11 years of jail time for Ms. Holmes I assume the board is running out of interest so I will not answer all of your points in detail, but am happy to discuss further if you want.
When I graduated from medical school in 1978, over half the class went into internal medicine, as it was intellectually exciting, involved doing something for people and was close to other specialties in salary. We had little debt. Neither of these last two points are the case now , and students are following their pocket books so lots of specialists and few Internists. The specialists have manufactured their markets, insisting all older people get "skin checks" and anyone with chest pain see a cardiologist etc.
I was against the AMAs stand in almost everything and remain so today.
All I had to offer my patients when I was in practice was the time they needed, my experience and training and deep interest in their problems and their lives. That could not be crammed into less than 15 minutes. But our office visits became more and more important to them because they never heard from specialists about test results, saw the surgeon once ( maybe) before surgery and usually not after, and got life changing results (ie cancer diagnoses) without explanation by email.
Patents who did not have docs like me to rely on, went to the ED, had more symptoms, got more tests, more visits and more costs.
If this society is to achieve cost control with better results in health care, we desperately need an economic environment where competent well trained PCPs can function effectively, without constantly trying to see more patients in less time and have payors continually cut their fees, add more to their workloads and office requirements. We need to stop incentivizing medical students to go into lucrative subspecialties with ridiculous salaries that add little to the nation's health. Countless studies show PCPs are much more cost effective than specialists in management of most medical problems, and that our medical costs are so high because of an overreliance on specialists that no other western nation needs.
I don't know of the accuracy of your reference, but the table shows a salary increase from $147000 to $189000 or 28% total in 20 years. These increases however hardly beat inflation. Compared to lawyers and MBAs (who have only three years post college, not seven for PCPs) these salaries don't seem excessive. The fact that specialists make three to ten times that of a PCP is where American MD salaries are really skewed far away from other countries averages.
No one I hired or recruited out of residency started at $147,000, and I rarely made that much in 30 years of practice.
My main point remains: with fixed fees the only way to achieve a salary increase with more experience and seniority a PCP has to either see many more patients in less time, do lucrative but unnecessary procedures in the office or work longer hours. None of these are conducive to good patient care.
Medicare rates are set in a complicated political process involving local cost differentials, usual and customary adjustments, advisory boards (loaded with subspecialists), caps on Part B reimbursements requiring budget reconciliation legislation etc, not by "negotiations" with any group. In fact, due to the budget reconciliation process, rates are automatically cut almost every year without a specific restoration from Congress.
Medication costs for Medicare patients are finally going to be negotiated, but this will not stop the enormous political pressure applied by big pharma to get "copy cat" drugs approved at lucrative rates, or get ineffective medications for Alzheimer's approved at $58,000 a year. As some of these will be outpatient services( Part B) , not just drugs, it could decrease physician payments further.
The system is stacked against a specialty that uses it's brains and humanity to talk to patients, hear their concerns, make an accurate diagnosis and determine an individual plan rather than ordering an MRI in 60 seconds or referring to a specialist because there is not enough time to figure out what the problem is.
October Inflation Report Price Pressures Show Signs of Cooling
RPHIX vs US Treasuries vs CDs RPHIX TTM yield, per M*, is 2.36%, but I don't care about yield, by itself, for a bond oef like RPHIX. For a bond oef, like RPHIX, I only care about total return. For RPHIX, its YTD total return is 2.09%. Its shorter term TR is .90 for 3 months, but there is no guaranteed TR with a bond oef, so everything is a projection based on a performance pattern.
For a MM, I get 3.71% for SWVXX and 3.85% for SNAXX--and so I know what my total return pattern, for now, is and there is no threat to principal. CDs are paying about 4.8% for 1 year. Will RPHIX produce a TR over 3.71% or 3.85%, up to a CD high of 4.8%%? Its a guess, but currently I prefer my guaranteed 4.8% for a large part of my principal, and 3.71% and 3.85% for my more liquid holdings. I look at MMs and CDs in combination for my total return projections for my cash.
So, just for me, I need to see RPHIX total return performance hiigher than .90% for 3 months, before I will start "believing" that in this environment of rising interest rates, likely recession, that this is the time to abandon my guaranateed total return, via MMs and CDs.
Each person can read the market and decide what they want to invest their cash in, based on their analytical criteria for risking their cash. I am not recommending any investment action for others, but that is my current personal criteria, subject to change in the future.
RPHIX vs US Treasuries vs CDs I haven't found the 30 day SEC yield on Riverpark's website, which is why I linked to Fidelity.
Regardless of where one finds the figure, it is calculated by the fund itself. I infer this from the fact that even M* does not compute the yield but relies upon funds to compute it themselves. M* also notes that this is a figure calculated at the end of the previous month, so the most current figure is as of 10/31.
From M*'s glossary:
SEC Yield
This calculation is based on a 30-day period ending on the last day of the previous month. It is computed by dividing the net investment income per share earned during the period by the maximum offering price per share on the last day of the period. The figure listed lags by one month. When a dash appears, the yield available is more than 30 days old. This information is taken from fund surveys.
https://www.morningstar.com/invglossary/sec_yield.aspxM* Fixed Income Survey GuidelinesAs to how the figure is calculated, it is more complicated than just looking at the latest dividend payment. "SEC yield requires averaging the yield to maturity of the fund’s holdings over the prior 30 days and accounts for fund expenses."
https://advisors.vanguard.com/insights/article/UnpackthechallengesofrisingbondfundyieldsShorter term yields have increased significantly in November. I expect (with qualifications already stated) that the 11/30 SEC yield for RPHIX will therefore be notably higher than the 10/31 3.68% yield. Especially given all its "dry powder" (see Lewis' post above).
With respect to SNOXX's state tax exemption, though it is named Treasury Obligations MMF, the name is misleading. Only 69% of the fund's income in 2021 came from government obligations exempt from state taxes in any state. And less than
50% was from actual Treasuries, making the fund fully taxable in California, Connecticut, and New York.
https://www.schwabassetmanagement.com/resource/2021-supplementary-tax-information
11 years of jail time for Ms. Holmes A self-employed primary care doctor seeking reimbursements is different from a surgeon working in a hospital. Hospital medical staff do get raises based on experience:
https://work.chron.com/rate-salary-increase-physician-27112.htmlThe other interesting question is whether years of experience are the best measure of quality in medicine. I wouldn’t want to be a surgeon’s first patient, but I also wouldn’t want to be their last either. A doctor with five or more years of practical experience may be more aware of the latest medical research or trends than one with 40 years about to retire. A younger surgeon might also have steadier hands.
Yet in some respects, the question is moot because doctors of any level of experience tend to get paid handsomely here. I feel for the overworked internists with huge student loans still to pay, but that is a different issue. You don’t hear of too many poor established American doctors. The reason we don’t have national health insurance is directly due to the AMA, which lobbied hard to prevent it from happening many moons ago. And Old Joe is exactly right about the different levels of care here. This is not a country to be poor and sick in. And other countries have consistently better outcomes than we do both on the cost and health front for their entire populations.
The problem with just letting the market handle healthcare is the inequality of supply—limited—and demand—unlimited—for necessary life saving care. If it costs you
5 cents to make a candy bar and you want to charge $
50 for it, have at it. I’ll just buy something else, but there may be wealthy people who love your candy so much they’ll pay the $
50 for it. But if it costs you
5 cents to make a pill that you have an exclusive patent on and it keeps my parents, children, or spouse alive and you want to charge $
500 for it—we’ve got a problem.
Note, one of the additional problems our for profit healthcare industry has created is that through lobbying big pharma made it so that Medicare could not use its negotiating muscle to demand lower prices on drugs. That’s why you have poor seniors cutting pills in half. Medicare however does have the power to negotiate reimbursement rates for doctors visits and medical procedures. Doctors are unhappy with those lower reimbursement rates. I have a feeling many seniors are alive today because of them.
11 years of jail time for Ms. Holmes @ LewisBraham
You are referencing salaries paid to trainees in residency programs, not what a licensed physician bills and gets paid for to see a patient.
I used "medical intern" as the minimal amount of training most states require to get a license. I technically should have said "medical resident" because all states require at least one year ( internship) of post medical school training to be licensed and then to bill. So therefore technically a post internship MD
My point, based on 40 years of office practice is that insurance companies and Medicare pay the same amount for the procedure or office visit, regardless of what physician renders the service.
So a MD 366 days out of medical school gets the exact same $ amount for, say, an office visit that your long term internist with 40 years of experience and advanced training receives. Longer training, board certification, fellowship training etc have no effect on the fee, nor are they usually required to bill for procedures.
Nor is there, at the present time, any easy way to bill for additional time spent with the patient. This may change soon, but cognitive services will remain at a huge disadvantage when a dermatologist can remove a mole in 30 seconds for $100 and an internist only gets a little more to spend 45 minutes with you to diagnose your heart attack, or interpret your CT scan and plan your cancer care.
I too used to think the government was generally responsible for positive things in health care, but 40 years of running a small medical office convinced me otherwise. Most of our overhead, ( 50 to 60% of our revenues ) was due billing staff trying to collect a few dollars more from multiple payors, extra staff to deal with regulations from botht he government and our payors and mandated programing and Medicare mandated computers and electronic medical records. The latter required 3 to 4 hours a day of my time in front of the computer after the patients ( and staff) went home that added nothing to patient care or their health. I rarely left the office before 9 PM.
Is it any wonder why you can't find a primary care MD in practice taking new patients?
I could easily have taken home the same amount of money charging $50 to $100 a visit, and spent a lot less time with far fewer headaches.
I can't speak for specialists or hospitals and what what would happen to orthopedists, for example if they billed patients directly for a hip replacement. Specialists in high demand would obviously charge outrageous amounts. This is already happening in some states where subspecialty societies have limited sub specialist training.
Every study I have read demonstrates at least 30% of American health care expenses goes to needless administrative overhead and outrageous salaries of executives.
RPHIX vs US Treasuries vs CDs SVWXX 7 day SEC yield is 3.71% today. Taxed at 22% bracket plus Mass ( my state) income tax ( 5%) is 2.75%
SNOXX ( Govt obligations) is 3.45% or 2.691% without any default risk ( Repos are minimal so now state tax free).
For PRHIX, I don't see how Fidelity arrives at SEC yield of 3.68%, using October's income of 0.0256 a share
Using October's distribution ( after expenses) of .0256 a share if continued for next 12 months is .3072 or a yield of 3.2 % without compounding
Can you find the SEC yield on RPHIX website?
11 years of jail time for Ms. Holmes @LewisBrahamThere are myriad of reasons why the "health care is a right" movement, which was very popular when I was in medical school in the 70s, foundered.
The libertarians went after it, claiming that if people had a right to something, the professionals providing that service were denied freedom of action and were essentially slaves. This, of course was before the rise of health insurance companies totally controlling payments and making physicians essentially their slaves.
The BC/BS organizations in the
50's decided to pay for "procedures" rather than cognitive services, putting thinking and counseling at a major disadvantage, especially when they also decided ( in the 80s) that all cognitive services and non procedural treatments for a cold or cancer or septic shock were the same and reimbursed them equally.
Adding insult, unlike every other profession in America, experience and training and skill in medicine do not result in a differential in payment. An intern, one day out of medical school gets the same payment as a doc with decades of experience.
I think if we eliminated third party payors, and had people pay for their health care themselves, with subsidies directly to the consumer perhaps, it would solve a lot of the problems.
Few people would pay for brand name drugs if there was a cheap generic. Hospitals would be empty unless they had rates equal to the cheap hotels that most of them are. CEOs of "non-profit" health care institutions would not be paid millions of $. Professionals would have to compete on results, or services or reputation or price, but almost all would be forced to lower their fees or else go broke.
Eliminate the third party payors, and the typical physician would save 3
5 to
50% of overhead.
Overnight, the political pressure people and states put on insurers to pay for stuff that is not life saving ( plastic surgery, unnecessary procedures etc) would disappear.
I won't get in to the Billions of dollars of added expense that the Federal and state governments add with their demands for "meaningful use", protocols, and other regulations.
CD Questions When purchasing a long term CD , say 5 years, & the interest accumulates until the maturity date, does Uncle Sam want interest payments taxed & paid on a yearly basis ?
Do all CD's have a POD or TOD , or is this info part of due-diligence ?
Thanks for any info, Derf
RPHIX vs US Treasuries vs CDs SWVXX has a cumulative (not annualized) return of
1.218% from
March 16, 2020 through Nov 15, 2022. (Fund pays divs in mid-month.)
Schwab data source.
RPHIX has provided a cumulative return of
7.20% over the same time span.
M* data source.Recent performance (1 month/3 month, through 10/31):
RPHIX 0.47% / 0.69% (from
Morningstar performance page)
SWVXX 0.2
5% / 0.63% (from
Schwab's page for this fund)
As I've explained, extrapolating from today's yields is always risky, but FWIW, here are some yields (
7 day for the MMF and 30 day SEC for the Riverpark funds).
RPHIX 3.68% (
as of 10/31)
SWVXX 2.97% (
as of 10/31)
What is it about RPHIX's performance pattern that leads you to feel that you "can get better returns through Schwab Money Market accounts"? There are a lot of factors beyond the raw numbers above that one might look at. I've suggested option adjusted spreads as one factor to throw into the mix. Others?
