Sometimes I feel like I have nothing “new” to report to blog readers—yes,  we all get that.  Then  suddenly after a period of low profile, stars align and a clear re-visioning emerges that needs to be validated externally. 

That’s been happening for NNPEN over the past 6 months.  Our founding vision has been to connect NPEs w/ each other and with sustaining start-up resources.  But that really doesn’t describe an outcome, more like a process. We shifted gears to update the vision to something measurable: a performance metric.  Simply put, our vision has become to not only attract  as members NPEs who are assessing their readiness to be owners and connect them with each other; it will also measure the NNPEN model as an accelerator in the transition of NPEs into practice owners. 

We are betting the house on this re-visioning of  NNPEN  success.  Covid crises are terrible things to waste, and we haven’t.  During Q4 2020 we will greet a client’s inaugural NP cohort enrolled in a twelve-week Business Basics interactive online course developed by NPs and their advisors for NPs. The twelve-week course will be followed by a  period of mentorship that lasts at least through opening the NP practice’s doors.  Payor mix and sustainability of the practices will also be measured.

On the homepage of our website we share the question that has driven NNPEN from day one:

To preserve the benefits of nurse-led care, the number of nurse-led start-ups must grow substantially and operate sustainably…How will that happen?

We are getting closer to figuring out a cost-effective model to increase primary care access in this country:  our beta partnership of hi-tech Business Basics learning and lo-tech hand-holding is about to begin!  For all of us, it (hopefully)is a roadmap for proof of the concept that NPs’ cultural aversion to risk can be not only neutralized but leveraged to the practice and patients’ advantage.  

As I make calls to lapsed NNPEN members, I brace myself for recounts of how NNPEN has failed the member. Truth be told, those conversations still happen too often, which accounts for our 2021 strategic focus on how to enhance member-to-member dialogue supported by, but not filtered through, NNPEN.

But as Summer Solstice rolls over us and brings with it the temptation to believe COVID-19 is no longer a threat, what I hear in these calls is not how NNPEN has failed the member. Instead, it’s narrowly suppressed panic about whether an NP-owned practice will survive the pandemic. As of March 12, 2020, patient visits have plummeted in response to orders from state, local, and federal regulators to cease all elective and preventive care. FFS cash flow dried up [while cash flow for practices accepting capitation risk did not!]. One NP owner is in self-care retreat after watching her colleagues hoard PPEs. Some practices were not sufficiently insured by their business interruption policies, and face business recovery plans with a new appreciation for the impact of the “once every 100 years” event on supplies, medical records and patient access. All this is in addition to worries about patient and provider survival –literally—in the ongoing battle with an invisible virus that dares us to unmask.

Almost every practice owner I spoke with is planning to transition–partially or entirely–from brick and mortar office space to a virtual practice for some obvious reasons:

• Ongoing reduced costs.
• Telehealth has become mainstream, the quality of its encounters is “good enough” and improving, and cost is not prohibitive: the NP practice has choices.
• More patient access to the practice.
• More reimbursable patient encounters. [Will payors maintain their favorable reimbursement stance? Look to CMS but NNPEN thinks yes.]
• Less wear and tear on the practice owner.
• Less contagion risk.

What does successful transition from brick and mortar office operations to a virtual practice look like?

In May 2020, NNPEN invited Sam Lippolis, Telehealth Advisor, to get this conversation started with our Office Ours participants.

Click here to listen to the extensive and practical dialogue Sam provoked. If you are an NNPEN member, you may access the recording as often as you like, no charge.  If you are not a member, the recording is available to rent. 

With Sam’s permission, we’ve edited her remarks below. 

Shared Secrets for Telehealth (TH) Success

1. How do I grow my patient panel into a virtual practice?

a. Try Sam’s Post-it strategy to generate TH candidates from your current patient panel in 30 minutes.

2. Does my state’s regulations permit TH practice and reimbursement that is sustaining?

a. See the State by State map on Sam’s website.

3. Telehealth device options?

a. Integrated w/ EMR in one platform.

b. HIPAA-compliant Zoom=$199/mo.

4. Integrating telehealth [TH] into my current practice: how to work the virtual and the face to face practices together?

a. Workflow: being on time matters; it’s annoying to sit in any waiting room!

• Schedule TH visits first thing in morning and after lunch.
• Pre-visit prep!

b. Risks of blocking virtual time on your calendar:

• Not enough virtual patient volume.
• No room for non-virtual patient complaints assessment.
• Until you build volume, don’t do dedicated time blocks.

c. Phased approach to reach ideal schedule!!

5. Training and testing.

a. How does the patient connect to telehealth?

• Patient & practice support.

b. ALL staff need to understand the workflow/be comfortable w/ TH so all staff need training.

• Scripts [choreographed dialogue] are part of the preparation of staff.

c. Don’t waste billable time because TH access is untested on either patient or provider side.

d. Multiple practice sessions with different devices in different settings.

• Discover Internet dead spots in home and office.
  You may need to toggle between 2 different devices: ipad to see patient and EMR too.

6. Virtual patient visits volume.

a. Need to keep up volume to get comfortable with virtual encounter.

b. Virtual visit etiquette FAQ should be created for patients and staff.

c. Goal: 5 virtual visits/week.

d. Patient acceptance of virtual visit depends on how invitation is worded and if the practitioner extends the invite: 30-60% increased acceptance if practitioner, not staff, extends the invite!

7. Work-life fit.

a. Invest in attractive virtual practice setting aesthetic.

b. Good lighting, private space, not cluttered, quiet.

c. Breathe deeply!

Action Cures Anxiety

We are planning an invitation-only virtual Office Ours on July 28, 2020 8:00 p.m. Eastern. This program is for NNPEN member-- past and present --practice owners who are at that fork in the road called Virtually Brick and Mortar. Virtually Brick and Mortar is built around a presentation created by American-APN called “Integrated Digital Healthcare: Technology in the Time of COVID-19.” Part of the program has been approved by the North Dakota Board of Nursing; NNPEN practice owners --past and current members --who attend will receive 1 CEU. The discussion will explore how the evolution of nursing has prepared nursing to excel in this turbulent time, as well as the role technology and the digital experience plays for patients and providers. Additionally, we’ll take a closer look at independent practice and the nurse practitioner entrepreneur. Nurses who have been delivering virtual care and contributing to the development of a platform that integrates the electronic health record, telemedicine technology, and the technology to deliver remote patient monitoring through advanced Bluetooth technology will be available to answer your questions. Transitioning from brick and mortar by integrating telemedicine into your practice can serve as something of a lifeline. Let us give you the information you need to make it work quickly for you. Indicate your interest by clicking here.

Finally, is there NNPEN member interest in a Transitioning My Practice support group facilitated by a fellow NNPEN member? We know you may not have an ounce of energy left over at the end of the day, but support from a like-minded community is more than gratuitous—it’s critical! We know attending one more Zoom session may not be part your summer plan.  However, if you are interested in a Transitioning Practices support group, click here. No pressure!

In the meantime, remember Yogi Berra’s advice: “When you come to a fork in the road, take it!” While wearing your mask, of course!

Stay healthy—we need you!

SB

Sandy Berkowitz
Co-founder and CEO NNPEN

I’d like to recreate for those NP entrepreneurs who didn’t make it to Blueprint for Success: Building and Growing Your Home-based Primary Care Practice the energy and synergy that fueled the content of this February 2020 debut conference collaboration between NNPEN and HCCI—and what it can mean for you and for continuity of service homebound patients. And as luck would have it, Joe Flores, NP and attorney, set the table for us on starting house call practices the month before at our January 21 Office Ours virtual meeting.  Bottom line, you need to do some self-scrutiny before jumping in with both feet; the home-based care setting presents challenges. Joe was enthused about house call and HBPC opportunities within reach of the NP entrepreneur because they are low cost start up options that create a win/win for the NP practice owner and for the vastly underserved home-bound population.  Here’s a link to Attorney Flores’ January 2020 Office Ours recorded session. https://nnpen.org/Office-Ours.

NNPEN is a for-profit LLC, co-founded in 2017 by four determined nursing leaders who share the belief that America’s 250,000 nurse practitioners (NPs) are the key to primary care access in this country, and it is not immoral or even unbecoming for NPs to profit from solving access challenges.

We believe this is possible if we can incubate an ecosystem that connects aspiring NP entrepreneurs with each other and with sustaining start-up resources.

But our vision depends on three things:

1. Full practice authority
2. Value-based payment (VBP) contracts with payers that reward the quality and cost savings that reliably flow from the patient-centered nursing process and
3. Providers who, with support, learn how to lean into VBP as an informed risk-taking alternative to predictable --but not practice-sustaining --fee-for-service (FFS) payments.

We are constantly looking for partners on this journey who see this linkage of full practice authority, VBP and informed risk-taking as the win-win that it is.  HCCI approached NNPEN last year and they had us cold when they shared with us this powerful graph—that tells us that delivering primary care in the home setting is a path forward being considered primarily by NPs, and these NPs need support with clinical, practice management and ownership issues.

Through this lens (above) we undertook joint sponsorship of the February 2020 HBPC conference to cross-fertilize not-for-profit Home-Centered Care Institute’s (HCCI) professional development mission with NNPEN’s entrepreneurship agenda to produce  i) a well-defined HBPC practice ownership blueprint ii) to make start-up and sustainability iii) easier for you as a practice owner and iv) primary care access feasible for the 85% eligible but unserved home-bound population in this country—whether through a cash business, referrals from hospital discharge planners, or marketing to your local Medicare Advantage plans, this might be your market!

So what are some of the takeaways that will excite you?  Let me share, with HCCI’s permission, a few slides that highlight issues HBPC owners will inevitably face:

Michael Helle @Blueprint 0220

Hands-On @Blueprint0220

Laura Snider @Blueprint0220

Laura Snider @Blueprint0220

Payments Panel @Blueprint0220

BPlecner/LRapsilber @Blueprint0220

Cyber Security @Blueprint0220

A final takeaway: Home-based Primary Care can be an ownership opportunity with the Nurse Practitioner’s name written all over it.  HCCI is the very best at delivering your HBPC professional development training; find them at  www.hccinstitute.org.  NNPEN www.nnpen.org will support your ownership agenda. Check out both our websites.

So, drivers: start your engines…Entrepreneurship is simply Prochaska change management in an MBA outfit: You Got This!

SB

Sandy Berkowitz
Co-founder and CEO NNPEN

Dear NNPEN Colleague and Friend: Our comments back to CMS Scope of Practice both 1) congratulates the Trump Administration for putting Full Practice Authority at stage center, recognizing it as the bipartisan issue it is; and 2) suggests ways CMS can uniquely contribute to value-based payment reform for advanced practitioners by encouraging advanced practitioners to accept the challenge of becoming informed risk-takers.  Happy reading to start out 2020!

PatientsOverPaperwork@cms.hhs.gov

Re: Scope of Practice response to a request for feedback from CMS regarding President Trump’s Executive Order 10/3/2019

January 16, 2020

Ladies and Gentlemen of the Patients Over Paperwork Initiative:

1. My name is Sandra Berkowitz and I am the CEO of NNPEN, a national network of Nurse Practitioners (NPs) who are owners of, and employees within, nurse-led clinical practices.  These NPs are included within MACRA’s QPP definition of “eligible clinician” and CPC+’s definition of “practitioner”.
2. My comments relate to Executive Order #13890 specifically, but also more broadly to how CMS can take the lead withother payers in the construction of infrastructure that facilitates the quickest uptake of, and access to, advanced practitioners into the Medicare provider network. Build outcomes and claims data set specifications, ensuring CMS actuaries will have the ability to compare longitudinal data quality and cost for physician and other advanced practitioners practicing at the top of their license. If CMS makes participation in databases mandatory the cost calculations are run on a leveled playing field.  The metaphor when Medicare sneezes everyone gets a cold is trite but true here. Think of this as the encore to our government’s funding technology development in early years by supplying the expensive hardware. 
3. As a general statement, NNPEN agrees that replacing a legislative/prescriptive definition of scope of practice with one that defers to the education and training of the designated practitioner’s license is a good thing.
4. Expecting that AANP and many other friends of NPs will also be responding, NNPEN restricts our other comments to preparing NPs to be informed risk-takers in Value Based Payment risk programs—a skillset that is not part of the NP’s cautious nature—and in fact, is not part of any practitioner’s training.
5. NP Scope of Practice success is a pyrrhic victory without NP access to Value-Based Payment arrangements that we know can reliably reward the NP outcomes that flow from the Nursing Process.  Executive Order #13890 gives this conversation—i.e., NP risk-taking skills required to succeed in Value Based Payment programs --new and significant urgency. 
6. Here are our comments detailing opportunities for CMS to level the SOP playing field short and long term:

#1—Preserve/extend the cost and quality benefits of the Nursing Process

• Uncontroverted literature of >100 peer-reviewed studies finds that NPs produce quality and cost outcomes as good or better than those of physician PCPs. Why? because of the integrated view of the patient that is the backbone of the Nursing Process. This hard-wired Nursing Process also explains why nurses are consistently viewed as the most trusted profession
• Yet the Nursing Process is desecrated by the dominant medical model pressure to “see”25-30 patients per day, squeezing patient office visits into 15 -minute segments
• To preserve the benefits of nurse-led care, NPs need many more sustainable independent practice options, that give consumers access to healthcare and preserve the benefits of the Nursing Process in all fifty states.  This Executive Order does that.

#2—Full Practice Authority (aka Independent Scope of Practice) will generate a much-needed NP primary care outcomes database

• As long as the NP is not the independent Primary Care Provider, no performance data is being separately attributed to the NP--- both syphoning NP value off to benefit the billing physician and allowing payers to resist exploration of VBP with NPs for “lack of credible data”. CMS can require collection of the longitudinal data that is essential to measuring and documenting the NP’s (and all other PCPs’) management of population health risk 

#3--Without NPs delivering primary care access across the nation, CMS will fail to meet its Triple Aim Goals

• We are losing primary care physicians at an unprecedented rate across the U.S., especially in rural areas where the needs are extremely high and opioid addiction/deaths are skyrocketing.  Many doctors are moving to "concierge" care models which leave out the poorest/sickest in the U.S.
• NPs are the fastest growing health care professional group by a lot. The American Association of Nurse Practitioners’ website reports there are 270,000 NPs in America in 2019.  According to the New England Journal of Medicine, “Between 2010 and 2016… growth in the NP supply accelerated to nearly 10% per year, whereas growth in the PA supply slowed to 2.5% and growth in physician supply slowed to 1.1%.”   n engl j med 378;25 nejm.org June 21, 2018

Armed with EO #13890, CMS has the power and gravitas with a top- of -license SOP vision to overcome the payer resistance and physician stonewalling that still confounds SOP progress in more than half of our 50 states.  The marketplace and the workforce are ready for SOP change that is refreshingly bipartisan.  The timing of EO #13890 couldn’t be better! 

We applaud President Trump and CMS for moving SOP to center-stage and look forward to working with CMS as it is rolled out.  Please let us know if NNPEN can be of any assistance.

On behalf of our NP entrepreneur membership and an America filled with consumers without access to primary care, NNPEN thanks you for our opportunity to comment on SOP today.

Sincerely,

/s/Sandy Berkowitz, RN, JD

Welcome to our new ‘hood! As NNPEN grows members, we are getting more requests for direct member-to-member interaction capabilities. This new website has been designed with that capability as one of our satisfaction metrics: demonstrate material growth in member-to-member direct interaction. Now the Blog, the Forum (discussion board) and the Membership Directory are 3 website tools NNPEN offers to support peer- to-peer dialogue with no “mother may I?’ tollgate. The key here is that these tools aim to support NNPEN members. Are you a member? If not, ask yourself: is becoming part of something bigger than you -- a growing NP entrepreneur advocacy network -- worth $144/year?

Your call to action is to try these tools out and give us feedback. Oh, and if you can’t access the forum and directory because you’re not a member, Join NNPEN today!

Many more things to talk about in 2020: a co-hosted Home-Based Primary Care Blueprint for Success conference in Phoenix in February and NNPEN’s Value-Based Payments survey, for instance. Get there in good health!

s/s Sandy Berkowitz

Co-Founder and CEO

NNPEN Partnering with American-APN/CareSpan for a Giant Step Forward

Back in my February 2019 blog to NNPEN’s members and friends, I introduced the question: “What’s ahead for the NP-owned practice?” At the time, I strongly suggested that small NP-owned practices may reach a certain revenue threshold and plateau. The small NP practice, as an economic buyer, does not have the fiscal clout to, for example, negotiate performance-based adjustments to the payer’s stingy FFS fee schedule. By aggregating NP-owned practices into a single signature contracting entity, NPs create critical mass and economic value. So, my No. 1 takeaway for indie NPs is the need to join a contracting entity that creates clout through aggregating practices – without NP practice owners losing control of their practices or brand. “Aggregate” is my fancy way of saying GO BIG.

Then, in June 2019, I blogged about why NNPEN has begun offering business services through partnerships with PRMS for revenue cycle management (RCM) and SBSC for credentialing. In short, we see NP practices needlessly leaving 20-30% of their collectibles on the table, most notably by letting claim denials go unchallenged due to lack of time or confidence – most likely both. NNPEN encourages NP practice owners to spend their time with patients, where there is reimbursable value – and outsource RCM and credentialing.

Now it’s September, and we invite NP practice owners to kick the tires on our recently formalized partnership with the American Advanced Practice Network (American-APN) and CareSpan. We three partners aim to accelerate a nurse practitioner’s ability to establish and operate a sustainable independent clinical practice! Read our official press release announcing the partnership on CareSpan’s website.

We know that NP practice owners want to:

• Spend more time with patients
• Grow revenue
• Be part of something bigger

Being part of something bigger can mean being part of a professional community that offers evidence-based practice guidelines, peer review and emotional support, as well as the capacity to offload backroom activities that interfere with patient care time. But it can also mean bulking up to a size that third parties – read payers – cannot ignore. From NNPEN’s perspective, that is the long-term play here we find irresistible.

An important NNPEN undertaking in this partnership is to identify nurse-led practices who 1) are new to independent practice and whose collectibles goals at 24 months exceed $100,000; or 2) are established owners but have growth aspirations that are not translating into collectible revenue. For these growth- oriented practices, American-ANP/CareSpan offer important options to explore, especially before investing or reinvesting in an EMR. An NP practice owner should be asking these questions:

• Is my practice up but not growing?
• Is my practice up-and- growing but placing a 24/7 demand on me that is not sustainable?

American-APN/CareSpan is probably not an option for an NP practice satisfied seeing fewer than 10 patients a day. Nor is it the right choice if you are not planning to add a virtual practice (telemedicine) component to your repertoire. But NNPEN sees positive work/life balance relief, managed care contracting leverage, and other economies of scale in this first creation of an NP network, and NPs need practice management choices for NP-led practices.

Information is power. NNPEN is dedicated to informing NP practice owners about emerging practice management choices. We already offer ala carte options – specifically for stand-alone revenue cycle management and credentialing – but none of these get at NPs’ needs for a network that creates critical mass in negotiations with payers. American-APN/CareSpan does.
This is a call to action for NP practice owners: Get Big! Contact us: businessservices@nnpen.org.

I’m hoping you’ve been on NNPEN’s website recently and found our new menu tab: Business Services. But maybe you haven’t. In any event, NNPEN wants you to know why we are moving into this space, and the role we think NNPEN can play to make practice start-up easier.

First: Why?

Like every good business owner, you want to ensure your practice is running as smoothly and efficiently as possible. However, with the numerous requirements and nuances they don’t teach you in nursing school, it can seem daunting to run a successful business on top of providing top-notch care.

NP business owners need to rely on trusted third parties to remain compliant and keep the doors open. NNPEN has identified two areas where a small investment in outsourcing will yield big dividends on your part: revenue cycle management (aka billing and collections) and credentialing.

Revenue Cycle Management

Because so many dollars and hours are at stake, revenue cycle management (RCM) is a priority for NP practice owners to investigate outsourcing. RCM’s aim is to maximize your reimbursement revenue. One stage in RCM where NP practice owners fall short is challenging claim denials; they’re not what NPs know, they can require aggressive moves, and they take time.

NNPEN partners with PRMS, a firm that is particularly comfortable challenging insurer denials because their medical record professionals are grounded in the patient’s medical record. We like this sweet spot: the industry estimates that between delays in hiring providers due to protracted credentialing timelines and the failure of providers to challenge claim denials, 30% of your gross collectable revenue is conceded to insurers here. This is money from your pocket just going free! Don’t be penny-wise and pound foolish; face up to the money you are leaving on the table!

Credentialing

Credentialing is important to understand but not to do yourself because the rules are arcane. Even small oversights/errors in the application process means the insurer will send your application back to square one. The longer the credentialing and contracting process takes, the longer it will take you to start generating revenue, whether it be for your services or for a new NP you want to hire. A credentialing service will track your application from beginning to end so that the needed badgering is done without sucking the energy out of your practice.

NNPEN’s partnership with nurse-owned credentialing service SBSC negotiated a material discount for a la carte credentialing services, priced at a $295 one-time provider set-up fee plus a $100 -per- application fee. Assuming you manage five applications through this system, $800 is the cradle-to-grave credentialing services cost that the NP needs to weigh against the value of her or his time.

What’s NNPEN’s Role?

NNPEN is not employing professionals with specific business services expertise, such as SBSC and PRMS. Our business model is that we find the best thoroughbreds and invite them into our stable as independent contractors. We are air traffic controllers with respect to their service delivery to you. We envision that we are a concierge service for you to find the right fit between vendors and you, and to be your mouthpiece when things go awry.

This business model of concierge services is not unique to NNPEN, but we embrace it – both because in our view it’s the right way to run our business and because it passes our smell test as a way NNPEN can earn the revenue we need to grow while furthering the business sustainability goals of our clients.

Next post will focus on the most developed business services NNPEN offers: Consulting with the Founders. WHAT we four gals know is valuable, and WHO we know is priceless. Need to know more right now? Contact us at businessservices@nnpen.org.

SB

CEO

On Feb. 2, 2019, NNPEN hosted a half-day conference in Columbia, MD, titled Innovative Business Models for NP Practice: Do It Your Way! as an introduction to CareSpan, a digital healthcare platform, and AAPN, a CareSpan-aligned NP Group Practice Without Walls (GPWW). AAPN is the first NP-owned professional LLC to aggregate NP practices and negotiate NP managed care contracts as a single taxpayer identification number (TIN).

AAPN, the NP-owned PLLC, is the logical product of familiar forces converging in our healthcare marketplace:

• No primary care physician supply in face of growing healthcare demand;
• High NP primary care supply;
• Full confidence that, because of underlying nursing process, quality and cost outcome measurement will reward NP PCP practices for the value they create;
• Value aggregators like AAPN are how NPs negotiate value-based payment terms with 800 lb. payers

The Feb. 2 room was filled—nearly 80 registrants, wow! That tells us NP entrepreneurs are still looking for an ownership model that works for them. CareSpan’s Integrated Network, including AAPN, may be that model. It offers indie NPs access to a basket of business support services, including access to better managed care contracts because AAPN aggregates NP practices under a single TIN to create negotiation leverage.

From our Feb. 2 speakers JoEllen Koerner (CareSpan CNO) and Kate Fiandt (AAPN CEO), I enclose a link to AAPN, which outlines what the next steps would be to evaluate your practice future as part of AAPN. This assessment has value whether you go forward with AAPN or not. Right now, AAPN is focused on attracting established NP practices with established revenues—so that there is cash flow ballast to enable onboarding newbie practices without developed revenues.

A point made by many of our speakers is that AAPN is not for everyone. (For example, if you do not foresee virtual practice as part of your business plan, this practice model may not be for you.)
But this much is true: Some NP practice aggregator alignment will be in your future; that’s how NPs will create contract leverage. AAPN/CSIN is the first (but not the last) NP-focused aggregator for you to consider. For their foresight, we applaud them. NNPEN’s role here (we think) is to encourage the growth of additional aggregator options for you and be right there with you to evaluate the fit as you consider this question: What’s Ahead For My Practice?

Are we on the right track? Say it by joining us at www.NNPEN.org.

SB

WHY NP PRACTICES NEED “VALUE AGGREGATORS”: LET’S TALK MONEY

NP practice owners are entrepreneurs who want to be independent—to be free-standing.  But best case, these independents will each see 1500 patients, and a 1500 patient panel is too small to create contracting leverage, even with remarkable outcomes that are reliably great.  But if 10 NP practices, each with 1500 patient panel, combine their quality data, 15,000 lives begins to have credibility. Who collects the data and leverages these 10 NP practices’ outcomes into some share of the savings flowing to the NPs?  Who supports the business end of the 10 practices so the NPs can do what they love?  Below I propose the not-so-new idea of a value aggregator as the entity that brings the necessary capabilities to the table to give those 10 practices “the independence they want and the support that they need”.  What will success of an NP value aggregator look like?  I vote for negotiation of payment models that leverage the quality and cost value the nursing process invariably produces.

At NNPEN’s second annual conference, Minneapolis 2018, we saw an independent (indie) NP practice profile developing: maybe no brick and mortar office space, outsourced backroom functions, digital clinical platform, and miserly (even in FPA states) commercial insurer payments, based on an unsustaining Fee For Service schedule at 85% of Medicare’s Physician rate.  And adding insult to injury, payments offered no opportunity to boost the NP practice’s FFS revenue base with either or both of two enhancements health insurers offer every primary care physician: 1) care coordination fees and 2) shared savings (SS) programs that encourage the provider to benefit from better than average quality of outcomes and cost-effectiveness.  The economic implications of this for a small 1 FTE NP practice with a patient panel of 1500, are not chopped liver.  Modeling done for NNPEN for our Summer 2018 NPE Conference conservatively estimates a Shared Savings impact of $9,000 annually for our hypothetical 1 FTE NP practice.

How do nurse-owned practices negotiate for these fairly modest concessions—essentially, a leveling of the reimbursement playing field? Bring numbers to the table!  # of PCPs, # of patients, a depth and breadth of coherent data detail.  Aggregation generates value.   NNPEN’s position is that payment reform requires NPs looking beyond their individual practices to imagine what being part of a “single signature” contracting entity—an “aggregator”– might look like.  Is it a PC?  Is it an IPA? Is it a Management Services Organization (MSO)? Is it owned by the providers themselves? Does it offer a solution to the business acumen deficit most practice owners experience and, as noted earlier, want to outsource to a trusted MSO?

We see both national and local solutions emerging here.  Fortunately, the first “single signature” contracting entity opportunity for indie NP practices –the first “value aggregator”– is at our doorstep: CareSpan, a digital healthcare company.  .

NNPEN wants to be right there with our members in evaluating the fit between aggregators like CareSpan and independent NP practices.  SO: over the next few months NNPEN is scheduling live sessions with CareSpan and interested NP Entrepreneurs: the first will be in Baltimore, MD area in the first quarter of 2019—Saturday February 2, 2019 1:00pm to 4:30pm, to be exact.  Program information coming soon.

Pay attention.

SB

There was a lot of re-imagining to be had at the 2018 Midwest Region Dual Track NP Entrepreneurship  Conference in Minneapolis.  For one thing, we 4Mothers (Lynn, Lorraine, Beth and me) are beginning to think of NNPEN as industry “Conveners” and we like the way that fits us!  And I have some conference takeaways on the content side that challenge our vision of the future.

I moderated a Rural/Urban nurse-led practice session that looked at Minnesota Nice, Inc a commercial Direct Primary Care model in urban Minneapolis that is co-owned by 2 NPs and a medical economist, and sells medically necessary primary care services  to employers on a subscription basis.  This DPC does not take  commercial insurance.  And it does not have a brick and mortar component; instead it relies on telehealth imaging and home visits, including delivery of the meds they prescribe.  They provide all the backroom services the mobile practice needs.  They are considering franchising the model, including the  back room services and the marketing to local employers/consumers.  Now compare that mobile nurse-led primary care practice model in MN with S Dakota State University School of Nursing’s MSO [management services organization ] vision [and grant]to support rural South Dakota NP indie practices  that may have no brick and mortar base.  Like MN Nice, Inc., the MSO will provide a digital platform that becomes the virtual brick and mortar, allows the practices to share data and contract as one Virtual Group for value-based reimbursement contracts with payers.  And like MN Nice, Inc, the MSO offers NP practices an outsourced backroom function and an organizational structure that is poised for the best aggregation and leveraging of NP cost-effective and quality outcomes with payers.

We recognized several common features embedded in both these Midwest primary care models–the commercial DPC in MN and the academic MSO in South Dakota — that may foreshadow what a sustainable indie NP-led practice will look like in a few years—and maybe what we should be working toward now:

• No brick and mortar
• Telehealth platform (needs to integrate w/ multiple E H R versions )
• Back-room functions delegated
• Not insurance company reliant
• Openness to, but balance in, cash medicine product mix
• NP Virtual Groups created for payer contracting

I haven’t even gotten to the NP Value in Value-based Reimbursement session takeaways.  Or the HUGE popularity of our Getting Started Speed Dating 10 minute “Ask Anything” sessions with NPE heavy-hitters!  We Owe You More—but it’s mutual.  You need a Convener and we need you and your critical mass to make us smart. Please commit to membership and join NNPEN now!

Sandy Berkowitz

Co-Founder and CEO of NNPEN