Physicians with at least one retirement account (for example, an IRA, Roth IRA or 401k) and one taxable account will benefit from higher returns with comprehensive asset location. In asset location, all accounts supporting the same financial objectives (for example, providing income in retirement) are viewed collectively as a single portfolio. Asset classes (for example, U.S. stocks or government bonds) are preferentially placed in either retirement or taxable accounts.
In taxable accounts, high-yielding assets have a higher tax burden than in retirement accounts. These assets are prioritized for placement in retirement accounts. In contrast, tax-free municipal bonds bear no tax burden, so they are preferentially placed in a taxable account. The result is the risk-adjusted expected return from the sum of all accounts increases. This is particularly important for physicians who, by virtue of being in high tax brackets, pay a lot of taxes.
Consider what happens if you place a high-yielding investment in a non-tax sheltered account. You must pay 39.6% (top tax rate) on non-qualified distributions from that investment, as opposed to sheltering that high-yielding asset in a tax-deferred account. Clearly, your net returns are dependent upon more than just appreciation. Smart asset location matters, especially for high income earning physicians.
Think of it like a hospital – a complex entity separated into different wings and departments to maximize efficiency. Each department houses doctors and staff who are best equipped for their roles. Emergency room doctors are going to be dealing with people needing the most immediate and intense level of care. An ER doctor wouldn’t treat a patient with a sprained finger while someone who was just in a traumatic car accident sits in the waiting room. In much the same way, your aggregate investment portfolio can be separated into different accounts and investment vehicles. Inside each of those vehicles are investments and holdings that are suited for the particular account type.
A more efficient hospital will lead to greater outcomes and profitability. The same is true for your portfolio. Strategic asset location maximizes efficiency and leads to better outcomes and portfolio growth.
Last fall I had the pleasure of interviewing Dr. Juan Aragon, Executive Director of Primary Care, Specialties and Physicians’ Services at Evergreen Health.
His story begins in Costa Rica where he grew up and completed his medical training. His journey into medicine was sparked on a casual car ride with his father who asked Juan the question: “what are you going to do for a living?” When Juan told him that he wanted to be a missionary, his father pressed back, asking how he would pay the bills. Right then and there, Juan decided he would go into medicine.
After starting a medical training program in Costa Rica, Juan took 9 months off for bible school at Capernwray Hall in England. His goal was to mature, away from his family, and spend some time in self-reflection to ensure that medical school was truly the right path for him.
Juan finished medical school at age 24 and took a job in the remote location of Drakes Bay on the Oso Peninsula in Costa Rica. Juan was the second doctor Drakes Bay ever had and, needless to say, he gained a ton of clinical experience there.
Missionary work continued to call to him, so he left Drakes Bay to work for a bible school, and did pro-bono work for the affiliated hospital. This is where he learned the administrative side of medicine. And, how much he liked it. He wore a lot of hats: Chief of Human Resources, Chief Risk Officer, etc., and by the time he moved on, the school had built up an unprecedented $300,000 cash reserve.
In 2008 he received his Master of Medical Management, Health Systems Management from Tulane University. He moved to Seattle in 2009 to start his career at Evergreen Health.
After learning about his background, I asked Dr. Aragon a series of questions, as follows:
Lowell: How do you give back?
Juan: My religion – Christianity – should have a visible impact. It is not just a philosophy. Early on I gave back with my talents and skills via board participation. I focused on organizations that had youth programs, like the YMCA, with the goal of helping kids navigate the messy teen years. I have continued to work with the YMCA in tandem with Evergreen.
I am currently involved with the University of Washington Masters in Health Administration program. I see these kids as the ones who will be here when I am not. Investing in their future is paramount. My participation in panels and business cases also helps me learn and succeed in my current role at Evergreen Health.
Lowell: How do you “Live Fully”?
Juan: At the end of the day when you look back at a day’s worth, a year’s worth or even 10 years’ worth of time, you need to ask: did I invest enough time in my family that I am preparing them to be better individuals to face the challenges of this world than I am? Am I fully investing in the people I love the most? Was I conscious enough to be grateful to the people who contributed to my life, in recognition that I am where I am because of them? Answering “yes” to these question brings fullness. A friend once told me – “be grateful with your treasures, be grateful with your talents and be grateful with your touch.”
Lowell: What is the best piece of financial advice you ever received?
Juan: Live like it’s your last day but plan like you are going to live a hundred years. Don’t get into credit card debt. Save enough money to have fun. Always have the attitude that if you are willing to give, opportunities will present themselves constantly. Look at things as opportunities. The same thing is true with investing: Don’t leave it all in one place. Leave it where you can take advantage of opportunities.
Lowell: Do you miss practicing medicine?
Juan: Yes. But, I made the choice in 2008 to pursue an administrative career. I find alternative ways to be with people, and I see the long term impact that my work will have on patients. I know that at some point, I or my loved ones will need these services and I want to make sure they are the best services possible.
Lowell: What is the biggest challenge and opportunity for health care?
Juan: Challenge – Affordability. Our health care is so expensive that it is not sustainable. For the past 6 years, we have tried 200 experiments and none have delivered results. Opportunity – Same thing. If you think about how our nation was formed, it has always figured out how to force its way through complex problems. The US is the way it is because it figures out innovative solutions to transform the market. We will break through. Consider the innovations of Amazon, Google and Apple for instance.
Lowell: What advice do you have for physicians?
Juan: As you are figuring out what you want to do with your life, take the time to figure out what you are passionate about. Make sure you have the skills and financial support to do it. Figure out your priorities and have a plan to make sure those priorities are met. As long as you have a plan, you know where you are going. You can figure it out. Ask for help. Design the map to fit your lifestyle. Develop a plan to make enough money and enjoy it. Have a plan and understand choices and tradeoffs. Understand where true north is. Figure out how to overcome obstacles and stay on track.
Society presses kids to have it all figured out; this pressure is incredible. You do not have to have it all figured out. Have a plan. Talk to smart people. Work hard. Have a good attitude. Don’t think that when you go to college you need to have your retirement date figured out. It’s okay to not know all the answers. Never be afraid to ask for help.
Juan is an impressive person, and I thoroughly enjoyed speaking with him. His global perspective, work ethic, and humble attitude bring a unique perspective to the medical field. I hope you glean some insight from his thoughts, and that they lead you to a fuller place.
Medical technology (medtech) angel investments can be a great opportunity for physicians to engage as mentors with startup companies within their field of expertise. A cardiac surgeon, for instance, can offer expertise to an entrepreneur building a new stint. Typically the physician will make some level of investment and be heavily involved in the company, hopefully seeing it and their investment prosper.
Another route is to invest in multiple companies and be much less involved. Obviously, it would be difficult to offer day-to-day or even month-to-month mentorship for more than one or two companies as a busy physician. In this case, you need to be economical and look for resources to help you with your investment selection. Most major cities have angel investment groups that, for a nominal fee, will help you vet companies and offer other resources as you make your investment decision.
Your best option for plugging in to medtech angel investing in Seattle is WINGS.
Whichever route you take (mentor or passive investor), be aware of the risk and return. While not much has been written on the subject, the white paper “Returns to Angel Investors in Groups” by Robert Wiltbank and Warren Boeker does a nice job of setting the expectations.
Here are seven things you need to know when considering medtech angel investments:
- Risk. 30% of your investments will fail. 30% will return your money. 10% will go big. 20% will return something. To succeed, you must understand this and have the wherewithal (assets) and stomach (guts) to ride out the losses.
- Return. 27% IRR. Most of this coming from the 10% that are home runs. See Returns to Angel Investors in Groups.
- Time horizon. Companies that fail (lemons), fail faster than those that succeed (plums). Proper investment requires patience and the ability to reinvest over periods of time.
- Invest 5-10% of your portfolio assets. Your risk is concentrated and your return is dependent upon “home runs.” Subjecting more than 5-10% of your assets is just too risky.
- Diversification. Single company risk is big with these investments. Prudent investment requires investing in at least 15 to 20 companies.
- Involvement. If mentoring within your field of expertise is the desired path, how much time do you have to devote to it?
- Do your due diligence, or depend on a group such as WINGS to help you do it. Success rates and due diligence are highly correlated.
If you’re serious about becoming a medtech angel investor, learn the local landscape. Spend some time with local groups, such as WINGS. Figure out how much you want to invest and what role you want to take on. Most importantly, know your downside risk, be mechanical in your decision-making and limit your investment to 5-10% of your total portfolio.
From the heights of K2 to the war struck Syrian-Jordan border, Albert (Skip) Edmonds’ journey is one of intrigue and insight. I had the pleasure of sitting down with him to hear his story.
As the son of a pediatrician, medicine presented itself as a likely career path for Skip at an early age, although his route was somewhat circuitous. Upon graduating from Williams College, he pursued oceanographic research in the Antarctic. He spent 200 days at sea, south of Australia in a 200-foot vessel, stomaching choppy waters. During this time, he was also able to pursue his love for mountaineering in the mountains of New Zealand.
After a year in the Antarctic, Skip was faced with a decision: Continue with oceanography and get a PhD, or pursue an MD. The variety of opportunities in medicine ultimately won out and Skip headed to Virginia for medical school.
Early in his career as a practicing physician, Skip put his mountaineering skills to the ultimate test as part of the first American expedition to K2 in 1978. Led by Jim Whitaker of REI, the group was 14 people strong. It was a long trip, beginning in mid-June and lasting well into October. Skip remembers the toughest elements being the weather and the confinement, not to mention dehydration and limited oxygen. Just when the group’s food supply was on the brink of depletion, there was a break in the weather and two groups of two made it to the summit in two successive days, marking the first American ascent of K2 and the third overall ascent.
After many years practicing medicine in Seattle, Skip was ready to retire. It was then that an opportunity to join Doctors Without Borders (DWB) presented itself. Skip was at his cabin in 2010 when the Haiti earthquake struck, and he immediately realized his skill set would be useful. He sent in his application to DWB and went through a rigorous selection process. DWB is very careful in selecting its members, and for good reason. Electricity is intermittent and the living conditions are tough. Experiencing third world medicine is a shock for most American physicians, and DWB wants to make sure each physician can not only handle it, but will want to come back for a second mission. Surgical missions are typically in trauma zones and last about a month, with physicians working around the clock. Non-surgical missions last 3-6 months and have a less intense daily schedule.
Skip says it’s the individual patients you remember the most. There is one 7-year-old Nigerian boy he remembers well. The boy was hit by a car and, after a dozen surgeries, lost both of his legs to infection. Despite his trial, the boy always had a smile for Skip and his colleagues and appreciated their work.
In 2012 he was stationed on the Syrian-Jordan border during the Syrian civil war. They could see the bombs going off a few kilometers away and patients were pouring in. It was an emotionally challenging experience. Skip and his team attempted to save one woman for over a month, and Skip recalled how brave she was to endure. Unfortunately, the infection eventually took her life.
His advice for physicians who are thinking about joining DWB is to do your homework. Make sure you understand it will be harder than you think. Something will come around the corner, either medically or culturally, that will shock you. In the end, Skip always learns an incredible amount on his missions. And, he takes home more than he is able to give back.
If you are interested in more information, you can visit the DWB website. Skip would also be happy to talk with you one-on-one; e-mail me and I will make the introduction.
Skip’s advice for life in general is to find something that occupies your head and that you love to do. It will take you away from the stresses of medicine, allowing you to unplug, decompress and approach your work with a clear head. For Skip, this is rock climbing because it takes total focus and concentration and doesn’t allow him to worry about the daily stresses of life.
The best piece of financial advice Skip ever received was to not try and do it himself. When the tech bubble popped in 1999 that became clear. Skip was in his late 40s at the time and lost half of his retirement nest egg. Later, he entrusted money to a friend and got burned. All in all, he had little interest for investing and therefore was not going to stay on top of it. Hiring a financial advisor allowed him to focus more on the things he really enjoys, like rock climbing.
Knowing what we know about stock markets, how can we achieve the highest possible return with the lowest amount of risk? This is the primary question driving the allocations that follow. It’s a simple question that’s packed with layers of complexity.
Here’s a brief review of how we broke down the complexity to make it simple for you to execute.
- Calculated risk
- Stocks are riskier than bonds. History tells us you receive a higher return for taking this risk.
- Certain stocks outperform other stocks – small cap and value stocks, for example.
- Controlled risk
- Do not put all your eggs in one basket.
- Use high quality bonds to offset stock market risk.
- Be patient. The best way to capture stock market returns is to stay invested and keep investing with your periodic 401(k) contributions.
Of course, the biggest factor in all of this is YOU. While we know how to develop retirement plan portfolios, we do not know your specific goals, objectives and values. Specifically, I can’t tell you whether you should be in the 100% stock allocation, the 60% stock 40% bond, or some iteration thereof. Can I assume that a 32-year-old who recently became a physician should take more risk in light of a longer investment horizon? Sure. But that changes for a physician in his forties, and for one who wants to retire early.
If you have specific questions about which mix to choose, shoot me an email at firstname.lastname@example.org.
Likewise, if your 401(k) is not listed on our site, send me your available investment options and I’d be happy to provide my thoughts.