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

I’m home a few weeks or so following the first of NNPEN’s Regional NP Entrepreneurship Conference, in Minneapolis.  So many lessons to learn!  Who knew that we put conferences together for our members but without supportive sponsors we will never break even?  [A projected $9K loss is not a good thing for our start-up’s first year but NEVER did we contemplate cancelling the day.]  In our defense, we also know much more about what kind of sponsors and exhibitors most naturally align with you, the NPE “market.”   Not just product alignment: e.g., cash medicine products and services.  But also alignment of vision as to who NPEs are:  a burgeoning workforce of small practices together capable of innovation that will disrupt how and where primary care services are rendered?  An emerging group of primary care practice owners with purchasing power—NPE buyers creating the same –and different–commercial opportunities that young physician practices once did?  We might want to start with how bank lending officers underwrite independent NP primary care practice startups vs independent primary care physician practice start-ups….

I’m reminded that for now, every project we do tells us something new about ourselves.  Nothing is just “work”.  Right now, it’s all good and that’s a good time to stop for just a bit to savor rewards like this one, tucked into an attendee’s post-conference follow-up to NNPEN:

“20 years ago a group of us had a dream.  20 years later YOU and your team have given it wings! Thank you!  Thank you!  Thank you!”

A CALL TO ACTION

For NNPEN, hearing from conference attendees and speakers that the NP Entrepreneurship practice gauntlet is being passed to us is reward but it’s also sobering.  Like you, we are an NP-led start-up that thinks we can make a difference.  Like you, we completed our post conference evaluation form and had to answer the concluding question:

“What step or steps toward ownership will you be taking in the next 12 months as a result of attending this NP Entrepreneurship Conference? “

We will host an Office Ours call for open discussion of attendees’ feedback on this question.  As of September, Office Ours will be a Members Only event, so join NNPEN now to ensure your place at the table.  We need you!

• Have you been wondering what else NNPEN is up to, in addition to planning our signature NP Entrepreneur Conference in July and our monthly Office Ours calls?  Here’s where I pat NNPEN on the back. Right side, then Left side. 

  Why?  Because NNPEN took seriously CMS Innovation Center’s recent (May 25, 2018 deadline) Request for Information (RFI)/public comment on the desirability of standing up a Medicare Direct Provider Contracting advanced payment model, one that could 

• ·       be open to contracting with NPs as a Virtual Group and as independent PCPs, AND
• ·       offer nurse-led practices opportunity to learn critical Value-Based Payment (VBP) skillsets, AND
• ·       accumulate sustaining practice surplus. 

NNPEN has done preliminary analysis that leads us to believe strongly that the nursing model can be relied on to deliver less costly, quality health care outcomes and still generate Shared Savings, which in turn is the nurse-led practice’s only sustainable source of surplus.  To grow substantially and operate sustainably, we NEED access to shared savings (value-based) payment models, and clearly it’s a fight to get seats at the table.

We have said since our inception that NNPEN’s mission is to connect Nurse Practitioner Entrepreneurs (NPEs) with each other and with quality start-up resources.  But we have also been clear that a strong NPE network creates meaningful opportunities for NP participation in reimbursement negotiations.     In essence, NP professional associations’ best negotiation positions likely will present NP solutions to America’s health care access crisis--keeping focus on the patient, which is as deeply ingrained in nurses as the Hippocratic Oath is for physicians.  But NPEs also need advocates who see NPs as a powerful market and workforce, and that is a different message from focus on the patient. By forcing ourselves to respond to RFIs like this one, NNPEN is beginning to see an NP payment advocacy niche that we can fill for all NPs.  NNPEN is interested in your thinking: are we on the right track?  And if you agree that we’re on the right track, joining NNPEN gives us more power to speak on your behalf.

Read NNPEN’s DPC RFI response: https://www.nnpen.org/wp-content/uploads/2018/05/CMS-RFI-DPC-NNPEN.pdf

Worth joining in this fight?  I say yes; what say you?

SB

• March 20, 2018 was the real-time debut of NNPEN’s Office Hours to you, our potential NP Entrepreneur customers, and it was scary.  Here’s how we coped:

• ·       We learned not to fall apart when we didn’t meet a deadline (like when we blew our November 2017 roll-out date for Office Hours). 
• ·       We convinced ourselves that Office Hours would be a success even if only one person showed up (i.e., whether to one or one hundred, we have declared ourselves as LIVE to the outside world, both in real time and in digital format).
• ·       We prepped.  Brian, our IT guru, made NNPEN’s vision visible on rotating NNPEN info panels that filled the Zoom screen. 
• ·       We wrote a script. We timed each of our parts to be SURE that we left time for audience Q&A. We wrote questions to ask if no one in the audience asked any.
• ·       We laughed, even when our weekly NNPEN status call had already run 30 minutes overtime.

• In fact, many more than one NPE (NP Entrepreneur) joined our Office Hours debut, and you came from all over the country: Texas, Florida, Wisconsin, DC, Connecticut, Pennsylvania Minnesota. 

  So why am I telling you this? Recall that NNPEN is a start-up too.  If we can identify and share barriers to, and secrets of, success at one start-up (NNPEN), there’s a good bet that NPEs (NP Entrepreneurs) out there are encountering the same challenges and want to talk about it.  This blog, we hope, will be a forum for nurse-led start-up experience-sharing.

  Here are some takeaway from the Office Hours rollout:  

• ·       DON’T LET DELAYS OVERCOME YOU…and DON’T LOSE FOCUS
• ·       HAVE A PLAN
• ·       HAVE A BACK-UP PLAN  
• ·       LAUGH!!               

Join Office Hours every third Tuesday at 8:30-9:30 pm ET.  Our next call will be April 17, 2018.  Calls will be open to all until the end of July; at that time our monthly call will become members-only.  Join NNPEN now as a charter member; but first, come look us over: Click here TO FIND OUT MORE

Until next blog,

Mom (aka NNPEN CEO AND Co-Founder Sandy Berkowitz)