Diabetes expert and practice owner KC Arnold, NP, explains that an insulin pump is like a "portable pancreas" in this news clip from the
local Ocean Springs, Miss., ABC affiliate. Click on Video Gallery to the right
of the article to watch the clip.
Maintaining contacts with the local news media is an
excellent way for practice owners to educate the public about healthcare and to
market their practice at no cost.
Arnold was named the ADVANCE for Nurse Practitioners 2007
Nurse Practitioner Entrepreneur. Read how she started The Diabetes Center in
the weeks following Hurricane Katrina.
What boosts your ego, gets you national recognition and is fun, too? Winning the ADVANCE for Nurse Practitioners Entrepreneur of the Year Award! At least that's what past winners tell me.
If you own your own business -- whether you see patients, provide education, sell a product; size doesn't matter -- consider entering the Nurse Practitioner Entrepreneur of the Year competition. Fill out the entry questionnaire online; there's nothing extra to mail in or upload this year. I've listed the "tough" questions from the entry form at the bottom of this post, so you can think about them before entering.
But first, read what past winners have to say about the award:
Scharmaine Lawson-Baker, NP Entrepreneur of the Year 2008: "[After winning] I started getting several opportunities to speak at various conferences as a keynote speaker. And I always seem to get whatever I want after giving a complimentary copy of my ‘cover' magazine to prospective collaborators and vendors."
KC Arnold, NP Entrepreneur of the Year 2007: "I will be sitting at a meeting sharing my story with colleagues about The Diabetes Center. Suddenly the nurse practitioner will look at me and say, ‘Wait a minute, I heard this story before. You're the one on the front cover of ADVANCE for Nurse Practitioners.' National Recognition: Priceless"
Teri Bunker, NP Entrepreneur of the Year 2009: "You'll feel like a rock star for a while. It has been a great boost for my practice and has given me a lot of exposure. My patients and family are very proud. It has helped me with networking and in growing my practice. I have attracted patients and quality employees because of the award. I have met people I never would have before and have been presented with opportunities that would never have come my way. It also helped me to get noticed for the Outstanding Alumni Award. It's just been a great ego boost and a lot of fun."
And that's not to mention the grand prize of $1,000.
Here's a preview of the entry form:
- Why did you create your business the way you did? What gave you the idea? What in the marketplace led you to believe your business could succeed?
- Describe your patient/client population, practice/business niche and average number of patients/clients per week.
- List your start-up costs and sources of financing. Have you paid off your initial business loans or financiers?
- Explain the current financial health of your practice/business.
- Are you earning a salary from this business?
- Describe your marketing activities.
- Give examples of challenges your business or practice has faced and how you've overcome them.
- Explain how your business or practice goes "above and beyond" to reach out to the community.
- Describe novel approaches your business or practice takes to improve productivity and patient outcomes.
- In what ways does your business or practice implement "gold standards" of care and new technology?
This article was written for physicians, but the information would apply for nurse practitioners, too. It stresses checking out the books and considering just what part of the practice you're purchasing. And if you're looking for a buyer, a hospital is a good bet.
Has anyone bought or sold their NP-owned practice?
If you're interested in starting your own practice but have no idea where to start, check out this free phone seminar. NP practice owner and business consultant Barbara Phillips will be hosting a seminar "Getting Started in Your OWN Practice" this Sunday (April 25) at 8 pm Eastern time. Register in advance online, and then call in for the free seminar.
Phillips will cover the following topics:
- What MUST be done before anything else. Failure to take these steps WILL decrease chance of success.
- Ideas for financing.
- Strategies to bring on a collaborating physician.
- The easy way to get credentialed.
- How to get paid.
- The kinds of business and practices that are available to NPs.
- What an NP business owner's real job is, and it's not what most think.
This week we are testing an integrated billing system to use with our EMR. Last week I had the opportunity to view three EMR and billing systems. I felt like Goldilocks and the three bears: One was way too expensive and required little effort, one was so complicated I was lost on the log in page, and the third was "just right" -- integrated billing, Internet based, fairly straightforward, ability to customize, fairly "cheap", etc.
Some of the newer programs allowed for feedback to the provider regarding their coding. If the documentation did not support the level of service the provider selected, an alert appeared that advised the provider to review the documentation and modify as needed. Some were so sophisticated I was expecting them to make coffee and schedule my dental apts.
Elements that were very important to me were ease of use, ability to retrieve data in a meaningful way, logical organization of patient records, ability of system to allow nonprovider and provider to see same record, and ease of transmitting to other locations. I was exhausted by the end of the day.
We have decided to stay with our "free" EMR and look for billing programs that may integrate with what we have. That may seem like a logical move, but it is not without its costs. The advantage is that we do not have to sign a long-term contract; we can "try it out" with one of our providers, and we can add providers on a rolling basis. There is no cost difference or price break for part-time versus full-time providers. That could be a problem for smaller practices that employ part-time or volunteer providers. In our case it will run approximately $600 per month without our very part-time providers.
This week we also hired an IT consultant to evaluate our existing hardware and software and make recommendations for modifications that will speed up the system, develop a secure internal wireless network, advise on what type of net book or note pad devices that would best suit our needs and maintain the system. I am thrilled that we can finally find someone to take on the computer systems as we have been flying on a wing and a prayer for the past couple of years -- when our previous IT group went out of business.So, at the end of the first decade of the 21st century, we finally feel we are a part of the age of technology. Hey, anyone know how to program this new keyboard phone thing?????
It has been a very busy fall for ECFC. In addition to general patient care and all the day-to-day administrative issues, we are faced with another task. The state of MN has mandated that all recipients of state-sponsored health insurance have access to and are members of a state-certified Health Care Home.
Eagan Child and Family Care is one of 15 recipients of a grant to attend the Institute or Family Centered Care Intensive Training session at the end of this month, in preparation for meeting the requirements to become a certified health care home. Our plan is to meet these requirements over the next 90 days. We are fortunate to have a DNP student who is helping us with this process as part of her doctoral project.
There are a number of agencies that offer some type of Medical Home or Health Care Home certification. Along with the State of MN, The National Committee for Quality Assurance (NCQA), The Joint Commission Accreditation on Ambulatory Care and Hospitals, Bureau of Primary Care/Health Resources and Service Administration, Medicare CMS Demonstration, and other state agencies. Some of these groups have fees associated with the process.
Criteria for certification for Health Care Home/Medical Home are slightly different, depending on which agency is involved, but there the basic requirements to measure performance are in these critical areas: patient access and communication, patient tracking and registry functions, care management, patient self-management, test tracking, referral tracking, performance reporting and improvement measures, electronic prescribing and advanced electronic communications. Within each of these areas there are components that are considered key and some that are highly recommended. Minnesota is developing a process to reimburse providers for care coordination services in an effort to defray the actual and potential costs of implementing and sustaining health care home services.
Care coordination, collaboration, patient centered care...these are the foundations of NP practice. I know the way we deliver our services is not going to change, more so the way we track and monitor the delivery of those services. I will keep you posted on our progress!
We've noticed just a couple of practices across the country that are turning to a so-called membership plan to help curtail costs for patients. The model requires patients to pay a flat rate monthly or annually and then covers office visits, routine tests and the like.
All the coverage I've seen of this model is careful to emphasize that this is not an insurance plan. If it were deemed insurance, a whole host of regulations would apply.Here's a nice local news clip of a physician-owned practice in Utah that has implemented the membership model. What do you think? Would this be beneficial for your patients and practice? Would you risk the insurance-regulation implications?
This past month we have been working toward dragging our office into the 21st century. As I have mentioned in the past, the state of Minnesota required all healthcare providers to have electronic billing by July 15, 2009. In addition, EMR is an essential component to healthcare home designation. Hence, July and August have been somewhat more chaotic than usual.
In July, we were able to register for the "free" electronic billing option offered by the State of Minnesota. It works very well but requires us to double key all data, first in our practice management system then in the billing system. Someday we will be able to have a system that does both, but for now, free is good. Our EMR is also free and online. The advantage of an online system is that the data is stored off site so daily backup runs are not necessary. A second advantage is that clinicians can access the records from home as well as the office.
The first week we had EMR (August 1) we just entered the demographics and continued with paper charts. The next week we had all new patients on the EMR system and the old patients with paper charts and entering the newer notes in the system. That actually took us a couple of weeks to do.
At the end of last week we started scanning in documents from the old record. This looks like a bit of a challenge, especially with my special needs kids who have care plans updated every 60 days.
All in all, the front staff is excited about the move toward electronics, but the provider staff has their concerns. It's a bit cumbersome and can be uniquely tailored to the individual provider but not the practice as a whole. I have yet to discover all that it can do, so this may be a feature that I haven't found. For those of you who are of my generation and my computer comfort level, the support both online and via phone calls, is excellent!!
In the future we hope to have an EMR, billing and practice management system that is fully integrated and will communicate well with the outside world (hospitals, specialists, etc.). For now, it will take extra work on our part to manage the separate systems. I shared with our patients the "exciting" news of our EMR. The response is mixed. Some see it as a step toward the future while others see it as a loss of our "small town" image. We will just have to keep serving tea!
I am sitting through my DNP program here at Robert Morris University, educating myself for a better tomorrow for myself and my patients. This is my second year, and I am projected to graduate in December of 2010.
There is a current debate over the need for a DNP within our profession. I must tell you that the further along I get into this program, the more convinced I am that the DNP role is absolutely needed in our current society.
I was an advocate of DNP programs even before I began this trek. I've heard arguments on both sides of the issue, and I have yet to find a definitive reason for not continuing on this logical path. If you are a nurse at any level -- CNA, LPN, RN, NP, or DNP -- you must ask yourself if you would like the opportunity to be represented as a profession that allows for advancement and change.
Out of all the credentials within this profession I held CNA, RN, NP, and intend to hold the DNP credential in a little over a year. Therefore, I am in a unique position to evaluate the need of this profession. I can tell you that we are all part of something bigger than ourselves, and sometimes one must think outside the box and welcome change if the opportunity presents itself.
In order to make changes in any profession, I feel it wise to allow those within a profession that can have a better understanding of the problems and needed changes within that profession to debate the topic at hand. We the nurses should be debating and adding our personal experiences along with education and current research to influence the changes ourselves. We are in the best position to assess the need for change regardless of what that change is.
We should not allow those such as legislators and government officials to make decisions on matters they have little or no understanding of. We really need to be educating our representatives and senators about who we are and what we do. Before we can do this, we must educate ourselves and therefore broaden our own awareness of where we are and where we are going.
For example, we look to those with advanced education for their expert decisions. Lawyers look for those who are in the highest degree of education within that body of knowledge for advice in legal matters. Just as research studies are valued more so with one who holds a PhD rather than someone who does not. I feel it very necessary for us to consider supporting the growth within our profession regardless of what level of education that we decide to occupy.
I would advise you to get online and check into how many nurses are in the United States. The number when you add up all our levels is staggering. Imagine the power behind the people (nurses) if we would all band together with this one common goal. Once we unify for a common goal of assisting one another in changing certain aspects of each level, we would have a significant number of voices and therefore an unimaginable influence in being heard.
This is our profession; we ought to demand the highest level of education within that profession. This allows the flexibility of choices for many levels of education and yet legitimizes this profession as one with an expert opinion. I am not suggesting that we all agree 100% on everything within this profession, but debate what is in the greatest good within our profession. I do, however, implore you to consider the implications of the influence we as a common body would have to make changes as we the nurses see fit.
Should you open a practice? If so, what kind?
During these unstable economic times it is difficult to decide if now is the time to take the risk and open your own clinic. A stable job with a guaranteed hourly wage is tempting. Even if it means you are working for someone else and have to punch a time-card.
Still, in the back of your mind you might wonder . . . Can I do this on my own, will my own place pay off with a better salary, flexible hours, and the satisfaction of business ownership? Or will I struggle to make payments and go further in to debt? This worry is complicated by whatever health laws are going on at the government level (I have lost track of it lately, all I know is that there is a lot of confusion and a lot of anxiety regarding healthcare in America).
Through my experience I hope to give you an idea of what you can do to make it on your own.
I own two distinctly different clinics in Utah. My first clinic is Pace Clinic. It is a small retail-type clinic in the back of an independent pharmacy. It is an 11' x 11' room with a reception desk in front of it. Rent on 121 square feet is minimal. I have good traffic since the pharmacy customers have been coming to this pharmacy for years. I have little overhead and no debt with this clinic. At this clinic I accept insurance and have a special prompt-pay discount for those who are self-pay. It is convenient with walk-in only appointments.
My second clinic is called Nucea Health and Fitness. It is a much larger facility (2,100 square feet) and is scheduled by appointment. Nucea includes a couple exam rooms, a room shared by a physical therapist and chiropractor, a massage room, a small OTC area, and even a gym with a full weight room, circuit line, treadmills, bikes, ellipticals, etc. I am very active and do triathlons, so Nucea was built with everything I needed to "stay in the game." It is my dream business.
One of these businesses gives me an income of over $120,000/year after all expenses,and the other has never shown a profit and is sucking finances from the other clinic. It is probably easy to guess that my little 121 square foot Pace Clinic is making me rich, while Nucea (designed for me) is costly and has yet to turn a profit.
So, the moral of the story is first, start small. Don't overspend or overbuild. Stay within a small budget. Grow with your business, rather than starting at the top. Secondly, direct your clinic to what people want, not what you want. I prefer working at Nucea because it is large, has a gym I work out at, I have my own office, etc. However, I made Pace Clinic affordable, convenient, and mom- and child-friendly. This is what my patients want and has turned this small one room clinic into a success.
--Aaron Hartle, FNP
* Note, the more successful Pace Clinic is for sale for which I guarantee at least a six figure income. If interested please call Aaron @ 801-491-2238 for details. I can also help start up your own clinic including ideas, location, credentialing, regulations, etc.
I spent the morning going through the submissions to the 2009 NP Entrepreneur of the Year competition. I was struck by how many of the entries are from very new practices: Just over a quarter are a year old or newer.
Of course, we have a special judging category for new practices, which encouraged new owners to enter, so our submissions might not be representative of NP-owned practices as a whole. To confirm the my impression, I checked some stats with our 2009 National Salary and Workplace Survey.
We're still collecting data, but based on responses from almost 1,100 NPs from so far, it looks like 22% of NP-owned practices have been open for 1 year or less, and the median age of NP-owned practices is 3 years. That makes sense when you note that the number of NP-owned practices has been increasing. Compared with all NPs, the number of practice owners is small but growing, up a percentage point from 2 years ago to 4%, according to our survey so far. The exciting news is that more than 10% of respondents said they plan to open their own practice in the next 5 years.
So what about older practices? One respondent listed a 25-year-old practice, and 15% indicate that their practices are 10 years old or older.
Finally, according to the survey so far, 57% of NP practice owners say they are very satisfied with their jobs. And they should be: The median annual salary for NP practice owners appears to be more than $109,000.
If you haven't yet, be sure to fill out the survey at http://nurse-practitioners.advanceweb.com/Article/Nurse-Practitioner-Salary-Survey.aspx. The more responses we get, the more reliable the data!
A few posts ago I wrote of adding alternative healings to my practice. Well, I must tell you that it has become a significant part of my practice now.
Many people are looking for a more natural approach with less medication, and Reiki Energy Healing and Hypnotherapy has definitely fit the bill. I continue traditional medicine, of course, however I blend the two together creating a more holistic approach toward the healing process.
As it is widely understood, individuals need to take a serious approach towards their own health care. The complementary approach allows just that. Many individuals can now have a choice in the avenue of healing, and many research studies show the benefits of these alternative therapies such as hypnotherapy, visualization, meditation, etc...
The mind, body, and spirit approach has always interested me, and now that I have an independent practice, I can implement these alternative therapies for patient choice. In fact, I linked my http://www.urgentcarecenter.us/ site with http://www.secretsofhealing.us/ to allow patients to review this information and allow them to decide on their own, if the information is suitable for themselves.
I of course do not promote one modality over the other, nor do I believe in every aspect of either modality. I simply present the information to the patient, evaluate their particular belief system, and tailor the plan of care by utilizing my experience in mainstay medicine and alternative therapy that best suits each individual patient.
The only major set back to holistic medicine is the lack of reimbursement via insurance companies. However, since many employers are providing less and less coverage to their employees, or individuals simply have no health care insurance, this kind of balances the scales per se. I must honestly tell you that a large portion of my practice is cash based. When patients are faced with alternative therapies or traditional medicine, they generally choose the alternative route.
Advertising has always been a difficult area for me. I know I need to spread the word about my clinic, but I cringe at the amount of money it costs to advertise. Despite all the money spent on advertising, I have found that word-of-mouth contacts are the best. To increase the chance that my patients will tell others about my clinic, I have purchased three tools or "toys" as my wife calls them. Despite the initial investment, I have had great success with them as an advertising tool. They are a digital camera, a stethoscope and a digital otoscope. I will explain how I use them, then how they catalyze advertising.
I bought a Nikon digital camera for about $100. Whenever a patient comes in with a rare rash, a gaping wound, or a cool symptom, I ask if I can take a picture. I print them a copy and offer to e-mail one as well. They also have the option of having the picture put on the Web site. Recently I had a patient with classic hand-foot-mouth disease. His mom was excited to have the picture for her records. She also thought it would be cool to have the picture put on the Web site so she could have all her friends go to my clinic Web site and see the picture. This led to increased traffic to my Web site and to the clinic.
I spent around $400 on a Littmann electronic stethoscope with recording capabilities. It may seem expensive, but I spent more than that on my last one-day newspaper ad. When a patient comes in with a heart murmur or crackles in the lungs, etc., I beam the recording to my computer and play it back for the patient and family. They appreciate the ability to hear exactly what I am talking about. This also leads them to tell their friends about this toy and what they heard. I can also send them home with a copy of the recording.
These can get pricey. I wish I had purchased the Welch Allyn Macroview version for $900. However, I went the cheaper route and bought a dino-scope for around $300. Anyway, parents love when I can show them a picture of their child's swollen ear-drum on my computer screen. Most of them never knew what it really meant when their son or daughter had otitis media. I print and e-mail them a copy. These pictures usually get forwarded by them to their family, friends, etc., to show off the red, bulging TM. Then when a neighbor says, "I think my son has an earache," the current client will tell them to come to my clinic where they can actually see it for themselves.
These tools have increased my business substantially. As you consider them, don't forget your state's HIPAA and confidentially laws. A waiver should be signed before taking a picture or recording and especially before e-mailing any patient information or posting any pictures, sounds, etc. I always make sure to have the waivers signed and to not include any identifying information with the digital media.
So, if your are looking to increase your clientele, for less than $1K you can buy these tools and jump start your word-of-mouth advertising, or you can put two ads in your local paper.
Aaron Hartle, FNP
Owner Pace Clinic and Nucea Health and Fitness
Summer is rolling along at ECFC. Thankfully, our June has been busier than May was. Within the next three weeks our state has mandated that all medical claims be filed electronically (July 15). The state has contracted with an organization to allow free access to their Web-based e-filing system. We are awaiting approval to go ahead and begin e-filing, but it seems like we are cutting it rather close.
In addition to e-filing, we have been looking at some Web-based electronic medical records and practice management systems. I will keep you posted. For those of you with little money to throw around, there are some free, corporate sponsored, EMR systems available which may be a way to get started.
I have been asked to represent my state nursing association on the Health Care Home Payment Methodology Steering Committee. Lots of words to say that we are charged with defining what constitutes coordination of care, which patients benefit from care coordination services and how cc services will be paid for.
The Health Care Home model is very hot in Minnesota. The thought is that by having a designated health care home for patients with chronic illness or at risk for chronic illness, health care providers can develop care models to include case management services within the primary care clinic and eventually lead to improved health and decreased medical costs. Care Coordination services are costly and have not been well defined in the past. It is believed that most primary care clinics provide some type of cc. Having a uniform definition of these services would help to guide primary care clinics in developing systems that would include all of the components of care coordination as defined in the Health Care Home mode. There are a number of agencies that have developed a process to "certify" clinics as Health Care Homes, most recognizable is NCQA.
It is exciting for me to see that the state is insisting that clinics provide health care services that are consistent with the NP model of care. Care coordination is fundamental to NP care. Developing plans of care for individual patient conditions, facilitating referral to specialty care or therapies, reviewing the treatment plan and making changes, as well as follow up phone calls or contact with patients between planned visits... hummm sounds like nursing to me.
I will keep you posted on our progress.I am looking forward to July, with all its bells and whistles. On a final note about the budget - we were able to renegotiate our lease and got a modest rent reduction to assist with our 20% across the board cuts. Yay...slowly chipping away.
Seventeen months ago when I opened Pace Clinic I was excited to be out on my own. No more working for somebody, I could set my own hours, come and go as I please, and do my own thing. I have thoroughly enjoyed working for myself.
However, even though I no longer have (a) boss, I still work for now thousands of bosses (my clients). Sure, I can leave early when I want, come in late, or take an extended lunch break, but now that I have an established clinic in the community, my patients expect me to be at the clinic. I won't get fired for not being at work, but I may loose business, which leads to a loss of revenue, then maybe a loss of the clinic.
So, "just hire some help" you say, but that is much more difficult than it seems. Unless you have a lot of discretionary income, starting up a clinic is expensive. Many start out solo since to hire another practitioner can cost quite a bit of money.
In addition to this, most nurse practitioners in Utah where I work are not credentialed with insurance companies. They work for and bill under the doctor. So if I want to hire a practitioner, I have to get her credentialed, which takes several months to finally be on all the insurance panels.
Now what? I just do what many other NP's do, I work too much. I believe that anyone that works over 40 hours per week is overdoing it.
When I started the clinic I worked 64 hours a week just to keep things going. I am now down to about 50 hours per week and still think it is too much. Since I started, I have hit a couple of "burn-out" stages that I have had to make it through and have learned a couple of coping mechanisms. Here are some that helped.
- First of all remember, anyone can do about anything for a little while. At first, it may simply take a lot of hours to get a clinic up and going, but remember, being overworked is probably necessary, and should be temporary. Focus on the long term benefits.
- Exercise daily. That has been a good outlet for me and helps open my mind for the day. It also helps burn off pent-up frustration from the business, patients, etc.
- Eat right. You need all the energy you can to start up a business. It is not easy.
- Have fun. Turn on a radio in your office and dance for a minute after a stressful patient or watch a funny Youtube video then get back to work.
- Have a lot of friends. I love spending time with friends, so I treat my patients like friends - well, sort of. We don't go hang out, but when they come in to the clinic, we chat, talk about exciting events since the last visit, etc. Due to time pressures, we don't do it for long, but the patient enjoys the feeling that I care about them, and I like the outlet to take my mind off work if only for two or three minutes.
- Remember you spouse and kids. You probably can't take off work for every little thing, but if your child has a school play or a field trip, then go. If your spouse has a special appointment, take off and watch the kids so he or she can go. If you feel you are fulfilling your responsibilities in the home, you will feel better at work.
- Finally, remember, you can't do it all. Ask for help, take one day at a time, remember your own limitations, and don't sell yourself short to your new practice.
Aaron Hartle, FNP
Owner of Pace Clinic (Springville, Utah) and Nucea Health & Fitness (Lindon, Utah)