BOARD CERTIFICATION EXAM STUDY GUIDES Lower Extremity Trauma
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The US kept adding jobs according to new data from the Bureau of Labor Statistics. The economy gained 339,000 pay-rolled employees in May, more than in each of the preceding three months and way more than the 190,000 Dow Jones predicted (to be fair, expert estimates low-balled 13 of the last 16 job reports, according to CNBC. This growth happened despite climbing interest rates, inflation, recent bank failures, and a nerve-racking debt ceiling standoff that threatened to destroy the economy And, Wall Street interpreted the data as a big green “buy” sign. For example:
Stocksleaped up last week as investors celebrated the deal to lift the debt ceiling being showed that the economy is still going strong. In fact, Lululemon stretched toward the heavens after beating earnings expectations thanks to a 24% year over year jump in sales.
But not all indications pointed to the hot streak continuing indefinitely.
The unemployment rate inched, wage growth slowed, and workers appear less self-assured in the labor market:
The self-employed lost 369,000 people from its ranks in May, a possible sign that folks might be ditching the self-employment for the security of a traditional employer.
And, recent data shows the quit rate has declined from an all-time high in late 2021, bringing an end to the pandemic job-hopping trend dubbed the Great Resignation.
Ultimately, the Fed will have to use the conflicting and mixed economic indicators to decide whether to further crank up interest rates at their next meeting. The Federal Reserve has been hinting that it might cease raising interest rates, and investors seem convinced the central bank will follow through and at least “skip” a hike this month even though the labor market is still radiating heat.
NOTE: The US debt-ceiling bill just passed, June 1, 2023. So, here are some budgeting rules for doctors and medical professionals.
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Budgeting is probably one of the greatest tools in building wealth. However, it is also one of the greatest weaknesses among physicians who tend to live a certain lifestyle. This includes living in an exclusive neighborhood, driving an expensive car, wearing imported suits and a fine watch, all of which do not lend themselves to expense budgeting. Only one in ten medical professionals has a personal budget. Fear, or a lack of knowledge, is a major cause of procrastination.
The following guidelines will assist in this microeconomic endeavor:
Set reasonable goals and estimate annual income. Do not keep large amounts of cash at home, or in the office. Deposit it in a money market account for safety and interest.
Do not pay bills early, do not have more taxes withheld from your salary than you owe, and develop spending estimates and budget fixed expenses first. Fixed expenses are usually contractual, and may include housing, utilities, food, telephone, social security, medical, debt repayment, homeowner’ or renter’s insurance, auto, life and disability insurance, and maintenance, etc.
Make variable expenses a priority. Variable expenses are not usually contractual, and may include clothing, education, recreational, travel, vacation, gas, entertainment, gifts, furnishings, savings, investments, etc.
Trim variable expenses by 10-15 percent, and fixed expenses, when possible. Ultimately, all fixed expenses get paid and become variable in the long run.
Use carve-out or set-asides for big ticket items and differentiate “wants from needs.”
Know the difference between saving and investing. Savers tend to be risk adverse and investors understand risk and takes steps to mitigate it.
Determine shortfalls or excesses with the budget period.
Track actual expenses.
Calculate both income and expenses as a percentage of the total, and determine if there is a better way to allocate resources. Then, review the budget on a monthly basis to determine if there is a variance. Determine if the variance was avoidable, unavoidable, or a result of inaccurate assumptions, and take needed corrective action.
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Verify Your Budget and Follow a Financial Plan
The process of establishing a budget relies heavily on guesswork, and the use of software or “apps”, that seamlessly track expenditures and help your budget and your financial plan become more of reality. Most doctors underestimate their true expenses, so lumping and best guesses on expense usually prove very inaccurate. Personal financial software and mobile phone applications make the verification of budgets easier. Once your personal accounts are setup, free apps like MINT.com will let give you a detailed report on where your money is going and the adjustments you must make. Few professions make larger contributions to the Internal Revenue Service than physicians and the medical profession. It is very important to categorize different budget categories not only to be proactive about your expenses, but also to accurately reflect the effect your different expenditures have on your real savings capability. All expense dollars are not equal.
For example, a mortgage payment, which is mostly interest expense in the early years, is likewise mostly tax deductible. Spending money on your family vacation is typically not tax deductible. Itemized deductions, which are deductions that a US taxpayer can claim on their tax return in order to reduce their Adjustable Gross Income (AGI), may include such costs as property taxes, vehicle registration fees, income taxes, mortgage expense, investment interest, charitable contributions, medical expenses (to the extent the expenses exceed 10% of the taxpayers AGI) and more.
Employing a qualifiedcertified medical planneR® that utilizes a cash-flow based financial planning software program may help the physician identify their actual after-tax projected cash flow and more accurately plan their future.
May 29th is observed across the U.S. as 529 Day or 529 College Savings day. It was introduced to increase awareness of these plans and encourage families to start saving toward future education expenses.
May isMental Health Month and we have to be acutely aware of the seen and unseen symptoms of related disorders. We need access to mental health care providers to foster appropriate treatment. Whether it is post traumatic stress disorder from a non consensual encounter, clinical depression from isolation, or the stress of everyday living, urgent and long term care is needed.Also, normalizing it in terms of the prevalence of mental health issues and ranges in the way mental health needs surface is vital. Trying to help people to not feel alone, or engage in self critical thinking for their own mental health needs is paramount. There is still much stigma around mental health issues. Getting more information is one part of the solution equation – education can help with this change by decreasing one’s internal barriers around seeking care.
Access to resources and services is another issue with different meanings to those addressed and their situation. There are too many barriers to accessing mental health care services. And, the idea that mental health is an important part of physical health in general, as well as the quality of life, must be accentuated.
TO WHIT:
Federal Regulations — The United States healthcare system is guided by programs such as those established under the Centers for Medicare and Medicaid (in the case of county mental health programs, Medicaid is especially important), Americans with Disabilities Act (ADA), Occupational Safety and Health Administration (OSHA), Health Insurance Portability and Accountability Act (HIPAA), and others.
State Regulations — These include general legislative guidelines, state management of benefits and reimbursement of the Medicaid program, and state allocations of budgets, which impact the centers’ operations.
County Regulations — Each county defines its own County Mental Health Program and decides which services will be provided or excluded.
We need to do our part and recognize the importance of mental health care.
Finally, by way of contemporary breaking news and all accounts, America’s youth are currently experiencing a mental health Social Media crisis. For example:
The number of teens and young adults with clinical depression doubled between 2011 and 2021, according to San Diego State University psychology professor Dr. Jean Twenge.
In 2021, the CDC found that nearly 25% of teenage girls had made a suicide plan.
So, we must remain vigilant on these, and related mental health emerging issues.
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NOTE: The Illinois’s 11th Congressional District is in the State of Illinois. It includes parts of Cook, DuPage, Kendall, Kane, and Will counties, and covers the southwestern suburbs of Chicago, as well as some rural areas. Regardless of your congressional district, affiliation and/or U.S. state, DR. KENT MERCADO JD is a political centrist and surely a rising new national star.
Thousands of clients of Maxim Healthcare Services are about to receive a payment of up to $5,000 in compensation for a data breach. According to information obtained by The Sun, the private medical personnel company based in Columbia, Maryland; agreed to pay 2020 data breach claims filed in a class action lawsuit by residents of the state of California.
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Gold futures tallied a third consecutive session decline settling at their lowest in nearly a week as further strength in the U.S. dollar pressured prices for the precious metal. Gold gave up early gains that had been driven by uncertainty surrounding a U.S. debt-ceiling deal in Congress.
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And, here is where the major benchmarks ended yesterday:
The S&P 500 Index was down 30.34 points (0.7%) at 4115.24; the Dow Jones industrial average was down 255.59 (0.8%) at 32,799.92; the NASDAQ Composite was down 76.08 (0.6%) at 12,484.16.
The 10-year Treasury yield was up about 4 basis points at 3.742%.
CBOEs Volatility Index was up 1.52 at 20.04.
Technology and regional bank stocks were among the weakest sectors, with the Philadelphia Semiconductor Index down more than 2%. Energy was one of the few gainers among S&P 500 sectors as crude oil futures climbed to a three-week high of near $74 a barrel. The U.S. dollar index rose a third straight day to a two-month high.
Atlanta, GA – Governor Brian P. Kemp, joined by First Lady Marty Kemp and their three daughters, Lt. Governor Geoff Duncan, Speaker David Ralston, members of the House and Senate, and mental health advocates, to sign the Mental Health Parity Act (HB1013) into law.
You may view his remarks from the bill signing ceremony below, and you can watch the full ceremony here.
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Mental Health Rights
People living with mental health conditions are people. They have people they love, activities they enjoy, and dreams for their lives. As people, they deserve to be treated with dignity, and under the law they have rights and protections.
Unfortunately, it has long been the case that individuals with mental health conditions are among the most abused and discriminated against in our country. From leaving people to languish in overcrowded state hospitals to lobotomies and forced sterilization, the treatment of those with mental health conditions is a dark stain on our history as a nation.
While we have come a long way, abuse and discrimination continue to be serious problems today. The shackling or restraining of children, keeping people out of work, and denying access to services are just a few examples of the way we continue to fail the 1 in 5 Americans that has a diagnosable mental health disorder.
This is not just a small issue for a small group of people: half of all Americans will experience a diagnosable mental health condition in their lifetime. If it is not us being directly impacted, it is likely that it will be our family members, friends, or loved ones– whether we know it or not. Beyond struggles in education or employment, we see the loss of human dignity and even human life for the people we love and care about when we do not work to address abuses in the system.
For Mental Health America, the fight against abuse and discrimination is essential to our history and continues to guide our work. MHA’s symbol, which sits in our national office, is the Bell of Hope cast from the chains and shackles that were used to restrain individuals in old state hospitals. As an organization, MHA is committed to the principles of human and civil rights inherent to the concept of equal justice under the law.
Last week, investors shrugged off debt ceiling worries to send the S&P and the NASDAQ to their best weekly performance since March. Tech stocks have posted impressive gains this year thanks to the hype around artificial intelligence:
Four giants that have made a big deal about investing in AI—Meta, Alphabet, Microsoft, and Nvidia—have surged in 2023 and now account for ~15% of the S&P 500’s market capitalization, according to Barron’s.
My name is Dr. Kent Mercado JD, and I am running for Congress to be a voice for the people of Illinois District 11.
I am a proud long-time resident of Illinois, and I am excited at the thought of representing my neighbors in District 11. I have achieved many accolades over the years in my professional career, but my proudest achievement of all is my family. I have been married to my lovely wife for over 30 years, and we raised three beautiful children together. I attended Kent State University and received my Juris Doctorate at the University of Illinois Chicago School of Law.
I am a licensed physician, attorney, and healthcare and governmental affairs consultant. I am also an accomplished leader in healthcare management and international medical missions. I was honored to serve as Medical Director of the Zacatacas Medical Mission in Mexico in 2008. I later led a team of nine doctors on medical missions in Haiti where we performed surgery and provided medicine to hundreds of patients. I played a large role in procuring medical and surgical supplies for the medical missions in Bolivia, Peru, Mexico and other countries. I was blessed to have been able to gather and send over one million dollars’ worth of supplies to help the victims of Haiti’s massive earthquakes. One of my favorite achievements in my medical missions experience is when I helped coordinate the donation of school supplies, backpacks and clothing for over 600 children in Kenya.
I believe I have unique perspectives and ideas that will benefit my constituents and have gained the skills needed to be a capable congressman. I am known for leading and implementing complex solutions while maintaining alignment with stakeholders and managing expectations. Throughout my time as an attorney and leading missions efforts, I have learned how to consistently and quickly adapt to deal with challenges in a manner that results in positive outcomes. I am aware of the importance of adhering to schedules and standards, particularly when working on large-scale initiatives. I work well among diverse groups of people at all levels, and I have extensive experience in leading timely delivery of reliable solutions. I have also worked with several government agencies to help grow non-profit organizations through fundraising and program management.
I have loved every minute of providing aid to those in different countries and gaining experiences both professionally and personally. While I have enjoyed and cherished my time providing for those in need around the globe, I am now ready to focus my efforts on serving my neighbors in District 11. I’ve never run for office before, but I know I am prepared for it and ready to help. I look forward to combining all areas of my professional background to make positive changes in my community.
I hope you will visit my website to learn more about my campaign and join our team by making a contribution of $3,300, $1,000, $500, 250, or $100. Any amount donated is greatly appreciated and will assist me in winning this race so we can ensure that the welfare of the people of District 11 is put first.
NEWS FLASH: NAPERVILE, I L- Ready to bring new ideas and unique perspectives to Congress, Dr. Kent Mercado is officially launching his campaign for Illinois’s 11th. Congressional District.
“Overall, I feel I bring a wealth of experience and expertise to my work. I am a true leader in my fields and have consistently demonstrated my commitment to improving the lives of those I serve.” Dr. Mercado has an extensive professional background as a surgeon and attorney and always seeks to better the lives of those around him. He is also an accomplished leader in healthcare management, governmental affairs and international medical missions.
While acting as the Medical and Executive Director of Medical Missions, Dr. Mercado worked with several government agencies to enhance non-profit organizations through fundraising and program management. He was instrumental in procuring medical and surgical supplies for the medical missions in Bolivia, Peru, Mexico and other countries. Dr. Mercado also sent over one million dollars’ worth of supplies to help the victims of Haiti’s massive earthquakes. Dr. Mercado has served and provided aid to those in need all around the globe and is now ready to focus his efforts on serving his neighbors in District 11.
Dr. Mercado supports pro-growth economic environments where businesses and workers of all levels can thrive with minimal government intrusion, which means lower taxes, deregulation and encouraging innovation in all industries. Dr. Mercado believes that we must maintain border security while welcoming with open arms immigrants who come into this great country legally. “We need to emphasize the value of safe and secure borders, as well as the need for legal immigration, because a country without borders is no country at all.” He is also a strong supporter of giving families the freedom to choose the very best education for their children and helping every American receive quality and affordable healthcare.
Dr. Mercado is ready to use his areas of professional expertise and his passion for helping people to provide the residents of District 11 with a congressman who listens, acts and fights for what they need. Dr. Mercado states on his campaign website, “I am confident that I can leverage my decades of expertise to effectively progress major legislative initiatives that will benefit my constituents.” Dr. Mercado will bring positive change to the district by mixing his experience and passions to benefit his community.
For more information on Dr. Mercado and his plans for Illinois District 11, please visit his website.
Because the inflation data came in roughly as expected, Wall Street sees the door still open for the Federal Reserve to leave interest rates alone at its next meeting in June. That would be the first time it hasn’t raised rates at a meeting in more than a year, and a pause would offer some breathing room for the economy and financial markets.
Today is the last day of the US Covid-19 public health emergency, which has been in place since Jan. 31st, 2020. With it comes the end of certain Covid-era rules, though some telehealth protections have been extended through the end of 2024. Here’s to all the medical professionals who got us through, and a remembrance for the millions who lost their lives to Covid.
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Brightline, a California-based mental health startup, laid off 20% of its staff this week following a data breach. North Carolina is the latest state to consider changes to the prior authorization process that advocates say delays care. A board member at Geisinger claims that consolidation prompted the healthcare provider to sell to Kaiser Permanente. Texas Gov. Greg Abbottsaid the state should address mental health issues in the wake of a shopping mall mass shooting, but did not call for gun control reform.
Finally, here is where the major benchmarks ended yesterday:
The S&P 500 Index was up 18.47 points (0.5%) at 4137.64; the Dow Jones industrial average was down 30.48 (0.1%) at 33,531.33; the NASDAQ Composite was up 126.89 (1.0%) at 12,306.44.
The 10-year Treasury yield was down about 8 basis points at 3.441%.
CBOE’s Volatility Index was down 0.80 at 16.91.
Oilfield services providers and other energy companies were among the laggards Wednesday, pressured by a more-than 1% drop in WTI crude oil futures.
Financial sector stocks struggling to escape the effects of the bank volatility earlier this spring helped push the KWB Regional Bank Index back near a 2½-year low reached last week.
INTRODUCING OUR NEXT GENERATION e-BOOK LIBRARYFROM iMBA, Inc.
An e-book is an electronic or digital book that can be read on a computer or a handheld device.
Our new e-books consists of text, images, and are fixed to a specific spot on the page.
And, our e-books are a data files similar in content and structure to a word-processing document that comes in a PDF format. To use our e-books, you need to purchase and download it to a device that has a .pdf file reader app, such as ADOBE® or similar on a smartphone, tablet or computer. A PDF, also known as a portable document format, is the format most people are familiar with and used in our e-books. PDFs are known for their ease of use and ability to hold custom layouts. They are the most commonly used e-Book formats, especially by professionals and adult-learners.
You can then access the e-book and read it, or highlight pages and even take side notes.
e-Books Save Money
With no manufacturing, printing, binding or shipping costs, e-Books are cheaper than traditional hard or paper back books.The price of each specialized and highly niche focused e-Book [50-100 pages] is only $25, whereas similar paperback printed books of this type generally cost $145, or more!
INTRODUCING OUR NEXT GENERATION e-BOOK LIBRARYFROM iMBA, Inc.
An e-book is an electronic or digital book that can be read on a computer or a handheld device.
Our new e-books consists of text, images, and are fixed to a specific spot on the page.
And, our e-books are a data files similar in content and structure to a word-processing document that comes in a PDF format. To use our e-books, you need to purchase and download it to a device that has a .pdf file reader app, such as ADOBE® or similar on a smartphone, tablet or computer. A PDF, also known as a portable document format, is the format most people are familiar with and used in our e-books. PDFs are known for their ease of use and ability to hold custom layouts. They are the most commonly used e-Book formats, especially by professionals and adult-learners.
You can then access the e-book and read it, or highlight pages and even take side notes.
e-Books Save Money
With no manufacturing, printing, binding or shipping costs, e-Books are cheaper than traditional hard or paper back books.The price of each specialized and highly niche focused e-Book [50-100 pages] is only $25, whereas similar paperback printed books of this type generally cost $145, or more!
Dr. Rochelle Walensky, the head of the Centers for Disease Control and Prevention, submitted her resignation yesterday, saying the waning of the COVID-19 pandemic was a good time to make a transition.
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The World Health Organization just reported that COVID-19 no longer qualifies as a global emergency, marking a symbolic end to the devastating coronavirus pandemic that triggered once-unthinkable lock-downs, upended economies and killed millions of people worldwide.
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Here’s where the major indexes ended:
The S&P 500® Index was up 75.03 points (1.9%) at 4136.25; the Dow Jones industrial average was up 546.64 (1.7%) at 33,674.38; the NASDAQ Composite was up 269.01 (2.3%) at 12,235.41.
The 10-year Treasury yield was up about 8 basis points at 3.431%.
CBOE’s Volatility Index was down 2.89 at 17.20.
Financial shares were a bright spot Friday, with the KBW Regional Banking Index up over 4% after sinking near a 2½-year low Thursday. Energy stocks were also strong as crude oil futures rallied over 4% and pushed back above $70 a barrel. Small-cap stocks also gained, with the Russell 2000 up more than 2%.
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* UNC Health might be able to expand its footprint faster, pending state approval. * A new chatbot called Pi is helping people with their emotional well-being. * The FDA approved the first RSV vaccine, which comes from GSK.
TERMS & DEFINITIONS FOR PHYSICIANSAND ALL INVESTORS:
PRUDENT BUYER: The efficient purchaser of market balance between value and cost.
PRUDENT MAN RULE: An 1830 court case stating that a person in a fiduciary capacity (a trustee, executor, custodian, etc) must conduct him/herself faithfully and exercise sound judgment when investing monies under care. “He is to observe how men of prudence, discretion and intelligence manage their own affairs, not in regard to speculation, but in regard to the permanent distribution of their funds, considering the probable income as well as the probable safety of the capital to be invested.” Allows for mutual funds and variable annuities.
PRUDENT INVESTOR RULE: A fiduciary is required to conduct him/herself faithfully and exercise sound judgment when investing monies and take measured and reasonable investment risks in return for potential future rewards. Allows for mutual funds, stocks, bonds, variable annuities asset allocation & Modern Portfolio Theory.
EDITOR’SNOTE: We interviewed noted authority Ben Aikin AIF® on this topic more than a decade ago. He was ahead of his time regarding fiduciary accountability and we appreciate his insights.
Under law, financial advisors and planners must provide you with a form ADV Part II or a brochure that covers the same information. Even if a brochure is provided, ask for the ADV. While it is acceptable, even desirable, for the brochure to be easier to read than the ADV, the ADV is what is filed with the appropriate state or SEC. If the brochure reads more like a slick sales brochure or the information in the brochure glosses over the items on the ADV to a high degree, one should consider eliminating the advisor from consideration.
Registering with a state or SEC gives an advisor a fiduciary duty to the client. This is a high standard under the law.
There are several types of advisors who are exempt from registering and filing an ADV.
First, there are registered representatives (brokers). Brokers have a fiduciary responsibility to their firms regardless of whether they are statutory employees or independent contractors. Not the client.
Second are attorneys and accountants whose advice is “incidental” to their legal or accounting practices. But, why would one hire someone whose advice is “incidental” to his primary profession? A top-notch advisor is a full-time professional and should be registered. One should insist that their advisor be registered.
The ADV will describe the advisor’s background and employment history, including any prior disciplinary issues. It will describe the ownership of the firm and outline how the firm and advisor are compensated. Any referral arrangements will be described. If an advisor has an interest in any of the investments to be recommended, it must be listed as well as the fee schedule. There is also a description of the types of investments recommended and the types of research information that is used.
ASSESSMENT: A review of the ADV should result in an alignment of what the advisor said during the interview and what is filed with the regulators. If there is a clear discrepancy, choose another advisor. If it is unclear, discuss the issue with the advisor.
Your thoughts and comments are appreciated.
SEC Headquarters 100 F Street, NE Washington, DC 20549 (202) 942-8088
The Institute of Medical Business Advisors Inc identified several reasons based on observations working with medical professional and physician clients over the years.
A late start
By the time doctors finish medical school and residency they’re typically in their middle or late thirties. Many have families to feed, and substantial student loans to pay off. It will be years before they can even start accumulating wealth. Consider that physicians typically enter careers at later ages, often with larger debts from training. Some specialties may not lead a case until 10 years of practice, and many specialties have limited longevity. Peak earning years may also be shorter for health care providers than other professionals. Financial survival skills are paramount for converting the limited earnings time period to personal financial security.
Challenging socio-political environment
It is increasingly challenging to practice medicine. With the Medicare Trust Fund slated to go bust in 2019, the Center for Medicare and Medicare Service (CMS) is increasingly resorting to cutting physician reimbursements and implementing capitation and bundled value based medical payments models. The medical reimbursement effects of the PP-ACA are not yet fully discerned; but appear to continue the decline in compensation. And to illustrate this potential governmental control, in what other industry can participants debate the simple question, “who is the customer?”
Lifestyle expectations
Society expects a doctor to live like a doctor, dress like a doctor, and drive like a doctor. Meeting social expectations can be quite expensive.
Time and energy
A doctor can’t be just a doctor any more. S/he also has to deal with ever increasing regulatory mandates, paperwork requirements by state and federal agencies and capricious insurance companies. It is estimated that for every hour spent on patient care, and additional half-hour is spent on paperwork. To-date, the use of electronic medical records has exacerbated; not ameliorated this problem. The demand on their time is mind-boggling. A typical doctor works a ten- to twelve-hour day. After work and family, they simply don’t have time and energy left to do comprehensive financial planning.
Financially naïve
Doctors are smart. They’re highly trained in their area of expertise. But, that doesn’t translate into understanding about finance or economics. Because they are smart, it’s easy for them to think they can easily master and execute concepts of personal financial planning, as well. Often, they don’t.
Lack of trust and delegation
Many doctors don’t trust financial advisors working for major Wall Street banks. They have the good instinct to realize that their interests are not aligned. Not knowing there are independent advisors out there who observe a strict fiduciary standard, they tend to do everything by themselves.
In fact, Paul Larson CFP®, President-CEO of the firm LARSON Financial Group LLC, noted a disquieting trend among physician client in his firm [personal communication]. Almost 90% of them fail to take care of their own family finances in a comprehensive manner; while only 10% are succeeding. The strategies in this chapter and book are common to their success.
Too Trusting
Another aspect of naivety, many physicians do not realize that the financial advisory industry lacks the same discipline and regulation that the average physician operates in. A primary care doctor would never even attempt a complicated surgery on a patient, but is trained to refer such patients to a specialist in the field with the proper training and experience. Financial Advisors often come from a sales background and are trained to keep a client in house even if the advisor is lacking in expertise. Also, many physicians are not trained to discern a qualified financial advisor from a sales person dressed up like a financial advisor. It is illegal to call yourself a physician in the United States unless you have the credentials to back it up; yet, anyone in the US can legally call themselves a financial advisor or a financial planner.
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Companies, mostly in tech and media, have laid off thousands of employees, so far this year. For example:
Amazon announced in early January that it’s eliminating 18,000 roles in total, including layoffs that were announced in November 2022. The company announced last month that it was laying off an additional 9,000 people.
Payments company PayPal is cutting 7% of its staff, which amounts to about 2,000 employees, President and CEO Dan Schulman said on Jan. 31st.
E-commerce company eBay announced in an SEC filing on Feb. 7 that it’s laying off 500 people, or 4% of its workforce.
And, Jenny Craig is saddled with $250 million in debt and has been looking for a buyer, Bloomberg Law reported in March. The weight loss industry is going through changes, as the obesity drug business has exploded in popularity. The medications, which mimic hormones found in the body to support weight loss, have recently grown in popularity thanks to reported use by celebrities and posts from everyday people on social media about successful weight loss.
Finally, General Motors terminated “several hundred” contract employees who worked at its Global Technical Center in Warren, Michigan, and other locations this weekend in its bid to shave $2 billion from its budget by the end of next year. The cuts come nearly a month after 5,000 salaried employees agreed to a voluntary separation package that GM said would help it achieve close to 50% of its cost-cutting target this year alone and prevent further involuntary cuts.
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Happy Tuesday! Today marks the first day of Mental Health Awareness Month. One in five US adults experiences mental illness each year, but fewer than half of them get care, according to the National Alliance on Mental Illness.
The MARKETS
The S&P 500® Index was down 1.61 points at 4167.87; the Dow Jones industrial average was down 46.46 (0.1%) at 34,051.70; the NASDAQ Composite was down 13.99 (0.1%) at 12,212.60.
The 10-year Treasury yield was up about 13 basis points at 3.585%.
According to Wikipedia, May Day is a European festival of ancient origins marking the beginning of summer, usually celebrated on 1 May, around halfway between the spring equinox and summer solstice. Festivities may also be held the night before, known as May Eve.
But in 1889, it was chosen as the date for International Workers’ Day by the Second International, to commemorate the Haymarket affair in Chicago and the struggle for an eight-hour working day. As a result, International Workers’ Day is also called “May Day”, but the two are unrelated.
Big banks including JPMorgan Chase & Co. and PNC Financial Services Group Inc. submitted bids for First Republic Bank to the Federal Deposit Insurance Corp., which is preparing to seize and sell the troubled lender, according to people familiar with the matter. The winning bidder could be announced soon.
Written by doctors and healthcare professionals, this textbook should be mandatory reading for all medical school students—highly recommended for both young and veteran physicians—and an eliminating factor for any financial advisor who has not read it. The book uses jargon like ‘innovative,’ ‘transformational,’ and ‘disruptive’—all rightly so! It is the type of definitive financial lifestyle planning book we often seek, but seldom find. —LeRoy Howard MA CMPTM,Candidate and Financial Advisor, Fayetteville, North Carolina I taught diagnostic radiology for over a decade. The physician-focused niche information, balanced perspectives, and insider industry transparency in this book may help save your financial life. —Dr. William P. Scherer MS, Barry University, Ft. Lauderdale, Florida This book was crafted in response to the frustration felt by doctors who dealt with top financial, brokerage, and accounting firms. These non-fiduciary behemoths often prescribed costly wholesale solutions that were applicable to all, but customized for few, despite ever-changing needs. It is a must-read to learn why brokerage sales pitches or Internet resources will never replace the knowledge and deep advice of a physician-focused financial advisor, medical consultant, or collegial Certified Medical Planner™ financial professional. —Parin Khotari MBA,Whitman School of Management, Syracuse University, New York In today’s healthcare environment, in order for providers to survive, they need to understand their current and future market trends, finances, operations, and impact of federal and state regulations. As a healthcare consulting professional for over 30 years supporting both the private and public sector, I recommend that providers understand and utilize the wealth of knowledge that is being conveyed in these chapters. Without this guidance providers will have a hard time navigating the supporting system which may impact their future revenue stream. I strongly endorse the contents of this book.—Carol S. Miller BSN MBA PMP,President, Miller Consulting Group, ACT IAC Executive Committee Vice-Chair at-Large, HIMSS NCA Board Member This is an excellent book on financial planning for physicians and health professionals. It is all inclusive yet very easy to read with much valuable information. And, I have been expanding my business knowledge with all of Dr. Marcinko’s prior books. I highly recommend this one, too. It is a fine educational tool for all doctors.—Dr. David B. Lumsden MD MS MA,Orthopedic Surgeon, Baltimore, Maryland There is no other comprehensive book like it to help doctors, nurses, and other medical providers accumulate and preserve the wealth that their years of education and hard work have earned them. —Dr. Jason Dyken MD MBA,Dyken Wealth Strategies, Gulf Shores, Alabama I plan to give a copy of this book written ‘by doctors and for doctors’ to all my prospects, physician, and nurse clients. It may be the definitive text on this important topic. —Alexander Naruska CPA,Orlando, Florida
Health professionals are small business owners who need to apply their self-discipline tactics in establishing and operating successful practices. Talented trainees are leaving the medical profession because they fail to balance the cost of attendance against a realistic business and financial plan. Principles like budgeting, saving, and living below one’s means, in order to make future investments for future growth, asset protection, and retirement possible are often lacking. This textbook guides the medical professional in his/her financial planning life journey from start to finish. It ranks a place in all medical school libraries and on each of our bookshelves. —Dr. Thomas M. DeLauro DPM,Professor and Chairman – Division of Medical Sciences, New York College of Podiatric Medicine
Physicians are notoriously excellent at diagnosing and treating medical conditions. However, they are also notoriously deficient in managing the business aspects of their medical practices. Most will earn $20-30 million in their medical lifetime, but few know how to create wealth for themselves and their families. This book will help fill the void in physicians’ financial education. I have two recommendations: 1) every physician, young and old, should read this book; and 2) read it a second time! —Dr. Neil Baum MD,Clinical Associate Professor of Urology, Tulane Medical School, New Orleans, Louisiana
I worked with a Certified Medical Planner™ on several occasions in the past, and will do so again in the future. This book codified the vast body of knowledge that helped in all facets of my financial life and professional medical practice. —Dr. James E. Williams DABPS, Foot and Ankle Surgeon, Conyers, Georgia
This is a constantly changing field for rules, regulations, taxes, insurance, compliance, and investments. This book assists readers, and their financial advisors, in keeping up with what’s going on in the healthcare field that all doctors need to know. —Patricia Raskob CFP® EA ATA, Raskob Kambourian Financial Advisors, Tucson, Arizona I particularly enjoyed reading the specific examples in this book which pointed out the perils of risk … something with which I am too familiar and have learned (the hard way) to avoid like the Black Death. It is a pleasure to come across this kind of wisdom, in print, that other colleagues may learn before it’s too late— many, many years down the road. —Dr. Robert S. Park MD, Robert Park and Associates Insurance, Seattle, Washington
Although this book targets physicians, I was pleased to see that it also addressed the financial planning and employment benefit needs of nurses; physical, respiratory, and occupational therapists; CRNAs, hospitalists, and other members of the health care team….highly readable, practical, and understandable. —Nurse Cecelia T. Perez RN, Hospital Operating Room Manager, Ellicott City, Maryland
Personal financial success in the PP-ACA era will be more difficult to achieve than ever before. It requires the next generation of doctors to rethink frugality, delay gratification, and redefine the very definition of success and work–life balance. And, they will surely need the subject matter medical specificity and new-wave professional guidance offered in this book. This book is a ‘must-read’ for all health care professionals, and their financial advisors, who wish to take an active role in creating a new subset of informed and pioneering professionals known as Certified Medical Planners™. —Dr. Mark D. Dollard FACFAS, Private Practice, Tyson Corner, Virginia As healthcare professionals, it is our Hippocratic duty to avoid preventable harm by paying attention. On the other hand, some of us are guilty of being reckless with our own financial health—delaying serious consideration of investments, taxation, retirement income, estate planning, and inheritances until the worry keeps one awake at night. So, if you have avoided planning for the future for far too long, perhaps it is time to take that first step toward preparedness. This in-depth textbook is an excellent starting point—not only because of its readability, but because of his team’s expertise and thoroughness in addressing the intricacies of modern investments—and from the point of view of not only gifted financial experts, but as healthcare providers, as well … a rare combination. —Dr. Darrell K. Pruitt DDS, Private Practice Dentist, Fort Worth, Texas This text should be on the bookshelf of all contemporary physicians. The book is physician-focused with unique topics applicable to all medical professionals. But, it also offers helpful insights into the new tax and estate laws, fiduciary accountability for advisors and insurance agents, with investing, asset protection and risk management, and retirement planning strategies with updates for the brave new world of global payments of the Patient Protection and Affordable Care Act. Starting out by encouraging readers to examine their personal ‘money blueprint’ beliefs and habits, the book is divided into four sections offering holistic life cycle financial information and economic education directed to new, mid-career, and mature physicians.
This structure permits one to dip into the book based on personal need to find relief, rather than to overwhelm. Given the complexity of modern domestic healthcare, and the daunting challenges faced by physicians who try to stay abreast of clinical medicine and the ever-evolving laws of personal finance, this textbook could not have come at a better time. —Dr. Philippa Kennealy MD MPH, The Entrepreneurial MD, Los Angeles, California Physicians have economic concerns unmatched by any other profession, arriving ten years late to the start of their earning years. This textbook goes to the core of how to level the playing field quickly, and efficaciously, by a new breed of dedicated Certified Medical Planners™. With physician-focused financial advice, each chapter is a building block to your financial fortress. —Thomas McKeon, MBA, Pharmaceutical Representative, Philadelphia, Pennsylvania An excellent resource … this textbook is written in a manner that provides physician practice owners with a comprehensive guide to financial planning and related topics for their professional practice in a way that is easily comprehended. The style in which it breaks down the intricacies of the current physician practice landscape makes it a ‘must-read’ for those physicians (and their advisors) practicing in the volatile era of healthcare reform. —Robert James Cimasi, MHA ASA FRICS MCBA CVA CM&AA CMP™, CEO-Health Capital Consultants, LLC, St. Louis, Missouri Rarely can one find a full compendium of information within a single source or text, but this book communicates the new financial realities we are forced to confront; it is full of opportunities for minimizing tax liability and maximizing income potential. We’re recommending it to all our medical practice management clients across the entire healthcare spectrum. —Alan Guinn, The Guinn Consultancy Group, Inc., Cookeville, Tennessee Dr. David Edward Marcinko MBA CMP™ and his team take a seemingly endless stream of disparate concepts and integrate them into a simple, straightforward, and understandable path to success. And, he codifies them all into a step-by-step algorithm to more efficient investing, risk management, taxation, and enhanced retirement planning for doctors and nurses. His text is a vital read—and must execute—book for all healthcare professionals and physician-focused financial advisors. —Dr. O. Kent Mercado, JD, Private Practitioner and Attorney, Naperville, Illinois
Kudos. The editors and contributing authors have compiled the most comprehensive reference book for the medical community that has ever been attempted. As you review the chapters of interest and hone in on the most important concerns you may have, realize that the best minds have been harvested for you to plan well… Live well. —Martha J. Schilling; AAMS® CRPC® ETSC CSA, Shilling Group Advisors, LLC, Philadelphia, Pennsylvania I recommend this book to any physician or medical professional that desires an honest no-sales approach to understanding the financial planning and investing world. It is worthwhile to any financial advisor interested in this space, as well. —David K. Luke, MIM MS-PFP CMP™, Net Worth Advisory Group, Sandy, Utah Although not a substitute for a formal business education, this book will help physicians navigate effectively through the hurdles of day-to-day financial decisions with the help of an accountant, financial and legal advisor. I highly recommend it and commend Dr. Marcinko and the Institute of Medical Business Advisors, Inc. on a job well done. —Ken Yeung MBA CMP™, Tseung Kwan O Hospital, Hong Kong I’ve seen many ghost-written handbooks, paperbacks, and vanity-published manuals on this topic throughout my career in mental healthcare. Most were poorly written, opinionated, and cheaply produced self-aggrandizing marketing drivel for those agents selling commission-based financial products and expensive advisory services. So, I was pleasantly surprised with this comprehensive peer-reviewed academic textbook, complete with citations, case examples, and real-life integrated strategies by and for medical professionals. Although a bit late for my career, I recommend it highly to all my younger colleagues … It’s credibility and specificity stand alone. —Dr. Clarice Montgomery PhD MA,Retired Clinical Psychologist In an industry known for one-size-fits-all templates and massively customized books, products, advice, and services, the extreme healthcare specificity of this text is both refreshing and comprehensive. —Dr. James Joseph Bartley, Columbus, Georgia
My brother was my office administrator and accountant. We both feel this is the most comprehensive textbook available on financial planning for healthcare providers. —Dr. Anthony Robert Naruska DC,Winter Park, Florida
Eli Lilly (NYSE: LLY) investors continued to be in a good mood about their stock on Friday. Following the estimates-beating first quarter reported by the big pharmaceutical company the previous morning, they traded the shares up by 1.4% on the final trading day of the week. That eclipsed the 0.8% gain of the S&P 500 index.
Researchers at MIT have created a new type of tabletop printer that spits out vaccine doses on demand in the form of thumbnail-size microneedle patches. Once scaled, this mobile technology could produce hundreds of doses per day, revolutionizing pandemic response. And in a boon for warmer or more remote parts of the world, the vaccine patches can be stored at room temperature for months before they’re slapped on—no refrigeration or professional administering required.
In this episode we are joined by Dr. Brent Jackson, Chief Medical Officer for Mercy General in Sacramento, CA to discuss the physician life-cycle, burnout, and transitioning into leadership within healthcare.
The CARES Act, a COVID relief law that was enacted in March of 2020, made it easier to pull money from one’s 401(k) or IRA It allowed people to take up to $100,000 out of their accounts and have three years to pay it back without the normal 10% early withdrawal penalty and tax payment. For Americans who needed cash quickly, their 401(k) was a tempting well to dip into that wouldn’t have been otherwise available.
In the spring of 2020, nearly 20% of all withdrawals from 401(k)’s, between April 6th and June 26th were related to COVID, according to CNBC. CNBC reported that at Fidelity Investments, the largest provider of 401(k) plans in the U.S., more than 700,000 people took from their 401(k) or their 403(b) plan. The median amount was about $5,000, while more than 18,000 people asked for the full $100,000 amount.
And Vanguard’s How America Saves report from 2021 found that more than 7% of people withdrew from their 401(k) or a 401(b) — similar to a 401(k) but available to not-for-profit companies — in 2020.
The S&P 500 Index was down 65.41 (1.6%) at 4071.63; the Dow Jones industrial average was down 344.57 (1.0%) at 33,530.83; the NASDAQ Composite was down 238.05 (2.0%) at 11,799.16.
The 10-year Treasury yield was down about 12 basis points at 3.394%.
CBOEs Volatility Index was up 1.99 at 18.92.
Transportation stocks also had a rough day after United Parcel Service’s (UPS) shares dropped some 10% after its results missed analysts’ forecasts. Energy companies were lower after WTI crude oil futures dropped under $77 a barrel for the first time this month. Small-cap companies, which are considered to have greater recession exposure than larger businesses, were also under pressure, with the Russell 2000 index falling more than 2% and nearing a five-week low.
Much like the False Claims Act, the Anti-Kickback Statute (AKS) remains a frequent tool used by the Department of Justice to investigate the healthcare industry. Unlike the False Claims Act, the AKS imposes criminal penalties on violators.
The leaders of a physicians’ practice may be held liable for what others in the practice do, even if the leader did not know precisely what was going on. It has been called the “crime of doing nothing.”
1. Providing free dinners or lunches to physicians
2. Travel expenses paid to physicians
3. Entering into consulting or research agreements with physicians under which payments are made but minimal (or zero) work is done in return
4. Other gifts, such as electronics or tickets to sporting events
5. Laboratory pays a specimen processing fee to physicians above the fair value for those fees
6. Physician retention or recruitment agreements, when those agreements provide for payments above fair market value or are made with the intent to induce Medicare referrals
7. Agreements for speaking or teaching where the payments are above fair market value or made with the intent to induce referrals
8. Discount schemes that do not meet the safe harbor requirements
Source: Sara Kropf and Logan Lutton, Physicans Practice
1. Regional banks’ plight was Morgan Stanley’s perk. The bank saw nearly $20 billion in new client assets in the wake of the banking crisis that rocked smaller banks like First Republic. Why the bank became a “destination of choice” amid the crisis.
2. Taylor Swift was the only one asking the right question on FTX. The mega star didn’t sign a $100 million sponsorship deal with the crypto exchange because, unlike seemingly everyone in Silicon Valley, she did some form of due diligence.
4. It’s starting to get scary in the housing market. Foreclosure filings were up 22% in Q1 compared to last year, and repossessions are headed in the wrong direction as well.
Finally, Fintel reports that on April 21, 2023, Goldman Sachs maintained coverage of Tesla (NASDAQ:TSLA) with a Buy recommendation. As of April 6th, 2023, the average one-year price target for Tesla is $203.14. The forecasts range from a low of $24.58 to a high of $315.00. The average price target represents an increase of 24.63% from its latest reported closing price of $162.99. The projected annual revenue for Tesla is $118,517MM, an increase of 37.75%. The projected annual non-GAAP EPS is $5.70.
The S&P 500® Index was up 3.52 points (0.1%) at 4137.04; the Dow Jones industrial average was up 66.44 (0.2%) at 33,875.40; the NASDAQ Composite was down 35.25 (0.3%) at 12,037.20.
The 10-year Treasury yield was down about 7 basis points at 3.50%.
CBOEs Volatility Index was up 0.12 at 16.89.
Real estate and financials were among Monday’s weakest-performing sectors, while energy companies led gainers thanks to a jump of about 1% in crude oil futures. The U.S. dollar index fell to about 101.37, its weakest level since mid-April, while Treasury yields eased slightly.
Physicians Who Accept Medicare, Medicaid at All-time Low of 65%
Reduced Medicare and Medicaid payments are having more physicians considering reducing those patient bases, according to Medscape’s “Physician Compensation Report” for 2023. Sixty-five percent of physicians surveyed said they would continue treating current Medicare or Medicaid patients and take on new ones, according to the report. Medscape said it is the lowest percentage it has seen in its annual compensation reports. Five years ago, 71 percent of physicians said they would continue treating current Medicare or Medicaid patients and take on new ones.
For the report, Medscape collected responses from 10,011 physicians across more than 29 specialties. The data was collected between Oct. 7, 2022, and Jan. 17, 2023. Eight percent of physicians surveyed said they would not take on new Medicare patients, and 5 percent said they would not take new Medicaid patients. Four percent said they will stop treating some or all of their current Medicare patients and will not take on new ones, and 3 percent said the same about Medicaid patients. Twenty-two percent said they have not yet decided how they will move forward regarding Medicare and Medicaid patients, according to the report.
Source: Andrew Cass, Becker’s Payer Issues [4/18/23]
Did you know that the probability of being audited by the IRS is generally low, with less than 1% of tax returns receiving a second look? The average chance of being audited is 1 in 333, or 0.3%. But, certain factors can increase the likelihood of being audited, such as earning a lot of money or claiming complex deductions.
For example, the audit rate among filers with income of $10 million or more is 6.66%, while the audit rate for filers with incomes between $25,000 and $500,000 is roughly 0.5%. If selected for an audit, the taxpayer must demonstrate that the information on their tax return is correct
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The following is a round-up of yesterday’s market activity:
The S&P 500 Index was up 13.68 points (0.3%) at 4151.32; the Dow Jones industrial average was up 100.71 (0.3%) at 33,987.18; the NASDAQ Composite was up 34.26 (0.3%) at 12,157.72.
The 10-year Treasury yield was up about 8 basis points at 3.3.60%.
CBOE’s Volatility Index was down 0.13 at 16.94.
Among S&P 500 sectors, real estate stocks led advancers, while financials and industrials were also higher. Small-caps rose, with the Russell 2000 up about 1%. Communication services companies were among the weakest performers, and energy companies slumped as crude oil futures dropped nearly 2%.
The U.S. dollar index strengthened slightly, and equity market volatility remained subdued, with the VIX extending a decline to the lowest levels since late 2021.
National Healthcare Decisions Day (NHDD) exists to inspire, educate and empower the public and providers about the importance of advance care planning. NHDD is an initiative to encourage patients to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be.
NHDD was founded in 2008 by Nathan Kottkamp, a Virginia-based health care lawyer, to provide clear, concise, and consistent information on healthcare decision-making to both the public and providers/facilities through the widespread availability and dissemination of simple, free, and uniform tools (not just forms) to guide the process.
NHDD is a series of independent events held across the country, supported by a national media and public education campaign. In all respects, NHDD is inclusive and brings a variety of players in the larger healthcare, legal, and religious community together to work on a common project, to the benefit of patients, families, and providers. A key goal of NHDD is to demystify healthcare decision-making and make the topic of advance care planning inescapable. Among other things, NHDD helps people understand that advance healthcare decision-making includes much more than living wills; it is a process that should focus first on conversation and choosing an agent.
As of June 2016, The Conversation Project has been responsible for the management, finances, and structure of NHDD. NHDD’s founder, Nathan Kottkamp, continues to be involved in NHDD and provides leadership by ensuring the maintenance of NHDD’s high quality resources and support for the community.
DEFINITION: What is advance care planning for financial advisors and lawyers?
Advance care planning involves discussing and preparing for future decisions about your medical care if you become seriously ill or unable to communicate your wishes with your estate planning attorney or financial advisor. Having meaningful conversations with your loved ones is the most important part of advance care planning. Many people also choose to put their preferences in writing by completing legal documents called advance directives.
What are advance directives?
Advance directives are legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes.
The two most common advance directives for health care are the living will and the durable power of attorney for health care.
Living will: A living will is a legal document that tells doctors how you want to be treated if you cannot make your own decisions about emergency treatment. In a living will, you can say which common medical treatments or care you would want, which ones you would want to avoid, and under which conditions each of your choices applies. Learn more about preparing a living will.
Durable power of attorneyfor health care: A durable power of attorney for health care is a legal document that names your health care proxy, a person who can make health care decisions for you if you are unable to communicate these yourself. Your proxy, also known as a representative, surrogate, or agent, should be familiar with your values and wishes. A proxy can be chosen in addition to or instead of a living will. Having a health care proxy helps you plan for situations that cannot be foreseen, such as a serious car accident or stroke. Learn more about choosing a health care proxy.
Think of your advance directives as living documents that you review at least once each year and update if a major life event occurs such as retirement, moving out of state, or a significant change in your health.
Advance care planning is not just for people who are very old or ill. At any age, a medical crisis could leave you unable to communicate your own health care decisions. Planning now for your future health care can help ensure you get the medical care you want and that someone you trust will be there to make decisions for you.
Advance care planning for people with dementia. Many people do not realize that Alzheimer’s disease and related dementias are terminal conditions and ultimately result in death. People in the later stages of dementia often lose their ability to do the simplest tasks. If you have dementia, advance care planning can give you a sense of control over an uncertain future and enable you to participate directly in decision-making about your future care. If you are a loved one of someone with dementia, encourage these discussions as early as possible. In the later stages of dementia, you may wish to discuss decisions with other family members, your loved one’s health care provider, or a trusted friend to feel more supported when deciding the types of care and treatments the person would want.
What happens if you do not have an advance directive?
If you do not have an advance directive and you are unable to make decisions on your own, the state laws where you live will determine who may make medical decisions on your behalf. This is typically your spouse, your parents if they are available, or your children if they are adults. If you are unmarried and have not named your partner as your proxy, it’s possible they could be excluded from decision-making. If you have no family members, some states allow a close friend who is familiar with your values to help. Or they may assign a physician to represent your best interests. To find out the laws in your state, contact your state legal aid office or state bar association.
Will an advance directive guarantee your wishes are followed?
An advance directive is legally recognized but not legally binding. This means that your health care provider and proxy will do their best to respect your advance directives, but there may be circumstances in which they cannot follow your wishes exactly. For example, you may be in a complex medical situation where it is unclear what you would want. This is another key reason why having conversations about your preferences is so important. Talking with your loved ones ahead of time may help them better navigate unanticipated issues.
There is the possibility that a health care provider refuses to follow your advance directives. This might happen if the decision goes against:
The health care provider’s conscience
The health care institution’s policy
Accepted health care standards
In these situations, the health care provider must inform your health care proxy immediately and consider transferring your care to another provider.
Other advance care planning forms and orders from doctors
You might want to prepare documents to express your wishes about a single medical issue or something else not already covered in your advance directives, such as an emergency. For these types of situations, you can talk with a doctor about establishing the following orders:
Do not resuscitate (DNR) order: A DNR becomes part of your medical chart to inform medical staff in a hospital or nursing facility that you do not want CPR or other life-support measures to be attempted if your heartbeat and breathing stop. Sometimes this document is referred to as a do not attempt resuscitation (DNR) order or an allow natural death (AND) order. Even though a living will might state that CPR is not wanted, it is helpful to have a DNR order as part of your medical file if you go to a hospital. Posting a DNR next to your hospital bed might avoid confusion in an emergency. Without a DNR order, medical staff will attempt every effort to restore your breathing and the normal rhythm of your heart.
Do not intubate (DNI) order: A similar document, a DNI informs medical staff in a hospital or nursing facility that you do not want to be on a ventilator.
Do not hospitalize (DNH) order: A DNH indicates to long-term care providers, such as nursing home staff, that you prefer not to be sent to a hospital for treatment at the end of life.
Out-of-hospital DNR order: An out-of-hospital DNR alerts emergency medical personnel to your wishes regarding measures to restore your heartbeat or breathing if you are not in a hospital.
Physician orders for life-sustaining treatment (POLST) and medical orders for life-sustaining treatment (MOLST) forms:These forms provide guidance about your medical care that health care professionals can act on immediately in an emergency. They serve as a medical order in addition to your advance directive. Typically, you create a POLST or MOLST when you are near the end of life or critically ill and understand the specific decisions that might need to be made on your behalf. These forms may also be called portable medical orders or physician orders for scope of treatment (POST). Check with your state department of health to find out if these forms are available where you live.
At enrollment, Medicare in the future could offer three advancedirectives with goals of care: DirectiveA: CONSENT to treat — inpatient medical treatment DirectiveB: CONSENT to comfort — home bound holistic care DirectiveC: CHOOSE against medical advice — outpatient palliative resources.
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Instead, physician assistants (PAs) and nurse practitioners (NPs) will increasingly provide primary care services, according to a report from consulting firm Mercer.
A Chief Strategy Officer [CSO], or chief strategist, is the senior executive responsible for assisting the Chief Executive Officer [CEO] with developing, communicating, executing, and sustaining corporate strategic initiatives. Some companies give the title Chief Business Officer [CBO] to its’ senior executives who are holding the top strategy role.
My opinion in academia
A few decades ago, the role of university Chief Strategy Officer [CSO] did not exist or marginally existed as a mid-level project manager in the communications department. It may have consisted of a formal background in teaching and education exhibited by the BA and/or B.Ed degrees or HR certification.
A first generation didactic CSO 1.0; if you will.
Then, as academic competition and granularity increased along with new technology information exchange, the need for deeper subject matter expertise arose. Next – generation business, under/graduate LAs, HUMANITIES, modern culture, psychology / sociology and STEM expertise arose to create and explore new – real or perceived – strategic advantages for university public relations in the form of the M.Ed, MA or MBA degrees in marketing, advertising, sales or competitive analysis.
THINK: Michal Porter PhD, known for his theories on economics, business strategy, and social causes. He is the Bishop William Lawrence University Professor at Harvard Business School, and a social impact consultant. He is credited for creating Porter’s five forces analysis, which is instrumental in business strategy development today.
Also, consider traditional S.W.O.T analysis, as well. SWOT analysis (alternatively SWOT matrix) is an initialism for strengths, weaknesses, opportunities, and threats—and is a structured planning method that evaluates those four elements of a project or business venture. A SWOT analysis can be carried out for a product, place, industry, university or person.
So, let’s call this a second generation expert CSO 2.0
However, as the complex business of running any college or university is ever changing, the ideal profile of CSO is still morphing to face modern business and management challenges like: physical and cyber security; culture and organizational behavior; gender differences, racial disparities and workplace violence issues; enrollment and international expansion; corporatization and competition; online and e-learning initiatives; with accounting, financial and economic pressures, etc.
Consequently, BODs are now seeking and embracing a new kind of CSO with advanced PhD or DBA degrees; and college and university experience. In fact, the role of contemporary CSO is emerging and becoming closer to that of an experienced corporate Chief Executive Officer, than the mere educator, academician or manager of the past.
Insightful academic search committees are now seeking a new type of modern CSO who can build university and college rankings, maintain relationships with stakeholders, and project a positive image as a “celebrity university”.
This means shepherding students and attracting qualified youth, and faculty, for matriculation as areas of particular importance. This new entrepreneurial CSO must focus on business management, economics and finance – operational, marketing, advertising and consultative sales strategies to attract a qualified, protean and diverse student / professional staff that sets it apart from the competition; as well as more meaningfully interacting within [research and development], and without the university [outreach].
Accordingly, this modern CSO must be a combination and protean surrogate for the university CEO / CFO / CMO / COO / CAO and leader – NOT just a teacher or manager – who will help run it like a matrix business unit that makes a profit to generate needed capital and ROI.
Multiple lines of business – tuition; certifications; worker-placement; grants and endowments; CEUs and non-degree program fees; as well as for-profit R&D, publications, patents, copyrights and trade-marks; and applied business incubators – must ALL be created and managed as a diversified portfolio. S/he must lead in the implementation, planning and operations of systemic community responsive programs, as well as policy interventions requiring advocacy, political action and public analysis.
I prefer the moniker – CSO 3.0
Assessment
This academic CSO 3.0 must be a change-agent, crisis manager, corporate strategist, Machiavellian devotee and/or seasoned C-suite executive with the required inter – disciplinary skills outlined for this important position.
Above all – the modern CSO 3.0 must be pro-active, flexible and market responsive. This is not the place for tenure tracking.
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MEDICAL PRACTICE AND HOSPITAL OPERATIONS, STRATEGIC DEVELOPMENT, ORGANIZATIONAL BEHAVIOR AND FINANCIAL MANAGEMENT COMPANION TEXTBOOK SET
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A 2020 analysis of Doximity’s physician compensation data found that men physicians make an estimated $2 million more than women over the course of their careers.
Men physicians outearned women physicians by at least 10% across all specialties, except pediatric cardiology (9.2%) and nuclear medicine (3%).
Specialties with the largest gender pay gaps were: oral and maxillofacial surgery ($568,789 vs. $395,687), pediatric pulmonology ($282,272 vs. $227,958), allergy and immunology ($329,634 vs. $268,938), urology ($515,850 vs. $424,733), and ophthalmology ($468,515 vs. $387,295).
Specialities with the smallest gender pay gaps were: nuclear medicine ($394,231 vs. $382,431), pediatric cardiology ($334,384 vs. $303,622), pediatric gastroenterology ($293,771 vs. $264,135) hematology ($358,736 vs. $320,938), and medicine/pediatrics ($283,034 vs. $253,019).
Markets: Stocks ran on a treadmill yesterday as investors waited for the high-stakes inflation report to drop this morning. Major cryptocurrencies have emerged as the biggest winners of 2023 so far, and Bitcoin topped $30,000 for the first time in 10 months.
Dueling economic visions: Depending on who you ask, the economy is doing just fine…or it’s about to slow down dramatically. Treasury Secretary Janet Yellen said yesterday that “the US economy is obviously performing exceptionally well.” But that’s not obvious at all to the IMF, which predicted weak global growth this year and gave its gloomiest five-year economic forecast since 1990.
Instead of waiting on regulatory reform, corporate America has sought to disrupt the healthcare industry over the last few years, by streamlining the delivery of healthcare (and associated costs) and taking advantage of technological advancements.
This entrepreneurial approach to problem-solving may provide meaningful competition to traditional healthcare organizations, which may result in higher quality, more affordable healthcare. Some of the biggest companies in the U.S. – CVS Health, Walgreens, Amazon, Walmart, and Best Buy – are expanding their healthcare empires through acquisitions and other strategic moves. (Read more…)
Open Payments is a national disclosure program that promotes a transparent and accountable healthcare system. Open Payments houses a publicly accessible database of payments that reporting entities, including drug and medical device companies, make to certain healthcare providers, which are referred to as covered recipients.
Pre-publication review and dispute for the Program Year 2022 Open Payments data opened on April 1st and is available through May 15th, 2023. Disputes must be initiated by May 15th, 2023 in order to be reflected in the June 2023 data publication.
Markets: The NASDAQ extended its losing streak for a third day yesterday amidst a mixed showing for stocks overall. Among the tech stocks having a rough day was cybersecurity giant Zscaler, as investors got new data suggesting the labor market may be cooling (setting off recession jitters again).
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This week’s economic numbers “all point to a softening economy,” but not necessarily a “soft landing,” says Kevin Gordon, senior investment strategist at the Schwab Center for Financial Research. An economic slowdown that averts recession “is what the Fed is looking for, but the market is saying today—with both stock prices and bond yields lower—that recession fears are outweighing hopes for a soft landing,” Kevin says.
The S&P 500® Index fell 10.22 points (0.3%) to 4090.38; the Dow Jones industrial average rose 80.34 (0.2%) to 33482.72; the NASDAQ Composite fell 129.47 (1.1%) to 11996.86.
The 10-year Treasury yield fell about 3 basis points to 3.309%.
CBOEs Volatility Index was up 0.12 at 19.12.
Among S&P 500 sectors, consumer discretionary and industrial stocks led declines. One bright spot was the healthcare sector, which jumped nearly 2%, helped by gains in Johnson & Johnson (JNJ) and Eli Lilly (LLY). Recession concerns weighed particularly heavily on small-cap stocks, as the Russell 2000 index dropped near a two-week low. WTI crude futures fell slightly but remained above $80 a barrel and near two-month highs.
Gold futures extended this week’s rally and ended at a 13-month high.
All about the Medical Executive-PostBusiness Model
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One of the questions we receive most often from readers of the Medical Executive-Post is how can we “afford” to give away so much content for free. Or stated another way, “how do we get paid for all of this?”
The simple answer is that we know many (or even most) of you will simply take the ideas that we share and implement them yourself. Do-It-YourSelfers can always simply purchase our texts, books and peer reviewed handbooks redacted in more than a thousand, medical, law, business and graduate schools, as well as the Library of Congress,Institute of Health and Library of Congress.
On the other hand, some of you will realize you need some additional help.
For example:
Maybe as a financial advisor you’re “stuck” in your financial planning business and recognize that some outside assistance is necessary to help you get to the next level of niche specificity thru our Certified Medical Planner™ chartered certification program designation. Helping physicians of all specialty types in a fiduciary focused manner is the proverbial Win-Win for all concerned.
OR, perhaps you are seeking a glossary of terms and definitions in heath economics, finance, accounting, insurance, managed care, health information technology and security; found in our Health Dictionary Series Wiki Project? Free and print versions are available.
OR, as a doctor maybe your medical practice is growing so much you just hit a wall where you don’t have time to do it all for your patients. After all, with only “so much” time available every day and week, it’s vital to delegate or outsource anything that isn’t really core to your practice and management skill set.
OR, maybe you are even starting, buying or selling your medical practice and need our financial and valuation services. Part (1) – Part (2) – Part (3) Financial, estate, investing and retirement planning services are also available.
OR, you may just need a second informed opinion about a topic not listed; there are a myriad of issues to consider in the competitive ecosystem today.
So, in the meantime, I hope that the ME-P content continues to be helpful food for thought, and perhaps we’ll have an opportunity to cross paths soon at a future conferences or podcasts. Feel free to invite us to speak at your own seminar/podcast online V-log, as well.
Analysts at Morgan Stanley downgraded Charles Schwab Corp (NYSE: SCHW) on Tuesday, citing concerns over cash sorting and regulatory changes. But, Schwab CEO Walt Bettinger recently said that the company’s banking unit had enough liquidity to cover if 100% of its bank deposits ran off without having to sell a single security — Morgan Stanley says otherwise. Schwab’s recent performance has not been up to Morgan Stanley’s expectations, with customers moving cash out of sweep accounts into money market funds at a rate twice that which the bank had been modeling.
The S&P 500® Index rose 23 points (0.57%) to 4050.84; the Dow Jones industrial average was up 141 points (0.43%) at 32859.03; the NASDAQ Composite was up 87 points (0.73%) at 12013.47.
The 10-year Treasury yield slipped 2 basis points to 3.555%.
CBOE’s Volatility Index was little changed at 19.14.
Colleagues know that I enjoy personal coaching and public speaking and give as many talks each year as possible, at a variety of medical society and financial services conferences around the country and world. All in a Corona safe environment.
MARCINKO in the METAVERSE
These include lectures and visiting professorships at major academic centers, keynote lectures for hospitals, economic seminars and health systems, end-note lectures at city and statewide financial coalitions, and annual lectures for a variety of internal yearly meetings.
When it comes to purchasing a medical practice, there are a variety of factors that one must consider in evaluating the worth of the practice. Assessing the value of a practice is fraught with potential landmines if one does not go into the process with a strong understanding of some key principles to medical practice valuation.
According to the Dictionary of Health Economics and Finance, practice valuation is the “formal process of determining the worth of healthcare or other medical business entity at a specific point in time and the act or process of determining fair market value.” Fair market value is defined as “ … the price at which a willing buyer will buy and a willing seller will sell an asset in an open free market with full disclosure.”
The Internal Revenue Service (IRS) Revenue Ruling 59-60 clearly states that fair market value “is essentially a future prophecy and must be based on facts available at the required date of appraisal.”
Unfortunately, one cannot directly observe the value of a medical practice as there are a number of underlying issues. Obviously, the buyer and seller are pursuing opposite objectives, and this reality is not necessarily conducive to facilitating clarity on those issues.
Accordingly, let us consider a few mistakes that are commonly made by physicians who are considering the purchase of a medical practice.
A Guide To The Myths And Realities Of Medical Practice Valuation
• Valuations are material representations providing a range of transferable worth. • Valuations are reproducible estimates based on economic assumptions. • Valuations are not “back of the envelope multiples” using specious benchmarks. • Valuations are defensible and should be “signed off” by the completing firm attesting to origination guidelines and in accordance with the Uniform Standards of Professional Appraisal Practice (USPAP) and IRS formats as needed. • Financial accounting value (book value) is not fair market value. • Professional valuators represent only one party. The buyer or seller-owner is the client. • Unbiased valuators do not provide financing or equity participation schemes.
Knowing The Distinctions Among Engagement Types
The Institute of Medical Business Advisors uses three levels that approximate engagement types for the industry. These levels are comprehensive valuation, limited valuation and ad-hoc valuation.
A comprehensive valuation is an extensive service designed to provide an unambiguous opinion of the value range. It is supported by all procedures that valuators deem relevant with mandatory onsite review. This gold standard is suitable for contentious situations like divorce, partnership dissolution, estate planning and gifting, etc. The written opinion of value is applicable for litigation support activities like depositions and trial. It is also useful for external reporting to bankers, investors, the public and IRS, etc.
A limited valuation lacks additional suggested USPAP procedures. It is considered to be an “agreed upon procedure,” which is used in circumstances in which the client is the only user. For example, one may use the limited valuation when updating a buy-sell agreement or when putting together a practice buy-in for a valued associate. This limited valuation would not be for external purposes. No onsite visit is needed. A formal opinion of value is not rendered.
An ad-hoc valuation is a low level engagement that provides a gross and non-specific approximation of value based on limited limited parameters or concerns by involved parties. Neither a written report nor an opinion of value is rendered. The ad-hoc valuation is often used periodically as an internal organic growth/decline gauge.
Are You Following Industry Standards And Rules?
Specifically, when it comes to USPAP transactions involving physician practices, the following points are implied by the industry and the IRS.
• Discounted cash flow analysis is the most relevant income approach and must be done on an “after-tax” basis. It generally produces a higher value but is costly, detail-oriented and time consuming. • Project practice collections based on reasonable assumptions for the practice and market, etc. • Physician compensation is based on market rates consistent with age, experience and productivity. • Majority (control) premiums and minority (lack of control) discounts are also to be considered. A majority premium is the amount paid to gain enough ownership to set policies, direct operations and make decisions for the practice. A minority discount for partial ownership does not allow this power. Thus, majority ownership is valuated higher than minority ownership purchase.
What About Personal Goodwill And Practice Goodwill?
Goodwill represents the difference between practice purchase price and the value of the net assets. Personal goodwill results from the charisma, skills and reputation of a specific doctor. These attributes accrue solely to the individual, are not transferable and cannot be sold. Personal goodwill has little or no economic value.
Transferable medical practice goodwill has value, may be transferred and is defined as the unidentified residual attributes that contribute to the propensity of patients and managed care contracts (and their revenue streams) to return in the future.
However, bear in mind that the Goodwill Registry, an older source used to determine the average percentage of revenue contributed to practice goodwill, has sparse to no podiatry input, may be dated for some specialties and leads to abnormally high values.
In addition to various multiple factors, one must also appreciate the impact of a changing environment and practice transfer in a local market, which can augment or blunt goodwill value. It is also important to determine whether patients or HMOs return because of true goodwill or are mandated to do so by contractual obligations.
Now to further confuse the issue, how each kind of goodwill is allocated in situations like divorce depends on state law. For example, some courts weigh in on the apportionment of both kinds of goodwill, other courts exclude both kinds of goodwill and other courts pursue a case-by-case approach.
Understanding ‘Excess Earnings Capitalization’ And Compensation Issues
Another way to determine goodwill value is through “excess earnings capitalization.” This economic method looks at the difference between salary and what you would have to pay a comparable doctor replacement.
As an example, when you subtract the numbers and divide the result by 20 percent, an important percentage referred to as the capitalization rate emerges. The final number gives a dollar value for practice goodwill. Courts seem to prefer this method in divorce situations because it tends to reflect a practice’s current value.
Regardless of the practice business model, physician compensation is inversely related to practice value. In other words, the more a doctor takes home in above average salary, the less the practice is generally worth and vice versa.
Emphasize Practice Specifics Over Benchmarks And Formulas
In the stable economic past, physicians may have used industry benchmarks as quick and inexpensive substitutes for professionally prepared valuations. However, this practice can be fraught with peril if challenged. The courts seem to frown on this simplistic and dated methodology. Moreover, generic benchmark formulas assume a financial statement reporting standard that just does not exist with contemporary professional valuations.
Therefore, almost every competitive issue that impacts value should be addressed with each practice engagement. This includes but is not limited to:
• contemporary dislocations by third parties, Medicare and commercial payers; • retail clinics and changes in supply/ demand and specialty trends; • the rise of ambulatory surgery centers, walk-in clinics and specialty hospitals; • outsourced care and medical tourism; • alterations in resource based-relative value units, ambulatory payment classifications (APCs), diagnosis-related groups (DRGs) and newer Medicare-severity diagnosis-related groups (MS-DRGs); and • the Medicare Modernization Act, HIPAA, OSHA, the EEOC and other regulations.
One must also consider the impact of current employee trends to high-deductible health care plans and private concierge medicine. Another consideration is employer shifts away from defined benefits plans to defined contribution plans.
Aggregating Or ‘Normalizing’ Financial Information: What You Should Know
In addition to possibly conducting employee interviews, one must gather appropriate financial information in order to properly value a practice. As a starting point, interested physician buyers should be able to see the following information for the most recent three-year period.
It is especially important to eliminate one-time, non-recurring practice expenses. These are adjusted for excessive or below normal expenses on the profit and loss statement. Such “normalization” can produce a big surprise for benchmark proponents and formula-driven advocates when a selling doctor runs personal expenditures through the practice that a buyer or court would not consider legitimate. Of course, one is less likely to encounter such shenanigans when the valuation is conducted according to professional USPAP and IRS style guidelines.
For example, we recall one doctor who painted his home and wrote it off as a valid business expense. Deleting other major expenses such as country club memberships make a practice look more profitable. This is good news if you are selling it. It is bad news if you are getting a divorce.
Conversely, you may have to defend legitimate business expenses that an appraiser may seek to normalize. For example, doctors may pay for a vehicle through their practice. If they use the vehicle to travel between multiple offices and hospitals, the expense may be legitimate.
Also realize that the appraiser may also add expenses that have not been incurred. For example, the appraiser may add an office manager’s salary if your spouse is in that role for free. This produces a lower appraised value and is common in small podiatry practices. Honorarium is another example that does not figure into value calculations.
Of course, normalization is a sophisticated and time intensive process. However, the expert earns his or her professional fee, and defends the resulting valuation range when challenged.
Keys To Selecting The Right Valuator Professional
The most important credentials to look for are fiduciary level experience, specificity and independence. Some doctors mistakenly turn to those who may have never appraised a practice before. Just because an appraiser has initials behind his or her name, it does not mean he or she understands the peculiarities of medical specialties. Agents, brokers, solicitors and other intermediaries are not fiduciaries.
Physicians looking to assess a practice for possible sale/purchase should only select an independent health economist, who will be your advocate under Securities Exchange Commission (SEC), IRS or other relevant managerial accounting guidelines.
Moreover, be very wary if the valuation is not done in an independent manner or, worse, performed for both parties simultaneously.
Essential Insights On Professional Fees And What You Can Expect
Of course, it is almost impossible to answer concerns regarding fees without specific information. The cost of a valuation can range from $0 to $50,000 for an onsite team of experts for behemoth practices and ambulatory surgery centers. Keep in mind that in most cases you want to ensure the value determination will stand up to IRS scrutiny so the $0 rule of thumb approach is not an option.
However, most reputable firms use a blended fee schedule of fixed and hourly rates (plus expenses). Internists should expect to spend approximately $5,000 to $10,000 for an average sized practice and a limited appraisal that is completely suitable for most internal activities.
External appraisals or poorly aggregated financial information, onsite reviews and litigation support services incur additional costs. However, most doctors find the money well spent. Expect to pay a retainer and sign a formal professional engagement letter.
Finally, once the practice price is agreed upon, sales contract terms and agreements present a plethora of financing challenges for both parties to consider. For example, one must negotiate bank loans (if they are even available), payment rates and length, personal promissory guarantees, down payment offsets, earn-out arrangements and Uniform Commercial Codes.
Final Notes
Do not be surprised if a sales broker does not consider the aforementioned issues as the modern health era emerges. Most agent-appraisers are predominantly concerned with earning commissions by working both transaction parties and may not represent your best interests. Also be aware that they are usually not obliged to disclose conflicts of interest and do not provide testimony as a court approved expert witness.
However, it is a fait accompli that medical practice worth is presently deteriorating. As the population ages and third-party reimbursements plummet, doctors are commoditized and traditional retail medicine is replaced by more efficient wholesale business models like workplace health clinics. The subprime mortgage default fiasco, credit freeze, potential tax reform law expiration, the ACA, VBC, capitation payments and the political specter of a nationalized healthcare system only add fuel to the macroeconomic fires of uncertainty. Do not forget the corona pandemic.
As a result, a good medical practice is no longer good business necessarily and retiring doctors can no longer automatically expect to extract premium sales prices. Moreover, uninformed young physicians should not be goaded to overpay.
A rare alignment of five planets will be visible in the night sky this week, but this Tuesday [tonight] evening will be your best bet. Just head outside right after sunset, look west, and you’ll see Mercury, Venus, Mars, Jupiter, and Uranus appear to line up in an arc shape below the crescent moon. Anyone on Earth should be able to see it, even if you’re living in a city with light pollution.
The word syzygy is often used to describe interesting configurations of astronomical objects in general. For example, one such case occurred on March 21, 1894, around 23:00 GMT, when Mercury transited the Sun as would have been seen from Venus, and Mercury and Venus both simultaneously transited the Sun as seen from Saturn. It is also used to describe situations when all the planets are on the same side of the Sun although they are not necessarily in a straight line, such as on March 10, 1982.
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Here’s how the mixed markets fared yesterday on Monday:
The S&P 500® Index was up 6.54 points (0.16%) at 3977.53; the Dow Jones industrial average was up 194.55 points (0.6%) at 32432.08; the NASDAQ Composite was down 55.12 points (0.47%) at 11768.84.
The 10-year Treasury yield was up around 17 basis points at 3.542%.
CBOEs Volatility Index was down 1.05 points (4.8%) at 20.71.
Outside of the financial sector, energy also had a good day Monday, as the apparent return to calm in the world of banks helped ease concerns about the economy. Oil prices recovered, with West Texas Intermediate rising more than 5% to roughly $73.
In Part 1, we discussed how to establish fair market value (FMV) for a medical practice in the article, “Establish Your Practice’s Fair Market Value.” This time, we’ll review important terms and conditions for the sale transaction.
Unfortunately, as a general rule, medical practice worth is presently deteriorating. A good medical practice is no longer a good business necessarily, and selling doctors can no longer automatically expect to extract a premium sale price. Nevertheless, appraising your medical practice on a periodic basis can play a key role in obtaining maximum value for it.
Competent practice valuation specialists typically charge a retainer to cover out-of-pocket expenses. Fees should not be based on a percentage of practice value, and may take 30-45 days to complete. Flat fees should be the norm because a sliding scale or percentage fee may be biased toward over-valuation in a declining marketplace. Fees range from $7,500-$50,000 for the small to large medical practice or clinic.
Expect to pay a retainer and sign a formal, professional engagement letter. Seek an unbiased and independent viewpoint. Buyer and sellers should each have their own independent appraisal done, using similar statistics, accounting measures, and economic assumptions.
At the Institute of Medical Business Advisors, Inc www.MedicalBusinessAdvisors.com we use three engagement levels that vary in intensity, purpose, and cost:
1. A comprehensive valuation provides an unambiguous value range. It is supported by most all procedures that valuators deem relevant, with mandatory onsite review. This gold standard is suitable for contentious situations. A written “opinion of value” is applicable for litigation support activities like depositions and trial. It is also useful for external reporting to bankers, investors, the public, Internal Revenue Service (IRS), etc.
2. A limited valuation lacks additional suggested Uniform Standards of Professional Appraisal Practice (USPAP) procedures. It is considered to be an “agreed upon engagement,” when the client is the only user. For example, it may be used when updating a buy/sell agreement, or when putting together a practice buy-in for a valued associate. This limited valuation would not be for external purposes, so no onsite visit is necessary and a formal opinion of value is not rendered.
3. An ad-hoc valuation is a low level engagement that provides a gross non-specific approximation of value based on limited parameters or concerns involved parties. Neither a written report nor an opinion of value is rendered. It is often used periodically as an internal organic growth/decline gauge.
Structure Sales Transactions
When the practice price has been determined and agreed on, the actual sales deal can be structured in a couple of ways:
(1) Stock Purchase v. Asset Purchase
In an asset transaction, the buyer will receive a tax amortization benefit associated with the intangible value of the business. This tax amortization represents a non-cash expense benefiting the buyer. In this case, the present value of those future tax benefits is added to the business enterprise value.
(2) Corporate Transactions
Typical private deals in the past involved some multiple (ratio) of earning before income taxes (EBIT)—usually a combination of cash, restricted stock, notes receivable, and possibly assumption of liabilities. For some physician hospital organizations, and public deals, the receipt of common stock can increase the practice price by as much as 40-50 percent (to accept the corresponding business risk, in lieu of cash).
Complete the Deal
The deal structure will vary depending on whether the likely buyer is a private practitioner, health system or a corporate partner. Some key issues to consider in the “art of the deal” include:
Working capital (in or out?): Including working capital in the transaction will increase the sale price.
Stock vs. asset transaction: Structuring the deal as an asset purchase will increase practice value due to the tax amortization benefits received by the buyer for intangible assets of the practice.
Common stock premium: The total sale price can be significantly higher than a cash equivalent price for accepting the risk and relative illiquidity of common stock as part of the payment.
Physician compensation: If your goal is to maximize practice value, take home a lower salary to increase practice sale price. The reverse is also true.
Understand Private Deal Structure
Assuming a practice sale is a private transaction, deal negotiations are based on the following pricing methodologies:
Seller financing: Many transactions involve an earn-out arrangement where the buyer puts money down and pays the balance under a formula based on future revenues, or gives the seller a promissory note under similar terms. Seller financing decreases a buyer’s risks (the longer the terms, the lower the risk). Longer terms demand premiums, while shorter terms demand discounts. Premiums that buyers pay for a typical seller-financed practice are usually more than what you would expect from a simple time value of money calculation, as a result of buyer risk reduction from paying over time, rather than up front with a bank loan or all cash. Remember to obtain a life insurance policy on the buyer.
Down payment: The greater the down payment for acquisition of a medical practice, the greater the risk is to the buyer. Consequently, sellers who will take less money up front can command a higher than average price for their practice, while sellers who want more down usually receive less in the end.
Taxation: Tax consequences can have a major impact on the price of a medical practice. For instance, a seller who obtains the majority of the sales price as capital gains can often afford to sell for a much lower price and still pocket as much or more than if the sales price were paid as ordinary income. Value attributed to the seller’s patient list, medical records, name brand, good will, and files qualifies for capital gains treatment. Value paid for the selling doctor’s continuing assistance after the sale and value attributed to a non-compete agreement are taxed at ordinary income. A buyer willing to allocate more for items with capital gains treatment, or a seller willing to take more in ordinary income, can frequently negotiate a better price. This is the essence of economically prudent practice transition planning.
Sidestep Common Buyer Blunders
Here are 10 blunders to avoid, as a buyer:
1. Believing the selling doctor’s attestations. Always verify data through an independent appraisal.
2. Wanting to change the culture of the practice. Be careful: Patients may not adjust quickly to change.
3. Using all available cash without keeping a reserve for potential contingencies.
4. Creating a conflict with the seller by recognizing a weakness and continually focusing on it for a bargain price.
5. Failing to realize that managed care plan contracts can be lost quickly or may not be always transferable.
6. Suffering from analysis paralysis. Money cannot be made by continually checking out a medical practice, only by actually running one.
7. Not appreciating the uniqueness of each practice, and using inaccurate “rules of thumb” from the golden age of medicine.
8. Not realizing that practice worth and goodwill value have plummeted lately and continue to decline in most parts of the country.
9. Not understanding that practice brokers may play both sides of the buy/sell equation for profit. Brokers usually are not obligated to disclose conflicts of interest, are not fiduciaries, and do not provide testimony as a court-approved expert witness.
10. Not hiring an appraisal professional who will testify in court, if need be, using the IRS-approved USPAP methods of valuation. Always assume that the appraisal will be contested (many times, it is).
After pricing and contracting due diligence has been performed, the next step in the medical practice sale process—as Donald Trump might say—is just good, old-fashioned negotiation.
Cimasi, R.J., A.P. Sharamitaro, T.A. Zigrang, L.A.Haynes. Valuation of Hospitals in a Changing Reimbursement and Regulatory Environment. Edited by David E. Marcinko. Healthcare Organizations: Financial Management Strategies. Specialty Technical Publishers, 2008.
Marcinko, D.E. “Getting it Right: How much is a plastic surgery practice really worth?” Plastic Surgery Practice, August 2006.
Marcinko, D.E., H.R. Hetico. The Business of Medical Practice (3rd ed). Springer Publishing,New York,N.Y., 2011.
Marcinko, D.E. and H.R. Hetico. Risk Management and Insurance Planning for Physicians and Advisors. Jones and Bartlett Publishers, Sudbury, Mass., 2007.
Marcinko, D.E. and H.R. Hetico. Financial Planning for Physicians and Advisors. Jones and Bartlett Publishers, Sudbury, Mass., 2007.
Marcinko, D.E. and H.R. Hetico. Dictionary of Health Insurance and Managed Care. Springer Publishers, New York, N.Y., 2007.
Marcinko, D.E. and H.R. Hetico. Dictionary of Health Economics and Finance. Springer Publishers,New York,N.Y., 2007.
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