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CYAI – It’s Back! Afford both college AND med school for the kids?

Home Personal Finance and Budgeting CYAI – It’s Back! Afford both college AND med school for the kids?

  • Avatar EntrepreneurMD 
    Participant
    Status: Physician
    Posts: 34
    Joined: 06/10/2019

    Hatton1, this is how my medical business is set up.

    We are 3 providers (I have 2 physician extenders) and based on volumes will probably need a fourth within the next year (currently up to 90-100 patients/day (including ancillaries)). We do of course provide all of the traditional primary care services. We also do aesthetics including botulinum toxin/fillers/face masks/etc., motor vehicle accidents, dermatologic procedures/laceration repair, weight loss and smoking cessation programs, pediatric care, gynecology, men’s health, phlebotomy, CLIA waived laboratory services, we have an in house pharmacy (wife is a pharmacist) and vitamin/supplement shop, allergy testing/immunotherapy, vaccinations (in house and remote), ultrasounds/echocardiograms, autonomic neuropathy testing, nerve conduction testing, ankle brachial index testing, spirometry/pulmonary function testing, Holter monitoring, ACO shared savings program, second opinions, pre-operative/bariatric clearance, medical directorships. Working on in house x-ray, intravenous hydration, cool sculpting, medical spa/salon. It’s a lot of work to continue innovating and steering a growing ship, probably more than most physicians are willing to do but with the passion comes the willingness to sacrifice. I’m shifting to an ever growing supervisory role but still enjoy the clinical aspect very much.

    We prefer PPO plans and avoid capitation (which essentially trades off profitability for volume). We prefer to grow slower and avoid a less satisfactory practice style for both patients and providers as well as shrinking margins. We accept walk-ins and cash pay patients and have payment plan options.

    Two physicians retired and gave us their practices. Now that is God’s blessing.

    We have a large nearly 2000 sq ft lobby that is shared with  our 3 non-competing medical tenants and large screen televisions advertising our services to our patients and theirs. We also use it for weekend/after hours community events. We are heavily engaged in social media and referral source marketing. It also helps that we’re in a growing Florida market, and on a main road with 35K cars/day visibility.

    15-20% of total annual revenues is currently derived from the commercial real estate leases, which is much more passive.

    That’s a simple summary.

    #221381 Reply
    jfoxcpacfp jfoxcpacfp 
    Moderator
    Status: Financial Advisor, Accountant, Small Business Owner
    Posts: 7503
    Joined: 01/09/2016

    Hatton1, this is how my medical business is set up.

    We are 3 providers (I have 2 physician extenders) and based on volumes will probably need a fourth within the next year (currently up to 90-100 patients/day (including ancillaries)). We do of course provide all of the traditional primary care services. We also do aesthetics including botulinum toxin/fillers/face masks/etc., motor vehicle accidents, dermatologic procedures/laceration repair, weight loss and smoking cessation programs, pediatric care, gynecology, men’s health, phlebotomy, CLIA waived laboratory services, we have an in house pharmacy (wife is a pharmacist) and vitamin/supplement shop, allergy testing/immunotherapy, vaccinations (in house and remote), ultrasounds/echocardiograms, autonomic neuropathy testing, nerve conduction testing, ankle brachial index testing, spirometry/pulmonary function testing, Holter monitoring, ACO shared savings program, second opinions, pre-operative/bariatric clearance, medical directorships. Working on in house x-ray, intravenous hydration, cool sculpting, medical spa/salon. It’s a lot of work to continue innovating and steering a growing ship, probably more than most physicians are willing to do but with the passion comes the willingness to sacrifice. I’m shifting to an ever growing supervisory role but still enjoy the clinical aspect very much.

    We prefer PPO plans and avoid capitation (which essentially trades off profitability for volume). We prefer to grow slower and avoid a less satisfactory practice style for both patients and providers as well as shrinking margins. We accept walk-ins and cash pay patients and have payment plan options.

    Two physicians retired and gave us their practices. Now that is God’s blessing.

    We have a large nearly 2000 sq ft lobby that is shared with  our 3 non-competing medical tenants and large screen televisions advertising our services to our patients and theirs. We also use it for weekend/after hours community events. We are heavily engaged in social media and referral source marketing. It also helps that we’re in a growing Florida market, and on a main road with 35K cars/day visibility.

    15-20% of total annual revenues is currently derived from the commercial real estate leases, which is much more passive.

    That’s a simple summary.

    Click to expand…

    So much to be learned from you. May I suggest a side hustle as practice consultant. Bypass the fancy-pants degrees, titles, and multiple initials after a professional’s name we all have to Google (yep, me, too). Just talk to someone who has been there, done that, and figured out how to make it work. I’m not joking.

    Johanna Fox Turner, CPA, CFP, Fox Wealth Mgmt & Fox CPAs ~ 270-247-0555
    https://fox-cpas.com/for-doctors-only/

    #221394 Reply
    Liked by hatton1
    Avatar Panscan 
    Participant
    Status: Resident
    Posts: 785
    Joined: 03/18/2017

    Hatton1, this is how my medical business is set up.

    We are 3 providers (I have 2 physician extenders) and based on volumes will probably need a fourth within the next year (currently up to 90-100 patients/day (including ancillaries)). We do of course provide all of the traditional primary care services. We also do aesthetics including botulinum toxin/fillers/face masks/etc., motor vehicle accidents, dermatologic procedures/laceration repair, weight loss and smoking cessation programs, pediatric care, gynecology, men’s health, phlebotomy, CLIA waived laboratory services, we have an in house pharmacy (wife is a pharmacist) and vitamin/supplement shop, allergy testing/immunotherapy, vaccinations (in house and remote), ultrasounds/echocardiograms, autonomic neuropathy testing, nerve conduction testing, ankle brachial index testing, spirometry/pulmonary function testing, Holter monitoring, ACO shared savings program, second opinions, pre-operative/bariatric clearance, medical directorships. Working on in house x-ray, intravenous hydration, cool sculpting, medical spa/salon. It’s a lot of work to continue innovating and steering a growing ship, probably more than most physicians are willing to do but with the passion comes the willingness to sacrifice. I’m shifting to an ever growing supervisory role but still enjoy the clinical aspect very much.

    We prefer PPO plans and avoid capitation (which essentially trades off profitability for volume). We prefer to grow slower and avoid a less satisfactory practice style for both patients and providers as well as shrinking margins. We accept walk-ins and cash pay patients and have payment plan options.

    Two physicians retired and gave us their practices. Now that is God’s blessing.

    We have a large nearly 2000 sq ft lobby that is shared with  our 3 non-competing medical tenants and large screen televisions advertising our services to our patients and theirs. We also use it for weekend/after hours community events. We are heavily engaged in social media and referral source marketing. It also helps that we’re in a growing Florida market, and on a main road with 35K cars/day visibility.

    15-20% of total annual revenues is currently derived from the commercial real estate leases, which is much more passive.

    That’s a simple summary.

    Click to expand…

    and thats how you print money folks

     

    are you doing all these procedures yourself?

    #221458 Reply
    Avatar EntrepreneurMD 
    Participant
    Status: Physician
    Posts: 34
    Joined: 06/10/2019

    Portlandia, fear, ignorance, insecurity?

    Yes, all of the above. I don’t like to refer to myself as a 1 percenter, but since you referenced it, even us 1 percenters have the same weaknesses and imperfections as the 99%.

    When I initially posed the question regarding the $800K educational expense, I was genuinely concerned about affordability, given it’s about $1.2M in pre-tax income needed to cover since I have no 529 plan, in the context of recently taking out $2.3M in loans, practice expenses that continue to rise and feeling my cash flow isn’t great. Also most of my assets are illiquid and I wasn’t sure regarding appropriate levels of emergency funds. That’s fear.

    It may be that the real question I was subconsciously asking was how do I allocate my resources between future education obligations, current debts, rainy day funds and investments. I let Johanna know I’ve never read a financial book and just acting on gut instincts, without a vision for our future finances. Now, I know medicine and maybe how to run an efficient office, but couldn’t convince Johanna that I really don’t know what I’m doing regarding finance, I think her comment was I “think you know exactly what you’re doing”. Any doctor knows that as doctor’s, we feel we can save but otherwise not so confident about management of those savings. That’s ignorance and insecurity.

    Anyway, I feel a lot better knowing that Johanna, XRAYVSN and almost every respondent here agreed education funding for the kiddos should be doable without introducing a significant hardship. Given the education my wife and I received, I feel that education is the single best investment someone can have, along with a lifetime of support – our goal for the kids.

    Growing a medical business and managing real estate is, to me, a walk in the part compared to the complexities of money and risk management, tax optimization, and legacy planning.

    #221485 Reply
    fatlittlepig fatlittlepig 
    Participant
    Status: Physician
    Posts: 742
    Joined: 01/26/2017

    didn’t read the whole thread but you have 3 doctors who do all of this ??

    that seems really bizarre.

     We do of course provide all of the traditional primary care services. We also do aesthetics including botulinum toxin/fillers/face masks/etc., motor vehicle accidents, dermatologic procedures/laceration repair, weight loss and smoking cessation programs, pediatric care, gynecology, men’s health, phlebotomy, CLIA waived laboratory services, we have an in house pharmacy (wife is a pharmacist) and vitamin/supplement shop, allergy testing/immunotherapy, vaccinations (in house and remote), ultrasounds/echocardiograms, autonomic neuropathy testing, nerve conduction testing, ankle brachial index testing, spirometry/pulmonary function testing, Holter monitoring, ACO shared savings program, second opinions, pre-operative/bariatric clearance, medical directorships. Working on in house x-ray, intravenous hydration, cool sculpting, medical spa/salon.

    #221513 Reply
    hatton1 hatton1 
    Participant
    Status: Physician
    Posts: 2975
    Joined: 01/11/2016

    I think he is the only doc.  He has 2 extenders.  Kudos to EntrepreneurMD in figuring out a way to make FP really pay well.  I have noticed that several of the highest net worth docs who post here are in some of the traditionally low pay specialities.  Many docs just accept a salary and never really try IMHO.

    #221523 Reply
    Liked by SLC OB, jfoxcpacfp
    fatlittlepig fatlittlepig 
    Participant
    Status: Physician
    Posts: 742
    Joined: 01/26/2017

    Never heard of the term extenders. If there is one doctor doing all of that stuff listed above that is some strange type of medicine and not the kind of clinic that I would want to frequent. Sounds like the kind of clinic you see advertised In the classified with the big bold type “weight loss, been in accident? Etc “

    #221531 Reply
    Avatar Panscan 
    Participant
    Status: Resident
    Posts: 785
    Joined: 03/18/2017

    Ya I guess my concern is that I doubt you can be proficient in everything and if you’re the only doc then by definition you have to be.

    Iv hydration? I’ve seen some clinics that will do iv vitamin infusions. Sounds like just praying on foolish people with treatments that have no proven benefit. Sticking a needle in someone’s arm is not benign, no matter how small. Not sure we should advocate doing it for pointless reasons.

    #221532 Reply
    Liked by Peds
    hatton1 hatton1 
    Participant
    Status: Physician
    Posts: 2975
    Joined: 01/11/2016

    Extender is a term used for NPs and PAs.

    #221536 Reply
    Avatar Kamban 
    Participant
    Status: Physician
    Posts: 2250
    Joined: 08/01/2016
    o of course provide all of the traditional primary care services. We also do aesthetics including botulinum toxin/fillers/face masks/etc., motor vehicle accidents, dermatologic procedures/laceration repair, weight loss and smoking cessation programs, pediatric care, gynecology, men’s health, phlebotomy, CLIA waived laboratory services, we have an in house pharmacy (wife is a pharmacist) and vitamin/supplement shop, allergy testing/immunotherapy, vaccinations (in house and remote), ultrasounds/echocardiograms, autonomic neuropathy testing, nerve conduction testing, ankle brachial index testing, spirometry/pulmonary function testing, Holter monitoring, ACO shared savings program, second opinions, pre-operative/bariatric clearance, medical directorships. Working on in house x-ray, intravenous hydration, cool sculpting, medical spa/salon.

    Click to expand…

    I have only one question. With you doing all this and being the only doc where do you even find time to have a true vacation. I mean 1 week – 2 week ones, not the 4 day extended one. I would not feel comfortable with my extenders doing procedures while I am thousands of miles away on a beach. Unless you get a locum who will charge quite a bit to take on all these responsibilities.

    #221544 Reply
    Avatar Dont_know_mind 
    Participant
    Status: Physician
    Posts: 852
    Joined: 11/21/2017

    Certainly if I don’t find that great opportunity in the equities markets or real estate opportunities my instincts are to accelerate debt payments rather than invest in THIS market. Others may do things differently. My take is the interest payments are a guaranteed cost, market investments are not a guaranteed return.

    Alternatively I can invest the money in the markets and hope the next major correction doesn’t happen over the next 8 1/2 years while the debt gets paid off, but admittedly that thought gives me anxiety! I understand the argument for investing instead as the market returns should outpace my interest rates, but no one can replace the word should with the word would. One of my definite weaknesses – I’m a control freak. CD returns I can get a guarantee on, stock market I can’t control. I’ll have more to say on market timing, and why my thought process would have been very different under different market circumstances where I wouldn’t hesitate to choose the market investment option over debt repayment, real estate or even reinvestment into my personal business. I don’t wish for it, but if the markets were to crash my entire line of reasoning would be completely different. Unlike others here, I just don’t like the vibes I’m getting from the current markets.

    Click to expand…

    This makes sense. The risk adjusted return from debt payoff is higher.

    I have the same connundrum, and particularly with indexers. On the one hand you have the expected return from equities – and everyone has a subjective opinion, but like you, I tend to think 10 year compounded rate will be low, say 3-5% and that hardly compensates for the risk versus risk free 3-4% from debt payoff. Also there is the expected higher return from being able to have cash to buy something during a downturn.

    But then you have to be able to execute this and there is the risk that it will not pay off. But I tend to think that it will pay off and am possibly even more cash buffered than you are. But I do sometimes wonder whether I might be wrong and everyone I mention it to says my liquid holdings are too high also. I think the problems are potentially behavioral and in execution. To be able to buy more during a downturn, you have to lighten up during the boom. The problem is that people do this too quickly and are struck with fear of missing out too much. I think it is possible to do though, it is like $100 sitting there waiting to be picked up. Everyone sees it but few can pick it up.

    There is an interesting fellow here , Crazyroadtodublin who did better than everyone else by leveraging index funds and apple from what I recall. I would never be able to do that but he did very well. I guess you have to be comfortable with your strategy as well. I see the risks in your market-timing strategy but am comfortable with it and it is basically what I am doing. I am basically accumulating a large liquid pool. Every year of additional bull market is a bonus but I will certainly be prepared if things turn south.  I guess I have left some on the table but I’m comfortable with it and it sounds like you are too. What gives me anxiety is deploying more of my capital currently so I guess on some base level, my risk management is not comfortable with it. I have thought about it a lot.

    Having too much cash is not insurmountable. I will probably just buy 400k properties every few years that are attractive if I do find I accumulate too much cash and the bull market goes a lot longer than expected, like say in 6 years or something if things are still going well. Unfortunately, I have not been very good at holding onto index funds, and that is definitely not an area of strength for me. But I have done well with holding property and have still done well. I guess you gravitate to what you’re comfortable with and if that works…

    #221547 Reply
    Avatar Dont_know_mind 
    Participant
    Status: Physician
    Posts: 852
    Joined: 11/21/2017

    I would reassess paying my low interest rate loans earlier than is required to invest in a young bull instead. I’m not talking day trading buy low sell high. I’m talking young to mature bull runs which generally hang around about a decade. I don’t generally wait for the next major correction as I have been a buyer on the dips over the past decade, but there comes a point in the cycle when I am concerned enough to be a seller on the rally’s than a buyer on the dips or else I risk buying high. Ultimately, do I think the markets will at some point be lower than they are now. Yes, I think there is a high probability. Other’s may not. See below:

    This is my take on market timing.  Like anything else, it’s a game of likelihoods, no one can predict. This is my concern about putting money in the current markets. 1- It has quadrupled since the 2009 lows. 2- It is one of the longest bulls we’ve had. 3- It has essentially moved sideways since January 2018 for the most part with the peak August 2018 but no real direction and a recent “head and shoulders chart pattern”, but with a recent uptick, I’d want to see that it break that resistance. 4- The dreaded yield curve has inverted. 5- The trade war is unlikely to go away any time soon. 6- The bond markets are flashing warning signs 7- election uncertainty. 8- Once we hold the 2% inflation target with such a tight labor market, the Fed will have no more reason to be support the stock market. 9. When a major correction happens, the markets tend to bottom out at the peaks of the last bull market, or about Dow 15K.

    Obviously I don’t expect an imminent correction, as I still have about $1.8M in IRA stock market investments and even if it corrected I would have no problem riding it out thru the next bull market and beyond, given my age and FI cushion. I’ll always be in the market the question will be to what degree so it’s not temporary, just the level of investment for me depends on the amount of risk I’m willing to take in a mature bull and the opportunities (or lack thereof) to mobilize my resources to other investments not just 3% CD’s.

     

    Click to expand…

    All true. I think your risk (and mine) is FOMO in a late stage melt-up. I figure, as long as I can hold my nerve, it should be ok. I think there was Y-C inversion in 1998 and things continued for another 50% and another 2 years. In any case, in terms of my type of investing, the opportunities are not there currently, so I am happy to take it easy. On market timing, the market is infuriating and the adage that it makes fools out of the most people makes sense. My only real question is whether I should buy some more index funds here even though I know it is bad value, to avoid succumbing to FOMO and buying at the peak. Which I could imagine doing.

    #221551 Reply
    Avatar DrC83 
    Participant
    Status: Physician
    Posts: 5
    Joined: 02/28/2019

    One doctor and two NP’s doing all that, including dermatology, gynecology, allergy/immunotherapy, nerve testing, pulmonary testing, US/echo? You are quite the omnidoctor. Do you send US/echo/pending In house x-ray our for interpretation or doing that in house?

    #221554 Reply
    fatlittlepig fatlittlepig 
    Participant
    Status: Physician
    Posts: 742
    Joined: 01/26/2017

    One doctor and two NP’s doing all that, including dermatology, gynecology, allergy/immunotherapy, nerve testing, pulmonary testing, US/echo? You are quite the omnidoctor. Do you send US/echo/pending In house x-ray our for interpretation or doing that in house?

    Click to expand…

    Fatlittlepig is calling BS. Ain’t no way one MD and two extenders or whatever they are called, are providing all of these services. And if they are they shouldn’t be. This is not medicine, this is some weird pseudo-medicine/wellness clinic/diagnostic procedure mill.

    #221570 Reply
    Avatar Panscan 
    Participant
    Status: Resident
    Posts: 785
    Joined: 03/18/2017

    That’s how you print money in primary care. You don’t do fm, you do all the bs stuff like botox, various injections, etc.

    #221572 Reply

Reply To: CYAI – It’s Back! Afford both college AND med school for the kids?

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