NP Practice Owners : Cultural Issues

Politics and Practice

Gretchen Moen — Mon, 26 Jan 2009 14:06:00 GMT

I started this last month and was called away to care for my father. These are a few of the thoughts that fill my head when I look to the future of my practice and my profession.

On the heels of an historic election, we continue to fight the good fight. Politics is as important to your practice as education and equipment. Whether we need to be "politically correct" in approaching a problem with our peers, are involved in the latest catastrophe on the job or observe what is happening with health care reform around the nation. It is time for all of us to take notice of what is going on in the political arena and make our voices heard.

I recently read the "resolutions" approved by a state medical group. The current group of resolutions includes one that hits close to home. This group is seeking legislative support requiring all insured persons to identify a "medical home." This primary care provider would be the "gate keeper" for referrals and preventive care as well as case management services and education for chronic health conditions. (Sound familiar?)

While I applaud this idea (once again), I am very angry and a bit nervous about their insistence that, while nurses, nurse practitioners, physician assistants, physical and occupational therapists and mental health providers may be involved in the care of a patient, the physician must be designated as the "team leader" and in charge of the Medical Home. If you own your primary care practice, you may want to keep your eyes on this.

A newsletter from one of the larger medical insurance companies crossed my desk this past week. They are rolling out a new program that will provide their members disease management services. The company will assign a disease management coordinator to the patient when they have received a diagnosis. The patient can call this person and ask questions about their condition and ask for recommendations for treatments that would help the patient in managing their condition including information about prescribed medications, outside interventions, diagnostic tests or procedures and expected course of the disease or condition. Patients would be given pricing information so they could choose where and how they would like their condition to be managed.

I am encouraged by this company's effort to help their members manage their conditions. I am fortunate to be able to provide this information while I care for the patient in my office. Nurse practitioners have recently received a 15% reduction in reimbursement by this company due to economic woes.

Individual states are working on health care reform. One of the proposals that captured the attention of the legislators involves identifying "baskets of care" for certain diseases and conditions and encouraging health clinics and systems to set pricing based on the elements included in these baskets of care. Consumers would have another piece of information when choosing their health care providers -- pricing. It is similar to "capitation" processes of yesteryear. The state awarded a grant to three organizations to help define the criteria for each basket of care. None of the organizations represents advanced practice nurses.

I am excited about the general direction that health care reform seems to be headed -- greater patient control and responsibility, access, medical homes, programs for underinsured and uninsured, abolition of health insurance, single-payer systems, focus on wellness and optimum health achievement, health education, and all the elements of NP practice. Changes in leadership of our country have brought bipartisan hope toward a better future. We cannot be silent in the coming days. We cannot be left out of the decision making. Keep your eyes and ears open, listen for opportunities to make your voice heard. Do big things in small ways.

As a business owner, I am worried about the economy and its impact on my business. As a health care provider I am encouraged by the potential for real reform. As a nurse practitioner, I cannot be silent and see what may pass my way. As the CEO I am the visionary. I encourage people to be what they can be. Make your own destiny.

Rah! Rah! Rah!

Marketing the Old Fashioned Way

Gretchen Moen — Wed, 17 Dec 2008 13:01:00 GMT

This is a busy month for all of us. One of the biggest events we host during the year is a holiday open house. It started out as a way to get new patients to visit the clinic, take a tour and have the opportunity to ask questions about our practice. It has evolved into a way for us to say thank you to our patients and community for supporting our efforts the past year.

The "reindeer party" is a big event. As soon as school resumes in the fall I get calls and questions about the party and the reindeer. We have had real reindeer with sleigh rides every year. (The reindeer are in training and are unable to fly so this seems to be OK with the little ones.)

I call the local high schools and ask if they have anyone who would like to be Santa and his elves. I try to get the music departments involved but run into conflicts with school programs. We contact the county Early Childhood Special Education team to provide crafts and information about their programs during the party. We have had guest authors, illustrators, musicians, storytellers and a book fair. The proceeds of the book fair are donated to the ECSE programs.

Our community fire truck and firemen pay a visit and present a quick fire safety program for the kids. The county health department is involved, and this year they brought a vehicle crash game to illustrate the importance of proper car restraints. We invite a variety of local businesses to promote their products or services and have hosted massage therapists, Mary Kay cosmetics, family fitness centers, book vendors and chiropractic services.

Kids are encouraged to write a letter to Santa, and our staff looks forward to responding to the letters. This year, one of our 8-year-old patients thought there should be a coloring contest so she brought 5 designs and markers for the party participants. Her mom told us that the girl came up with the idea on her own and insisted on bringing her own markers!

Each year we have numerous volunteers offer to help with face painting, refreshments and traffic control. The event is scheduled for two and a half hours on a Thursday evening, when we would typically be open for business.

Promotion for this event is tricky as we usually do not have extra money for advertisement in the budget, so we include fliers with our November statements, a note to the "community happenings" section of the newspaper, a message on the Web site and distribute cards or fliers to businesses nearby. Families take fliers to distribute to friends and bring around the neighborhood.

We spend a lot of energy and time thinking of ways to promote what we do when a "simple" community party can have the same result. I did not keep an accurate count, but I estimate there were over 200 guests at the party. In the past we have had as many as 500+guests. In a small office like ours the benefit of gaining one new family to our patient panel because of the reindeer makes it all worthwhile.

Happy Holidays and Best Wishes for the New Year!

Administration vs. Practice

Joseph Marra — Thu, 09 Oct 2008 11:39:00 GMT

Owning your own business comes with many challenges. Including, managing the practice as well as seeing patients. Although I love seeing patients, I also enjoy spending time managing my own practice. This includes hiring, advertising, determining hours of operations, etc...

After practicing for several years now, I have come to really enjoy the administrative end of the practice. In fact, I hired a CRNP last month and am now in negotiations for another psychiatric CRNP to start within the next couple of weeks.(If anyone that is credentialed in Pennsylvania is interested........)

I would really like to move in to the administrative end of the business. This not only allows me to keep close tabs on the business, but allows for employment opportunities and population awareness. I feel strongly that the more of us that open our own practice and pave the way, the more acceptable, or could we say "standard NP practice" would become mainstay medicine.

I have seen a huge difference in reimbursement as far as insurance companies that will credential NPs since I first started. We are on the cutting edge of change in this country. Some of us must work for others for now, depending on their situation and state regulations, and others may find the opportunities available for self-employment. Some NPs may even be happy working for someone else.

However, we can all make a contribution to our profession by talking to legislators and lobbyists. If the time permits, do what you can to make a change. We are far from "total" independence at this point, therefore we must continue to face the obstacles and overcome them one at a time. We have obvious opposition who want us to fail. With so many seeing the benefits including cost effectiveness accompanied by care and compassion, a positive change is inevitable.

We are also faced with voting for a new President at this point. Who can benefit us the most with our profession? The debate is still out on that issue, in my book. It is unfortunate that so much is involved in voting for the next president. Consideration must be made in regard to the financial stability of our country and even the world. War is another hot topic. Do we continue in Iraq until the job is done or do we withdraw troops so that our young people do not have to face continued tours of duty and risk of life or limb? What of Afghanistan? Are we spreading ourselves to thin? What of the environment and even our addiction on fossil fuels?

So many major issues to consider at this point, may make our drive for independence and our place in this world seem small. Though these are some major topics on the political trail, health care is also very important. Health care is fortunately on the table, and reform may indicate a much needed revision with current health care, including NPs.

So maybe our drive is not so insignificant after all, you be the judge.

DNP?

Joseph Marra — Mon, 14 Jul 2008 23:51:00 GMT

There have been numerous accounts of NP opinions on thecontinuing education and creation of standardized DNP programs. We have allheard of the pros and cons of each camp and must make a decision on whether ornot this is beneficial to our profession.

I for one am in favor of this endeavor for many reasons. Imust first remind you that I own and operate my own practice and would be thelast person many would find continuing on this path. I already have as muchautonomy as any NP can have, and yet now that a doctorate program is availableto solidify my profession, I am forced to act.

I feel it necessary to have the credentials that we alldeserve. It seems to me that those who hold the highest level of education getgrants easier, are asked for their opinions more often, and are generally moreaccepted into research.

Many professions are going to doctorate programs, and seethat this level of education invites respect and credibility. I can think ofmany professions that are not MD/DO, where it is acceptable for the individualto call themselves “Doctor.” A psychologist, chiropractor, and collegeprofessor are just a few.

If you have spent the time and money to obtain this level ofexpertise in your field of study, then I feel you should be permitted to referto yourself as “Doctor” as long as you advise the individual of what you have adoctorate in.

I don’t pretend to be an MD or DO in my daily practice. Infact, I currently have many safeguards to protect me from this. At thereception area I have pamphlets that educate patients: “What is a NursePractitioner?” I also have my office staff simply address me as “Joe” andintroduce the patients to me as “You will be seeing Joe, our nursepractitioner.”

Many patients insist on calling me doctor, and I continuallyhave to correct them. Patients want to give you the respect you deserve, but ifyou don’t own the title, don’t use it!

When I complete my DNP program I will be addressed as “Dr.Marra, our nurse practitioner.” I will have earned the right to use the titleat that point and intend to use it. Many of my physician colleagues often liketo introduce me as doctor and cannot; however, they actually welcome thechange.

But make no mistake I will never portray myself as an MD or DO! I like who I am andwhat I do. NPs do a similar job and have an uphill battle educating andfighting for all that we have. An MD/DO can simply open up shop and go to it. Ienjoy the challenge. The NP profession is on an uphill climb, but we arechanging this daunting task, one patient at a time. Also I have seen manyresearch studies recently that compare MD/DOs with NPs, and the results are eyeopening.

How many times have you seen surveys that ask, “Out of allthese professions who would you trust the most?” Nurses are always the numberone answer! Why would I want to be anyone or anything else? We have the best ofboth worlds.

In my opinion, the DNP should not be mandatory for those whohave been practicing and established for a certain time. I of course am noauthority in this area but feel that a grandfather clause should apply. Thiswould most likely lessen many opposing opinions that current NPs have. I agreewith the notion that those who have been practicing have proven that they canpractice safely and effectively and require no further education to providecare that they have been providing for years.

I also feel that we have to start somewhere, and the bugsshould be worked out by our certifying bodies. We as a profession need to cometo common ground on this issue. A change is inevitable, and input is alwayswelcome, hence the discussion in this forum.

Joseph F. Marra CRNP

Urgent Care Center (Owner)