PHYSICIANS BEWARE: Traditional Financial Planning “Rules of Thumb”


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By Dr. David E. Marcinko MBA CMP®


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  • 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.
  • Great Health Industry Resignation:

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 colleagues and life insurance.



EXAMPLES: Old/New Rules

  • 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:

Compensation in the Physician Specialties: Mostly Stable - NEJM  CareerCenter Resources

RULES 72, 78 and 115:




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The DUPONT Decomposition Equation for ROI


DEM blue

By Dr. David E. Marcinko MBA CMP


According to the Dupont Decomposition Equation – which involves the conglomeration of net operating income, revenues, expenses and average operating assets – ROI and economic profit is increased in three prioritized ways:

  1. Cost and expense reductions.
  2. Revenue increases [Rev]
  3. Reduced average operating assets [AOO]

Note: ROI = NOI / Rev X Rev / AOO

Cost and expense reductions

Although many hospitals have reduced expenses, postponed projects and put clinical or information technology projects on hold because of the MU conundrum, this may be unwise and quality may suffer. And, mental health care programs are almost always the first cost center to be reduced in tough times.

Upgrades today, especially with concurrent marketing and advertising promotions, may well be considered a strategic competitive advantage, and at bargain basement prices for those with cash or credit. This cost reduction is easy because it gives the biggest buck-bang in the ROI equation, and is the first line of ROI augmentation by savvy administrators and CEOs. It is also intuitive and wholly “wrung-out” in the marketplace, to date.

Revenue increases

On the other hand, revenues can usually be only incrementally increased by improving services like emergency care, urgent care, wellness, out-patient and/or surgical departments. This is the more difficult part of the equation and yields a positive, but lesser return in the ROI equation.


DuPont Formula: Learn More At Accounting Play

Three Modern Collections Rules for Hospitals

The following medical practice procedures will markedly increase upfront office collections:  

  • Train staff to handle exceptions. What is your policy if the patient payment is significant? Will you allow 25% payments—one today and three over the next three months? Communicate your policy to all staff. What will you do if a patient shows up without an insurance card? There will be other exceptions. Train employees to call the appropriate practice-management contact when an exception does not fit in the categories you provide and make sure those managers are responsive.
  • Understand that not everyone will shine in collections. The value of this new front-desk function should be reflected in job descriptions and wages. Track staff performance and hold employees accountable for collection goals. The most successful practices collect in the 90% range.
  • Provide professional signage that states your basic policy. “Payments are due at time of service.” Avoid typewritten, lengthy explanations taped to walls or desks that look like clutter.

Reduced average operating assets

Finally, any delay in updating facilities – while easy and may reduce operating assets – there is little ROI advantage and profit potential. Of course, facility asset upgrades mean borrowing funds through tax-exempt bonds – the main source of debt for most hospitals – and is currently difficult or impossible in this climate. Loans from banks, private investors, angels, venture capitalists or other financial institutions are similarly difficult to obtain. Thus, this part of the equation may often be neglected; as is the case now.






Managing for Endowment Fund Portfolio Alpha

Understanding Non-Systematic Return on Investment

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DEM 2013

[By Dr. David Edward Marcinko MBA]

According to Wayne Firebaugh CPA, CFP®, CMP™ alpha measures non-systematic return on investment [ROI], or the return that cannot be attributed to the market.

It shows the difference between a fund’s actual return and its expected performance given the level of systematic (or market) risk (as measured by beta).


For example, a fund with a beta of 1.2 in a market that returns 10% would be expected to earn 12%. If, in fact, the fund earns a return of 14%, it then has an alpha of 2 which would suggest that the manager has added value. Conversely, a return below that expected given the fund’s beta would suggest that the manager diminished value.

In a truly efficient market, no manager should be able to consistently generate positive alpha. In such a market, the endowment manager would likely employ a passive strategy that seeks to replicate index returns. Although there is substantial evidence of efficient domestic markets, there is also evidence to suggest that certain managers do repeat their positive alpha performance.

In fact, a 2002 study by Roger Ibbotson and Amita Patel found that “the phenomenon of persistence does exist in domestic equity funds.” The same study suggested that 65% of mutual funds with the highest style-adjusted alpha repeated with positive alpha performances in the following year.

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More Research

Additional research suggests that active management can add value and achieve positive alpha in concentrated portfolios.

A pre 2008 crash study of actively managed mutual funds found that “on average, higher industry concentration improves the performance of the funds. The most concentrated funds generate, after adjusting for risk … the highest performance. They yield an average abnormal return [alpha] of 2.56% per year before deducting expenses and 1.12% per year after deducting expenses.”


FutureMetrics, a pension plan consulting firm, calculated that in 2006 the median pension fund achieved record alpha of 3.7% compared to a 60/40 benchmark portfolio, the best since the firm began calculating return data in 1988. Over longer periods of time, an endowment manager’s ability to achieve positive alpha for their entire portfolio is more hotly debated.  Dimensional Fund Advisors, a mutual fund firm specializing in a unique form of passive management, compiled FutureMetrics data on 192 pension funds for the period of 1988 through 2005.

Their research showed that over this period of time approximately 75% of the pension funds underperformed the 60/40 benchmark. The end result is that many endowments will use a combination of active and passive management approaches with respect to some portion of the domestic equity segment of their allocation.


One approach is known as the “core and satellite” method in which a “core” investment into a passive index is used to capture the broader market’s performance while concentrated satellite positions are taken in an attempt to “capture” alpha. Since other asset classes such as private equity, foreign equity, and real assets are often viewed to be less efficient, the endowment manager will typically use active management to obtain positive alpha from these segments.


  • Ibbotson, R.G. and Patel, A.K. Do Winners Repeat with Style? Summary of Findings – Ibbotson & Associates, Chicago (February 2002).
  • Kacperczyk, M.T., Sialm, C., and Lu Zheng. On Industry Concentration of Actively Managed Equity Mutual Funds. University of Michigan Business School. (November 2002).
  • 2007 Annual US Corporate Pension Plan Best and Worst Investment Performance Report.  FutureMetrics, April 20, 2007.


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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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How [DOCTORS] Construct Investment Portfolios That Protect Them




Vitaliy N. Katsenelson, CFA - YouTube

By Vitaliy N. Katsenelson, CFA


Question: How do you construct investment portfolios and determine position sizes (weights) of individual stocks?

I wanted to discuss this topic for a long time, so here is a very in-depth answer.

For a while in the value investing community the number of positions you held was akin to bragging on your manhood– the fewer positions you owned the more macho an investor you were. I remember meeting two investors at a value conference. At the time they had both had “walk on water” streaks of returns. One had a seven-stock portfolio, the other held three stocks. Sadly, the financial crisis humbled both – the three-stock guy suffered irreparable losses and went out of business (losing most of his clients’ money). The other, after living through a few incredibly difficult years and an investor exodus, is running a more diversified portfolio today.

Under-diversification: Is dangerous, because a few mistakes or a visit from Bad Luck may prove to be fatal to the portfolio.

On the other extreme, you have a mutual fund industry where it is common to see portfolios with hundreds of stocks (I am generalizing). There are many reasons for that. Mutual funds have an army of analysts who need to be kept busy; their voices need to be heard; and thus their stock picks need to find their way into the portfolio (there are a lot of internal politics in this portfolio). These portfolios are run against benchmarks; thus their construction starts to resemble Noah’s Ark, bringing on board a few animals (stocks) from each industry. Also, the size of the fund may limit its ability to buy large positions in small companies.

There are several problems with this approach. First, and this is the important one, it breeds indifference: If a 0.5% position doubles or gets halved, it will have little impact on the portfolio. The second problem is that it is difficult to maintain research on all these positions. Yes, a mutual fund will have an army of analysts following each industry, but the portfolio manager is the one making the final buy and sell decisions. Third, the 75th idea is probably not as good as the 30th, especially in an overvalued market where good ideas are scarce.

Then you have index funds. On the surface they are over-diversified, but they don’t suffer from the over-diversification headaches of managed funds. In fact, index funds are both over-diversified and under-diversified. Let’s take the S&P 500 – the most popular of the bunch. It owns the 500 largest companies in the US. You’d think it was a diversified portfolio, right? Well, kind of. The top eight companies account for more than 25% of the index. Also, the construction of the index favors stocks that are usually more expensive or that have recently appreciated (it is market-cap-weighted); thus you are “diversified” across a lot of overvalued stocks.

If you own hundreds of securities that are exposed to the same idiosyncratic risk, then are you really diversified?

Our portfolio construction process is built from a first-principles perspective. If a Martian visited Earth and decided to try his hand at value investing, knowing nothing about common (usually academic) conventions, how would he construct a portfolio?

We want to have a portfolio where we own not too many stocks, so that every decision we make matters – we have both skin and soul in the game in each decision. But we don’t want to own so few that a small number of stocks slipping on a banana will send us into financial ruin.

In our portfolio construction, we are trying to maximize both our IQ and our EQ (emotional quotient). Too few stocks will decapitate our EQ – we won’t be able to sleep well at night, as the relatively large impact of a low-probability risk could have a devastating impact on the portfolio. I wrote about the importance of good sleep before (link here). It’s something we take seriously at IMA.

Holding too many stocks will result in both a low EQ and low IQ. It is very difficult to follow and understand the drivers of the business of hundreds of stocks, therefore a low IQ about individual positions will eventually lead to lower portfolio EQ. When things turn bad, a constant in investing, you won’t intimately know your portfolio – you’ll be surrounded by a lot of (tiny-position) strangers.

Portfolio construction is a very intimate process. It is unique to one’s EQ and IQ. Our typical portfolios have 20–30 stocks. Our “focused” portfolios have 12–15 stocks (they are designed for clients where we represent only a small part of their total wealth). There is nothing magical about these numbers – they are just the Goldilocks levels for us, for our team and our clients. They allow room for bad luck, but at the same time every decision we make matters.

Now let’s discuss position sizing. We determine position sizing through a well-defined quantitative process. The goals of this process are to achieve the following: Shift the portfolio towards higher-quality companies with higher returns. Take emotion out of the portfolio construction process. And finally, insure healthy diversification.

Our research process is very qualitative: We read annual reports, talk to competitors and ex-employees, build financial models, and debate stocks among ourselves and our research network. In our valuation analysis we try to kill the business – come up with worst-case fair value (where a company slips on multiple bananas) and reasonable fair value. We also assign a quality rating to each company in the portfolio. Quality is absolute for us – we don’t allow low-quality companies in, no matter how attractive the valuation is (though that doesn’t mean we don’t occasionally misjudge a company’s quality).

The same company, at different stock prices, will merit a higher or lower position size. In other words, if company A is worth (fair value) $100, at $60 it will be a 3% position and at $40 it will be a 5% position. Company B, of a lower quality than A but also worth $100, will be a 2% position at $60 and a 4% position at $40 (I just made up these numbers for illustration purposes). In other words, if there are two companies that have similar expected returns, but one is of higher quality than the other, our system will automatically allocate a larger percentage of the portfolio to the higher-quality company. If you repeat this exercise on a large number of stocks, you cannot but help to shift your portfolio to higher-quality, higher-return stocks. It’s a system of meritocracy where we marry quality and return.

Let’s talk about diversification. We don’t go out of our way to diversify the portfolio. At least, not in a traditional sense. We are not going to allocate 7% to mining stocks because that is the allocation in the index or they are negatively correlated to soft drink companies. (We don’t own either and are not sure if the above statement is even true, but you get the point.) We try to assemble a portfolio of high-quality companies that are attractively priced, whose businesses march to different drummers and are not impacted by the same risks.  Just as bank robbers rob banks because that is where the money is, value investors gravitate towards sectors where the value is. To keep our excitement (our emotions) in check, and to make sure we are not overexposed to a single industry, we set hard limits of industry exposure. These limits range from 10%–20%. We also set limits of country exposure, ranging from 7%–30% (ex-US).


In portfolio construction, our goal is not to limit the volatility of the portfolio but to reduce true risk – the permanent loss of capital. We are constantly thinking about the types of risks we are taking. Do we have too much exposure to a weaker or stronger dollar? To higher or lower interest rates? Do we have too much exposure to federal government spending? I know, risk is a four-letter word that has lost its meaning. But not to us. Low interest rates may have time-shifted risk into the future, but they haven’t cured it.



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Return on Investment Calculations for [Concierge] Medical Practice Marketing Initiatives

Calculating Tangible ROI for Intangible Activities

By DeeVee Devarakonda; MBA [Former CMO of Quaero, Inc]

By Dr. David Edward Marcinko; MBA [Publisher-in-Chief]Doctor with Advisor

Gone are the days when money was freely spent on medical practice marketing activities such as the yellow pages, radio or TV advertisements. And, today’s internet based business climate is especially harsh for ethereal programs that can not present a clear Return on Investment [ROI] for their existence. Concierge and cash-based medical practice marketing is especially vulnerable in this climate unless supported with a sound ROI argument.

The Challenge

A very basic challenge all medical practices is not only pooling the resources but also allocating them wisely. ROI arguments help practices make those choices. Typically marketing budget and outlay decisions focus on operating expenses like public relations, podcasts, webcasts and internet advertising. However, marketing can also involve capital investment decisions. To be successful, medical practitioners should learn to speak the language of business and build ROI analysis to support such initiatives.

How do you calculate the ROI for internet marketing initiatives?

Here are some basic steps to help you build the ROI scenario for your marketing initiatives:

  1. Detail the marketing costs:
  2. Estimate the revenue impacts:
  • Hardware – computers, servers, accessories
  • Software  – database, campaign management software
  • Implementation costs of hardware and/or software
  • Internal resource costs associated with the deployment of the capital improvement
  • Upfront investments in call centers, staff, equipment and so on.
  • Increase in patient response rates
  • Increase in patient conversion and practice acceptance rates
  • Increase cross-sell product and services ratios
  • Decreased account patient attrition rates
  • Increase in practice CM fees
  • Increase in average spend per patient/account
  • Increase in average number of patient transactions.

Practices can use past experiences to guesstimate the revenue impact; others like-minded colleagues.

Net Present Value

Once you calculate the revenue and cost impacts, you need to calculate the Net Present Value (NPV) of your marketing initiative. For a marketing project, if the NPV is greater than zero that means your project will make money; if it is less than zero – it will not (and you typically need a compelling business reason to implement a marketing project with an NPV less than zero).

NPV calculations include:

1) Investment – money you expend for the initiative at the beginning

2) Revenues – that accrue as a result of the initiative over a period – can be one time or a recurring revenue

3) Costs – that accrue as a result of the initiative over a period – can be one time or a recurring item

4) Discount rate – your accountant can give this rate.

5) Time Period – define the time period for which you would like to compute the NPV.

6) NPV is the cumulative differential between the revenue and cost stream discounted at the discounted rate minus the investment.

NPV=SUM ((Rt-Ct) / (1+r)t) – I



where t represents time, n  represents the number of time periods, R is revenue impacts, C is cost impacts, r is the discount rate and I is the Investment.

An NPV >0 means the project will pay for itself, <0 means the project does not pay for itself and an NPV of zero will give you a break even.


Remember NPV is simply a guideline to help quantify the marketing results to make informed investment decisions. Note: NPV calculations that include assumptions also allow room for error. Spreadsheets help calculate the NPV for any initiative. Simple software can also help develop “what-if” scenarios with various values for NPV components and marketing options. The model can be used for non-marketing, or any initiative, as well.


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Problems with HIT in Minnesota

The Continuing eHR Saga

By Darrell K. Pruitt; DDSpruitt2

If you were one of fifty governors who decide to jump off a cliff because flying looks so cool, would you proudly race to be the first to grab the air? Blissfully, Minnesota Governor Tim Pawlenty is way ahead of the pack. He’s so confident in healthcare information technology [IT]  that he doesn’t even have to watch where he’s going – leaving him free to smile for the cameras. Now that’s cool.

Initial Ambitious Plans

Attention ME-P readers! Please gather around to watch a world-class belly-flop of a gutsy statewide eHR mandate. A few years ago, Governor Pawlenty had ambitious plans to lead the nation with an interoperable eHR system that was touted to include all providers – that means Minnesota dentists as well. Your landing could be vertical and abrupt, Pawlenty.

CCHIT Approved? 

In fairness to a brick, back in 2005 Pawlenty could not have predicted the economic collapse that began three years later, nor could he have known about the subsequent $19 billion eHR money that would be made available to providers – but only if they purchase healthcare IT software that is approved by the Certification Commission for Healthcare Information Technology (CCHIT).

CCHIT Laggards 

Even if the descending Pawlenty could have predicted the recent changes in the terrain, including the CCHIT qualification, he would have never guessed that to this day in March of 2009, the certifying commission would still be yet to certify even one single electronic dental record – thereby blocking Minnesota dentists from copious federal help in their efforts to become compliant in Pawlenty’s brave new state.

“The government is actually looking for places to spend the money where there is a strong likelihood of success stories”.

Mike Ubl

Executive Director Minnesota Health Information Exchange

[Owned by Blue Cross Blue Shield of Minnesota, HealthPartners, Medica, Fairview Health Services, UCare and the Minnesota Department of Health].


And that after this is accomplished, and the brave new world begins – When all men are paid for existing and no man must pay for his sins”.

-Rudyard Kipling

The CCHIT qualification was incredibly bad luck for Pawlenty’s nifty ideas of interoperability with all providers. When Minnesota dentists discover that they must pay $30 thousand for software they don’t want in order to practice in paradise, some may just swallow their pride, sell the portable ice-fishing house, and move to slow-moving Iowa.

Dentists, MDA and the ADA News

Why the surprisingly quick landing? If Pawlenty actually gave any consideration for dentistry at all, just like everyone else, he must have assumed that dentists’ concerns about digital records would be adequately attended to by the Minnesota Dental Association [MDA] and the American Dental Association. It was easy to make that mistake because of the enthusiasm for eDRs radiating from ADA Headquarters and expressed in confident terms in ADA News Online articles that have since stopped appearing.  Most eDR enthusiasts naturally assumed that by now the majority of dentists in the nation would be saving money, lives and trees with paperless practices. However, the ADA has been nowhere to be found for a long time. As it turns out, the professional organization has still not yet even contacted the certifying commission. We know this, because when I personally contacted CCHIT a few weeks ago, it caught them off guard. I was told that I was one of the first to ever mention dentistry.


No Endorsements

To show how far the ADA has slipped, and as an example of its flagging influence on membership, I doubt that more than 5% of American dentists have made the ADA-endorsed leap from paper to digital. Why should they? It makes good business sense to wait, and most dentists are not techno-silly. Consider this; Even if a dentist is happy with a costly eDR system that demanded unanticipated time and effort to learn, in less than a year, CCHIT could determine that his or her favorite system is not worthy of certification because it does not integrate with physicians’ one-size-fits-all, CCHIT-certified eMRs. Tough luck, Minnesota dentists! Uncertified eDRs will be outlawed, while favored, large healthcare IT companies in Madison and Chicago will profit and pay more state taxes with Twin-Cities’ dollars. By then, all the stimulus money will be gone and lawmakers will no longer be giddy about eHRs due to the imminent explosion of data breaches everywhere caused by moving too fast. No return on investment [ROI] there. 


Still, Tim Pawlenty could have never known, yet away he sails with a stupid grin on his face.


And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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