The Ortho Money Show
Money, business, and life strategies for orthopedic surgeons who want to build wealth beyond the operating room
Ep #132: Closing the Contribution Gap: The Payroll Math, the Super Catch-Up, and the Cash Balance Lever
What percentage of your paycheck is actually going into your 401(k) right now, this pay period, not what you elected back in January? If you'd have to go check, you're not alone.
In this episode, Jared breaks down a new wrinkle in this year's contribution limits: surgeons turning 60 through 63 get a super catch-up of $11,250 that replaces, rather than stacks with, the standard $8,000 catch-up, bringing the total to $35,750. He walks through the payroll math on a stale January election (a flat per-paycheck number that has to triple or more once only a handful of checks remain before December 31), and why waiting until November to change it is often already too late once payroll processing lag is factored in.
Then he covers the bigger lever most of this conversation misses entirely: the cash balance plan, which runs on the actuary's funding schedule rather than a payroll election, and can dwarf the 401(k) catch-up figures for a surgeon in her late 50s or 60s.
Ep #131: The ILIT Strategy Most Surgeons Overlook Until It’s Too Late
Here's a number worth sitting with. A surgeon can have a $9 million estate, comfortably under the federal exemption, owe nothing in federal estate tax, and still have less than $300,000 of it sitting in cash. That's not a stress test. That's the ordinary math of a practice-heavy balance sheet.
In this episode, Jared picks up where the show's estate-exemption episode left off, on the tool that closes that gap: the Irrevocable Life Insurance Trust, or ILIT. He walks through the actual mechanism (the trust owns the policy, not you, which is what keeps the death benefit out of your taxable estate), how to fund it correctly using Crummey withdrawal rights without touching your lifetime exemption, and the three-year lookback rule that matters if you're moving an existing policy into a new trust.
Jared also covers what nobody sells you on: the real cost isn't the legal fees, it's control. Once the policy belongs to the trust, it belongs to the trust. He closes with a second worked example, a blended family where an ILIT solves an inheritance-fairness problem without forcing a sale of the practice itself.
Ep #130: The 2.5% Cut Nobody Warned You About
Has anyone on your billing team, your practice manager, or your specialty society actually told you the real number behind this year's Medicare cut? Not the 2.5% headline. What it works out to on your two highest-volume procedures.
In this episode, Jared breaks down CMS's CY2026 "Efficiency Adjustment," a 2.5% reduction to intraservice time work RVUs that explicitly exempts time-based care (office visits, care management, behavioral health, telehealth) and, by that same design, falls disproportionately on procedural and surgical work. For two of the highest-volume codes in orthopedics, total hip and total knee arthroplasty, CMS's own published figures show an overall reduction of 7.3% to 7.8%, well above the headline number.
Jared walks through what that actually costs a high-volume joint replacement practice in real dollars, using an illustrative planning range rather than a false-precision figure, and lays out three structural moves worth making regardless of politics: reviewing payer mix intentionally, accounting for Medicare-benchmarked commercial contracts, and re-running retirement plan funding projections before this year's numbers surprise you in Q4.
Ep #129: Your Practice Is Your Biggest Bet. Are You Treating It Like One?
If your financial advisor put 46% of your portfolio into a single stock with no liquidity, no hedging, and no diversification, you'd fire them. That's roughly where most practice-owning surgeons already sit, just with the practice instead of a stock, and almost nobody frames it that way.
In this episode, Jared breaks down why "my practice is my retirement plan" is one of the more dangerous sentences in surgeon finance: a retirement plan compounds, diversifies, and protects against risk, and a practice does none of those things on its own. He walks through three ways to reduce that concentration without selling tomorrow: diversifying revenue within the practice so it doesn't depend entirely on you, documenting personal goodwill years before any sale (the difference between ordinary income and capital gains treatment on a $4M sale is $678,000), and building a transition timeline even if you have no plans to leave.
He also gets into private equity as one legitimate de-risking option among several, and the four things a polished PE pitch deck tends to leave off the slides: rollover equity terms, compensation adjustments, EBITDA normalization, and the hold-period reality.
Ep #127: Roth Conversions & The IRMAA Warning That Doesn’t Apply To You
Quick question: when's the last time someone actually checked whether you're already at the top of the Medicare IRMAA scale, before warning you that a Roth conversion might push you into it? For most surgeons, the answer is never, and the warning doesn't apply to them anyway.
In this episode, Jared walks through why the standard Roth conversion advice breaks down at surgeon income. The IRMAA surcharge tops out around $750,000 in household income for a married couple. If you're earning $1.1 million, your regular income already put you at the ceiling years ago, a conversion adds nothing further on top of it. Once that's off the table as a deciding factor, Jared lays out the three-branch framework that actually applies: when conversion helps, when deferral wins, and when a partial conversion timed to a low-income window beats both.
He works two side-by-side examples, same age, same income, same $150,000 conversion, opposite answers, because the underlying goals were different, to show the framework produces a personal answer, not a universal rule.
Ep #126: The Cliff Nobody Tells You About
Here's a number that should bother you: $773,000. That's what a surgeon in New York can owe in state estate tax on an $8 million estate, even while sitting $7 million under the new federal exemption.
In this episode, Jared unpacks what the "permanent exemption" headline leaves out. The One Big Beautiful Bill Act set the federal estate and gift tax exemption at $15 million per person with no scheduled sunset, real and welcome news for most surgeons. But federal exemption and total exposure aren't the same thing. Jared walks through New York's estate tax cliff, where crossing the state exemption by more than 5% doesn't just reduce the exemption, it erases it, and the state taxes the entire estate from dollar one. He maps the twelve states plus Washington, D.C. that still run their own estate tax, and explains why a surgeon who owns a second property in one of them can have exposure they've never considered.
Then he covers the trap some surgeons already walked into: irrevocable trusts built to dodge the old exemption sunset that may now be costing more in lost step-up basis than the estate tax they were built to avoid.
Ep #125: Life Beyond the OR - What the Best Practice Transitions Have in Common
The happiest surgeons two years after a practice transition aren't the ones who got the highest multiple, and they aren't the ones who negotiated the most aggressive earn-out. They're the ones who knew what they were transitioning to.
In this episode, Jared walks through the question that almost never shows up in transition planning: who are you when you're not a surgeon? He lays out what happens when that question goes unanswered, using a scenario where a surgeon nets $2.9 million from a practice sale, has no next-chapter plan, and watches the balance fall to $1.7 million within three years through a series of individually reasonable, collectively costly decisions. Then he runs the same $2.9 million exit with a plan in place: a structured budget, a waiting period on large purchases, and identity work done before the sale closed. Same starting number, $1.5 million apart three years later.
Jared closes with the three elements that make the difference: identity work, purpose architecture, and financial guardrails, and why they matter as much at a $2 million exit as a $10 million one.
Ep #124: Why I Recommend A Financial Second Opinion, And What To Look For
You've ordered hundreds of second opinions in your career. Have you ever gotten one on your financial plan?
In Episode 3, Jared makes the case for a financial second opinion. Financial services are built in silos: your CPA handles compliance, your advisor handles investments, your attorney handles the estate plan. Each does their piece well. Nobody's looking at how the pieces interact, and that's where the money leaks.
Jared walks through the four areas a real second opinion should cover (entity structure, retirement plan design, tax strategy, and investment allocation), and works through a scenario where an $850,000 surgeon's second-opinion review surfaces a cash balance plan opportunity, a SEP restructuring, and uncoordinated tax-loss harvesting worth $50,000 to $80,000 in year one, and over $400,000 across a decade.
Then he gives you three questions to ask before you sit down with anyone offering a "second opinion": what's their motive, will the findings be specific, and will they respect your existing team.
Ep #123: Practice Valuation 101: What Buyers See That You Don’t
Two numbers, same practice, same year: $4.4 million and $5.5 million. The difference comes down to one concept most surgeons never encounter until an LOI is already on the table: normalized EBITDA.
In this episode, Jared walks through what normalized EBITDA actually is and why a buyer's number is almost always higher than the one on your tax return. He breaks down the five adjustments that create the gap: owner compensation above market, family employment at above-market pay, personal expenses running through the business, one-time non-recurring costs, and lease terms on owner-held real estate. On a practice reporting $1.1 million in net income, those five adjustments can add over $1.1 million to the valuation.