Risk/Reward Ratio with 16M in assets for Medicine?

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I am a 43 year old MD/MBA physician who has obtained approximately 16M in both inherited and earned investments. I wrote a previous forum post around 2019 asking about risk of specialities etc at my previous net worth of 11M or so.

I have changed from a W2 to a 1099 physician after an acrimonious split from a previous partnership (two docs got jealous with fake accusations blah blah) into a seemingly nicer position in terms of work after a little drama.

Assets basically include 6.5M with 4M in taxable account, 2 million in retirement accounts and 530K or so house.
Another approximate 10M are with 7M in an irrevocable spendthrift trust and 3M in a future inherited retirement account. Estate taxes have been managed by getting most of the monies irrevocably transferred so that even if there is an estate tax cut by 2026 it will be fine.

Investment accounts are largely placed in well diversified funds that approximate 70/30 Domestic/International depending on world market free float cap coupled with a midcap tilt to attempt to replicate the best potential Sharpe ratio of the markets over the last >50 years (I know Jack Bogle doesn't like tilting or international at all by have to be slightly against the mold). I am attempting to get a CABG for the overall assets at approximately 5-7% per annum considering the lower return environment we will be in over the next few years.

CABG of 7% on 16M should achieve 1.12M per annum (not sure if realistic considering market conditions currently)

I am currently a 1099 physician averaging approximately 65-80K/month with some CME/medical reimbursement and malpractice paid for.

Since everyone seems to be "business" oriented on this forum, some questions I would like to discuss related to my situation is thus:

1) Thoughts on Asset Protection for taxable assets: LLC/DAPT are worth it? Add in potential offshore option if LLC/DAPT fails? Or just do WhiteCoat investor idea of increasing malpractice insurance with umbrella insurance and leaving it there?

I suspect most would recommend avoiding higher risk work even if it paid less then higher risk medical work considering risk for assets.

2) Is an S Corp with it as a 1099 at my income level? >50% split is the "standard" CPA recommendation for W2 to K1 distribution income ratios. The S Corp idea only seems to save approximately 2% Medicare tax though (2.9% is before standard employer deduction on 1099). So if one has a distribution of 300-400K, it is only 6-8K before the costs of maintaining the S Corp as per fees/CPA costs. Is it worth the hassle?

The 199A deduction phases out at a low number.

White Coat Investor seems to think anything >100K/year in K1 distribution is worth it but I am unsure of this assertion.

Is it worth cutting back on at work?

3) Thoughts on CLAT vs CRUT for inherited account to achieve best NPV after SECURE act? Has anyone worked out the numbers of CLAT vs CRUT as an NPV analysis with a 10-20 year time horizon in a testamentary trust after inheritance? This clearly is also used for asset protection purposes but limits taxable costs especially if continuing to work.

4) Is a solo 401k/Cash Balance Plan worth doing at this point? 150K can be put away vs 63K or so in SEP IRA. However, 2/3s of the money in the "cash balance" is only allowed to grow at the 4% rate or so to avoid going over the actuarial calculations that can be costly on the IRS code.


Hopefully some savvy investor docs/MBAs/CPAs/CFPs can brainstorm 1 to 4 above.

Thanks for any help.
I think you'd get a lot more knowledgeable professionals answering if you asked this on the Whitecoat Investor forum.
 
I am a 43 year old MD/MBA physician who has obtained approximately 16M in both inherited and earned investments. I wrote a previous forum post around 2019 asking about risk of specialities etc at my previous net worth of 11M or so.

I have changed from a W2 to a 1099 physician after an acrimonious split from a previous partnership (two docs got jealous with fake accusations blah blah) into a seemingly nicer position in terms of work after a little drama.

Assets basically include 6.5M with 4M in taxable account, 2 million in retirement accounts and 530K or so house.
Another approximate 10M are with 7M in an irrevocable spendthrift trust and 3M in a future inherited retirement account. Estate taxes have been managed by getting most of the monies irrevocably transferred so that even if there is an estate tax cut by 2026 it will be fine.

Investment accounts are largely placed in well diversified funds that approximate 70/30 Domestic/International depending on world market free float cap coupled with a midcap tilt to attempt to replicate the best potential Sharpe ratio of the markets over the last >50 years (I know Jack Bogle doesn't like tilting or international at all by have to be slightly against the mold). I am attempting to get a CABG for the overall assets at approximately 5-7% per annum considering the lower return environment we will be in over the next few years.

CABG of 7% on 16M should achieve 1.12M per annum (not sure if realistic considering market conditions currently)

I am currently a 1099 physician averaging approximately 65-80K/month with some CME/medical reimbursement and malpractice paid for.

Since everyone seems to be "business" oriented on this forum, some questions I would like to discuss related to my situation is thus:

1) Thoughts on Asset Protection for taxable assets: LLC/DAPT are worth it? Add in potential offshore option if LLC/DAPT fails? Or just do WhiteCoat investor idea of increasing malpractice insurance with umbrella insurance and leaving it there?

I suspect most would recommend avoiding higher risk work even if it paid less then higher risk medical work considering risk for assets.

2) Is an S Corp with it as a 1099 at my income level? >50% split is the "standard" CPA recommendation for W2 to K1 distribution income ratios. The S Corp idea only seems to save approximately 2% Medicare tax though (2.9% is before standard employer deduction on 1099). So if one has a distribution of 300-400K, it is only 6-8K before the costs of maintaining the S Corp as per fees/CPA costs. Is it worth the hassle?

The 199A deduction phases out at a low number.

White Coat Investor seems to think anything >100K/year in K1 distribution is worth it but I am unsure of this assertion.

Is it worth cutting back on at work?

3) Thoughts on CLAT vs CRUT for inherited account to achieve best NPV after SECURE act? Has anyone worked out the numbers of CLAT vs CRUT as an NPV analysis with a 10-20 year time horizon in a testamentary trust after inheritance? This clearly is also used for asset protection purposes but limits taxable costs especially if continuing to work.

4) Is a solo 401k/Cash Balance Plan worth doing at this point? 150K can be put away vs 63K or so in SEP IRA. However, 2/3s of the money in the "cash balance" is only allowed to grow at the 4% rate or so to avoid going over the actuarial calculations that can be costly on the IRS code.


Hopefully some savvy investor docs/MBAs/CPAs/CFPs can brainstorm 1 to 4 above.

Thanks for any help.

I think more “big picture” questions to answer first, in order to get at your more technical questions:

1) how many days a week do you currently work
2) are you working mostly for fulfillment or for money at this point? What percentage for each?
3) how much money do you need yearly to support your lifestyle?
4) how long in practice so far? Kids?

Obviously many/most would retire from medicine at 16M net worth or just work very minimally given the risks, or just expand a low-paying hobby they enjoy as their “new job” etc. or start a risky venture to shoot for really being “ultra wealthy.”

However I could see a newer doc or someone with a very large lifestyle continuing to work full time in medicine - not sure where you fall.
 
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1) 4 days with potential to go to 5

2) As long as I can control my risk in medicine plus don’t have to take a bunch of late call, it currently appears to be a fulfilling career. The biggest hurdles have been physician drama and administrative annoyances.

Might try to use MBA more for administrative positions in the future if possible.

3) 80k or so? Drive relatively cheap cars. Use public schools except for preschools etc. House isn’t expensive and is paid off. Live pretty low key lifestyle.

4) About 10-11 years. 3 kids right now might have a fourth. With kids, it would be hard to retire plus it becomes difficult to get back into medicine if leave too long.

Really not too sure of my goals at this point.

So a few comments- You probably know this, but with your lifestyle you don’t need to work a single day further. You make more (on average) on passive income than you spend and you/family are set for life a couple times over. Regarding specifics:

1. The asset protection laws vary a lot per state so consult a lawyer who specializes in this. I assume you have a good estate lawyer- they probably know another estate lawyer who specializes in asset protection (preferably specific to doctors) to detail all your options.

What specialty are you in so we can assess your risk?

Definitely max your liability insurance. Also consider working 2-3 days a week. I personally would even look at a job with sovereign immunity, like the VA (as I said it doesn’t matter at all what you make at this point, as it’s all for fulfillment unless you plan to massively change your lifestyle).

2. I don’t think S corp is worth the hassle. You are talking about possibly only being ahead a very small amount…

3. I’m not knowledgeable about this topic so not going to comment.

4. Cash balance plan definitely worth it at your age with the caveat I don’t know if there is much difference between the solo and small group rules (haven’t asked my cpa that does our small group one).
 
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A lot of your questions are pretty high level, and it might be best to post on WhiteCoatInvestor forums or Boggleheads.

I can only point out a few things.

Max for a solo 401k is $61k for 2022, I think $68k for 2023. I'm not sure where you saw $150k. A cash balance/pension plan would be separate, regardless of whether you do 401k or SEP.

Your business entity doesn't make any difference with regards to malpractice/asset protection, unless you have employees, an office, or have a seperate business (real estate, etc.). Basically something/someone that puts you at risk (employee that sexually harrasses someone, floor for someone to slip on/break ankle, roof that can cave in, etc.) You're always personally liable for malpractice, so your assets are always at risk. There's no way around that. Best thing to do is reduce your risk--practice good medicine, but actually even more important is to see fewer patients (per the research). Also, working at the VA where it is incredibly, incredibly hard to actually sue an individual provider is another method. And upping your malpractice camp could be considered, though the odds of getting sued (successfully) above normal policy maximum of $1 million is incredibly low.

Some states have homestead laws, so putting the money into your property is one technique. Probably best to talk to a lawyer.

FYI many states, such as mine (CA), DON'T have asset protection for individual retirement accounts. On the other hand, CA capped non-economic damages, so our malpractice rates are incredibly low. Still not the greatest place to practice financially, but I love it here.
 
I am a 43 year old MD/MBA physician who has obtained approximately 16M in both inherited and earned investments. I wrote a previous forum post around 2019 asking about risk of specialities etc at my previous net worth of 11M or so.

I have changed from a W2 to a 1099 physician after an acrimonious split from a previous partnership (two docs got jealous with fake accusations blah blah) into a seemingly nicer position in terms of work after a little drama.

Assets basically include 6.0M with 4M in taxable account, 1.45 million in retirement accounts and 530K or so house. (Exact numbers probably down 10 percent or so since market drop)

Another approximate 10M are with 7M in an irrevocable spendthrift trust and 3M in a future inherited retirement account. Estate taxes have been managed by getting most of the monies irrevocably transferred so that even if there is an estate tax cut by 2026 it will be fine.

Investment accounts are largely placed in well diversified funds that approximate 70/30 Domestic/International depending on world market free float cap coupled with a midcap tilt to attempt to replicate the best potential Sharpe ratio of the markets over the last >50 years (I know Jack Bogle doesn't like tilting or international at all by have to be slightly against the mold). I am attempting to get a Compound Annual Growth Rate for the overall assets at approximately 5-7% per annum considering the lower return environment we will be in over the next few years.

Compound Annual Growth Rate of 7% on 16M should achieve 1.12M per annum (not sure if realistic considering market conditions currently)

I am currently a 1099 physician averaging approximately 65-80K/month with some CME/medical reimbursement and malpractice paid for.

Since everyone seems to be "business" oriented on this forum, some questions I would like to discuss related to my situation is thus:

1) Thoughts on Asset Protection for taxable assets: LLC/DAPT are worth it? Add in potential offshore option if LLC/DAPT fails? Or just do WhiteCoat investor idea of increasing malpractice insurance with umbrella insurance and leaving it there?

I suspect most would recommend avoiding higher risk work even if it paid less then higher risk medical work considering risk for assets.

2) Is an S Corp with it as a 1099 at my income level? >50% split is the "standard" CPA recommendation for W2 to K1 distribution income ratios. The S Corp idea only seems to save approximately 2% Medicare tax though (2.9% is before standard employer deduction on 1099). So if one has a distribution of 300-400K, it is only 6-8K before the costs of maintaining the S Corp as per fees/CPA costs. Is it worth the hassle?

The 199A deduction phases out at a low number.

White Coat Investor seems to think anything >100K/year in K1 distribution is worth it but I am unsure of this assertion.

Is it worth cutting back on at work?

3) Thoughts on CLAT vs CRUT for inherited account to achieve best NPV after SECURE act? Has anyone worked out the numbers of CLAT vs CRUT as an NPV analysis with a 10-20 year time horizon in a testamentary trust after inheritance? This clearly is also used for asset protection purposes but limits taxable costs especially if continuing to work.

4) Is a solo 401k/Cash Balance Plan worth doing at this point? 150K can be put away vs 63K or so in SEP IRA. However, 2/3s of the money in the "cash balance" is only allowed to grow at the 4% rate or so to avoid going over the actuarial calculations that can be costly on the IRS code.


Hopefully some savvy investor docs/MBAs/CPAs/CFPs can brainstorm 1 to 4 above.

Thanks for any help.
My question is why any sane person would continue to work with that amount in investments. You could pull a flat 4% while leaving it in the market and it would almost certainly net you $640,000 a year and keep up with inflation more years than not. Do you really just love what you do that much? Are you a masochist? Do you have needs that I cannot fathom which require extravogant sums of money? Do you want to build enough multigenerational wealth that multiple generations will never have to work a day in their lives? I'm legitimately curious
 
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Also, its not like im a billionaire, etc so there are plenty of others worth 100M+ to billions and even some of those continue to work.

True but 99.9999% with that type of money don’t work in middle management or a traditional “paycheck” anymore.

Point being unless you are making 2-3 mill+ a year or starting a business with potential to be worth 100s of millions, your doctor work is unlikely to make any meaningful difference in your net worth over the next 20 years. Retiring with 25 million vs 30 million isn’t substantially different in what you can do or your family’s security. I’ve always said once I hit 10 M net worth I would just work purely for fulfillment, possibly even volunteer at the VA or something a day a week as doctor paycheck isn’t impactful financially at that point.

That being said —if it gives you purpose and fulfillment more than other things (hobbies, entrepreneurship, etc) then it’s totally reasonable.
 
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You make 80k per month did I read that right? Is this a troll post?
 
You make 80k per month did I read that right? Is this a troll post?
GI docs can make that much working locum. One GI locum doc that was open about pay at my shop told me he was getting paid ~ 5k/day locum rate.

The one we have now got 4k/day I was told. You can make 60-80k/month with that kind of rate.


I would leave medicine or work part time for the VA if I was in OP's position (even with 3 mil plus a paid off home).
 
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GI docs can make that much working locum. One GI locum doc that was open about pay at my shop told me he was getting paid ~ 5k/day locum rate.

The one we have now got 4k/day I was told. You can make 60-80k/month with that kind of rate.


I would leave medicine or work part time for the VA if I was in OP's position (even with 3 mil plus a paid off home).

There was just a post on this same forum with people claiming they see docs with 2M+ salaries.

I wrote 65-80K/month. Who knows how long this will last with insurance reimbursement changes etc. Might go to half that in the next 5 years etc.

Also, assets vary so when the market drops 20%, net worth might be down etc.

Don't get why this is so complicated.
 
Congratulations on your success. It might feel a little tough to get advice on these kinds of "first world problems" anywhere, but particularly on a website aimed primarily at students. While there are residents and some attendings here, it does tend to skew young/early career kind of like the WCI Subreddit. Your questions are awfully high level so congrats on that too, but just realize the amount of help you're going to get on any forum is pretty limited. Let me see if I can help because I've personally struggled with some of the same issues.

1. I wrote a book about it. I would suggest starting there. Here's a link:

Amazon product

Put toxic assets in LLCs. A DAPT is probably worth it at your level of assets. While you're very unlikely to need it, why not? Doesn't cost much. Our home is in a DAPT since Utah provides very little asset protection for homes. You might also consider an IDGT/SLAT, but this is a discussion to have with your estate planning attorney.

The offshore stuff is for those who lie awake at night worrying about things that are very unlikely to happen. Mostly just an expensive hassle.

Obviously you need to have adequate personal and professional liability coverage.

Why should you not do what you want to do just because you're rich now? You're supposed to have MORE options when you become wealthy, not fewer.

2. 65-85K a month? Heck yes do an LLC filing as an S Corp and save yourself some Medicare tax. I guess if $8K is nothing to you then sure, don't bother. But it's not like it's some huge hassle IMHO.

Most with your level of assets are practicing only as much as they desire. For example, I do 6 day shifts a month. Medicine is so fun at that level. Dramatically different than working 15 where 2/3 of them are evenings and nights. Drop what you don't like, keep what you do.

3. Haven't seen much work on this. More info on charitable trusts here:


More on Secure Act 2.0 here:


A conversation with your estate planning attorney and accountant (and maybe both together) is in order here. But the first thing to figure out is what charitable desires do you have?

4. "Worth it" is in the eye of the beholder. Obviously you don't have to do any of this to never need to work again and never have to worry about running out of money. But a DB/CB plan would lower your taxes and improve your asset protection. Is that "worth it?" Only you can decide. I have one at my partnership but not at WCI mostly because it would lower my 199A deduction. If there were Roth DB/CB plans I would do it at WCI though. Maybe starting in 2026 when 199A is supposed to go away we'll do it.
 
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I am a 43 year old MD/MBA physician who has obtained approximately 16M in both inherited and earned investments.

Is it worth cutting back on at work?
Congrats. I would have retired 14M ago but that's just me!
 
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I dunno, I'm well into 7 and with 2 kids it seems like I'm not going anywhere plus what the hell else are you going to do all day? Its not like you can run off somewhere..
 
I'm curious what you do as that will help determine your level of risk. Ob/gyn is much different than occupational medicine. Assuming you're in a high paying specialty. If it's a surgical specialty risk is also very dependent on the type of surgery obviously, neurosurgeon vs a mohs surgeon
 
I'm curious what you do as that will help determine your level of risk. Ob/gyn is much different than occupational medicine. Assuming you're in a high paying specialty. If it's a surgical specialty risk is also very dependent on the type of surgery obviously, neurosurgeon vs a mohs surgeon
OP is an anesthesiologist.
 
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I dunno, I'm well into 7 and with 2 kids it seems like I'm not going anywhere plus what the hell else are you going to do all day? Its not like you can run off somewhere..

Exactly. 5M or 7M or whatever may sounds like a lot but it’s actually a lot less than it was just 2 or 3 years ago.

While food/energy may have gone up 25%, luxury items that tend to matter to those with high income (vacations, travel etc) have probably doubled.

If this goes on - you can think of your 5M as 2.5 and your 10M as 5M.

Given I still would retire at 16M in assets!
 
Exactly. 5M or 7M or whatever may sounds like a lot but it’s actually a lot less than it was just 2 or 3 years ago.

While food/energy may have gone up 25%, luxury items that tend to matter to those with high income (vacations, travel etc) have probably doubled.

If this goes on - you can think of your 5M as 2.5 and your 10M as 5M.

Given I still would retire at 16M in assets!

Agreed. 5m will soon be the new 1 million imo. In fact for my planning purposes I already consider it this. Printing half the money since 2020 has consequences not fully understood.
 

Great read on estate and tax law, should answer your first question with much detail

This doesn't really compare the CLAT vs CRUT idea well but I would assume CLAT is higher risk due to sequence of returns risk when setting the up the charitable intent.

CLAT seems higher risk but potentially higher return but probably not worth it compared to a CRUT which is more simplistic.

Still trying to figure out the NPV comparisons over 20 years.

 
Was eventually hoping to achieve a CABG (Compound Annual Growth Rate) of 7% but with the horrible state of the current US/Western economy, all bets are off.

Assumption of just CABG of 7% without extra savings at the current market cap (assuming it doesn't get back to previous high):

1) 13.91M
2) 14.88M
3) 15.92M
4) 17.02M
5) 18.22M



Assuming market grows from reduced 13M at 7% and assumption of 200K extra savings:

1) 13M * 1.07+.2= 14.1
2) 15.29M
3) 16.56M
4) 17.92M
5) 19.37M

I wouldn't assume past 5 years at this point.
Bro these are just numbers at this point..past 5M it’s just numbers on an account you’re way overthinking this unless you’re an extravagant spender..
 
This doesn't really compare the CLAT vs CRUT idea well but I would assume CLAT is higher risk due to sequence of returns risk when setting the up the charitable intent.

CLAT seems higher risk but potentially higher return but probably not worth it compared to a CRUT which is more simplistic.

Still trying to figure out the NPV comparisons over 20 years.

If you are thinking of CLAT vs CRUT as asset protection vehicles (I wouldn't think of them as investments), a major difference is that CLAT is not tax-exempt.
 
Thanks for the thoughtful response. There are a few deeper questions I have related to the information I read online from your website/Vanguard/etc.

1) I have both good umbrella and malpractice policies. Since I am working at hospital too, I think they would have liability in a malpractice case as well.

I don't have any "toxic" LLC assets. The LLC/DAPT method has been suggested to do in a state such as Nevada to place
a) Brokerage Accounts into the LLC, House into another LLC, etc. Then all placed into the DAPT
b) If doing a "hybrid" system such as noted on your website, there would be a "trigger" to an offshore option if they got through both malpractice (above limits), hospital insurance and LLC/DAPT with a "results oriented" judge". You get different opinions from different "asset protection" attorneys on this subject. (Many of the notable ones on your website contradict each other on this topic about if a DAPT will fail under federal law, offshore efficacy, etc). The "offshore" option is seems too expensive outright considering upkeep costs (Trustee such as Southpac in NZ, Swiss Account, etc) but makes sense if "under attack" as a trigger (very low chance ?)
c) Supposedly the LLC/DAPT method doesn't change tax policy as a "grantor" trust
d) I know the stats you give for "over the policy" lawsuits but this includes all doctors (many of which have no assets) so its hard to fully tell the outcomes for a higher net worth physician who is sued above policy limits (very opaque).

The IDGT/SLAT method would be helpful if assets are above the future estate deduction limit (6.8 million with inflation adjustment per person by 2026 so effectively 8 million each or 16 million for 2). Many of the assets are already in irrevocable trusts that have a supposed "300 year clause" through Florida. Estate tax has been managed pretty well right now unless my personal assets double in the next few years (unlikely) I think.

2) This is an unknown factor since I can't really tell how long this will last (reimbursement collapse, Medicare in bad shape, etc):
a) When reading CPA organizations related to "service based S corps" (unlike White Coat Investor that gets its money differently), the rule of thumb is 60% W2 and 40% K1. So basically 300K of distributions or so. Considering the employer portion of Medicare is a deduction, we are talking about a 2% savings on 300K at 6K. But the costs of an S Corp, extra CPA fees, etc will cost 3k+ so the profit margin seems to be only 1-2K with a decent amount of work?

3) Thanks for the CLAT vs CRUT discussion. It doesn't explain it fully for me though. The CLAT was a good vehicle to attempt to get around the "estate tax" getting over a "hurdle" rate that was quite low before interest rates were going upwards. It was an estate planning vehicle for the VERY rich until probably recently with high interest rates hurting the "hurdle rate". (Zuckeberg used a GRAT for fast appreciating IPO stock to get over the "hurdle" rate, this is far less effective now since interest rates are up and asset growth is down, effectively causing a bigger problem then it solves for the very rich going forward).

For me, I can get around the estate tax. So the real question is the NPV value of CLAT vs CRUT over 20 years (max duration of trust).

The CRUT would be utilized to "stretch" an inherited IRA from 10 to 20 years (compared to the new SECURE act guidelines) which would lower the marginal tax rate coupled with some charitable deduction producing a high NPV then just taking it out under the SECURE act at a higher marginal tax rate.

There is talk about "Shark Fin" CLATs that can produce higher NPV results then CRUTs but it takes complex math to determine the veracity of these claims (plus gambling on return rates and when the return occurs)

Would you know of anyone that would be able to answer these questions? I have difficulty finding professionals that are able to discern this.

4) I will probably add a DB plan this year. The problem with DB is:
a) Slower Growth rate for Cash portion (potentially can roll over to IRA every 5 years or so to put into better growth options?)
b) Running into SECURE act issues for inheritances (if this is an issue for kids?)

Obviously this is predicated on remaining at a higher income for the marginal tax break benefits (possible to drop in half in the next few years).
2. Yea, it's just a few thousand a year here. Probably irrelevant for you at this point.
3. NOt enough of an expert on these to really help you. Best to discuss with an estate attorney in your state.
4. I wouldn't expect any sort of inheritance issue with a DB plan. It would just go into an inherited IRA.
 
Set up an LLC in Delaware and put your brokerage assets into it. It's firewalled off effectively and requires no crazy schemes. If sued you simply don't take a personal payment and their charging order can't take it unless you do. You can siphon it thru other Entities and what not. Play the long game if necessary.

It becomes pointless for anyone to pursue it as they will never see a dime. Thus it leads to a settlement more effectively now.

Your home is in many states protected by a homestead act.

If you have tens of millions you can get fancy.
 
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