What I've Learned As A Hospital Medical Director

Continuing medical education (CME) is required for all physicians in order to maintain medical licensure. For example, here in Ohio, we must have 50 hours of CME credit every two years to keep our medical licenses. There are a lot of ways to get CME but the costs can vary substantially.

• Hospital grand rounds. Many hospitals provide free grand rounds lectures for physicians on their medical staff with one grand rounds equalling one CME credit hour. But it is difficult for most physicians to block out an hour each week to attend an in-person lecture – maybe they work night shifts, maybe the grand rounds conflicts with their operating room block, or maybe they have an outpatient clinic a distance from the hospital. For any number of reasons, most physicians are unable to attend the hospital’s 8-9 AM Thursday grand rounds. It still costs the hospital money to produce the grand rounds with administrative time to maintain CME accreditation and honoraria expenses for speakers. But the hospital generally provides CME for free as a perk to physicians. Nevertheless, every dollar that the hospital spends to put on a grand rounds is a dollar that they cannot pay the physicians in salary.
• Medical conferences. Every national medical society has an annual meeting. As a pulmonary/critical care physician, I often attended the annual CHEST (American College of Chest Physicians) and ATS (American Thoracic Society) meetings. These are usually held in convention centers at large cities once a year and last an average of about 4 days. You can get a lot of CME credit by attending lectures and symposia with the potential of getting 25 CME credit hours by attending one medical conference. But it comes with the cost of airfare, hotel stay, conference registration, food, and taxi/Uber fare. Using the 2026 CHEST conference in Phoenix as an example, airfare is about $550, hotel stay is about $1,000, conference registration is about $1,300, taxi/Uber is about $50, and food is about $300. The total cost for the conference is approximately $3,200.
• Professional societies. Many physician professional organizations will provide free online CME to members. But you have to pay an annual membership fee to access that CME. As an example, the American Medical Association has 64 online CME credit hours for members but the annual membership fee is $420/year.
• Professional society-sponsored. Other professional societies will sponsor online CME that can be purchased, with society members often getting a discount on the purchase price. As an example, the American College of Physicians offers up to 165 hours of online lecture recordings from its annual meeting for $1,500. East hour of recorded lecture provides one CME credit hour. This is a less-expensive alternative to attending the annual meeting in person.
• Medical journals. Many medical journals will provide free online CME to subscribers. As an example, the New England Journal of Medicine has 300 online CME credit hours available to subscribers. An annual subscription is $190.
• UpToDate. Since its inception in 1992, UpToDate has emerged as the main online reference for many physicians. It offers CME credit for reading “chapters” about thousands of medical conditions and medications. The subscription cost is $500 per year.
• Webcasts. Many academic medical centers provide online webcasts or podcasts for a fee. As an example, the OSU MedNet-21 webcast provides 40 hours of CME webcasts and podcasts each year at a cost of $25 per credit hour. As a disclaimer, I was the host/moderator of OSU MedNet-21 for 23 years.

Taking these as examples, it is clear that there is a huge difference in the cost of the various ways to get CME credits. Taking Ohio’s medical licensure requirements as typical for state medical boards, a physician must get at least 25 CME credit hours per year to maintain licensure. To get those 25 CME credits, the graph below shows the cost per credit hour between the various options.

At $128 per credit hour, attending a national medical conference is the most expensive way to get CME and if the sole reason for attending is for CME purposes, it is a poor investment. However, there are many other reasons to attend national medical meetings – networking with peers, access to the latest research study results, ability to present one’s own research, and time away from clinical practice to focus purely on learning. Moreover, these meetings are usually in desirable travel destinations, allowing physicians to make mini vacations out of attending a conference. Many employers will reimburse the cost of attending one conference every year as an employment perk so the conference may not cost the physician anything directly out of pocket. However, if the employer is paying for the cost to attend a conference, that is money that is not being paid directly to the physician in salary.

Getting online CME from a professional society that the physician is a dues-paying member of is relatively inexpensive. Being a member of the American Medical Association gets you access to CME at $17 per credit hour for 25 CME credits. Most physicians belong to at least one professional society so this can be a very cost-effective way to keep up CME credits.

However, online CME courses that are sponsored by professional societies but not offered for free can be quite expensive. To get 25 credit hours of online CME through the American College of Physicians every year would cost $60 per credit hour.

Subscribing to medical journals is one of the least expensive ways to get CME. At $8 per credit hour, a subscription to the New England Journal of Medicine is a bargain.

An annual subscription to the online reference UpToDate will get you CME at $20 per credit hour. This is a particularly efficient way to get CME since most physicians who use UpToDate use it primarily to look up the current recommended approach to diagnosing and treating various conditions that their patients have. So, many physicians subscribe to UpToDate for its use as a reference and then get the CME credit as a bonus for reading that material.

Webcasts, such as OSU MedNet-21, cost about $25 per CME credit hour in order to get the 25 credit hours per year required for medical licensure. This can be a great option for physicians who like to get their continuing medical education in a lecture format, like a grand rounds, but with the advantage of watching on-demand at a time that is most convenient for the physician.

The bottom line…

The least expensive way for most physicians to meet their state’s CME requirements is to find a hospital that provides free CME to grand round attendees. But because attending a grand rounds each week at a set time on a set day is not possible for most physicians due to conflicts with patient care, the most practical way to get inexpensive CME is by subscribing to a medical journal that offers free CME to subscribers or by becoming a member of a professional society that provides free CME to members. UpToDate is slightly more expensive but allows physicians to get CME for topics that they were going to look up and read about anyway. Webcasts are a cost-effective way to get grand rounds-type CME on-demand. Professional society sponsored online CME courses and attendance at a professional society annual meeting are the most expensive ways to get CME, although there can be other reasons why a physician might want to attend a conference other than purely for CME purposes.

January 20, 2026

Currently, 70% of graduating medical students owe money on educational loans. The average amount of these loans is $228,000 ($215,000 from medical school and $13,000 from undergraduate college). A new Federal law limits the amount of Federal loans to $50,000 per year of professional school and $200,000 total for all of undergraduate and professional school combined. The result is that most medical students are no longer able to afford medical school on just Federal student loans in combination with their personal savings. Their only options are to either take out private commercial loans or obtain scholarships.

Medical school is expensive. The average cost of tuition, fees, and insurance for an in-state resident at a public medical school is $48,000 per year. Private medical colleges are more expensive and cost an average of $68,000 per year. However, there is considerable variation between medical schools and between different years of medical school. For example, at the Ohio State University, the cost of tuition and fees for years 1 & 2 is $32,000 per year and for years 3 & 4 is $48,000 per year for Ohio residents. For non-residents, the cost at OSU for years 1 & 2 is $57,000 per year and for years 3 & 4 is $58,000 per year. Add to that the cost of books, supplies, transportation, living and personal expenses at an average of an additional $30,000 per year. This means that the average total cost to attend a 4-year public medical school as an in-state resident is $312,000. For a private medical college or an out-of-state resident at a public medical college, the average total cost is $392,000!

The result is that no medical student can pay for medical education with Federal student loans alone. Options for students are to ask their parents for financial support, to work for a few years between college and medical school, to get scholarships, or to take out private commercial loans. Nationwide, 65% of medical students have non-loan financial support, usually scholarships or grants. Increasingly, medical students take a “gap year” between college and medical school. As discussed in a previous post, 73% of medical students reported taking at least 1 year between college graduation and medical school; 48% reported taking between 1 and 2 years; 16.5% reported taking 3 to 4 years, and 8.7% took 5 or more years off. Although there are numerous reasons why medical students take gap years, 40% reported that the main reason was to earn money to pay for medical school.

Commercial student loans are often the only other option for medical students. After all, banks consider medical students good loan risks given that when they become attending physicians, they will not have difficulty getting a job and they will have a relatively high salary. However, commercial student loans come with a very high cost with annual interest rates as high as 18% (Federal graduate student loans are currently at an annual interest rate of 7.94%). These commercial loans often come with variable interest rates that start off very low but then rapidly balloon upward into double digits. The bottom line is that commercial loans in the long run come with a higher interest rate than Federal student loans. Furthermore, unlike Federal student loans, commercial loans generally do not have income-based repayment plans that can lower payments during the years of residency and fellowship. Also unlike Federal student loans, commercial loans are not eligible for PSLF (public service loan forgiveness). Because of these factors, commercial loans are the last resort for most medical students trying to finance their medical education.

How scholarships can help

With the new Federal loan limit of $200,000 per medical student, financial need-based scholarships are more important than ever before in order to cover the gap between the cost of medical education and the Federal student loan limit. To have the greatest impact, these scholarships should be need-based rather than merit-based. Let’s face it, you’ve already got to be really, really smart to get into medical school. As a result, merit-based scholarships award money to only the smartest of a bunch of very smart students. On the other hand, need-based scholarships ensure that those students who are smart enough to get into medical school have the financial ability to attend. Otherwise, these students may find the cost of medical school to be an insurmountable barrier and choose to go into a different career.

Most scholarships come from endowments into scholarship funds. These funds are designed to generate money to award scholarships indefinitely. They are therefore invested into institution investment portfolios in order to generate predictable annual returns. Thus, most scholarship funds will award 4% – 5% of the fund value each year in order to continue awards in perpetuity. Given that the new Federal student loan limit for medical students is $200,000 and that the average student loan debt for graduating students is $228,000, there is currently an average $28,000 gap ($7,000 per year for 4 years) that each student needs come up with to attend medical school. A scholarship fund that awards $7,000 per year would need to maintain a balance of between $140,000 and $175,000.

But… the problem with the gap year

Many students take gap years to earn enough to cover the difference in the cost of medical school compared to what they can borrow in Federal loans. When a student takes a gap year between college and medical school, that student enters the physician workforce a year later than if the student had gone straight into medical school after college graduation. Most medical students now take at least one gap year and 1 out of every 12 students take five or more gap years. Medical school admission committees like students who take gap years because of the perception that these students are more mature and are more certain of their career choice.

But gap years are terrible for society. Doctors who took gap years do not retire at an older age than those who did not take a gap year. Therefore, taking a gap year results in a shorter career as a practicing physician. Shorter careers result in a smaller physician workforce and a greater shortage of physicians. For taxpayers who subsidize public medical schools, it means that those taxpayers are getting a smaller return on their investment into every medical student who takes a gap year. Gap years are also terrible for physician financial health. If taking a 3-year gap between college and medical school results in a physician working 3 fewer years over the course of their career, then that means the physician has 3 fewer years to save for retirement while paying off student loans. Taking a 3-year gap results in a 10% shorter career as a practicing physician. A medical education can be a great financial investment but only if you then work enough years in clinical practice to derive the benefit of a physician income.

I would argue that the target for an annual scholarship award should be higher than $7,000 so that students do not need to take gap years in order to pay for the cost of medical education that is not covered by Federal loans. From a societal standpoint and from a physician financial health standpoint, we should be doing everything possible to eliminate gap years, rather than encouraging them. Having an average annual scholarship award of $10,000 – $12,000 would pay for the average cost of medical education not covered by Federal student loans and also eliminate the need for most students to take gap years.

So, how large should scholarship funds be?

The reality is that average financial needs are just that… average. Some graduating medical students have education debt that far exceeds the $200,000 Federal student loan limit. Maybe a student had to borrow the entire amount for both undergraduate college and medical school. Maybe a student could only get into an out-of-state public medical college with high non-resident tuition. Or maybe the student could only get into a costly private medical college. Maybe the student really wants to go into family medicine, a relatively low-paying specialty, but feels pressure to go into a surgical specialty that pays several times more than family medicine in order to be able to pay off student loans. For any of these reasons, some students may need larger annual scholarship awards than others. A $10,000 annual scholarship award might completely fill the needs of one student but another might need a $100,000 annual scholarship award to have the same impact.

But for simplicity, let’s say that a scholarship fund’s annual award target is $10,000. To generate that annual award, the fund balance would need to be between $200,000 – $250,000. Most of us do not have a quarter of a million dollars to donate as a charitable contribution to create a scholarship. But there are other options.

• Contribute to existing scholarship funds. Every medical school will have multiple scholarship funds that anyone can contribute to. Many medical schools have class funds where physicians who graduated in a given year can donate to their class scholarship fund. When selecting a scholarship fund to donate to, look at the requirements for different scholarships – some will be merit-based, some will be financial need-based, and others might be for students coming from a particular hometown or high school.
• Utilize a donor-directed fund. In a donor-directed fund, you donate to the fund and take a charitable deduction from your Federal income tax return that year. The fund then grows tax-free until you direct the fund administrator to disperse some or all of the funds. The disbursements can be made as scholarship awards and you can dictate the application requirements, such as financial need or desire to practice in a underserved area.
• Put it in your will. Every college of medicine has development officers who can advise you on putting a contribution to a scholarship fund in your will. If you have a trust, you may need to have your own attorney modify the trust documents to include a scholarship contribution. The advantage of this approach is that if you live a long time and need all of your money, you can spend it. But if you die earlier than you expected, the money left in your estate can be put to good use as a contribution to a scholarship fund.
• Charitable gift annuity. With a charitable gift annuity, you make a cash or stock contribution to a charity, such as a college of medicine scholarship. The charity then pays you a guaranteed fixed percentage of that contribution every year for the rest of your life. At death, the remaining amount in the annuity goes to the charity., A typical annual percentage would be about 5% – 6% for a donor in their late 60’s increasing to about 9% for a donor over age 85. This allows the donor to have a predictable income stream if the donor lives longer than they expect while still ensuring that there is a substantial contribution to the charity.

Now is a particularly good time to donate to a scholarship fund

Last year, Congress passed a law that makes it more favorable for Americans to donate to charities. By increasing the SALT (State And Local Tax) deduction limits, it has now become more advantageous for many taxpayers to itemize deductions. And when you itemize deductions, you can deduct charitable contributions such as donating to a scholarship fund. Before 2025, the most you could deduct on your Federal income tax returns for the amount you paid in property tax, state income tax, and local income tax was $10,000 if you are married filing jointly. With a standard deduction of $29,200 (married filing jointly), taxpayers would have to have $19,200 in charitable deductions combined with the $10,000 SALT deductions to even reach the amount of the standard deduction. So, most taxpayers just took the standard deduction and did not get any additional tax benefit from their $5,000, $10,000, or $15,000 donations to charity.

For 2025, the SALT limit increased to $40,000 and the standard eduction is $31,500 (married filing jointly). The result is that for many Americans, particularly those with higher incomes, it is now more advantageous to itemize deductions instead of taking the standard deduction. This means that your $5,000, $10,000, or $15,000 charitable contribution to a scholarship fund is now tax deductible whereas in 2024 it likely was not. If you are in the 32% tax bracket, then donating $1,000 to a scholarship fund in 2025 is like donating $1,320 in 2024 – you’re now giving more of your donation to charity and less to the IRS.

Its about giving back

The vast majority of physicians went into medicine in order to make positive contributions to society by improving health. We can continue that by ensuring that qualified students are able to go into medicine without having to borrow at excessively high interest rates or take gap years. I regularly donate to my medical school alma mater’s class scholarship fund. I don’t get any special recognition, no one is going to name a building after me, and the students who get scholarship awards from our class fund will never know my name. I do it simply because it is important and for decades to come will help students who otherwise could not afford medical school.

January 14, 2026

A few years ago, I was talking to one of the young gastroenterologists at our hospital who told me about how he had listened to a financial pundit who emphasized the importance of being debt-free and therefore dedicated his finances to paying off his student loans early. He had two young children at home and his wife did not work. He was proud of his recent debt-free accomplishment – I didn’t have the heart to tell him that he had just made a big financial mistake.

Student loan debt is an enormous problem for physicians. Currently, 70% of graduating medical students have student loan debt, averaging $228,000 per physician. After medical school, physicians must complete 3 – 7 years of residency and fellowship, depending on the specific specialty. Resident income is relatively low, with first year residents averaging about $67,000 per year. Most physicians do not complete their training and enter the attending physician workforce until they are in their early 30’s. The temptation to pay off student loans early once earning an attending physician income can be very strong. But I will argue that physicians should not make extra payments on those loans in an effort to be debt-free.Instead, physicians should be debt-smart.

Why not pay off student loans early?

Let’s take my gastroenterologist colleague as an example and go through the reasons why paying off his student loans early was a mistake.

• He is an employee of a not-for-profit hospital. I asked him about PSLF, the public service loan forgiveness program, and he said he had heard about it but didn’t know if he was eligible. PSLF was signed into law by President Bush in 2007. To be eligible, people with Federal Direct student loans have to work full-time for 10 years for a government or non-profit organization, make 120 on-time monthly payments on the loans, be on an income-driven payment plan, and submit a PSLF certification form every year. At the end of the 10-year period, the Federal government will forgive the remaining balance of the loan. Because he wasn’t aware that he qualified for PSLF, the gastroenterologist had not submitted annual PSLF certification forms to the government. The result was that his 6 years of residency and fellowship at a non-profit hospital could not be counted toward PSLF. Had he submitted those certification forms during residency and fellowship training, the government would have forgiven the remaining balance on his loans after 4 years of being an attending gastroenterologist at our university medical center (qualifying as both a state government university and a non-profit hospital). No one should never pay off student loans early if they qualify for PSLF since it reduces the amount of the loan that the Federal government will ultimately forgive.
• His wife does not work outside of the home. Federal Direct student loans are repaid on an income-based repayment plan, meaning that the higher your annual income, the higher your monthly payments. If you are married filing jointly for Federal income taxes, then the income-driven repayment plan is based on you and your spouse’s combined incomes. If your spouse does not have an income, then your monthly student loan payments will be lower, leaving more loan principal that can be forgiven under PSLF. Since my gastroenterologist colleague’s wife did not have an income, he could have had a sizable amount of his student loans forgiven under PSLF.
• He has two children. College education is expensive and tends to increase in cost at a rate higher than inflation. Vanguard estimates that in 18 years, a 4-year education at a state-supported public university like the Ohio State University will cost $290,000 and a private university like the University of Notre Dame will cost $860,000. The only way most parents can come up with that kind of money is to start saving early and make regular contributions to their child’s college education fund. This allows the magic of compound interest to work for them and amplify the amount of money in that education fund. In order to have $290,000 to pay for four years of a college education at a public university in 18 years, a parent would need to make an initial investment contribution of $16,000 for a child born today and then contribute $465 every month for the next 18 years with an average annual return of 8%. That works out to a total of $60,640 in contributions but compound interest will turn that into $290,000 in 18 years. The longer you delay contributing to a child’s college education fund, the less benefit you get from compound interest and consequently, the more money you have to contribute to cover the cost of college. Because the gastroenterologist prioritized paying off his student loans early, he had not yet started to contribute to his kids’ college education funds.
• He might have been able to deduct the interest on the student loan… maybe. You can deduct up to $2,500 of annual student loan interest on your Federal income tax returns if you meet income thresholds. For a married couple filing jointly, the modified gross annual income limit is $170,000 for the full deduction and $200,000 for a partial deduction. Most gastroenterologists earn more than $200,000 a year but many primary care physicians earn considerably less than $200,000 and can qualify for the student loan interest deduction.
• He is not adequately funding his retirement. A recent post on the website The White Coat Investor noted that 25% of physicians retire with less than $1 million in net worth. A million dollars may sound like a lot but net worth includes all of your investments plus everything you own, like your house and your cars. Even if you retire today with $1 million in investments, using a 4% per year withdrawal strategy, that only yields an annual retirement income of $40,000 per year from your investments. Add in an average Social Security benefit of $24,000 per year and you end up with a total annual retirement income of $64,000. Far too many physicians have to either accept a less expensive lifestyle in retirement or work beyond their desired retirement age because they have not saved enough during their working years. Once again, compound interest works its magic best the sooner you start to invest in your retirement account. Assuming an average annual return of 8%, investing $10,000 per year will result in $1.8 million in 35 years. Investing $20,000 per year will result in $3.7 million in 35 years. Investing $30,000 per year will result in $5.6 million in 35 years. By putting money into paying off his student loans early, the gastroenterologist did not have enough money to maximize his contributions to his 403(b) retirement plan.
• But wait, isn’t it better to pay off the loans early so you can avoid paying all of that loan interest? Not necessarily. If y0u have an extra $10,000 at the end of the year, you are almost always better off in the long run putting that money into a 401(k) or 402(b) rather than making extra payments on a student loan. Even assuming a loan interest rate of 8% and an annual investment return also of 8%, you are better off putting the money in a 401(k) or 403(b). The reason is that those 401(k) or 403(b) contributions reduce your taxable income and thus reduce your marginal income tax rate, thus reducing the amount you have to pay the Federal government in income tax. In addition, the 401(k) or 403(b) contributions reduce your modified adjusted gross income, thus reducing your monthly student loan payments on an income-based repayment plan. Factoring in the loan interest, the investment return, today’s income tax effects, and the income tax eventually paid in retirement when taking 401(k) or 403(b) withdrawals, I calculate that the total financial benefit to putting $10,000 into a 401(k) or 403(b) instead of making early payments on a student loan to be $23,000 after 20 years in favor of the 401(k)/403(b) contributions. If you participate in PSLF, then that amount could be even greater by resulting in a larger loan balance to be forgiven at the end of 10 years.

What does being “debt-smart” mean?

In an ideal world, we’d all be debt-free. But education (especially medical education) costs a lot of money and that education can be a tremendous investment that can pay huge dividends in earning power. Education loans can be healthy debt if the education gets you a job with a high annual income. Education debt can also be unhealthy debt if it does not result in a job after college that more than pays for the cost of eduction loans. Doctors have a high enough income that student loan debt is almost always healthy debt. Be sure to make your full monthly repayments every month but do not pay them off too early, particularly if early repayment causes you to neglect other aspects of financial health such as:

• Have an emergency fund with enough money to cover 3 – 6 months of living expenses.
• Contribute to your 401(k), 403(b), 457, or SEP plan.
• Contribute to your children’s college education plan.

On the other hand, avoid unhealthy debt, particularly early in your career. Ways to avoid unhealthy debt include:

• Always pay your credit cards off every month to avoid high interest charges.
• Don’t buy a more expensive car than you can really afford and then face high car loan interest rates.
• Don’t buy a bigger house than you can afford.
• Make an annual budget at the beginning of each year and then stick to it.
• Be adequately insured including home, automobile, term life, health, and disability insurance (and probably an umbrella insurance policy for good measure).

Physicians spend years training for one of the hardest jobs in the world. But that training doesn’t include learning about financial health. All too often, we rely on someone’s talk show, podcast, or website to tell us how to manage our finances, including student loans. Understanding how those loans uniquely fit into one’s personal financial health is a responsibility for each of us.

January 6, 2026

Until 5 years ago, telemedicine was only reimbursed for patients in rural locations where long-distance travel for patients to get to a doctor’s office was difficult. Medicare required these patients to go to a rural health facility and the telemedicine encounter with a remote physician would then be conduced with the patient physically at the rural health facility. At the beginning of the COVID pandemic, Congress expanded telemedicine in order to allow patients to continue to receive outpatient services without having to physically go to a doctor’s office. This protected patients from exposure to contagious diseases in the waiting room, protected medical staff from exposure to contagious patients, and helped conserve personal protective equipment (PPE). The expansion of telemedicine was supposed to be a temporary measure with the intention that it would go away as the pandemic receded. But it turns out that both patients and doctors like telemedicine and now the onus is on Congress to make telemedicine permanent.

The temporary telemedicine expansion was set to expire on October 1, 2025. It had been anticipated that Congress would pass legislation to extend telemedicine beyond that date but with the government shutdown, Congress did not meet to pass any new legislation. Thus, as October 1st came and went, physicians largely stopped providing telemedicine because Medicare no longer paid for it. When the government shutdown ended, Congress passed a stopgap legislation to temporarily continue telemedicine coverage by Medicare until January 30, 2026. Without new legislation, telemedicine coverage will revert to the pre-pandemic restrictions of rural-only coverage.

Telemedicine is popular with patients

At the beginning of the COVID pandemic, telemedicine was hugely popular with both patients and physicians. Office staff revised their workflows with many staff able to work from home. Physicians added cameras to their computer workstations to permit video conferencing with patients. Clinic parking lots became empty. The percent of Medicare patients using telemedicine shot up with 47% of them having a telemedicine visit in the second quarter of 2020 alone. As the pandemic waned, use of telemedicine fell but even this year, about 12% of Medicare patients have a telemedicine visit in any given quarter as shown from a graph below from a November 2025 CMS report.

The use of telemedicine varies based on population demographics

Race and ethnicity. CMS reports that Hispanic and Asian Americans on Medicare are most likely to currently use telemedicine whereas White and Native Americans are least likely to use telemedicine. A household pulse survey by the U.S. Census Bureau about telemedicine utilization between July 2021 to August 2022 found similar differences in race/ethnicity utilization of telemedicine in all Americans and not just those on Medicare. However, the Census Bureau’s survey also found that White Americans were significantly more likely to use video telemedicine than Hispanic, Black, or Asian Americans; the latter were more likely to use audio-only telemedicine.

Medicare versus Medicaid. According to the CMS report, patients who are dually eligible for both Medicare and Medicaid are more likely to use telemedicine than those with Medicare alone. Dual eligible patients are more likely to be poor or disabled.

Age. The CMS report found that patients’ age also influenced telemedicine utilization with Medicare patients under age 65 twice as likely to use telemedicine as those over age 65. However, most Americans under age 65 are covered by commercial health insurance rather than Medicare unless they qualify for Medicare because of disability or end-stage renal disease. Commercially-insured patients were not included in the CMS report. So the data from the graph below may reflect use of telemedicine by disabled Americans on Medicare who have mobility and transportation barriers to coming to physician offices, and not reflect age effects per se. The Census Bureau survey that included Americans with commercial insurance found that older patients were more likely to use telemedicine than younger patients, although older persons are more likely to have any kind of physician visit than younger persons so the Census Bureau data may simply reflect the higher utilization of outpatient medical care in older persons.

Gender. Throughout the pandemic and extending to the present, women on Medicare are slightly more likely to utilize telemedicine than men.

Rural versus urban. Before the pandemic, only rural Medicare patents were eligible for telemedicine visits. However, since the onset of the pandemic, telemedicine is more likely to be used by urban Medicare recipients than rural Medicare recipients. This suggests that the distance a patient must travel to get to a doctor’s office is less of a predictor of telemedicine utilization than other factors.

Reason for Medicare qualification. There are three main ways a person can qualify for Medicare benefits: age over 65, disability, or end-stage renal disease (ESRD). Those qualifying for Medicare because of disability are most likely to use telemedicine, followed by those with ESRD. This likely reflects mobility and transportation barriers faced by disabled persons and those with ESRD.

Other factors. The Census Bureau report included other demographic variables not reported in the CMS report. Specifically, the Census Bureau report found that income correlated with telemedicine utilization with lower income persons more likely to use telemedicine than higher income persons. The Census Bureau report also found that telemedicine utilization varied by a person’s type of insurance with 26.8% of persons on Medicaid, 25.5% of those on Medicare, 19.2% of those with commercial insurance, and 9.0% of uninsured having a telemedicine visit within the previous 4 weeks. It is unclear whether income and insurance type independently affect utilization or whether patients with lower income and those on Medicaid are more likely to have disability or mobility barriers to traveling to physician offices for in-person visits.

Telemedicine is most popular with certain specialties.

Physicians practicing specialties where a large part of the encounter is devoted to counseling use telemedicine more than those in specialties that require an in-person physical examination. A report by the American Medical association found that psychiatrists were the most likely to utilize telemedicine with 68% of psychiatrists using telemedicine for more than 20% of patient encounters. At the other extreme, only 4% of dermatologists and 2% of ophthalmologists utilize telemedicine for >20% of patient encounters, reflecting the necessity of direct physical examination of the skin and eyes to complete these encounters. Notably, 32% of neurologists use telemedicine for >20% of encounters – many neurology patients have mobility barriers that make coming to the neurologist’s office for an in-person visit difficult.

On the surface, it may seem surprising that telemedicine is utilized as much as it is in gastroenterology (20% using telemedicine for more than 20% of encounters), urology (19% using telemedicine for more than 20% of encounters), and general surgery (12% using telemedicine for more than 20% of encounters). However, these procedure-based specialties often schedule post-procedure follow-up encounters to discuss pathology results with patients and these encounters primarily consist of counseling which lends itself very well to telemedicine. In addition, many post-surgical follow-up visits are bundled into the procedure code for the initial surgery and are thus not reimbursed separately. These post-op visits are often used primarily for symptom reporting which can be done by audio telemedicine or simple examination of an incision which can be done by video telemedicine.

Telemedicine encounter complexity

Early in the pandemic, both primary care physicians and specialty physicians mostly billed low-complexity encounters for telemedicine. A study from a New York City health system found that primary care physicians billed low complexity E/M codes for most of their new and return telemedicine encounters. On the other hand, as the pandemic progressed, specialty physicians billed moderate complexity E/M codes for most of their new and return telemedicine encounters. Primary care physicians rarely billed high complexity telemedicine E/M codes but specialists billed a significant number of telemedicine encounters as high complexity (albeit fewer than moderate or low complexity).

So, what should physicians do now?

Unless Congress passes new legislation in the next month, telemedicine will no longer be covered by traditional Medicare for most Americans who are not living in rural parts of the country with access to a local rural health facility that participates in telemedicine with physicians located elsewhere. Behavioral health telemedicine will continue to be covered as this was made permanent by Congressional legislation in 2021 (of note, behavioral health patients must have an initial new patient in-person visit and an annual return in-person visit). Given the popularity of telemedicine, particularly among those with disability, mobility, and transportation limitations, it is hopeful that Congress will pass new legislation to extend traditional Medicare coverage for telemedicine or make telemedicine coverage permanent. Even if Congress fails to pass an extension, many Medicare Advantage Plans (Medicare Part C) may continue to cover telemedicine since these plans are administered by commercial insurance companies that have the freedom to cover or not cover telemedicine at their own discretion. Similarly, state-specific Medicaid plans and regular commercial health insurance plans may elect to continue telemedicine coverage for their enrollees.

This could result in a patchwork of telemedicine coverage with some patients within a medical practice being eligible for telemedicine coverage and others not eligible. Physician practices will then need to decide if they will offer telemedicine to those patients who do have insurance telemedicine benefits. This would require schedulers to determine whether or not each individual patient is eligible for telemedicine based on their specific health insurance coverage. Some practices may find that it is simpler to just not offer telemedicine to any patients rather than risk denials of bills for telemedicine encounters if a particular patient’s insurance plan no longer covers telemedicine after January 30, 2026.

Even if Congress lets Medicare telemedicine coverage expire in January 2026, patients in certain rural areas will still be eligible for telemedicine coverage based on the pre-pandemic telemedicine rules. However, these rural patients would now be required to go to a local rural health facility for their telemedicine encounter instead of having the telemedicine encounter in their own home. In addition, telemedicine could still be used for post-procedure and post-surgical follow-up encounters when those encounters are bundled into the procedure CPT code and not billed separately.

For now, physicians should not schedule telemedicine encounters for patients with traditional Medicare beyond January 30, 2026. Patients with Medicare Advantage Plans, with state-specific Medicaid plans, and with commercial health insurance policies should be scheduled on an individual basis, depending on whether or not their specific insurance carrier has agreed to continue telemedicine coverage after the telemedicine provisions for traditional Medicare expire. Uninsured patients can continue to be scheduled for telemedicine encounters since these patients pay out of pocket (or do not pay at all) and are thus not subject to Medicare telemedicine coverage rules. Post-procedure telemedicine encounters can continue to be scheduled for all patients if those encounters are bundled into the procedure CPT code, unless the specific code dictates that an in-person post-procedure visit is mandated. Neurologists and endocrinologists will be particularly impacted since these specialties have the greatest penetrance of telemedicine in their practices.

All physicians who use telemedicine should advocate for Congress to make Medicare telemedicine coverage permanent since telemedicine has become particularly beneficial for patients who are disabled and who otherwise have mobility and transportation barriers to in-person office visits.

December 27, 2025

In October, the U.S. Department of Education released its final rule on the Public Service Loan Forgiveness program (PSLF). The 36-page document is available online in the Federal Register. The central tenet of the rule is that it gives the Secretary of the Department of Education the ability to disqualify organizations as being eligible for PSLF if the Secretary determines that the organization has a “substantive illegal purpose”. Employees of those organizations would then no longer be able to count their years of employment toward public service loan forgiveness. This now allows the Executive Branch of the federal government to use PSLF as a weapon against hospitals and universities.

What is PSLF?

The Public Service Loan Forgiveness program was established by the U.S. federal government in 2007 under President George W. Bush as a way to help college graduates who enter a career or public service pay for college education by forgiving a portion of their student loans. The specific criteria are:

• Be employed by a federal government, state government, local government, tribal government, or qualifying not-for-profit organization.
• Work full-time
• Have federal direct student loans
• Make 120 qualifying monthly payments on the loans.

Once those criteria are met, any remaining principal and interest on the loan is forgiven. Thus far, 694,900 government workers and 305,500 workers at non-for-profit organizations have met all of the PSLF criteria and had the remainder of their student loans forgiven. The amount of loan forgiven for the average government worker was $73,100 and for the average worker at not-for-profit organizations was $82,200. Combined, 1,000,400 people have had loan balances forgiven at an average of $75,900 per person. 163,900 employees of healthcare organizations (mostly doctors and nurses) have had loans forgiven under PSLF.

Not all non-profits companies or organizations qualify as employers for PSLF purposes. Those that that are tax-exempt under Section 501(c)(3) of the Internal Revenue Code do qualify. Other non-profit organizations that devote a majority of their full-time equivalent employees to providing certain types of services also qualify. These services are: civilian service to the military, emergency management, National Guard, public safety, law enforcement, public interest law, early childhood education, public service for individuals with disabilities, public health (including physicians and nurses in a clinical setting), public education, public library, school library, school-based services, and public service for the elderly.

For physicians and nurses, this means that most public universities and most non-profit hospitals qualify as PSLF employers. Physicians can currently count their employment during residency and fellowship for PSLF purposes – there has been federal legislation proposed to no longer count residency toward the 120 loan repayment months but thus far, this legislation has not been voted on. Because most physicians do their residencies at non-profit hospitals, they can count 3-6 years of residency and fellowship toward the 10 years of required loan payments. 70% of medical students have education debt with an average of $220,000. The “One Big Beautiful Bill” now limits federal direct student loans for medical students to $200,000. Because federal direct student loan monthly payments are based on one’s income and because residents have a low income ($67,000 for a first year resident), it is very advantageous for physicians to begin paying off their direct student loans during residency since this results in a greater amount of principal that is forgiven at the end of 10 years.

What organizations will the Department of Education disqualify for PSLF?

The Department of Education’s new rule will permit the Secretary of the Department of Education to disqualify an organization if it engages in activities with a “substantive illegal purpose”. This is defined in the rule:

The activities indicative of a substantial illegal purpose include aiding and abetting violations of Federal immigration laws, supporting terrorism or engaging in violence for the purpose of obstructing or influencing Federal Government policy, engaging in the chemical and surgical castration or mutilation of children in violation of Federal or state law, engaging in the trafficking of children to another State for purposes of emancipation from their lawful parents in violation of Federal or State law, engaging in a pattern of aiding and abetting illegal discrimination, and engaging in a pattern of violating State laws.

The rule is proactive and goes into effect in July 2026. Organizations that are disqualified by the Secretary of the Department of Education have to wait 10 years to reapply as a PSLF qualifying organization unless the Secretary approves a corrective action plan for that organization.

The rule gives the Secretary of the Department of Education broad authority to determine what constitutes activities indicative of a substantial illegal purpose. Some of the criteria include:

“Chemical castration of children”. The rule defines chemical castration of children as:

• The use of puberty blockers, including GnRH agonists and other interventions, to delay the onset or progression of normally timed puberty in an individual who does not identify as his or her sex.
• The use of sex hormones, such as androgen blockers, estrogen, progesterone, or testosterone, to align an individual’s physical appearance with an identity that differs from his or her sex.
• Child means an individual under 19 years of age.

This essentially means any hospital or other organization that provides gender-affirming care to patients under age 19. It also means that physicians employed by hospitals cannot themselves provide gender-affirming care to anyone younger than age 19. By defining a child as younger than age 19 (rather than younger than age 18), the rule means that physicians at university student health clinics are not able to prescribe or refill sex hormone medications as part of gender-affirming care, even if those medications were initiated by the student’s personal (non-university) physician.

Aiding and abetting illegal discrimination. The Trump administration has taken the position that all DEI (diversity, equity, and inclusion) activities are discriminatory and thus illegal. Many hospitals and universities have had a variety of DEI initiatives and any of these could be considered as illegal by the Secretary of Education. Because the Secretary is given sole authority for determine what constitutes substantive illegal activities, the Secretary could choose to categorize transgender athletes, race or ethnic-specific college clubs, or implicit bias training programs, or race/religion/ethnicity-based scholarships as discriminatory.

Aiding and abetting violations of Federal immigration laws. Once again, the Secretary of the Department of Education has the authority to determine if an organization has violated immigration laws. Will this include schools that enroll students who are undocumented? Will it include hospitals that provide non-emergency medical care to undocumented immigrants? Will this include universities where students protest ICE activities? Will it include homeless shelters and food pantries that do not require proof of citizenship to get in the door?

Engaging in a pattern of violating state laws. This is very broad and gives the Secretary authority to disqualify organizations for any violation of a state-specific law. The rule does state that: “Organizations will not be penalized if their actions are legal in the State in which they are operating.” However, many organizations operate in more than one state. So, if a hospital organization has a hospital in Texas where abortion is illegal and has a second hospital in New Mexico where abortion is legal, will the organization be disqualified if it performs abortions in New Mexico since it also operates a hospital in Texas? The Secretary’s interpretation of this will be final.

Engaging in violence for the purpose of obstructing or influencing Federal Government policy. The current administration has already demonstrated that it has little tolerance for behaviors opposing its policies. When Sean Charles Dunn threw a Subway sandwich at an ICE agent in August 2025, he was arrested and charged with felony assault of a Federal officer. A jury subsequently found him not guilty. But next summer, if a university student throws a sandwich at an ICE agent, there will be no jury trial – if the Secretary decides that it constitutes assault, then the university could be determined to have activities of a substantive illegal purpose. The Secretary will be the sole arbitrator of whether a student protest is violent or not.

This is going to be huge…

The Department of Education states that the average amount of loan forgiveness is $75,900 per person. The new rule estimates that it will eliminate $1.616 billion in loans. This works out to 21,291 people who currently qualify for PSLF to be disqualified because they work for an organization that the Secretary of the Department of Education will disqualify. The implication is that the Department has already determined that it will be disqualifying a large number of organizations in July 2026. In looking over the definition that the new rule is using for “activities with a substantive illegal purpose”, it appears that the rule will mainly be implemented against public universities and non-profit hospitals.

The Trump administration has used similar justification for freezing Federal grants and withdrawing accreditation to effect policy and idealogical change at universities. It follows that the administration will use this new rule for disqualifying organizations for PSLF in a similar fashion. It is an extraordinarily powerful weapon, indeed. Because 70% of graduating medical students and 69% of nursing students have student loans, any hospital that becomes disqualified for PSLF will have a very, very hard time recruiting residents, attending physicians, or nurses. At particular risk are residents and nurses employed by university hospitals since any activities that happen on campus that the Secretary of the Department of Education deems to be “activities with a substantive illegal purpose” will result in those residents and nurses no longer being able to count their employment toward their 120 months of PSLF employment. Residents locked into a 3-5 year residency contract could face significant financial harm. Universities such as Harvard, Columbia, and Cornell that have already been extensively targeted by the Trump administration could be at highest risk.

Way too much power in one person’s hands

When the new rule was open for public comments, many commenters questioned how the determinations would be made and what the process for appeals would be. The Department of Education responded: “The Secretary will weigh any evidence presented showing that an organization’s activities violated any laws and make a determination if those violations rise to the level of substantial illegal purpose.” In other words, whatever Secretary of the Department of Education Linda McMahon says is the final word. There is no option for an appeal. This places enormous power in the hands of a single individual who is a political appointee not elected by the general populace.

I personally agree that there are organizations that are dangerously terroristic should not qualify for PSLF, such as the Klu Klux Klan and Al-Qa’ida. But the vagueness of the new rule now allows Secretary McMahon to decide what rises to a level of substantial illegal purpose. Normally in the United States, an action is determined to be illegal by conviction in the court system. The sixth amendment of the U.S. Constitution guarantees the right of citizens to a trial by jury for non-petty crimes. But in the new Department of Education rule, there is no court, Linda McMahon alone becomes the prosecutor, judge, and jury. And there is no court of appeals.

A changed mission for the Department of Education

The U.S. Department of Education’s official mission statement is “To promote student achievement and preparation for global competitiveness by fostering educational excellence and ensuring equal access.” The Department’s new rule on PSLF indicates that will use existing personnel to enforce the new rule and estimates an annual cost of $1.5 – $3 million per year. The rule represents a substantial departure from the Department’s stated mission and will now shift the Department’s mission to forcing ideologic and policy to eliminate “wokeness” and left-wing bias at our nation’s universities and hospitals. The Department of Education has now become a weapon to be used against any non-profit organization that the administration disagrees with.

Every physician, nurse, and resident who works at a university hospital or non-profit hospital should be afraid… very afraid.

December 24, 2026

If you ask 100 business, government, military, or academic leaders what are the most important factors in successful career development, 99 of them will include identifying a good mentor. For medicine in general and for academic medicine especially, mentors are essential in order to achieve one’s maximum potential. The reality is that most of us will have many mentors that each guide us through different facets of our careers. But there is usually one person who we can look back on and say that that individual had the biggest impact on helping us realize our career success.

The best mentors are not those who you model your own behavior from, but are those who actively guide you and advocate for you. The mentor’s actions should be with the mentee’s best interest in mind and not the best interest of the mentor. In other words, the mentor should act in a fiduciary manner.

When mentors do not act as fiduciaries

I’ve seen a lot of people who thought of themselves as mentors but were actually using those junior to them to advance their own careers rather than the junior colleagues’ careers. Here are some examples.

25 years ago, I was on a search committee for a new division director. We had narrowed the search to three finalists and invited each of them for a formal visit that included interviews with various hospital and college of medicine leaders. During my interview with him, he asked me if he was selected, whether he would be able to put his name on all manuscripts written by the members of the division. At the time, this included about 20 physicians and PhDs who collectively wrote dozens if not hundreds of papers a year. It was clear that he wanted to use the position of division director to advance his own career rather than to advance the careers of the members of the division. Needless to say, we didn’t offer him the job.

Our hospital had a quality director who always had a junior physician functioning as a quality intern. The junior physician spent months and countless hours reviewing patient charts in the analysis of a particular quality issue and then analyzing the data. The director had the junior physician prepare a PowerPoint presentation and then the director presented the findings to the medical staff leadership committee, to the Dean, and ultimately to the hospital’s Board of Trustees. In none of these presentations did the director mention the name of the physician who did all of the work and ultimately, the junior physician decided to leave academic medicine and go into a private clinical practice.

As a resident, there was an attending cardiologist whose main interest was his research laboratory. However, he was required to attend on the inpatient cardiology service 3 months a year in order to earn enough clinical income to cover his salary. He viewed the residents on the cardiology service as indentured servants whose main role was to do H&Ps, write progress notes, collect data, and put in orders. To him, residents were a tool for him to use to earn clinical income. He would show up for an hour a day to round on patients and then would go back to his research lab for the rest of the day. His belief was that residents were responsible for their own education and did little to no teaching.

When my own mentors acted at fiduciaries

As a third year medical student, I spent the month of December at a community hospital in Columbus on a general surgery rotation. At the time, students on surgery rotations were pretty low in the pecking order and were generally relegated to doing history and physical exams, collecting lab results, and performing general scut work. If a student was lucky, he or she might be granted the opportunity to stand in the corner of the operating room and watch the attending surgeon and residents perform an operation. But on the first day of December, my attending told me that he and the resident would do the H&Ps and that his nurse would collect labs and do scut. He said that I could learn the most about general surgery from being in the operating room. His goal for me was for me to scrub in on 100 surgeries during the month. He told all of the other surgeons at the hospital the plan and I held retractors during a Whipple procedure, made an incision to remove a lipoma, stood by the operating table during heart and brain surgeries, and helped suture abdominal surgery closures. I still rounded with the attending and resident every day but by the end of the month, I had been in on 100 procedures and learned more than any other month of my medical school clinical rotations.

During my first year of pulmonary/critical care fellowship, we had a weird case in our ICU of a college student who developed respiratory failure with diffuse pulmonary infiltrates and a large number of lung eosinophils found during bronchoscopy. We soon identified 3 other cases of a previously undescribed disease that we called “acute eosinophilic pneumonia”. One of my attending physicians suggested that I write it up and send it to the New England Journal of Medicine. It took me 35 drafts with the attending physician finding something to change in the first 34 but eventually we sent it in and it was accepted. The attending physician told me to put my name first on the article, rather than his name – and it launched my academic clinical career.

During the second and third years of my fellowship, I was assigned to do research with a different attending physician who specialized in the role of interleukins in lung disease. He had seen an article that suggested that some interleukins were bound to microtubules, the intracellular scaffolding that gives cells their shapes. He had me do a few experiments that supported the role of microtubules with interleukin production by a type of lung cells called alveolar macrophages. He then anointed me as the alveolar macrophage microtubule guy. That became the basis of grants I received from the National Institutes of Health and the American Lung Association – it launched my academic research career and for a few years, I was the world’s leading expert in the very obscure and esoteric field of the role of human alveolar macrophage microtubules during inflammation (mainly because no one else was doing research on it).

Fiduciary mentors put the mentee’s interests first

As a species, we physicians often have big egos that need to be constantly stroked. We have spent 15 to 20 years of training after high school competing to get into the best colleges, medical schools, residencies, and fellowships. Success in that competition usually means trying to make ourselves look better than everyone else – better test scores, better grades, more publications, more grant money, and more leadership appointments. So it is the rare physician who can step away from making themselves successful and famous to making a trainee or junior colleague successful and famous. Here are some of the specific actions that a fiduciary mentor can take for their mentees. Although these are derived from my experiences and observations as an academic physician, they can be generalized to most professions.

• Trainees are there to be trained. Whether the trainee is a resident, a PhD post-doc, or a business intern, the reason they are there is to learn. At that level, learning is by a combination of the learning triad: (1) observation of experts performing their skills, (2) practice performing those skills themselves, and (3) didactic training. A fiduciary mentor ensures that the mentee has the opportunity to do all three. The trainee is not there to simply do the senior colleague’s work for them.
• Nominate for or appoint to committees. A common warning given to junior professionals is to “protect your time” and this often translates to avoiding committee work. But whether the committee is at the hospital, university, corporate, or professional society level, committee membership can expose the junior professional to other organizational or national leaders and can be a vehicle for invaluable career networking.
• The person who does the work should be the first name on the manuscript. Too many tenured professors put their name first on any research papers that come out of their lab. This is self-promotion at the cost of their junior colleagues’ reputation building.
• Credit earned is credit due. When a medical resident is the one who figures out the perplexing rare diagnosis, the attending should publicly credit the resident with the diagnosis rather than taking credit themselves. Same with the committee chairman when a committee member performs some cost savings analysis of hospital operations. Or the research lab director when a PhD student makes some new scientific discovery.
• Share lectureships. When the fiduciary mentor is asked to give a grand rounds or other lecture, invite the mentee to be a co-presenter for the lecture. It sends the world the message that this mentee is an expert and what they have to say has value.
• Nominate the mentee for local and national presentations. Professional societies all have their own annual national or regional meetings. The fiduciary mentor nominates mentees to give presentations. For 25 years, I hosted the OSU MedNet continuing medical education webcast and I invited junior faculty physicians to be guest presenters in their chosen area of sub specialization in order to get their name out as emerging experts.
• Tailor the degree of autonomy to the level of experience of the mentee. In my outpatient clinic, I had medical students, internal medicine residents, and pulmonary fellows who rotated to work with me. Each of these three types of trainees came with different degrees of experience and required different degrees of supervision. The fiduciary mentor neither sets the mentee up for failure by giving them too much autonomy nor holds them back by not giving them enough autonomy.
• Prepare the mentee for where the field is going to be in the future, not just where it is today. Hockey legend Wayne Gretzky famously said: “I skate to where the puck is going to be, not where it has been.” This is a great lesson in any career, not just hockey. The fiduciary mentor identifies the future needs and demands in the field and prepares mentees to be the experts in those needs and demands. When our hospital was considering purchasing our first surgical robot for the operating room, our Chief of Surgery sent one of the junior general surgeons to spend a couple of weeks at a hospital that had already acquired a surgical robot. When he came back, he instantly became the go-to surgeon for robotic herniorrhaphies and cholecystectomies. Pretty soon, he was giving regional and national lectures in the then-new field of general surgery robotics.
• Foster expertise. In the research lab, the lab director should identify new side areas of research that the research fellows and doctoral students can explore and develop in order to create new areas of research that they can claim as their own in order to launch their own careers. If a junior physician has an interest in pulmonary vasculitis and there is no current expert in pulmonary vasculitis on the faculty, then figure out how to direct all of the pulmonary vasculitis consults to that junior physician’s clinic. And be sure that the physician is assigned to give pulmonary vasculitis lectures to fellows and residents.
• Listen. Too many people who think they are mentors ascribe to the old saying that “Children should be seen and not heard.” A mentor cannot be a fiduciary unless he/she listens to the mentee in order to determine what it is that they really want. 90% of internal medicine residents who apply to cardiology fellowships will say that they want to be teachers and researchers – that is what it takes in order to get into a cardiology fellowship. But most cardiology fellows eventually change their mind and actually go into private practice. And when they do change their mind, their future careers would benefit more by additional clinical training and business training rather than performing experiments in a research lab. The fiduciary mentor listens to what the mentee really wants rather than what the mentee thinks the mentor wants to hear.
• A mentor’s most valuable gift is his or her time. Few things are more impactful to a mentee than one-on-one time with their mentor. Whether that be time spent teaching a laboratory technique, demonstrating a physical examination technique, or reviewing a business document prepared by the mentee, when a mentor gives their time purely for the benefit of the mentee, a true fiduciary role is established.

The legacy of a mentor is the mentee

I carry with me a little piece of every mentor I ever had. I’ve incorporated all of their behaviors, phrases, priorities, and skills into my own persona. And I’ve passed them on to my own mentees over the course of my career. Human civilization has been built by mentors passing on knowledge and skills to their mentees and by doing so, fiduciary mentors create their true legacies.

December 1, 2025

When I turned 65-years-old, I anticipated my healthcare insurance costs would go down as I went on Medicare. After all, I had been paying into Medicare in the way of payroll taxes for decades. But my annual health insurance premiums (medical, vision, and dental) instead went up from $5,736 per year to $6,924 per year. The reason was IRMAA, the Income-Related Monthly Adjustment Amount rule used by Medicare to calculate monthly Part B and Part D premiums.

Understanding the basics of Medicare

To understand IRMAA and how it affects Medicare recipients, we first need to understand the basics of the various Medicare Parts:

• Part A – this covers inpatient hospital care, skilled nursing facilities, hospice, and some home health services. It is free for all Americans over age 65-years-old who have paid payroll taxes for at least 10 years. However, Medicare enrollees are responsible for the cost of various co-pays and deductibles.
• Part B – this covers outpatient care, physician charges, and medical supplies. It is partially paid for by payroll taxes but Medicare enrollees must also pay a monthly premium.
• Part C – also called “Medicare Advantage Plans”, seniors eligible for Medicare can opt to enroll in Part C instead of Parts A & B. These plans are administered by commercial health insurance companies that contract with Medicare to cover everything that Medicare Parts A & B cover, with additional coverage for medications and often for dental care, vision care, or fitness centers. They also have deductibles and co-pays but these are typically less than the deductibles and co-pays of traditional Medicare. Think of Part C plans as a bundle of Parts A, B, and D plus a Medigap plan. The downside of these plans is that they have stricter prior authorization requirements for medical services, greater denial of coverage for services, and limit coverage to in-network physicians and hospitals.
• Part D – these are Medicare drug plans that are administered by commercial health insurance companies. They charge monthly premiums that vary in amount based on the extent of coverage of medications. Part C Medicare Advantage Plans usually incorporate Part D coverage in the plans.
• Medigap – this is “Medicare supplemental insurance” sold by commercial health insurance companies to help cover the deductibles and co-pays of Parts A & B. They will generally also help cover healthcare costs if hospitalization or skilled nursing facility stays exceed the limit of days covered by Medicare. They can also cover foreign healthcare costs when traveling outside of the U.S. since these costs are not covered by Medicare Parts A & B.

IRMAA adds additional costs

Medicare premiums are complex. Part A is free and has no premiums associated with it but it does come with an annual $1,736 deductible for inpatient hospital care for 2026. Part B has a base monthly premium of $202.90 and has an annual deductible of $283. Part D plan premiums vary among the various commercial insurance companies that offer these plans with each of these plans providing different degrees of coverage for specific medications and different co-pays for medications. Part D plan monthly premiums range from $0 to $123.40 with annual deductibles ranging from $0 to $615. Medigap plan monthly premiums vary among the commercial insurance companies sponsoring Medigap policies and range from $36 to $798 based on age, gender, and health status.

But the base premiums for Medicare Part B and Part D only apply to Medicare enrollees with low annual incomes. The cost of the premiums goes up as enrollee income increases and these additional costs are the Income-Related Monthly Adjustment Amount, or IRMAA. Medicare uses the “modified adjusted gross income” calculated from federal income tax returns to determine the amount of IRMAA. The modified adjusted gross income is calculated by:

• First, determine your total annal taxable income, found on line 9 of the 1040 income tax form.
• Next, subtract all of your annual adjustments (deductibles), found on line 10 of the 1040 income tax form.
• The result is your adjusted gross income, found on line 11 of the 1040 income tax form.
• Next, calculate the modified adjusted gross income by adding back amounts of certain types of deductions, non-taxable income, and tax credits including:
  • Child tax credit
  • Lifetime learning tax credit
  • American opportunity tax credit
  • Student loan interest deduction
  • Employer-provided adoption benefits
  • Foreign earned income
  • Foreign housing deduction
  • Tax-exempt interest income
  • Non-taxable Social Security benefits
  • IRA contribution deduction
  • U.S. Savings Bond interest

The modified adjusted gross income (MAGI) does not appear on the IRS 1040 income tax form and has to be calculated separately. However, each year, Social Security will calculate your modified adjusted gross income for you, based on your income tax returns from two years previously. Seniors get a letter from Social Security in late November each year notifying them of their modified adjusted gross income. So, letters were sent out this week reporting the 2024 modified adjusted gross income and from that determining the 2026 IRMAA amounts for every Medicare enrollee. The tables below show how IRMA affects monthly premiums for Medicare Part B and Part D.

Single, Head of Household, or Qualifying Surviving Spouse:

Married filing jointly:

Married filing separately:

Because the Medicare Part D premiums vary depending on which Part D plan each Medicare enrollee choses, the total monthly Part D premium will be the base price of the specific Part D plan plus the amount of the Part D IRMAA. Because Medicare Advantage Plans include drug coverage, Medicare recipients who elect to enroll in Medicare Part C will also pay the Part D IRMAA amounts.

IRMAA is not paid to the various commercial insurance companies that sponsor Part D and Part C plans, instead, IRMAA is paid directly to Medicare, along with the usual monthly Medicare Part B premium.

The total amount that any given Medicare enrollee pays for healthcare insurance per year will thus vary based on their annual income, whether or not they purchase a Medigap plan coupled with traditional Medicare, whether they opt for a Part C plan instead of traditional Medicare, and whether they opt for a Part D plan. The least amount paid would be for an individual with a modified adjusted gross income of less than $109,000 who chooses a $0 monthly premium Part D plan and no Medigap plan who would pay $2,435 per year. The highest amount would be for an individual with a modified adjusted gross income of more than $500,000 who opts for the most expensive Part D plan plus the most expensive Medigap plan who would pay $20,428 per year.

Approximately 18% of Medicare enrollees also receive Medicaid and Medicaid will cover some or all of the costs of Part B premiums, Medicare co-pays, Medicare deductibles, and medications. Other government programs that help low-income individuals pay for Medicare premiums, co-pays, deductibles, and medications include the Supplemental Security Income program, Medicare Savings Programs, and the Extra Help program.

Healthcare is expensive for seniors

Healthcare costs in the United States are the highest in the world and those costs increase as Americans get older. CMS estimates that the total annual cost of healthcare for Americans over age 65-years-old was $22,356 per person in 2020. Because of inflation, those costs have increased to approximately $28,000 today. Even with the IRMAA increases to Medicare premiums, American seniors pay less for their healthcare than they actually spend for health insurance, deductibles, and co-pays after age 65 – all because they are supplemented by workers who are currently paying payroll taxes today.

The additional monthly IRMAA costs that are added to monthly Medicare Part B and Part D premiums often come at a surprise to retirees. For a married couple, this can be many thousands of dollars a year that they had not budgeted to spend in their retirement. As physicians, it is important that we understand IRMAA and educate our patients about its costs before our patients retire in order to avoid unexpected health insurance bills that could jeopardize their retirement plans.

November 24, 2025