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On December 19, 2022, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) published Advisory Opinion (AO) No. 22-20, analyzing the utilization of nurse practitioners (NPs) in lieu of attending physicians within medical units. The OIG concluded that the arrangement utilizing NPs in certain medical units, subject to several safeguards, presented a low risk for fraud or abuse.
As noted by legal experts, this AO deviates from OIG’s typical approach to limiting arrangements involving potential remuneration from a hospital to its referring physicians. (Read more…)
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
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.
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.
Technology stocks have largely been in favor since the COVID-19 pandemic began, but re-openings in the U.S. and elsewhere as vaccines take hold have pushed investors toward value stocks, which are geared more toward the economy. But lately, stronger growth expectations are also sparking worries of higher inflation, and a potential tapping of the brakes by central banks.
Therefore, an important concept for physicians and all investors to understand is the Current Rate of Return (CCR).
So, What Exactly is CRR?
According to this principle, the current rate of a taxable return must be evaluated in reference to a similar non-taxable rate of return. This allows you to focus on your portfolio’s real (after-tax return), rather than its’ nominal, or stated return. Since most medical professionals own a combination of both vehicles, it is important to calculate the average rate of return (ARR), as demonstrated in the following matrix. Usually, this will result in the assumption of more risk, for the possibility of great return.
To compare after tax yields, with taxable yields, use the following formulas:
Tax equivalent yield = yield / (1 – MTB), while taxable yield X (1-tax rate) = tax exempt yield.
Example: if the yield on a tax exempt municipal bond was 6%, and you are in a 28% tax bracket; the equivalent taxable yield (ETY), is 8.3%, calculated in the following manner: 06 / 1.00 – .28 =.083, or, 8.3% ETY.
This means that you would need a taxable instrument paying almost 9 % to equal the 6 percent tax exempt bond.
While financial planning rules of thumbs are useful to people as general guidelines, they may be too oversimplified in many situations, leading to underestimating or overestimating an individual’s needs. This may be especially true for physicians and many medical professionals. Rules of thumb do not account for specific circumstances or factors occurring at a particular time, or that could change over time, which should be considered for making sound financial decisions.
For example, in a tight job market, an emergency fund amounting to six months of household expenses does not consider the possibility of extended unemployment. I’ve always suggested 2-3 years for doctors. Venture capitalist lay-offs of physicians during the pandemic confirm this often criticized benchmark opinion of mine.
As another example, buying life insurance based on a multiple of income does not account for the specific needs of the surviving family, which include a mortgage, the need for college funding and an extended survivor income for a non-working spouse. Again a huge home mortgage, or several children or dependents, may be the financial bane of physician colleaguesand life insurance.
A home purchase should cost less than an amount equal to two and a half years of your annual income. I think physicians in practice for 3-5 years might go up to 3.5X annual income; ceteras paribus.
Save at least 10-15% of your take-home income for retirement. Seek to save 20% or more.
Have at least five times your gross salary in life insurance death benefit. Consider 10X this amount in term insurance if young, and/or with several children or other special circumstances.
Pay off your highest-interest credit cards first. Agreed.
The stock market has a long-term average return of 10%. Agreed, but appreciated risk adjusted rates of return..
You should have an emergency fund equal to six months’ worth of household expenses. Doctors should seek 2-3 years.
Your age represents the percentage of bonds you should have in your portfolio. Risk tolerance and assets may be more vital.
Your age subtracted from 100 represents the percentage of stocks you should have in your portfolio. Risk tolerance and assets may still be more vital.
A balanced portfolio is 60% stocks, 40% bonds. With historic low interest rates, cash may be a more flexible alternative than bonds; also avoid most bond mutual funds as they usually never mature.
There are also rules of thumb for determining how much net worth you will need to retire comfortably at a normal retirement age. Here is the calculation that Investopedia uses to determine your net worth:
If you are employed and earning income: ((your age) x (annual household income)) / 10.
If you are not earning income or you are a student: ((your age – 27) x (annual household income)) / 10.
OUR OEUVRE’ OF TEXT BOOKS IS GROWING WITH OUR INDUSTRY STATURE
We believe that by writing and sharing our experiences in standard textbook, white-paper and new media electronic format, our experts are able to address most areas of physician-focused financial planning, business or medical practice management needs in an understandable and unbiased manner.
But, we recognize that some consultants and financial advisors may appreciate reading current medical business management theory, healthcare economics, technology or financial planning information privately, prior to becoming a Certified Medical Planner® professional.
However, there is a virtual information overload out there, little of which addresses the pragmatic concerns of the modern medical provider or healthcare industry. None imparts the wisdom to become a better financial advisor or medical management consultant. All motivate the purchase of products.
Therefore, as part of the iMBA Research Library for the Certified Medical Planner® program, we highly recommend the following in-house produced books. You may even recognize some of our nationally known contributing authors and CMPs®.
According to Wikipedia, the Federal Open Market Committee (FOMC), a committee within the Federal Reserve System (the Fed), is charged under United States law with overseeing the nation’s open market operations (e.g., the Fed’s buying and selling of United States Treasury securities). This Federal Reserve committee makes key decisions about interest rates and the growth of the United States money supply. Under the terms of the original Federal Reserve Act, each of the Federal Reserve banks was authorized to buy and sell in the open market bonds and short term obligations of the United States Government, bank acceptances, cable transfers, and bills of exchange. Hence, the reserve banks were at times bidding against each other in the open market. In 1922, an informal committee was established to execute purchases and sales. The Banking Act of 1933 formed an official FOMC.
The FOMC is the principal organ of United States national monetary policy. The Committee sets monetary policy by specifying the short-term objective for the Fed’s open market operations, which is usually a target level for the federal funds rate (the rate that commercial banks charge between themselves for overnight loans).
The FOMC also directs operations undertaken by the Federal Reserve System in foreign exchange markets, although any intervention in foreign exchange markets is coordinated with the U.S. Treasury, which has responsibility for formulating U.S. policies regarding the exchange value of the dollar.
The Federal Reserve is set to announce today whether it will impose another interest rate hike, the central bank’s latest move in a months long fight that has eased inflation but risks plunging the U.S. into a recession.
The Fed [FOMC] has put forward a string of borrowing cost increases as it tries to slash price hikes by slowing the economy and choking off demand. The approach, however, risks tipping the U.S. economy into a downturn and putting millions out of work.
And so, at a meeting in December 2022, the Fed raised its short-term borrowing rate a half-percentage point, pulling back from three consecutive 0.75% increases and signaling confidence that sky-high inflation could be brought down to normal levels.
Economists expect the Fed to continue softening its approach with a 0.25% rate hike today? The decision comes weeks after a government report showed that inflation slowed in December, marking six consecutive months of easing price increases.
FINANCIAL ADVISER WANTED: New York’s Belfer family, which gained riches from oil, is racking up quite an investing losing streak. They lost billions in Enron’s collapse and were clients of Bernie Madoff, and now it’s come to light that they were shareholders in FTX.
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CPAs WANTED: Just as tax season kicks off, US firms are facing a national shortage of accountants, forcing them to look overseas for workers to look over your W-2. More than 300k accountants and auditors have quit in the last two years, per the WSJ.
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CMPs NEEDED: The Certified Medical Planner® program was created in response to the frustration felt by doctors in small and mid-sized practices that dealt with top financial, brokerage and accounting firms. These non-fiduciary behemoths often prescribed costly wholesale solutions that were applicable to all, but customized to few, despite ever changing needs.
Learn why brokerage sales-pitches and/or internet resources will never replace the knowledge and deep advice of a collegial Certified Medical Planner® professional.
Last week, the S&P 500 dropped 0.7%, snapping a two-week winning streak, though the index rallied 1.9% Friday, thanks to a surge in tech stocks as Fed officials dialed back fears of overly aggressive policy moves. The tech-heavy NASDAQ 100 Index had its best day since November 30th to eke out a 0.7% gain for the week. At the same time, stocks from rate-sensitive industries like financials, real estate, and growth-oriented technology tend to lag during that period.
In this coming week, markets will sort through earnings results from Microsoft Corp., Tesla Inc. and International Business Machines Corp. that are poised to shape the direction of equities more broadly. Also, the Commerce Department will release its first estimate of fourth-quarter US gross domestic product, which is expected to show an acceleration.
Hospitals saw a slight financial boost in November 2022, despite continued negative operating margins throughout the year, according to a new Kaufman Hall National Hospital Flash Report, as reported in Healthcare Brew.
Lower expenses and increased outpatient revenue help buoy their performance and increase margins by 12% month over month from October 2022. But Kaufman Hall, a management consulting firm, reported that its year-to-date operating margin index reflected an actual negative figure of -0.2% in November 2022.
The findings underscore the financial challenges hospitals continue to face as they recover from the Covid-19 pandemic.
And, Erik Swanson, senior vice president of data and analytics at Kaufman Hall, wrote that the “November data, while mildly improved compared to October, solidifies what has been a difficult year for hospitals amidst labor shortages, supply chain issues, and rising interest rates.”
The monthly report, which is based on data from more than 900 hospitals, partially attributed November’s lowered expenses to a decline in patient volume and slightly shorter lengths of stay. Decreased labor costs, likely due to a drop in a reliance on contract labor, also helped lower expenses, the Kaufman analysis found.
Hospitals further saw a 10% increase year over year in outpatient revenue in November 2022, despite inpatient revenue remaining flat, according to the report. Swanson said “[h]ospital leaders should continue to develop their outpatient care capabilities amid ongoing industry uncertainty and transformation.”
According to Rick Kahler MS CFP® ChFC CCIM[www.KahlerFinancial.com] real estate is one of the largest asset classes in the world. The family home is the largest asset many middle-class Americans own. And, real estate makes up a significant portion of the net worth of many wealth accumulators. Directly owning real estate is not an investment for the faint of heart, the armchair investor, or the uneducated. Most wealth accumulators would do well to leave direct ownership of real estate to the pros and invest in real estate investment trusts (REITs) instead [personal communication].
Still, as we have seen, the lure of investing in a tangible asset like real estate is enticing for high risk tolerant physician-investors who need a sense of control and interaction with their investments. If you are among them, here are a few guidelines that may keep you on a profitable path.
1. Don’t attempt to purchase investment real estate without the help of a commercial real estate specialist who is a fiduciary bound to look out for your best interest. Engage a Certified Commercial Investment Member (CCIM) with years of training and experience in analyzing and acquiring investment real estate. To find a CCIM near you, go to http://www.ccim.com.
2. You will sign a disclosure agreement that will tell you who the Realtor represents. Be sure the Realtor you engage represents you and not the seller, both parties, or neither party.
3. Never trust the income and expense data provided by the seller’s Realtor. While a seller represented by a CCIM will have a greater chance of supplying you with accurate data, most will significantly understate expenses and overstate the capitalization rate. Selling Realtors often understate the average annual cost of repairs and maintenance. I estimate this annual expense at 10%.
4. Another often understated expense is management. Many owners manage their own properties, so the selling broker doesn’t include an estimate for management expenses. They should. Real estate doesn’t manage itself, ever. You will either need to hire professional management or do your own management (always a scary proposition). Even if you do it yourself, you have an opportunity cost of your time, so you must include a management fee in the expenses. Most small residential apartments and single-family homes will pay 10% of their rents to a manager.
5. You must verify all the costs presented to you by the seller’s Realtor. Demand copies of at least the last three and preferably five years of tax returns. Research items like utility bills, property taxes, legal fees, insurance costs and repairs, maintenance costs, replacement reserves, tax preparation and all management fees. As a rule of thumb, expenses will average 40% of rental income on average-aged properties where the tenants pay all utilities except water. Newer properties may have expenses as low as 35%, while older properties can be as high as 50%.
6. By subtracting the vacancy rate and stabilized expenses from the rent, you will find the net operating income. This is the income you will put in your pocket—assuming the property is paid for. By dividing the net operating income by the purchase price, you will find the return you will receive on your investment, called the capitalization or “cap” rate. In Rapid City SD, for example, the cap rate tends to be 4% for single-family homes, 5% to 8% for duplexes to eight-plexes, and 8% to 12% for larger residential and commercial properties.
ASSESSMENT: Yes, physician-investors and all of us can build wealth with real estate. You just need to educate yourself, work hard, start conservatively, think long-term, and be prepared for lean years. This is not a quick or easy path to riches.
Human beings make most of our decisions—including financial ones—emotionally, not logically. Unfortunately, too much of the time, our emotions lead us into financial choices that aren’t good for our financial well-being. This is hardly news to financial planners or financial therapists. Nor is it a surprise to any parent who has ever struggled to teach kids how to manage money wisely.
Economic Model Assumptions
Yet many of the economic models and theories related to investing are based on assumptions that, when it comes to money, people act rationally and in their own best interests. There’s a wide gulf between the way economists assume people behave around money and the way people actually make money choices. This doesn’t encourage financial advisors to rely on what economists say about financial patterns, trends, and what to expect from markets or consumers.
2017 Nobel Prize in Economics
It’s significant, then, that the 2017 Nobel Prize in Economics went to Dr. Richard H. Thaler, professor of behavioral science and economics at the University of Chicago Booth School of Business. Dr. Thaler’s work has focused on the differences between logical economic assumptions and real-world human behavior. His research not only demonstrates that people behave emotionally when it comes to money; it also shows that in many ways our irrational economic behavior is predictable.
This predictability can help advisors and organizations find ways to encourage people to make financial decisions in their own better interest. The book Nudge, by Dr. Thaler and Cass R. Sunstein, describes some of those methods.
Example:
One example is making participation the default option for company retirement programs like 401(k)’s. Employees are free to opt out, of course, but they need to actively choose to do so.
A second example is the “Save More Tomorrow” plan, which offers employees the option of automatically increasing their savings whenever they receive raises in the future.
Both of these examples rely on a predictable behavior—human inertia. Most of us tend to postpone, ignore, or forget to take action even when that action would be good for us. So if a system is set up so not taking action leaves us with the choice that serves us better, we are “nudged” toward helping ourselves toward a healthier financial future.
Integration
As one of the pioneers in integrating the emotional aspect of money behavior into the practice of financial planning, I’ve long since come to understand that managing money is about much more than numbers. The world of investing may seem to be cold and calculating, but it’s actually driven by emotions. I’m familiar with the work of researchers who have demonstrated that some 90% of all financial decisions are made emotionally rather than logically.
I was pleased in 2002 when one of those researchers, psychologist Daniel Kahneman, won the Nobel prize in economics for his studies of human behavioral biases and systematic irrational behaviors. (That research was done jointly with psychologist Amos Tversky, who died in 1996.)
I’m even more pleased to see the economics Nobel prize go to a behavioral researcher for the second time. Maybe the realm of economics is beginning to integrate the untidy realities of human emotions into its theories. Eventually, this might lead to new economic models that take into account the emotions that shape people’s money decisions and the fact that money is one of the most emotionally charged aspects of our lives.
Assessment
Perhaps economists are beginning to appreciate the truth of the statement Dr. Thaler made at a news conference after his prize was announced. “In order to do good economics, you have to keep in mind that people are human.”
Conclusion
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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.
People living in the US are finding it increasingly difficult to afford needed health services—even with employer-sponsored health insurance, a new analysis suggests.
Researchers at the NYU School of Global Public Health (GPH) examined data from the National Health Interview Survey—an annual CDC survey—that was collected from 2000 to 2020 for 230,000+ adults who received health insurance through an employer or union. Both men and women found most healthcare services to be less affordable now compared to the early 2000s, according to the finding of the NYU analysis reported in a December 2022 JAMA abstract. Women, in particular, found all types of health services to be less affordable than men.
From a nationally representative survey which is conducted annually, researchers included data from 5,545 women and 5,353 men sampled in 2020, and found that about 6% of women reported they couldn’t afford needed medical care. This compares to just 3% of slightly larger sample groups from 2000, per the analysis. By contrast, about 3% of men gave that response in 2020, compared to 2% in 2000.
Avni Gupta, a doctoral student in the public health policy and management department at NYU GPH and the lead author of the analysis, offered that “lower incomes and higher healthcare needs among women could be driving these differences in reported affordability.”
And, José Pagán, the department chair and co-author of the JAMA analysis, said people with employer-sponsored coverage—the largest source of health insurance for people living in the US—“generally think they are protected.”
“[B]ut our findings show that health-related benefits have been eroding over time,” he said; according to Healthcare Brew
Carta Inc., a financial software company valued at $7.4 billion in August 2021, told employees on Wednesday it was cutting about 10% of the workforce. The job cuts, earlier reported by TechCrunch, are more evidence of the chill that has set in for even the best-funded tech startups. Carta raised $500 million in equity last year, bringing its total fundraising haul to more than $1 billion. Carta makes software to manage equity stakes in private companies, and has been backed by firms including Andreessen Horowitz, Lightspeed Venture Partners and Silver Lake. Prominent venture capitalist Marc Andreessen sits on the company’s board.
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U.S. equities finished higher to add to gains seen this year, with the NASDAQ on a four-day winning streak. However, caution was prevalent, as the markets awaited tomorrow’s December consumer price inflation report, and as Q4 earnings season will kick off on Friday with results from some prominent names from the Financials sector.
Treasury yields were lower and the U.S. dollar was little changed, while crude oil prices and gold were higher.
The economic calendar was relatively light today, but mortgage applications snapped a two-week losing streak. The airline industry was in focus after the FAA temporarily suspended all flights across the U.S. after a computer system failure, and Wells Fargo & Company announced that it will reduce the size of its mortgage lending business.
Asia finished mixed, and Europe saw widespread gains, as the global markets awaited this week’s inflation and earnings data out of the U.S.
A Medical Practice business valuation is a set of procedures to estimate the economic value of a physician owner’s interests. Valuation is used to determine the price they are willing to pay or receive to affect a sale of the practice.
The same valuation tools are often used to resolve disputes related to estate and gift taxation, divorce litigation, allocated purchase price among business assets, establish a formula for estimating the value of partners’ ownership interest for buy-sell agreements, and other business and legal purposes.
QUERY: But, what are the most common medical practice valuation blunders to avoid? Written over a decade ago, this white paper highlights the most common mistake still seen today.
Most of the thousands of buy and sell orders executed on a typical day on the NYSE are in 100 share or multi-100 share lots. These are called round lots. Some of the inactive stocks traded at post 30, the non-horseshoe shaped post in the northwest corner of the exchange, are traded in 70 share round lots due to their inactivity. So, while a round lot is normally 700 shares, there are cases where it could be 10 shares. Any trade for less than a round lot is known as an odd lot. The execution of odd lot orders is somewhat different than round lots and needs explanation.
When a stock broker receives an odd lot order from one of his doctor customers, the order is processed in the same manner as any other order. However, when it gets to the floor, the commission broker knows that this is an order that will not be part of the regular auction market. He takes the order to the specialist in that stock and leaves the order with the specialist. One of the clerks assisting the specialist records the order and waits for the next auction to occur in that particular stock. As soon as a round lot trade occurs in that particular stock as a result of an auction at the post, which may occur seconds later, minutes later, or maybe not until the next day, the clerk makes a record of the trade price.
Every odd lot order that has been received since the last round lot trade, whether an order to buy or sell, is then executed at the just noted round lot price, the price at which the next round lot traded after receipt of the customer’s odd lot order, plus or minus the specialist’s “cut “. Just like everything else he does, the specialist doesn’t work for nothing. Generally, he will add 1/8 of a point to the price per share of every odd lot buy order and reduce the proceeds of each odd lot sale order by 1/8 per share. This is the compensation he earns for the effort of breaking round lots into odd lots. Remember, odd lots are never auctioned but, there can be no odd lot trade unless a round lot trades after receipt of the odd lot order.
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, today signed 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.
DEFINITION: GE HealthCare is a subsidiary of American multinational conglomerate General Electric incorporated in New York and headquartered in Chicago, Illinois. As of 2017, it is a manufacturer and distributor of diagnostic imaging agents and radio-pharmaceuticals for imaging modalities used in medical imaging procedures
TUCSON, Ariz., Dec. 06, 2022 (GLOBE NEWSWIRE) — Sheila Page, D.O., a family physician in Aledo, Texas, and president of the Association of American Physicians and Surgeons (AAPS), is featured in the winter issue of the of the Journal of American Physicians and Surgeons. She writes: “Today physicians often feel constrained to pick from among options that are not in the best interest of patients but are ‘covered’ by insurance or approved by officials.”
“An apparently free choice when there is no real alternative is a Hobson’s Choice, and physicians must understand the political structure in which this type of ‘choice’ is embedded,” Dr. Page explains.
“During the COVID pandemic, people often faced a Hobson’s Choice of taking a shot that they believed put their life, health, or fertility at risk, or be barred from their education or career,” she noted.
“Voters generally believe that they have two choices, Republican or Democrat, and that they represent extremes of political ideology. However, when they are in office, politicians behave as if they belong to the same club,” she writes.
“Physicians have accepted the Hobson’s Choice of either abiding by ridiculous regulatory burdens or refusing to treat the senior population,” she explains. They “accept the Hobson’s Choice of either standing against the oppression or keeping their ‘place at the table.'”
“The phrase ‘we need to keep our place at the table to avoid being on the menu’ entirely misses the point,” she states. “The profession is on the table already being carved up. How many times have we been told we must choose the lesser of two evils? Either choice is still evil!”
“We must identify the enemy within,” Dr. Page writes. “The medical profession must grasp the extent to which it has been manipulated by pharmaceutical, insurance, and other systems tied to medicine. We have been burdened with regulations and threats to our licenses by the same people who are selling us the solutions.”
“There is tremendous profit in the existing system, but we must nevertheless offer healing and hope, learn how to fight back effectively, and reject the Hobson’s Choice,” she concludes.
DEFINITION: NBER defines a recession as “a significant decline in economic activity that is spread across the economy and that lasts more than a few months.” That definition encompasses a range of economic factor but is based on three main criteria: The depth, diffusion and duration of a downturn.
Former Federal Reserve Chair Alan Greenspan recently said a US recession is the “most likely outcome” in 2023 as the central bank tightens monetary policy to curb inflation.
If you’re looking at this tab, chances are you are fed up, burned out, seeking better work-life balance, looking for a new non-clinical career, thinking of retirement, or all of the above. Perhaps you are just looking to regain the joy and meaning in your medical career.
The Fed hikes interest rates, sending economy teetering toward a recession?
If everyone was an opinionated virologist in 2020, then 2022 turned us all into macro-economists. In an effort to fight historic inflation, the Fed raised its benchmark interest rate seven times this year, pushing it to a 15-year high. Chair Jerome Powell’s hawkish turn slowed the economy and was a major catalyst for the brutal sell-off in stocks, particularly in the tech sector. This year, Amazon became the first public company to lose $1 trillion in market value.
The U.S. housing market is experiencing its second-biggest home price correction of the post-World War II era. Macro Trends Advisors founding partner Mitch Roschelle attributed the massive correction to Americans’ uncertainty for the markets and their “uneasiness” regarding the economy. He explained on “Varney & Co.” that the “shoe to drop” would be if the nation starts to see a rise in unemployment, which could cause a “leg down” in the housing market.
Finis?
So what’s ahead for 2023? According to MorningBrew, Economists think that a recession is likely, but a few are holding out hope that the Fed can achieve a so-called “soft landing,” where it brings inflation down to normal levels without causing the economy to shrink. Recent months have brought cautiously hopeful news: Annual inflation has cooled from a peak of 9.1% to 7.1%, so rate hikes are expected to be much less aggressive next year.
About the Institute of Medical Business Advisors, Inc
The Institute of Medical Business Advisors, Inc provides a team of experienced, senior level consultants led by iMBA Chief Executive Officer Dr. David Edward Marcinko MBA CMP™ MBBS [Hon] and Ann Miller RN MHA CMP™ to provide ongoing contact with our clients throughout all phases of each project, with most of the communications between iMBA and the key client participants flowing through this Senior Team. iMBA Inc., and its skilled staff of certified professionals have many years of significant experience, enjoy a national reputation in the healthcare consulting field, and are supported by an unsurpassed research and support staff of CPAs, MBAs, MPHs, PhDs, CMPs™, CFPs® and JDs to maintain a thorough and extensive knowledge of the healthcare environment. The iMBA team approach emphasizes providing superior service in a timely, cost-effective manner to our clients by working together to focus on identifying and presenting solutions for our clients’ unique, individual needs.
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The iMBA Inc project team’s exclusive focus on the healthcare industry provides a unique advantage for our clients. Over the years, our industry specialization has allowed iMBA to maintain instantaneous access to a comprehensive collection of healthcare industry-focused data comprised of both historically-significant resources as well as the most recent information available. iMBA Inc’s specific, in-depth knowledge and understanding of the “value drivers” in various healthcare markets, in addition to the transaction marketplace for healthcare entities, will provide you with a level of confidence unsurpassed in the public health, health economics, management, administration, and financial planning and consulting fields. iMBA Inc’s information resources and network of healthcare industry textbook resources enhanced by our professional consultants and research staff, ensure that the iMBA project team will maintain the highest level of knowledge regarding the current and future trends of the specific specialty market related to the project, as well as the healthcare industry overall, which serves as the “foundation” for each of our client engagements.
Considered for years to be a “duopoly” over the advertising industry, they are on track to account for only 48.4% of US ad revenues this year. It’s the first time their market share has fallen below 50% since 2014, per Insider Intelligence.
Initial claims for state unemployment benefits rose 9,000 to a seasonally adjusted 225,000 for the week ending December 24th, the Labor Department reported, in line with the median estimate among economists polled by Reuters. Meanwhile, the number of people receiving benefits after an initial week of aid rose 41,000 to 1.710 million in the week ending December, 17th, 2022.
Meanwhile, Amazon stock closed the December 22 trading session at $83.79, which represents a 49.7% drop compared to December 31, 2021. This is the lowest closing level for the Amazon stock since March 12, 2019. Basically, the group, founded by Jeff Bezos, has completely erased all the gains during the two years when strict restrictions were put in place to limit the spread of COVID-19. It closed today at $84.18.
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Finally, U.S. stocks rose sharply, ending a two-session losing streak, though trading volumes remain subdued in the final days of the year. The heavyweight Information Technology sector led the rally, rebounding from a recent drop that has weighed on the markets this week. The equity front continued to offer little in terms of headlines, though shares of Cal-Maine Foods fell after the company missed earnings estimates.
The economic calendar introduced labor data, as jobless claims ticked slightly higher compared to the prior week.
Treasury yields were mixed, the U.S. dollar dropped, crude oil prices were lower, and gold traded higher.
Asian stocks finished mostly lower after yesterday’s downturn in the U.S., while markets in Europe were higher despite uncertainty regarding the ultimate global impact of aggressive monetary policy tightening across the world.
U.S. equities were mixed on the first trading session of the week following the long holiday weekend. The markets reacted to a host of economic data that was released, as home prices decreased on a seasonally adjusted basis, the trade deficit narrowed much more than expected, wholesale inventories increased, and manufacturing activity in the Dallas region contracted more than predicted.
Equity news was light, but shares of Southwest Airlines declined after the U.S. Department of Transportation said that it would examine the mass flight cancellations and delays. Additionally, Tesla’s shares fell after the company announced that it plans on running a reduced production schedule at its Shanghai factory.
Treasury yields continued to rise, and the U.S. dollar dipped, while crude oil prices were little changed, and gold was solidly higher.
Asian equities increased, led by mainland Chinese stocks, after the Chinese government announced that it would put an end to quarantine restrictions for inbound travelers effective early January.
Markets in Europe were mixed amid improved sentiment in the wake of the news.
Value of a $1,000 investment in Microsoft’s IPO today
Microsoft completed its initial public offering (IPO) on March 13, 1986, at a price of $21 per share. Since then, the company has grown so valuable, and its stock price has soared so high, that management opted to conduct nine stock splits over time to ensure its shares remained accessible to small investors.
Had you invested $1,000 in Microsoft at its IPO, you would have acquired 47 shares at $21 per share. Adjusting for the stock splits, you’d actually have 13,536 shares today with a cost basis of $0.0729 per share.
Given Microsoft now trades at $238.73 per share, that translates to a return of 327,401%.
In dollar terms, that $1,000 investment in 1986 would be worth a whopping $3.23 million today. But it gets better, because Microsoft has paid a dividend since 2003 — and assuming you never sold a single share along the way, you’d have also received $341,513 in dividends.
Given Microsoft continues to pay a quarterly dividend of $0.68 per share, you would still be collecting a cool $36,817 each year, or 36 times your initial $1,000 outlay. That’s the power of long-term investing.
The bargain-hunting value style is looking for shares that are under priced in relation to the company’s future potential. A value investor will invest in a company in the expectation that its shares will increase in value over time. Value investing is based essentially on quantitative criteria; asset values, cash flow, and discounted future earnings. The key properties of value shares are low Price/Earnings, Price/Sales ratios, and normally higher dividend yields.
So, on observing a company’s earnings growth, a value manager will decide whether to buy shares based on the company’s consistency or recovery prospects. The key research questions are: 1) Does the current P/E ratio warrant an investment in a slow growth company or, 2) Is the company a higher growth candidate that has dropped in price due to a temporary problem. If this is the case, will the company’s earnings growth recover, and if so, when? The key to value investing is to find bargain shares (priced low historically or for temporary and/or irrational reasons), avoiding shares that are merely cheap (priced low because the company is failing).
The buying opportunity is identified when a company undergoing some immediate problems is perceived to have good chances of recovery in the medium to long term. If there is a loss in market confidence in the company, the share price may fall, and the value investor can step in. Once the share price has achieved a suitable value, reflecting the predicted turnaround in company performance, the shareholding is sold, realizing a capital gain. A potential risk in value investing is that the company may not turn around, in which case the share price may stay static or fall.
Happy Holidays from the Institute of Medical Business Advisors, Inc
At this special time of year, we give thanks for our clients and our employees, as well as all essential workers in hospitals, health centers and medical practices across the country.
May the holiday spirit be with you and your family throughout the season and everyday We look forward to serving you in 2023.
he emerging Omicron subvariant XBB contributes to an increasingly high number of COVID-19 cases in the U.S., rivaling the sister strains BQ.1.1 and BQ.1, according to the latest estimates from the Centers for Disease Control and Prevention (CDC).
Recent studies have indicated that the updated bivalent COVID-19 booster performed poorly against BQ.1.1, with even a weaker antibody response against XBB.
In late November, citing its poor neutralization effect on BQ.1 and BQ.1.1., the FDA pulled the emergency use authorization granted for bebtelovimab, a COVID-19 antibody therapy developed by Eli Lilly (LLY) and AbCellera Biologics (ABCL).
The CDC estimates for the week ending Dec. 24 show that XBB has made up ~18% of COVID cases in the U.S. compared to ~11% a week ago. Meanwhile, BQ.1.1 has led to ~36% of cases unchanged from a week ago, and BQ.1 caused ~27% of cases, a decline from ~29% last week.
Blue Cross Blue Shield has deployed several trackers on its website, according to the web extension Ghostery, a tool that can tell you what kind of technology web pages are using.
Ghostery returned a list of trackers from Twitter, Google, and LinkedIn.
Though we don’t know specifically what kind of data is being transferred, these pixels are usually installed to help marketing departments. Tracking pixels, for the uninitiated, are hidden or embedded graphics that can give a more complete picture of a customer’s journey: what they’ve clicked on, if they’ve searched for something specific, if they’ve put something in a shopping cart, or whether an advertisement drove them to, say, Blue Cross Blue Shield’s homepage. For example, if an insurer wants to show that its ads are working, it can use a pixel to determine that it was their ad that got someone to finally sign up for health insurance, not Susan in HR.
Trackers are ubiquitous, but experts and consumers have raised serious questions about the data that’s shared between companies. For example, investigative reporting outlet The Markup found that hospitals shared sensitive information with Facebook through the Meta pixel. And just this month, Indianapolis-based Community Health Network reported that pixels may have affected 1.5 million of its patients.
For more, read Marketing Brew’s interview with sociologist Mary F.E. Ebeling, who wrote a book about the collection of sensitive health data.
As I read Predictably Irrational by Dan Ariely, I found his ideas not only enlightening to understand my own predictable irrationality but also to think through ideas on motivation and change management for our teams. 1️⃣ Context matters – we find it hard to understand things in absolute terms so explain value in relative terms […]
The decision to sell, buy or merge a medical practice, while often financially driven, and is inherently an emotional one for these impact investors who went into the profession largely because of a deep seated zeal to help others.
Still, beyond impact investing musings, there are other economic reasons for a practice valuation that include changes in ownership, determining insurance coverage for a practice buy-sell agreement or upon a physician-owner’s death, organic growth meter, establishing stock options, or bringing in a new partner; etc.
Practice appraisals are also used for legal reasons such as divorce, bankruptcy, breach of contract and minority shareholder complaints. In 2002, the Financial Accounting Standards Board (FASB) issued rules that required certain intangible assets to be valued, such as goodwill. This may be important for practices seeking start-up, service segmentation extensions, or operational funding. Some other reasons for a medical practice appraisal, and the considerations that go along with them, are discussed here.
Medical practice valuation may be required for estate planning purposes. For a decedent physician with a gross estate of more than current in-place tax limits, his or her assets must be reported at fair market value on an estate tax return. If lifetime gifts of a medial practice business interest are made, it is generally wise to obtain an appraisal and attach it to the gift tax return.
Note that when a “closely-held” level of value (in contrast to “freely traded,” “marketable,” or “publicly traded” level) is sought, the valuation consultant may need to make adjustments to the results. There are inherent risks relative to the liquidity of investments in closely held, non-public companies (e.g., medical group practice) that are not relevant to the investment in companies whose shares are publicly traded (freely-traded). Investors in closely-held companies do not have the ability to dispose of an invested interest quickly if the situation is called for, and this relative lack of liquidity of ownership in a closely held company is accompanied by risks and costs associated with the selling of an interest said company (i.e., locating a buyer, negotiation of terms, advisor/broker fees, risk of exposure to the market, etc.). Conversely, investors in the stock market are most often able to sell their interest in a publicly traded company within hours and receive cash proceeds in a few days. Accordingly, a discount may be applicable to the value of a closely held company due to the inherent illiquidity of the investment. Such a discount is commonly referred to as a “discount for lack of marketability.”
Discount for lack of marketability is typically discussed in three categories: (1) transactions involving restricted stock of publicly traded companies; (2) private transactions of companies prior to their initial public offering (IPO); and, (3) an analysis and comparison of the price to earnings (P/E) ratios of acquisitions of public and private companies respectively published in the “Mergerstat Review Study.”\
With a non-controlling interest, in which the holder cannot solely authorize and cannot solely prevent corporate actions (in contrast to a controlling interest), a “discount for lack of control,” (DLOC), may be appropriate. In contrast, a control premium may be applicable to a controlling interest. A control premium is an increase to the pro rata share of the value of the business that reflects the impact on value inherent in the management and financial power that can be exercised by the holders of a control interest of the business (usually the majority holders). Conversely, a discount for lack of control or minority discount is the reduction from the pro rata share of the value of the business as a whole that reflects the impact on value of the absence or diminution of control that can be exercised by the holders of a subject interest.
Several empirical studies have been done to attempt to quantify DLOC from its antithesis, control premiums. The studies include the Mergerstat Review, an annual series study of the premium paid by investors for controlling interest in publicly traded stock, and the Control Premium Study, a quarterly series study that compiles control premiums of publicly traded stocks by attempting to eliminate the possible distortion caused by speculation of a deal.
Buy-Sell Agreements
The ideal situation is for physician partners to put in place a buy-sell agreement when practice relationships are amicable. This establishes the terms for departure before they are required, and is akin to a prenuptial agreement in the marriage contract. Disagreements most often occur when a doctor leaves the group, often acrimoniously. Business operations of the practice decline, employee and partner morale suffers, feuding factions develop spilling over into the office, and the practice begins to implode creating a downward valuation spiral. And so, valuations should be done every 2-3 years, or as the economic circumstances of the practice change. Independence and credibility are provided, and emotional overtones are purged from the transaction.
Physician Partnership Disputes
Medical practice appraisals are often used in partnership disputes, such as breach-of-contract or departure issues. Obvious revenue declinations are not difficult to quantify. But, revenues may not immediately fall since certain Current Procedural Terminology [CPT®] code reimbursements may actually increase. Upon verification however, lost business may be camouflaged as the number of procedures performed, or number of patients decrease after partner departure.
Physicians getting divorced should get a practice appraisal, and either side may hire the appraiser, although occasionally the court will order an expert to provide a neutral valuation. Such valuations should be done in light of both court discovery rules and IRS requirements for closely held businesses. Generally, this requires the consideration of eight elements:
• Practice specialty and operating history
• Economic and healthcare industry condition
• Estimates of practice risks and future returns
• Book value and financial condition of the practice
• Practice future earning capacity
• Physician bonuses, dividends and distributions
• Intangible assets
• Comparable practice sales
Sometimes, the non-physician spouse may even desire a lifestyle analysis to evaluate the potential for under reported income, by a forensic accountant, or appraiser. A family law judge is often the final arbiter of different valuations, and because of varying state laws there may be 50 different nuances of what the practice is really worth.
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U.S. stocks fell amid a host of monetary policy decisions globally. The markets continued to digest the economic implications of yesterday’s 50-bp rate hike from the Fed, which was followed by 50-bp increases from the European Central Bank, Bank of England, and Swiss National Bank earlier today. The economic calendar provided a host of data, as retail sales decreased more than expected, industrial production declined, and manufacturing activity in New York and Philadelphia both contracted, though jobless claims moderated much more than expected.
The equity front was relatively quiet, but Lennar Corporation posted mixed results and offered some cautious guidance, while Netflix saw pressure from a report about softer-than-expected ad-supported viewership.
Treasury yields were lower, and the U.S. dollar gained ground, while crude oil prices declined, and gold dropped. Asian and European stocks finished broadly lower, as the global markets digested mixed data and a flood of monetary policy decisions around the world.
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The DJIA Briefly surged over 600 points this morning.
WHY DOW?
Inflation data showed the Consumer Price Index rose 0.1% on the month of November, cooler than the expected 0.3% rise. The index rose 7.1% year over year, lower than the 7.3% Econoday estimate.
In addition, the next meeting Fed meeting kicks off Tuesday with an interest rate decision on Wednesday. While the Fed has already heavily telegraphed a 50-basis-point hike, investors will be looking for further guidance on the Fed’s plans.
Finally, according to the CME’s FedWatch tool, traders place a 79% chance of a 50-basis-point rate hike.
This could be the revolutionary tool drug companies have been waiting for
By MIT Tech Review
Mendelian randomization could help bypass large-scale clinical trials by focusing on the genetics of patients.
The backstory:
For years, medical researchers have noted the presence of markers alongside certain traits. For instance, it’s known that a high presence of HDL is tied to a lower risk of heart attacks. But what wasn’t always known was whether the HDL caused the healthy heart, or was just correlated with it.
The breakthrough:
As Gary Taubes explains for us, researchers say that by employing innate genetic differences between people—an inborn susceptibility to alcohol, say, or to higher cholesterol levels in the arteries—they can now mimic, at much less effort and expense, the kinds of large trials that would be necessary to determine if an HDL-lowering medicine is really beneficial.
Random facts:
The new technique, called Mendelian randomization, is already being used by drug companies to make billion-dollar decisions about which drugs to pursue.
Conclusion
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In statistics, a confounding variable (also confounding factor, a confound, or confounder) is an extraneous variable in a statistical model that correlates (directly or inversely) with both the dependent variable and the independent variable.
IOW: It is an extraneous variable whose presence affects the variables being studied so that the results you get do not reflect the actual relationship between the variables under investigation.
Kevin O’Leary should stick to investing in things like pimple popping toys.
The Shark Tank’s “Mr. Wonderful” admitted he was paid $15 million to act as FTX’s spokesperson. And of the ~$9.7 million he put into crypto, “it’s all at zero,” he told CNBC.
Like Tom Brady and other celebs, O’Leary hyped FTX on social media and TV over the past year; now, he’s being named in a class-action lawsuit over the exchange’s implosion.
“Physicians who don’t understand modern risk management, insurance, business, and asset protection principles are sitting ducks waiting to be taken advantage of by unscrupulous insurance agents and financial advisors; and even their own prospective employers or partners. This comprehensive volume from Dr. David Marcinko and his co-authors will go a long way toward educating physicians on these critical subjects that were never taught in medical school or residency training.” —Dr. James M. Dahle, MD, FACEP, Editor of The White Coat Investor, Salt Lake City, Utah, USA
“With time at a premium, and so much vital information packed into one well organized resource, this comprehensive textbook should be on the desk of everyone serving in the healthcare ecosystem. The time you spend reading this frank and compelling book will be richly rewarded.” —Dr. J. Wesley Boyd, MD, PhD, MA, Harvard Medical School, Boston, Massachusetts, USA
A Required Minimum Distribution (RMD) is an amount of money the IRS requires you to withdraw from most retirement accounts, beginning at age 72. Due to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, RMDs were not required in 2020, but RMDs are required in 2021 and each year after. RMDs can be an important part of your retirement income strategy.
TO H.R. RECRUITERS, UNIVERSITY HIRING MANAGERS & SEARCH COMMITTEES
Sooth My Academic Teaching and Classroom Withdrawal Pangs!
I’m screening for my next university Dean, Chair or teaching Professorship opportunity.
Currently, an endowed Resident-Scholar completing a text book production assignment complete with aligned case models, tests, quizzes, rubrics, curriculum teaching portfolio, and accreditation review.
Two-decades of domestic and international teaching experience and credentials in health economics, finance, investing, business, policy, risk management, IT and administration. Hundreds of peer-reviewed and trade publications [TNTC] with 30 major textbooks redacted in more than a thousand university libraries [NIH, Library of Congress and National Institute Health, etc]. Public and population health global speaker and thought leader. Wall Street experience as start-up founder, entrepreneur and CXO.
Ideal mentor for under graduate thru post-doctoral and fellowship students [PhD, DBA, MD/DO, MHA and MBA, etc].
Compensation important, but fit is paramount as servant-leader. [+] RANKED: Google Scholar and “H” Index CV available upon request.
Call for Manuscripts, Articles, Essays, Comments or Opinions,
Dear Medical and Financial Services Colleagues, Health Economists, CPAs, JDs, Insurance Agents and Consultants
The Medical Executive-Post (ME-P), supported by iMBA Inc., with (ISSN 13: 978-1-4665-5873-1] is currently accepting manuscripts for publication.
The ME-P is an open access, multidisciplinary, international, blind peer-reviewed and non-peer-reviewed electronic forum which publishes high-quality solicited and unsolicited research, commentary, opinions, curated news and review articles in English, in all areas of Physician Focused Financial Planning, health economics, finance, accounting, medical practice management, health law, IT, policy and administration.
The Free Market Medical Association Promotes Transparency in Healthcare
The free market movement in healthcare is gaining steam. This is because of providers, patients, and self-funded employers, who believe that changing the way we purchase healthcare services is necessary, and seeking out value driven healthcare providers is important.
Matching a willing buyer with a willing seller of valuable healthcare services is the goal of everyone involved in this movement. We help identify patients willing to pay cash, doctors willing to list their prices, businesses attempting to provide affordable quality insurance, and providers/services/and patient advocates that are helping make everything work.
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Assessment
To further promote this movement, the FMMA is dedicated to bringing together BUYERS and SELLERS.
And, our Publisher-in-Chief, Dr. David E. Marcinko MBA will be joining FMMA soon. Will you join, too?
Conclusion
Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.
Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com
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