Categories
Epidemiology

Australians Are Not Getting Influenza Infections This Year. What’s Going On?

It is summer in North America and that means that it is winter in Australia. Normally, Australia’s winter influenza season predicts how influenza will behave in the United States 6 months from now. But something very weird is happening in Australia this year – Australians are not getting influenza. So, what does this mean for the U.S.?

Last winter was a pretty average influenza season in the United States. Data from the CDC indicates that somewhere between 32 and 57 million Americans had an influenza infection last year. The statistics are always listed as an estimated range because not everyone who gets influenza gets tested. The CDC’s estimates are based on a mathematical model based on the CDC’s weekly influenza surveillance data. It is estimated that there were between 24,000 and 81,000 U.S. deaths from influenza last year.

Compared to previous years, this was fairly average. In most winters, between 25,000 and 50,000 Americans die from influenza. Once again, because not everyone who dies in the winter gets tested for influenza, the CDC reports annual influenza deaths as a range between what is the statistical 95% lower confidence level and 95% upper confidence level, as shown in the graph below.

Because the southern hemisphere experiences the annual influenza season 6 months before the northern hemisphere, the data from the Australian Centre for Disease Control often provides a preview of what the United States will experience in its winter. The graph below shows the number of laboratory confirmed cases of influenza in Australia for the past 4 years. Data from 2026 through June 14th is shown in the dark blue dashed line. Normally, cases of influenza in Australia peak in June or July. But so far this year, cases of influenza have been steadily falling since January and in fact are lower than the usual number of cases in Australia’s summer.

Similar to influenza, the number of reported COVID infections in Australia this year is lower than in past years. The graph below shows that Australia is not experiencing a peak in COVID infections during the current Australian winter, unlike the past three years.

Unlike the remarkably low number of influenza cases in Australia this year, there is a fairly typical number of RSV infections. The graph below shows the number of reported RSV infections in Australia for the past 4 years. Data from 2026 is in the dark blue dashed line. Although there are fewer cases of RSV this year compared to previous years, the trend in seasonal RSV infections looks typical, with a rising number of cases as winter progresses and a likely peak within the next month.

Surprisingly, the number of patients admitted to the hospital with influenza has been dropping since the Australian summer (January 2026). The graph below shows that RSV (green bars) currently accounts for far more hospitalizations than either influenza (blue bars) or COVID (black bars).

Public health authorities track the percentage of influenza tests that are positive. Test positivity is similarly tracked for COVID and RSV tests. This is considered to be an early indicator of an upcoming spike in infections – when the test positivity percentage begins to rise, the number of cases of that particular respiratory virus can be expected to rise within the next 2-3 weeks.

So far this year, the influenza test positivity in Australia has been very low (blue bars in the graph below). COVID test positivity has remained fairly constant so far this year (black bars) but RSV test positivity has been increasing (green bars).

Epidemiology is 2 parts science and 1 part art. We usually do not fully understand a disease outbreak until after the outbreak is over and public health epidemiologists have had a chance to fully study both the rise and the fall in cases. So, we probably will not fully understand why the number of Australian influenza infections are so low this winter for another year or two. Nevertheless, there are some preliminary suspects as to the reasons why.

  • Last year was a particularly bad influenza season. 2025 was the worst year for influenza in Australia this century. The number of reported cases was the highest ever recorded since Australia began tracking influenza in 2001. Australia also recorded 1,701 influenza deaths last year; prior to that the highest number of influenza deaths was 1,276 in 2017. The result was that Australians who survived the 2025 influenza season had good immunity against influenza in the way of antibodies developed from infections. These antibodies can then provide immunity against influenza the following year, particularly if the circulating strains of influenza are similar.
  • Good effectiveness of this year’s influenza vaccine. Each spring, public health epidemiologists predict which strains of influenza will most likely circulate the following winter. This is not an exact science and the vaccines do not always end up protecting optimally against the influenza strains that actually show up in circulation. In Australia this year, the 2026 vaccine is turning out to be a particularly good match against the influenza strains that are in circulation. So far, 100% of influenza A(H1N1) isolates, 81.8% of influenza A(H3N2) and 87.0% of influenza B/Victoria lineage isolates are antigenically similar to this year’s vaccine components.
  • An unusually warm Australian winter. 2026 is turning out to be an exceptionally warm winter in Australia. Sydney has had its warmest winter on record and the southeastern Australian states have had June temperatures 9℉ hotter than average. Warm temperatures mean that more people will be outdoors, rather than crowded together indoors. This results in natural social distancing that retards the spread of influenza.

If history holds, then next winter could be a mild influenza season. However, there are notable differences in influenza recently between Australia and the U.S. First, whereas the previous influenza season in Australia was unusually bad, it was fairly average in the U.S. so Americans may be going into the flu season with less antibody protection than Australians have during their current winter. Second, there is no guarantee that the influenza vaccines for next season will match up to the influenza isolates that actually show up in circulation in the U.S. next winter – Australia may simply have gotten lucky this year with an unusually good vaccine match. Third, the U.S. may not have the unusually warm winter that Australia is having – the new El Niño weather event will likely bring warmer than average temperatures to the northern U.S. but colder than normal temperatures to the southern U.S.

There are steps that Americans can take that will give us an edge against influenza this season. The single most important way to avoid getting infected by influenza is to not have close contact with anyone else with influenza. That means getting as many Americans vaccinated against influenza as possible and means implementing tactics to keep infected people away from uninfected people. Here are some specific tactics that we can implement to reduce influenza and other respiratory infections next winter:

  • Increase influenza vaccination rates. Actually, the United States does a better job vaccinating its citizens against influenza than Australia. Last year, 46.5% of American adults and 49.3% of American children received an influenza vaccination. This year, only 26.2% of Australians received an influenza vaccination. When the person standing next to you in the grocery store checkout line gets a flu shot, then that person is not only less likely to get influenza themself but also less likely to give you an influenza infection. People who live in crowded living conditions should be particularly targeted for vaccination. George Washington realized this when he required his soldiers to be inoculated against smallpox, resulting in his army being healthy when the British army was impaired by a smallpox outbreak. The recent decision by the U.S. Secretary of War to not mandate influenza vaccination in the military is simply dumb.
  • Facilitate work-from-home policies for sick employees. During the early years of COVID, the United States had historically low rates of influenza. One of the main reasons was that everyone who could was working from home and students were attending classes on-line in their own homes. The result was that a sick employee did not pass influenza on to everyone else in the office and a sick student did not infect the entire class. Employers and schools should create policies that allow sick employees to work from home when job requirements permit. Schools should also create policies that allow students to attend classes remotely when they get sick.
  • Face masks work. To prevent getting infected by an airborne virus y0urself, you need to wear an N-95 grade face mask. But to prevent you from giving your influenza virus to someone else, your wearing of a simple medical mask will do the job. The anti-mask frenzy that overtook many Americans during the COVID pandemic reflected the ignorance of infection transmission that too many people had during those years. Employers should create work environments where the wearing of face masks by people with cold and flu symptoms who cannot work from home is encouraged or better yet, required. This means creating a workplace culture of face mask acceptance and preventing a workplace culture of face mask shaming.
  • Improve RSV vaccination rates. Although COVID vaccinations and influenza vaccinations seem to get the most press, in Australia this year, there are far more hospitalizations for RSV than either COVID or influenza. That is unfortunate because the RSV vaccines are highly effective in preventing RSV infections. Healthcare providers should especially target pregnant women and people over age 65 to get vaccinated against RSV.
  • Don’t forget about COVID. The COVID pandemic is a distant memory for most Americans. We’ve forgotten that 1.2 million Americans have died from COVID and that the United States had the highest COVID death rate in the world. Although COVID numbers are decreasing, it is still exceptionally deadly. Last year, about 40,000 Americans died from a COVID infection. Vaccination can save your life and save the lives of those people you are in contact with.

We will not know the full story of Australian influenza in 2026 for several months. But the data for the first half of the year is encouraging and hopefully portends a mild influenza season in the United States next winter. However, influenza always has the last word, so we should not let our guard down prematurely.

June 26, 2026

Categories
Physician Retirement Planning

Cryptocurrency As A Retirement Investment 2: Why Crypto Will Never Become A Mainstream Currency

Earlier this year, I posted about the pros and cons of including cryptocurrency, such as Bitcoin, in your retirement portfolio. The greatest argument against cryptocurrency as a retirement investment is that its inherent qualities will preclude any country from adopting it as a mainstream currency in the long run. The reasons why? Cryptocurrency is deflationary and interferes with countries’ monetary policy.

You might ask “If inflation is bad and deflation is the opposite of inflation, then deflation must be good, right?“. It is not even close, deflation is much worse than inflation. On the surface, deflation sounds like it ought to be desirable – over time, the cost of goods and services falls and everything gets cheaper. But hidden behind that statement are implications that can wreck a country’s economy and bring misery to consumers.

Let’s use Bitcoin as an example of a typical cryptocurrency. Bitcoins are created by “miners” who use powerful computers to create blockchains by solving complex mathematical problems. But there is a limited number of Bitcoins that can be created – 21 million. As of this year, 96% of these have already been “mined”, leaving less than 1 million left to be mathematically discovered. Every year, it gets harder and harder to mine the remaining Bitcoins and it is projected that all of them will be mined by 2140. After that, no more Bitcoins will exist to be generated and put into circulation.

But Bitcoins get lost. A Bitcoin is simply a long number and to store a Bitcoin, you either have to write that number down on a piece of paper or store it on a computer somewhere. Inevitably, people lose their Bitcoin numbers. Maybe a Bitcoin owner loses the piece of paper that the Bitcoin number was written down on. Maybe their computer is stolen or destroyed in a house fire. Maybe the Bitcoin owner dies without telling anyone where the Bitcoin number is hidden. Presently, it is estimated that between 11% and 20% of Bitcoins have already been irretrievably lost. Once lost, those Bitcoins cannot be re-mined. They are lost forever and thus the number of circulating Bitcoins progressively falls.

Paper currency does not have this problem. Every year, millions of $1, $5, $10, $20, and $100 bills are accidentally burned, torn, or misplaced. Nickels, dimes, and quarters are accidentally thrown away, lost, or damaged. This poses no problem for the U.S. government – we simply print more dollar bills, keeping the total amount of U.S. currency in circulation constant.

But as the number of new Bitcoins mined each year continues to fall and some Bitcoins are inevitably lost, the Bitcoins remaining in circulation become more and more valuable since there are less and less of them. The result is deflation – a car costing 1 Bitcoin today might cost 0.9 Bitcoin tomorrow. Sounds great, right? Wrong – it also means that a worker getting paid 1 Bitcoin per month in wages will only earn 0.9 Bitcoin the next month.

When an economy undergoes deflation, consumers hold off on making purchases, anticipating that their currency (in this case a Bitcoin) will buy more in the future than in the present. This suppresses consumption. As consumer consumption falls, demand for goods and services fall and producers have to start laying off workers, leading to rising unemployment. It gets worse because during deflation, investors start hoarding currency because it can increase in value faster than other investments, such as stocks and bonds. Deflation would thus take even more Bitcoins out of circulation, causing a spiral of worsening deflation and negative economic growth.

One of the advantages of cryptocurrency is that it avoids manipulation by governments. But this is also one of its liabilities. Central banks, such as the Federal Reserve, adjust interest rates and money supplies in order to combat inflation and unemployment. Because cryptocurrency, such as Bitcoin, is decentralized, adoption of a cryptocurrency as a national currency would strip the ability of that country’s central bank from adjusting interest rates to increase or decrease the money supply. This essentially makes central banks impotent to fight inflation or to prevent recessions. So, if there are supply chain disruptions, such as occurred with shipping during at the beginning of the COVID pandemic, or oil transport disruption such as occurred during the U.S.-Iran war, then the Federal Reserve would be unable to raise interest rates to prevent runaway inflation. No country (or group of countries in the case of the European Union) wants to give up its autonomy over its internal monetary policy.

For blockchain-based cryptocurrencies to function in a transaction, there has to be a large network of independent computers that compete to validate a transaction involving a particular cryptocurrency unit by solving a complex mathematical puzzle. Once a computer on the global network solves the mathematical puzzle, other computers on the network must then confirm the validity of the transaction. Only then is, a new block is permanently added to that cryptocurrency unit’s blockchain and the transaction is completed. The computers on the global network are called miners, because they also solve mathematical puzzles to discover or “mine” new cryptocurrency units. These miners make money by selling their newly mined cryptocurrency and also by charging a transaction fee when validating every cryptocurrency transaction.

Transaction fees are not new. Every time you buy something using a credit card, the person selling that something has to pay the credit card company a percentage of that transaction, typically 1.5% to 3.5%, depending on the specific credit card. Retailers detest these transaction fees because they significantly increase their overhead expenses. That is why many small business owners accept only cash and do not accept credit cards. That is also why many businesses charge customers 2.5% or 3% more if they use a credit card.

Unlike credit card fees, Bitcoin transaction fees are paid by the buyer, not the seller. Also unlike credit card fees, Bitcoin transaction fees are a fixed amount, rather than a percentage of the transaction. Bitcoin miner transaction fees vary depending on how busy the miner network is that moment and the amount of data in that particular Bitcoin transaction. In general, the transaction fees range between $0.20 and $2.00. So, if you are paying your $1,500 monthly apartment rent in Bitcoin, that transaction fee is inconsequential. But if you are paying for a $2 coffee at your local coffee shop, the transaction fee can double the price of a cup of coffee. Moreover, you won’t know what the transaction fee is until after that transaction is completed.

For small purchases, cryptocurrency is simply untenable.

Over the centuries, humans have used all sorts of things as currency – salt, cowrie shells, squirrel pelts, for example. The United States printed silver certificates until 1964 – these were paper currency used in circulation that could be exchanged with the U.S. Treasury for a defined amount of silver bullion. In 1973, the U.S. went fully off the gold standard when Richard Nixon permanently revoked the ability of banks and foreign governments to convert U.S. dollars into gold bullion.

At present, the most important currencies are the U.S. Dollar, European Euro, Japanese Yen, and British Pound. But national currencies have their own drawbacks. Countries can manipulate their currencies by depressing their value in order to make their exports cheaper, as China did in 2019. Countries can simply print too much currency, as post-World War 1 Germany did resulting in hyperinflation in 1923 with prices doubling every few days. Currency crises can result when investors lose confidence that a country can maintain a fixed exchange rate, as happened in Argentina in 1998 following years of budget deficits, corruption, and governmental economic mismanagement.

Even the venerable U.S. Dollar is susceptible to losing its prominence as the world’s currency standard because of the threat of the Federal Reserve losing its independence from political pressure and because of the threat of our rising national debt. Nevertheless, the downsides of cryptocurrency are overall more hazardous than the downsides of national currencies.

Bitcoin is not going to go away in the near future. It is untraceable, transferable with a computer mouse click, easily moved from one country to another, and totally anonymous. It will remain the currency of choice for money launderers, kidnappers, scam artists, and drug cartels. It is also currently fashionable as currency for tech bros who feel avant-garde paying for stuff with Bitcoin the way their parents felt when flashing their American Express Platinum credit cards.

But a country would have to be completely nuts to adopt Bitcoin as its main currency. It would be economic suicide. Because of this, it is extremely unlikely that Bitcoin will be a future mainstream currency. And Bitcoin is not alone – there are currently about 30,000 different active cryptocurrencies that have been created on blockchain networks. One of the most notable is $TRUMP, a cryptocurrency and World Liberty Financial, a crypto platform, both created by the Trump family when Donald Trump was inaugurated for his second term in presidency. By selling World Liberty Financial tokens and $TRUMP mime coins to foreign governments and others seeking political favors, Donald Trump and his family personally made over $2 billion last year. It is unlikely that there will be much of a market for WLF tokens and $TRUMP mime coins when Mr. Trump’s term ends and he no longer welds the economic and political power he currently has.

Past generations have bought up Beanie Babies, Cabbage Patch Kids, Hummel figurines, and holiday Barbie dolls in expectation of their increasing in value in the future. Today, these “investments” are practically worthless. Many of today’s highly sought cryptocurrencies are destined for the same future fate as Beanie Babies. So, before you invest in a cryptocurrency as a part of your retirement portfolio, think about whether that cryptocurrency will realistically be used in the future as a mainstream currency to purchase goods and services. If it won’t be, then in 30 years, your retirement portfolio will consist of a bunch of worthless numbers, like a vault full of Beanie Babies today.

Personally, I do not believe that cryptocurrency will be widely used as mainstream national currencies and for that reason, I do not believe that cryptocurrency will hold its value as a long-term investment. That is why I do not have cryptocurrency in my long-term retirement portfolio.

June 19, 2026

Categories
Hospital Finances

Does Your Hospital Really Need A Management Consultant?

Hospitals frequently hire outside management consultants in an effort to improve operational efficiency. I have been on both sides in the past, as someone who has brought in consultants to review our own operations and as someone who has been a paid consultant to other hospitals to review their operations. A recent study in the journal JAMA suggests that money spent on management consultants may not be money well spent.

Non-profit hospitals frequently hire outside consultants to evaluate hospital business operations including finances, management structure, staffing, billing, and patient flow. Depending on the size of the hospital and the scope of the consult, these management consultants can require many months to complete and can cost millions of dollars. In the JAMA study, the investigators found that during a 12-year period, 20% of U.S. non-profit hospitals obtained outside management consults at an average cost of $15.7 million per consult. Management consulting companies often promise enormous cost savings, citing examples of hospitals that saved $100 – $200 million after implementing their recommendations. But do they really deliver on what they advertise?

In the study, 306 non-profit hospitals that hired management consultants between 2010 – 2022 were compared to a control group of 513 matched hospitals that did not use outside management consultants. The investigators found no significant difference in nearly all measurements including:

  • Net patient revenue
  • Operating expenses
  • Fixed assets
  • Bad debt
  • Days’ cash on hand
  • Total margin
  • Operating margin
  • Inpatient length of stay
  • Total inpatient days
  • Patient experience score
  • Patient mortality

The only measure that reached statistical significance was a reduction in 30-day readmission for patients hospitalized with stroke; there was no difference in readmission rates for patients with pneumonia or acute myocardial infarction.

There are many reasons why hospitals or departments bring in outside consultants. Every institution’s situation is different but there are several common themes when it comes to the motivation to hire a management consulting company.

The hospital board does not trust the hospital leadership. Hospital board members do not serve on the board of trustees as their full-time jobs. Indeed, many, if not most, non-profit hospital boards are voluntary and members do not receive any income for their service. Larger hospitals do sometimes pay board members but it is usually a relatively small amount and since these board members are generally successful business owners, attorneys, and bankers, the amount they receive is a pittance compared to what they earn from their regular full-time jobs. Consequently, most board members simply do not have enough time to devote to in-depth scrutiny of day-to-day hospital operations beyond looking at monthly profit and loss statements. The CEO of a corporation with annual revenue of $5 billion might bring prestige as a hospital board member but the reality is that CEO will actually have very little time to devote to oversight of hospital business operations. The solution for many board members is to have the hospital pay someone else to come in to do an in-depth analysis of operations so the board members can be sure no-one in hospital management is screwing up.

There is a new hospital CEO, dean, or department chair. The average medical school dean in the United States only stays on the job for an average of 4 years. Department chairs last a little longer, with an average tenure of about 8 years. These medical school leaders are often hired because of past success in one facet of academic medicine (usually research) and not because of their business acumen. Because these new chairs have generally not been chairs before and new deans have not been deans before, there is a steep learning curve in the first year on the job. And because new chairs and deans are commonly hired from other institutions, they are generally unfamiliar with the business operations of their new department, hospital, or college. There is a saying in academic medicine that new department chairs are hired because of their previous research successes and fired because of their financial management failures. The solution for these new leaders who lack a lot of experience in business management is to hire someone who is an expert to tell them what to do. It is unfortunate that our medical schools do not value a Masters of Business Administration degree or Masters of Healthcare Administration degree as much as they value previous NIH RO1 grants when looking at applicants for deans and department chairs.

The hospital leadership knows what the problems are but want to blame unpopular solutions on someone else. Several years ago, an academic hospital in another state hired me to do a review of the department of internal medicine’s business operations. I was able to complete it in a week for a few thousand dollars; if they had hired McKinsey & Company, it would have taken more than a year and cost several millions of dollars. The thing was that the hospital leadership already knew what the core problem was. There was a department of cardiology and a separate department of internal medicine that included all of the other specialties. The structure had evolved that way because a particularly powerful cardiologist had threatened to leave and open a competing private cardiology practice unless he could have his own department, separate from the rest of internal medicine. Because the cardiology group brought so much money into the hospital, the dean and the hospital acquiesced and gave him his own department. The result was a huge salary disparity between the cardiologist and the other internal medicine specialists and major conflicts when it came to the deployment of internal medicine residents. I’m pretty sure that the hospital knew that this was the root of the department of medicine’s financial woes and faculty dissatisfaction but they wanted to be able to say that the solution of reuniting cardiology back into the department of internal medicine was my idea rather than theirs so that the chairman of cardiology would be angry at me rather than the hospital’s internal leadership.

They are expensive. In the recent JAMA study, the average cost of a management consultant for an entire hospital was $15.7 million. Consultants brought in for a more narrow focus or brought in for a review limited to one specialty or one department are considerably less expensive. Regardless, an extensive review by a consulting company usually involves flying in numerous staff for days or weeks at a time as well as hundreds of billable hours doing analysis and report generation behind the scene. The result is a very large expense. There is a very good reason why senior partners of large healthcare consulting companies have personal incomes of up to $5 million per year.

No one likes to be investigated. For the rank and file employees, the outside consultants lurking in the hospital hallways can seem like homicide detectives who suspect everyone of being a criminal. Staff (and physicians) can feel like their job is at risk of being eliminated or that the consultants are going to accuse them of not doing their job right. Because the consultants generally take months to interview staff, analyze reports, and do direct observation of hospital activities, the sensation of being under the microscope for so long can lead to burnout, mistrust, and anger among staff.

Consultants feel obligated to find that something is wrong. I’ve reviewed reports from many different outside management consultants during my career and never once did one conclude that “Everything is great. You are already doing everything right.” In order to justify their cost (and existence), consultants will always find something wrong. But often, their recommendations are not realistically actionable or would have their own negative unintended consequences. Early in my career as the treasurer of our department, I brought in a highly regarded outside consulting company to review our faculty salary plan and advise about modifying it. They ultimately recommended instituting a new physician compensation plan that was overly complicated and would have negatively incentivized clinical revenue generation. Change simply for change sake can be unnecessarily disruptive.

Even though this new study showed no benefit in the measurements evaluated, I do believe that there are occasions when outside management consultants can be useful.

Specific, targeted operational areas. The more that you can narrow the scope of the consultant, the better. For example, we determined that our days in accounts receivable was higher than benchmark departments so we hired a revenue cycle consultant to specifically advise us on how to improve our billing operations. It was relatively inexpensive and allowed us to target just one area of our department’s business operations. With institution of her recommendations, we were able to reduce our days in accounts receivable, reduce our insurance denial rate, and improve our overall collection rate. This consultant was extremely beneficial from a financial standpoint.

You need supportive evidence to fire somebody. Sometimes, you realize that you need to terminate someone in a leadership position because of suspected incompetence. But you are at risk of being perceived as seeking personal vengeance or eliminating personal competition. In this situation, the fallout could end up damaging you. An outside consultant concluding that a change in management is needed can be perceived as an objective independent justification for terminating a specific person or downsizing a specific department. As an example, years ago, we had a medical system CEO who was disliked by a large number of physicians and widely believed to be incompetent. Several of the division directors and other hospital leaders signed a letter to the president of the university demanding that the CEO be fired. The local newspaper got a copy of the letter and created a very public scandal. Ultimately, the president did fire the CEO but by the end of the year, all of the division directors who had signed the letter also lost their jobs. A management consultant recommending replacement of the CEO would have been far less messy and would not have resulted in an expose by the local newspaper.

You are considering purchasing or merging with another hospital. You would not buy a house without first having a building inspection and you should not buy a hospital without having its operations inspected. In this situation, you are far better off knowing what the operational problems are before purchasing a hospital than waiting until those problems are painfully apparent a year later. An outside management consultant can be useful in this situation.

The hospital management is extremely understaffed or extremely overstaffed. If the hospitals management team is woefully understaffed, there may not be enough people to do basic operational management or improve operational efficiency. On the other hand, if the hospital’s management team is bloated, then the hospital’s overhead expenses will be excessive and operations could be slowed by the weight of the excessive bureaucracy. In these two situations, the benefits of a management consultant can significantly outweigh the cost. But you don’t want to pay a consultant $15 million just to tell you that you need to just terminate a single $100,000 per year hospital manager position.

You are auditioning the consultant. Say that your hospital’s chief financial officer is close to retirement and there is a CFO at another hospital that you are interested in recruiting to replace him or her. One way to “test drive” this CFO would be to hire him or her to do a financial management consult for your hospital.

If your hospital has an intelligent, experienced, and competent group of leaders, then they should have the necessary skills and expertise to optimize hospital operations internally without the need for a management consultant’s report. Too often, management consultants are equated with auditors, with the thinking that every hospital should have a periodic management consult. But whereas every large organization does need to have regular audits, they don’t need to have regular management consults.

Moreover, a management consultant should not be used as a substitute for hospital board members who lack the time or expertise to evaluate hospital operations. This can be a real problem if board members are selected purely because of their political connections or because they are famous for their success in some other industry.

Too many new hospital CEOs, college of medicine deans, and department chairs view management consultants to be a necessary and expected requirement when taking on a new job. Although sometimes such a consultant is necessary, all too often it is obtained because the new leader lacks the necessary experience, skills, or confidence to do the job he or she was hired to do.

So, before hiring an outside management consulting company to do a global review of your hospital’s overall operations, ask yourself a few questions. Can we reduce the consultant’s focus to a single, narrow operational issue? Are realistically achievable expense reductions or net revenue increases greater than the cost of the consult? Can you afford to wait the months or years it will take for the consultant to render the final report? Is the consult being used your current hospital leadership or board members lack the time or competency to do an internal evaluation of operations themselves?

There is a place for hospital management consultants. But the recent study suggests that U.S. hospitals are overusing consultants and many (or most) consultants promise greater results than they actually deliver.

June 13, 2026

Categories
Hospital Finances Medical Economics

The Disadvantage Of Medicare Advantage Plans

Three events happened in the past week that should be concerning to all physicians and hospitals that take care of patients on Medicare Advantage Plans. First, the U.S. Congress Joint Economic Committee issued a brief concluding that Medicare Advantage Plans overcharge Medicare and cost 120% of traditional Medicare per enrollee. Second, Aetna was fined $117 million because of Medicare Advantage Plan false claims. And third, a study in JAMA found that in 2026, 10% of enrollees in Medicare Advantage Plans are being dropped from coverage. These three events will have a direct impact on medical practices.

When a U.S. citizen turns age 65, they have a choice – either enroll in traditional Medicare or enroll in a Medicare Advantage Plan. Traditional Medicare includes Part A and Part B. Part A is free and funded by payroll taxes. Seniors pay a monthly premium for Part B with the rest of Part B funded by federal income tax. Most people with traditional Medicare will purchase a separate Medigap policy through a commercial health insurance company that helps cover deductibles, co-pays, and other healthcare expenses not covered by traditional Medicare. Additionally, most people with traditional Medicare will purchase a Medicare Part D policy to cover outpatient medications that are not covered by traditional Medicare.

A Medicare Advantage Plan (also known as Medicare Part C), is an all-inclusive health insurance policy sold by commercial insurance companies that bundles Medicare Part A, Medicare Part B, Medigap coverage, and usually a Medicare Part D plan. In addition, many Medicare Advantage Plans also provide perks that are not available to seniors on traditional Medicare such as gym memberships, dental insurance, or vision insurance. Medicare Advantage Plans are usually less expensive than the combined cost of traditional Medicare Part B plus a Medigap plan plus a Medicare Part D plan. For this reason, the Medicare Advantage Plans are very popular. Currently, 54% of Medicare beneficiaries are enrolled in a Medicare Advantage Plan and only 46% are enrolled in traditional Medicare.

Medicare Advantage Plans are inexpensive because commercial insurance companies have tactics to control costs that Medicare lacks. These include:

  • Prior authorization. By requiring many services, procedures, and referrals to get prior authorization, insurance companies can impose strict authorization criteria that must be met before a physician or hospital can perform a procedure or service. This is done under the guise of preventing unnecessary procedures and services. However, many insurance companies have very strict criteria that can create a barrier for procedures or services that are actually needed by patients. In addition, the prior authorization process is onerous, requiring time and expense for doctors and hospitals to call the insurance company and negotiate with an insurance representative. Because this is such a hassle, many physicians find the path of least resistance to be to forgo a certain test or procedure rather than have to deal with another tedious prior authorization, even if they believe that the test or procedure is needed for optimal care of the patient.
  • Denials. Frequently, there is no time to get prior authorization, for example, for an emergency hospital admission or for an urgently needed outpatient CT scan. In these situations, the Medicare Advantage Plan insurance company can retrospectively deny payment for the hospital admission or CT scan if the insurance company decides that there was insufficient indication for that hospital admission or CT scan. Physicians and hospitals can appeal those denials but the appeals require a great deal of time and paperwork. As a result, many of these services and procedures are written off because of the cost and effort necessary to appeal. Thirty years ago, a claims worker for one of the major health insurance companies told me that their company’s policy was to randomly deny every 20th claim because many physicians and hospitals would not bother to appeal them, ultimately saving the insurance company millions of dollars every year.
  • Provider networks. With traditional Medicare, a beneficiary can see any physician or hospital in the country that takes Medicare. Because nearly all doctors and hospitals that provide care to adults accept Medicare, this means that the person with traditional Medicare can see any doctor he or she wants. Each Medicare Advantage Plan insurance company will have its own limited number of in-network doctors and hospitals. Beneficiaries have to pay steep extra costs to see a doctor who is out-of-network or go to a hospital that is out-of-network. This is sometimes unavoidable, for example, if a person needs a surgery done by an in-network surgeon but the anesthesiologist is out-of-network. In the past, insurance companies had no motivation to keep their list of in-network physicians current. Indeed, they were actually incentivized to let those lists become out of date with “ghost doctors”, physicians who had retired or moved and were no longer practicing in the area. By making it harder for enrollees to find a doctor in a particular specialty, it reduced the chances that the enrollee would eventually see a specialist and thus avoided having to pay for expensive services or procedures. A recent class action lawsuit has resulted in Medicare Advantage Plans now being required to ensure that their lists of in-network physicians is current.
  • Favorable selection. Since Medicare Part B pays the Medicare Advantage Plan commercial insurance company on a per-enrollee basis, the more healthy enrollees the insurance company can attract, the less that insurance company will have to pay for healthcare services and procedures. The average amount paid by Medicare Part B this year is $9,739 per beneficiary. If a commercial insurance company can attract a group of enrollees that will on average generate less than $9,739 in healthcare expenses per year, then the insurance company stands to make a profit. There are several tactics that insurance companies use to preferentially attract healthier patients. Zero premium Medicare Advantage Plans often appeal to healthier seniors who do not require frequent, costly healthcare. Perks such as gym memberships attract more active, healthier seniors. Targeted advertising can reach seniors who are likely to have lower healthcare costs – this could include targeting geographic areas or demographic groups that are likely to have lower healthcare requirements. Provider network design can emphasize primary care providers with limited access to specialists, thus selectively appealing to seniors with no medical conditions requiring specialist care. The bottom line is that the more healthy people a Medicare Advantage Plan can enroll, the more profitable that plan will be for the commercial insurance company.
  • Upcoding. Medicare pays commercial insurance companies administrating Medicare Advantage Plans based on the number of enrollees and how medically complex those enrollees are. The more medical problems an enrollee has, the more Medicare will pay the commercial insurance company for that particular enrollee. Therefore, the insurance companies are incentivized to exaggerate the number and severity of medical illnesses for every enrollee. When I first enrolled in a Medicare Advantage Plan, the insurance company kept wanting to send out a nurse to my home to do a “wellness visit”. That nurse’s real job was to find and document as many medical conditions as possible. If the nurse finds that the enrollee’s blood pressure is 1 mm Hg above normal, the insurance company can claim that the enrollee has hypertension and charge Medicare more. If the nurse weighs the enrollee with all of their clothes and shoes on and the enrollee’s weight is 1 pound above the threshold for morbid obesity, then the insurance company can document morbid obesity and charge Medicare more. Needless to say, I refused the wellness visits.

On March 10, 2026, the Joint Economic Committee of the U.S. Congress issued a brief stating that Medicare Advantage Plans are overpaid, resulting in an increase in Medicare premiums for all Medicare beneficiaries. The original intention of the Medicare Advantage Plans was to decrease cost of care by reducing unnecessary medical services and procedures and by substituting private insurance company efficiency for Medicare government bureaucratic inefficiency. The original projection was that Medicare Advantage would cost 95% of what traditional Medicare costs per beneficiary. The reality is that Medicare Advantage costs 120% of what traditional Medicare costs per beneficiary. In other words, rather than saving money, Medicare Advantage Plans are costing Americans more money. MedPAC estimates that this year, commercial insurance companies will be over-charging Medicare by $76 billion because of upcoding. This ends up costing Medicare beneficiaries more in Part B premiums and costing American taxpayers more in income taxes.

Medicare Part B covers outpatient healthcare services and doctors’ charges. By statute, 25% of Medicare Part B is covered by monthly Medicare premiums charged to all Medicare enrollees (both traditional Medicare and Medicare Advantage Plan enrollees). The annual Medicare Part B premiums are based on income with $2,435 per year for most Medicare enrollees. Higher income enrollees pay as much as $8,279 per year. The other 75% of the cost of Medicare Part B is covered by income taxes paid by working Americans. Because Medicare Part B pays the Medicare Advantage Plan insurance companies on a per-enrollee basis, the more the insurance companies charge per-enrollee, the more Medicare Part B has to pay. This increases the overall cost of Medicare Part B and that increase in cost results in higher Medicare Part B premiums for enrollees and more money from federal income taxes.

Over the next 9 years, Medicare Part B premiums are projected to double to approximately $5,000 per year in 2035 for most Americans. Of this amount, $450 will result from Medicare Advantage Plan overpayments. Commercial health insurance companies are for-profit corporations and as such, they are incentivized to charge as much money as possible – because the Medicare Advantage Plans are paid by Medicare, they are incentivized to charge Medicare (i.e., the federal government) as much money as possible. The temptation to upcode is just too great.

Aetna is owned by CVS Health and has the 4th largest number of Medicare Advantage Plan enrollees (after UnitedHealthcare, Humana, and Blue Cross/Blue Shield affiliates). The U.S. Attorney’s office in Philadelphia announced last week that Aetna agreed to pay $117.7 million to settle federal charges of false claims of billing. The allegation is that Aetna added diagnosis codes in an attempt to upcode Medicare Advantage Plan enrollees to make them appear to be sicker than they actually are. $11.5 million of the penalty went to a whistleblower who alleged that Aetna added inaccurate diagnosis codes for morbid obesity.

A study published in JAMA last week found that 10% of Americans enrolled in Medicare Advantage Plans were forcibly disenrolled in 2026. Disenrollment happens when a commercial insurance company stops offering its Medicare Advantage Plan in a certain geographic location. The main reason that a Medicare Advantage Plan leaves a local market is financial – they lose money in that particular market area. Prior to 2025, the annual disenrollement was less than 1% per year. In 2025, disenrollment increased to 6.9% and in 2026, increased further to 10.0%.

Disenrollees were more likely to have been in smaller Medicare Advantage Plans, in plans with a lower Medicare star rating, and in rural areas. Seven states had very high disenrollment rates (>40%): Vermont, New Hampshire, Maryland, North Dakota, South Dakota, Wyoming, and Idaho. Vermont is particularly notable with 92.2% of Medicare Advantage Plan enrollees in Vermont being disenrolled in 2006.

The good news is that most of these Medicare Advantage Plan enrollees were able to switch to a different Medicare Advantage Plan insurance company. However, this often results in patients needing to switch doctors when their previous doctor is not in-network for their new Medicare Advantage Plan. This can also affect hospitals that are not in-network for the new plan. Even for those doctors and hospitals that remain in-network for their patient’s new Medicare Advantage Plan, it can mean re-submitting prior authorization applications for upcoming services or procedures.

The recent uptick in Medicare Advantage Plan disenrollments is a sign that commercial insurance companies are finding some areas of the United States to be unprofitable. For disenrollees, the only option to enrolling in a different Medicare Advantage Plan is to go back to traditional Medicare. But switching to traditional Medicare can be fraught with hazard.

When a person turns 65-years-old, that person can choose to either enroll in traditional Medicare or a Medicare Advantage Plan. For a Medicare beneficiary who is already enrolled in a Medicare Advantage Plan, there are two times each year that they can change back to traditional Medicare: either during the Medicare Open Enrollment period (October 15 – December 7) or during the Medicare Advantage Open Enrollment period (January 1 – March 31).

But there is a catch. Most people on traditional Medicare will also have a Medigap policy to cover the out of pocket healthcare expenses not covered by traditional Medicare. When you are 65 and first enroll in Medicare, commercial insurance companies offering Medigap policies have to accept everyone, regardless of pre-existing medical conditions. But once you are enrolled in a Medicare Advantage Plan, if you go back to traditional Medicare, the insurance company can deny you a Medigap policy if you have pre-existing conditions such as cancer, diabetes, or heart disease. In other words, if you have a significant pre-existing medical condition, once you go on a Medicare Advantage Plan, you realistically cannot go back to traditional Medicare because you won’t be able to get a Medigap policy. And if a Medicare Advantage Plan has upcoded diagnoses in your insurance record, you may find yourself ineligible for a Medigap policy because the number or severity of your medical problems was exaggerated by the Medicare Advantage Plan insurance company.

With greater public awareness of the practice of upcoding by Medicare Advantage Plans, we can expect more whistleblowers and more prosecutions such as occurred last week with Aetna. If commercial insurance companies dial back their upcoding efforts, they will need to look to other ways of ensuring Medicare Advantage Plan profitability. That is likely to mean ramping up their prior authorization requirements, further restricting the number of in-network providers, and increasing denials.

In anticipation of this, doctors should ensure that their chart documentation is complete and accurate to reduce retrospective denials. We should be sure that the diagnoses associated with test and procedure orders are correct and complete to reduce prior authorization phone calls. And we should check every patient’s current insurance at every visit in order to avoid denials for being unexpectedly out-of-network.

Hospitals should ensure that their revenue cycle departments are fully staffed with personnel to handle prior authorizations and denials. There should be robust processes in place to distinguish observation hospital stays versus inpatient admissions. And patients’ current insurance should be checked at every visit since the prior authorization for an elective hip surgery obtained in March may not be honored when the surgery is actually performed in April if the patient had to switch to a different Medicare Advantage Plan in the interim.

We should have all seen this coming. The Medicare Advantage Plans were supposed to reduce healthcare costs by substituting the streamlined efficiency of private industry for the bloated inefficiency of the federal government’s Medicare operations. But it turns out that Medicare is actually more cost-effective than commercial insurance companies because unlike UnitedHealthcare for example, Medicare isn’t required to turn a profit each year, didn’t have to pay a CEO $26 million in salary last year, and didn’t have to pay shareholders $8 billion in dividends last year. When it comes to making a profit, businesses will always find a way. Even if that way results in higher Medicare Part B premiums to all seniors and increased income tax burden on all American taxpayers.

March 17, 2026

Categories
Physician Retirement Planning

Why 2026 May (or may not) Be A Good Year To Contribute To Roth Retirement Accounts

In very general terms, the best years to contribute to a Roth IRA, Roth 403(b), or Roth 401(k) are years when your income tax rate today is lower than your income tax rate will be when you retire. There are two ways this can happen, either (1) your taxable income is higher in retirement than it is today or, (2) income tax rates are higher in your retirement years than they are today.

Many financial pundits say that most people’s income is lower in retirement than it is when they are working. But as a retiree myself, I think it is better to save so that your disposable income in your retirement years is higher than during your working years. The reasons why I believe this is that when you are retired, you want to have the resources to do all of the things that you didn’t have time to do when you were working such as travel, take up new hobbies, buy a boat, buy a retirement home, etc. Additionally, healthcare costs increase exponentially such that the average healthcare expenditures for an 85-year-old is $46,500 per year whereas healthcare expenditures for a 40-year-old is only $8,600. Americans need sufficient annual retirement income to cover these increasing healthcare costs. Assuming tax rates remain constant, good years to contribute to a Roth account are:

  • Early in your career when your salary is relatively low before you get promotions or gain seniority
  • Years when you are off work or working part-time for a few months, resulting in a lower annual income
  • When you plan on retiring late in life, resulting in a large amount of retirement savings and thus a high annual retirement income
  • If you anticipate a large taxable inheritance during your retirement years, such as an inherited tax-deferred IRA or annuity

Federal personal income tax rates are at historic lows at present. The big question is will they remain low or will Congress increase personal income tax rates in the future? It takes a lot of money to run the federal government and the way governments get money is through taxes. If any government lowers or eliminates income taxes, it has to increase other types of taxes, like excise taxes, capital gains taxes, property taxes, sales taxes, or tariffs. It is kind of like the whack-a-mole carnival game.

Last year, Congress voted to continue the 2016 federal income tax cuts. In order to do this, the government reduced expenses by laying off a large number of government employees and eliminating a large number of federal grants and programs. Reducing expenses alone was not sufficient to permit the low income tax rates, so the President instituted sweeping import tariffs, which are consumption taxes paid by American consumers who purchase products and supplies that originate from other countries – essentially a sales tax on anything that is not manufactured or produced in the United States.

The largest federal government expenditures are Medicare & Medicaid (24%), Social Security (22%), interest (14%), and defense (13%). Together, these 4 spending categories account for nearly three-quarters of the annual U.S. budget. Eliminating or cutting back on other federal programs is great for scoring political points but in reality has a negligible effect on the federal budget. There are reasons to believe that none of these four major categories of government spending will decrease in the near future:

Medicare and Medicaid

There are two reasons to believe that Medicare and Medicaid expenditures will rise in the future: healthcare inflation and the aging U.S. population. American healthcare is expensive and increases significantly with age, averaging $26,490 per year for Americans between 65-84 and $46,506 for Americans over age 85-years-old.

Historically, healthcare costs has risen faster than the general inflation rate. Between 2000 and 2023, healthcare costs increased by 121% whereas the cost of all goods and services in the U.S. increased by 86%. Assuming this trend continues for the next 10 years, the cost to provide healthcare to all Americans will continue to outpace the country’s overall inflation rate.

The U.S. population is aging due to a longer life expectancy and a decreased birth rate. In 1960, the U.S. birth rate was 3.7 children per every American woman. In 2024, the birth rate had fallen to the lowest in history at 1.6 births per woman. This declining birth rate has resulted in fewer young Americans compared to elderly Americans. At the same time, Americans are living longer. After a drop in life expectancy during the COVID pandemic, U.S. life expectancy reached an all-time high in 2024 at 79.0 years. The net result is that the number of retired Americans is increasing relative to the number of working Americans.

Medicare is paid for by both payroll taxes and U.S. government general funds. Payroll taxes that you pay during your working years are not saved in an account somewhere to cover your Medicare expenses later in life. Instead, Medicare costs of today’s retirees are paid by today’s U.S. workers’ payroll taxes. But Medicare is also funded by government general funds and the source of those general funds is federal taxes. As the percentage of Americans over age 65 increases at the same time that the healthcare inflation rate increases, it will put increasing demand on a shrinking percentage of American workers to pay for Medicare through taxes. The bottom line is that the federal government will have to increase some form of taxes to pay for the future increased cost of Medicare.

Social Security

Medicare and Social Security are both funded through payroll taxes. Thus, the declining U.S. birth rate and increasing U.S. life expectancy are affecting Social Security in the same way that they are affecting Medicare. Previous estimates were that the Social Security Trust Fund would run out of money in 2033. Yesterday, the Congressional Budget Office released projections that the Social Security Trust Fund will be depleted sooner than previous estimated, in 2032. The main reason for this is that the CBO revised its economic forecast and now predicts a higher inflation rate than it previously predicted. Because the annual cost of living increase in Social Security benefits is tied to inflation, if inflation rises, so too do Social Security expenditures. Once the Social Security Trust Fund is depleted, monthly Social Security checks will be reduced to equal the amount taken in by payroll taxes each year. Current payroll tax rates will only provide enough money to pay for 81% of future Social Security monthly benefit checks. Therefore, beginning in 2032, the federal government will only have two options: either reduce Social Security benefits by 19% or increase taxes to maintain current Social Security benefits.

Interest payments

The interest rate that the federal government pays on Treasury bonds, notes, and bills is tied to the Federal Reserve’s lending rate. In turn, the main driver of the lending rate is the nation’s inflation rate. Although inflation has cooled since the supply chain disruption caused by the COVID pandemic, it has stubbornly remained above the Federal Reserve’s annual inflation target of 2.0%. One of the main reasons for the persistently high inflation rate this year is tariffs being charged on goods and products imported from other countries. Tariffs are essentially a sales tax on imports that are ultimately paid by American consumers, thus raising the prices of anything manufactured abroad or made from products and natural resources produced abroad.

There are two ways to reduce the amount that the federal government pays for interest: either lower the Federal Reserve’s lending rate or stop borrowing money. The Federal Reserve is currently opposed to reducing the lending rate because rate reductions will worsen inflation. The federal government cannot stop borrowing money because it is spending more than it takes in from taxes and tariffs. Therefore, the government is stuck with having to borrow more and more money at high interest rates. This will grow the amount that the Federal government must pay each year in interest. To make matters worse, as the U.S. deficit increases, its credit rating will eventually fall, resulting in even higher interest rates that the government must pay to borrow more money.

Defense spending

The United States spends slightly less on defense each year than it does on interest. However, the U.S. prides itself on the most powerful and technologically sophisticated military in the world. The U.S. uses the threat of its military for geopolitical leverage. To cut back on military spending would be to allow other world powers, such as China, to overtake the U.S. in military clout. The Congressional Budget Office projects that defense spending will increase by 1.1% between 2025 and 2029 (adjusted for inflation) and then increase a whopping 11% between 2029 and 2039 (also adjusted for inflation). Thus, not only will defense spending not be lower in the future but it will actually be a lot higher in the future.

With 73% of U.S. government spending most likely to increase, rather than decrease, the only way to avoid spiraling federal debt will be to increase taxes.

Source of Federal Revenue

Data from the U.S. Department of the Treasury reports that individual tax accounts for the largest percentage of federal revenue at 52%. The vast majority of individual tax is the personal income tax accounting for 91% of individual tax; capital gains tax accounts for about 9% of individual tax. Payroll tax is the second largest income source at 32% and is taxed at 15.3% of gross income with half paid by the employer and half paid by the employee. Payroll taxes only apply to the first $184,500 of gross income – any amount above that is not subject to payroll tax. Tariffs account for 7% of government revenue and are applied to imported goods and products. Corporate income tax accounts for 6% of government revenue and is a flat 21% of corporate profits (gross revenue minus expenses and deductibles). Excise tax is a form of sales tax charged on things like alcohol, gasoline, tobacco, and airline tickets. Estate and gift taxes account for <1% of government revenue and are charged on inherited estates greater than $13.61 million (individual) or $27.22 million (married couples). Gift taxes are levied on annual gifts exceeding $19,000 (individual) or $38,000 (married couples). Estate and gift tax rates range from 18% to 40%.

Tariffs and excise taxes are “consumption” taxes, similar to sales taxes levied by states and local communities. Personal income tax and payroll tax are both types of income tax that are paid by the individual worker and based on the amount that you earn. Corporate income tax and individual capital gains tax are very different from personal income tax in that they only apply to profits – either corporate profits or personal profits from asset sales. Because of this, corporate income tax is ultimately paid by investors in the way of reduced dividends and by consumers in the way of higher prices for the products produced by the corporations. Capital gains tax is simply paid by the individual investor.

Over the past 50 years, the percentage of total federal government revenue from payroll taxes has grown while the percentage from excise taxes and corporate income taxes has fallen. The percentage from individual income taxes has also grown, albeit at a much slower rate than payroll taxes.

If the federal government increases personal income tax rates in the future, then investing in Roth accounts now is advisable. But increasing any other type of tax will not affect Roth accounts. Payroll taxes paid by the individual are always paid in the year that you earn money, even if that money then goes directly into a tax-deferred retirement plan such as a 401(k) or 403(b) and thus are not at all subject to the financial forces that govern the decision of whether to contribute to a tax-deferred retirement account or a Roth retirement account. Similarly, capital gains tax is only paid on non-retirement investments and does not affect the decision about whether to contribute to a tax-deferred or Roth retirement account.

Increasing payroll taxes or increasing the maximum income subject to payroll taxes can help keep Medicare and Social Security solvent but will not help cover the increasing federal expenditures on interest and defense spending.

Increasing capital gains tax rates could be applied to increased interest spending and increased defense spending but capital gains accounts for only a very small amount of total government revenue – about 4.6%. Therefore, capital gains taxes would need to be increased to astronomical levels to make up for the projected increases in government spending on interest and defense.

Increasing tariffs could be applied to interest and defense spending but tariffs would need to be dramatically increased. Like any consumption tax, tariffs are inflationary in the short term and this could potentially result in higher interest rates and thus more money that the government has to pay for interest payments to borrow money. However, because tariffs cause a one-time increase in the price of imported goods and products, they have relatively little impact on long term inflation. Another problem with tariffs is that they encourage consumers to buy domestically produced goods and products so that over time, American consumers buy less imported goods and products, thus reducing the amount of money that the federal government brings in from tariffs.

Increasing corporate income tax could be applied to future increased government spending. However, when corporations are faced with increased tax expenses, they either have to reduce dividends paid to investors or increase the cost of goods and services sold. Last year, U.S. corporations distributed $2.26 trillion in dividends. The government collects a total of $5.23 trillion in revenue each year so increasing the corporate income tax rate would seem to be a viable option to solve the looming U.S. debt. Especially because foreign investors own approximately 40% of U.S. stocks, meaning that foreign investors receive about 40% of the dividends from U.S. companies. However, not all corporations distribute dividends, so increasing the corporate income tax rate to 25% or 30% would likely result in increased costs of goods and services purchased by consumers. In other words, inflation.

Excise tax is a type of sales tax ultimately paid by consumers. Currently, the amount of revenue from excise taxes is so small that to cover the looming deficit, the federal government would need to start taxing other goods and services, in essence instituting a national sales tax, similar to the “value added tax” used by 160 different countries. The value added tax used in European Union countries averages 22% and the value added tax used in the U.K. averages 20%. Excise tax and sales tax cause a short term increase in inflation but have little impact on long term inflation.

Estate and gift taxes account for such a small amount of government revenue that any realistic increase in these taxes would have a negligible impact on the federal deficit.

From the above discussion, it is clear that the federal government will need to increase some form(s) of taxes in the near future in order to pay for the projected increases in Medicare, Social Security, defense, and interest spending. The big question is which types of taxes will be increased? Increasing consumption taxes such as tariffs, excise taxes, or a national sales tax would likely be favored by conservatives. Increasing individual income tax rates and corporate income tax rates (particularly on high earners and large corporations) would likely be favored by liberals. Consumption taxes disproportionately affect lower income people whereas income taxes disproportionately affect higher income people.

If the government increases individual income tax rates in the future, then now is a great time to put money in a Roth 401(k), Roth 403(b), or Roth IRA. If the government increases other kinds of tax, then there will be no impact on whether or not to contribute to a Roth retirement account. Does the United States have the stomach for returning to the pre-2016 personal income tax rates? Or will the U.S. increase some other form of tax?

What is clear is that the rates of some type or types of tax are going to have to increase between now and when most working Americans eventually retire.

The safest approach for the prudent investor is to contribute to both tax-deferred retirement accounts and Roth retirement accounts this year. That way, you hedge your bets on whether your personal income tax rate will be higher or lower in retirement than it is today. If political sentiment seems to be shifting toward increasing the personal income tax rate, then change your strategy and put as much money as you can in Roth accounts before the higher tax rates are instituted. If, on the other hand, political sentiment seems to be to increase consumption taxes or corporate income taxes, then the decision about whether to contribute to a tax-deferred or Roth retirement account should be based on your assessment of whether your taxable income today is likely to be higher or lower than your taxable income in retirement. By contributing to both tax-deferred and Roth retirement accounts, you create a diversified retirement portfolio and a diversified portfolio is the strongest portfolio you can build.

Your retirement portfolio should be diversified by having money in five different types of accounts:

  • Fixed income. This includes Social Security benefits, pension income, and annuities.
  • Tax-deferred. This includes a regular 401(k), 403(b), 457, traditional IRA, and SEP.
  • Roth. This includes a Roth 401(k), Roth 403(b), and Roth IRA. Not all employers offer a Roth 401(k) or Roth 403(b) and if your income is too high, you cannot directly contribute to a Roth IRA. However, anyone can contribute to a traditional IRA and then do a “backdoor Roth” by then immediately converting that money into a Roth IRA.
  • Regular investments. These are investments that you make with your post-tax income such as mutual funds or stocks from a brokerage account. This could also include investment possessions such as gold, art, or real estate properties.
  • Cash. This includes money held in your checking, savings, or money market accounts. Holding a lot of money in cash is a poor choice for long term investing because it will lose money compared to inflation. However, even in retirement, it is desirable to keep a cash emergency fund sufficient to cover at least 3 and preferably 6 months of basic expenses in case of unexpected large expenses or a sudden dramatic fall in the stock and bond markets.

By having your retirement portfolio split between these 5 buckets, you can strategically withdraw from different buckets depending on how the market is doing and what the income tax rates are in any given year of retirement. This then allows for maximal annual disposable income while maximally preserving portfolio principal.

February 25, 2026

Categories
Inpatient Practice

Changing Your Hospital’s Cafeteria Offerings In The Era Of GLP-1 Drugs

A study from the Kaiser Family Foundation recently found that 1 in 8 American adults are taking a GLP-1 receptor agonist for either weight loss or diabetes. The implication is that 12% of the hospital visitors and hospital stafff who eat at hospital cafeterias are taking these drugs. An additional 6% of adults have used GLP-1 drugs in the past. GLP-1 drugs not only reduce overall appetite, but they also change food preferences in people who take them. Hospital cafeterias are in a unique position to both accommodate these changes in food preferences and also educate the public about healthy eating while taking GLP-1 receptor agonists.

In 1983, researchers at the University of Chicago found that the glucagon gene could produce more than just one peptide because of tissue-specific post-translational processing. One of these hormones produced by the glucagon gene was glucagon-like peptide-1, also known as GLP-1. Although naturally occurring human GLP-1 seemed to have some promising metabolic effects, it had an extremely short half-life. So it did not appear to have much promise as a therapeutic agent. But in 1992, a researcher at the VA medical center in New York was studying peptides found in Gila monster venom. One of these peptides was almost identical to human GLP-1 except that it lacked a single crucial alanine residue. As a result, it was resistant to enzymatic degradation and had a much longer half life. This led to the FDA approving the first GLP-1 analog, exenatide, in 2005. Exenatide was sold under the brand name Byetta and used to treat type 2 diabetes.

During the initial clinical trials of extenatide in diabetes, researchers noticed that there was an unexpected side effect, namely, weight loss. As additional longer acting GLP-1 analogs were created and studied, the weight loss became more apparent. In 2021, the first GLP-1 agonist was approved by the FDA specifically to treat obesity. In the 5 years since, GLP-1 agonists have revolutionized the way that we treat obesity. Most people who take GLP-1 agonists for obesity will lose 15% – 25% of their body weight in the first year of treatment. Two months ago, the FDA approved the first oral GLP-1 agonist, Wegovy, making these drugs even more accessible. Within the first 2 weeks of oral Wegovy’s launch, 26,000 prescriptions were written and this number is expected to increase dramatically by the end of 2026.

A study published last month in JAMA found that when people take GLP-1 agonists, their food preferences change. The study looked at 13,565 people in Denmark who donated their grocery store receipts. Those taking GLP-1 drugs were matched 1:3 with controls of the same age, gender, and income. For those taking GLP-1 drugs, food category purchases were compared from before to after starting the drugs. Compared to controls, those taking GLP-1 drugs had a drop in total calorie consumption, sugar consumption, carbohydrate consumption, and saturated fat consumption. Protein consumption increased after staring GLP-1 drugs. In addition, there was an increase in consumption of unprocessed foods and a significant decrease in ultraprocessed foods when taking GLP-1 receptor agonists.

GLP-1 receptor agonist users also decrease their overall grocery purchases. A study published in the Journal of Marketing Research in December 2025 found that when a household has at least 1 member taking a GLP-1 drug, grocery purchases drop by 5%. The food category most affected was calorie-dense processed foods, such as chips, that dropped by 10%. Currently, 20% of American households have at least one member taking GLP-1 drugs.

Another study by PwC found that GLP-1 drug users have a 33% reduction in alcohol consumption, 84% reduction in dessert consumption, and a 70% increase in fresh produce consumption.

Food producers have responded to the changing preferences of people taking GLP-1 receptor agonists. For example, Greek yogurt sales have skyrocketed, particularly for products like Oikos Triple Zero Greek yogurt with a high protein content and no added sugar. Last year, Conagra began adding a GLP-1 friendly label to packaged foods to make them easier for users to spot on grocery store shelves.

The GLP-1 drug revolution represents a unique opportunity for hospitals both to optimally serve the increasing population of people taking these drugs and to educate customers (and hospital staff) about healthy eating. Here are some specific tactics hospital food services departments can take:

Changing food and beverage offerings
  • Increase availability of high protein, low sugar foods such as zero sugar added Greek yogurt, chicken entrees, shrimp entrees, and fish entrees.
  • Increase offerings of fresh fruits and vegetables.
  • Reduce sugar-added soft drinks and juices by putting them on lower shelves than diet soft drinks and bottled water. Also, put more bottles of diet soft drinks and water than sugar-added soft drinks in refrigerated shelves to signal to customers that these are the preferred beverages.
  • Stock 16 ounce cans and bottles of diet soda and water but only stock 8 or 12 ounce cans and bottles of sugar-added sodas to encourage sugar-free drink purchases.
  • Eliminate or reduce available package sizes of ultraprocessed snack foods, such as chips.
  • Stock packages of nuts and seeds as alternatives to chips.
  • Reduce serving sizes of desserts.
  • Ensure daily high protein vegetarian entrees are available such as rice and bean, lentil, quinoa, tofu, and edamame dishes.
Healthy eating education
  • Label foods as being “GLP-1 smart choices” to help GLP-1 drug users know which foods best complement GLP-1 receptor agonists for weight loss. This should not only include low-calorie, high protein foods but also include sugar free drinks.
  • Create signage that indicates the calorie, protein, and carbohydrate contents of all food and beverage offerings.
  • Create posters or table placards that state in simple terms what foods best complement GLP-1 drugs and what category of drugs to avoid, such as the example below:

American food manufacturers see the GLP-1 drug writing on the wall and are already producing and promoting food products at our grocery stores that are GLP-1 friendly. But there are gaps – for example, a head of broccoli or a head of lettuce will probably never carry stickers promoting their benefits for GLP-1 drug users. Grocery stores are never going to try to dissuade customers from buying beer, Cheetos, or cartons of Coke because these products have a high mark-up and grocers make a lot of profit from their sales. Similarly, McDonalds is never going to encourage customers to avoid buying Big Macs and fries.

But hospital cafeterias have a dual mission of feeding hospital visitors and hospital staff as well as improving community health. Hospitals can fill the gaps left by grocery stores and fast food restaurants when it comes to helping GLP-1 receptor agonist users lose weight by offering food options that complement GLP-1 drugs and by providing education about these food options. And the benefits go way beyond GLP-1 drug users – it turns out that the foods that complement GLP-1 drugs are also foods that form a healthy diet for the vast majority of Americans.

This is a tremendous opportunity. Make sure that your hospital’s food services department takes advantage of it.

February 23, 2026

Categories
Physician Retirement Planning

Should You Have Cryptocurrency In Your Retirement Investment Portfolio?

Cryptocurrencies, such as Bitcoin, have been getting a lot of attention as investment options recently. But should you add cryptocurrency into your retirement portfolio? Financial advisors often recommend a 5 group diversification strategy for retirement investments: (1) U.S. stocks, (2) foreign stocks, (3) U.S. bonds, (4) foreign bonds, and (5) real estate. Instead of buying individual stocks, individual bonds, and individual real estate properties, most investors opt for stock mutual funds (or ETFs), bond mutual funds, and real estate investment trusts (REITs). Many investors are now questioning whether they should add cryptocurrency as a sixth group.

Cryptocurrencies are digital currencies that are contained on networks of computers using a public ledger technology called blockchain. Transactions involving cryptocurrency is recorded in digital “blocks” that are attached to previous blocks of transactions resulting in a chain of blocks that represent the chain of custody of that particular cryptocurrency, for example, a bitcoin. The blockchains cannot be altered but each transaction must be validated by computers on the blockchain network called “miners”. Once the transaction is validated, that transaction block is added to the blockchain and the cryptocurrency then transfers to its new owner.

When you invest in a stock, you buy part ownership in a company. When you invest in a bond, you buy part ownership of a loan to a company (or a loan to a government). When you invest in gold, you own metal that can be converted into jewelry or electronics. But investing in cryptocurrency is like investing in any kind of currency: U.S. Dollars, British Pounds, Euros, Yen, etc. The difference is that U.S. Dollars are backed by the “full faith and credit” of the U.S. government. Similarly, Pounds are backed by the British government and Euros are backed by the European Union government. Cryptocurrencies are not backed by any government or anybody. They are simply strings of computer code that a lot of people have decided to use as money.

The value of any given nation’s currencies is based on the general perception of the strength of that nation’s economy. In turn, that perception is based on such metrics as that nation’s inflation rate, interest rates, GDP, government debt, trade balance, and central bank monetary policies. An advantage of cryptocurrencies is that they are not regulated by any government and are thus immune to government interventions. Additionally, they are decentralized, thus allowing for rapid transfer of money, anywhere on the planet. For these reasons, many people have embraced cryptocurrency as the future medium of exchange to replace currencies of individual countries.

Currently, cryptocurrency is used by 7% of U.S. adults for investment, 1% of U.S. adults for purchases (transactions), and 1% of U.S. adults to transfer money from one individual to another. Men are twice as likely to use cryptocurrency for transactions as women and the majority of cryptocurrency users are under age 60. Interestingly, low income adults making less than $25,000 per year are four-times as likely as middle income or high income adults to use cryptocurrency for transactions. On the other hand, high income adults are twice as likely as other income groups to buy cryptocurrency as an investment.

As I see it, there are several reasons why investors should be cautious adding cryptocurrency to their retirement portfolios:

  • Lack of precedent on long-term returns. A key factor in deciding whether to buy a particular investment is one’s investment horizon. The investment horizon is how long you plan on holding that investment before selling it. For example, saving for a down payment on a new car purchase in 6 months is a short investment horizon whereas saving for retirement 35 years from now is a long investment horizon. It would be imprudent to hold the car loan down payment exclusively in stocks because of the short term volatility of stocks. It would be equally imprudent to hold the retirement investment for 35 years exclusively in bonds because of the low returns of bonds in the long term. Bitcoin was first launched in 2009 and first used for an actual purchase in 2010. Thus, Bitcoin, and other cryptocurrencies, are very new types of investments. In the short time since that first cryptocurrency purchase, Bitcoin has increased in value from $0.30 per Bitcoin at the end of 2010 to $68,000 per Bitcoin today. This represents enormous short term returns. However, no one knows what the long term returns are going to be for Bitcoin and other cryptocurrencies. There simply is no precedent. Are cryptocurrencies a fad or are they the future of money?
  • Short term volatility. Cryptocurrencies are unsuitable for short term investments given their volatility. In the past three and a half months (October 2025 to present), Bitcoin has lost nearly 50% of its value. Volatility is acceptable for investments held for long term but excessively risky when used for short investment horizon needs.
  • Will cryptocurrency really be used as currency? When was the last time you bought a loaf of bread at the grocery store with Bitcoin? Or a hamburger at McDonalds? Or a tank of gas at an Exxon station? As with any kind of currency, its value is to be able to buy stuff and currently, cryptocurrency is rarely accepted as payment (unless you are a kidnapper, drug dealer, extortionist, or ransomware crook). Unless countries adopt Bitcoin or some other cryptocurrency as official legal tender, consumers are likely to prefer to use the national currency for most transactions.
  • Cryptocurrency subdivisions are complicated. With a Bitcoin currently valued at around $60,000 per 1 Bitcoin, a pint of beer at your local pub would cost about 0.0001 Bitcoin. Americans are used to pricing in dollars and cents; Europeans are used to pricing Euros and cents; and British are used to pricing in pounds and pence. Would you prefer to see the price of a beer at $6 or at 0.0001 Bitcoin? Although there are Bitcoin denominations, they are foreign to most people: 1 Decibitcoin = 0.1 Bitcoin, 1 Centibitcoin = 0.01 Bitcoin, 1 Millibitcoin = 0.001 Bitcoin, 1 Microbitcoin = 0.001 Bitcoin, and 1 Satoshi = 0.00000001 Bitcoin.
  • Cryptocurrency’s volatility creates excessive risk for retailers and consumers. The substantial daily and weekly swings in the value of Bitcoin and other cryptocurrencies creates enormous problems for those who sell goods and services. For example, let’s say you are a house painter and give a quote of 0.0452 Bitcoin to paint someone’s house but you are currently scheduling 2 months out. If the value of a Bitcoin drops by 20% in those 2 months, then you are going to lose money and go out of business pretty soon. On the other hand, if the value of Bitcoin increases by 20% over a 2-month period, then an employer who hires an employee with an annual contract to be paid 0.09482 Bitcoin each month could face an unsustainable increase in overhead expenses and go out of business. Retailers that carry an inventory of goods would need to change prices of goods on an almost daily basis to account for daily changes in the value of Bitcoin (i.e., the daily Bitcoin exchange rate). For businesses to be able to create workable budgets, they need to confidently predict the rate of inflation (or deflation) in the upcoming year. The same holds for individuals preparing household budgets. Volatility is a budget destroyer.
  • Countries are unlikely to give up their own currencies. Governments like to control their own currencies. Great Britain refused to adopt the Euro even when it was part of the European Union. Similarly, Denmark and Sweden also have kept their own currencies rather than adopt the Euro. Each country’s central bank sets its own interest rates based on its own monetary policy. Each country has differing degrees of nation debt. Each country has different GDPs. Each country has differing economic performance, such as unemployment rates and productivity efficiency. Each country has different degrees of geopolitical stability,. And each country has differing trade balances. Because of these differences, the value of a Bitcoin or other cryptocurrency will vary from one country to another. In one country, a dozen eggs might cost 0.00001 Bitcoin but in another country, a dozen eggs might cost 0.000005 Bitcoin. By giving up its national currency, a country’s government loses economic control.
  • Transactions take too much time. Cryptocurrencies can only reach maximum long term value if they become used as currency for most sales transactions. For Bitcoin transactions to be validated by miners and new blocks to be added to an existing blockchain requires about 1-hour on average. Each transaction requires multiple different miners to each perform independent validations. Each of those individual validations requires a great deal of complex computations. If the Bitcoin network is busy, there can also be long wait times in the validation queue that results in transactions taking several hours. In addition, each transactions results in a given blockchain becoming longer; as blockchains get longer, it takes more computer CPU to perform validation computations. This makes cryptocurrency, like Bitcoin, unsuitable for day-to-day transactions unless the cryptocurrency is associated with a credit card or a debit card.
  • Cryptocurrencies cannot be used during power failures or internet outages. If there is a power failure after a storm or a hurricane, you can still buy supplies at your local hardware store using cash. If your internet service provider has an outage because a construction crew accidentally cut your regional fiberoptic cable, you can still buy a cup of coffee at your local coffee shop using cash. In fact, many small retailers only accept cash and do not accept credit cards because of their associated fees. Although the transaction validation fees charged by Bitcoin miners are relatively small, they can spike upward significantly during periods of network congestion. This could potentially result in dynamic pricing to accommodate these variable validation fees… and consumers do not like dynamic pricing, particularly for day-to-day purchases.
  • Transaction validation uses an enormous amount of electricity. Currently, Bitcoin miners consume about the same amount of electricity as the entire country of Argentina every year. This electricity consumption will grow if more transactions occur every year. The only way to create this amount of electricity is to increase fossil fuel power plants or renewable energy sources. Many communities are already facing objections to building new data centers because of their excessive electricity consumption that increases the cost of electricity to everyone in the community. Limits on future electricity generation could pose a barrier to widespread adoption of cryptocurrencies for day-to-day transactions.
  • If you lose your key, you lose your Bitcoin. The key is a 256-bit random number that functions as a “master key” or signature to unlock and spend your Bitcoin. It must be kept secret. If you lose that number, that Bitcoin is lost forever. If you store that number on a piece of paper in your home and there is a fire, you lose your entire investment. If that number is kept on your home computer and the computer is stolen, you lose your entire investment. If your number is hacked, you lose your entire investment. Stefan Thomas, a San Francisco programmer, famously lost a hard drive containing the keys for 7,000 Bitcoins – in other words, he lost forever the equivalent of $420 million. It is currently estimated that 20% of Bitcoin keys have been lost, essentially making those Bitcoins disappear. Bitcoins can be held in cryptocurrency exchanges, such as Coinbase, that offer a secure place to store your Bitcoin; however, exchanges charge fees for storage and transactions.
  • Mainstream adoption of cryptocurrency is affected by politics. Political leaders can have a profound effect on whether cryptocurrencies become mainstream. For example, they can decide to accept a particular cryptocurrency as legal tender for paying taxes, paying for tickets to enter National Parks, etc. Conversely, politicians can deny mutual funds or ETFs from dealing in cryptocurrency. A single executive order can make or break a cryptocurrency,

For every ardent cryptocurrency skeptic, there is an equally passionate cryptocurrency advocate. Here are some of the reasons cryptocurrency proponents cite for why people should invest in cryptocurrency:

  • The number of Bitcoins is capped. Currently, 19.9 million Bitcoins have been created. The maximum number that can be eventually mined is 21 million. That means that 95% of Bitcoins have already been mined. As a result, the more people use Bitcoins, the more valuable they become. It is sort of like the opposite of inflation – an automobile costing 1 Bitcoin today might cost 0.5 Bitcoin a year from now if Bitcoin replaces traditional currency. As the demand for Bitcoins increases in order to complete more and more transactions, then if there is a finite number of Bitcoins in existence, the value of each Bitcoin will rise. Because of this, the value of Bitcoin will steadily increase as it is used for more and more transactions.
  • Over time, many Bitcoins are irretrievably lost. If you lose your bitcoin key, that Bitcoin is gone forever and no one will ever be able to use it. Just like pennies and dollar bills, over time, a certain percentage of them become lost and go out of circulation. Since there are a maximum of 21 million Bitcoins, as some Bitcoin keys are inevitably lost each year, there will be fewer and fewer Bitcoins in circulation, thus increasing the value of those remaining Bitcoins.
  • Cryptocurrency cuts out the middlemen. An advantage of cryptocurrency is that it eliminates banks as middlemen for various transactions. In addition, cryptocurrency operates outside of government control, making it immune to monetary policy meddling by governments.
  • It is taxed at your capital gains tax rate rather than your income tax rate. When you sell a Bitcoin, any profits you make are taxed at your capital gains tax rate, as long as you have held that Bitcoin for more than one year. For the vast majority of Americans, the capital gains tax rate is lower than their income tax rate. Unless you have a very low income or a very high income, that capital gains tax rate is 15%.
  • It is extremely portable. You can take your cryptocurrency across national borders with ease. This makes it efficient for someone sending money back home to their family in Costa Rica and also makes it easy for someone fleeing the U.S. to move all of their assets out of the country without being taxed or having their accounts frozen.
  • Diversification. The value of cryptocurrency is affected by different forces than those that affect the value of other investments, such as stocks or bonds. However, cryptocurrency is new enough that the factors that influence its value have not been fully determined. Nevertheless, it provides diversification that may protect investors during periods of stock and bond market decline.

The future value of cryptocurrency depends entirely on whether its use for transactions increases. If so, then the value of cryptocurrencies, such as Bitcoin, will increase and likely increase a lot. On the other hand, if cryptocurrencies fail to be used for future transactions, then they will have little or no future value. In that sense, buying and holding cryptocurrency is more speculation than investing. Cryptocurrency will either be a boom or bust as a long term investment. There are so many variables that will affect whether cryptocurrency goes mainstream that it is impossible to confidently predict the future of cryptocurrency. Twenty years from now, either cryptocurrency’s advocates or naysayers will be saying “I told you so” but no one knows which group it will be.

A third possibility is that cryptocurrency continues to be used for a some transactions and as a means of transferring money from one individual to another. In this regard, cryptocurrency is a great way to launder money if you are a criminal or to avoid taxes on money transfers if you don’t want the IRS to know about the transfer. It is far easier for a drug cartel to charge a few hundred Bitcoin for a shipment of cocaine than to try to figure out how to move a pallet of $20 bills across the border.

If you do decide to include Bitcoin or some other cryptocurrency in your retirement portfolio, it should be a relatively small percentage, 1% – 5%. If cryptocurrency has future widespread adoption, that small percentage will be worth a fortune in 10 or 20 years. If cryptocurrency does not become widely used for ordinary transactions in the future, then a total loss of only a small percentage of one’s investment portfolio will not result in a significant loss of one’s total assets. If Bitcoin does not go mainstream but continues to be used by drug dealers and ransomware criminals, then you probably won’t make a fortune on your Bitcoins but you probably won’t lose your initial investment, either.

February 22, 2026

Categories
Hospital Finances

American Hospitals Have An Immigration Problem. But It Is Not What You Might Think

The Somali refugee population in Minnesota has received a lot of national attention recently because of a daycare fraud scandal. The twin cities of Minneapolis/St. Paul have the largest Somali population in the United States at approximately 80,000. Central Ohio has the second largest Somali refugee population at about 70,000. Most of these refugees came to the United States in the late 1990’s, fleeing Somalia’s Civil War. Approximately 82% of Central Ohio’s Somali population are either naturalized citizens or legal permanent residents (green card holders). However, some Somalis in Ohio are under federal temporary protected status, allowing them to live and work in the United States as refugees when return to their home country is unsafe due to war or environmental disaster. Last month, the Trump administration canceled temporary protected status for Somalis, requiring them to leave the country by March 17, 2026.

Twenty years ago Somali refugees accounted for a large percentage of our hospital’s housekeeping and janitorial staff. These are largely unskilled workers who often had limited education. Today, the children of those refugees now occupy skilled positions in our hospital as nurses, respiratory therapists, and physicians. From my own experience as our hospital’s medical director, it is difficult to fill unskilled positions, such as hospital housekeeping staff. U.S.-born citizens with U.S. educations are largely uninterested in cleaning soiled hospital bed linens, moping floors, or washing dishes in the hospital kitchen. We rely heavily on immigrants and especially refugees who are willing to take on any job as long as that job allows them to stay in America. Immigrants do the hospital jobs that no one else will do.

Our hospital is not unique. A study from the Kaiser Family Foundation found that 1 out of 6 hospital workers (16%) in the U.S. are immigrants. But there are significant geographic variations. For example, only 0.5% of hospital employees are immigrants in Wyoming but in California, 32.4% of hospital employees are immigrants.

For low-paying hospital jobs requiring less education, such as cleaning and maintenance jobs, nationwide, fully 29% are immigrants. More specifically, 17% are naturalized citizen immigrants and 12% are non-citizen immigrants. A recent study in JAMA found that 9% of hospital housekeeping and janitor workers are undocumented immigrants. These jobs are essential for our nation’s hospitals to function and we cannot fill all of these jobs with American-born workers.

The United States allowed approximately 1.2 million immigrants to enter the country in 2023 as lawful permanent residents. Of these, the largest percentage, 756,000, entered by being sponsored by an immediate family member, for example, a spouse, child, or parent of a U.S. citizen. Approximately 197,000 entered the U.S. as employment-based immigrants – mainly skilled workers on work visas. The annual diversity visa lottery accounts for about 55,000 immigrants each year – these visas are allotted to people from countries that have low rates of immigration to the U.S. such as Ghana, Nepal, and Armenia. Refugee status accounted for 125,000 immigrants.

Immigrants tend to be young and of working age. Data from the U.S. Citizenship and Immigration Services indicate that in 2024, 88.1% of all individuals becoming naturalized citizens that year were under age 65. Data from the U.S. Department of Homeland Security indicates that 88% of undocumented immigrants are under age 55 and 79% are between ages 18 – 55, indicating that the vast majority of undocumented immigrants are in prime working age.

In 2023, there was a total of 51.8 million immigrants living in the U.S. Of these, 23.8 million (46%) were naturalized U.S. citizens, 11.9 million (23%) were green card holders, 2.1 million (4%) were temporary lawful residents, and 14.0 million (27%) were unauthorized.

Of those 14 million unauthorized immigrants, 2.6 million were asylum applicants, 700,000 entered the U.S. legally after receiving parole (“parole” from an immigration definition is a person who has been granted legal authorization to remain in the U.S. because of humanitarian reasons or significant public benefit), 700,000 were authorized to be in the U.S. because of being victims of crime or violence, 650,000 had temporary protected status, 650,00 were brought to the U.S. illegally as children (DACA). Another 1 million had been apprehended by U.S. Border Patrol agents and released into the country with an order to appear in immigration court. Finally, 8 million of the unauthorized immigrants were undocumented; this is the group that the government has targeted for deportation. 50% of undocumented immigrants live in just three states: Texas, California, and Florida. The most common country of origin is Mexico:

When it comes to employment, 64% of immigrants in the U.S. are in the workforce. The majority of the rest are homemakers, children, or the elderly. Of the unauthorized immigrants, fully 71% are in the U.S. workforce. In contrast, only 44% of U.S. born citizens are currently in the U.S. workforce. In other words, a much higher percentage of immigrants are in the workforce than U.S. born citizens, reflecting the younger average age of immigrants compared to U.S. born citizens. In addition, undocumented immigrants have to work as they are not eligible for federal programs such as SNAP, ACA insurance, Social Security, Pell grants, Medicare, or Medicaid.

The United States is heavily dependent on immigrant physicians who account for 27% of all physicians in American hospitals. Of these 19% are naturalized U.S. citizens and 8% are noncitizen immigrants. Because of the rigorous training and licensure requirements for doctors, essentially no practicing physicians are unauthorized/undocumented immigrants. In other words, they are all here legally.

16% of U.S. hospital nurses are immigrants of which 13% are naturalized citizens and 3% are noncitizens. 22% of nursing assistants are immigrants of which 15% are naturalized citizens and 7% are non-citizens. Similar to physicians, nurses require training and licensure; as a result, essentially no practicing nurses are unauthorized/undocumented immigrants.

For home-based services, the U.S. relies even more on immigrants with 41% of home health aides being foreign born. As our nation’s population ages, home health will be increasingly important and without these immigrant workers, home health delivery would be unable to meet the country’s needs. Although many home health aides are employed through home health companies that require their employees to have documentation of legal immigrant status, many other home health aides are employed directly by families and often paid in cash. As a result, undocumented immigrants account for 3.8% of home health workers.

We have healthcare employment needs that cannot be fully met by U.S. born citizens. Currently, nearly half of U.S. nursing homes have limited admissions due to staffing shortages and only 19% meet the minimum staffing numbers required by 2029 as mandated by Medicare. Data from 2023 indicated that two-thirds of hospitals had to reduce inpatient capacity due to staffing shortages, a number that will be of no surprise to anyone who has had to wait in the emergency department for hours or days for an inpatient bed because no open beds were available.

Immigrants in the United States have always taken the jobs that no-one else wanted to do. Forced immigrants (the enslaved) were brought to America in the 1600’s and 1700’s to do farm labor that free Americans would not do. Following the Great Famine of 1845, Irish immigrants took unskilled jobs in American, such as building canals, working in textile mills, and working in mines. Chinese immigrants came to the U.S. in the 1860’s to work building railroads, a dangerous and low-paying job that railroad owners could not fill with American born workers. After the railroads were built, the Chinese went on to work in laundries, another job that could not be filled with American born workers. In the 1900’s, it was migrant farmworkers who were essential for much of the U.S. agricultural output. These also were physically demanding and low paying jobs that few U.S. citizens would take. Today, immigrants continue to do the jobs that cannot be completely filled with U.S. born workers: kitchen staff, farmworkers, day laborers, roofers, daycare workers, drywall installers, painters, etc.

In the U.S. healthcare system, immigrants perform many of the so-called entry-level jobs that require minimal skills and little training. While it is true that these jobs can frequently be filled by U.S. born citizens entering the workforce with only high school or less education, these least educated U.S. born citizens are often less motivated to work than immigrants and are more likely to move on to some other job after a short period of time. Quite simply, immigrants often make the best employees for unskilled jobs in healthcare – they are glad to have a job, work hard, and are less likely to quit after just a few weeks or months on the job.

The U.S. citizenry is aging and the U.S. birthrate is falling. As a result, we will have a large population of elderly Americans needing home healthcare, nursing home care, and hospital care over the next several decades. And at the same time, the low birth rate will result in fewer young Americans available and willing to take unskilled hospital jobs like home health aides, hospital kitchen workers, nursing aides, and hospital housekeeping staff.

As with all too many things in life, politics gets in the way of pragmatism. The pragmatic solution to our current and soon to be worsening shortage of unskilled hospital workers is to bring in more legal immigrants who are of working age. The politics is that too many Americans feel threatened by immigrants – either because of fear that the immigrants are criminals, fear that the immigrants are going to take their jobs, or simply fear of people from a different culture.

The best way to reduce unauthorized/undocumented immigration is to allow more young immigrants who are motivated to come to the U.S. for jobs to enter legally. We need to allow hospitals and other healthcare employers to sponsor immigrants who agree to take those jobs that cannot be filled with U.S. born citizens. They can then do the work that is needed by our healthcare system, pay into the Social Security system (which is needed to prevent Social Security from running out of money), and avoid wasting money being spent to round up, detain, and deport those who can contribute to society.

Our nation’s hospitals’ immigration problem is that we need more immigrants.

February 6, 2026

Categories
Physician Retirement Planning

Should You Have Gold In Your Retirement Investment Portfolio?

Traditional retirement investments consist of 5 types of holdings: U.S. stocks, foreign stocks, U.S. bonds, foreign bonds, and real estate. But in reality, you can put any kind of holdings in your retirement portfolio, from fine art to cryptocurrency, from pork belly futures to stamp collections, and from collectible sneakers to gold. But should you?

As an investment, gold has recently received a lot of attention because it has increased in value by 162% in the past 2 years. At the same time, the S&P 500 stock index increased by 24%. The graph below shows how an investor would have performed by investing $2,000 in either gold or the Vanguard Total U.S. Stock Index Fund (VTSAX) in January 2024 through January 2026.

Based on the returns for gold during the past 2 years, it looks like a great investment. But is it really and is now a good time to invest in gold?

For hundreds of years, gold was treated as a form of money. Until the Great Depression, the United States tied its currency to the value of gold, the so-called “gold standard”. But today, you cannot pay for your groceries or pay your rent using gold. Gold’s value is because of its value as a commodity.

A commodity is a raw material or primary agricultural product that can be bought and sold on a commodities market. Commodities include things like wheat, corn, copper, crude oil, and gold. Commodities can typically be consumed or made into a product that can then be sold. Wheat can be made into flour, crude oil can be made into gasoline, and gold can be made into jewelry. As an investment, gold is unique among commodities because it does not spoil if you hold it too long (unlike wheat or corn) and it is small enough that the average person can keep it in a safe at home or in a safe deposit box at a bank (unlike crude oil or copper). Because of these qualities, gold (and other precious metals) can serve as a long term investment for the average person.

There are many factors that can affect the price of gold. Gold is considered to be a safe haven asset, meaning that in times of geopolitical instability, gold is generally considered to hold its value better than the currency of unstable countries. Thus, when there is geopolitical tension, the price of gold usually increases. During periods of economic uncertainty, the central banks of countries buy gold as a hedge agains uncertainty and this can further drive up the price of gold as demand increases. Gold is viewed as a hedge against inflation so when the rate of inflation increases, the price of gold increases. Also, when the value of the U.S. dollar falls, the price of gold in the United States increases. Interest rates can additionally affect the price of gold – when bond interest rates increase, the price of gold decreases since unlike bonds, gold does not pay out annual interest or dividends, making bonds more attractive to investors than gold.

Since 2000, gold has outperformed stocks but over a longer period of time, stocks have outperformed gold. The table below shows the current value of $1 invested in either gold or stocks, assuming that stock dividends are reinvested.

One the surface, it appears that gold is the better investment over the past 25 years. However, if you compare the returns from gold versus the S&P 500 between 2000 and 2019, those returns are similar – most of gold’s increase in value has occurred in the past 6 years, related to the COVID pandemic, geopolitical instability related to the wars in Ukraine and Israel, and more recent global economic instability related to tariffs and the falling value of the U.S. dollar. The risk of gold today is that it may be overvalued – easing of geopolitical tensions and greater global economic certainty could result in gold falling in value in the future.

In the short term, gold is highly volatile – even more volatile than stocks. This makes it a poor choice for short term investing. Thus, the role of gold in a retirement portfolio should be as a long term investment.

The most direct way to invest in gold is to purchase gold bars or gold coins. However, this means that you need a secure way to store it, such as in a safe at home or in a safe deposit box in a bank. Even with seemingly secure storage, physical gold can be subject to theft. Buying gold bars or coins from a gold dealer also requires paying a commission – generally 1% to 5% of the purchase price. These commissions are not reflected in graphs showing an increase in the price of gold and these commissions can significantly erode investment returns. Additionally, secure storage can add costs that can further erode the overall return on investment in gold. To summarize – the cost of buying, storing, and selling physical gold can negate a lot of the returns from increases in the price of gold as a commodity.

Physical gold can also be held in an IRA for retirement. However, there are specific IRS rules about gold IRAs. For example, the gold must be stored in an IRS-approved third party storage facility – you cannot store gold in a bank safe deposit box if that physical gold is in an IRA. The IRS also requires that the gold in a gold IRA be purchased by an IRS-approved custodian and that the gold bullion be IRS-approved (> 99.5% purity). Fees paid to the custodian to buy and sell gold in the IRA and fees paid to the storage facility to store and insure the physical gold in the IRA can significantly erode the returns from investment.

An alternative to physical gold is to purchase shares of a gold mutual fund or gold ETF where the fund then holds the physical gold in a secure location. Gold ETFs have expense ratios of around 0.40%, which is considerably cheaper than the commissions paid when buying physical gold from a gold dealer. In addition, the ETF expense ratio also covers the cost of storaging and insuring the physical gold that is held by the ETF. When compared to a gold IRA, having a gold ETF in your regular traditional or Roth IRA is much less costly and avoids the rather high custodian fees, storage fees, and dealer mark-ups associated with gold IRAs.

Lastly, you can buy shares of stock in gold mining companies; however, this poses additional risk since the companies can lose value from operational problems, poor management, or political upheaval in the country where the mine is located – even as the value of physical gold as a commodity is increasing.

Gold’s volatility makes it a poor choice as the main component of a retirement portfolio. However, as a minor component, it can serve an important role as a hedge against inflation and hedge against falling purchasing power of the U.S. dollar. Gold usually (but not always) increases in value when bonds decrease in value. Sometimes gold will also increase in value when stocks decrease in value. In a retirement portfolio, this gives the retiree the ability to strategically draw from gold investments during months or years that stocks or bonds have fallen in value.

Whether to have gold in your retirement investment portfolio and what percentage to have will depend on several factors:

  • Comfort with investment risk. The percentage of one’s retirement investment portfolio invested in gold will depend on one’s personal degree of risk aversion. As an example, someone who is risk averse from an investment standpoint may want to have no retirement holdings in gold whereas someone who is comfortable with investment risk may want to have as much as 5% of the portfolio invested in gold.
  • Years until retirement. As with any volatile investment, the closer one is to retirement age, the lower the percentage of volatile investments one should have in their retirement portfolio. There is too great of a risk that gold could lose significant value in the short term and if an investor is dependent on gold to provide a large percentage of their annual retirement income, then that investor could need to draw from the gold investment at a time when it has lost value. It is unwise to make a large new investment into gold a year before retiring.
  • Projected annual retirement income to living expense ratio. The closer a retiree’s annual income from investment is to their basic living expenses, the lower the percentage of volatile investments should be in their portfolio. The danger is that if there is a fall in value of a volatile investment in any given year, the retiree may have to withdraw a greater amount of their total portfolio to pay the bills and risk running out of money later in life. On the other hand, if the annual retirement income is considerably greater than annual basic living expenses, then the retiree can simply reduce discretionary spending for a year or two when volatile investments fall in price and thus preserve total investment portfolio value for the future.
  • Life expectancy after retirement. A longer life expectancy from the year that one retires means a longer investment horizon for retirement investments. The longer the investment horizon, the more volatility and risk the investment portfolio can withstand since some of that investment can be considered long term. On the other hand, if one anticipates a relatively short life expectancy after retirement, then the portfolio should predominately contain low risk, non-volatile investments since they will all be short term investments. Factors that can affect life expectancy after retirement include one’s age when retiring, the presence of any chronic diseases, whether one smokes, whether one is obese, and how long one’s parents and grandparents lived.
  • The amount of one’s Social Security benefit or pension. Social Security and pensions are considered fixed income sources – they may keep up with inflation but they do not increase in value above inflation. The advantage of a fixed income component in one’s retirement portfolio is that it serves as a financial buffer during times when stock, bond, or gold investments drop in value. The larger one’s annual fixed income, the greater risk and volatility one can tolerate with other retirement investments. On the other hand, someone with no pension and a relatively small Social Security benefit cannot tolerate excessive volatility in their investment portfolio and gold would be a poor choice.
  • One’s opinion about the future. No one can predict if the U.S. or other major powers will become enmeshed in a future war. No one can predict whether future U.S. policies will result in a fall in the value of the U.S. dollar. No one can predict when the next surge in U.S. inflation will occur. No one can predict when the surging federal deficit will reach the tipping point and cause a new wave of U.S. austerity. If you are a pessimist about the economic and geopolitical future, then a higher percentage of gold in your retirement investment portfolio is warranted. If you are an optimist about the future, then a lower percentage of gold would be more appropriate.

The general rule of investing is to “buy low and sell high”. One of the challenges is that you never know if the price of any investment is going to go up or going to go down in the future. However, understanding the factors that affect the price of gold can provide some direction to the investor. Historically, the best time to buy gold has tended to be during periods of low inflation, rising interest rates, geopolitical stability, a strong U.S. dollar, and U.S. policies fostering economic stability. These are times when the price of gold is relatively cheap. On the other hand, the worst time to buy gold is during periods of rising prices, falling interest rates, geopolitical turmoil, a weakening U.S. dollar, and U.S. economic uncertainty. These are times when the price of gold is relatively expensive.

My personal opinion is that we are currently in the latter times. Inflation has proven to recently be sticky with tariffs increasing consumer prices. Although interest rates remain high, they appear to have crested, with gradual reductions over the past year. We are currently experiencing tumultuous geopolitical events with the persisting Ukraine war, U.S. involvement in Venezuela, U.S. posturing toward Greenland, and political instability in Iran. The U.S. dollar has weakened approximately 10% over the past year, largely as a result of U.S. tariffs, federal government shutdowns, and perceived threats to the autonomy of the U.S. Federal Reserve. There is considerable economic uncertainty with threats of even greater tariffs that can result in higher inflation, the increasing federal deficit, the impending exhaustion of the Social Security Trust Fund, and the realignment of traditional U.S. trading partners resulting from “America first” policies.

Should you have a gold component in your retirement investment portfolio? Yes, it can be an important diversification component that will strengthen an investment portfolio. But I believe that now is not the time to buy gold for one’s retirement investment portfolio. Instead, now is the time to be selling gold that you already have in your investment portfolio. Then wait until the various factors historically associated with lower gold prices emerge and then buy gold bars, gold coins, gold ETFs, or gold mining company stocks. Avoid gold IRAs since they have excessively high expenses – if you want a gold component in your IRA, then buy shares of a gold ETF instead.

Because there is no way to know when gold (or any other investment) has bottomed out in price, a good strategy for buying gold is dollar cost averaging. That is, buying small amounts of gold every month or so over a long period of time. Then rebalance your portfolio every year by buying or selling gold to maintain whatever the desired percentage of your total investment portfolio you have decided should be invested in gold, generally 10% or less. As an investment, gold may look hot today, but that just means that you should have bought it 5 years ago.

February 3, 2026

Categories
Medical Malpractice

Occurrence Or Claims Made Medical Malpractice Insurance? And The Answer Is… It’s Complicated

Every physician and health care provider needs to have medical malpractice insurance. An average of 20,000 medical malpractice lawsuits are filed each year and by the time physicians reach age 55, about half have had at least one malpractice suit. A study by the AMA found that some specialties are at particularly high risk with the majority of general surgeons, OB-GYNs, radiologists, emergency medicine physicians, family physicians, and orthopedic surgeons being sued at some point in their careers.

There are two types of malpractice insurance: occurrence and claims made, with important differences between the two:

  • Occurrence. This type of insurance policy covers the time period during which the malpractice event occurred. Because it provides lifetime coverage, there is no need to purchase a tail policy.
  • Claims made. This type of insurance policy covers the time period during which the suit was filed in court. This is usually months or years after the malpractice event occurred. There is usually a retroactive date for when that coverage starts – generally the retroactive date is the date that the physician first purchased that particular claims made policy. For this reason, a tail policy must be purchased when changing insurance companies or changing jobs to a new employer. A tail policy must also be purchased when a physician with claims made insurance retires.

To understand the difference, take an example of a physician employed by City Memorial Hospital and covered by occurrence malpractice insurance. The physician retires on December 31, 2024. In July 2025, a patient that the physician cared for in 2024 files a malpractice suit. The occurrence malpractice insurance covers the physician since the malpractice event occurred in 2024, when the physician was employed and paying occurrence malpractice insurance premiums.

On the other hand, if the physician had a claims made policy when working at City Memorial Hospital in 2024, that claims made policy would not cover the physician since the malpractice claim was made in 2025, after the physician retired. Instead, the physician’s tail policy would cover lawsuit.

In the past, occurrence policies were the most common. Occurrence insurance is simple and covers the physician for life, even if a lawsuit is filed after the physician changes jobs or retires. Because occurrence insurance provides lifetime coverage, it is more expensive than claims made insurance. As more and more physicians become employed by hospitals or corporations owned by private equity groups, occurrence policies have become less frequent since employers prefer to purchase the less expensive claims made policies. Those employers can then transfer the responsibility and cost of a tail coverage policy on to the physicians if they change jobs or otherwise resign from the hospital.

In theory, the total lifetime cost of occurrence insurance should be the same as the total lifetime cost of claims made plus tail insurance. After all, a physician is equally likely to be sued whether they have occurrence or claims made policies. So, why are claims made policies becoming so much more common?

Most physicians do not have a choice between occurrence policies and claims made policies – that decision will be made by the hospital or corporation employing the physician. Physicians in solo practice or in a physician-owned group practice do have a choice between these insurance policies but fewer and fewer physicians are now self-employed. Here are some of the considerations that impact the two types of medical malpractice insurance:

  • Statute of limitations and statute of repose. The length of time of the statute of limitations and statute of repose can impact the likelihood of a future lawsuit and impact the cost of a tail insurance policy. Each state has different laws governing the statute of limitations for medical malpractice lawsuits. For example, in Ohio, there is a 1-year statute of limitations from the time that the malpractice event was discovered and an additional 4-year statute of repose from the time that the malpractice event occurred. As an example, let’s say an Ohio surgeon leaves a sponge in the abdomen during a surgery in 2020 and the patient first discovers this when he develops an abdominal abscess in January 2023. The patient has until January 2024 to file a malpractice suit because of the 1-year statute of limitations. Now let’s say that the same patient doesn’t develop the abdominal abscess and discover the retained sponge until 2025. The patient cannot file a malpractice lawsuit because it is now beyond the 4-year statute of repose. In contrast, the statute of limitations in Florida is 2 years with a 4-year statute of repose. In New York, there is a 2.5 year statute of limitations with no additional statute of repose for most medical malpractice lawsuits but for retained foreign bodies (like a retained sponge), the statute of limitations is 1-year from discovery with a 10-year statute of repose. Thus in New York, a physician who performs invasive procedures (for example, a surgeon) could be sued 10-years after retirement whereas a physician who does not perform invasive procedures (for example, an allergist), could only be sued 2.5 years after retirement. The statute of limitations for malpractice involving minors is different and in most states does not start until the child’s 18th birthday meaning that a malpractice suit involving an event that occurred to a child could be filed up to age 19 in Ohio or age 20.5 in New York.
  • Regional difference in the cost of malpractice insurance. The same insurance policy will have different costs in every state in the U.S. The biggest impact on cost is state-specific laws regarding medical malpractice. Those states that have passed malpractice reform laws have lower cost malpractice premiums than those states with malpractice laws that favor plaintiffs. In addition, the citizens of some states are more litigious than others based on social factors and state-specific legal precedents. As an example, a general surgeon practicing in Los Angeles, California will pay an average of $42,000 per year for malpractice insurance but a general surgeon practicing Miami, Florida will pay an average of $244,000 per year. With a tail policy costing 2-3 times the annual cost of a claims made policy, the general surgeon would pay about $105,000 for tail coverage in Los Angeles but could pay as much as $610,000 for tail coverage in Miami.
  • The claims made retroactive date. It is crucial to understand the fine print of the malpractice insurance policy. Claims made policies will include a retroactive date – that is, the date that coverage commences. Malpractice events that occurred prior to the retroactive date are not covered. In most policies, the retroactive date will be the day that the physician first bought that particular insurance policy. That means that if a physician changes jobs or changes insurance companies, the physician would need to purchase a tail policy for any suits that later get filed for an event that occurred during their previous job or previous claims made policy since those events would be prior to the retroactive date. Some claims made policies will not have a retroactive date and (in theory) will cover any malpractice lawsuit from past employment that is filed during time that the claims made policy is active. The retroactive date will determine whether a physician needs to purchase a tail policy when changing insurance companies or when changing employers.
  • The tail policy retroactive date. Tail policies are often purchased from the same insurance company that held the physician’s most recent claims made policy. The retroactive date of the tail policy is usually the date that the claims made policy first went into effect. When purchasing a tail policy it is critically important to be sure that these dates match up to be certain that there is no gap in coverage. A physician who changes jobs or insurance companies frequently might need to hold several different tail policies – one for each of several different previous claims made policies. It is necessary for the physician to have sufficient tail coverage with a retroactive date at least as far back as the state’s statute of limitation and statute of repose.
  • Occurrence policies are more expensive than claims made policies. Claims made policies will not cover malpractice events that happened prior to the retroactive date and will not cover claims that are filed after the policy ends. This requires purchase of separate tail policy when a physician has a claims made policy. As a result, the annual premium for a claims made policy alone is considerably less expensive than the annual premium for an occurrence policy. That difference is made up for in the future, when the physician has to purchase a separate tail policy.
  • Claims made premiums increase in the first years. Because most malpractice lawsuits are not filed for months or years after the actual event occurred, claims made policies are less expensive in the first year of the policy. The annual cost of claims made insurance premiums will then rise each year before leveling off at about 5 years into the policy. On the other hand, occurrence policies will not change appreciably from one year to the next. This can make the cost of malpractice insurance seem deceptively low when first purchasing a claims made policy compared to an occurrence policy. It is important to look beyond the cost of the first year of the claims made policy to fully appreciate the long-term cost.
  • Will your employer purchase a tail for you? Many hospitals and corporate employers with claims made malpractice insurance policies will purchase a tail for physicians who leave the practice. Sometimes, this is only for physicians retiring after a certain number of years of employment. Sometimes, this is for any physician leaving the practice but only after a minimum number of years of employment. It is critical for physicians to understand the fine print about tail coverage in order to know whether the hospital or corporate employer will pay for your tail policy or whether you will have to. Also, if the hospital closes, or the corporation employing the physician goes out of business, the physician may have to purchase a tail policy even though the original employment contract promised that the employer would provide tail coverage. This happened to emergency medicine physicians employed by American Physician Partners (APP) and NES Health – both companies ceased operations, leaving tail coverage unexpectedly up to the physicians who worked for the companies. Additionally, some employment contracts will specify that the hospital or corporate employer will not purchase a tail policy for physicians who are terminated “for cause”, meaning that if the physician is fired, that physician will have to purchase their own tail policy.
  • Beware of coverage gaps. If a physician with claims made insurance changes jobs with a new employer and there is a gap of a few weeks or months between the two employers, that gap in time needs to be covered. If the new employer offers to purchase a tail policy, the physician needs to be sure that the tail policy is in effect starting from the date the physician stopped working for the old employer. Otherwise the physician may be responsible for purchasing insurance coverage in case a claim is filed during the gap between employers.
  • You may need more than one tail. Because the retroactive date on most tail policies is the date that the claims made policy first went into effect, a physician changing employment or changing insurance companies frequently may need to purchase a tail policy for each of several claims made policies. Again, careful attention to the fine print of the tail policy is essential as is awareness of the specific state’s statute of limitations and statute of repose.
  • “Nose policies” are the opposite of tail policies. A nose policy (aka, “prior acts coverage”) is sometimes included with a new claims made policy. With a nose policy, any malpractice event occurring prior to the retroactive date of the new claims made policy is covered by the nose policy. Having a nose policy with a new claims made policy will eliminate having to purchase a tail policy with the previous claims made policy. If the nose policy has its own retroactive date, be sure that it corresponds with the statute of limitations and statue of repose of the state. “Full prior acts” policies do not have a retroactive date and cover any new claims, regardless of how long ago the malpractice event occurred.

The bottom line is that the complexities of claims made insurance policies often necessitate having an attorney review new employment contracts and insurance policy contracts to be sure that physicians do not find themselves unexpectedly not covered by malpractice insurance.

Most physicians are now employed by either a hospital or a private equity-owned corporation. A minority work in physician-owned group practices. Solo private practices are largely a thing of the past. Hospitals and corporations will usually provide malpractice insurance for their employed physicians. This allows for a unified defense in event of a malpractice suit filed against both the hospital and a doctor thus preventing the finger pointing that occurs when the doctor and the hospital are represented by different insurance companies and different attorneys in a malpractice suit. Furthermore, offering to provide malpractice insurance is an important fringe benefit that hospitals use in recruiting physicians in order to remain competitive with other hospitals recruiting from the same pool of physicians.

As a physician, I would much prefer that the hospital that employs me buys occurrence malpractice insurance. But, there are several reasons why hospitals (and private equity-owned corporations) prefer to buy claims made insurance rather than occurrence insurance for their physicians.

  • The premiums are lower in the first years of employment. As discussed above, malpractice claims are filed with the court months or years after the malpractice event occurs. As a result, claims made insurance is relatively inexpensive for the first year of employment and gradually increases every year until leveling off at about 5 years. Occurrence insurance costs the same per year no matter how many years the physician has been employed. A recent study found that most newly trained physicians change jobs within 2 years of their first employment after residency. Knowing this, hospitals can save a lot of money in malpractice premiums if they buy the less expensive claims made insurance for new physicians, knowing that many of them will only work at the hospital for 2 years or less.
  • They may require the physician to purchase a tail policy. Some hospitals will include a tail policy with the initial employment contract but not all will. If the physician has to purchase the tail policy, this transfers a large part of the cost of malpractice insurance to the physician.
  • The hospital can use a tail policy as an a work incentive. Some hospitals will agree to pay for a tail policy but only after a physician has been vested by working at the hospital for some minimum number of years, for example, 5 years. If the doctor resigns before that vestment period, then the doctor must purchase the tail policy. This can serve as a deterrent for physicians to leave the hospital practice after too short of a time, thus reducing the cost to the hospital of recruiting replacements for those physicians.
  • The hospital can avoid claims histories on their physician malpractice insurance by dumping high-risk physicians. Let’s say that the hospital’s quality department identifies a physician who has not been practicing good quality medicine. Maybe the physician has a lot of patient complaints, or is found to not be using standard of care practices, or is found to be drinking on the job. These are often “for cause” reasons that the hospital can terminate the physician’s employment contract. If a tail policy is contractually not provided by the hospital for physicians terminated for cause, then the doctor will have to buy his or her own tail coverage when fired. Any future malpractice claims would then appear on the physician’s insurance record and not the hospital’s insurance record. This potentially could help the hospital avoid a costly increase in its physician malpractice insurance premiums by keeping any future malpractice claims against the physician off of the hospital’s claim history. Having a vestment period before the hospital will buy a tail policy is another way for the hospital to avoid paying for tail policies for bad physicians – if the hospital identifies a physician as being a malpractice risk because of poor performance, the hospital can terminate that physician prior to the vestment period, thus requiring the physician to buy the tail policy.
  • It keeps the hospital from having to pay more for physician malpractice insurance than the other hospitals. Frequently, hospitals will purchase nose insurance as a recruitment incentive when hiring new physicians. If the last hospital that the physician worked at had claims made insurance, then the new hospital will often buy a nose policy but if the last hospital that the physician worked at had occurrence insurance, then the new hospital does not need to spend the money on a nose policy. No hospital wants to be the only hospital offering occurrence insurance since not only will the hospital be paying more in annual premiums, but they still may need to offer to also buy nose policies when recruiting new physicians who had claims made policies at their previous employer. When one hospital starts using claims made insurance policies for its doctors, other hospitals will follow suit since no hospital wants to be the only one offering occurrence insurance.

When it comes to malpractice insurance, the physician is ultimately the buyer and must be aware of all the nuances of that specific malpractice insurance policy. Occurrence policies are great and I would personally prefer occurrence insurance because of its simplicity – it covers you forever for the period of time that you were practicing and paying your malpractice insurance premiums. But claims made policies are much more complex and fraught with potential pitfalls that can result in the physician being unexpectedly uncovered and thus personally responsible for attorney costs and plaintiff awards in the event of a lawsuit. Specifically, physicians should:

  • Understand the retroactive date of any new claims made policy.
  • Know and understand the statute of limitations and the statute of repose of every state you practice in.
  • When changing employers, try to negotiate for the new employer to purchase a tail policy for the previous employment. Alternatively, see if the employer will include a nose policy provision to the new claims made policy (without a retractive date).
  • When changing employers, be sure that the gap period between employers is covered by a tail policy or a nose policy.
  • Negotiate with your employer for tail coverage with your initial employment contract, before you start working and thus still have negotiation power.
  • If the employer has agreed to purchase a tail policy for you if you leave for a new employer, be sure to understand any terms for coverage, such as if the employer terminates you versus you leaving on your own accord. Also, whether you need to be vested (work for the employer for a certain number of years) to be eligible for tail coverage.
  • If the employer has agreed to purchase a tail policy you when you retire, be sure to know how many years you must work before you are vested, that is, how many years you must work for the employer to be eligible for a retirement tail policy.
  • Most residency programs either provide occurrence insurance or provide claims made along with tail coverage. However, if a resident moonlights outside of their hospital, the resident needs to check the malpractice insurance policy provided by the moonlighting employer because tail coverage may be necessary for the moonlighting malpractice insurance.

In theory, a claims made policy coupled with a tail policy should be just as good as an occurrence policy. Moreover, over the course of a physician’s career, the cost between these two options should even out to be the same. However, the nuances of the physician employment contract including the retroactive date, whether the physician or the employer pays the tail, and the requirements that the physician must meet in order for the employer to pay for the tail are critical. Without careful attention to these details, physicians could unexpectedly face gaps in time when they are uninsured. This could result in a physician having to personally pay hundreds of thousands or even millions of dollars in the event of a malpractice lawsuit filed during a coverage gap period.

February 1, 2026