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Physician Finances Physician Retirement Planning

Planning For Retirement For Physicians Part 8: Pay Off Student Loans Versus Save For Retirement?

This is the eighth in a series of posts made in preparation for a presentation I will be making for physicians in fellowship training at an upcoming ACCP meeting. In the last post, I discussed how to invest your post-tax money for optimal returns in retirement. In this post, we’ll look at whether it is better to pay your student loans off early or invest in retirement.

First, let’s just get this out of the way, if you have the option, the best way to manage your student loans is to get someone else to pay for them. There are a few ways of getting your student loans paid off. If you are pursuing a career in medical research, there are NIH loan repayment programs that will pay up to $35,000 a year on your loans. There are loan repayment programs if you join the military or if you agree to practice in certain underserved parts of the country. Lastly, when you get your first job out of residency, ask if the hospital or group practice will pay off some of your loans – most won’t but some will (particularly if they’ve been having a hard time recruiting into the position) and the only way to find out is to ask.

The average medical student graduates from a public medical school with $172,751 in loans and from a private medical school with $193,483 in loans. That is a lot of debt for a resident making $50,000-$55,000 a year. If you can’t get someone else to pay off your loan, then you’ll be making monthly payments for a long, long time. The jump in annual income from being a resident to being an attending physician can seem like a lot, and it is, but it comes with a rapid ramp-up in the loan repayment requirements. Plus, as a medical student and resident, you may have been driving your grandmother’s hand-me-down 1998 Honda Civic and living in a one-bedroom apartment… you’re 30+ years old and you’re ready for a lifestyle upgrade. So, it is easy to find yourself spending all of that new income on stuff and not on your future retirement.

Above all, do not get behind in your regular student loan payments. The cost in penalties is just too high and you’ll just fall further and further behind. So, we’ll assume that you are making your regular monthly payments on your student loans and then you have to decide if it is better to make a few extra payments on your loans or if it is better to put some extra money into a tax-deferred retirement plan?

As a general rule, I am pretty debt-adverse and just feel better getting out of debt but if you are disciplined (and to get through 11-16 years of college, medical school, residency, and fellowship presumably you do have personal discipline), then you can use some strategic financial planning and budgeting to give you the best long-term financial outcome. So, let’s make some assumptions in a hypothetical case:

  1. You have $150,000 in student loans. You probably have more than this but it is an easy number to use as an example.
  2. The average interest rate on your loans is 6%.
  3. You have a 15-year repayment period for your loans. This will equate to $15,316 of payments per year ($1,276 per month) of which about $9,000 per year is interest.
  4. You can deduct up to $2,500 of annual interest payments off of your income tax each year.
  5. Your tax deferred 401(k)/403(b)/457 has an 8% annual return on investment.
  6. Your taxable income is $258,000 ($255,500 after the loan interest deduction).
  7. You are married and filing jointly.
  8. We’ll use 2015 income tax and capital gains tax rates.
  9. We’ll compound interest monthly on the loan and we’ll compound capital gains monthly on the tax-deferred retirement account.
  10. You are financially responsible and you project that this year, you will have $20,000 in pre-tax income that you can use to either (1) put in your tax-deferred retirement account or (2) pay income taxes now on the $20,000 and use it to make extra payments on your student loans.

Now let’s take a look at what your financial picture will look like if you make extra payments on the loans versus if you invest the money into a tax-deferred retirement account.

tax analysis 5

The first thing to notice is that with either choice, your taxable income drops to $255,500 because you can deduct $2,500 of your $9,000 in interest payments off of your taxable income for that year. The $20,000 in pre-tax money that you decide to use for extra payments for your student loan becomes $15,3116 after you pay an effective income tax rate of 23.42%. On the other hand, if you put the money into a tax-deferred retirement account, then after 1 year, that $20,000 becomes $21,660 and the value of that money if you were to retire after a year at your current effective income tax rate would be $16,743.

Next, look at your overall financial picture at the end of the year if you make extra payments on your student loans. We’ll define the overall financial picture as your total assets (salary that year + the projected value of your tax-deferred retirement fund [after you pay taxes on it when withdrawing it in retirement] minus your debts (the balance remaining on your student loan). In this scenario, your effective income tax rate will be 23.42% and your overall financial picture will be $37,349.

If, on the other hand, you decide to put money into a tax-deferred retirement account, your effective tax rate will drop to 22.70% and your overall financial picture will be $38,922. In other words, you come out ahead $1,573 by putting that $20,000 in a tax-deferred retirement account as opposed to making early payments on your student loans.

Now let’s assume that your student loan interest rate is a little higher, say 7% rather than 6%:

tax analysis 6

Note that the value of the loan changes due to the effect of the higher interest. If you make extra payments on the student loan, your overall financial balance is $35,920 whereas if you put the extra money in a tax-deferred retirement account, your financial balance is $37,330. In other words, you come out $1,410 ahead by putting the money in a tax-deferred account.

Finally, let’s take a worst-case scenario and assume that you have an exorbitant student loan at 9% annual interest:

tax analysis 7

Now, your overall financial balance will be $33,022 if you make extra payments on your student loans versus $34,103 if you put the money into a tax-deferred retirement account for a net advantage of $1,081 to put the money in the retirement account. The bottom line is that you always come out ahead by putting the money into a tax-deferred retirement account instead of making extra payments on your student loan.

Finally, let’s assume that you do not have the flexibility to put money into a 401(k), 403(b), or a 457. Should you put money into a regular investment after you have already paid income tax on that money?

tax analysis 8

If the student loan is 6% then you come out only $145 ahead by investing the money (for all practical purposes, break-even). If your student loan is 7% (analysis not show), you come out only about $18 ahead by making an extra payment on the student loan (also, essentially break-even). If your student loan is 9% (analysis not shown), you come out $1,428 ahead by making the extra payment on the student loan. In other words, unlike the situation with a tax-deferred retirement fund where you always come out ahead by investing in your retirement fund, the situation with a regular investment funded out of your post-tax dollars is more complicated. If your student loan interest rate is high, then you are better off making extra payments on the loan and if the student loan interest rate is lower, it doesn’t make a lot of difference which choice you make.

Every physician’s situation is a little different and you have to take into account the nuances of your own particular circumstances in deciding whether to put additional money into your retirement account versus make additional payments on your student loans. What is not taken into account in the above analysis is the peace of mind that you get when your student loans are finally paid off and from my own past experience that peace of mind is priceless.

In the next post, we’ll take a look at options for investing in your children’s college expenses.

August 30, 2016

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Physician Finances Physician Retirement Planning

Planning For Retirement For Physicians Part 7: Choosing Post-Tax Investments

This is the seventh in a series of posts made in preparation for a presentation I will be making for physicians in fellowship training at an upcoming ACCP meeting. In the last post, I discussed how tax-deferred investments outperform post-tax investments for retirement planning for most physicians. In this post, I will take you through the pros and cons of various post-tax investment options for retirement planning to use after you have maxed-out your tax-deferred options.

As a physician, you will have a myriad number of investment options and there are going to be a lot of people out there who are going to try to convince you that they have the best option for you. In previous posts, I went through some of the factors that should influence your investment decisions. In this post, I am going to focus on 3 general options for you to use with the money that is in your checking account after you have paid this year’s income tax on it:

  1. Regular investments. These could be stocks, bonds, mutual funds, money market accounts, etc. They consist of money that you have from your regular salary after you have paid income taxes for that year. As a general rule, these accounts will be taxed in three ways: (1) annual interest income, (2) dividend income, and (3) capital gains income. Interest income will be taxed every year as you earn it at whatever your effective regular income tax rate is for that year. Dividend income will be taxed each year at your capital gains tax rate. Capital gains income is taxed at your capital gains tax rate for the year that you sell your stock or mutual fund on the difference between the selling price and the original purchase price (i.e., you don’t have to pay capital gains on the amount that you originally invested when you opened the account).
  2. Traditional IRAs. You can put many different kinds of investments in an IRA: stocks, bonds, mutual funds, real estate, etc. Traditional IRAs are taxed at your effective regular income tax rate for the year that you withdraw money from the IRA. For a typical physician with a relatively high income, you will put money into an IRA from your salary after you have already paid income tax on it for that year. When you take the money out, you won’t have to pay income tax a second time on the amount of your original investment, only on the difference between the selling price and the original purchase price.
  3. Roth IRAs. For a typical physician with a relatively high income, you will not be able to invest directly into a Roth IRA. But, you can take advantage of a current loophole in the tax law that allows you to open a traditional IRA and then immediately convert it into a Roth. This is a so-called “backdoor Roth” that has been available since 2010 when a law governing IRAs expired. This is a surprisingly easy thing to do and most large investment companies will allow you to do it in just a few computer keystrokes from the comfort of your home. The great thing about a Roth IRA is that once you put money into it, you never have to pay any income tax or capital gains tax on it when you withdraw money from it in retirement.

So, which one should you choose? Let’s take an example of a physician who has $5,500 left over in her checking account at the end of the year and she decides she wants to put a little more into her retirement savings over and above what she put in her 401(k) that year. We’ll assume she is going to retire in 30 years and that when she retires, she is projecting an annual retirement income that will put her in the 15% capital gains tax bracket and that her effective regular income tax rate will be 21.3%.

tax analysis 4

In this analysis, her $5,500 grew to $60,147 in all three accounts. For regular investments and the tradition IRA, her taxable amount at the time of retirement is $54,647 ($60,147 – $5,500). On the regular investment, she pays capital gains tax. On the traditional IRA, she pays regular income tax.

At the end of the day, once she retires, she will have been much better off with the Roth IRA than with either a regular investment or a traditional IRA. What a lot of physicians don’t realize is that they are better off with a regular investment than with a traditional IRA. For many years, I was one of those physicians and I dutifully put money every year in a traditional IRA thinking that I was making a good investment. But here is the catch: you will pay capital gains tax on your investment income from a regular investment account but you will pay regular income tax on your investment income from a traditional IRA, and your regular income tax rate will almost certainly be higher than your capital gains tax rate.

The above analysis is pretty simplistic but it works if you are a young physician starting your career. It gets complicated if you’ve been around a while and have rolled investments into a traditional IRA. You see, the federal income tax law allows you to move money around from one type of tax-deferred account into another. This is a good thing because if you change jobs, you can end up with a bunch of different 401(a) accounts, 401(k) accounts, 403(b) accounts, etc. You’d be amazed at how many people lose track of all of their various retirement accounts and leave a few thousand dollars here and there in various pension accounts from different jobs that they have had in the past and never claim that money. So, the law allows you to transfer the money from (for example) a 401(a) pension account into your IRA or your 403(b) account when you change jobs. You have to be careful with transferring tax-deferred retirement account money into a traditional IRA or you can make your ability to convert that traditional IRA into a Roth IRA difficult. Here’s why:

About 15 years ago at Ohio State, we consolidated all of the various individual department practice corporations into a single multi-specialty practice company. So, the Department of Medicine Foundation, Inc. became a subsidiary of the larger OSU Physicians, Inc. I had a 401(a) pension with the Department of Medicine Foundation, Inc. and when we closed out that company to become OSU Physicians, Inc., we also closed out the 401(a) plan so I needed to move that retirement money somewhere. I thought I was being real smart by rolling the 401(a) money into my traditional IRA where I would be able to invest it in low cost index mutual funds. But then in 2010, the law prohibiting the conversion of traditional IRAs into Roth IRAs expired opening up the possibility of the backdoor Roth IRAs. The problem was that by that time, my traditional IRA account contained pre-tax money from my (tax-deferred) 401(a). Tax law requires that if you do a Roth IRA conversion, you have to consider all of your traditional IRAs together as a whole so movement of any money out of that traditional IRA has to be considered to consist of the same ratio of pre-tax/post-tax money that is contained in the entirety of your traditional IRAs. So for me to convert my traditional IRA into a Roth, I was going to have to pay regular income tax on the money in it from my previous 401(a) rollover during the year that I did the conversion. That was going to create a huge tax liability during the conversion year. Fortunately for me, the great recession occurred causing a massive drop in the value of the money in my traditional IRA so I was able to convert it into a Roth when the stock market price was close to its lowest in years, thus minimizing the amount that I had to pay in regular income tax on the conversion. If I had to do it all over again, I would have rolled the 401(a) over into a 403(b) account so that I could keep the traditional IRA account free of any tax-deferred account dollars and available to do an annual Roth IRA conversion each year without having to pay additional income tax.

So the bottom line:

  1. If you have extra $5,500 of spending money at the end of the year ($6,500 if you are over age 50), put it into a traditional IRA and then immediately convert that traditional IRA into a Roth IRA.
  2. If you have more than $5,500 ($6,500 if you are over 50) to invest at the end of the year, leave it in a regular investment account.
  3. Do not leave money in a traditional IRA; only use the traditional IRA as a vehicle to get that money into a Roth IRA.
  4. If you need to consolidate tax-deferred accounts, do not put them into a traditional IRA since that will contaminate your traditional IRA with pre-tax money that will be taxed at your regular income tax rate if you try to roll any portion of your traditional IRA into a Roth IRA in the future.

Most new physicians have a lot of college and medical school debt. In the next post, we’ll look at whether it is better to pay off that debt early or put money into retirement accounts.

August 28, 2016

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Physician Finances Physician Retirement Planning

Planning For Retirement For Physicians Part 6: Should I Do A 401(k)/403(b)/457?

This is the sixth in a series of posts made in preparation for a presentation I will be making for physicians in fellowship training at an upcoming ACCP meeting. In the last post, I discussed the basics of how Americans are taxed. In this post, we’ll cover whether physicians should put their money into a 401(k)/403(b)/457 or should they instead go ahead and pay income tax now and then put the money in a regular investment account in order to maximize the eventual value of that investment in retirement. If the goal is to use that money in retirement, then the answer is almost always to put it into a tax-deferred investment (401(k), 403(b), or 457). The reason is that the tax-deferred investment gets taxed once and the regular investment gets taxed twice.

As an example, let’s make a couple of assumptions:

  1. You want to save $20,000 of your pre-tax income this year
  2. Your current taxable income is $258,000 (current average pulmonologist salary per the 2015 Medscape compensation report)
  3. Your effective income tax rate is 23.2%
  4. You project that your annual income in retirement will be $200,000 in today’s dollars
  5. Your post-retirement effective income tax rate will be 21.3%
  6. Your capital gains tax rate is 15%
  7. You project that your investments will appreciate by 8% per year
  8. You plan to retire in 30 years
  9. You are married and file joint income tax with 0 exemptions (you won’t really have 0 but it is easier to do the calculations and doesn’t affect the outcome of the analysis)

 

tax analysis 1What the analysis above shows is that there are several things happening from a tax standpoint that most investors don’t take into account. First, by reducing the take-home salary from $258,000 to $238,000, the income tax bracket of 28% does not change but the effective income tax rate does drop from 23.5% to 22.7%. This drop in the effective income tax rate results in a $1,918 reduction in income tax that year. Second, if instead the investor had paid the regular effective income tax rate of 23.5% and put the $20,000 in a regular (post income tax) investment, then the investor would have to pay tax a second time in the form of capital gains tax when the money is withdrawn in retirement. The net result is that the investor is better putting the $20,000 into a tax-deferred account from the beginning and ending up with $173,833 when they retire versus $144,514 if they had paid regular income tax on the $20,000 up front and then put it in a mutual fund investment.

You can even further improve your financial picture if you take the $1,918 that you saved from having a lower effective income tax rate and investing it in a regular investment account or (better yet) in a Roth IRA.

But many physicians (including yours truly) hope that their annual income in retirement will be the same or even more than their annual income during their working years. So, would they still be better off putting their retirement money in a 401(k)/403(b)/457? The answer is yes and to show you why, let’s take an extreme example of a physician who plans to have a post-retirement income of much, much more than their current income; consider these assumptions:

  1. You want to save $20,000 of your pre-tax income this year
  2. Your current taxable income is $258,000 (current average pulmonologist salary per the 2015 Medscape compensation report)
  3. Your effective income tax rate is 23.2%
  4. You project that your annual income in retirement will be $700,000 in today’s dollars
  5. Your post-retirement effective income tax rate will be 31.6%
  6. Your capital gains tax rate is 20%
  7. You project that your investments will appreciate by 8% per year
  8. You plan to retire in 30 years
  9. You are married and file joint income tax with 0 exemptions (you won’t really have 0 but it is easier to do the calculations and doesn’t affect the outcome of the analysis)

tax analysis 3What this analysis shows is that you still come out ahead by putting your retirement investment in a tax-deferred account, even if your income will be much higher in retirement.

Some physicians will have a choice between a regular 401(k)/403(b) and a Roth 401(k)/403(b). The decision about whether to put retirement in one or the other can be a tough call and really requires careful analysis of the individual’s personal tax situation. The traditional wisdom is that if your post-retirement annual income tax rate will be higher than it is now, then you are better off with the Roth 401(k)/403(b) and if your post-retirement annual income tax is lower than it is now, then you are better off with a traditional 401(k)/403(b). What these recommendations don’t take into account is what the effect of taking a Roth 401(k)/403(b) will do to your current effective income tax rate, namely, that it will go up since your taxable income goes up by the amount of the Roth 401(k)/403(b) contribution. As I mentioned in a previous post, you can’t predict what politicians will do to tax rates 4 years from now, let alone 35 years from now. My own take on it is that unless you expect your post-retirement income tax rate to be considerably higher than it is now, you are better off with a regular 401(k)/403(b) and not a Roth 401(k)/403(b).

The last situation to consider is whether your employer offers a matching 401(k) or 403(b). If they do, then this is an even stronger reason to put your retirement savings into a tax-deferred 401(k) or 403(b) since the matching funds are free money and who in their right mind would ever turn down free money?

The bottom line is that for the typical physician, you will almost always be better off putting your retirement funds in a tax-deferred investment. This includes the 400-group of investments (401(a), 401(k), 403(b), 457, or 415(m)), a pre-tax traditional IRA (as a physician you will likely make too much money to qualify for one of these), or an SEP. In the next post, we’ll examine the question of where you should put your post-tax investments: a traditional IRA, a Roth IRA, or a regular investment.

August 26, 2016

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Physician Finances Physician Retirement Planning

Planning For Retirement For Physicians Part 5: Taxes 101 For Physicians

This is the fifth in a series of posts made in preparation for a presentation I will be making for physicians in fellowship training at the upcoming ACCP meeting. Whether you do your own income taxes or you pay an accountant to do your taxes for you, you have to understand the basics of how taxes work in order to maximize your yield from your various retirement accounts. In the last post, I discussed some of the common mistakes physicians make in their investment decisions that can erode total returns. In this post, I’m going to give a very general overview of income taxes and capital gains taxes to set the stage for future posts about the best retirement investments for physicians.

tax bracketsLet’s start with income taxes. I am continually amazed at how much misconception there is about the American income tax system. The first thing to understand is that although we have tax brackets, we operate on a marginal tax system. This means that as your income goes up, your tax rate also goes up but it does so incrementally so that you pay a different tax rate for each successively larger chunk of income that you have. The table at the right shows the 2016 regular income tax brackets.

One of the problems with tax brackets is that you can’t predict where they will be in the future. Presidential candidates love to run on promises to change tax rates, generally by either increasing the taxes on the rich or by decreasing the taxes on the rich. One of the common ways that politicians change taxes is on what the income tax rate is on the top income tax bracket. This number has fluctuated considerably over the past 30 years, depending on who was president. As you can see from the graph below, the biggest change occurred during Ronald Reagan’s term when the tax rate on the highest tax bracket fell from a tax rate of 50% at the beginning of his presidency to to a tax rate of 28% at the end:

Tax brackets 1984-2015

To understand how the marginal tax system works, let’s take an example of a single physician who makes $250,000 in taxable income. For the first $9,275 of her income, she pays 10% income tax ($927). For the next $28,375, she pays 15% income tax ($4,256). For the next $53,500, she pays 25% income tax ($13,375). For the next $99,000, she pays 28% income tax ($27,720). For the last $59,850, she pays 33% income tax ($19,750). Her total income tax is the sum of each of the components from each of her tax brackets ($927+$4,256+$13,375+$27,720+$19750 = $66,028). Many people have the mistaken belief that if they have a taxable income of $250,000 (the 33% tax bracket), that they have to pay 33% income tax on the whole $250,000 (i.e., $82,500). You will pay income tax on your income from your regular salary and on your income from interests (for example, from bond investments).

Capital gains tax brackets 1The other tax that most physicians will pay is capital gains tax. This is tax that you pay for income you get from dividends and the profit that you get from what you sell a stock for compared to what you originally bought it for. The capital gains tax rates are lower than the regular income tax rates. Unlike regular income tax, the capital gains tax is not a marginal tax, in other words, whatever your total taxable income is, that dictates your capital gains tax rate for all of your capital gains. The table above to the right shows the 2016 capital gains tax rates.

So if we put all of this together for several hypothetical taxable incomes, for a married couple filing jointly, here is the tax bracket (the amount you pay on the highest portion of your income) versus the effective tax (what you actually pay overall for your entire salary) versus the capital gains tax:

Marginal v effective v capital gains rates 1

As you can see from the table, the income tax bracket is not what is really important, it is the effective tax rate, since what you are really going to pay is the effective tax rate. The table also shows that for the range of typical physician incomes, you are better off paying a capital gains tax than a regular income tax if you can. This will become important in future posts as we look at how to select investments for a physician’s retirement portfolio.

Another feature of taxes is when you pay them. For some taxes, you pay during the distribution year, that is the year that you take the money, for example, withdrawing money from a 401(k). For other taxes, you pay during the contribution year, that is the year that you actually earned that money. Of note, Pennsylvania is unique in that state income tax is paid during the contribution year rather than the distribution year**.

When taxes are paid

Now that we’ve covered the basics of taxes, we can determine the best place to put your money in order to maximize the amount that you will actually have in your hand when you retire. The next post will examine this in more detail.

August 24, 2016

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Physician Finances Physician Retirement Planning

Planning For Retirement For Physicians Part 4: Maximizing Your Annual Return?

This is the fourth in a series of posts made in preparation for a presentation I will be making for physicians in fellowship training. In the last post, I demonstrated how reaching a goal of a $9,000,000 retirement fund is achievable in 35 years if you invest $40,000 per year and get an annual rate of return of 7.5%. On the surface, this sounds so simple, but in reality, many physicians never get this rate of return due to the pitfalls that get in the way. In this post, I’ll outline some of the common pitfalls.

Physicians are in one of the highest paid professions on the planet and so they have a lot of money to invest. But we usually know a lot less about investment than other professionals in business or law. Consequently, there are a lot of people who would like to get paid to steer us toward our retirement goal. Although you are going to need some advice, it is up to you to be sure that you are not being taken advantage of. Here is where we often go wrong:

  1. Expense ratios. Lower is better. If you are investing in a mutual fund, for example, there will be a certain percentage of the total fund balance that you pay each year to the investment company for them to manage that mutual fund. This is called an expense ratio. These can vary from as little as a tenth of a percent to as much as 2%. Let’s assume that you have $100,000 to invest and you anticipate an 8% annual rate of return and you’re going to leave the money in for 20 years before you use it. Now let’s look at two mutual funds: Fund A has an expense ratio of 0.21% and fund B has an expense ratio of 1.15%. The cost to manage fund A over the next 20 years will be $19,000. The cost to manage fund B over the next 20 years will be $96,000. In other words, when you get ready to take the money out of this account in retirement, you’ll have $77,000 less if you paid the higher expense ratio.
  2. Index v managed fund returnMutual fund category. Index funds are better than managed funds. With an index fund, the investment company buys stocks based on the proportion of various companies in some index, for example, the S&P 500. It is all done by computer and the investment company does not have to hire a lot of expensive analysts and stock-pickers to choose the stocks that are in that fund. With a managed fund, there are analysts, managers, and stock pickers that try to outwit other investment companies’ analysts, managers, and stock pickers in order to get a higher annual rate of return. As a general rule, index funds have lower expense ratios than managed mutual funds and so right away, you’ll have more money in your retirement account when you retire if you invest in index funds. On the surface, you might think that the managed funds would perform better than the index funds because they are backed up by all of this human brainpower to choose better stocks to put in the fund. However, as it turns out, humans are pretty fallible in the stock market just like they are in other professions. Although there will always be some winning funds that outperform everyone else, you won’t know for sure now which funds will be winners. Over time, index funds outperform managed funds as a whole..
  3. Commissions. No load is better than a front load. Some mutual funds will require a “front load fee” which is essentially a commission that you pay when you first put money into that fund. This reduces the amount of your investment and over time, this results in a reduction in your total retirement fund amount. Let’s go back to the example of $100,000 invested for 20 years with an 8% annual return. If a mutual fund has a 1.5% front load fee, the ending value of that investment will be $485, 290. If the mutual fund does not have a front load fee, the ending value will be $492,680. That is a $7,390 difference that you ended up paying over the course of that investment.
  4. Value of $1 invested in 1965Stocks versus bonds. In the long run, stocks perform better than bonds. In the short run stocks are more volatile than bonds. In the 50 years since 1965, the average annualized rate of return in stocks has been 9.91% whereas the average annualized rate of return of bonds has been 6.58%. In other words, $1 invested in stocks in 1965 was worth $112 by 2014 whereas $1 invested in bonds in 1965 was worth $24 by 2014. The problem is that the value of stocks can vary wildly from year to year whereas the value of bonds varies relatively little from year to year. Therefore, if you have a long investment horizon, stocks are a better investment but if you have a short investment horizon, bonds are safer. But remember, when you retire, you are not going to be taking all of the money out of your retirement fund the day you retire; some of that money is going to need to stay invested until you die 15, 20, or 30 years later. Therefore, it is best to have a mixture of stocks and bonds in your retirement fund with a higher percentage of stocks when you are younger (say 80-90% when you are age 30) and a lower percentage of stocks when you are older (say 50% when you are age 65). An important caveat to this is that if, in addition to your retirement fund, you also have a pension or an annuity and can expect a fixed income from that pension or annuity for the rest of your life in retirement, then you can afford to have a greater percentage of your other retirement portfolio in stocks since that pension or annuity will give you some insulation from the inevitable year-to-year volatility in stock prices.
  5. Stock turnover. Less is better. If you are purchasing stocks in individual companies for your retirement fund, then every time you buy and sell a stock, you are going to have to pay a stock broker a fee. If you are buying and selling frequently, then those fees add up and you can end up with less money in your retirement fund than if you bought a stock and held it. This has to be tempered with not holding onto loser stocks forever but you have to be judicious. Beware of the financial advisor who periodically sends out sell and buy advisories for the stocks that you own; although it is possible that he (or she) is some kind of stock market oracle with a unique ability to see into the future of stock prices, it is also possible that he needs to make a boat payment on his new yacht.

In the next post, I’ll show how the tax implications of different investment options affect your final net retirement fund value.

August 22, 2016

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Physician Finances Physician Retirement Planning

Planning For Retirement For Physicians Part 3: How Much Money Do You Need To Save For Retirement?

This is the third in a series of posts made in preparation for a presentation I will be making for physicians in fellowship training. In the last post, I made the argument that a physician making $250,000 per year now will need about $9,000,000 in retirement savings 30 years from now in order to maintain the same standard of living that he or she has now. In this post, I’m going to outline the path for getting to that $9,000,000 number.

A $9,000,000 retirement fund is not that difficult for a physician to achieve, as long as the physician starts saving early in their career, saves regularly and invests wisely. And it is all due to the wonder of compound interest.

Let’s again start with an example of a new physician making $250,000 a year currently. Assume that the hospital or group practice employing that physician has a retirement plan that automatically puts away 10% into a retirement plan. That is $25,000 per year right away. Now let’s assume that the physician also puts away an additional $15,000 per year in a 403(b) plan each year. That is a total of $40,000 per year in retirement savings each year. In other words, 16% of your annual income is going into saving for retirement. Let’s further assume that the physician is 30 years old and plans to retire in 35 years at age 65.

Because retirement is a long way away, you can tolerate a lot greater year-to-year volatility in the value of the retirement fund than you could if you were 5-10 years away from retirement. This means that your retirement fund should be primarily invested in stocks as opposed to bonds at age 30. Historically, over the past 90 years, the stock market has averaged a 10% return per year. However, this is an average and there is a lot of year-to-year variability and even decade-to-decade variability so a more realistic return is lower, for example, 7.5%.

At the optimistic 10% average annual rate of return, the $40,000 invested in a retirement fund today will be $1,306,000 in 35 years. At the more realistic 7.5% annual rate of return, that $40,000 will become $548,000 in 35 years. But you will not just be investing into your retirement fund this year, you’ll be investing every year up until retirement.

So, let’s assume that you invest $40,000 per year every year for the next 35 years. At a 10% annual return, the value of your retirement fund will be $14,000,000. At the more realistic 7.5% annual rate of return, the value of your retirement fund will be $7,360,000.

But the reality is that you are unlikely to just put $40,000 into retirement every year for the next 35 years. As inflation gradually increases your salary over time, the amount that you put into your retirement plans will also increase over time, even if your retirement contributions stay as a fixed percentage of your total salary. Therefore, if you keep up with your current investment contributions of 16% of your annual income, you will easily exceed the $9,000,000 retirement fund goal in 35 years.

The good news is that reaching your projected retirement fund balance is achievable. The bad news is that many physicians fall prey to the 2 biggest obstacles in achieving their goal: bad advice and bad judgment. In the next post, I’ll outline some of the common ways that physicians’ annual rate of return gets eroded, leaving them with less money in their retirement account than they had planned on.

August 20, 2016

Categories
Physician Finances Physician Retirement Planning

Planning For Retirement For Physicians Part 2: Retirement Fund Options

This is the second in a series of posts about physician retirement planning that I created as part of a presentation that I am giving to fellows in training at the upcoming American College of Chest Physicians annual meeting. In this post, I am going to define some of the common retirement options that physicians may have available to them.

For many physicians, the decision you make on the first month of your job will dramatically affect your retirement decades later because some these retirement planning decisions are permanent. After going through medical school, residency, and maybe a fellowship, physicians are not trained in how to invest for retirement and when they finally sign a contract for their first job out of training, they don’t understand the nuances of the retirement options that they are about to choose from. This blog post is a primer on the different choices that you have. In future posts, I’ll go into some of the unique pros and cons of several of these different options that physicians face.

  1. Pension plans. In these plans, the employer, employee, or both put pre-income tax money into a pension fund and when the employee retires, he or she can draw down on the fund, paying income tax as the money is withdrawn. There are two general types of pensions:
    1. Defined benefit pension plans. In these plans, the employee and employer contribute a percentage of the employee’s income into the pension plan every year that the employee is working. The employer usually controls how the money is invested. Then, when an employee retires, they get a fixed annual income (the “benefit”) every year for life. The amount of the benefit is usually based on the amount of the employee’s final salary before retirement plus years of service to the employer.
    2. Defined contribution pension plans. In these plans, the employee and employer contribute a percentage of the employee’s income into the pension plan every year that the employee is working but the employee controls how the money is invested. Unlike a defined benefit plan, when the employee retires, they can determine how to withdraw money from their pension account but when that money is gone, they no longer have any benefits.
  2. Annuity plans. These are really an insurance plan for retirement income. In these plans, a person purchases an annuity and then when they retire, the annuity pays them a certain amount every year. In this sense, it is sort of like buying into a defined benefit pension plan. Some people who have a defined contribution pension plan with their employer will take the money out of their account at retirement and purchase an annuity to ensure that they always have some annual income for as long as they live. An advantage is that it gives the person a fixed annual income for life after retirement. A disadvantage is that annuities can have a lot of overhead expenses.
  3. Social Security. In reality, this is just a big defined benefit pension plan. It was originally created as a safety net to address the high poverty rate among older Americans by providing them with a minimum basic income. It is funded from payroll taxes. But the amount of income a retired person gets from Social Security is fairly low and barely enough to live on. For physicians, social security will only be a very small part of their retirement income. And for physicians who are employed through state governments that have state-affiliated pension plans (for example state teachers retirement systems), the Social Security annual benefits are reduced and in some cases, non-existent (since the government pension takes the place of Social Security).
  4. 401(k) plans. These are deferred compensation plans used by companies. They are a way for employees to carve off a chunk of their take-home income to save for when they retire. When you contribute to a 401(k), your taxable income for that year drops by however much you contribute to the 401(k). So, for example, if you make $200,000 and contribute $15,000 to a 401(k), then you only have to pay state and federal income tax on $185,000 that year. The 401(k) money can then be invested and grows but you pay no taxes on it until you retire. When you take the money out in retirement, you pay regular income taxes on it. So, for example, that $15,000 you invested today may be worth $250,000 when you retire due to interest, dividends, growth in stock prices, etc. If you take money out of your 401(k) before age 59 ½, then you have to pay a penalty for early withdrawal. Some companies will have a policy of matching some or all of your 401(k) contributions so if you put $10,000 in your 401(k), the company will contribute an additional $10,000 but if you don’t contribute to your 401(k), the company contributes nothing. The maximum you can contribute to a 401(k) in 2016 is $18,000 per year if you are under age 50 years old and $24,000 if you are over 50 years old. You can decide how much you want to put away into a 401(k) each year from as little as $100 or so to as much as the $18,000 (or $24,000) limit. You may have to pay local income tax on the money you put into your 401(k) even though you don’t have to pay state or federal income tax on it.
  5. 403(b) plans. These are very similar to 401(k) plans except they are used by not-for-profit companies. Like the 401(k), you contribute to the 403(b) pre-tax and then pay regular income tax on the withdrawals you make after you retire. The maximum contribution is also $18,000 per year (or $24,000 if you are older than 50 years old) for 2016 and there is a penalty for withdrawal before age 59 ½.
  6. 457 plans. These are also similar to 401(k) plans except that they are for state and municipal employees. They have the same contribution limits. The one important difference with a 457 plan is that there is no penalty for withdrawal before 59 ½ years of age.
  7. 401(a) plans. These are retirement plans that are set up by the employer and usually have a fixed percentage of the employee’s salary going into the 401(a) plan. These plans are tax-deferred so that the employee does not pay state or federal income tax when contributing to the 401(a) but do pay income tax when withdrawing money from the plan after retirement. 401(a) plans are for non-profit organizations, government organizations, and teachers.
  8. 415(m) plans. These are retirement plans for public employers (colleges, universities, etc.) that allow for additional pre-income tax money to be put into a tax-deferred account after an employee has exceeded the contribution limits set by the IRS for other retirement plans (such as a 403(b). The 415(m) plans do not get lot of press because they don’t really apply to the vast majority of employees, only the highest paid employees. However, at a university, physicians are often the among the highest paid employees so these plans may be available.
  9. Traditional IRA. This is money that you put away for retirement. Unlike the 401(k), 403(b), and 457 plans that usually have a limited number of mutual funds or other investment options, you have total control over what you invest your IRA money in. If you are single and make less than $61,000 a year ($98,000 if you are married filing jointly), then you can make the entire IRA contribution pre-tax and then pay regular income taxes when you withdraw money in retirement. If you make more than $71,000 a year ($118,000 if you are married filing jointly), then you can still contribute to an IRA but you have to pay income tax on the money first (i.e., use post-income tax dollars); when you take the money out in retirement, you pay regular income tax on however much the IRA appreciated over the amount that you initially put into the IRA. Most physicians have an annual income that is too high to allow pre-tax traditional IRA contributions but they can still contribute to a traditional IRA with post-tax dollars. The most you can put into a traditional IRA in 2016 is $5,500 per year ($6,500 if you are over age 50).
  10. Roth IRA. Like a traditional IRA, this is money that you have total investment control over. Unlike a traditional IRA, you don’t have to pay any income tax on it when you take withdrawals in retirement. Also unlike a traditional IRA, anyone who puts money into a Roth IRA has to use post-income tax dollars. There are limits of who can contribute directly to a Roth IRA: the income limit to do this in 2016 is $117,000 if you are single and $194,000 if you are married filing jointly. However, current tax law allows a person who would not normally qualify to put money in a Roth to open a traditional IRA using post-income tax money and then immediately “convert” it to a Roth. This is sometimes called a “backdoor” Roth.
  11. Self-employment plans (SEPs or SEP-IRAs). This is a retirement plan for self-employed persons. Physicians frequently have the bulk of their clinical income from either a hospital or group practice that they work for but may also have some income that they make on the side, for example, money from giving talks or from outside consulting. The SEP is an option for investing part of that self-employment income for retirement. Each year, the physician puts away a part of his or her pre-tax income into the SEP. The SEP money grows untaxed, similar to a 401(k), and then when the physician retires, they take money out of the SEP and pay income tax on the withdrawals. The maximum amount a person can contribute to an SEP in 2016 is 25% of their compensation for that year up to a maximum contribution of $53,000.
  12. Regular investments. These can take a lot of different forms, such as stocks, bonds, and mutual funds. The money you invest is all post-income tax. You may get annual interest or dividend income from these investments and you may sell them for a profit in the future. Interest income is taxed at your regular income tax rate. Dividend income and the profit from selling one of these investments at a higher price than you originally paid for it is taxed at the capital gains tax rate, which is generally lower than the income tax rate.

If you are wise, you’ll have retirement investments in more than just one of these and preferably, in more than half of these. In future posts in this series, I’ll tell you which options I think make the most sense for physicians.

August 18, 2016

Categories
Physician Finances Physician Retirement Planning

Planning For Retirement For Physicians Part 1: How Much Money Will You Need In Retirement?

I was asked to give a presentation on financial planning to fellows attending this fall’s annual meeting of the American College of Chest Physicians. In preparation for that presentation, I am preparing several posts about retirement planning for physicians. This is the first of these posts. As a disclaimer, I am not a financial planner but after more than 30 years of being a physician with 15 of those years spent as the treasurer of our Department of Internal Medicine, I have seen physicians make a lot of good choices and bad choices so I have a few thoughts on the subject.

The question everyone asks when planning retirement income is: “How much money will I need?”. The answer is… a lot. Before you can even begin to try to answer the question, you have to consider a number of variables including:

  1. How long will you live in retirement? Somehow, this one always gets me queasy whenever I have to consider it. Currently, the average life expectancy for an American who is 30 years old is age 77 for a man and age 81 for a woman. Since you are a physician, you can probably add a couple of years to that since you are likely a non-smoker and have reasonably healthy eating and exercise habits. So, if you are looking at retiring at age 65, then you’re going to need 15-20 years of income saved up. And if you’re planning on living to 100 like me, then you’re going to need to support yourself for 35 years.
  2. What is the inflation rate? The consumer price index goes up each year with an average inflation rate for the past 100 years of 3.1% per year. But remember, that is an average. The year I started medical school, the inflation rate was 13.5% and a couple of years of that rate will dramatically erode your retirement account. For the sake of simplicity, let’s assume the consumer price index goes up the same amount in the next 30 years when you get ready to retire as it has in the past 30 years when I was a resident. If that is the case, then an annual income of $250,000 this year will be equal in purchasing power to an annual income of $549,813 in 30 years.
  3. Will your fixed expenses change? Hopefully, you’ll have the house paid off, the kids out of the house and their college paid off. Once you retire, you won’t have to be setting aside a big chunk of your annual income for retirement savings since you’ll be drawing off of those savings. But things happen and it is possible that you’ll have different fixed expenses in 30 years. But for simplicity sake, subtract out your current mortgage payments, retirement contributions, and kid’s college savings contributions from your current income to determine what percentage of your current income is used for your activities of daily living in order to determine what you will need to maintain that level of daily living in retirement.
  4. What portion of your retirement income will be subject to income tax? As you will see in a later post, there are taxable and non-taxable retirement savings options for you but most of your retirement income is likely to be subject to income taxes, just like your current income is.

So, for the purposes of example, let’s assume you are a physician making $250,000 a year currently. And let’s further assume that you are spending $30,000 a year on your mortgage, you are putting $40,000 a year away for retirement, and you are saving $10,00 a year for your children’s college savings and all of those expenses are going to go away when you retire with your house paid off and your children graduated from college. That means that your effective current income is $170,000 per year. If the consumer price index goes up at the same pace as it has for the past 30 years, then in order to have the same lifestyle in 30 years as you do now, you’ll need to have $374,000 per year. The good news is that your annual income will likely be also going up each year for the next 30 years and presumably the amount that you are contributing into your retirement fund will also so it won’t be quite as much of a sudden shock to your finances.

There are a lot of formulas for estimating how much of your retirement account you should plan to take out each year. A commonly quoted number range is 3-5% of your total retirement portfolio.  Let’s go with 4% as your initial withdrawal rate and you estimate that you will live for 30 years in retirement. In order to have $374,000 per year, starting 30 years from now, you’ll need to have about $9,000,000 in your retirement account in order to fund yourself entirely out of your retirement savings.

If you are a physician and you and your spouse are making a lot more than $250,000 per year, then your retirement target may be closer to $15,000,000 or $20,000,000. These are really scary numbers but as I’m going to show you in the next several posts in this series, it is actually pretty do-able as long as you start saving early and you save smartly.

 

August 16, 2016

 

 

Categories
Medical Economics Physician Finances

What Is The Return On Investment For Residency?

Let me preface this post by saying that my advice to any medical student when choosing a specialty is to follow their passion and not the dollars. That having been said, money ultimately does make a difference. So what is the return on investment per year of residency?

Let’s start with medical student debt. No matter how altruistic a medical student is on day one of medical school, by the end of the fourth year, debt pressures can significantly influence career choices. The Association of American Colleges estimates that the average medical student debt is $172,751 for students graduating from public medical schools and $193,483 for graduates of private medical schools. With the median first year resident salary being about $52,000 with an increase of about $2,000 per year for subsequent residency years, physicians starting their careers following residency can face a huge debt burden. Many student loans will require relatively small monthly payments during residency but as soon as residency is completed, the monthly payments can skyrocket to as much as a mortgage payment.

Most physicians would assume that the longer the duration of residency, the higher the salary a physician makes after completion of residency and it turns out that this is generally correct. Pediatrics and family medicine with only 3 years of residency are usually the lowest paying specialties. Surgical specialties requiring 6 or 7 years of residency after medical school have the highest salaries for physicians. But those additional years of residency mean that the physician will either need to retire at an older age to make up for the lost earning years from the longer residency or they will have a shorter career duration for lifetime earnings.

A different way of looking at residency choices is the salary return on investment based on the number of years of residency. In other words, the best return on investment would be a specialty that has the highest salary per year of required residency training. Sure, there are a lot of potential criticisms of this method of analyzing the economics of post-graduate medical training but it is interesting, nevertheless.

The first challenge in this analysis is to pick a physician compensation report. There are reports put out by the MGMA, the AAMC, Medscape, Merritt Hawkins, and the AMGA, just to name a few. The data from each one is a little different. For example, the MGMA report mainly samples large physician group practices whereas the AAMC report is for academic physicians. Th AMGA is comprised of medical group practices and health systems. The Medscape report relies on self-reported individual physician surveys and may be subject to reporter bias. Reports based on first year salaries can be affected by relatively small numbers of physicians sampled. The bottom line is that there is no perfect compensation survey that fits all physicians. The Medscape Physician Compensation Report 2015 is based on surveys submitted by 19,657 physicians between December 2014 – March 2015 and is freely available on the internet. The American Medical Group Association (AMGA) is an organization for medical group practices and has 125,000 physician members. The AMGA Compensation Report 2015 is based on surveys received to member medical groups and health systems. The Merritt Hawkins Physician Compensation report is based on hospital and group practice offers to newly recruited physicians and primarily reflects entry-level salaries.

In the table in the PDF link below, the average compensation reported by Medscape is listed along with the number of years of residency for each specialty. I have counted years of fellowship as years of residency for simplicity. By dividing the average salary by the number of years of residency, you can come up with the average salary per year of residency training. If you think of think of residency as a career investment, then this number gives you an idea of the return on your residency time investment. Some of these numbers have to be viewed with caution, however. For example, unlike the MGMA and AAMC reports, Medscape lumps all cardiologists into a single category of cardiology so this may include not only general cardiologists but also interventional and electrophysiology cardiologists who have longer fellowships and make a higher salary. There is no separate category for outpatient general internal medicine and hospitalist medicine in the Medscape survey so presumably the category of “internal medicine” includes both even though they have very different salaries.

Medscape Physician Compensation Analysis

The AMGA physician compensation report gives fairly similar results as Medscape but does give results for some specialties not included in the Medscape survey:

AMGA Physician Compensation Analysis

The Merritt Hawkins report shows slightly different results, mainly what to expect in the first year after residency. It has a smaller “n-value” for each specialty so this may affect its accuracy compared to other reports:

Merritt Hawkins Physician Compensation Analysis

The MGMA report is for starting salaries in the first year post-residency in larger medical groups. Like the Merritt Hawkins survey, the results for any given specialty represent a small number of physicians and my not be as reflective of true numbers as other reports:

MGMA Physician Compensation Analysis

If you combine these three reports, the three highest return on investment specialties for all 4 surveys are emergency medicine, dermatology, and orthopedic surgery. Anesthesiology makes the highest return on investment list in 3 of the surveys and neurosurgery makes the list on 1 survey (however neurosurgery was only included as a specialty in two of the four surveys).

The lowest return on investment depends on the survey. For the Medscape, AMGA, and MGMA surveys that survey all practitioners, the two consistently lowest return on investment specialties are endocrinology and infectious disease. Pulmonary/critical care medicine and rheumatology make two of the surveys’ lowest return on investment list. Allergy and nephrology each made the bottom list in one of the surveys.

However, in the Merritt Hawkins survey, the four specialties giving the lowest return on investment are non-invasive cardiology, radiology, psychiatry, and hematology/oncology. Although this could just be a result of small numbers of physicians sampled in the Merritt Hawkins survey as opposed to the other surveys, it is also possible that these four specialities are becoming saturated with a supply of physicians beginning to exceed the supply.

No one would advise a medical student to choose a specialty purely based on this analysis. The good news is that all physicians make a high income relative to other professions and so the decision should be more about what you enjoy doing rather about a pure financial return on investment. There are also quality of life issues to consider, for example, an emergency medicine physician has to be willing to work a lot of evening and night shifts since that is when emergency rooms get busy.

In an ideal free market world, physician salary would be dictated by the supply and demand for any given specialty but the market for physicians is not a free market system since income is tied to reimbursement and the reimbursement for any given service or procedure is determined by Medicare and commercial insurance companies.

For myself, I started off my career as a pulmonary and critical care physician, one of the specialties with the lowest return on investment. Even if I had read this blog post 30 years ago, I still would have gone into pulmonary/critical care since that is where my passion lies.

August 1, 2016

Categories
Physician Finances

40 Questions To Ask During Physician Contract Negotiations

Entering a used practice can be like buying a used car. You just never know where it has been or how well it is really running, regardless of what it looks like on the outside. At our hospital, physicians have a lot of different employment models with some employed by the University, some in small group practices, some who are in solo practices, and some that are in large multi-specialty practices with hundreds of physicians. Our fellows asked me to give a talk next month on what to look for as they begin their job searches for their future medical practices. Here is a summary of my thoughts… 40 questions to ask during job negotiations:

  1. What is the salary? BEWARE OF THIS QUESTION!! Salary ≠ Salary. There can be hidden benefits and there can be hidden costs. This is a question often best left to the end of the job interview. There is often considerably more to job satisfaction than income than money alone. Don’t say “yes” to the first job offer but do your homework and check the MGMA salary report as a general guide of what salary to expect.
  2. Will you be hospital-employed or privately employed? In 2002, 75% of physician practices were owned by physicians. By 2011, more than 60% were owned by hospitals. The current trend is definitely toward hospital employment and even if you are looking at a private group, there is a chance that it is negotiating an employment agreement. Although there can be advantages to either model, current healthcare economic policies and reimbursement make it easier to succeed in a hospital-employed model in most cases.
  3. Who governs the practice? In small groups it is the partners. In large groups it is typically a CEO and board of trustees. In hospitals it is usually a CEO and board of trustees. At Universities it is usually the Dean and board of trustees. In government agencies, it is an administrator or political appointee. Be sure that the governance places a priority on your interests.
  4. Who do you really work for? Particularly with hospital or academic employment, the leadership structure can be complex and more resemble a matrix than a hierarchy. With large organizations and practices, be sure you know who you will report to and who will be making the decisions that will affect different aspects of your job.
  5. How does the group define clinical productivity? RVUs? Patient encounters? Shifts? Billings? Receipts? Each of these has advantages and disadvantages. How clinical productivity is measured for one specialty may not be best for a different specialty.
  6. How many patients should I see? This is not only specialty-specific but can vary tremendously from one patient population to another within the same specialty. Hospitalists generally see about 1.5-2 patient encounters per hour or 15-18 encounters per day. But not all encounters are equal, for example, a hospitalist co-managing reasonably healthy patients admitted for joint replacement surgery can see far more patients per shift than a hospitalist doing primary management of complex medical admissions admitted through the emergency department. Ambulatory physicians should expect about 20 minutes per patient. 82% of physicians work 8-12 hours per day for an average of 10 hours per day and an average of 59.6 hours per week. For internal medicine it works out to about 110 patient encounters per week.
  7. Do I need a productivity ramp-up period? If you are an emergency room physician, anesthesiologist, trauma surgeon, or critical care physician, then the answer is no because you will have a full slate of patients your first day in the hospital. If you are a surgical specialist, a consultant in a competitive market or a primary care physician then the answer is likely to be yes. Ramp-ups give the new physician a guaranteed salary if they are not able to make their own salary with their own billings and are usually phased out over a 1-3 year period. Also, most physicians do not reach optimal clinical efficiency until about 7 years after completing their formal training, which is why physicians age 50-60 are currently the most productive physicians in the United States.
  8. What is the group’s payer mix? You can plan on bringing in about $34/RVU for Medicare, $25/RVU for Medicaid (depending on your state), and $30-70/RVU for commercial insurance. Self-pay patients can vary but most of the time will provide negligible reimbursement.
  9. Will my payer mix affect my income? In Ohio, it can take up to 180 days to get commercial insurance company provider approval. Therefore, building a practice may mean more self-pay and Medicaid in the beginning. If you plan to rely on inpatient unassigned ER admissions to build your practice, bear in mind that these patients will generally have a lower payer mix. The affordable Care Act Medicaid expansion states have much better payer mixes than those states that opted out of Medicaid expansion. States that did NOT adopt Medicaid expansion include: Alabama, Florida, Georgia, Idaho, Kansas, Maine, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.
  10. Who negotiates commercial insurance contracts? Small group practices will usually get the “standard” rates from insurance companies and this is typically 90-110% of Medicare on a per RVU basis. Large groups may have higher reimbursement from the same insurance companies, depending on their leverage. Huge groups or those with monopolies may get 150-180% of Medicare rates. If the hospital is sponsoring the contract negotiation with an insurance company, the focus may be more on hospital reimbursement rates than on physician reimbursement rates. Most patients don’t realize that when they get admitted to the hospital, the amount that 2 physicians get paid by an insurance company to provide a given service or do a procedure can vary depending on who those physicians are employed by.
  11. Are “easy” duties equally shared? There are some clinical activities that can generate a lot of income per physician work hour. Be sure that the more senior members of the practice are not hoarding all of these relatively easy activities such as EKG interpretation, PFT interpretation, bone density interpretation, reading cardiology non-invasive tests, EEG interpretation, EMG interpretation, and sleep study interpretation.
  12. Are there medical directorships? These can be a great way to balance your overall employment activity portfolio, much like having some bonds in your investment portfolio. These can take the form of hospital directorships, practice-owned lab/imaging directorships, governmental directorships, industry directorships, and university teaching salary lines.
  13. Is there a buy-in? This used to be pretty standard but is uncommon now and should be a red flag to you. There are some things that are appropriate for buy-in: property, equipment (depreciated), and accounts receivable. Think twice before buy-in for: referral base, patient charts, or practice equity.
  14. Can I moonlight? No two moonlighting activities are exactly the same and be sure you know what the rules are before you sign your employment contract. Expect on having some unexpected expenses in your first few years of practice so being able to make a little extra money can really help. These may take the form of extra hospital shifts, extra clinics, expert witness testimony, business consulting, honoraria for giving talks, or board memberships. In some groups, income from these activities belongs to the practice and in other groups, the income belongs to the individual physician.
  15. What intangibles will add to your job satisfaction? These can include teaching, research, publication, public health, community service, sports medicine, and medical volunteerism. Don’t underestimate the value of these things. In a recent survey of physicians, 17% said they were very dissatisfied and 25% said they were somewhat dissatisfied with their job. Only 41% of physicians said that they were very likely or somewhat likely to recommend a young person to go into medicine. I have lots of uncompensated intangibles in my job and that is one of the reasons that I’m so happy with my job.
  16. Are there plans to be an accountable care organization (ACO)? ACOs were started as a provision of the Accountable Care Act in 2012. They are created by physicians and hospitals combining to provide all of the healthcare for at least 5,000 Medicare beneficiaries for 3 years. The providers are jointly responsible for the care of the patients with a goal of reducing unnecessary tests, keeping costs down, meeting quality benchmarks, and focusing on prevention. Those ACOs that are successful get paid extra by Medicare. However, many ACOs have failed, resulting in lower income. ACOs’ existence is also vulnerable to who is in Congress and who is the President so there is no guarantee that they will still exist 3 years from now. The bottom line, beware of practices that are ignoring ACOs but also beware of practices that are counting on ACOs to survive.
  17. Does the practice use advanced practice providers? These can be nurse practitioners, physician assistants, CRNAs, clinical nurse specialists, or nurse midwives. The scope of practice of these providers varies from state to state so know the laws of the state you will be moving to. Also, there is a big difference between advance practice providers employed by a hospital versus employed by a physician practice. If they are employed by the hospital, then you the physician cannot use their documentation for your own notes in order to justify the level of service billed. It is possible, however, for the physician group to lease some of the advance practice provider’s time from the hospital enabling the physician to use the advance practice provider’s documentation as part of the physician’s note.
  18. Is there an electronic medical record? This is not as much of an issue now compared to a few years ago since now, most practices will have an EMR of some kind. However, you do need to ask a few questions. Does it meet federal EMR requirements? Does it interface with the hospital EMR? Does it interface with referral physicians? Does it interface with the billing department? Does it work for you or do you have to work for it (not all EMRs are equally user-friendly)?
  19. Are there restrictive covenants? Even though you think that your first job out of residency will be the one you will stay with for the rest of your life, it probably isn’t. Restrictive covenants can take many forms including: geographic non-compete, non-solicitation, hospital non-compete, and chart ownership. Restrictive covenants can be appropriate for some specialties but they must be reasonable. A 10 mile geographic non-compete clause may be OK for a thoracic surgeon specializing in robotic surgery. A 50 mile geographic non-compete is probably not OK for a hospitalist.
  20. What about call? Do all partners participate equally? Not all call is created equal, for example, is call taken at home or in the hospital? If it is home call, how frequently do you have to come into the hospital at night? How many hospitals do you cover when you are on call? Is there a surge plan in case you get overwhelmed with admissions or consults? Are there residents or hospitalists who are in the hospital covering the patients with you?
  21. What about shift work? If you will be working shifts (for example emergency medicine or hospitalist medicine), then who makes up the schedule? Does the new guy do all of the night shifts? Is there a shift pay differential for the undesirable shifts? Beware of productivity-based salary plans that have shift work because not all shifts are productivity-equal, for example, you probably won’t hit your RVU targets if you are primarily working the midnight to 8 AM shift in the emergency department.
  22. How will my success be defined? RVUs? Total income? Number of procedures? Quality metrics? Patient satisfaction? Readmission rates? Length of stay? Publications? Grants? None of these are necessarily bad measures of success but just know what the rules are and what is valued by the practice before you start.
  23. What is the history of the practice? Recent physician turnover can be a warning sign. A new venture may be riskier than an established group practice. Some turnover is OK – many/most physicians change jobs in their first 5 years of practice.
  24. What’s under the rug? Some of the things that they won’t put in the employment ad you read in a medical journal can include: Medicare fraud history; federal investigations such as HIPAA violations, tax fraud, Stark violations, or discrimination; employee civil suits; state Medical Board violations; and malpractice history. If there was recent attrition, why did the previous doctors leave? Always Google the practice and the senior members of the practice to be sure that there is no hidden dirt on the practice.
  25. Are there negotiable incentives? The salary may be non-negotiable, but there are a lot of other things that the hospital or practice may be willing to pay for. Sometimes, all it takes is just asking about student loan repayment, moving expenses, signing bonuses, board certification exam fees, DEA license fees, state medical license fees, practice advertising/promotion costs, and pager/cell phone/answering service.
  26. What are the benefits? Computer? Expense accounts (CME, travel, books & journals, equipment?), Sick time accrual? Vacation time accrual? Retirement? Maternity leave? Paternity leave? Tuition discounts? Health insurance? Life insurance? Disability insurance? Health club membership? Meals? These can really add up and can make a job more valuable even though the salary alone may be considerably lower.
  27. What is the practice overhead? There are some elements of overhead expense that all practices will have such as billing expense (“revenue cycle”), legal expenses, practice administration, rent, equipment, nurses, etc. Academic institutions will uniquely have additional expenses such as “Dean’s tax”, departmental tax, fellow salaries, research faculty support, and support of money-losing specialties. None of these are necessarily bad but you should know where every penny of your collected dollar is going.
  28. What is the collection rate? This is a point of confusion for most physicians. The gross collection rate is the amount that you get paid versus amount you billed and typically 40-60%. It is completely dependent on where the practice sets its fees and is largely irrelevant. The net collection rate is the amount you get paid versus the contractual rates. This should be as close to 100% as possible and should always be > 90%. The net collection rate is a reflection of billing efficiency and is highly relevant.
  29. What are the contract termination conditions? Most initial contracts are for 1-3 years. Frequent re-negotiation can be tedious but can protect you against changing medical economics. The contract should contain a termination clause. Typical “without cause” termination is 90 or 180 days and typical “with cause” termination is immediate.
  30. Where will you actually be practicing? Most practices will have multiple locations that they practice in and just because your initial interview was at the flagship hospital does not mean that you will be spending all or even any of your time there. Know if you will be working at an outpatient clinic, an inpatient hospital, an urgent care, doing telemedicine, an LTACH, an affiliated hospital, or a nursing home.
  31. Do you have a unique marketable skill? This can be negotiated into a higher salary than the standard base salary and can include expertise in interventional endoscopy, interventional bronchoscopy, cardiac MRI, endoscopic ultrasound, robotic surgery, laparoscopic surgery, or experience in a specific disease.
  32. Does it feel right? For most physicians, that sense of it “feeling right” was one of the main factors in deciding what residency to choose. That same sense is helpful for your first job after residency and can be affected by, the partners, the practice, the administrator, the hospital, and the community.
  33. What kind of malpractice do they have? “Claims made” means that the insurance coverage period covers the period of time the claim is filed. Claims made policies require purchase of a tail to cover any claims filed after the coverage period. “Occurrence” means that the insurance coverage period covers the period of time when the actual event occurred and it does not require purchase of a tail.
  34. Who pays malpractice? The contract will usually say who pays for the annual premiums but be sure that you know who will pay for a tail insurance policy if you leave the practice. The cost of the tail can vary depending on the cost of the regular premium, the physician’s specialty, and how long the physician worked at the practice before resigning. Tail coverage can be very expensive.
  35. What is the retirement plan? There are a bewildering number of retirement plan options including defined benefit pension plans, defined contribution pension plans, 401a plans, 401k plans, 403b plans, 457 plans, Social Security, IRAs, and SEPs. If you assume that you will work for 30 years and then live for 15 years after you retire and you are now making $150,000/year and you estimate you will need 80% of your annual income in retirement, then you are going to need about $5,000,000 by the time you retire. It is not as difficult to achieve as you might think but it is very important that you start early in your career. Be sure you know what your retirement savings options are and then take advantage of them early in your career to the best that you can afford.
  36. How difficult was the contract negotiation? Was it a struggle? Was it fair? Your first negotiation with the partners or the hospital will not be your last.
  37. Did they give it to you in writing? Some of the warning signs to be on the look-out for include a partner’s spouse who is involved in practice administration, an “acting” chairman (academic position), resistance to provide details in writing, no incentive bonus, a history of frequent physician turnover, and partners who are all old or all young.
  38. Is the contract assignable or non-assignable? In the event of a potential group acquisition, consolidation, or merger will you be obliged to work for the new group (assignable contract) or will you be free to leave (non-assignable contract).
  39. What happens if you leave? Can you cash in your unused vacation time and does it accrue from one year to the next? Can you cash in your unused CME time or unused sick time? Do you get to keep your accounts receivable or will they stay with the practice?
  40. Do I need to have an attorney review the contract? Maybe…The bigger the practice, the less negotiable the contract but it is usually worth a few hundred dollars for the peace of mind that an attorney will give you that you are not being taken advantage of.

 

July 21, 2016