Nurse practitioners: Newest members of the IDN family?

Nurse practitioners are in the public eye; now a growing number are managing their own practices.

When Robert Smithing and a partner sought out bank loans to open their practice in the mid-1980s, they met some resistance. “Nurses don’t fit into our model of opening up a practice,” loan officers told Smithing and his partner, both nurse practitioners. It wasn’t until they met with a loan officer with a family member who was a nurse practitioner, and who understood what nurse practitioners do, that they were able to get the loan and launch their practice. Today, after several iterations, including a spell under the ownership of another corporation – that practice – Family Care of Kent, Kent, Wash. – is thriving, with a staff of four nurse practitioners and several medical assistants and office staff.

“There weren’t a lot of nurse practitioner groups in 1985,” says Smithing. “We opened our doors to demonstrate that consumers would be interested in seeing a nurse practitioner, even in suburban areas where they had access to other types of care.

“Was it risky? Yes. But from our perspective, we knew nurse practitioners provide excellent care, and that patients would love to see us.” Turns out they were right.

In the public eye
There are approximately 150,000 nurse practitioners in the country. Though it is difficult to determine how many own their own practices, signs point to the growth of a new type of customer for med/surg distributor sales reps – the nurse-practitioner-owned and -managed clinic. Here’s why.

• The public is more aware of and comfortable with nurse practitioners than ever before, given their presence in hundreds of retail clinics in Walgreens, CVS, Krogers and other retail/grocery outlets.
• Nurse practitioners may be in demand more than ever if, as expected, as many as 30 million Americans enter the healthcare system as part of healthcare reform.
• People appear to be seeking out more personalized care than they typically find with in-and-out, lightning-quick visits with their family doctors, who already find themselves overworked and, in the opinion of many of them, underpaid.

Setting up practice is a popular topic in state and national nurse-practitioner conferences, notes Jill Olmstead, MSN, NP-C, who practices in a large multispecialty physician practice at St. Jude Heritage Healthcare, Fullerton, Calif., a ministry of St. Joseph Health System. She is also president of the American College of Nurse Practitioners. “It’s a wonderful opportunity.”

What is a nurse practitioner?
Nurse practitioners are registered nurses who are prepared, through advanced education and clinical training, to provide a wide range of preventive and acute healthcare services, according to the American College of Nurse Practitioners. They complete graduate-level education leading to a master’s degree, and virtually all of them maintain national certification.
The first nurse practitioner program was developed at the University of Colorado in 1965. “Early on, [nurse practitioners] gravitated toward serving more of an underserved population,” says Tine Hansen Turton, CEO, National Nursing Centers Consortium, an organization supporting the growth and development of more than 250 nurse-managed health centers. “Just as we’re talking about the workforce problem and access to primary care today, we’ve had that problem for 40 years or more.”

The number of nurse practitioners grew as more schools of nursing developed programs. Even today, as many as two-thirds of the Consortium’s members are academically affiliated, run by schools of nursing. But the movement toward independent, nurse-practitioner-owned practices is gaining steam. It has only been within the last five or six years that the insurance industry has truly embraced such practices, she says.

The scope of a nurse practitioner’s duties depends to a large extent on the state in which he or she practices. In about half the states, nurse practitioners must have a “collaborative physician” of record, that is, a physician who serves as a “quality control” check, and with whom the nurse practitioner consults when questions arise. But many states – approximately 20 – have no such requirement. And today, all 50 states grant nurse practitioners the right to prescribe medications.

According to the ACNP, nurse practitioners take health histories and provide complete physical examinations; diagnose and treat common acute and chronic problems; order and interpret laboratory results and X-rays; prescribe and manage medications and other therapies; provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance; and refer patients to other health professionals as needed.

Almost half of nurse practitioners focus on family practice, with another 20 percent focusing on adult practice. The remainder specialize in such things as women’s health, pediatrics, gerontology, acute care, neonatal care, oncology and psychiatric health, according to the American Academy of Nurse Practitioners.

Metro Medical Direct
Raymond Zakhari, EdM, MS, ANP-BC, FNP-BC, founded Metro Medical Direct in Manhattan three years ago. He graduated in 2003 with a master’s degree in the adult nurse practitioner field, and subsequently received a master’s in nursing education in health behavior counseling. He completed a post-master’s program to complement his family practice training, and completed his boards with the American Nurses Credentialing Center, which is a subsidiary of the American Nurses Association.

An Air Force deployment to Baghdad and work as a traveling nurse gave Zakhari an appreciation of how much medical care could be delivered portably. Living in Manhattan, he sensed an opportunity. “Manhattan is a walker’s town; it’s not car-friendly,” he says. People who live in New York are used to having goods and services, such as their groceries, delivered to their homes or apartments.

While working through a health issue of his own, Zakhari was struck by two things. First was the complexity of the healthcare system. “I can advocate pretty well for myself,” he says. But even so, he found the system complex, with doctors and specialists unable or unwilling to communicate and coordinate care.

The other thing? “It takes half a day to go to the doctor’s office for an appointment that lasts 10 minutes. It’s tiring and time-consuming.” Not to mention the fact that in order to see the doctor, typically between the hours of 8 or 9 am and 4 or 5 pm, Zakhari himself would have to cancel his own patients. It’s a hardship for any working person.

“So I built a virtual practice,” he says. Patients schedule appointments online, and Zakhari goes to their hotel, apartment or home to deliver care, bringing an array of medical supplies and devices, as well as a laptop with a wireless modem. “People don’t come to see me to get out of work; they come to see me because they love to work,” he says. “You don’t have to take off a half day to see me.

“I developed a model that uses the patient’s bricks and mortar,” rather than incurring the cost of an office of his own, he continues. New York has a well-developed system of home-based medical services, such as imaging, EKGs and other diagnostic testing, “so I’ve been able to work with them.” Zakhari supplements home visits with e-mail and web camera sessions.

“It’s a convenient primary care option for people in Manhattan, including residents, travelers and visitors, he says. But he prefers the home-based approach for another reason. “I get to see the patient in their context. I can appreciate their struggles of moving around, getting from the bed to the bathroom, for example, which may explain incontinence.”

It’s a model that many physicians are either unwilling or unable to duplicate. Most physicians who make house calls tend to treat them as an adjunct to their office-based practices, points out Zakhari. What’s more, physicians’ malpractice insurance costs typically are higher than those of nurse practitioners, so the cost of their house calls are high.

Zakhari provides a broad range of services, including general comprehensive physical exams; geriatric assessment and care plan development; management of chronic conditions, such as diabetes, high blood pressure and high cholesterol, congestive heart failure; anticoagulation management; wound care; men’s health; and treatment of a variety of acute medical problems, including flu, infections, sprains, back pain, pink eye, pneumonia, gastroenteritis and sexually transmitted infections.

“My patients text me when they have a problem; we do webcam followups,” he says. “They feel they can be in touch with me. And I have a small enough panel, where I actually know them.”

Zakhari developed a program called Intensive Primary Care, whose aim is to reduce hospitalization and hospital readmissions, primarily among elderly people with chronic medical issues. Zakhari visits the patient on a regular basis (making sick visits as needed). “The purpose is to identify high-risk times and events that may lead to a hospital admission, and to become sufficiently familiar with the patient’s caretakers to establish a good rapport with them, so that subtle changes are picked up sooner and mitigated.”

Family Care of Kent
Nurse practitioners tend to pride themselves on their emphasis on health maintenance and patient-centered care. “Nurses practitioners were talking about ‘medical homes’ 15 years ago,” says Turton.

“The captain of our team is our patient,” says Smithing. “We listen, we care, and that’s why people come to see us. And with chronic illnesses, our patients do particularly well, because we use a nursing model of care, which enables our patients to assume more responsibility for their care. They stay healthier.”

Studies have shown that the quality of care delivered by nurse practitioners can be as good as or better than that delivered by MDs, and less costly, says Smithing. Patients newly diagnosed with a chronic illness, for example, may see the nurse practitioner more often than he or she would see a doctor, at least initially. But at least one study of congestive heart failure patients showed that even though the cost of ambulatory visits was higher, the patients took fewer medications, had fewer hospitalizations, and had a higher quality of life than those cared for by physicians, he says.

While primary care doctors feel pushed to the limit to see more patients, nurse practitioners can avoid that treadmill, says Smithing. Nurse-practitioner practice owners have the flexibility to match their practice with their lifestyle choices. “We make sure we schedule time for same-day acutes, so I’m not trying to get 60 patients in my schedule a day,” he says. “We plan for that.” And Family Care of Kent staggers its shifts, so that two of the four nurse practitioners work on Monday, two on Friday, and all four on Tuesday, Wednesday and Thursday. “We have three-day weekends. That helps us with our home life, and gives us time off to recover.”

Reimbursement
Reimbursement has been a challenge for nurse practitioners, but that’s changing. Smithing, for example, says that Medicare reimburses nurse practitioners at 85 percent of the physician scale. It’s not ideal, he says, but it’s something. Medicaid, on the other hand, reimburses nurse practitioners at the same rate as physicians. Most – but not all – insurers do too.

Though the vast majority of his patients have insurance, Zakhari bills them directly. The patient then seeks reimbursement on his or her own. He finds that doing so is not only easier from an administrative point of view, but can actually lead to a better experience for both patient and nurse practitioner. Because they pay Zakhari directly for the care they receive, “they’re as incentivized as I am to get a good outcome,” he says.
Nurse practitioners typically are directly involved in equipment and supply purchasing for their practices. Olmstead speaks of one colleague who was personally involved in purchasing everything from latex gloves to otoscopes to exam tables.

Like any customers, nurse practitioners value sales reps who look out for their practice. “Don’t push us,” says Smithing. “Educate us. Provide us with information. We love it. And deliver on what you promise. Follow through. If you can’t make it happen, let us know. We get life.