A MEDICAL “TREATMENT PLAN” APPROACH

By David Edward Marcinko, MBA, CMP®

SPONSOR: http://www.CertifiedMedicalPlanner.org

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MEDICAL TREATMENT PLAN: A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and possible side effects, and the expected length of treatment.

CITE: https://www.r2library.com/Resource/Title/082610254

COMMON INVESTING MISTAKES

Fees are down, expenses are up and the days of fat profit margins for physicians are over. Managed care in some form is here to stay. The tidal wave of baby boomers approaching retirement suggests the pendulum will not swing back to the “good old days” of fee-for-service medicine. Even the venture capitalists are laying off doctors because of the corona virus pandemic. And, the ACA and U.S. government, the payer for more than 50 percent of the covered population, continues to ratchet down reimbursement. Accordingly, many doctors are now working harder than ever. Unfortunately, they are also prone to irrational investing behavior and making more investment mistakes than ever before.

Here are the Institute of Medical Business Advisors’ “dirty dozen” investing blunders of physicians. Indeed, we see these common miscues among a variety of medical professionals.

Mistake 1: Having No Investment Policy Statement
Just as one would not think of treating a patient without a careful history and physical examination, you should not embark on investing your hard earned capital without an investment policy statement (IPS). This important document separates do-it-yourself investors, financial salesmen, stockbrokers and amateurs from true financial professionals.

An IPS is a document specifically detailing what you want your money to do for you with an understanding of who is to do what and how they are supposed to do it. It may be three to five pages long for an individual physician, 10 to 15 pages for a small medical group retirement plan or dozens of pages for a clinic or hospital endowment fund.

Treatment plan: A properly written IPS should contain the following:
• Statement of purpose
• Statement of responsibilities
• Investment goals and objectives
• Proxy voting policy
• Trading and execution guidelines
• Asset mix guidelines
• Social policies or other restrictions
• Portfolio limitations
• Performance review benchmarks
• Administration and fee policy
• Communication policy
• Reporting policy

Mistake 2: Not Diversifying Portfolio Objectives
Although the media frenzy of a few years ago has subsided, anecdotes of easy money still abound and doctors may forget that investment portfolios serve a specific purpose (e.g., retirement, college funding, etc.) within the content of a broader financial plan. Moreover, a single investment may become too large or too small a portion of the portfolio. This may be due to market growth in one component or slack in another.

Treatment plan: Diversify, monitor your holdings and select components with your risks and goals in mind. Time horizon and risk tolerance are likely to change as will the investment environment. One key contribution of modern portfolio theory (MPT), according to the 1990 Nobel Prize winner Professor Harry Markowitz, PhD, is the understanding that diversification can reduce portfolio risk. Indeed, the specific risk of a single stock may overwhelm any justification for failing to diversify.

Consider investing in sectors like basic materials, capital goods, communications and services, technology, consumer cyclicals and non-cyclicals, healthcare, energy, financial services and utilities. Investors can purchase most as individual securities, in mutual funds or as exchange traded funds (ETFs) or worldwide equity benchmark shares. Do not forget about cash equivalents, treasuries, zero coupon and municipal bonds and international securities.

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Mistake 3: Forgetting The Investing Risk/Return Tradeoff
Some physicians fall into the trap of chasing “hot” securities like hedge funds, limited partnerships, non-registered securities or alternate investments promising high returns. High returns are associated with increased investment risk. Accordingly, it is important to understand the risks embedded in an investment before it becomes an exposed reality.

Treatment plan: Beware of projecting historic averages going forward. The stock market is inherently volatile. While it is easy to rely on past historic averages, there are long periods of time where returns regress from their long-term historic mean. On the other hand, slumps eventually correct themselves so you should continue a prudent investing plan.

Do not confuse investing with trading or speculation. According to Gene Schmuckler, PhD, the Director of Behavioral Finance for the Institute of Medical Business Advisors, Inc., there are momentum-driven market periods when investors start to believe profits are easy and there is always a “greater fool” to buy at a higher price. Such trading has more in common with gambling than investing. Avoid market timing and the urge to jump in or out at every economic hiccup.

Mistake 4: Not Factoring In The Impact Of Taxes
The desire to avoid capital gains and other taxes as a result of solid investment returns may lull some doctors into a false sense of security. An attractive investment and a slick sales pitch sometimes hide the underlying tax costs of the investment, especially when the investment is questionable. This leads doctors to give up a significant portion of the long-term growth of their assets.

Treatment plan: Income tax brackets, rates and estate taxes are almost at an all-time low in the U.S. This good fortune is due in part to the Taxpayer Relief Act of 1997, the Economic Growth and Tax Relief Reconciliation Act of 2001, and the Job and Growth Tax Relief Reconciliation Act of 2003, among other tax credits and deductions. Some mutual funds, for example, are not tax efficient while some ETFs may be tax efficient. Strive for legitimate tax reductions and avoidance but remember that tax evasion is illegal.

Mistake 5: Not Factoring In Fees And Expenses
Front-end loads, back-end loads, disappearing and hidden loads, 12-b1 fees and commissions, and advertising and sales expenses can all have a significant impact on a particular investment program.

Treatment plan: Monitor the costs of your investment program to ensure that total costs are known, reasonable for the services provided and are not consuming a disproportionate amount of the investment returns. Carefully consider full-service versus discount brokerages.

Take care using discretionary assets under management (AUM) accounts where you pay a percentage for personalized money management. More often than not, these one-size-fits-all accounts are aggregated under a larger automated umbrella to harvest economies-of-scale automatically. Indeed, the mistaken notion that the advisor “is sitting on the same side of the investment table as you” starts deteriorating on critical reflection. Do not fall for the siren sales pitch (“If I make money, you make money”). Excessive risk taking, purchases and sales activity may be at your expense.

Carefully consider whether golf balls, seminars, football game tickets, pens or quarterly meetings with your “advisor” are worth the price you may ultimately pay for these minor trinkets and services.
For example, in a 2 percent AUM program of $1 million, you may pay $20,000 annually, which is automatically deducted from the account. Are these “perks” worth $200,000 over the course of a decade? During the “golden age of medicine” in the ‘80s or the ranging bull market of the ‘90s, some doctors may have thought it was worth it. What about during a bear market or the projected market of lower than average returns that may be upon us?

Other problems with AUMs include: a higher fee to managed stocks than bonds, creating an equity bias; bias against paying of the mortgage, practice or acquiring real estate; bias against gifting initiatives or charitable intent. These are all problematic for the same reason that over-weighted equity classes increase advisor compensation while these other equally important considerations do not.

Mistake 6: Inappropriate Risk-Management Techniques
Traditionally, physicians protected their families with life, disability, malpractice and business interruption insurance yet insurance products are not investment vehicles. They merely indemnify against catastrophic economic losses that are typically extinguished over time. Behavioral economists like Daniel Kahneman, PhD, of Princeton University, and Vernon L. Smith, PhD, of George Mason University, warn us to use these insurance products carefully since we tend to experience financial losses more intensely than gains and evaluate risks in isolation.

Additionally, a comprehensive risk management plan for doctors must acknowledge risks such as sexual harassment risks; workplace violence risks; Medicare documentation, recoupment and compliance risks; and the economic risks of divorce. There is also a plethora of acronymic risks such as the Health Insurance Portability and Accountability Act (HIPAA), the Occupational Safety and Health Administration (OSHA) Act, and many others.

Treatment plan: Be willing to abandon ancient thoughts and remain open to new ideas that identify and provide solutions to the contemporaneous insurance problems of physicians. As an example, in 2001, economist Christian Gollier, PhD, of the University of Geneva, asked, “Should one even buy personal insurance since the industry itself is so skilled at exploiting human foibles?”

Mistake 7: Inappropriate Insurance Agent
It is no surprise that goaded physicians might prefer insurance vehicles like the guaranteed minimum death benefit of variable annuities or traditional cash value life insurance policies despite their high costs, huge commissions and lower returns. Agents sell these products and they work for the insurance company, not for you. Basic insurance agent credentials include the chartered financial consultant and chartered life underwriter designations, but they may remain product salesmen.

Treatment plan: Always beware the fear-mongering insurance agent salesman as the flowing coverages may be unnecessary, too expensive, provide only minimal benefits or be duplicated in other insurance policies. These include credit life or home mortgage insurance (decreasing term), life insurance for children or the elderly, accident policies for students, hospital indemnity policies, dread disease insurance, credit card insurance, pet, flight or funeral insurance, prepaid legal insurance, trip cancellation, flood, earthquake and termite insurance, and most appliance extended warranties.

Instead, consider a licensed insurance advisor or insurance counselor who sells no products, accepts no commissions and charges by the hour, all while shopping for the best companies and rates for the risk being researched. A fiduciary focused Certified Medical Planner® may be even better.

Mistake 8: Selecting The Wrong Accountant
When asking for the value of a practice, ask specifically for the fair market value (FMV). One podiatrist who consulted us asked her accountant for the “value” of her practice and received its lower “book value” rather than the higher fair market value as a profitable ongoing concern. The MD lost tens of thousands of dollars in a subsequent sales transaction. Unfortunately, although the CPA produced correct figures for exactly what she requested, the doctor did not differentiate between the two terms. Later legal mediation determined that neither was responsible for the linguistic error as both parties acted in good faith. Of course, the doctor paid dearly for her mistake.

Treatment plan: Dr. Gary L. Bode, CPA, MSA, a former medical practitioner and CFO for iMBA, Inc., suggests that you take the time to discuss wants and needs with your accountant. Those from the National CPA Healthcare Advisors Association (www.hcaa.org) or the Healthcare Financial Management Association (www.hfma.org) may also increase your comfort level through additional medical expertise. Better yet, contact an experienced medical practice valuation expert or healthcare economist.

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Mistake 9: Not Having Your Practice Professionally Valuated [not appraised]
The sale or purchase of a medical practice may be the most important investment decision of your life. We have observed neurotic purchasers who spend far too much time, money and energy researching a fairly priced and modest practice to no avail (paralysis of analysis). Others have purchased exorbitantly priced practices for over $1 to $2 million on a handshake and promise. Accordingly, give this complex task the gravitas due, and run from those who would broker your sale with a “free” or “Internet-based valuation,” or provide “finance participation” schemes for purchase as a young practitioner.

According to IRS Revenue Ruling 59-60, the value of any medical practice is generally based upon the following:
• level of expected distribution and future cash flows;
• time of expected distributions and cash flows; and
• uncertainty of the expected cash flows and distributions.

Moreover, one should recall that a valuation is not a source document audit. Know specialty and industry economic conditions, trends, operating history, physician bonuses, dividends, distributions and comparable practice sales. A commission or percentage-based fee is considered unethical and may be illegal.

Accounting book value is not the same as a fair market valuation. Do not use back-of-the envelope trade magazine “multiplier methods” and obtain only Uniform Standards of Professional Appraisal Practice (USPAP)-styled valuations, which were first issued by the IRS in 1994-1995.

Combine the recognized USPAP-IRS valuation methods: income method with discounted cash flow analysis, market method and cost approach. Be sure to adjust financial statements in order to normalize each line entry. You must do the discounted cash flow analysis (DCFA) on an after-tax basis and base proper assumptions on physician compensation market rates.

Understand the intangible difference between personal and business goodwill, major premiums and minority control discounts.

Doing a walk through of the practice is mandatory for your protection. Trust but verify tangible assets and liabilities, estimates of practice risks, economic assumptions and future earning capacity.
Obtain a separate and independent real estate appraisal if necessary.

Make sure the valuation is written, substantiates value, supports conclusions and is signed by an appraiser who will defend the valuation in court as a qualified expert witness if necessary. This certification is formally known as an “opinion of value” and the only type we perform.

Remember to obtain two independent valuations, one for the buyer and one for the seller, and pay for each separately.

Treatment plan: Have the financing lined up before you buy a practice. The three major impediments to loan acquisition are school loan debt, a home mortgage and an automobile note in that order So, strive to reduce or eliminate them before applying for a loan. Hire licensed appraisal professionals with publishing, teaching and/or academic experience. Do not hire brokers or commissioned agents.
Organizations that accredit businesses but not necessarily medical practice appraisers include:

• The Institute of Business Appraisers (www.go-iba.org) awards the certifications of certified business appraiser and business valuators accredited in valuation.
• The National Association of Certified Valuation Analysts (www.nacva.com) awards the designations of certified valuation analysts and accredited valuation analysts.

Well-known medical practice and healthcare system appraisers include the big 10 consulting firms for hospitals and national healthcare systems. However, the Arthur Andersen debacle confirms that “bigger is not always better.” Medical practice niche players include Health Capital Consultants, LLC, (www.healthcapital. com), which provides large- and medium-sized practice valuations.

The Institute of Medial Business Advisors Inc, (www.MedicalBusinessAdvisors.com) specializes in small to medium practices, emerging healthcare organizations, clinics and ambulatory surgery center valuations and confers the designation Certified Medical Planner® on its independent consultants, appraisers and advisors.

Mistake 10: Selecting The Wrong Attorney
Consider the bizarre tale of the two fledgling internist partner/classmates who signed an attorney-prepared, buy-sell agreement upon creation of their nascent practice 30 years beforehand. The agreement stipulated that upon departure or dissolution, the remaining partner’s ownership would be determined not by some periodically updated valuation formula or appraisal process, Instead, it would be determined by a “matched and lost” process, also known as the “flip of a coin” for a medical conglomerate now worth over $1 million.

Treatment plan: Select a health law attorney and not your brother-in-law. More importantly, experience in the medical arena counts. Consult iMBA, Inc. or the American Health Lawyers Association (www.healthlawyers.org) as a referral resource.

Mistake 11: Blind Trust Of Wall Street And Financial Advisors
Stockbroker salesmen and the big brokerage houses that underwrite and recommend stocks may have credibility problems and some physicians get burned with the adrenaline rush of “self-directed” portfolios. Presently, both the Security Exchange Commission (SEC) and National Association of Securities Dealers are investigating far too many insurance companies and major wire houses for reverse churning (charging a fee on assets for which the stockbroker is providing virtually no services) and/or double dipping (charging an ongoing fee on mutual funds on which the client already paid a substantial commission).

No one knows for sure how to mitigate such shenanigans since human nature and self-interest are involved. Rest assured that the economic cycle will never be repealed and you must beware the four most dangerous words on Wall Street: “This time, it’s different.” Yet some believe the answer may lay with the independent fee-only advisor who charges by the hour, by the engagement, or pro re nata for advice.
Beware of taking the advice of a financial advisor carte blanche. The prime duty of a financial advisor should be to clients. Yet the very term “financial advisor” has no real academic or consistent meaning in the industry. The only hurdle to becoming one is passing a simple securities industry or state insurance sales licensing examination. Most are brokerage and agency employees with a duty to their respective firms, not you.

Treatment plan: Commissioned stockbrokers are fine to use if their fees are transparent and they offer value to you. However, be aware that Wall Street sales mavens and large broker-dealers (wire-houses) recently lobbied Congress not to be responsible to you after the sale. The Financial Planning Association is suing the SEC over this proposal to exempt the nation’s largest wire-house brokerages from certain fiduciary responsibilities associated with investment advisory regulations.

To avoid selecting the wrong financial advisor, choose an independent advisor who takes pride in fiduciary responsibility, knows the medical profession and eschews product sales commissions whenever possible. Such a professional is more than deserving of a fee. Do not hesitate to pay it.

To determine if your current advisor is the right choice, just ask to see the documents below:
• form ADV parts I and II;
• sample investment policy statement;
• registered investment advisor or series #65 investment advisory license
• CMP® license number;
• ethics requirement or attestation statements; and
• advanced degrees and designations, etc.

Some CMPs® and fee-only financial advisors possess these professional certifications as required. Stockbrokers, salesmen, intermediaries and insurance agents may not. All monikers suggest but do not guarantee impartiality and a lack of bias. Also make sure your financial advisor is experienced in the rapidly changing healthcare industrial complex.

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Mistake 12: Lack Of A Complete Financial Plan
While many doctors have an investment portfolio, few have a comprehensive personal financial plan, especially one designed for medical professionals.

Treatment plan: Typically such plans consider the risk tolerance and time frame of several standard components such as insurance, taxation, investing, retirement and estate planning. Today’s practicing physicians should direct attention toward practice enhancement, economic risk management, valuations, charitable giving and succession planning. All should be interrelated in an economically sound manner and not be counterproductive to individual components of the plan.

In Conclusion
Often, successful investing and avoiding a life of economic servitude is simply a matter of delayed gratification and mistake avoidance rather than investing acumen. A good rule of thumb is to pursue fundamentals over fads and seek wise counsel when required.

About the Author

Dr. Marcinko is a Certified Financial Planner and Certified Medical Planner® and CEO for www.MedicalBusinessAdvisors.com, sponsor of the Certified Medical Planner charter designation program. He can be reached by phone at (770) 448-0769 or by e-mail at MarcinkoAdvisors@msn.com.

References:

References
1. Marcinko DE. Financial planning for Physicians and Advisors. Jones and Bartlett Publishers, Sudbury, Mass., 2005.
2. Marcinko DE. Insurance and Risk Management Strategies for Physicians and Advisors. Jones and Bartlett Publishers, Sudbury, Mass., 2005.

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