What It Costs to Hire and Train New Employees

H. R. Financial Information for Doctors, Clinics and Hospitals, etc.

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Sometimes, during slack periods in the economy, you have to reduce expenses by laying-off workers. Replacing them later, though, can be costly for your hospital HR department, clinic, medical practice or other business. Especially, for the knowledge based healthcare sector.

The Complete Financial Picture

So, whether it’s recruiting, on-boarding, extra salary, or something else, hiring new staff isn’t cheap. Make sure you understand the entire financial picture before you move forward with staffing changes.

 

Assessment

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Conclusion

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How to Burglar-Proof Your Cash Stash?

Avoid Burglar-Friendly Spots

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If the wobbly financial markets have you hoarding cash at home, beware. Yes, as a doctor, you may be safe from bear markets, but you’re still vulnerable to losses, especially if you leave your money and valuables in burglar-friendly spots.

View the image below to expand the infographic and see where you’re best off hiding your cash, according to tips gathered from a real burglar, and places where you shouldn’t put any money.  

Conclusion

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A New Take on Accounts Receivable [AR] Factoring for Doctors

 Understanding How Medical Practice Business Factoring Works

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AR factoring is a financial transaction whereby a business, like a medical practice, sells its accounts receivable (i.e., invoices) to a third party (called a factor) at a discount in exchange for immediate money with which to finance continued business.

Factoring differs from a bank loan in three main ways.

First, the emphasis is on the value of the receivables (essentially a financial asset), [1][2] not the firm’s credit worthiness.

Second, factoring is not a loan – it is the purchase of a financial asset (the receivable).

Finally, a bank loan involves two parties whereas factoring involves three.

Factoring: ARs 1

Conclusion

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At a Time of Needed Financial Overhaul

A Leadership Vacuum

By Jesse Eisinger
ProPublica, May 18, 2011, 3:10 p.m.

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After the worst crisis since the Great Depression, President Obama has unleashed an unusual force to regulate the financial system: a bunch of empty seats [1].

With Sheila C. Bair soon to leave her post at the Federal Deposit Insurance Corporation, the Obama administration will have five major bank regulatory positions either unfilled or staffed with acting directors.

About The Trade

In this column, co-published with New York Times’ DealBook, I monitor the financial markets to hold companies, executives and government officials accountable for their actions. Tips? Praise? Contact me at jesse@propublica.org

The administration has inexplicably left open the vice chairman for banking supervision, a new position at the Federal Reserve created by the Dodd-Frank Act, despite having a candidate that many people think is an obvious choice: Daniel K. Tarullo [2]. The new Consumer Financial Products Board chairman is unnamed. There are some lower-level positions that don’t have candidates, including the head of the Treasury’s Office of Financial Research and the Financial Stability Oversight Council insurance post.

Perhaps most important, the Office of the Comptroller of the Currency, is being headed by an acting comptroller, John Walsh, who took over the agency last August. Nine months have passed without a leader who might better reflect the Obama administration’s views on banking regulation, a time lag made worse by the office’s coddling of the banks [3] even as they have acknowledged rampant abuse and negligence in the foreclosure process.

The vacancies come at a time that calls for stiffer regulatory examination. The financial regulatory system was remade under Dodd-Frank and requires strong leaders to put the changes into effect. Though the acting heads insist they feel empowered to make serious decisions, they have roughly the same authority as substitute high school teachers.

The Obama Administration

Supposedly, the Obama administration is getting close to naming people to head the comptroller’s office and the F.D.I.C. But we’ve been hearing that for a while. In April, Barbara A. Rehm of American Banker wrote that the administration was working on a big package of nominations to send to the Hill all at once. A month later, we’re still twiddling our thumbs in anticipation.

So what’s going on?

In a vacuum of leadership, conspiracy theories arise. One is that Treasury Secretary Timothy F. Geithner is making a power grab and doesn’t mind that these roles aren’t filled. The idea is that he is asserting his influence over the Dodd-Frank rule-making process. A former adviser to Mr. Geithner dismissed that notion as ridiculous, and that’s persuasive to me. It seems too Machiavellian by half.

If it’s not Mr. Geithner, then who or what is responsible for the vacancies? Not surprisingly, people close to the administration blame Republicans. The nomination process has become hopelessly broken in Washington. Even low-level appointments are now deeply partisan affairs, the playthings of score-settling senators with memories like elephants and the social responsibility of hyenas (which probably insults hyenas).

The Obama administration put up Peter A. Diamond for a position on the Federal Reserve board. Winning a little something called the Nobel Prize [4] hasn’t helped him with confirmation, however Sen. Richard Shelby, the powerful Alabama Republican and ranking member of the banking committee, is standing in his way. The senator also quashed the nomination [5] of Joseph A. Smith Jr. to head the Federal Housing Finance Agency.

Blame Game

But much of the blame for this situation lies with the Obama administration. It’s almost as if the president and his staff have thrown up their hands. The administration has had trouble finding good candidates who are willing to go through the vetting process and has shied away from fights. It also hasn’t seeded the ground or supported the nominations it has made, people complain.

A Democratic Senate staff member confided worry to me about the fate of Mark Wetjen, whom the administration nominated last week as a candidate for a seat on the Commodity Futures Trading Commission. “They didn’t shop it and they didn’t get buy-in,” the staff member said. “The administration doesn’t seem to be putting any sort of effort into it.”

Making these appointments will help answer a question: Where does Mr. Obama stand on financial regulation?

With the Geithner appointment, the president chose early on the path of continuity over muscular regulation. Immediately, the Treasury secretary became the personification of every Obama financial policy. Mr. Geithner remains the most politically costly appointment Mr. Obama has made, saddling him with all the Bush presidency’s financial crisis decisions. After all, Mr. Geithner, as head of the Federal Reserve Bank of New York, was intimately involved in the emergency actions of September 2008. Republicans made great hay tying Democrats to the Wall Street bailouts in the 2010 midterm elections. Now, of course, Republicans are leading Democrats in Wall Street campaign donations [6].

With these positions unfilled, Mr. Obama is losing out on a political opportunity to draw a line between himself and his opposition.

Assessment

But it’s more important than that. Allowing these vacancies to linger drains leadership from the financial overhaul at the exact moment when it is needed most.

Link: http://www.propublica.org/thetrade/item/at-a-time-of-/0763745790

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Conclusion

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Budget Committee Proposes 25% Tax Rate

The Ryan Plan for FY 2012

By Children’s Home Society of Florida Foundation

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On April 5th House Budget Committee Chair Paul Ryan (R-WI) presented his budget proposal for Fiscal Year 2012. The comprehensive proposal included over $4 trillion in reduced spending during the next decade and a plan to reduce both the personal and corporate top tax rates to 25%.

House Ways and Means Committee

The tax reform provisions will be handled by the House Ways and Means Committee. Chairman Dave Camp (R-MI) noted that, “with nearly 4,500 changes in the last decade alone, the code is too complex. And with Americans spending over 6 billion hours and over $160 billion annually to comply with the code, it is too costly and too burdensome. Clearly, the time for comprehensive reform has come.”

Many Loopholes

Both parties have raised the possibility of tax reform this year. At a meeting in Pennsylvania, President Obama was asked about the potential for reforming corporate taxes. He noted that the U.S. has “one of the highest tax codes for corporations in the world.”

However, due to “many loopholes” a number of U.S. corporations pay little or no taxes. Moreover, President Obama suggests that it would be good “to reform our tax code, simplify it, lower the rate for corporations, but eliminate a bunch of the loopholes.”

Assessment

Treasury Secretary Timothy Geithner also indicated to the Senate Committee on Appropriations that he is developing a “comprehensive corporate tax reform plan” and it will be released quite soon. Sec. Geithner indicated his plan would include, “a very strong pro-investment, pro-growth, pro-competitiveness proposal.”

Conclusion

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“A Guide to Sound Money”

The ME-P Recommends

By Staff Reporters

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“A Guide to Sound Money”, by economist Judy Shelton PhD from the University of Utah, is a 19 page report on global finance, the value of money as a standard unit of worth, inflation, the USD and related monetary issues.

Link: http://www.soundmoneyproject.org/wp-content/uploads/2010/11/Booklet-SMP-Guide-Spread-PDF1.pdf

We highly recommend it for all doctors, financial advisors and ME-P readers and subscribers   

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The Fiscal Commission Publishes A Draft Report

National Commission on Fiscal Responsibility and Reform

By the Children’s Home Society of Florida Foundation

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In a surprise press conference on November 10, 2010, Co-Chairs Erskine Bowles and Alan Simpson of the National Commission on Fiscal Responsibility and Reform decided to release a preliminary report. Bowles is a Democrat who served as the Chief of Staff for President Bill Clinton. Simpson is a Republican who previously was a Senator from the state of Wyoming. They indicated that in their view a joint presentation that explained the current positions of the Fiscal Commission would be preferable to leaks by staff members of various provisions. In order to discuss the full range of tax and budget provisions, they released the initial report.

There are 10 guiding principles for the first phase of the report:

1. Patriotic Duty – The “American people are counting on us to put politics aside, pull together not pull apart, and agree on a plan to live within our means and make America strong for the long haul.”

2. Washington Leads the Way – The national government must lead the nation in shared sacrifice and “tighten its belt.”

3. Truth in Promises – The federal government must be truthful and explain the tough budget choices. Washington must be sure to avoid promises that cannot be kept.

4. Gradual Implementation – The economy is still recovering. Budget cuts would not start until 2012 to allow the economic recovery to continue.

5. Protecting Those In Need – There must be an “affordable and sustainable safety net.”

6. Promoting Growth – Government spending will need to continue to support education, infrastructure and research and development.

7. Spending Reductions – All areas of government including defense, domestic spending, entitlements and tax expenditures are up for consideration. Total government spending will be changed initially to 22% of Gross Domestic Product (GDP) and later to 21% of GDP.

8. Government Productivity – The government must also become more efficient and set a target goal of 3% annual increase in productivity for all employees.

9. Simplify the Tax Code – The tax code should be reformed to broaden the base and bring down the deficit. There will be a cap of 21% of GDP for tax receipts.

10. Sound US Finances – Protect Social Security finances, support healthcare and stabilize the federal debt.

Now, based on those ten guiding principles, the Fiscal Commission then established four specific goals:

1. Deficit Reduction – A total of $4 trillion of deficit reduction by the year 2020. Two-thirds or more of that reduction is accomplished through reduced spending, while the balance is through increased taxes.

2. Deficit Level – Reduce the deficit to 2.2% of GDP by the year 2015.

3. Federal Debt – Stabilize the federal debt by 2014. Reduce debt to 60% of GDP by 2024 and 40% of GDP by 2037.

4. Social Security Solvency – Make changes to avoid a potential 22% cut in benefits in 2037.

Co-Chair Erskine Bowles acknowledged that the plan is very comprehensive and will produce strong debate. He noted, “What we have done is laid out a strong predicate for how the nation faces up to a very critical problem.” And, Senator Cranston noted that there will be opposition to most parts of the plan. In his view, the bipartisan Co-Chairs had “harpooned every whale in the ocean.”

Assessment

The final draft of the Fiscal Commission report is due December 1st. Fiscal Commission members will debate the many provisions of the draft report. The hope of the Co-Chairs is that 14 of the 18 members will be willing to vote in favor of the final report. If that happens, the report will then be considered for further action by the House and Senate.

Editors Note: Your editor and this organization take no specific position on these proposals. This information is offered as a service to readers because it has potential impact on all Americans. Because the support transferred to philanthropy depends upon a solid economy in the nation, it is in the interest of all charitable organizations that a bipartisan agreement be achieved. Hopefully, a bipartisan agreement will stabilize the federal fiscal position and restore economic growth that will lead to greater support of philanthropy.

Conclusion

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US Budget Deficits Require Both Spending Cuts and Tax Increases

The CRFB Speaks

By Children’s Home Society of Florida Foundation

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The nonpartisan Committee for a Responsible Federal Budget (CRFB) has published a release on October 20 that discusses some of the options to tackle the federal deficit. According to a Bloomberg News poll, there are two major issues that are foremost in the minds of voters as they go to the polls on November 2nd. The first is jobs and the US economy. The second issue focuses on federal finances and the budget deficit.

CFRB Suggestions

The CFRB suggests that there are four potential options for reducing expenditures and one for increasing revenue.

1. Fraud, Waste and Abuse – A favorite comment of all political candidates is that he or she will reduce fraud, waste and abuse. While there may be some savings, this historically has been a fairly modest part of actual deficit reduction.

2. Strengthen Social Security – Congress will need to address methods for strengthening Social Security. The Social Security program used to run a substantial surplus each year. However, in 2010 the federal deficit will total approximately $40 billion. That is, the amounts received by Social Security will be $40 billion lower than the amounts distributed for benefits.

Social Security

By 2020, Social Security could be running a $100 billion deficit. Social Security Trustees have stated, “The projected trust fund shortfalls should be addressed in a timely way so that necessary changes can be phased in gradually and workers can be given time to plan for them.”

3. Healthcare – The Congressional Budget Office notes that the current healthcare programs could require nearly one-half of the federal budget by 2030 or 2040. Therefore, there will need to be further changes in healthcare in order to make the program fiscally sustainable.

4. Defense – Defense expenditures in 2010 were 4.7% of Gross Domestic Product (GDP). This amounted to $692 billion. Defense Secretary Gates has acknowledged that there may be opportunities to eliminate some weapons systems and reduce expenditures.

5. Increased Taxes – The CFRB release states, “It is very difficult to lay out a credible deficit plan that would not increase taxes. It is also very difficult to develop a comprehensive plan that would not raise taxes on families making less than $250,000 per year.” The potential for increased taxes has focused on income taxes, capital gains taxes, estate taxes and a consumption tax such as a gas tax or a value added tax.

Assessment

The Fiscal Commission appointed by President Obama is expected to issue a report in December that discusses these issues.

Editor’s Note: Your editor and this organization take no position with respect to the many financial and tax options that are available to Congress. This information is offered as a public service to our readers.

Conclusion

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On the US Budget Deficit in 2010

Now North of $1.3 Trillion Dollars

By Children’s Home Society of Florida Foundation

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The federal fiscal year for 2010 concluded on September 30th. The Office of Management and Budget and Department of Treasury have released the official figures for fiscal year 2010. The deficit was $1.294 trillion.

Geithner Speaks

Treasury Secretary Tim Geithner noted that the cost of the financial rescue of banks and automotive companies was lower than expected. He stated, “By carefully managing the emergency initiatives to stop the financial panic and by accelerating our exit from those investments, we have significantly lowered the cost to taxpayers, bringing the costs of the financial rescue down by more than $240 billion this year.”

TARP

The Troubled Asset Recovery Program (TARP) cost to Treasury was $9 billion in 2010. During this year, the Federal Government also spent $52.6 billion to support the housing industry through troubled lenders Freddie Mac and Fannie Mae.

Deficit Concerns

The deficit declined slightly from 10% in 2009 to 8.9% of the 2010 gross domestic product (GDP). Tax receipts for 2010 were $2.16 trillion or 14.9% of the economy. Government expenditures were $3.45 trillion or 23.8% of the economy. Senate Budget Committee Ranking Minority Member Judd Gregg (R-NH) expressed concern about this deficit and noted, “These abrupt and shocking changes in our fiscal situation cannot be dismissed as “inherited” problems when the tally of the majority’s spending spree has climbed into the trillions.”

Assessment

The Fiscal Commission appointed by President Barack Obama is developing a plan to reduce the deficit. The target for the Fiscal Commission is to reduce the current 8.9% GDP deficit down to 3% of GDP within five years.

Editor’s Note: Your editor and this organization take no position with respect to the many financial and tax options that are available to Congress. This information is offered as a public service to our readers.
Conclusion

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Doctor-Why Is It So Difficult to Save?

A Poetic Tale: Gurus of Marketing

By Somnath Basu PhD MBA

What is in spending today that cannot wait?

Surprisingly, the answer in not so much a financial one but much more one that is sociological and psychological in nature. Much of the answers lie in how we, as a society, react to the titillations carried through media that cajole us to spend even in the face of distressing financial conditions while exhorting us mercilessly to do so during economic bubbles.

Our spending on basic living needs is not the issue here. It is the add-ons, the options bundles, much like when we buy a car. The basic need of going from A to B as simply as possible fade when we consider issues of images (yellow Ferraris, superfast Vettes, 57 Mustangs, etc.), or comfort (plush leather, auto all) and all the other complex factors that go behind the “bundling options” decisions. Behind all these images are some very clever folks who subtly or not so subtly, intrude in our mind and link connections between our desired images and a product that seems to exclusively cater to it.

Consumer [Physician] Behavior

This realm of the study of the purchase decision process lies in the academic arena of consumer behavior and market research. Some very smart folks study how we make these spending decisions, in every possible combination. They study how kids get excited about various toys when they watch Sponge Bob or Barney on Nickelodeon and suggest their appeasement possibilities. They copiously study every buying habit of yours when you save oh-so-many dollars because you used your grocery’s preferred card(s).

Of course your credit card company knows these already down to the details of what you charged $3.25 for on your card. The popular magazines and journals know exactly what type of people read their rag, down to the last details of the number of kids you have and whether you eat out more than five times a week. In turn, for most consumers, it is extremely difficult to resist such consumption spurring. Understanding our own personal financial health condition is somewhat akin to most people not wanting to conduct their own surgery and self-medication of their own appendicitis, no matter that drugstores may any day introduce do-it-yourself kits! In a nutshell, we are quite helpless.

Just Imagine

Imagine you are parents of two or three kids and you both work. You come back home at the end of a long hard work day after picking up the kids from various activities and figure out the day’s dinner protocol. After that, tuck them in bed and sit in front of a TV to relax and enjoy your personal quality time a bit. This is your prime relaxation time. Your guards are finally down.

Obviously, it also happens to be prime time TV for which corporations pay top $ to be in front of you. Wafting through the TV (or from the newspaper / magazines or radio for the snobbier) come through subtle and not so subtle images of a happier you skiing down some fine Colorado powder or on a Caribbean beach sipping umbrella-clad drinks. Pictures of yourself – a happy retired millionaire at 40 or so. And, you know what happy people do. Next morning the natural query is to enquire about credit possibilities on your home equity or credit card. What chance do we have to resist being like such beautiful people? Our present is all we know of our future and how can we step into this future without a happier now!

My Proposal

A friend once proposed this financial study to me. Call up a financial advisor, one you do not know, pls. Maybe someone from the yellow pages or from the local classifieds with lots of credentials after their name, preferably starting with a “C”, though any alphabet soup will do.  Ask them what you should do with the $200,000 you just inherited. Now watch for the effects of the underlying corporate marketing gurus to come through to you – fangs and all.

Assessment

Who can protect us from this onslaught? Not corporations, politicians, bureaucrats or government. Can things get worse? We’ll have to wait and see what kind of a mess we get into, or not, when the Consumer Protection Act of the financial reform bill gets implemented and understood over time.

Conclusion

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NOTE: Somnath Basu is a Professor of Finance at California Lutheran University and the creator of the innovative AgeBander (www.agebander.com) retirement planning software.

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Preparing Physicians for Financial Emergencies

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Domestic Personal Savings Rate Increasing?

By Somnath Basu PhD, MBA [www.clunet.edu/cif]

[Director California Institute of Finance]

There is a heartening change that we are observing today, an event that is truly national in character. At the bottom of the financial abyss we single-handedly turned around our personal savings for the first time in 12 years.  The chart (Department of Commerce publications data) below expresses this turnaround emphatically.

Graph: Personal Savings Rate

It is the timing of this turnaround that is so heartening. The realization that this crisis may truly be worse than any other enabled us as a nation to halt this decline. We have our emergency “nest eggs’ rebuilt again. Amazing still is that this feat was achieved with a determined effort to curtail our consumption levels to ensure that our emergency funds were rebuilt. Again, a similar chart expresses this aspect much better.

Graph: Change in Consumption

What next then?  With our emergency nest eggs rebuilt, we must now ponder the question as to continue to increase our savings or not. For lay and senior physicians, the object would be to ensure they did not outlive their funds. For those medical professionals, and the rest of us, between the ages of 45-65 in general, retirement must loom somewhere, and retirement is sweet. Similarly, for those between ages 25 to 45, thoughts would turn towards families, home purchase and children’s education; all worthwhile savings objectives.

Assessment

Thus, the central question is whether we should increase our current consumption or postpone consumption to attain our future objectives. Only time will tell whether we continue the trend of increasing savings and moderating consumption or whether we go back to drawing down on our savings to increase current consumption.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. What is your propensity to save or consume? Is it more or less for medical professionals? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe. It is fast, free and secure.

 

Editor’s Note: Somnath Basu PhD is program director of the California Institute of Finance in the School of Business at California Lutheran University where he’s also a professor of finance. He can be reached at (805) 493 3980 or basu@callutheran.edu. See the agebander at work at www.agebander.com

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Questioning [Physician’s] Upward Social Mobility and the State of the Union Address

Broad Consensus Seems Impossible for Medical Professionals – and Everyman

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

While an undergraduate student at Loyola University in Maryland, I learned from my Jesuit teachers and philosophers that a couple of centuries ago, the decider of all matters of importance in Jerusalem was the Great Sanhedrin, or a council of 71 judges. The council met most every day except on festivals and the Sabbath. It functioned as sort of a combination of the Supreme Court, Congress and a political debate boiler room.

Incorrect Unanimity

As one might imagine, the Sanhedrin’s members normally disagreed as they hammered out their daily opinions; much like today’s political debates over healthcare reform. But occasionally they came to a unanimous decision, and they had an amazing and very wise rule when that occurred: The decision was immediately overturned because the sages believed that a unanimous conclusion among so many individuals just had to be wrong.

THINK: The US Senate and Congress

Rules for Upward Mobility

Anyway, I was thinking about the Sanhedrin’s rule after last night’s 2010 State of the Union address by President Barrack H. Obama while I was considering the current state of the economic union for doctors – specifically. The translation is easy for non-physicians [everyman] as well; so bear with me.

Anyway, I was struck by the fact that if there was one grand unified theory which gets at least 90-100% agreement from current generations of America’s medical and lay punditocracy – it is the rules for upward [medical professional] mobility.

These rules, especially for second generation Americans like me, were:

  • A medical degree [college education] leads to a lucrative profession [job] and a satisfying lifestyle.
  • [Working hard], or practicing long hours, means your income will grow.
  • Devotion to medicine, or your job, will produce a comfortable retirement.
  • Your children will follow your career path [job] and create a lasting legacy

The Paradigm Shift

Today, with a national unemployment rate hovering around 10%, doctors and everyman may need to reconsider the above unwritten rules that have governed our upward mobility since the end of World War II. As the son of a GM auto worker – I did decades ago – and still do.

For example, from 1945 to 2000, various private and public health insurance mechanisms were developed, along with the idea that health insurance was a fringe benefit in lieu of the wage and price controls instituted after the war. Today it is even considered a “right” by some.

Nevertheless, the doctor-class was a surrogate for the affluent American upper middle class lifestyle, and a type of perpetual prosperity machine that created wealth.

There were periodic general economic dislocations of course, like the recessions of the mid-1970s and early 1980s, and the rise of managed care in the early 1990s. But, wealth seemed to compound for physicians, and progress always resumed its upward trajectory. This was especially true for all medical professional during the “golden age of medicine” [circa 1965-1990, approx].

After all, wasn’t [isn’t] healthcare considered a recession proof business? Perhaps no more!

The Physician Net-Worth Numbers

Then: I was involved in study a few years ago [September 16, 2008] which determined that the average 47 year-old physician, earning $180,000 annually, needed to amass a net-worth of about $5.5-M in order to maintain the same lifestyle throughout retirement at age 65.

Link: http://www.hcplive.com/finance/publications/pmd/2005/92/3951

Link: www.CertifiedMedicalPlanner.com

Now: Today, with the DJIA down about 30% from its’ October 2008 high, is this retirement / employment scenario still possible? Are our opinions Sanhedrin-like?

And remember, the estate tax laws sunset back to their original rates in 2011. Moreover, many financial advisors, like me, believe income tax rates and brackets will increase going forward; along with increasingly onerous regulations for small businessmen and women like physicians and private medical practitioners. New business innovations of all stripes will also be adversely affected.

Full Disclosure: I am founder of the Certified Medical Planner™ online education program for financial advisors and medical management consultants.

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Assessment

And so, I ask, do the rules of upward mobility for physicians or everyman still apply; or have they changed?  Why or why not? If so, is the change permanent or temporary, and is it for the positive or negative. Please consider financial, societal and/or generational implications.

IOW: Is President Barack H. Obama correct?

Conclusion

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Capital Formation for Hospitals

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Understanding Strategic Expenditures

[By Calvin W. Wiese; MBA, CMA, CPA]

[By Dr. David E. Marcinko MBA CMP]

Some of the most important strategic decisions hospital executives make are related to capital expenditures. Almost every hospital has capital investment opportunities that are far in excess of their capital capacity. Capital investments are bets on the future. How these capital bets are placed has long-lasting implications. It is of utmost importance that hospitals bet right.

Strategic Importance of Capital Investing

Hospitals are capital intensive businesses. Hospital buildings are unique structures that require large amounts of capital to construct and maintain. Inside these buildings are pieces of expensive equipment that have fairly short lives. Technological innovations continually drive demand for new and more expensive equipment and facilities. The ability to continually generate capital is the lifeblood of hospitals. In order to compete and succeed, it’s imperative for hospitals to continually invest in large amounts of capital equipment and expensive facilities.

Profit Driven

Capital investment is fueled by profit. In order to continually make the necessary capital investments, hospitals must be profitable. Hospitals unable to generate sufficient profit will fail to make important capital investments, weakening their ability to compete and survive.

Capital Opportunity Selection

Hospital managers bear important responsibility in choosing which capital investments to make. There are always more capital opportunities than capital capacity. In many cases, capital opportunities not taken by hospitals create openings for others with capital capacity to fill the vacuum. By not taking such opportunities, hospitals are weakened, and their operating risk increases.

Stewardship

Stewardship is a term that aptly describes the responsibility borne by hospital managers in making capital investments. The New Testament parable of the talents describes this kind of stewardship. In this story, a merchant entrusted three managers with money to invest. One manager was given five units, another two, and a third one. At the end of the investment period, the two managers given five units and two units reported a 100% return. The manager given one unit reported zero return — he was fired and his unit was given to the first manager.

This is stewardship — and hospital managers are stewards of their organizations’ assets. Too often, not-for-profit hospital managers hold an erroneous view of the returns expected of them. Like the third manager in the parable, they think zero return on equity is acceptable. They understand capital investment funded by debt needs to cover the interest on the debt, but they view capital investments funded by equity as having no cost associated with the equity. From an accounting perspective, they are right. From a stewardship perspective they are dead wrong — just like the third manager in the parable.

Here’s why: as stewards, they are responsible for managing the entrusted assets. They can either put these assets at risk themselves, or they can put those assets in the market and let other managers put them at risk. If they choose to put them at risk themselves, and then they have the mandate of creating as much value from putting them at risk as they would realize if they put them in the market for other managers to put at risk. They have the duty to realize returns that are equivalent to the returns they could realize in the market; otherwise, they should just put them in the market. They can either invest in hospital assets or work the assets themselves, or they can invest in financial market assets so others can work the assets. When they choose to invest in hospital assets, the required return is not zero. That’s the return they get fired for. The required return is equivalent to market returns.

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Assessment

Thus, when evaluating performance of hospital management teams, the minimum acceptable performance level is return on equity that is equivalent to the return that could be realized by investing the hospital assets in the market. And when evaluating a capital investment opportunity, it is important to apply a capital charge equivalent to the hospital’s weighted cost of capital — a measure that imputes an appropriate cost to the equity portion of the capital along with the stated interest rate for the debt portion of the capital structure.

CASE MODEL: CASE MODEL

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Conclusion

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Ten Questions on Section 127 Plans for College Funding

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Physician-Parents and the Cost of Education

[By Staff Reporters]

IRS Section 127 plans are used to pay and deduct college costs. These plans allow your practice to pay up to $5,250 of college expenses per year, but do not require your child to recognize the tuition payment as income. The following questions and answers relate to the IRS Section 127 Educational Assistance Plan which became effective on July 1, 2002

1. What benefits are provided under the Section 127 Plan?

The Section 127 Plan is intended to provide favorable tax benefits only. The Plan will exclude from taxation graduate-level courses provided to eligibles up to a maximum of $5,250 per calendar year. Section 127 plans provide relief from taxation for those eligibles whose graduate-level educational benefits are not covered under other Code provisions.

2. Who will benefit under the Plan?

Employees enrolled in graduate-level courses under the Reduced Fee Enrollment Policy that are not job-related will benefit from the Plan.  The value of such courses will not be taxed, up to the $5,250 annual limit.  Employees enrolled in non-job-related graduate courses taken for professional development at another educational institution are also covered by the Plan and will not be taxed on the value of those courses, subject to the annual limit.

3. What kinds of graduate courses are covered under the Plan?

The Plan covers graduate-level courses of a kind normally taken by an individual leading to a law, business, medical, or other advanced academic or professional degree. Covered courses do not include courses or other education involving sports, games, or hobbies. Courses covered by the Plan may be taken at another educational institution.

4. Are any undergraduate courses covered under the Plan?

No.  Undergraduate courses are excluded from taxation under IRC section 117.

5. Why are job-related courses not covered under the Plan?

Job-related courses are already exempt from taxation under IRC section 162. Thus, only courses taken for professional development that are not directly related to an employee’s current position are covered by the Plan.

6. What is the definition of a job-related course?

A job-related course is a course taken by an employee either to maintain or improve skills required in the employee’s current job; or to meet the express requirements of the employer; or the requirements of law or regulations, imposed as a condition to retaining the employee’s salary, status, or employment.

7. Are Section 127 educational benefits reportable on the Form W-2?

No. The instructions for Form W-2 provide that payments qualifying under a Section 127 educational assistance program are not reportable in box 1 as wages.  Only waivers or reimbursements (for non-job-related graduate courses) in excess of the $5,250 annual exclusion limit would be reported on the Form W-2 as taxable compensation, subject to withholding. Accordingly, such excess amounts should be paid through a payroll system.

8. What are the requirements for a Section 127 Plan?

Section 127 requires that an employer prepare a separate written plan for the exclusive benefit of its employees to provide such employees with educational assistance. In addition, eligible employees must be provided reasonable notification of the availability and terms of the plan; and the plan must not discriminate in favor of highly compensated employees.  Section 127 does not require the educational assistance program to be funded.

9. May benefits be provided on a retroactive basis?

No. Section 127 requires that employees be provided with reasonable notice about the benefits available under the plan.  If benefits are provided before the plan is in effect, employees have not been provided with the requisite notice.

10. Are there any IRS information reporting requirements related to 127 Plans?

No. The IRS has indefinitely suspended the reporting of data related to the administration of a Section 127 Plan (IRS Notice 2002-24).

Assessment

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To properly use a Section 127 plan, physicians must adhere to several rules: the student must be 21 years old; the student cannot be a tax dependent of the physician; the student must be an employee of the medical practice; and the plan cannot discriminate against employees not related to the physician.

Conclusion

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Kathleen Sebelius Please Pay Attention to Dr. Darrell Pruitt

Deferred Investment [An Incentive to Access]

By D. Kellus Pruitt; DDS

On Friday, the editor of the Chicago Dental Society’s [CDS] blog “Open Wide” posted a progressive, brief article titled, “State of Illinois offers incentive for dentists to treat Medicaid patients” (no byline).

http://chicagodentalsociety.blogspot.com/2009/12/state-of-illinois-offers-incentive-for.html

CDS says that last week, Governor Pat Quinn signed a law which allows Illinois dentists who treat Medicaid patients to accept payment deposited into a tax deferred investment portfolio instead of the traditional delayed, unpredictable payments that offer no tax advantages – only headaches.

Illinois Governor Quinn is a vast improvement over his predecessor. What was his name? He’s gone on to become a TV personality …. Oh yeah. Blagojevich!

I don’t know about you, but for me, Quinn’s incentive to access could offer not only more relief for those who cannot afford dental care in Texas, but it could also be a more or less painless way for dentists to fund IRAs – rather than having to do it at the last minute like I’ll do in a few months – just like every year. Instead of having an IRA hanging over my head, all I would have to do is donate my skills to help a few more people every now and then. That’s noble, charitable duty, friends – even with the Quinn incentive.

I especially respect current Medicaid dentists who work for nothing at all on the more profitable days.

To HHS Secretary Kathleen Sebelius

Pay attention. You only think you run the show.

The nations’ dentists you need aren’t being paid what they deserve, yet they put up with expensive and threatening CMS bureaucracy and struggle on – simply because they wish to ease suffering everyone else chooses to ignore.

Medicare dentists are American heroes to be sure. But let me warn you, Ms. Sebelius, they will turn on you hard and cold if you try to push them around. It’s time that you welcome real dentists to the bargaining table instead of ambitious ADA-approved stakeholders. You need us more than we need you, Ms. Sebelius. Forget the ADA. That is a foundation on which we can build … or not.

And this is for my stunned dentist colleagues in Texas who cross the street to ignore grandiose special bastards like me. Most of you detest the messy stuff I drag around, but nevertheless can’t stop watching from a safe distance. Rather than get your own hands messy, most of you simply pay the TDA to quietly and ineffectively hide or delay huge approaching problems. So what’s the trade-off? To remain “In the Loop,” you must obediently take up your differences with leadership in the approved, professional manner through designated ADA representatives. And. that’s so cute.

Now that you read about Quinn’s incentive, don’t you also hope that a TDA committee has already approved a draft of a deferred investment proposal to be offered to state lawmakers as soon as possible? After all, similar plans are already being tried in not only Illinois, but in four other states as well: Louisiana, Florida, Mississippi and Arkansas.

Hope as we may, nimrods, I fear those in Austin who should be paying attention to legislative opportunities such as this only heard about Quinn’s incentive to access law a minute or so ago at best.

Of Face Book Accounts

Both the TDA and the ADA desperately need functional Facebook accounts like Chicago Dental Society’s. By the way, it is the CDS which will be hosting their annual mid-winter dental conference in Chicago – reliably a tremendous meeting. This year it is Thursday-Saturday, Feb. 25-27, 2010 in the McCormick Place West Building.

http://www.cds.org/mwm_2010/

The TDA’s Facebook Wall is pristine white and graffiti-ready, and the spray paint is free to any artist who walks by. Not unexpectedly, it’s a mess. Nobody is joining, and whoever is in charge of managing the site is busy deleting unacceptable comments from a jerk who has no respect for anyone. (It’s not me). The TDA Facebook is in trouble, and it has been suggested that it should be shut down. It is indeed an embarrassment.

Assessment

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Here’s something we’ll all laugh about later: The one dentist in Texas who could have sent the rogue artist on down the road (me), was kicked off for badmouthing BCBSTX and the NPI number as well as 13 other listed allegations, including posting pornography. I’ll let the TDA Director of Membership explain that and the other allegations if you are curious. I was not provided access to the evidence on which the sudden and uncontestable revocation of my TDA benefit was based. But there’s still hope because a friend of mine resented the way I was treated and complained to the TDA using the approved channels. That was 2 months ago. I wonder how well that one is progressing from the Austin City dump.

The ADA Facebook is no better. Over 1600 fans have piled up at the door waiting for the ADA’s grand opening, yet nothing is happening. What do you think is going on there?

If you’ve missed hearing from me for the last 2 weeks and have an inquisitive mind, I’ve been pursuing answers for such questions about ADA and TDA transparency on Twitter. They call me Proots.

Conclusion

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More on Doctors and Personal Net Worth

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Determinations Using Rules-of-Thumb

[By Staff Reporters]fp-book1

Once the value of all personal assets and liabilities is known, physician net worth can be determined with the following formula: Net worth – assets minus liabilities. Obviously, higher is better.

And, although eschewed in the past, rule-of-thumb determinations are making a comeback because of the recent financial implosion and stock market meltdown.

Benchmarks

In The Millionaire Next Door, Thomas H. Stanley, Ph.D., and William H. Danko gave the following benchmark for net worth accumulation. Although conservative for physicians of a past generation, it may again be more applicable in the future because of the current managed care environment and political turmoil.

Here is the guide: Multiple your age by your annual pre-tax income from all sources, except inheritances; and then divide by ten.

Example

As an HMO pediatrician, Dr. Curtis earned $60,000 last year. So, if she is 35, her net worth should be at least $210,000. How do you get to that point? In a word, consume less and save more. Stanley and Danko found that the typical millionaire set aside 15 percent of earned income annually and has enough invested to survive 10 years, at current income levels if he stopped working. If Dr. Curtis lost her job tomorrow, how long could she pay herself the same salary?

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Assessment 

In one non-medical but stark example of inattentiveness to net-worth, John McAfee, the entrepreneur who founded the antivirus software company that bears his name, is now worth about $4 million, down from a peak of more than $100 million, according to the New York Times.

Conclusion

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

What is a Zero-Based Budget?

A Most Cruel – but Needed – Endeavor

[By Staff Reporters]fp-book2

A zero-based budget means you start with the absolute essential expenses and then add-back expenses from there until you run out of money. This is an extremely effective, yet rigorous, exercise for most doctors and medical professionals; and can be used personally or at the office.

Triage and Prioritize

Your first personal financial item should be retirement plan contributions, then your mortgage and other debt payments, and then other required fixed expenses. From the office perspective, the first budget item should be salary expenses for both you and your staff. Operating assets and other big ticket items come next, followed by the more significant items on your net income statement. Some doctors even review their P&L statements quarterly, line by line, in an effort to reduce expenses. Then, you add discretionary personal or business expenses that you have some control over.

More Month than Money

Now, do you run out of money before you reach the end of the month, quarter, or year? Then you better cut back on entertainment at home or that fancy new, but unproven piece of office or medical equipment. This sounds Draconian until you remind yourself that your choice is either (1) entertainment now but no money later or; (2) living a simpler lifestyle now as you invest so you’re able to enjoy yourself at retirement.

Assessment

When you were a young doctor, budgeting may have seemed a task needed far into the future; but at midlife, you are staring retirement right in the face.

Conclusion

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IRS Warning on Hospital Charity Care

On Hospital Community Benefit Laws 

By Staff ReportersOslo Port

According to an Internal Revenue Service survey of nearly 500 not-for-profit hospitals in May 2006, only nine percent of total revenues were dedicated to community charity care. The report warned charity [Samaritan] and not-for-profit healthcare entities that attempts to set a percentage threshold for determining tax-exempt compliance may have a:

disproportionate impact on hospitals, depending upon their size, where they are located their community benefit mix, and other hospital and community demographics.”

In a follow-up, February 12, 2009, the IRS reported on executive compensation of the same tax-exempt hospitals”.

Link: http://greisguide.com/wp-content/uploads/2009/02/eo_interim_hospital_report_072007.pdf

Existence Justification

HO-JFMS-CD-ROMWhile the question whether  tax-exempt hospitals are providing enough charity care to justify their tax exemption remains, the report failed to reach specific conclusions on whether existing community benefit standards are appropriate and if tax-exempt hospital executives are being compensated too richly. The findings also serve as a caution to long term acute care hospital [LTACH] governance and compensation committees.  The CEOs and CFOs of these entities should note that a similar survey may be performed on for-profit hospitals in the near future.

Defining “Community Benefits”

According to Jason Greis, of the Gries Guide on LTACHs, on February 12, 2009:

“The current ‘community benefit’ standard was established by the IRS in 1969 in Revenue Ruling 69-545.  The standard sets out factors to be considered in measuring community benefit, including: (i) a board made up of a broad base of community members; (ii) an open medical staff; (iii) participation in Medicare and Medicaid; (iv) application of surplus funds toward improving facilities, equipment, patient care, medical training, research, and education; and (v) a full-time emergency room open to all regardless of ability to pay (the emergency room standard applies differently to tax-exempt Long Term and Acute Care Hospitals [LTACH] that do not maintain a full array of emergency department services).  Under the current community benefit standard, individual hospitals are given flexibility to determine what services will-best serve their communities.”

Today, some pundits suggest that if Congress doesn’t establish new charity care requirements imminently, the IRS should revert to its community benefit standard above, and revise down or eliminate the tax exemption.

Link: http://greisguide.com/wp-content/uploads/2009/02/eo_interim_hospital_report_072007.pdf

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Should non-profit hospitals be evaluated more carefully by the IRS for their community benefit? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Physician’s Acquiring Real-Estate

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Innovative Funding in Difficult Times

[Staff Reporters]mortgaged-house

Real estate can be acquired by physician-investors, even in these difficult times, in many different ways. For example, through direct purchase, participation in a real estate partnership vehicle with other investors [such as general partnerships, limited partnerships, various corporate entities, and, in most states, limited liability companies (LLCs), and investments in real estate securities such as Real Estate Investment Trusts (REITs).

Section 1031

Real estate also can be acquired through tax-deferred exchanges under Section 1031 of the IRS Code, in which a client “trades” one investment property for another, deferring the taxes due on the sale of the exchanged property. This allows the doctor to reinvest “pre-tax” dollars in another real estate investment, potentially benefiting from appreciation on the larger investment. The physician may also exchange one larger property into two or several smaller properties and pay tax consequences on each one as those properties are sold as cash is needed.

Tax and Risk Management

The way a physician takes ownership of real estate will affect the tax treatment of income and profit. For example, having an LLC-owned investment property will provide him/her with the same protection from individual liability as a corporation, while allowing him/her to have much more favorable tax treatment. Real estate can be bought directly by purchasing it in the following manners:

1. Paying cash,

2. Paying a cash down payment and acquiring a loan,

3. Paying cash to the seller who is financing, or

4. Financing the purchase by using either new real estate financing, seller financing, or credit borrowing when a lender is willing to loan solely on the strength of, and the financial statement of, the borrower, or a combination of these.

Trading and Secured Loans

Real estate also can be acquired by trading other valuable assets, sometimes in combination with financing. A client can obtain interests in real estate by making loans on real estate assets that are secured by a deed of trust or a mortgage. Another method is to invest as a participating lender. In such an instance the borrower needs to agree to provide equity kickers or participation in cash flow whereby the lender (doctor) can benefit directly from the real estate performance.fp-book21

Equity Participation Plans

With an equity participation, the physician-investor can profit or gain from the sale of the property, sometimes in a preferential manner (i.e., the money the doctor loaned is returned, with interest, and a predetermined percentage or portion of the gain is given to the owner/borrower before distribution of the sales proceeds). Similarly, the doctor can participate in annual cash flow, giving a fixed or a fluctuating amount depending on the performance of the investment. As a lender, many of the benefits of ownership of real estate are not available to the MD, but the doctor should have a security interest in the property and no direct responsibility for operation of the real estate investment. Also, if possible, the borrower should provide additional guarantees of performance. The borrower could do this by providing additional security, such as the deeds of trust on the borrower’s house, other real-estate, and the acquired property; bank letters of credit; or guarantees of performance from people other than the party to whom the money is originally loaned.archway

Assessment

If a physician-investor is considering acquiring or lending on real estate, s/he should check with his professional advisors, including accountants and attorneys, before proceeding. The doctor’s attorney should review any contracts or agreements before the client signs anything. The physician also will need a due diligence review to ascertain both the relative values of the real estate on which money is being loaned and the borrower’s track record and background.

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Asset Allocation Methods for Physician-Investors

What’s Old … is New Again?

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chiefdem23

Asset allocation policies, incorporating the risk/return fundamental equation, have traditionally been classified under the following approaches: Principal Stability and Income, Income, Income-Oriented, Balanced, Growth, and Aggressive Growth.

Traditional Concepts

In all forms of traditional asset allocation and diversification policy approaches, the physician-investor is presumed to diversify within the chosen asset class in order to reduce the potential for specific or unsystematic risk.

Principal stability and income approach

Objective: Income, liquidity, and stability of principal.

Investment: Shorter-term fixed income securities with a large concentration in money market exposure to enhance liquidity and price stability. Accounts tend to maintain cash equivalent reserve balance of 30–50% of the portfolio.

Income approach

Objective: Maximum income.

Investment: 100% fixed income exposure.

Income portfolios arise from the traditional notion that an investor should spend only income and reinvest capital gains. Sometimes this is a legal requirement, as in a trust that has an income beneficiary distinct from the principal beneficiary.

Income-oriented approach

Objective: Income and some capital growth.

Investment: Accounts tend to maintain 15–35% in equity investments; balance of investment in fixed income.

Income and growth approach

Objective: Capital growth and income using a balanced approach to limit volatility.

Investment:  Accounts tend to maintain 45–65% equity exposure; balance of investment in fixed income.

Income and growth portfolio policies generally refer to both the fixed income and equity portions of the portfolios. Because of the income bias, the overall stock portion of the portfolio will usually have a dividend yield greater than the market yield. This method allows the portfolio manager to invest in some no- or low-dividend yielding issues.

Growth approach

Objective: Capital growth with income as a secondary objective.

Investment: Accounts tend to maintain between 65%–85% equity exposure; balance of investment in fixed income, usually cash reserves.

Aggressive growth approach

Objective: Long-term capital growth.

Investment: Accounts maintain 100% equity exposure. Exposure to variety of equity types normal (small capitalization, international, emerging markets, etc).

fp-book15

Assessment Of course, the above is much more accurate during stable economic times, than it is today; don’t you think? Are newer concepts required today … or is past … prologue.

Link: https://healthcarefinancials.wordpress.com/2008/10/25/new-wave-thoughts-on-investing/

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Using Home Mortgage Brokers

Advantages and Disadvantages

By Staff Reporterswinter-house2

A physician or other medical professional may consider using the services of a home mortgage broker when s/he does not want to spend much personal time searching for the best loan. Other reasons include poor credit history, low credit ratings level; or similar. Of course, this will cost the doctor-client money, but the expense may be worth it; or not.

Duties and Responsibilities

A mortgage broker’s main responsibility is to represent a physician-borrower to different lenders and to take the borrower through the process of acquiring a loan. These brokers are usually aware of the best lending institutions and where to get the best deals.

Disadvantages

However, using a broker has three disadvantages. First, a fee will be charged. Second, some lenders will not work with some brokers. Third, some lenders will add extra fees to their loans to pay the broker’s commission.

Assessment

During the current financial crisis, the use of this intermediary may be a necessity in some cases. 

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. What has been your experience using the services of a mortgage broker; if any?

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Physician Household Borrowing and/or Investing

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Deciding What Works?

[By Staff Reporters]fp-book4

Another way of asking the above titled question might be, “Is it smart for a doctor’s household to build savings while they are getting out of debt?”  

Financial Priorities

In the first instance, the doctor already has debt and would be increasing the terms of any loans by deferring some of the payments to savings, which is equivalent to borrowing the same amount.

In the second instance, the doctor would be taking on debt to save more money. The answer is that it makes sense to borrow money for investment purposes only if the financial gains derived from the investment are larger than the financial benefits of paying off the debt. But, who can know for sure?

www.MedicalBusinessAdvisors.com

Minimum Account Payments

Assuming that a medical professional has more debt than needed, and doesn’t make contributions to a retirement account, the concern becomes: [1] should he/she make minimum payments to the debt and contribute to a retirement account; or [2] should he/she make the maximum payments toward the debt or loans, etc?

Downside Risks

It is important to understand the downside risks of a lower payment strategy. Just as stocks return more than bonds due to their higher risk, the lower payment strategy returns more because of its’ higher risk. Taking on debt to finance an investment is riskier than paying off debt for a number of reasons.

First, the US economy may continue its’ current depressionary spiral, and investments and savings could disappear as financial institutions fail. This would leave the doctor with debt that he or she could not service.

Second, the rate-of-return required to decide whether or not to borrow for investment purposes may not be achieved, leaving the doctor in worse financial shape than if he or she had just paid off the debt.

Assessment

Ultimately, the doctor must decide if the added risks are worth the possible gain. But, the services of a fiduciary financial advisor may also be required. However, some doctors may not be ready to receive the sort of “tough-love” required in this case. 

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Conclusion

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Debt Consolidation for Physicians

Advantages and Disadvantages

By Staff Reportersfp-book5

The main advantage of debt consolidation is that it allows a doctor to make one payment instead of many, and this helps avoid late fees for missed payments. The doctor may save time by having to make only one payment per month instead of many.

Other Advantages

Another advantage is that debt consolidation promotes self-discipline by transferring credit card debt (and other lines of credit) that does not require mandatory principal payments into a fixed-term loan – with mandatory payments that include both principal and interest. This is a useful tool for doctors who may find it difficult to make more than the minimum payments on their loans because they spend too much. It should be obvious that budgeting should go hand-in-hand with this process, because if the doctor continues to spend at the former level, yet now has a mandatory payment, the result can be financially devastating.

A final advantage to debt consolidation is it may result in a lower overall interest rate. This is, of course, conditional on the lender providing the consolidation.

Disadvantages

One disadvantage of debt consolidation is that it can lock a doctor into mandatory payments. Depending on the situation, this can be either a blessing or a curse. It becomes a curse when the fixed payments are so high that he/she can no longer make the full debt payments each month. Depending on the lender, and the terms of the consolidation loan, this could result in the loan being called. The effects of this are obviously detrimental to the doctor.

Other Disadvantages

A second disadvantage is that the doctor loses flexibility when he or she takes on a fixed payment that is larger than the combination of all smaller minimum payments. The fixed-payment schedule becomes detrimental when h/she has an unexpected reduction in income. The doctor without a fixed-payment schedule can increase payments to many small individual loans, and if income reduction occurs, drop the payments back down to the lower level. Then; when normal levels of income return, the higher payments can be resumed.insurance-book2

Assessment

Making larger payments requires discipline; because a lack of same was likely causative of the debt in the first place.

Conclusion

Your thoughts and comments on this Medical Executive-Post are appreciated. Have you ever been in this situation? Feel free to opine anonymously.

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Defining “Deep” Physician Debt

Exiting the Quagmire

By Staff Reportersfp-book3

There is no magical method or SIMPLE button that a physician or lay household can use to get out of debt. The two most critical factors in this process are budgeting and discipline, as discussed elsewhere on this ME-P blog forum. And, a payment plan that pays off debt by a selected target date will help. Debt consolidation can also be of assistance in this regard.

Defining “Deep-Debt”

According to Eugene Schmuckler PhD, MBA, of the Institute of Medical Business Advisors Inc:

“deep debt” is any financial burden that produces negative daily thoughts, interferes with professional work and/or keeps the doctor awake at night.”

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Payment Plans and Budgets

Once a payment plan has been computed, the doctor should develop a budget that will free up enough money to make the payments. If this isn’t possible because the monthly payments are too high, the payoff period should be lengthened until the amount available for debt payment is equal to (or greater than) the readjusted monthly payment. After this, the doctor should set up a more disciplined approach to spending, budgeting and investing, going forward.

www.HealthDictionarySeries.com

Consumer Credit Counseling Services

Unfortunately, more than a few doctors get themselves so deeply into debt that they can’t make the minimum payments required by lenders. This is a very serious situation and usually involves negotiation for payment adjustments. Unless the doctor or his fiduciary financial advisor has experience in this area; it is a good idea to seek help from to an organization like the Consumer Credit Counseling Service.

The CCCS

The CCCS is an organization that works with those who are struggling to manage their financial debt through counseling in the areas of budgeting, understanding credit reports, and debt management. CCCS also provides educational courses for the public, with fee services ranging from $0 to a few hundred dollars. The counseling sessions focus on developing a budget that allows the client to pay all of his/her monthly expenses. The debt management program teaches about debt and also negotiates with lenders for adjusted monthly payments. CCCS tries to get the payment reduced by spreading the payments over a longer period of time and has been successful at getting lenders to reduce or even waive interest on the loans, in some cases.

Bill Consolidation

Another service of the debt-management program is bill consolidation. The debtor sends one payment a month to CCCS, who in turn pays the client’s bills. The education service provides seminars at which various speakers address different financial issues. A medical professional can find the location of the nearest CCCS office (or similar organizations) by calling the National Foundation for Consumer Credit referral line at 800-388-2227.

Assessment

In the climate of today, the above post is no longer one that some physicians might not heed. In fact, the days of the financial super-specialist with arcane products or sophisticated strategies that depend on a perfect storm of economic indicators, is long over. It is time to call in the financial primary care doctor and get back to basics; live on less than you make, and invest prudently, watching all costs.

www.CertifiedMedicalPlanner.com

Conclusion

Your thoughts and comments on this Medical Executive-Post are appreciated. Have you ever used the serves of CCCS, or similar? Feel free to opine anonymously.

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Physician Cash Maximization Rules

One Doctor- Advisor’s [How-To] Diatribe

[By Dr. David Edward Marcinko; MBA]

[Publisher-in-Chief] www.CertifiedMedicalPlanner.orgdr-david-marcinko4

For some doctors – even more than laymen – cash management is the pivotal issue in the financial planning process. Accumulation of investment assets cannot occur if cash inflows do not exceed cash outflows. On the other hand, accumulated assets are eventually spent to fund expenses during planned time periods when cash outflow exceeds inflow.

Inflation

Traditionally, financial advisors have opined that inflation has a dramatic impact on both ends of the cash management spectrum because inflation has a compounding effect. That compounding effect means that a mere ¼% change in planning assumptions about anticipated inflation can have more significant influence over long-term projected outcomes than a 5% change in the amount of a particular item of budgeted income or expense. Well, true enough if projected linearly using some Monte-Carlo type software simulation. But, in the real word, economists appreciate cost and efficiency improvements [email over snail mail] and the potential for substitution of goods [diesel fuel for gasoline – chicken for steak, etc].

fp-book2

Be More Like … my Dad

On the other hand, far too few of my fellow medical colleagues – and financial advisors – are like my dad. Not well educated by academic standards, but with common sense that seems a precious commodity, today.

Dave, he used to tell me – and still does at age 84:

“Invest your money for growth carefully – and take some risks – but don’t be too afraid of inflation.”

 Why not, dad?

“Because; if you’re not a conspicuous consumer, you’ll have less to worry about.”

Cash Management

Well, most of us are not like my dad; me included. But, his depression-mentality has never completely worn off. A doctor’s household can maximize the cash available for investing by setting up the account in this manner.

1. The first step is to open a checking account, money market account, and a brokerage account. The money market account is often included in a brokerage account.

2. The second step is to initiate electronic direct deposit of the paycheck into the money market account.

3. The third step is to determine the amount of cash reserve needed. As mentioned elsewhere on this ME-P, we are suggesting 3-5 years of cash-reserves on-hand, as an emergency fund for most medical professionals.

Once, when, and if, the amount of the reserve is determined and achieved, any extra money should be transferred to the brokerage account and invested according to personal goals, objectives and risk-tolerance. A small balance of a few thousand dollars can be kept in the checking account to prevent overdrafts. Beyond the few thousand dollars, the checking account should serve as a pass-through account where money is transferred from the money market account to cover checks written for the budgeted expenses.

Example of Managing Cash Reserve Amountsbiz-book1

A physician client recently asked me to help him increase his savings. He explained that he had a very detailed realistic budget, but had a hard time staying within the budget when cash was available; as he lectured occasionally and was fortunate to have a few extra dollars every now and then.

Recommendations

As a financial planner, and the founder of an online educational-certification program for physician focused advisors, I recommend that he set up his checking, money market and investment accounts and have his medical practice directly deposit his paycheck in the money market account. He then was to transfer only enough money to his checking account each month, to cover his very carefully budgeted and spread-sheet driven expenses. Furthermore, his money market account was to be equal to our predetermined cash reserve needs, with any excess cash transferred to his investment account and according to his financial and investing plan.

Assessment

Of course, his carefully constructed budget included no cash reserves or emergency fund!  He forgot to budget cash! And so; the usual conundrum ensued.

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On Emergency Funds for Physicians

dr-david-marcinko3Cash Reserves Now More Important Than Ever!

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

CEO: www.MedicalBusinessAdvisors.com

This is a basic question in financial planning circles that has generated much activity in the medical community, of late. Previously considered so mundane – as to be dismissed by some haughty physicians – it has acquired increased urgency with the current financial meltdown.

What Security Level Desired?

Yet, the answer to this question is dependent upon the security level desired by the medical provider and his/her family. Traditionally, financial planners suggested most people with solid employment, and transferrable skills, have at least three months of living expenses (not including taxes) in a reserve fund that is easily accessible (i.e., liquid). The amount needed for a one-month reserve is equal to the amount of expenses for the month, rather than the amount of monthly income. This is because during no-income months – there is no income tax.

The Usual Checklist

We suggest the following questions as helpful in determining the amount of reserve needed by medical professionals:

1. How many incomes do you have in your household?

2. How secure is your current practice, or medical job?

3. Do you have other unrelated sources of income; medically or non-medically related?

4. How long would it take you to find another position in your specialty, if suddenly unemployed? [Hint: Assume one month per ten grand of income; at $150-k annually, this means searching for 15 months].

5. How much money do you spend, and save, each month?

6. Would you be willing [able] to lower your monthly [fixed or variable] expenses, if you were unemployed?

Many Factors to Considerinsurance-book1

But, many other factors come into play when determining how much money a particular physician and his/her family should have on hand. Does the family have one income or two? How stable is this income source? Does the doctor work for himself [managing partner], or is she employed [minority partner, associate, etc]? What kind of firm, company or hospital employs him; private, HMO, MCO, Federal or State entity? Does the family use all of the income each month? What about, life, health, disability or LTC insurance as fringe benefits? Does the family anticipate the possibility of large liability exposures and expenses occurring in the future (i.e., medical school or practice start-up debt, private tuition for the kids, medical expenses, liability suits etc.)? Are you willing to relocate for a new job?

Family Situation Appraisal

If the doctor is in a dual-income family – with stable incomes – and/or lives on a single income – the need for a liquid reserve is minimal; but still much more than for the average layman. On the other hand, if the doctor is a single individual, with an unstable income and she spends everything each month, the need for a liquid cash reserve is higher.

In the previous example, and in the stable past, the doctor may have opted for a six-to-nine month reserve if the need for security was high; and a three-to-six month reserve if the need for security was low. For the last five to seven years however, we have suggested to our medical clients that they expand this reserve cash corpus to 12-24 months; and as a blanket rule of thumb for all medical professionals. Of course, I was roundly criticized for it; until now.

Today, we are suggesting 3-5 years; with considerably less criticism. Cash is power, choice, swagger, potency, freedom and represents options. Acquire it!

Stashing the Cash

Once the amount of reserve is determined, the doctor should consider the appropriate investment vehicles for the reserve fund. At minimum, the reserve should be invested in a money market mutual fund with NAV @ 1.00 USD. Larger income earners may opt for tax-exempt money market mutual funds, as needed.  For larger reserves, an ultra-short term, no-low bond fund, might be appropriate for amounts over three months – in periods of deflation; not so during inflationary periods.

Assessment

Today, we recommend doctors keep 3-5 years of cash-on-hand. Yes, I am aware of the “paradox-of-thrift” conundrum. But, do you want to help the domestic GDP, or your family; you decide? Personally, my own concern is not the macro-economic milieu.

Full disclosure: I am a former insurance agent, registered investment advisor; board certified surgeon and Certified Financial Planner™

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. How stressed out are you, right now? You are sleepless if previously considered cash, as trash.

But, if sitting on a little pile; you should be sleeping like a baby.    

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

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

Front Matter with Foreword by Jason Dyken MD MBA

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“BY DOCTORS – FOR DOCTORS – PEER REVIEWED – FIDUCIARY FOCUSED”

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Physician Retirement Threats and Opportunities

Investing Vehicle Updates for Modernity

By Steven Podnos; MD, MBA, CFP®

coins

Most physicians count on their retirement plans for the bulk of their financial security. Yet, few of us understand the intricate workings of these plans, and are therefore misled or at the least miss out on a number of cost savings and benefits. Here are some examples to consider, especially during this time of financial upheaval:

1. Jim L, an endocrinologist in private practice, works with his wife as office manager and has four other employees.  Jim had a “free” prototype profit sharing plan with a well known brokerage and has been putting 15% of his total employee compensation away every year in order to fund about $35,000 dollars a year into his own plan.  He pays his wife $60,000 dollars a year in order to get a $9,000 dollar annual contribution for her, but at a social security cost of the same $9,000 dollars.  His plan is invested in a variety of “loaded” mutual funds and stocks at the brokerage, and he was not really sure how it was doing in terms of performance.

Change:

The plan was changed to a customized 401k/profit sharing plan using a Third Party Administrator at a cost of 2500 dollars.  Jim’s wife lowered her salary to $20,000 dollars, which saved over $5,000 dollars a year in social security taxes.  Yet Jim and his wife were now able to contribute over $65,000 dollars in pretax money (rather than $44,000 dollars in prior years.  His employee cost for the plan dropped from 15% of a $100,000dollar payroll to 6%, another annual savings of $9,000 dollars. 

2. Statewide Healthcare medical group had an insurance based “retirement” plan.  All of the investments allowed were wrapped in variable annuity/insurance wrappers with an annual expense ratio of between 2 and 4% annually. The plan was “free” to the group but did not allow any differentiation in benefits or contributions between the physicians and their employees

Change:

An unbundled 401k/profit sharing plan was designed that allowed physicians to contribute the maximum in salary deferral and profit sharing contributions. Using an age-weighted contribution formula, the physicians were able to put away 14% of their salary in the profit sharing plan as compared with a 5% contribution for employees.  The new investment portfolios carried an annual cost well below 1% annually and were actively monitored by a fee only fiduciary advisor, mostly relieving the group from the fiduciary responsibility for the fund investments.

3. Kirk L, an orthopedic surgeon employed his wife and 5 employees in a busy practice.  He is 55 years of age and looking towards retirement in ten years.  He had a reasonably well designed 401k/profit sharing plan advisor which let him and his wife put away about 70-75 thousand dollars a year with an employee cost of about 15 thousand dollars. He was beginning to worry about not having enough savings to make his retirement goal.

Change:

Kirk and two of his younger employees were switched to a new Defined Benefit plan, but also continued in the 401k salary deferral plan. Kirk’s wife and the remaining employees stayed in the old plan and his wife’s salary was reduced to lower Social Security costs.  With the new plan, Kirk and his wife are now putting away about $200,000 dollars in pretax contributions annually at a marginally higher cost for the employees.

Poorly Designed Retirement Plans

None of these stories are unusual, in fact they are typical.  Most physician retirement plans are poorly designed, expensive and misunderstood.  Few existing plans are updated to capture the many positive changes made in tax law over the last decade.  Many plans are shoddily designed to catch the “quick” dollar, with financially terrible consequences to the physicians.

Qualified Plans

And so, I’ll review the most common types of retirement plans available to medical practices and discuss the pros, cons and specific opportunities each type for most practices. Note that most of these plans are considered “qualified” plans by the US Government.  Being qualified means that contributions to the plans are allowed to be deducted as business expenses and that the plan assets are generally protected from creditors.  In exchange, the government requires extensive paperwork and mandatory contributions for employees on the lower end of the salary scale. 

1. SEP-IRA

The SEP-IRA allows a fixed percentage of salary (up to 25% of W2 income) to be contributed to individual IRAs of most employees (including the physicians). There can be no discrimination in what percentage of compensation is used between owner/managers and lower paid employees, making this a relatively expensive plan in terms of employee funding. There is no component of salary deferral by employees, and all plan funding is immediately “vested” (belongs to the employee immediately if they leave employment).

The advantages of the SEP plan include a minimum of paperwork and ease of setup. Generally, SEP-IRA plans are used by small family owned businesses with few to no outside employees. It does work well for physicians that act as Independent Contractors (no employees) such as many Emergency Room physicians.  However, an individual contractor with an income of less than around $170,000 dollars can actually put more pre-tax money away in a Self-Employed 401k plan.

2. SIMPLE-IRA

This plan is another relatively easy one to set up and administer. It allows companies that have less than 100 employees to open individual IRA accounts for employees. The employees may defer salary in amounts of $10,500-$13,000 (depending on age), and the employer supplies a “match.” All money in the plan is immediately vested. The match is generally (but not always) a dollar for dollar matching contribution of up to 3% of the employee’s compensation.

For example, a company owner with a compensation of 100,000 dollars would be able to defer salary in an amount of up to $13,000 (if age 50 or older), and then have the company “match” 3% or $3,000 more. A SIMPLE IRA plan is a good choice for small businesses in which the owners are highly compensated, and few employees wish to defer salary. The disadvantages of the SIMPLE-IRA are immediate vesting for the matched funds, and relatively low total amounts of contributions compared to other qualified plans. 

NOTE:

I have seen these plans work well in small practices that wish to avoid paperwork, have few to no employees that wish to defer salary, and who don’t mind the limited ability to make contributions.  Note one unusual feature of this plan, in that the 3% match has no limits. I have seen one physician with a small group of employees and an income of $600,000 dollars per year put away 13,000 in salary deferrals and another ($600K X 3%) 18K in the match at no employee cost!

3. 401k/PROFIT SHARING PLAN

This is by far the most common type of qualified plan in existence.  These plans actually have three components:

 

a)       401k salary deferral-In 2008, employees may defer between 15,500 and 20,500 dollars. This money and earnings on it are not subject to Federal income tax until withdrawn in retirement, and are immediately vested.

b)       A “match”-this is an optional part of the plan in which an employer may offer to contribute a matching amount of dollars to give employees an incentive to participate.  Matching funds are usually subject to vesting on a time schedule.

c)       Profit sharing-like the match, this is a discretionary contribution by the employer of up to 25% of payroll and usually subject to vesting.

 

It is crucial to have a skilled plan designer customize a 401K plan for your individual practice.  The most common abuse of these plans is the use of “cookie cutter” prototype plans used by brokerages and insurance companies. These prototype plans are for the convenience and profit of the person “selling” the plan, and are a solid negative for the practice. Customization allows the physicians to have maximal participation at the lowest employee cost.

There is also a self employed 401k option for small practices that have no full time employees other than the physician and spouse. They operate in much the same way, but with little expense and much less paperwork.

4. DEFINED BENEFIT PLAN

Once common, these plans are now rarely used by most companies. They are based completely on company contributions to a fund (no salary deferral) that are actuarially designed to produce a set benefit amount at retirement. All the risk for providing the promised benefit is the responsibility of the employer, which is an advantage when the major beneficiary is the physician. Defined Benefit plans work best for practices in which the physician/employee ratio is low and the physician(s) is approaching age 50 or older. The advantage of this plan is allowing much higher contributions on a pretax basis, with the disadvantage of higher administrative costs. These plans work extremely well for high income businesses employing one individual (plus or minus a spouse) who is nearing age 50 or over. However, physician practices that employ a spouse or physicians of different ages can often use a Defined Benefit Plan in conjunction with a 401k/profit sharing plan to great benefit as in example three.

Assessment

Doctors have a tremendous opportunity to review and enhance the retirement plan options. Although the article focuses on these medical professionals and related occupations, much of the material applies to other professional and business clients.  A relationship with a good Third Party Administrator [TPA] and some independent study are invaluable to your ability to perform this function well.

Conclusion

Dr. Podnos is a fee-only financial planner and the author of “Building and Preserving Your Wealth, A Practical Guide to Financial Planning for Affluent Investors” (available at Amazon.com and bookstores). He can be reached at Steven@wealthcarellc.com And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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

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Recent Elder Housing Updates

Legal Protections, Home Equity Resources and Housing Options

By Staff Reporters

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Recently, significant updates and expanded coverage of the housing market for the elderly has occurred. Several items include efforts to protect consumers, and senior medical professionals, from current difficulties in the housing market. For example, these include the following three updates:

1. FINRA on Reverse Mortgages

An alert issued by the Financial Industry National Regulatory Authority (FINRA), warns that:

“as more Americans near retirement age, some financial institutions are aggressively marketing reverse mortgages as an easy, cost-free way for retirees to finance lifestyles – or to pay for risky investments  that can jeopardize their financial futures.” 

FINRA’s position is that such vehicles should be used only as a last resort.

2. HECM on Primary Residences

The Home Equity Conversion Mortgage Demonstration (HECM) program, which was first authorized by Congress in 1987, helps elderly homeowners meet their financial needs and provides borrowers with insurance against lender default. Now, homeowners can also use a HECM to purchase a primary residence if they are able to use cash on hand to pay the difference between the HECM proceeds and the sales price plus closing costs for the property they are purchasing.

3. ERA Home-Keeper Program

As a result of the passage of the Housing and Economic Recovery Act of 2008, Fannie Mae announced the discontinuance of its Home Keeper reverse mortgage program, effective as of December 31, 2008.  Some state programs encourage the use of reverse mortgages, in contrast to federal warnings, as a financial tool to help elderly homeowners pay for home and community services so they can “age in place.”

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated, as we follow-up our four part series on: At Home or Nursing Home Care for Long Term Care. Comments from physicians and LTC insurance agents are especially valued.

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

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At-Home or Nursing-Home for Long Term Care [Part III]

Cost and Duration of Long-Term Care at Home

By Dr. David Edward Marcinko; FACFAS, M.B.A., CPHQ™, CMP™

By Thomas A. Muldowney; M.S.F.S., CLU, ChFC, CFP® CMP™

By Hope Rachel Hetico; R.N., M.H.A., CPHQ™, CMPdr-david-marcinko1

This is the third post, in an exclusive four part series for the ME-P titled: At-Home or Nursing Home Care for Long-Term.”

Average Nursing Home Stays

It is generally agreed that if short, recuperative stays are excluded, the average stay in a nursing home is about 21/2 years. Nursing home studies show that residents experience four types of stay before death: 12 percent remain for less than 90 days; 21 percent stay between 91 and 365 days; 43 percent stay for up to five years; and 24 percent stay longer than five years. It is not possible to know in advance which type of stay you or your family may experience. But, put in another way, two-thirds stay more than one year and one-quarter stay more than five years. Most seniors also have home care services before entering a nursing home.

Custodial Services 

Custodial nursing home services are paid from the elder’s savings or by Medicaid. The current estimated annual cost for a nursing home resident is about $35-40,000. However, the annual cost for a nursing home in metropolitan areas may be at least twice as much.

Assessment

In the past decade, nursing home charges increased 8 percent a year. At a minimum, these costs may be expected to climb at a 5 percent annual rate in the future.

Conclusion

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At-Home or Nursing-Home for Long Term Care [Part I]

Cost and Duration of Long-Term Care at Home

By Dr. David Edward Marcinko; FACFAS, M.B.A., CPHQ™, CMP™

By Thomas A. Muldowney; M.S.F.S., CLU, ChFC, CFP® CMP™

By Hope Rachel Hetico; R.N., M.H.A., CPHQ™, CMPdr-david-marcinko

This is the first post in an exclusive four part series for the ME-P titled: At-Home or Nursing Home Care for Long-Term Care.”

Remaining at Home

It is not surprisingly, eighty-five percent of married elders prefer to remain at home instead of moving to a nursing home or some other senior care facility. Staying at home is easier, more comfortable, and less traumatic. Home care statistics are limited, but three years is the estimated average number of years that elders will require custodial care services. This estimate also may combine home care followed by nursing home care. And, the anecdotal healthcare experience of two authors [DEM and HRH] confirms this period length.

Incremental LT Cost Approach

Quantifying the annual incremental costs of LTC home custodial services is difficult. Today, a high percentage of home care services are provided by unpaid family members, friends, or volunteer organizations. In the future, however, there will be fewer available unpaid caregivers, and more elders will have to pay for home custodial care.

Because of this potential shortage of caregivers, new business opportunities are springing up and, as usual, let the buyer beware. Many of these new businesses, for a fee, contract with a family that needs home LTC for a family member.  Upon contract, the new LTC business owner begins a search for a candidate caregiver who will live in your house and care for your parent or spouse. Often the in-home caregivers have difficulty speaking the language or may not be familiar with local customs.

Furthermore, many of them wish to be paid in cash rather than by check. As you might imagine, background checks, tax compliance and other legal considerations are of utmost importance.  Career education and career experience are also very important. Be sure that if you look for such a caregiver, you must exercise thorough due diligence so that your loved one will be cared for properly.

LTC Costs Vary Widely

LTC home care cost estimates vary widely by location and type of service. At present, the average annual cost for a live-in, full-time aide in the United States (especially if part-time help to relieve a full-time aide is added) is estimated at $40,000, the same as the estimated cost of staying at a nursing home for a year. If living expenses are added to costs for custodial aides, LTC home care costs can be more expensive than nursing home costs.

For three shifts of paid LTC custodial services, home care costs may exceed $100,000 annually; more than triple the current estimated cost for nursing home care. These numbers should not be surprising.  In a nursing home environment, one caregiver may be able to provide care for multiple patient/residents. This reduces the cost per patient. In your private home, your personal caregiver can give only care to a single patient.

Custodial Aide Costs

Costs for custodial aides in the fragmented, rapidly expanding, competitive home care industry may increase at a faster rate than the Consumer Price Index [CPI]. Employed aides will replace family caregivers. The Bureau of Labor Statistics [BLS] indicates that jobs for home health aides, human service workers, and personal and home care aides are expected to grow faster than any other industry in terms of total jobs.

In the next decade, there will be more than 2 million home care jobs, and they will become a larger component of total gross domestic product expenditures. Using an estimated three-year home care requirement and current estimated costs, and allowing for 15 years of inflation at 5 percent, $225,000 per person is a reasonable estimate to use for financial planning purposes.

Assessment

However, in some metropolitan or suburban areas, such as New York City, the cost should be increased by at least 100 percent. Of course, three years of required care is an estimate. About one-third of the people who require nursing home care will need it for more than three years. Presumably, nursing home care will be preceded by home care. Moreover, only one full-time aide was assumed. Some elders also will require additional part-time help.

And so, your thoughts and comments on this Medical Executive-Post, which represents the first in a series of four parts on: At Home or Nursing Home Care for Long Term Care, are appreciated. Comments from physicians and LTC insurance agents are especially valued.

Conclusion

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Superannuation Demographics and LTCI

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“PAYING TO AGE”

  • By Dr. David Edward Marcinko; MBA, MEd CMP™
  • By Thomas A. Muldowney; MSFS, CLU, ChFC, CFP®, AIF®, CMP™
  • By Hope Rachel Hetico; RN, MHA, CPHQ™, CMP™ 

According to the US Bureau of the Census, there were almost 49 million people in the United States who were over age 60 in 2001. There are approximately 4,000,000 people over the age of 85 living in the US and there are over 60,000 people older than age 100 estimated as of July 1st 2004. For every 100 middle aged people in the US there at present about 114 persons over the age of 65. This statistic will change as we move forward through time. In the year 2025, there will be about 253 people over age 65 for every 100 middle aged people. Today, there are more than 55 million over age 60.

The Ticking Clock

Beginning on January 1st, 2006 at midnight and every 12 seconds thereafter for fifteen years, a baby boomer will have a birthday and cross over the age threshold of age 60. In the next 30 years, the 60+ age group will more than double, becoming 25 percent of the total population, and will have to be supported by a proportionately smaller workforce.  Research published in June 2005 by AARP (based on data from 2002) estimates that: “In 2002, roughly $140 Billion was spent on nursing home and home health care, with 24% of these costs being paid out of pocket (O’Brien and Elias, 2004)

Baby Boomers

As the baby boom generation ages, their care needs will expand precipitously. Add to this, scientific and technological improvements in healthcare. These very same people will need more expensive healthcare, more expensive custodial care and they will need it for an even longer period of time. Who will pay for this expanded need is not so clear. What is clear is that it will take money and lots of it to make these payments.

Financial Variables

There are only three variables associated with the accumulation or preservation of money:  “Time, Money and Rate of Return.”  Time is reduced to the following two questions “How long until I will need my money?” and “How long will I live?” an uncertainty to be sure.  Rate of return is either a function of the financial markets or the successful maintenance of an LTC plan. Because of the volatility in the financial markets, the “money” question is equally as uncertain.  In order to accumulate sufficient assets a client must ‘tradeoff’ many other alternatives such as ‘lifestyle.”

Assessment

What is certain is this…financial planning is important.  More important is the implementation or funding of an accumulation strategy or a Long-Term-Care [LTC] investment strategy to overcome these hurdles.

Conclusion

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Retail Banking Today

Ten Things your Bank and/or Banker Won’t Tell You

Staff Reporters

From: Smart Money

Do you assume that your bank serves your best interests? Do you believe that a big bank’s products are better than a smaller bank? Do you think that that your online bank account information is accurate or secure? If so, think again!

And don’t ever believe everything your bank, or banker, tells you.

Review

As readers of the Executive-Post know; medical, dental, allied healthcare and administration students of all stripes are increasingly in school-debt these days.

Assessment

Therefore, we trust this basic, but important, report will be reviewed by medical practitioners and administrators of all ages. Don’t let the bankers add to your economic misery.

Link: http://articles.moneycentral.msn.com/Banking/BetterBanking/10ThingsYourBankWontTellYou.aspx

Conclusion

Your comments are appreciated.

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

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Ensuring the Welfare of a Disabled Child

Special Financial Planning Techniques Required

By Roger J. Warrum

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

Estate Planning

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

Direct Bequests

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

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

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

Spendthrift Trust

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

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

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

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

Important Issues

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

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

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

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

Assessment

The key elements in planning for a disabled child include:

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

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

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

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

Conclusion

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

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Doctors and Divorce Settlements

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Effects on a Physician’s Financial Plan

[By John R. Connell, MBA, JD, CPA / PFS]

Just because a physician or other couple is getting divorced, does not mean that all previous financial planning has become untenable. The parties’ goals and objectives may remain the same. However, even though assets are divided equally, income and expenses rarely follow the same pattern.

Therefore, savings rates may decrease from previously projected levels. Consequently, the main planning activity for divorcing doctors and spouses may be segregating goals and objectives and fine-tuning the previous financial plan. This is where a healthcare focused financial advisor may be very helpful.

The Advisor

It is likely that a physician focused financial planner will be called upon to provide specific advice related to the actual divorce settlement. Such advice generally includes strategies for disposition of assets, determining reasonable levels of maintenance, and tax and other considerations.

The Process

It is important for the financial advisor providing advice to a first-time divorcing couple to help explain the divorce process to them [doctor client and/or spouse]:

 

  1. Generally, the first step in a divorce is the service of summons and petitions. The petition briefly states what is being requested. The party that commences the dissolution is, in most cases, the Petitioner (unless both parties commence, in which case each would be called Co-Petitioner).
  2. The person answering the petition files a response and is known thereafter as the Respondent. The response indicates the requests of the Respondent. In no-fault states, no wrongdoing is necessary to obtain a divorce. In states which do not have a no-fault provision, fault is generally required to allow the parties to divorce. Also, jurisdictions may have waiting periods that must pass before the divorce can be finalized. Because many domestic court dockets are quite full, the chances are that most cases will not be heard within the 90-day waiting period.
  3. Discovery may begin at this time. Discovery is used to determine the assets of the parties. Once the assets are determined, each asset must be categorized as either marital or non-marital.

At this point, it may be possible to propose a settlement. In most cases, however, some time will pass before settlement discussions begin.

Temporary Orders

It may become necessary for the case to proceed to the stage of Temporary Orders. At this point many items may be considered, including use of the assets, payment of debts, payments of attorneys’ and accountants’ fees, custody of children, and temporary maintenance. Then the court will issue Permanent Orders, which permanently decide the questions of custody of children, division of assets and debts, and provisions for maintenance and child support.

Separation Agreement

When the parties are amicable, court appearances may not be necessary and the parties may be able to create a separation agreement outlining issues related to custody, maintenance, property, and debt. The financial advisor should feel free, with the client’s permission, to discuss the process with the attorney handling the matter. Because divorces are governed by jurisdictional statutes, each advisor must educate him-or-herself regarding the statutes of his or her individual jurisdiction.

Areas to Consider

A survey of the general areas of financial planning suggests that typical advisory engagements will include cash flow and budgeting, analysis of net worth, estate planning, tax planning, and risk management, including life insurance, disability insurance, property insurance, and umbrella liability insurance. In addition, a planner may be called upon to provide advice on funding for education and other goals.

Post-Marriage Changes

In almost all situations, cash flow is most significantly affected by a divorce. The net worth of the parties will generally be halved, the tax situation may be significantly different, insurance matters may change, estate matters will probably be quite different, and planning for education and other goals may be significantly affected.

As with all financial planning engagements, the planner’s first step should be to understand the assets of the parties and cash flow so he or she can assist the client in formulating realistic goals and objectives. The more focused the goals and objectives, the better the results of the process will be.

Unusual Events

In a physician divorce situation, the financial planner may be faced with certain unusual issues that must be considered. Such items will likely have a significant effect on the future lives of the parties. Major other considerations can include the disposition of the family residence, division of retirement plans (especially with use of a Qualified Domestic Relations Order [QDRO]), structuring of property settlements and maintenance, deferred income taxes and their effects on the property settlement, and analysis of partnership interest and tax shelters, etc.

Assessment

Other physician specific or medical practice management topics include practice valuations and appraisals, practice succession planning, buy-sell agreements and restrictive covenants, potential partner dissolutions and a host of other considerations depending on specific circumstances.

Conclusion

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HIT Congressional News

New CBO Report

Staff Reporters

Official congressional analysts just dealt a blow to the prospects of broad legislation to boost health information technology, by taking a skeptical view of the savings that would likely result.

Yet, iMBA Inc www.MedicalBusinessAdvisors.com – a sponsor of the Executive Post – took the opposite posture this past summer with release of the Dictionary of Health Information Technology and Security.

Link: www.amazon.com/Dictionary-Health-Information-Technology-Security/dp/0826149952/ref=sr_1_4?ie=UTF8&s=books&qid=1211753612&sr=1-4

The Report

In an analysis released this week, the Congressional Budget Office [CBO] discounted earlier projections of large cost savings that might result from the adoption of information technology, such as digital health and patient records, particularly questioning an estimate of $77 billion a year that appeared in a widely cited RAND Corporation analysis.

The CBO has an important voice in such debates because of its role in calculating how much legislation will cost the federal government.

Assessment

Although the CBO found savings potential under certain circumstances – particularly when information technology was combined with broader reforms – it found that the technology itself was unlikely to generate sizable financial benefits; according to the Wall Street Journal.

Conclusion

Is any practicing physician today surprised with this report; why or why not?

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Medical Care and Tuition Payments

Understanding Direct Payments

By Lawrence E. Howes; CFP™
By Joel B. Javer; CFP™
fp-book

Medical care and tuition payments are either direct payments to a health care provider for the medical care of another person; or direct payments of tuition to an educational institution for another person and are not transfers for gift tax purposes.   

For instance, parents may pay all the college tuition for their grandchildren free of gift tax.  This is limited to tuition, so room and board and other personal expenses are not included. 

Conclusion 

Please opine and comment if you have ever considered or used this strategy; and what was the result?

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Linguistics: www.HealthDictionarySeries.com

 

IRC Section §529 College Plans

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Understanding Funding Options

[By Lawrence E. Howes; CFP™]
[By Joel B. Javer; CFP™]

Internal Revenue Code Section 529 Plans are for college education funding.  

These plans allow assets to grow tax-free if the money is used to pay for qualified higher education expenses.  Costs include tuition, room and board, books, and some miscellaneous expenses. 

But, there are penalties if the money is not used for qualified higher education expenses. 

State Pre-Paid Plans 

Some states have what they call pre-paid tuition plans and they vary dramatically from state to state.

Contributions qualify for the $12,000 annual exclusion and the annual gift of $12,000 may be aggregated – X5 years – into one payment of $60,000.   

Assessment 

However, the right to use the $12,000 gift is eliminated for the subsequent four years. 

The maximum amount per beneficiary was $235,000 until recently. The account may be structured so that the proceeds will be part of the child’s estate versus the UTMA where the account is included in the custodian’s estate. 

Some states permit contributions to be income tax deductible.

Conclusion

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