National Nurse Practitioner Entrepreneur Network Articles

What happens if the ACA subsidies expire at the end of the year?

Fri, 14 Nov 2025 16:03:15 GMT

CEO BLOG:

What happens if the ACA subsidies expire at the end of the year?

Here are key facts about the subsidy change:

Enhanced premium tax credits (PTCs) that reduced marketplace premiums for many enrollees are set to expire at the end of 2025.
If they expire, the assistance for many marketplace enrollees will shrink or vanish — meaning subscriber premium contributions will go up.
For example, estimates are that net premiums could increase by 75% or more on average for subsidized enrollees if the enhancements aren’t extended.
Also: many enrollees whose incomes are above 400% of the federal poverty level (FPL) could lose eligibility for subsidies entirely, reversing the temporary expansion of subsidy eligibility above 400% FPL.
Because of this, enrollment in ACA marketplace plans is projected to drop if subsidies expire.
Premium rates (gross) may also rise because the risk pool could worsen (healthier individuals drop out) which insurers already are referencing in their rate filings.

What this means for your NP-owned practice

As a practice owner (especially if you serve self-employed individuals, freelancers, uninsured or under-insured populations, or rely somewhat on patients with marketplace coverage), here are some of the issues you might face:

Potential challenges

Patient affordability and access: If marketplace premiums go up, some patients may drop or reduce their insurance coverage. That may lead to more uninsured or under-insured visits, increased uncompensated care, or no-shows because of cost concerns.
Volume changes: If fewer people maintain marketplace coverage, your patient base might shift (fewer insured patients means higher risk for you of patients delaying care or avoiding visits).
Mix of payer risk: A shift toward more uninsured patients or patients with less coverage may reduce your average payment per patient (if you provide care out-of‐pocket or sliding scale) or raise your administrative burden (billing difficulties, bad debt).
Negotiation/contract pressure: Some insurers may increase premiums or reduce plan offerings. That may indirectly influence provider reimbursement dynamics or network access.
Planning uncertainty: Without knowing whether subsidies will be extended, insurers and providers are in a uncertain environment which makes budgeting and forecasting harder for your practice.

Potential opportunities

New patient growth: If premiums increase and people drop employer-coverage or marketplace coverage, they might seek lower-cost care alternatives (like NP-led practices) especially if you offer more affordable, flexible models.
Value-based/cost-effective care positioning: Your practice can position itself as a lower‐cost alternative for routine / primary care, which becomes more attractive when insurance costs rise.
Population health / outreach: You may find an opportunity to reach self-employed or independent workers whose marketplace coverage becomes more burdensome — you could offer self-pay packages or membership models.
Strategic partnerships: With insurer changes ahead, you could explore alternative models (direct primary care, hybrid models) that appeal when coverage becomes less generous or more expensive for patients.

Operational & financial considerations

Review payer mix: What portion of your patient base has marketplace‐insurance vs other coverage vs uninsured?
Monitor trend in patient cancellations or changes in coverage termination: Supplemental ask your front-desk or billing team to flag when patients report higher premiums or dropping plans.
Evaluate sliding scale/out-of-pocket pricing: If more patients shift to self‐pay, do you have a model for that pricing or membership model?
Consider billing/collections risk: If patients lose subsidies and become uninsured or partially insured, collection risk goes up; evaluate your policy for uninsured patients.
Consider marketing message: If affordability becomes a concern, you can emphasize cost transparency, affordable access, convenient care.
Keep an eye on policy/insurer changes in your state: Subsidy impact varies by state (because some states have additional subsidies or Medicaid expansion differences). For example, in your state (Connecticut) the marketplace () reports many enrollees would lose subsidies.

What you should do now (and plan for)

Stay informed: Track Congress’s action on extending subsidies (as of now, enhancements expire end of 2025).
Scenario planning: Build financial models for your practice that assume: (a) subsidies stay (b) subsidies expire. What happens in each case re: patient volume, payer mix, bad debt?
Engage patients/education: Have discussions with patients about their insurance coverage, premium burdens, possible changes next year — they may need to adjust their choices, and sooner you know, the better for your scheduling/planning.
Review contracts: Especially if you participate with marketplace‐plans; see what the insurer is doing for 2026. Are they planning rates/benefits changes that will affect access to your practice?
Consider alternative models: If you haven’t already, think about offering direct membership care, hybrid pricing, telehealth, or bundling to capture demand from cost-sensitive patients.
Billing and collections readiness: Tighten policies for patients who may lose coverage; assess your allowance for sliding scale; possibly review charity care policy.
Communicate with staff: Prepare your team about possible shifts in patient behavior (e.g., delayed care, insurance drop-outs) so scheduling, billing, and patient flow can adjust.

Specific relevance for NP-owned practice

Since your practice is NP-owned (likely smaller, more agile than large hospital systems), you have some advantages: you may be better able to pivot to more cost‐effective models and respond to patient affordability needs. But you also may have fewer resources to absorb sudden increases in uninsured visits or bad debt.

Your practice may benefit from emphasizing affordability: As marketplace premiums rise, patients may look for lower cost care alternatives — your NP-led model could appeal.
You may consider membership or subscription models: Direct primary care (DPC) or hybrid models might become more attractive to patients facing higher premiums.
You may also need to monitor payer reimbursement trends: If insurers raise premiums because of subsidy expiration, they may also try to negotiate provider rates differently; staying aware and actively managing contracts is key.

In short: The expiration of ACA marketplace subsidies is likely to increase cost pressures for patients, which in turn can impact your practice via changes in payer mix, uninsured volume, and patient behavior. But if you anticipate and adapt, your NP-owned practice may be well-positioned to respond to those changes.

Here are several reliable sources that discuss what the expiration of the enhanced Affordable Care Act (ACA) marketplace premium tax credits (subsidies) would mean:

The Kaiser Family Foundation (KFF) Issue Brief: “Inflation Reduction Act Health Insurance Subsidies: What is Their Impact and What Would Happen if They Expire?” — shows that if the enhanced subsidies expire at the end of 2025, almost all Marketplace enrollees would face steep increases in premium payments starting in 2026. KFF+1
KFF’s “About Half of Adults with ACA Marketplace Coverage…” — indicates that around 48% of adults under age 65 enrolled in the individual market are either self-employed or small business owners/small business employees, meaning this change affects a lot of people in your category (NP‐owned practice serving selfemployed patients). KFF
Analysis by the Health System Tracker (via KFF) “Early indications of the impact of the enhanced premium tax credit expiration…” — estimates that expiration will result in over a 75% average increase in enrollee premium payments, and that insurers anticipate a sicker risk pool. Health System Tracker+1
Commonwealth Fund Issue Brief: “Expiring ACA Premium Tax Credits Could Lead to Nearly 340,000 Jobs Lost Across the U.S. in 2026” — emphasises broader economic and coverage implications if the subsidies expire. Commonwealth Fund
KFF “Who Might Lose Eligibility for ACA Marketplace Subsidies …” — shows how eligibility for subsidies would change, particularly for incomes above 400% of the Federal Poverty Level (FPL). KFF
KFF “How Much Would People Pay in Premiums if the ACA’s Enhanced Subsidies Expired?” – interactive/analysis tool showing large increases in premium payments if the subsidies expire. KFF+1

BE INFORMED AS A BUSINESS OWNER.

The Silent Barriers Holding Back NP-Led Care—And What We Can Do About It

Wed, 25 Jun 2025 15:06:24 GMT

Across the country, Nurse Practitioners (NPs) are filling critical care gaps, especially in underserved communities. We’re driving value, improving outcomes, and offering cost-effective solutions in a strained system. But despite our impact, NP-led practices continue to face an uphill battle—one shaped not by clinical skill or patient demand, but by structural, policy-driven barriers that hold us back.

If we want a healthcare system that truly reflects the needs of patients and the realities of care delivery, we must start with the truth: the system was not built with NPs in mind. It’s time to name the problems, expose the inequities, and demand the reforms that will finally level the playing field.

Consolidation Is Undermining Community Health

Healthcare consolidation is often sold as a path to efficiency and streamlined care. But the reality on the ground tells a different story.

As NP practice owners, we’ve seen how corporate mergers prioritize shareholder returns over patient outcomes. Community voices are promised a seat at the table—but are quickly sidelined when governance is centralized and local accountability fades.

When decision-making is divorced from the people delivering and receiving care, equity becomes an afterthought. Health care cannot—and should not—be managed like a corporate portfolio. Our communities deserve better.

Value-Based Payment: Designed to Exclude?

NPs have long been at the forefront of providing patient-centered, preventive care—exactly what Value-Based Payment (VBP) models aim to reward. Yet we continue to face systemic exclusion.

Whether it’s being left out of ACO attribution models, grappling with outdated billing structures, or shouldering disproportionate risk as small practice owners, the barriers to VBP participation are clear. And they’re costing patients the benefits of NP-led care.

VBP programs must evolve to reflect how healthcare is actually delivered today. That begins by including all qualified providers—NPs included.

The “Full Panel” Lie: When Insurer Directories Mislead

Another quiet barrier lies in credentialing and network access. Time and again, NPs are denied entry to insurance panels under the pretense that they’re “full.” But those same panels often feature outdated directories filled with inactive providers.

This deceptive practice misleads patients and restricts access to high-quality, NP-led care. It’s more than an administrative oversight—it’s a form of gatekeeping that reinforces systemic inequity.

We must demand transparency, accuracy, and accountability from insurers. Patients deserve to know who’s actually available to care for them.

Credentialing Delays: A Hidden Threat to NP Practice Growth

When physicians onboard a new provider, they can bill during the credentialing period. But NP-owned practices? We’re left waiting—often for months—without support or reimbursement.

This delay doesn’t just hurt business viability; it blocks patient access and undermines our ability to grow the workforce. Equal care deserves equal process. Streamlining credentialing for NP practices is not a luxury—it’s a necessity.

Education Funding: Invest Where the Workforce Is

As physician shortages dominate headlines, federal and state funding continues to pour into medical education pipelines. Meanwhile, NP training remains chronically underfunded.

We need a national loan program for NP students, administered through community-based Doctor of Nursing Practice (DNP) programs, with dedicated funding for preceptors and infrastructure. We cannot build a resilient healthcare workforce while ignoring the fastest-growing segment of it.

Supporting NP education is not just about fairness—it’s about future-proofing healthcare.

The Path Forward: Real Solutions, Right Now

Change is possible—and within reach. From payment reform to antitrust enforcement, here are just a few policy priorities that can make an immediate difference:

End “incident to” billing that masks NP contributions
Modernize VBP programs to include NP attribution
Enforce insurer accountability on network accuracy
Streamline NP credentialing to match physician credentialing standards
Fund a national NP student loan program
Protect independent NP practices from anti-competitive transactions
Enforce existing healthcare anti-discrimination laws

We’re encouraged to see the Department of Justice’s Antitrust Division taking these issues seriously. But now we need action—not just analysis.

Conclusion: It’s Time to Be Heard

NPs are ready. We’re leading practices, educating students, filling care gaps, and building healthier communities. But we cannot do it alone—and we shouldn’t have to fight the system we serve.

It’s time for our voices to be heard in every room where decisions are made. Because when NPs are supported, patients thrive. And when policies reflect the real world of healthcare delivery, everyone wins.

Join the Conversation:

How has consolidation impacted care in your area?
What policy change would make the biggest difference for your practice?
What does an equitable future for NPs look like to you?

Let’s build it—together.

Harmful Barriers to Healthcare Competition: NNPEN feedback to the Department of Justice Antitrust Division

Fri, 16 May 2025 14:24:37 GMT

May 10, 2025

Ladies and Gentlemen of the DOJ Antitrust Division:

My name is Dr. Lynn Rapsilber, APRN 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”.

As a general statement, NNPEN believes 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. Is it the educational preparation or the license that counts?

My comments relate to the effect of recent Executive Orders but also more broadly to how CMS, guided by healthy healthcare competition policy, can take the lead with other payers in the construction of infrastructure that facilitates the quickest uptake of, and access to, advanced practitioners into the Medicare provider network—increasing competitors and competition.

Expecting that AANP and many other friends of NPs will also be responding, NNPEN restricts our comments to preparing NPs to be informed risk-takers in Value Based Payment risk programs that can sustain small, nimble group practices.

NP Scope of Practice [SOP] success is a pyrrhic victory and will not reduce harmful barriers to healthy competition without NP access to Value-Based Payment arrangements that we know can reliably reward the NP outcomes that flow from the Nursing Process. Recent executive orders give this conversation—i.e., NP risk-taking skills required to succeed in Value Based Payment programs --new and significant urgency.

Here are our comments detailing opportunities for the DOJ, partnering with CMS, to level the SOP playing field short and long term and create provider choices that the American consumer deserves:

#1—Preserve/extend the low cost and high 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 patient-facing hard-wired Nursing Process also explains why nurses are consistently viewed as the most trusted profession, and the group most trusted to “fix” health care.
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
NP-owned practices are typically small and community based—by design. They struggle to find SBA lenders that appreciate their creditworthiness. To preserve the benefits of nurse-led care, NP practices 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. Recent Executive Orders do not do that; CMMI has stood up only one model, the REACH ACO, as “NP friendly” because it recognizes the physician and NP PCP ‘s network eligibility and payment options as equivalent, while CMMI’s dominant Medicare Shared Savings ACO model does not.
Even Original Medicare, which does not reflect the anti-NP bias of private insurers that’s been built into managed Medicare, punishes the NP PCP by paying NPs only 85% of the physician fee schedule for the same work, and adds insult to injury by perpetuating an “Incident to” billing policy that recognizes the billing provider [deemed to be the physician in most institutional settings], not the treating provider who would be paid only 85% of the physician’s charges]. MedPac’s recommendation to abandon incident- to billing has not prevailed.
Given these VBP program limitations, the SBA needs much more encouragement to create a robust lender safety net for NP practices who form the healthcare safety net in underserved communities.

#2—Full Practice Authority (aka Independent Scope of Practice) will generate a much-needed NP primary care outcomes database that supports pricing based on competition

As long as the NP is not the independent Primary Care Provider, no performance data is being separately attributed to the NP--- 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 terminating the practice of incident- to billing would support collection of the longitudinal data that is essential to measuring and documenting the NP’s (and all other PCPs’) management of population health risk

· 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--Without NPs delivering primary care access across the nation, CMS will fail to meet its Quadruple 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 385,000 NPs in America in 2024. According to the Bureau of Labor Statistics, overall employment of physicians and surgeons is projected to grow 4 percent from 2023 to 2033 with 23,600 openings annually. https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm

Empowered by the current administration’s libertarian leanings, and reinforced [but never enforced] by ACA Section 2706 prohibiting insurer discrimination on the basis of license, DOJ and CMS have the power and gravitas with a top- of -license SOP vision to overcome the staunch 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 time is now!

We applaud President Trump for his recognition that advanced practice providers, specifically Nurse Practitioners that can practice independently, are the market disruptors his administration needs to break down the barriers to healthy primary care access.

On behalf of our independent NP practice membership and an America filled with consumers without access to primary care, NNPEN thanks you for our opportunity to comment on barriers to healthy competition in health care today.

Sincerely,

/s/ Dr. Lynn Rapsilber, APRN

Building your business: Engaging patients with packages and recurring memberships

Sat, 01 Mar 2025 13:22:27 GMT

Computer Clicks” Tips on EHRs

by NNPEN partner OptiMantra

Building your business: Engaging patients with packages and recurring memberships

For nurse practitioners in independent practice, finding ways to improve patient retention can help drive financial stability. Packages and recurring memberships offer a sustainable way to enhance engagement, generate predictable revenue, and streamline service delivery. However, implementing these models effectively requires careful planning—from pricing and perks to compliance and tracking.

While these tools have traditionally been much more common in cash-pay NP practices with non-primary care specialties, they are also increasingly used in primary care and insurance-based practices.

Interested in actionable insights? If you're already offering memberships and packages or considering adding them to your practice, check out our recommendations.

This article originally appeared on optimantra.com, published as part of their partnership with NNPEN: https://optimantra.com/articles/nnpen/computer-clicks-tips-for-ehrs.html?utm_source=nnpen

Tackling Your Data Security

Sat, 01 Feb 2025 13:25:34 GMT

Computer Clicks” Tips on EHRs

by NNPEN partner OptiMantra

Cyberattacks can target healthcare practices of any size, and protecting your patients' data should be a top priority. While it can seem daunting to start implementing security precautions, protecting your data happens one small and manageable step at a time.
For instance, password-sharing happens at most clinics -- if one account is compromised, your other accounts are at risk too -- and it's easy to address!

To get started, tackle the basics today:
‍
‍1. First, Keep Computers and Applications Locked and Password-Protected
‍
‍One of the easiest and most effective ways to protect your patient data is by ensuring that all computers and applications are properly secured! Many breaches are attributable either to i) unauthorized device access in the office, or ii) compromised passwords. Here are a few key steps to enact across your key systems - like your email, EMR, CRM, and any other office systems
Enforce strong passwords: Implement a robust password policy for all staff accessing your systems. Passwords should include a combination of uppercase and lowercase letters, numbers, and special characters.
‍Change your password regularly: Regularly remind your team to update their passwords - ideally every couple of months.
‍Avoid password sharing: Each staff member should have their own unique login credentials. Do not share passwords or leave them written near computers. Unique log-ins also ensure that you can monitor unauthorized access (more on that below).
‍Lock computers when unattended: Computers, particularly those in high-traffic areas like the front desk, should not be left unlocked or unattended - even if it’s just to check into the backroom. Make sure all your devices also have automatic time-outs, just in case you forget to close out before getting up.

‍3. Enable Two-Factor Authentication (2FA)
‍
‍Better monitoring of devices and strong passwords is a critical first step, but bad actors can use brute force to try to guess your password or, if they’ve secured access to your device, they may be able to log into your systems remotely. Two-factor authentication (2FA, also multi-factor authentication) is an effective way to further secure your access to your systems. By requiring not only a password but also a second form of identification (such as a text message code), you greatly reduce the risk of a security breach—if #1 was ineffective and your login credentials are compromised.
Set up 2FA for all users and all healthcare systems - Most systems have 2FA options. Set 2FA as a practice-level requirement where possible vs. waiting for your team to enable it themselves. This additional security layer is a must in today’s cyber threat environment.
In OptiMantra, you can easily add 2FA for all your providers and staff directly from Settings to ensure compliance. To reduce the log-in burden, you can also whitelabel/save secure IP addresses (like your office location) to avoid authenticating every time when you’re in a secure location.

‍2. Monitor and Install Regular Software Updates and Patches

‍Outdated software is one of the most common entry points for cyberattacks. Keep your systems up to date with the latest security patches to minimize your vulnerability. This doesn’t need to take long!
‍Regular updates: Ensure that all operating systems, browsers, and applications are updated frequently. For example, if you're using Chrome, you’ll often see reminders for updates in the top right corner of the browser. Don’t ignore these notifications!
‍Automate patches where possible: Set your systems to automatically download and install security updates, so you don’t miss critical fixes.

‍4. Talk to Your Team About Cybersecurity Awareness

‍Regularly educate staff on best practices to avoid falling victim to phishing attacks, social engineering, and other common online scams.
‍Stay vigilant against phishing: Most practices get tons of patient and vendor emails. Encourage patients to use HIPAA-compliant methods of communication (outside email) to connect with you to avoid getting emailed attachments. Remind your team to never open unexpected emails or attachments from unknown senders. If anything seems suspicious, encourage your team to double-check before clicking on links or downloading files.Bad actors can change the To address to look like it’s coming from a valid source, so that’s a good place to check first.
‍Run simulated phishing exercises: Consider testing your team’s response to phishing attempts by running mock phishing campaigns. The basics of this are easy - ask someone you know to send a sketchy email, and see how many folks in the office flag it! There are also online platform you can use to run a professional phishing exercise.

‍6. Use HIPAA-Compliant Communication Tools with Data Encryption

‍We touched on this in #5, but it bears repeating! To safeguard sensitive patient data, use communication channels that comply with HIPAA regulations and provide encryption for both data in transit and at rest.
‍HIPAA-compliant email and text: Use an email provider that offers encryption and HIPAA compliance when communicating with patients and other healthcare providers. This ensures patient information is protected from unauthorized access.
Remember that while your email may be HIPAA-compliant, your patients’ probably aren’t using HIPAA-compliant email! Make sure your consent forms include a consent for email and text reminders and communications.
‍Patient portal: Consider using a patient portal to centralize patient communications and avoid sharing sensitive medical information via email.

‍5. Strengthen Network Security
‍
‍Your network infrastructure should be designed with security in mind, especially when handling sensitive patient data.
‍Use a firewall: A robust firewall can help prevent unauthorized access to your practice’s network. Make sure your firewall is properly configured and updated regularly.
‍Update antivirus and anti-malware software: Keep your antivirus and anti-malware programs up to date to ensure your systems are protected from the latest threats.
‍Restrict access: Limit access to your systems to authorized personnel only. If your practice allows remote access, consider using a virtual private network (VPN) for secure communication.

‍8. Get Cybersecurity Insurance
‍
Consider purchasing your cybersecurity insurance to further protect your practice.

Tackling even just one item on this list today will help you enhance the security of your practice data! Staying proactive with regular updates, educating your team, and utilizing security measures like 2FA and encrypted communication will help you stay ahead of potential threats. Cybersecurity is an ongoing process — what you do today helps protect your practice for the future.

This article originally appeared on optimantra.com, published as part of their partnership with NNPEN: https://optimantra.com/articles/nnpen/computer-clicks-tips-for-ehrs.html?utm_source=nnpen

IS THERE MORE TO BUYING NP MED MAL INSURANCE THAN PRICE?

Thu, 25 Apr 2024 13:55:41 GMT

IS THERE MORE TO BUYING NP MED MAL INSURANCE THAN PRICE?

YES!!!!

Imagine a licensing board appearance for which you have no insurance policy that pays for license defense—this is not only threatening your license, but also your LIVELIHOOD. Or you have a cash hustle in aesthetics that you plan to expand, until you discover that your incumbent insurance co excludes an aesthetics practice that makes up more than 25% of the practice? Or surcharges a practice whose telehealth activity is >50%--suggesting that the practice is not seeing all patients for an in-person assessment—dashing your ideal 100% telehealth psychiatric NP practice vision?

Are you interested in what I’d look for in reviewing the NP’s medical malpractice policy? Here are some questions on my top 10 list that will help you customize the standard med mal policy to your situation:

1. Any rate increases imminent?
2. Do they curate/publish NP claim info, and specifically for NPs who are practice owners/self-employed?
3. Add to NP policy the NP’s’ Vicarious Liability [VL] for collaborator acts? Additional premium or no charge?
4. License defense endorsement
a. Ability to select counsel [remember, this is your livelihood] who is a nurse-attorney
b. Consent to settle with or without a hammer?
c. Covered only if complaint arises out of underlying medical incident or a broader professional services trigger?
5. Telehealth—any constraints e.g. max percent of practice that can be telehealth?
6. Cybersecurity—where is HIPAA protection—for defense and notification expenses. Do I really need separate stand-alone cybersecurity policy or will the med mal policy cover my defense expenses and any fines? Is the $25,000 limit adequate?
7. Do I need cover for just me, or also for employees/ medical directors?
8. Any cover for criminal allegations of unlicensed telehealth practice outside state of license?
9. Shop around—insurer underwriter hot buttons vary
10. Price—ask about premium increases that will affect next year’s renewal. Significantly lower premium is not necessarily troublesome: a new entrant into the marketplace may not have paid many losses yet and is buying your business. So long as the company carries an A.M. Best rating of A or above, your risk that the company will not be able to pay your claims is low.

NNPEN is here to help you ask the right questions. Your Insurance Advisor can answer them.

Members can use their free hour of consulting with a Founder to better understand what’s important to them in their policy choices. Together we can view your insurance policies as the important asset they are.

ENTREPRENEURS COLOR OUTSIDE THE LINES

Thu, 21 Sep 2023 12:36:49 GMT

Here we go again. Planning for NNPEN’s April 2024 conference is already underway and we are asking ourselves this question: will NP leaders feel that the healthcare delivery system, and NPs as a profession, are better off now than 12 months ago? Are we any closer to quantifying NP value? And if not, does it still matter?

From the outside, it is hard to “hear” movement from “silence to voice,” as authors Buresh and Gordon labeled nursing’s challenge in 2013 -- ten years ago. A few years later, here is what we thought NP disruptors would sound and look like, based on eight-year-old keynote slides from NNPEN’s Inaugural Boston conference in 2017:

Attributes of an NP Market Disruptor

Understands what is driving change in health care, especially in primary care access.
Sees NP FPA struggle in broader regulatory & economic markets context: classic competition battle. History is on our side!
Identifies business models available to NPs and the skillsets needed to survive.
Develops confidence in the business case for NPs as independent practitioners.

Can we declare “mission accomplished!”? Yes, and no…

I would argue that inside the NP community there is an unmistakable restlessness for change being channeled by NP entrepreneurs in increasing numbers. NP entrepreneurs take the road less travelled, color outside the lines, and make good trouble, in a nutshell are market disruptors. We will open our 2024 conference with case studies of NP entrepreneurs who are showing us disruption first-hand:

1] “call me doctor” litigation brought by 3 NPs against the CA Board of Nursing

2] a fact check challenge to the AMA’s disturbing put-down of NPs as primary care equals

3] an academic proposal to move nursing out from under the bed rate to financial accountability as a free-standing revenue center, be it in a corporate setting or health system or nurse-led clinics.

This year, NNPEN aims to open NP eyes to the possibility that NP practice transition to a growth mode and risk readiness is already underway. Indeed, we can find evidence of NPs as disruptors in two of our 2017 disruptor attributes list: [Understands what is driving change in health care? Check! Identifies business models available to NPs and the skillsets needed to survive? Check!

Do NPs see the FPA struggle as a classical competition struggle that history tells us NPs will win? Maybe.

Do NPs feel confident in the business case for NPs as independent practitioners? No.

Have we translated the impact of the nursing model, our patient-centered north star, into dollars as well as clinical value?

Not yet. There is clearly work to do.

Market disruption is not the only growth tale to unfold on April 13 at our conference. Two of our favorite NP-literate attorneys Justin Marti and Dena Castricone will share their views on how growth uncertainties can be managed even as we encourage NP entrepreneurs to color outside the lines. To top off the day, in-person attendees will sign up for consecutive breakout sessions that explore the everyday challenges to, and collaboration proposals for, making NP entrepreneurship sustainable by joining forces—not practice absorption but practice networking to make 2+2=5. Ponder one very encouraging data point from our 2023 survey of 1200 independent NPs in Connecticut: 65% of the NP respondents indicated interest in “collaborating with other nurse-led practices to access the benefits of value-based reimbursement.

Change comes when entrepreneurs and intrapreneurs become disruptors who color outside the lines TOGETHER. Bring an NP entrepreneur buddy with you so that your aspiration to “be the boss of me” does not die at the end of the day. We will supply the crayons!

Be there: April 13, 2024, at the Hartford CT airport’s convenient and safe Sheraton Hotel venue.

CENTERS FOR MEDICARE AND MEDICAID SERVICES' (CMS) MAKING CARE PRIMARY (MCP) MODEL

Tue, 11 Jul 2023 21:09:47 GMT

Making Care Primary (MCP) Model

On June 8, 2023, the Centers for Medicare & Medicaid Services (CMS) announced a new voluntary primary care model –improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients’ health needs as well as their health-related social needs (HRSNs) such as housing and nutrition. CMS is working with State Medicaid Agencies in the eight states to engage in full care transformation across payers, with plans to engage private payers in the coming months. CMS will begin accepting applications for the model in late summer 2023. https://innovation.cms.gov/innovation-models/making-care-primary

Making Care Primary [MCP], like REACH, targets Medicare FFS beneficiaries in underserved areas. MCP seems to focus on growing small independent primary care practice infrastructure sustainably, with an eligibility minimum of 125 attributed lives per practice, while ACO REACH focuses on the ACO as an aggregating vehicle to incentivize providers and measure outcomes of his/her panel minimum of 5,000 attributed lives. MCP is a 10-year beta beginning July 2025 in eight preselected states; ACO REACH is a 5-year beta that began January 1 2023 in all 50 states. It sounds promising for NPs to have two value- based payment models to compare and contrast, but we have very little detail until the MCP RFA [Request for Application] is released this summer. NNPEN tried to get an early answer confirming NP eligibility, attribution to NPs and the minimum # of attributed patients for MCP eligibility. We got back this partial answer the next day:
“Small, independent primary care practices that meet eligibility requirements listed in the RFA may participate in the model. Applicants must have a minimum of 125 attributed Medicare FFS beneficiaries in order to be eligible for MCP. This eligibility criteria will be assessed at the applicant level. The applicant will submit a list of primary care clinicians as part of the application which will assist CMMI in conducting this eligibility check. The RFA will be published later this summer.”

Model Overview

The Making Care Primary (MCP) Model is a 10.5-year multi-payer model with three participation tracks that build upon previous primary care models, such as the Comprehensive Primary Care (CPC), CPC+, and Primary Care First (PCF) models, as well as the Maryland Primary Care Program (MDPCP). MCP aims to improve care for beneficiaries by supporting the delivery of advanced primary care services, which are foundational for a high-performing health system. The MCP Model will provide a pathway for primary care clinicians with varying levels of experience in value-based care to gradually adopt prospective, population-based payments while building infrastructure to improve behavioral health and specialty integration and drive equitable access to care. State Medicaid agencies will commit to designing Medicaid programs to align with MCP in key areas. This model will attempt to strengthen coordination between patients’ primary care clinicians, specialists, social service providers, and behavioral health clinicians, ultimately leading to chronic disease prevention, fewer emergency room visits, and better health outcomes.

NNPEN’s conclusion: the VBP cauldron is bubbling; stay engaged and bring your colleagues with you! Curious NP PCPs in these eight states should evaluate the number of Medicare FFS patients they serve in aggregate as the threshold for application for this model—NOT whether they currently possess value-based payment experience: Colorado, Massachusetts, Minnesota, New Mexico, New Jersey, New York, North Carolina, and Washington.

Reach For It

Thu, 09 Mar 2023 15:02:17 GMT

REACH FOR IT!

March 2023 Blog

What a Difference a Year Makes

Last year when NNPEN polled NP Value Summit attendees, they didn’t see Value Based Payment [VBP] at their doors for 10 years: Not a surprise. No payers were offering VBP contracts to NPs, and NPs felt a very low sense of urgency to leave FFS, the devil they knew. But 12 months later, as of January 1, there are >100 payers willing to contract with NPs on VBP terms—a payer or two in most states.

Q: Who are these payers? A: REACH ACOs

REACH ACOs are the new Medicare payers for NPs, a five year pilot of CMMI focused on delivery of primary care services that create health equity and extend the reach of primary care into underserved populations—an NP sweet spot. [ REACH stands for Realizing Equity, Access and Community Health.]

And they are the NP friendliest of the CMS ACO models thus far—for one threshold reason [aside from NP’s love affair with seniors, especially high needs homebound beneficiaries]: REACH ACOs level the playing field for all eligible PCPs, docs and NPs alike—with a claims-based assignment system called Attribution also known as Alignment]. Attribution means eligibility for any auto-assigned revenue stream associated with traditional Medicare patients for the NP and any ACO s/he is part of. By recognizing the NP in larger numbers through claim-based auto assignment [in addition to current voluntary assignment] as both the treating and billing provider, REACH creates visibility for NP PCPs and data to quantify NP value.

We already have that with our traditional Medicare patients that we see in our nurse-led practices…right? Not really. NPs are still stuck in a FFS payment system that is fiscally unfair, not patient-centered and affords little opportunity to grow into a practice big enough—visible enough—to leverage payers into reimbursement contracts that value NP quality and cost outcomes.

Like other ACOs, REACH creates critical mass leverage by aggregating—but not owning—small practices, creating a powerful Double AA battery of Attribution and Aggregation. And with CMS as overseer and financial reconciler, REACH offers transparency and training wheels to accepting both risk and reward for your panel’s health .

How does REACH support the NP’s shift to value?

o You keep your non-REACH patients and bill them as usual, direct to Medicare
o Monthly care management payments
o Monthly payment advances to support cash flow [“capitation”]
o Value-based payer contracting and population health program management
o Downside risk protection
o Access to shared savings
o Opportunity to erase the 15% differential with the Medicare physician rate schedule

There are 3 types of ACO REACH but all abide by same CMS/CMMI rules. How do I tell these REACH ACOs apart?

o High needs beneficiaries only: typically HCC >4.0; minimum ACO size=500 attributed lives
o Standard: established Medicare expertise; 5000 attributed lives
o New Entrant: New as Medicare providers; 3000 attributed lives with growth timeline

REACH ACO Nurse Practitioner Services Benefit Enhancement New in 2023

Wait—one more NP friendly change! One of NNPEN’s members points to another way REACH ACOs will impact both the NP and the beneficiary, and in a much more immediate way. Through the Nurse Practitioner Services Benefit Enhancement 2023 the NP can certify the need for hospice, diabetic shoes, cardiac rehabilitation and several other therapies WHICH STILL REQUIRE PHYSICIAN CERTIFICATION FOR MEDICARE BENEFICIARIES NOT ALIGNED WITH AN ACO REACH. This is a benefit the REACH ACO can elect to offer in an effort to streamline both quality and cost for seniors. This benefit enhancement works for the patient [diabetic shoes today!] and also supports ongoing collection of quality and cost data starting this program year, and we know that data is what we need to change policy more broadly! See page 75 in this link for a complete list of enhancement services: https://innovation.cms.gov/media/document/aco-reach-rfa

If you’ve railed against the barriers created by the physician certification of need requirements, recognize the REACH Nurse Practitioner Services Benefit Enhancement effective 2023 as another opportunity to create the visibility NPs need to lay the foundation for quantifying NP Value.

Best ways to learn more about REACH ACOs

1. Interviews with ones in your state; are they NP -friendly? Do they understand your questions? Have they shown willingness to negotiate a cap on downside risk? Have they elected to offer the NP Services Enhancement Benefits?
2. Understand their timelines and match against yours
3. Follow NNPEN’s REACH reporting and strategy to build a critical mass of like-minded NP practices
4. Remember One and Done: Primary care providers cannot participate in >1 REACH at a time, but can withdraw
5. Join us April 1, 2023 in person or virtually for our spring conference: [In]Visible* to Value, which will focus on creating NP visibility as a precondition to NP success in VBP, and hear how peers assess the downside risk of this migration. Here’s the link to the NNPEN 2023conference landing page: https://mailchi.mp/2ed382004d0e/je04wxx0yw

See you April 1 [no fooling!]

POST 2022 SUMMIT BLOG NP VBP: IS THE JUICE WORTH THE SQUEEZE?

Fri, 25 Feb 2022 18:41:01 GMT

POST 2022 SUMMIT BLOG

NP VBP: IS THE JUICE WORTH THE SQUEEZE?

NNPEN hosted its first Value-based Payment Summit on February 11^th and 12^th with attendance of 30+ like-minded professionals, all focused on NPs getting paid for the nursing model’s value add . Together the Summit ROCKED on content, every session recorded to reach a much larger audience. NNPEN experts agreed that a fee-for-service model is unsustainable for nurse-led practices and NPs need to understand the benefits associated with an at- risk payment strategy. With a focus on health promotion and disease prevention under a nursing model of health care delivery, the NP can survive and benefit from a value-based payment arrangement. Our narratives built one on another and made sense together: how often does that happen? We think this summit marks the beginning of a ground-up mapping to critical mass numbers! Many, many thanks to our subject matter expert speakers: researchers, payers, practice owners and educators.

We owe equal gratitude to the robust support NNPEN received from first-time sponsors, topped off with exhibits by the Emory Nursing Experience, a professional development initiative for nursing and Medical Advantage, a practice management company supporting NPs. These sponsors see the value of NPs in this space, even while we recognize NPs lag behind for many reasons revealed during the Summit sessions: lack of knowledge, small panel size and lack of incentives, to name a few.

The Summit concluded with these questions: How can we do this? How will we raise the value-based payment participation rate of nurse-led practices—and in turn, give NP practices agency over how they deliver the services their patients need, create sustainability both financially and clinically for their practices, and act with urgency? NPs as a workforce cannot waste this opportunity to leverage the pandemic’s access crisis in each of the 50 states!

We have several takeaways to hold close as we push to construct the roadmaps to NP VBP model participation:

1. NP attendance at the Summit tells us there’s more work to be done to move the value- based payment needle for NPs – not in 10 years’ time [the most common chat response on timing of VBP’s arrival for nurse-led practices] but starting now. Policy wonks, including CMS, peg the transition timeline closer to 3-5 years.

2. VBP covers services that are patient-centered, not volume driven, and aligns with the patient-centered nursing model. Sharing values with payers bodes well for patient-centered partnerships—not so much with FFS payers that reward volume

3. Our biggest risk is NOT down-side risk, but NP failure to plan for a transition to VBP that will be here, championed by Medicare and employers, in the frequently cited timeline of 3-5 years.

4. We know that nurses are bottom-up problem solvers [because there has always been resource constraint in conflict with what our patients need?]. So, we need to get local NP organizations talking with each other, with a common agenda, to ultimately answer this one meta question: IS THE JUICE [THE TRANISITION TO VBP] WORTH THE SQUEEZE? WHO DECIDES? Remember if we are not at the table, we are on the menu!

How will this happen? NNPEN will edit the recorded Summit sessions, summarize a bit, and then invite partners on a local level to draft a consensus vision for NP VBP and to propose next steps, including sources of funding, that fit the region and that will lead to region-specific answers to our meta question, “Is the VBP Juice worth the Squeeze?”.

We are also looking for other stakeholders who see the need for action to join us. Is this too much to ask? We don’t think so.!!

Sandy Berkowitz, Lynn Rapsilber, and Lorraine Bock

NNPEN

WHY VALUE BASED PAYMENT IS NOT A NO-BRAINER FOR NP PRACTICE OWNERS

Tue, 11 Jan 2022 19:35:34 GMT

Value based payment (VBP) can be scary. Many NP practice owners have grown up under the fee-for-service (FFS) reimbursement structure. As we are seeing and will continue to see, payment is shifting to value-based payment (VBP) models. The goal of VBP is to control costs through keeping patients healthy-- preventing disease and optimizing level of wellness. Does this sound familiar? Nursing is rooted in health promotion and disease prevention-- the hallmarks of VBP. So then why are more NP practice owners not embracing this more sustaining (clinically and financially) payment model? Let’s look at some of the reasons.

First, NP practice owners start their businesses with small patient panels, perhaps working just one day a week. This inhibits NP practice owners from reaching the critical mass necessary to participate in VBP programs.

Second, NPs tend to be bottom-up problem solvers. Being on the front line of care delivery, we focus on the immediate solution that works for the patient. That is also how we solve problems with our practices. NP practice owners need to know their practices will not be compromised, fearful of consolidation efforts that have not worked for other providers. We have slim margins and fear being corralled into the potential for financial loss . Currently, there exists no incentive for NP practice owners to create critical mass to participate in VBP programs. We don’t yet see that the potential for gain is increased, not decreased, by the patient-centeredness of our shared nursing model.

Lastly, NPs have a tendency to “make-do”. For this reason, nursing’s blessing is also its curse. With our nature to make do, we preserve the status quo. We miss out on opportunities that capitalize on the value that the nursing model truly offers.

How do we elevate NP practice owners to risk takers and valued participants in VBP? What creates enough incentive for NP practice owners to color outside the lines of FFS? How do we leverage what we know about how nurses problem-solve to produce informed risk takers?

These are the very questions we will confront together at NNPEN’s NP VBP Virtual Summit on February 11^th and 12^th. These are questions we must answer; our time is NOW. So here’s my first message as NNPEN’s CEO to Nurse Practitioner practice owners and the resources that support them:

BE A PART OF THE START!! Join the Summit's payment conversation and post-Summit building of road maps to nurse-led practice sustainability; we need you NOW! Here’s the Summit information link: CLICK

Dr. Lynn Rapsilber

Co-founder and CEO NNPEN

Value-based Payment Trapped in an FFS Straight-jacket, a Virtual Summit

Wed, 08 Dec 2021 00:00:00 GMT

February 11, 2022 Friday Afternoon
& February 12, 2022 Saturday Morning

Four years ago, NNPEN’s founders were planning our first Nurse Practitioner Entrepreneur [NPE] Conference in Boston in collaboration with Northeastern University. Nervously we watched the registration numbers limp along, shocked when nearly 100 NPEs and educators showed up. Many still refer to that 2017 Boston event as the Ground Zero 1.0 of an NP practice owner [NPPO] community. Since then, NNPEN became an NP member services entity organized as an LLC with dreams of both profit and prophet. Among other things, we’ve fashioned from whole cloth an NP Business Basics curriculum, consulted with NP practices of an NP Aggregator, and convened signature conferences for NPPOs every year, including 2020.

These past 4 years’ Ground Zero 1.0 work has been nurturing a community of NPEs who wonder if they are ready to be owners of their own practices [autonomous practice with no doctor oversight is lawful in half the states and growing]. Now nurse-led practice doors are opening but payers will not negotiate revenue unless NP practices are willing to accept downside risk as well as upside incentives in alternative payment models [aka VBPs, or value-based payments]. Payers, led by CMS, are leaning heavily toward APMs that reward patient-centered outcomes we know that Fee for Service contracts with NPs do not and will not. Ground Zero 2.0 is about planning for this major risk-reward payment reboot, with NPs embracing the fiscal value of the nursing model’s “deliverable”: patient centeredness.

We are trying to connect many data points into a realistic payment reform strategy with the hope that like-minded attendees at this Summit hear the same call to action we do. Most of the sessions will feature non-NP subject matter experts, each paired with one or two NPPO [NP Practice Owner] respondents in a conversation that starts our program with Will the NP-owned Practice Survive? NNPEN’s job is to keep the ball in play, to connect the Summit participants in the drafting of a post-Summit consensus plan, Roadmap to Critical Mass.

On February 11 and 12, 2022 please join us to celebrate our arrival at Ground Zero 2.0, NNPEN’s 2022 NP Value-Based Payment Virtual Summit. We believe it’s time for NPPOs to develop their critical mass strategies and the road maps to get there. And we also believe that the Ground Zero 2.0 Summit is the beginning of the community that will do that work.

SB
Sandy Berkowitz
NNPEN Payment Reform Strategist

CEO Transition - July 2021

Fri, 25 Jun 2021 12:59:34 GMT

It’s not that often that change and I see eye to eye—but welcoming NNPEN co-founder Dr. Lynn Rapsilber as NNPEN’s CEO on July 1, 2021 is one of those times. Lynn is my dream-come -true to take the baton: DNP, healthcare policy wonk, sought-after national Billing & Coding presenter, GI practitioner and tested consensus-builder! And she knows that nurse-led start-ups have the power to solve the primary care access crisis in America. She will drive NNPEN to answer this question: How will that NP practice ownership explosion happen?

In this win-win, Sandy relinquishes CEO responsibilities and takes on Priority #1 for me personally, and NNPEN derivatively, which is NP Payment Reform. To lean into this initiative, the post July 1 Sandy is tasked with driving an NNPEN payment strategy whose goal is expanded NP practice participation in risk-based Alternative Payment Models (APM). Say what???

We have worked tirelessly to reduce barriers to NP entrepreneur [NPE] practice ownership: finding collaborating physicians, health benefits options for NPEs and their families; and business basics course work accessible 24/7that lays a foundation for the developing NPE business brain ...with more to come.

Looking back at earlier blogs, the need for payment reform has been lurking since NNPEN’s beginning. To be concrete: out of a total of 15 website blogs I’ve written since March 2018, payment reform appears 9 times. Why?

Because NO MARGIN NO MISSION. When we first birthed NNPEN and put those words on a slide as our call to action, the return was puzzled looks from NPs. The battle was/is Full Practice Authority [FPA] in all 50 states. But the potential for practice ownership in FPA states soon ran into this reality: even with FPA, Fee For Service reimbursement is not a sustaining revenue base. “Sustaining” as in paying your bills including your own salary, and having money left over [the margin] to invest in your mission of growing your practice, offering patient services you were educated to view as a piece of patient-centered primary care – not indulgences. And having time to engage with your patients!

We know there are barriers to negotiating sustaining payment for NPs. The big three are:
1. Critical mass: can NPs, happy to finally be owners of their own practices, be persuaded to look beyond their practice walls to aggregation of distinct nurse-led practices and their compelling quality and cost outcomes data? With NPs on so many different electronic health records, data aggregation, national or regional, is a costly challenge. How do we skin this cat?
2. Appreciation of the need to preserve nurse-led care and its framework, the nursing model. We need enlightened payers who see that nimble small practices go to where their patients are and must be sustained to ensure a primary care access solution in America. We then need payers to design APMs modified for small independent primary care practices, not just for the big groups and healthcare systems.
3. NPs’ ingrained risk aversion culture, including aversion to value-based payment risk. Maybe the pandemic has demonstrated that nothing is risk-free: when patient traffic stopped, FFS revenue stopped, while APM cash flow continued. Let me share how Doug Watson, CFO of Dignity Health [featured in a panel convened May 2021 by HealthLeadersMedia.com to explore Balancing Risks and Opportunities in Value-Based Care] answered the perennial question of how a provider/practice will know it’s time to leave FFS behind:

“I believe it is important to look at what risk allows you to accomplish

in terms of delivering better value to decide how and when to proceed.”

NP practice owners recognize the gap between what patient-centered services their training would dictate for their patients and the scope of patient-centered services FFS payments allow. You will become informed risk-takers when delivering a broader basket of patient services is the only path forward consistent with the analytics of the nursing model.

So I have my work cut out for me—and that works for me. Lynn says ditto.

How grateful we are that the NNPEN board was and is unanimous that the time to lean in, to invest in accelerating the pace of sustainable nurse-led practice growth, is now.

Here we go!

OUR 2021 GOALS

Fri, 29 Jan 2021 11:00:00 GMT

It’s 2021 and NNPEN is still vertical. And eager to act, to kick covid in the butt.

As painful as the past year has been, covid has been good to NNPEN in that instead of non stop travel the founders suddenly had time to collaborate even as covid changed everything around us. Demand for healthcare services as a result of covid has highlighted the NP’s ability to create access to healthcare services while delivering better care at lower overall cost than physician PCPs. Many states waived scope of practice constraints like physician supervision on NP freedom to practice autonomously on an emergency basis and have not looked back. On January 4th, 2021, Massachusetts, a restricted state blessed NP autonomous practice with bipartisan FPA (Full Practice Authority) legislation. Last July Florida, the second-largest Medicare market in the country, granted FPA status to NPs in primary care.

NPEs are kicking in the FPA door state by state, and it is swinging open. It is a call to action for NP entrepreneurs (NPEs) –for you, our members. In turn, What support can our members expect from NNPEN in 2021?

Our Goal #1 is acceleration of the pace of nurse-led practice startups, which in turn will lead to broader access to patient-centered health care services in America. In short, we have made substantial progress [during lockdown!] developing tools to accelerate our members’ transition from the pre-contemplation question of “Am I an Entrepreneur?”, through the Owner Go/No Go decision, to the satisfaction [and terror ] as a practice owner that at last “I am the boss of me.” We now offer Business Basics learning experiences that are modestly priced, taught by subject matter experts both in and outside of nursing and accessible 24/7 These offerings fill a content void created by the flawed thinking that dismisses the need for an orientation to business in nursing education, and introduces NP practice owners to a like-minded NP owner community that supplements the member services NNPEN currently can provide. Recall that NNPEN was created in 2017 in response to this question:

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?

Putting one foot in front of the other has led us to some initial strategies. But how do we know if we’re on the right track? We measure. We know that 2/3 of our NPE members are not practice owners. Given our goal is to accelerate NPE transition into ownership we have to ask “Are We making a difference?” We will be answering that question using two metrics which we invite you to track with us—and even more important, to dialogue with us about what we could be doing better:

1 .25% growth year over year in our membership

2. Positive trend in % of members who transition into ownership after joining NNPEN

Our Goal #2 is Nurse-led practice participation in Alternative Payment Model arrangements. Full Practice Authority legislative success is pyrrhic victory if practices are not financially sustainable. Results from NNPEN’s 2019-2020 survey of NP practice owners, which we hope to see published in 2021, confirmed that NP practices typically choose inadequate FFS arrangements over APM options that pay performance bonuses but also carry modest financial risk. Not surprisingly, lack of education about managing payment risk soundly beat out lack of willing payer partners as the biggest barrier to APM participation As a result, preparation for risk-based payment reform has become one of our explicit goals for late 2021 and beyond. Watch for new NNPEN workshops that link NP quality and cost outcomes directly to the nursing process, and that explain why NNPEN sees the nursing process as your practice’s reliable profitability PPE. NPs who see RISK as a four letter word will become informed risk-takers because APMs make sense financially. Our bookies are betting on NP APM participation by 2023.

Finally, these goals are only two of the exciting developments that have been incubating since lockdown began. My role will be changing as will Lynn’s. We have brought on board Korrynn Lancaster as the staffer who keeps us connected to each other—and to you. Hang in there as we roll out ways of connecting with you and for you that we never dreamed possible two years ago. 2021 is going to be a great year!

Open Payments are Coming… Open Payments are Coming….

Mon, 14 Dec 2020 22:27:57 GMT

Open Payments is a federal program, required by the Affordable Care Act, that collects information about certain payments that drug and device companies make to physicians and teaching hospitals for things like travel, research, gifts, speaking fees, and meals. It also includes ownership interests that physicians or their immediate family members have in these companies. This data is then made available to the public each year on openpaymentsdata.cms.gov. Guess who has been added to the list of Health Care Providers? Yep, we are! So, what does this mean?

Have you had to sign in for a speaker program, a lunch program, a dinner program or at a conference? Have you received an honoraria or speaker or advisory board fee? There is a value attached to the “gift” you just received. These monetary amounts will now be reported by the supplying party.

The Open Payments Search Tool https://openpaymentsdata.cms.gov/ records payments made by drug and medical device companies to physicians and teaching hospitals…and now US!

A Fun Fact: Connecticut was the first state to require tracking of payments to NPs as part of the Sunshine Act with passage of Full Practice Authority in 2014.

How will this affect NPs?

All the compensation we receive in goods, services, honoraria are tracked and reported to the public. This may deter NPs from participating in Pharma stuff. Yet, it may enlighten us in other ways.

The amount of $$ we receive in these “gifts” are far less than the MDs. Once we see some of these discrepancies, it can provide fuel to fight equal pay for equal work. It has always been my fight to be paid the same as the MDs for speaker honoraria: we learn the same slide deck, we present the same deck, yet we receive ~60% less than our physician colleagues. There is a fair compensation guide (anything but that) used by the drug companies to calculate this rate. This now makes it obsolete.

What you can do?

You can and should register to participate in Open Payments by clicking link https://www.cms.gov/OpenPayments/Program-Participants/Physicians-and-Teaching-Hospitals/Registration

Once you are registered you can look at what is listed under your name to insure it is accurate and true. You have until the end of the calendar year, in which the data is first published, to review and dispute the reported information. Changes that drug or device companies make to the data (because of your dispute) will be seen publicly in the data refresh (usually occurring in January of the next year).

THIS COUNTRY NEEDS PATIENT-CENTERED PRIMARY CARE PROVIDERS: HOW TO PUT THE PEDAL TO THE METAL FOR NURSE-LED PRACTICE OWNERSHIP

Wed, 04 Nov 2020 17:56:13 GMT

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.

COVID-19: The Sun May Shine Tomorrow, but How Will My Practice Survive?

Thu, 16 Jul 2020 12:30:00 GMT

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!

Sandy Berkowitz
Co-founder and CEO NNPEN

HBPC Joint Conference Recap

Mon, 24 Feb 2020 16:56:43 GMT

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:

Full practice authority
Value-based payment (VBP) contracts with payers that reward the quality and cost savings that reliably flow from the patient-centered nursing process and
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!

Sandy Berkowitz
Co-founder and CEO NNPEN

Scope of Practice Response from NNPEN

Thu, 16 Jan 2020 20:17:36 GMT

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:

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”.
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.
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.
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.
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.
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

New Website

Mon, 09 Dec 2019 15:46:14 GMT

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's New Partnerships

Thu, 26 Sep 2019 16:51:51 GMT

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.

BUSINESS SERVICES

Mon, 03 Jun 2019 16:30:00 GMT

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.

CEO

WHAT'S AHEAD FOR MY PRACTICE?

Thu, 14 Feb 2019 11:26:14 GMT

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.

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

Tue, 04 Dec 2018 20:30:00 GMT

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.

MORSELS FROM MINNESOTA CONFERENCE PART II

Sat, 04 Aug 2018 23:30:00 GMT

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

MORSELS FROM MINNESOTA CONFERENCE PART I

Tue, 31 Jul 2018 18:58:01 GMT

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!

NP PAYMENT REFORM ADVOCACY: TIME IS UP

Fri, 01 Jun 2018 13:42:16 GMT

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?

PLANNING A DEBUT

Thu, 01 Mar 2018 14:28:56 GMT

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)