margarine of the real estate investing world.
NAREIT, the National Association of Real Estate Investment Trusts, answers the question
“What is a REIT?” in the following way:
“A REIT, or Real Estate Investment Trust, is a type of real estate company modeled after mutual funds. REITs were created by Congress in 1960 to give all Americans – not just the affluent – the opportunity to invest in income producing real estate in a manner similar to how many Americans invest in stocks and bonds through mutual funds. Income-producing real estate refers to land and the improvements on it – such as apartments, offices or hotels. REITs may invest in the properties themselves, generating income through the collection of rent or they may invest in mortgages or mortgage securities tied to the properties, helping to finance the properties and generating interest income.”
While REITs typically own real estate, investors in REITs do not. REITs are paper assets that represent interest in a company that owns and operates income producing properties. In essence they are real estate flavored stock. As such, REITs are generally highly correlated with the stock market.
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TERMINOLOGY
When discussing REITs, you encounter the following terminology – public, private, traded, and non-traded. Public REITs can be designated as non-traded or traded depending on whether or not they are traded on a stock exchange.
Since traded REITs are traded on the stock exchange, they enjoy a high degree of liquidity just like any other stock. Unfortunately, traded REITs tend to follow the economic cycles and can closely correlate with the stock market. This can lead to a higher degree of volatility than what is usually seen with physical real estate. Additionally, they do not afford the investor the tax-advantages that come with investments in physical real estate.
Private REITs and non-traded public REITs are not traded on an exchange. These are usually offered to accredited investors through broker-dealer networks. These REITs are illiquid and generally have high fees. They have been plagued with transparency issues as well as conflicts of interest. Valuation of this stock is difficult and can be misleading to the investor. Due diligence is very important as the quality of non-traded REITs can vary widely.
1) Prior Authorization – Approval Must Be Given by the Health Insurance Company/PBM Before They Agree to Pay for a Medication.
2) Step Therapy – Certain Less Expensive Generic Medications Have to Be ‘Tried’ First and Fail Before a Doctor Can Prescribe a More Expensive Brand-Name Medication.
3) Mandatory Generics – If a Brand Name Medication Has A Direct Generic Equivalent, Then the Insurance May Only Agree to Pay for the Generic and Not the Brand.
4) Mandatory Mail Order – Certain Chronic Medications That Are Filled for 90 Day Supplies Must Be Filled via Mail Order and Not at the Retail Pharmacy.
Earlier this week, GE’s Chairman and CEO Larry Culp shared a note with employees reflecting on GE’s priorities as we enter the new year. “Ten days into 2022, our work has already begun,” Larry said in his note. “I am excited for our road ahead.”
As we shared in November, GE is on a path to become three stronger, more focused companies positioned to lead in aviation, healthcare, and energy. Here are our priorities for the year ahead to take us there:
Ensure safety is always first.
Build on our progress to further strengthen GE for today and tomorrow.
Lead in areas of urgent global need – Future of Flight, Precision Health and the Energy Transition.
Lay the groundwork for the creation of three independent companies – starting with Healthcare – positioned to succeed on their own.
MEDICAL TREATMENT PLAN: A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and possible side effects, and the expected length of treatment.
Fees are down, expenses are up and the days of fat profit margins for physicians are over. Managed care in some form is here to stay. The tidal wave of baby boomers approaching retirement suggests the pendulum will not swing back to the “good old days” of fee-for-service medicine. Even the venture capitalists are laying off doctors because of the corona virus pandemic. And, the ACA and U.S. government, the payer for more than 50 percent of the covered population, continues to ratchet down reimbursement. Accordingly, many doctors are now working harder than ever. Unfortunately, they are also prone to irrational investing behavior and making more investment mistakes than ever before.
Here are the Institute of Medical Business Advisors’ “dirty dozen” investing blunders of physicians. Indeed, we see these common miscues among a variety of medical professionals.
Mistake 1: Having No Investment Policy Statement Just as one would not think of treating a patient without a careful history and physical examination, you should not embark on investing your hard earned capital without an investment policy statement (IPS). This important document separates do-it-yourself investors, financial salesmen, stockbrokers and amateurs from true financial professionals.
An IPS is a document specifically detailing what you want your money to do for you with an understanding of who is to do what and how they are supposed to do it. It may be three to five pages long for an individual physician, 10 to 15 pages for a small medical group retirement plan or dozens of pages for a clinic or hospital endowment fund.
Treatment plan: A properly written IPS should contain the following: • Statement of purpose • Statement of responsibilities • Investment goals and objectives • Proxy voting policy • Trading and execution guidelines • Asset mix guidelines • Social policies or other restrictions • Portfolio limitations • Performance review benchmarks • Administration and fee policy • Communication policy • Reporting policy
Mistake 2: Not Diversifying Portfolio Objectives Although the media frenzy of a few years ago has subsided, anecdotes of easy money still abound and doctors may forget that investment portfolios serve a specific purpose (e.g., retirement, college funding, etc.) within the content of a broader financial plan. Moreover, a single investment may become too large or too small a portion of the portfolio. This may be due to market growth in one component or slack in another.
Treatment plan: Diversify, monitor your holdings and select components with your risks and goals in mind. Time horizon and risk tolerance are likely to change as will the investment environment. One key contribution of modern portfolio theory (MPT), according to the 1990 Nobel Prize winner Professor Harry Markowitz, PhD, is the understanding that diversification can reduce portfolio risk. Indeed, the specific risk of a single stock may overwhelm any justification for failing to diversify.
Consider investing in sectors like basic materials, capital goods, communications and services, technology, consumer cyclicals and non-cyclicals, healthcare, energy, financial services and utilities. Investors can purchase most as individual securities, in mutual funds or as exchange traded funds (ETFs) or worldwide equity benchmark shares. Do not forget about cash equivalents, treasuries, zero coupon and municipal bonds and international securities.
Mistake 3: Forgetting The Investing Risk/Return Tradeoff Some physicians fall into the trap of chasing “hot” securities like hedge funds, limited partnerships, non-registered securities or alternate investments promising high returns. High returns are associated with increased investment risk. Accordingly, it is important to understand the risks embedded in an investment before it becomes an exposed reality.
Treatment plan: Beware of projecting historic averages going forward. The stock market is inherently volatile. While it is easy to rely on past historic averages, there are long periods of time where returns regress from their long-term historic mean. On the other hand, slumps eventually correct themselves so you should continue a prudent investing plan.
Do not confuse investing with trading or speculation. According to Gene Schmuckler, PhD, the Director of Behavioral Finance for the Institute of Medical Business Advisors, Inc., there are momentum-driven market periods when investors start to believe profits are easy and there is always a “greater fool” to buy at a higher price. Such trading has more in common with gambling than investing. Avoid market timing and the urge to jump in or out at every economic hiccup.
Mistake 4: Not Factoring In The Impact Of Taxes The desire to avoid capital gains and other taxes as a result of solid investment returns may lull some doctors into a false sense of security. An attractive investment and a slick sales pitch sometimes hide the underlying tax costs of the investment, especially when the investment is questionable. This leads doctors to give up a significant portion of the long-term growth of their assets.
Treatment plan: Income tax brackets, rates and estate taxes are almost at an all-time low in the U.S. This good fortune is due in part to the Taxpayer Relief Act of 1997, the Economic Growth and Tax Relief Reconciliation Act of 2001, and the Job and Growth Tax Relief Reconciliation Act of 2003, among other tax credits and deductions. Some mutual funds, for example, are not tax efficient while some ETFs may be tax efficient. Strive for legitimate tax reductions and avoidance but remember that tax evasion is illegal.
Mistake 5: Not Factoring In Fees And Expenses Front-end loads, back-end loads, disappearing and hidden loads, 12-b1 fees and commissions, and advertising and sales expenses can all have a significant impact on a particular investment program.
Treatment plan: Monitor the costs of your investment program to ensure that total costs are known, reasonable for the services provided and are not consuming a disproportionate amount of the investment returns. Carefully consider full-service versus discount brokerages.
Take care using discretionary assets under management (AUM) accounts where you pay a percentage for personalized money management. More often than not, these one-size-fits-all accounts are aggregated under a larger automated umbrella to harvest economies-of-scale automatically. Indeed, the mistaken notion that the advisor “is sitting on the same side of the investment table as you” starts deteriorating on critical reflection. Do not fall for the siren sales pitch (“If I make money, you make money”). Excessive risk taking, purchases and sales activity may be at your expense.
Carefully consider whether golf balls, seminars, football game tickets, pens or quarterly meetings with your “advisor” are worth the price you may ultimately pay for these minor trinkets and services. For example, in a 2 percent AUM program of $1 million, you may pay $20,000 annually, which is automatically deducted from the account. Are these “perks” worth $200,000 over the course of a decade? During the “golden age of medicine” in the ‘80s or the ranging bull market of the ‘90s, some doctors may have thought it was worth it. What about during a bear market or the projected market of lower than average returns that may be upon us?
Other problems with AUMs include: a higher fee to managed stocks than bonds, creating an equity bias; bias against paying of the mortgage, practice or acquiring real estate; bias against gifting initiatives or charitable intent. These are all problematic for the same reason that over-weighted equity classes increase advisor compensation while these other equally important considerations do not.
Mistake 6: Inappropriate Risk-Management Techniques Traditionally, physicians protected their families with life, disability, malpractice and business interruption insurance yet insurance products are not investment vehicles. They merely indemnify against catastrophic economic losses that are typically extinguished over time. Behavioral economists like Daniel Kahneman, PhD, of Princeton University, and Vernon L. Smith, PhD, of George Mason University, warn us to use these insurance products carefully since we tend to experience financial losses more intensely than gains and evaluate risks in isolation.
Additionally, a comprehensive risk management plan for doctors must acknowledge risks such as sexual harassment risks; workplace violence risks; Medicare documentation, recoupment and compliance risks; and the economic risks of divorce. There is also a plethora of acronymic risks such as the Health Insurance Portability and Accountability Act (HIPAA), the Occupational Safety and Health Administration (OSHA) Act, and many others.
Treatment plan: Be willing to abandon ancient thoughts and remain open to new ideas that identify and provide solutions to the contemporaneous insurance problems of physicians. As an example, in 2001, economist Christian Gollier, PhD, of the University of Geneva, asked, “Should one even buy personal insurance since the industry itself is so skilled at exploiting human foibles?”
Mistake 7: Inappropriate Insurance Agent It is no surprise that goaded physicians might prefer insurance vehicles like the guaranteed minimum death benefit of variable annuities or traditional cash value life insurance policies despite their high costs, huge commissions and lower returns. Agents sell these products and they work for the insurance company, not for you. Basic insurance agent credentials include the chartered financial consultant and chartered life underwriter designations, but they may remain product salesmen.
Treatment plan: Always beware the fear-mongering insurance agent salesman as the flowing coverages may be unnecessary, too expensive, provide only minimal benefits or be duplicated in other insurance policies. These include credit life or home mortgage insurance (decreasing term), life insurance for children or the elderly, accident policies for students, hospital indemnity policies, dread disease insurance, credit card insurance, pet, flight or funeral insurance, prepaid legal insurance, trip cancellation, flood, earthquake and termite insurance, and most appliance extended warranties.
Instead, consider a licensed insurance advisor or insurance counselor who sells no products, accepts no commissions and charges by the hour, all while shopping for the best companies and rates for the risk being researched. A fiduciary focused Certified Medical Planner® may be even better.
Mistake 8: Selecting The Wrong Accountant When asking for the value of a practice, ask specifically for the fair market value (FMV). One podiatrist who consulted us asked her accountant for the “value” of her practice and received its lower “book value” rather than the higher fair market value as a profitable ongoing concern. The MD lost tens of thousands of dollars in a subsequent sales transaction. Unfortunately, although the CPA produced correct figures for exactly what she requested, the doctor did not differentiate between the two terms. Later legal mediation determined that neither was responsible for the linguistic error as both parties acted in good faith. Of course, the doctor paid dearly for her mistake.
Treatment plan: Dr. Gary L. Bode, CPA, MSA, a former medical practitioner and CFO for iMBA, Inc., suggests that you take the time to discuss wants and needs with your accountant. Those from the National CPA Healthcare Advisors Association (www.hcaa.org) or the Healthcare Financial Management Association (www.hfma.org) may also increase your comfort level through additional medical expertise. Better yet, contact an experienced medical practice valuation expert or healthcare economist.
Mistake 9: Not Having Your Practice Professionally Valuated [not appraised] The sale or purchase of a medical practice may be the most important investment decision of your life. We have observed neurotic purchasers who spend far too much time, money and energy researching a fairly priced and modest practice to no avail (paralysis of analysis). Others have purchased exorbitantly priced practices for over $1 to $2 million on a handshake and promise. Accordingly, give this complex task the gravitas due, and run from those who would broker your sale with a “free” or “Internet-based valuation,” or provide “finance participation” schemes for purchase as a young practitioner.
According to IRS Revenue Ruling 59-60, the value of any medical practice is generally based upon the following: • level of expected distribution and future cash flows; • time of expected distributions and cash flows; and • uncertainty of the expected cash flows and distributions.
Moreover, one should recall that a valuation is not a source document audit. Know specialty and industry economic conditions, trends, operating history, physician bonuses, dividends, distributions and comparable practice sales. A commission or percentage-based fee is considered unethical and may be illegal.
Accounting book value is not the same as a fair market valuation. Do not use back-of-the envelope trade magazine “multiplier methods” and obtain only Uniform Standards of Professional Appraisal Practice (USPAP)-styled valuations, which were first issued by the IRS in 1994-1995.
Combine the recognized USPAP-IRS valuation methods: income method with discounted cash flow analysis, market method and cost approach. Be sure to adjust financial statements in order to normalize each line entry. You must do the discounted cash flow analysis (DCFA) on an after-tax basis and base proper assumptions on physician compensation market rates.
Understand the intangible difference between personal and business goodwill, major premiums and minority control discounts.
Doing a walk through of the practice is mandatory for your protection. Trust but verify tangible assets and liabilities, estimates of practice risks, economic assumptions and future earning capacity. Obtain a separate and independent real estate appraisal if necessary.
Make sure the valuation is written, substantiates value, supports conclusions and is signed by an appraiser who will defend the valuation in court as a qualified expert witness if necessary. This certification is formally known as an “opinion of value” and the only type we perform.
Remember to obtain two independent valuations, one for the buyer and one for the seller, and pay for each separately.
Treatment plan: Have the financing lined up before you buy a practice. The three major impediments to loan acquisition are school loan debt, a home mortgage and an automobile note in that order So, strive to reduce or eliminate them before applying for a loan. Hire licensed appraisal professionals with publishing, teaching and/or academic experience. Do not hire brokers or commissioned agents. Organizations that accredit businesses but not necessarily medical practice appraisers include:
• The Institute of Business Appraisers (www.go-iba.org) awards the certifications of certified business appraiser and business valuators accredited in valuation. • The National Association of Certified Valuation Analysts (www.nacva.com) awards the designations of certified valuation analysts and accredited valuation analysts.
Well-known medical practice and healthcare system appraisers include the big 10 consulting firms for hospitals and national healthcare systems. However, the Arthur Andersen debacle confirms that “bigger is not always better.” Medical practice niche players include Health Capital Consultants, LLC, (www.healthcapital. com), which provides large- and medium-sized practice valuations.
The Institute of Medial Business Advisors Inc, (www.MedicalBusinessAdvisors.com) specializes in small to medium practices, emerging healthcare organizations, clinics and ambulatory surgery center valuations and confers the designation Certified Medical Planner® on its independent consultants, appraisers and advisors.
Mistake 10: Selecting The Wrong Attorney Consider the bizarre tale of the two fledgling internist partner/classmates who signed an attorney-prepared, buy-sell agreement upon creation of their nascent practice 30 years beforehand. The agreement stipulated that upon departure or dissolution, the remaining partner’s ownership would be determined not by some periodically updated valuation formula or appraisal process, Instead, it would be determined by a “matched and lost” process, also known as the “flip of a coin” for a medical conglomerate now worth over $1 million.
Treatment plan: Select a health law attorney and not your brother-in-law. More importantly, experience in the medical arena counts. Consult iMBA, Inc. or the American Health Lawyers Association (www.healthlawyers.org) as a referral resource.
Mistake 11: Blind Trust Of Wall Street And Financial Advisors Stockbroker salesmen and the big brokerage houses that underwrite and recommend stocks may have credibility problems and some physicians get burned with the adrenaline rush of “self-directed” portfolios. Presently, both the Security Exchange Commission (SEC) and National Association of Securities Dealers are investigating far too many insurance companies and major wire houses for reverse churning (charging a fee on assets for which the stockbroker is providing virtually no services) and/or double dipping (charging an ongoing fee on mutual funds on which the client already paid a substantial commission).
No one knows for sure how to mitigate such shenanigans since human nature and self-interest are involved. Rest assured that the economic cycle will never be repealed and you must beware the four most dangerous words on Wall Street: “This time, it’s different.” Yet some believe the answer may lay with the independent fee-only advisor who charges by the hour, by the engagement, or pro re nata for advice. Beware of taking the advice of a financial advisor carte blanche. The prime duty of a financial advisor should be to clients. Yet the very term “financial advisor” has no real academic or consistent meaning in the industry. The only hurdle to becoming one is passing a simple securities industry or state insurance sales licensing examination. Most are brokerage and agency employees with a duty to their respective firms, not you.
Treatment plan: Commissioned stockbrokers are fine to use if their fees are transparent and they offer value to you. However, be aware that Wall Street sales mavens and large broker-dealers (wire-houses) recently lobbied Congress not to be responsible to you after the sale. The Financial Planning Association is suing the SEC over this proposal to exempt the nation’s largest wire-house brokerages from certain fiduciary responsibilities associated with investment advisory regulations.
To avoid selecting the wrong financial advisor, choose an independent advisor who takes pride in fiduciary responsibility, knows the medical profession and eschews product sales commissions whenever possible. Such a professional is more than deserving of a fee. Do not hesitate to pay it.
To determine if your current advisor is the right choice, just ask to see the documents below: • form ADV parts I and II; • sample investment policy statement; • registered investment advisor or series #65 investment advisory license • CMP® license number; • ethics requirement or attestation statements; and • advanced degrees and designations, etc.
Some CMPs® and fee-only financial advisors possess these professional certifications as required. Stockbrokers, salesmen, intermediaries and insurance agents may not. All monikers suggest but do not guarantee impartiality and a lack of bias. Also make sure your financial advisor is experienced in the rapidly changing healthcare industrial complex.
Mistake 12: Lack Of A Complete Financial Plan While many doctors have an investment portfolio, few have a comprehensive personal financial plan, especially one designed for medical professionals.
Treatment plan: Typically such plans consider the risk tolerance and time frame of several standard components such as insurance, taxation, investing, retirement and estate planning. Today’s practicing physicians should direct attention toward practice enhancement, economic risk management, valuations, charitable giving and succession planning. All should be interrelated in an economically sound manner and not be counterproductive to individual components of the plan.
In Conclusion Often, successful investing and avoiding a life of economic servitude is simply a matter of delayed gratification and mistake avoidance rather than investing acumen. A good rule of thumb is to pursue fundamentals over fads and seek wise counsel when required.
About the Author
Dr. Marcinko is a Certified Financial Planner and Certified Medical Planner® and CEO for www.MedicalBusinessAdvisors.com, sponsor of the Certified Medical Planner charter designation program. He can be reached by phone at (770) 448-0769 or by e-mail at MarcinkoAdvisors@msn.com.
References 1. Marcinko DE. Financial planning for Physicians and Advisors. Jones and Bartlett Publishers, Sudbury, Mass., 2005. 2. Marcinko DE. Insurance and Risk Management Strategies for Physicians and Advisors. Jones and Bartlett Publishers, Sudbury, Mass., 2005.
With 43 Million Americans Having Lost Their Job at Some Point During the Pandemic and About 1/2 Those Jobs Providing Health Insurance… the 1st Group–People Who Do Not Have Health Insurance–Needs to Be Aware of How These Programs Work.
In this Video You Will Learn the Patient Assistance Program Process for:
1) 2 of the Most Common Types of Insulin
2) The Highest-Revenue Medication in America: Humira
**Note: At the Time of the Video’s Recording, the Unemployment Rate in the US was 15%. As of November 2021, the Unemployment Rate is 4.2%.
The Omicron variant spreads more easily than the original virus that causes COVID-19. Here are 3 things you can do to help protect yourself and others:
Get the COVID-19 vaccine, if you haven’t already. Vaccines are the best tool to protect us from COVID-19. They slow the transmission of the virus, and provide strong protection against severe illness and hospitalization.
Get the booster when you’re fully eligible. Everyone 18 years and older should get a booster shot 2 months after their Johnson & Johnson vaccine, or 5 months after completing their primary COVID-19 vaccination series of Pfizer-BioNTech or Moderna. Adolescents and teens ages 12 to 17 should also get a booster of Pfizer-BioNTech 5 months after their primary series.
Dean Clancy is a senior health care policy fellow at Americans for Prosperity and a nationally known health care freedom advocate and domestic policy expert with more than twenty years’ high-level policy experience in Congress, the White House, and the U.S. health care industry.
EDITOR’S NOTE: I first met Rich in B-school, when I was a student, back in the day. He was the Founder and CEO of Superior Consultant Holdings Corp. Rich graciously wrote the Foreword to one of my first textbooks on financial planning for physicians and healthcare professionals. Today, Rich is a successful entrepreneur in the technology, health and finance space.
Crypto currency is all the rage and continues to make some coin investors small fortunes even as prices swing widely and scams emerge. These are some basic defensive measures to keep your digital wallet safe.
In a recent article on the Mises Institute’s Power and Market blog, Kyle Ward appealed to the subjective theory of value to castigate Peter Schiff for his notorious skepticism of Bitcoin:
The Federal Reserve now owns $2.6 trillion in mortgages. That means about 24 percent of all outstanding residential mortgages in this whole big country reside in the central bank.
Dentists simply don’t write that many prescriptions.
Henry Schein employees are not defending Stanley Bergman’s venture into e-prescription software. That is because they know it stinks. Digital prescriptions not only endanger patients and dental practices, but they offer no tangible benefits over paper. None!
Digital only increases the profits for Stanley Bergman and pharmaceutical interests – who eliminate data entry personnel from their payroll.
“First do no harm”
Ancient Greek physician Hippocrates.
EDITOR’S NOTE: We welcome back the op-eds of colleague Dr. Pruitt and trust he remains well in 2022.
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Ransomware and Dentistry – Recent News
“Why Healthcare Will Remain a Top Cyberattack Target in 2022 – one of the main reasons criminals are interested in healthcare data is that it contains a lot of details, such as date of birth, Social Security numbers – the active ingredients for identity theft. You can get those data points from any number of places, but healthcare organizations are the richest sources.” Healthcare Info Security, December 28, 2021.https://www.govinfosecurity.com/interviews/healthcare-will-remain-top-cyberattack-target-in-2022-i-4999
“Ransomware in 2022: You May Be Screwed, but Without Insurance It Could Always Be Worse – A commentator recently summed up the risk of ransomware attack in 2022: ‘we’re all screwed.’ True enough. But that’s all the more reason to prepare right now. After all, the only thing worse than a ransomware attack is not having adequate insurance coverage when it occurs. The time to prepare is now.” National Law Review, Wednesday, January 5, 2022. https://www.natlawreview.com/article/ransomware-2022-you-may-be-screwed-without-insurance-it-could-always-be-worse
“Insurers run from ransomware cover as losses mount” Summary: – Lloyd’s of London discourages cyber expansion-sources – Ransomware as profitable as Colombian cocaine cartels – Some insurers asking policyholders to pay half of ransoms – Attackers change strategy from scattergun to focused.Reuters, November 19, 2021. https://www.reuters.com/markets/europe/insurers-run-ransomware-cover-losses-mount-2021-11-19/
I was having lunch with a close friend of mine. He mentioned that he had accumulated a significant sum of money and did not know what to do with it. It was sitting in bonds, and inflation was eating its purchasing power at a very rapid rate.
He is a dentist and had originally thought about expanding his business, but a shortage of labor and surging wages turned expanding into a risky and low-return investment. He complained that the stock market was extremely expensive. I agreed.*
What’s the best way to hold real estate in a retirement portfolio? For many investors, the answer seems to be “not at all.” That’s not the right answer. This asset class, appropriately owned, can help support you well in retirement.
Not like Stocks
Unlike stocks, which trade on a highly efficient and liquid exchange, trading real estate is inefficient and illiquid. The ease of buying and selling stocks is one of the major reasons the asset class is over-represented in most portfolios.
Based on the fascination of the financial press with the stock market, it’s easy to get the impression that stocks comprise the largest financial asset class. According to Matthew Yglesias, author of The Rent Is Too Damn High, the total value of commercial real estate in the US as of December 2013 was $20 trillion. This equals the value of publicly traded stock. (The largest asset class is bonds with $37 trillion.)
While one could make a strong argument for owning equal amounts of real estate and stocks in most retirement portfolios, very few hold any real estate at all.
Direct Ownership
Probably the worst way to hold real estate is to own it directly. The only popular retirement plan that allows direct ownership of real estate is the self-directed IRA. Unfortunately, the government discourages holding real estate this way by taxing it unfavorably. As I’ve described in a previous column, it’s not a good idea.
RLPs
Registered Limited Partnerships [RLPs] were a popular way to own real estate in the 1980’s. While someone must have made money on these investments, I don’t think it was the investors. I don’t know an investor who made a dime, but I do know some distributors and promoters who got very rich with them. The problem wasn’t the real estate but the lack of transparency inherent in a limited partnership. This allowed promoters and distributors to hide high fees and commissions that didn’t give the investors a chance of profiting.
REITs
Gradually, the real estate investment trust gained popularity as another investment vehicle for owning real estate. A publicly traded REIT is similar to an ETF (a form of a mutual fund) that trades on the major exchanges and invests directly in real estate. REITs receive beneficial tax breaks, must pass through 90% of their cash flow to investors, have a high degree of transparency, and are highly liquid. They also tend to specialize in certain types of real estate, so rather than hold REITs individually; I prefer to own a mutual fund that owns a diversified assortment.
The fees and commissions associated with REITs are very low, which helps make them a good choice for investment portfolios. It is also another reason they don’t often show up there, since most financial vehicles are sold, not bought. Mutual funds, annuities, and cash value insurance pay much higher commissions than exchange traded REITs.
Wall Street solved that problem by creating the non-traded REIT, which does not trade on a securities exchange and therefore is highly illiquid. The benefits touted by salespeople are the potential for higher dividends, plus lower volatility than publicly traded REITs. Here’s the downside: Their lower volatility is an illusion created by their high illiquidity. They also lack transparency, which gives cover to charging high fees and commissions. The non-traded REIT is scarily like its older cousin of the 1980’s, the registered limited partnership.
Assessment
Including real estate in a retirement portfolio can be a good idea as long as the ownership is properly structured. A mutual fund that holds a broad diversification of publicly traded REITS is one way to help you build a strong foundation for retirement.
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Seven predictions for healthcare technology trends in 2022
In the wake of a pandemic, shifting care delivery models, and a surge of clinical content, Wolters Kluwer healthcare experts have identified seven healthcare technology trends for 2022.
1. Building trust in an age of digital information overload 2. Telemedicine becomes a fixture of the healthcare landscape 3. Resilience is key to retaining the nursing workforce 4. Unstructured health data helps researchers build health equity 5. AI reduces healthcare-associated infections (HAIs) 6. Quality improvement accelerates evidence to implementation 7. Virtual simulation and technology transforms nursing education
Finding investments to weather the storm. Strategies and ways to mitigate inflation risk, including investing in businesses with pricing power, capital intensity, and investing abroad.
Instead of straining your eyes, you can strain your ears and listen to the following articles. I’m providing links to my pieces on the inflation landscape (read, listen) and how we invest in inflation (read, listen).
Entering the Last Chapter of Covid, From Omicron and Beyond – With Dr. James R. Baker, Jr., M.D.
Richard Helppie welcomes back University of Michigan Professor Emeritus of Internal Medicine, and Virologist, Dr. James R. Baker, Jr., M.D., who brings words of both encouragement and warning as the world comes to what he feels is the beginning of the final throws of the Covid-19 pandemic.
Dr. Baker has been a valued guest on the Common Bridge since the beginnings of the coronavirus over a year ago, and brings thoughtful, scientific, data-driven analysis to the most significant health issue of our lifetime.
NOTE: Mr. Selengut is a private investor and a contributing editor to LIFE&Health Advisor. He is the author of the book ‘The Brainwashing of the American Investor: The book that Wall Street does not want you to read.’
***
As [physician] investors, and we all are investors these days, it is important that we understand the idiosyncrasies of year-end Stock Market activity. On Wall Street, investing can be a minefield for those who don’t appreciate the non-economic, non-business-model, factors contributing to the market value numbers in fourth quarter brokerage account summaries.
Year end market values may not be what they seem ….
“Portfolio Window Dressing” (PWD) produces security pricing that is more a function of next year’s institutional marketing programs than a reflection of the economic forces that we would like to think are their primary determining factors. Not even close…
Toward the end of every calendar quarter, we hear the financial media report that “institutional PWD activities” are in full swing. But that is as deep as the stories ever go. What are they talking about, and just what does it mean to you as an investor?
According to Greg McBride CFA, before you invest your money, you’re likely wondering how much you’re going to earn. This is known as the rate of return. The rate of return is expressed as a percentage of the total amount you invested. If you invest $1,000 and get back your original investment plus an additional $100 in interest, you’ve earned a 10 percent return.
However, numbers don’t always tell the full story. You’ll also need to think about how long you plan to keep the money invested, how your investment options have performed historically and how inflation will impact your bottom line.
Key return on investment statistics
When you’re trying to get the best return on your investment, you’ll likely start combing through loads of data. A good place to start is looking at the past decade of returns on some of the most common investments:
StockMarkets: Stocks gained for the second straight day as a mini “Santa Clause Rally” picks up steam. Tesla made its grand return to the $1 trillion market cap club after Elon Musk said he was “almost done” selling 10% of his stake.
Economy: Consumer confidence rose this month to its highest level since July, showing that Omicron and inflation concerns are no match for the formidable American shopper.
DEFINITION: A palindrome is a word, number, phrase, or other sequence of characters which reads the same backward as forward, such as madam or racecar. There are also numeric palindromes, including date/time stamps using short digits 11/11/11 11:11 and long digits 02/02/2020.
CRUNCH: According to mathematician Neal Freyman, today is the sound of mathematicians scrambling to find another topic to tweet about besides dates that form palindromes.
WHY: Today, 12/22/21, is the 22nd and final palindromic date of the year. There won’t be another year with 22 palindromic dates until 2111.
FACT: 1/20/21 was the first Inauguration Day with a palindromic date in American history. The next one will come in 1,000 years, on 1/20/3021.
Digital technologies have completely transformed our lives in the last couple of years and started to entirely reshape the landscape of healthcare. Yet, this is only the beginning. Huge waves of changes are on their way. The future of healthcare is shaping up in front of our eyes with advances in digital healthcare technologies.
And so, here is the latest research, from the Medical Futurist’sHype Cycle Of The Top 50 Emerging Digital Health Trends.
The Medical Futurist’s Hype Cycle Of The Top 50 Emerging Digital Health Trends
Quantum Computing 3D Bioprinting Facial recognition in hospitals Vocal biomarkers 3D printing prosthetics Robots in hospitals Augmented reality in patient education A.I. in drug design Augmented reality in medical education Medical transportation platforms Private 5G in healthcare At-home lab tests 3D printing drugs Medical drones A.I. in diagnostics Voice-to-text apps A.I. in medical decision-making Nutrigenomics 3D printing equipment Virtual reality in patient education Chatbots Portable diagnostic devices Augmented reality in surgery Portable ultrasound devices Virtual reality in staff training Robots in rehabilitation A.I.-based prosthetics Longevity research Nutrition devices Employee wellness programs Exoskelotons Clinical trial recruiting Clinical trial management Remote care apps Cloud computing Nutrition apps Robot companions Medication management solutions Personal genomics services Microbiome testing Remote care platforms Digital health insurance Smartwatches Wearable health devices Personal Health Records Electronic Medical Records Smartphone health apps Mental health apps Fitness trackers Virtual reality in pain management
DEFINITION: In economics, inflation (or less frequently, price inflation) is a general rise in the price level of an economy over a period of time. When the general price level rises, each unit of currency buys fewer goods and services; consequently, inflation reflects a reduction in the purchasing power per unit of money – a loss of real value in the medium of exchange and unit of account within the economy. The opposite of inflation is deflation, a sustained decrease in the general price level of goods and services. The common measure of inflation is the inflation rate, the annualized percentage change in a general price index, usually the consumer price index, over time.
This essay is going to be long. I blame inflation, be it transitory or not, for inflating its length.
The number one question I am asked by clients, friends, readers, and random strangers is, are we going to have inflation?
I think about inflation on three timelines: short, medium, and long-term.
The pandemic disrupted a well-tuned but perhaps overly optimized global economy and time-shifted the production and consumption of various goods. For instance, in the early days of the pandemic automakers cut their orders for semiconductors. As orders for new cars have come rolling back, it is taking time for semiconductor manufacturers, who, like the rest of the economy, run with little slack and inventory, to produce enough chips to keep up with demand. A $20 device the size of a quarter that goes into a $40,000 car may have caused a significant decline in the production of cars and thus higher prices for new and used cars. (Or, as I explained to my mother-in-law, all the microchips that used to go into cars went into a new COVID vaccine, so now Bill Gates can track our whereabouts.)
Here is another example. The increase in new home construction and spike in remodeling drove demand for lumber while social distancing at sawmills reduced lumber production – lumber prices spiked 300%. Costlier lumber added $36,000 to the construction cost of a house, and the median price of a new house in the US is now about $350,000.
The semiconductor shortage will get resolved by 2022, car production will come back to normal, and supply and demand in the car market will return to the pre-pandemic equilibrium. High prices in commodities are cured by high prices. High lumber prices will incentivize lumber mills to run triple shifts. Increased supply will meet demand, and lumber prices will settle at the pre-pandemic level in a relatively short period of time. That is the beauty of capitalism!
Most high prices caused by the time-shift in demand and supply fall into the short-term basket, but not all. It takes a considerable amount of time to increase production of industrial commodities that are deep in the ground – oil, for instance. Low oil prices preceding the pandemic were already coiling the spring under oil prices, and COVID coiled it further. It will take a few years and increased production for high oil prices to cure high oil prices. Oil prices may also stay high because of the weaker dollar, but we’ll come back to that.
Federal Reserve officials have told us repeatedly they are not worried about inflation; they believe it is transitory, for the reasons I described above. We are a bit less dismissive of inflation, and the two factors that worry us the most in the longer term are labor costs and interest rates.
Let’s start with labor costs
During a garden-variety recession, companies discover that their productive capacity exceeds demand. To reduce current and future output they lay off workers and cut capital spending on equipment and inventory. The social safety net (unemployment benefits) kicks in, but not enough to fully offset the loss of consumer income; thus demand for goods is further reduced, worsening the economic slowdown. Through millions of selfish transactions (microeconomics), the supply of goods and services readjusts to a new (lower) demand level. At some point this readjustment goes too far, demand outstrips supply, and the economy starts growing again.
This pandemic was not a garden-variety recession
The government manually turned the switch of the economy to the “off” position. Economic output collapsed. The government sent checks to anyone with a checking account, even to those who still had jobs, putting trillions of dollars into consumer pockets. Though output of the economy was reduced, demand was not. It mostly shifted between different sectors within the economy (home improvement was substituted for travel spending). Unlike in a garden-variety recession, despite the decline in economic activity (we produced fewer widgets), our consumption has remained virtually unchanged. Today we have too much money chasing too few goods– that is what inflation is. This will get resolved, too, as our economic activity comes back to normal.
But …
Today, though the CDC says it is safe to be inside or outside without masks, the government is still paying people not to work. Companies have plenty of jobs open, but they cannot fill them. Many people have to make a tough choice between watching TV while receiving a paycheck from big-hearted Uncle Sam and working. Zero judgement here on my part – if I was not in love with what I do and had to choose between stacking boxes in Amazon’s warehouse or watching Amazon Prime while collecting a paycheck from a kind uncle, I’d be watching Sopranos for the third time.
To entice people to put down the TV remote and get off the couch, employers are raising wages. For instance, Amazon has already increased minimum pay from $15 to $17 per hour. Bank of America announced that they’ll be raising the minimum wage in their branches from $20 to $25 over the next few years. The Biden administration may not need to waste political capital passing a Federal minimum wage increase; the distorted labor market did it for them.
These higher wages don’t just impact new employees, they help existing employees get a pay boost, too. Labor is by far the biggest expense item in the economy. This expense matters exponentially more from the perspective of the total economy than lumber prices do. We are going to start seeing higher labor costs gradually make their way into higher prices for the goods and services around us, from the cost of tomatoes in the grocery store to the cost of haircuts.
Only investors and economists look at higher wages as a bad thing. These increases will boost the (nominal) earnings of workers; however, higher prices of everything around us will negate (at least) some of the purchasing power.
Wages, unlike timber prices, rarely decline. It is hard to tell someone “I now value you less.” Employers usually just tell you they need less of your valuable time (they cut your hours) or they don’t need you at all (they lay you off and replace you with a machine or cheap overseas labor). It seems that we are likely going to see a one-time reset to higher wages across lower-paying jobs. However, once the government stops paying people not to work, the labor market should normalize; and inflation caused by labor disbalance should come back to normal, though increased higher wages will stick around.
There is another trend that may prove to be inflationary in the long-term: de-globalization. Even before the pandemic the US set plans to bring manufacturing of semiconductors, an industry deemed strategic to its national interests, to its shores. Taiwan Semiconductor and Samsung are going to be spending tens of billions of dollars on factories in Arizona.
The pandemic exposed the weaknesses inherent in just-in-time manufacturing but also in over reliance on the kindness of other countries to manufacture basic necessities such as masks or chemicals that are used to make pharmaceuticals. Companies will likely carry more inventory going forward, at least for a while. But more importantly more manufacturing will likely come back to the US. This will bring jobs and a lot of automation, but also higher wages and thus higher costs.
If globalization was deflationary, de-globalization is inflationary
We are not drawing straight-line conclusions, just yet. A lot of manufacturing may just move away from China to other low-cost countries that we consider friendlier to the US; India and Mexico come to mind.
And then we have the elephant in the economy – interest rates, the price of money. It’s the most important variable in determining asset prices in the short term and especially in the long term. The government intervention in the economy came at a significant cost, which we have not felt yet: a much bigger government debt pile. This pile will be there long after we have forgotten how to spell social distancing.
The US government’s debt increased by $5 trillion to $28 trillion in 2020 – more than a 20% increase in one year! At the same time the laws of economics went into hibernation: The more we borrow the less we pay for our debt, because ultra-low interest rates dropped our interest payments from $570 billion in 2019 to $520 billion in 2020.
That is what we’ve learned over the last decade and especially in 2020: The more we borrow the lower interest we pay. I should ask for my money back for all the economics classes I took in undergraduate and graduate school.
This broken link between higher borrowing and near-zero interest rates is very dangerous. It tells our government that how much you borrow doesn’t matter; you can spend (after you borrow) as much as your Republican or Democratic heart desires.
However, by looking superficially at the numbers I cited above we may learn the wrong lesson. If we dig a bit deeper, we learn a very different lesson: Foreigners don’t want our (not so) fine debt. It seems that foreign investors have wised up: They were not the incremental buyer of our new debt – most of the debt the US issued in 2020 was bought by Uncle Fed. Try explaining to your kids that our government issued debt and then bought it itself. Good luck.
Let me make this point clear: Neither the Federal Reserve, nor I, nor a well-spoken guest on your business TV knows where interest rates are going to be (the total global bond market is bigger even than the mighty Fed, and it may not be able to control over interest rates in the long run). But the impact of what higher interest rates will do the economy increases with every trillion we borrow. There is no end in sight for this borrowing and spending spree (by the time you read this, the administration will have announced another trillion in spending). Let me provide you some context about our financial situation
The US gross domestic product (GDP) – the revenue of the economy – is about $22 trillion, and in 2019 our tax receipts were about $3.5 trillion. Historically, the-10 year Treasury has yielded about 2% more than inflation. Consumer prices (inflation) went up 4.2% in April. Today the 10-year Treasury pays 1.6%; thus the World Reserve Currency debt has a negative 2.6% real interest rate (1.6% – 4.2%).
These negative real (after inflation) interest rates are unlikely to persist while we are issuing trillions of dollars of debt. But let’s assume that half of the increase is temporary and that 2% inflation is here to stay. Let’s imagine the unimaginable. Our interest rate goes up to the historical norm to cover the loss of purchasing power caused by inflation. Thus it goes to 4% (2 percentage points above 2% “normal” inflation). In this scenario our federal interest payments will be over $1.2 trillion (I am using vaguely right math here). A third of our tax revenue will have to go to pay for interest expense. Something has to give. It is not going to be education or defense, which are about $230 billion and $730 billion, respectively. You don’t want to be known as a politician who cut education; this doesn’t play well in the opponent’s TV ads. The world is less safe today than at any time since the end of the Cold War, so our defense spending is not going down (this is why we own a lot of defense stocks).
The government that borrows in its own currency and owns a printing press will not default on its debt, at least not in the traditional sense. It defaults a little bit every year through inflation by printing more and more money. Unfortunately, the average maturity of our debt is about five years, so it would not take long for higher interest expense to show up in budget deficits.
Money printing will bring higher inflation and thus even higher interest rates
If things were not confusing enough, higher interest rates are also deflationary
We’ve observed significant inflation in asset prices over the last decade; however, until this pandemic we had seen nothing yet. Median home prices are up 17% in one year. The wild, speculative animal spirits reached a new high during the pandemic. Flush with cash (thanks to kind Uncle Sam), bored due to social distancing, and borrowing on the margin (margin debt is hitting a 20-year high), consumers rushed into the stock market, turning this respectable institution (okay, wishful thinking on my part) into a giant casino.
It is becoming more difficult to find undervalued assets. I am a value investor, and believe me, I’ve looked (we are finding some, but the pickings are spare). The stock market is very expensive. Its expensiveness is setting 100-year records. Except, bonds are even more expensive than stocks – they have negative real (after inflation) yields.
But stocks, bonds, and homes were not enough – too slow, too little octane for restless investors and speculators. Enter cryptocurrencies (note: plural). Cryptocurrencies make Pets.com of the 1999 era look like a conservative investment (at least it had a cute sock commercial). There are hundreds if not thousands of crypto “currencies,” with dozens created every week. (I use the word currency loosely here. Just because someone gives bits and bytes a name, and you can buy these bits and bytes, doesn’t automatically make what you’re buying a currency.)
“The definition of a bubble is when people are making money all out of proportion to their intelligence or work ethic.”
ByMike Burry MD [The Big Short]
I keep reading articles about millennials borrowing money from their relatives and pouring their life savings into cryptocurrencies with weird names, and then suddenly turning into millionaires after a celebrity CEO tweets about the thing he bought. Much ink is spilled to celebrate these gamblers, praising them for their ingenious insight, thus creating ever more FOMO (fear of missing out) and spreading the bad behavior.
Unfortunately, at some point they will be writing about destitute millennials who lost all of their and their friends’ life savings, but this is down the road. Part of me wants to call this a crypto craziness a bubble, but then I think, Why that’s disrespectful to the word bubble, because something has to be worth something to be overpriced. At least tulips were worth something and had a social utility. (I’ll come back to this topic later in the letter).
But ….
When interest rates are zero or negative, stocks of sci-fi-novel companies that are going to colonize and build five-star hotels on Mars are priced as if El Al (the Israeli airline) has regular flights to the Red Planet every day of the week except on Friday (it doesn’t fly on Shabbos). Rising interest rates are good defusers of mass delusions and rich imaginations.
In the real economy, higher interest rates will reduce the affordability of financed assets. They will increase the cost of capital for businesses, which will be making fewer capital investments. No more 2% car loans or 3% business loans. Most importantly, higher rates will impact the housing market.
Up to this point, declining interest rates increased the affordability of housing, though in a perverse way: The same house with white picket fences (and a dog) is selling for 17% more in 2021 than a year before, but due to lower interest rates the mortgage payments have remained the same. Consumers are paying more for the same asset, but interest rates have made it affordable.
At higher interest rates housing prices will not be making new highs but revisiting past lows. Declining housing prices reduce consumers’ willingness to improve their depreciating dwellings (fewer trips to Home Depot). Many homeowners will be upside down in their homes, mortgage defaults will go up… well, we’ve seen this movie before in the not-so-distant past. Higher interest rates will expose a lot of weaknesses that have been built up in the economy. We’ll be finding fault lines in unexpected places – low interest has covered up a lot of financial sins.
And then there is the US dollar, the world’s reserve currency. Power corrupts, but the unchallenged and unconstrained the power of being the world’s reserve currency corrupts absolutely. It seems that our multitrillion-dollar budget deficits will not suddenly stop in 2021. With every trillion dollars we borrow, we chip away at our reserve currency status (I’ve written about this topic in great detail, and things have only gotten worse since). And as I mentioned above, we’ve already seen signs that foreigners are not willing to support our debt addiction.
A question comes to mind. Am I yelling fire where there is not even any smoke?
Higher interest rates is anything but a consensus view today. Anyone who called for higher rates during the last 20 years is either in hiding or has lost his voice, or both. However, before you dismiss the possibility of higher rates as an unlikely plot for a sci-fi novel, think about this.
In the fifty years preceding 2008, housing prices never declined nationwide. This became an unquestioned assumption by the Federal Reserve and all financial players. Trillions of dollars of mortgage securities were priced as if “Housing shall never decline nationwide” was the Eleventh Commandment, delivered at Temple Sinai to Goldman Sachs. Or, if you were not a religious type, it was a mathematical axiom or an immutable law of physics. The Great Financial Crisis showed us that confusing the lack of recent observations of a phenomenon for an axiom may have grave consequences.
Today everyone (consumers, corporations, and especially governments) behaves as if interest rates can only decline, but what if… I know it’s unimaginable, but what if ballooning government debt leads to higher interest rates? And higher interest rates lead to even more runaway money printing and inflation?
This will bring a weaker dollar
A weaker US dollar will only increase inflation, as import prices for goods will go up in dollar terms. This will create an additional tailwind for commodity prices.
If your head isn’t spinning from reading this, I promise mine is from having written it.
To sum up: A lot of the inflation caused by supply chain disruption that we see today is temporary. But some of it, particularly in industrial commodities, will linger longer, for at least a few years. Wages will be inflationary in the short-term and will reset prices higher, but once the government stops paying people not to work, wage growth should slow down. Finally, in the long term a true inflationary risk comes from growing government borrowing and budget deficits, which will bring higher interest rates and a weaker dollar with them, which will only make inflation worse and will also deflate away a lot of assets.
Mental Health, Jury Bias, and Judicial Reform, with the Honorable Milton L. Mack Jr.
Rich brings back the Honorable Milton L. Mack, Jr. for a discussion on Mental Health, Jury Bias, and Judicial Reform. Judge Mack has been a leading voice on how mental health issues affect over half of the court cases in the US and how this needs to be addressed in judicial reform. He has also been on the forefront of bringing cutting edge technology into the courtroom.
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.
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.
How the government’s accelerating takeover of private medicine destroys doctors and threatens the health and well-being of every American.
By Leonard Peikoff
This lecture was delivered at Boston’s Ford Hall Forum in April 1985, published in the April – June 1985 issues of The Objectivist Forum and anthologized in The Voice of Reason.
Utilizing data from FAIR Health, the Urban Institute conducted an October 2021 study which reviewed commercial insurance claims across the U.S. (for approximately 60 insurers and third-party administrators covering over 150 million Americans under age 65) from March 2019 through February 2020.
This study assessed the gap between commercial insurance payments and Medicare payments for professional physician services to determine whether the payment gap between Medicare and commercial insurance differs by specialty. (Read more…)
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